NURS 6700- Exam 3
Medical Diagnosis
Is a concept that defines a disease process or injury
Nursing Diagnosis
Describe human responses to potential or actual health problems and life processes; is
a clinical judgment about actual or potential individual, family, or community
experiences/responses to health problems/life processes; provides the basis for
selection of nursing interventions to achieve outcomes for which the nurse has
accountability
Why do we have nursing diagnosis?
It is used to determine the appropriate plan of care for the patient. The nursing
diagnosis drives interventions and patient outcomes, enabling the nurse to develop the
patient care plan. Nursing diagnoses also provide a standard nomenclature for use in
the Electronic Health Record, enabling clear communication among care team
members and the collection of data for continuous improvement in patient care - drives
the nursing care plan for the patient
How to write a nursing diagnosis?
-Rules
-Must use from the NANDA list
-Cannot add/remove "risk for" for any diagnosis- must use as written
Components of Nursing Diagnosis
-NANDA
-PATHO
-As evidenced by statement - evidence you see supporting your diagnosis
Variations (Actual vs. Risk)
-Risk for nursing Dx. has a r/t (related to) statement followed by risk factors
-Actual risk nursing Dx has a r/t (related to) statement followed by evidence statement
-To differentiate between evidence and risk factors you may use "risk factors"
Care Plan Building
-Nursing diagnoses are the foundation of care plans
-Review your nursing diagnosis book for details to assist you in building a solid plan
Care Plans Include
1. Assessment
2. Planning
3. Interventions
4. Evaluation
Assessment
Subjective/Objective information - complete head to toe and collect all assessment and
chart data needed. How do you know these things? Did you get the information with
your 5 senses (objective)? Or did the patient tell you about is (subjective)?
Planning
Short-term and long-term goals
Think of these as during shift or less and those things which go beyond your 12 hour
day
Interventions
What will you DO to achieve these goals?
, Evaluation
Why will you do these things? Did the things you did help your patient meet the goals?
Care Plan Steps
1. Collect Information
2. Analyze
3. Think About How
4. Translate
5. Transcribe
Collect Information
-Get information from all sources together
-Your head to toe assessment
-Conversations with patient and loved ones
-Observations (lab values, vital signs)
-Report (or your report sheet)
-Chart review and notes
-Discussions with healthcare team members
Analyze
-Look at all information
-What are areas in which this patient has trouble and therefore needs to progress in?
-Think about the ways you could see the patient improving and how you would know
they were improving
-Write down the general issues, how you would help them progress in that area, and
how would you know they were progressing
Think About How
-Think about how you knew these were issues
-How did you know he was in pain? Did he tell you? Did you observe it? Was he getting
pain medications?
-Look at each "how" and decide if it subjective (is this pain or something the patient told
you about?) or objective (did you gather this information with your 5 senses?)
-Write an S or an O next to them
-What could these issues be related to?
-A recent surgery, trauma, or disease process?
-Write all of your reasons (again in layman terms) under the problems you have
identified
-What would you do to make this better? (interventions)
-How would you know it got better? (evaluation)
Translate
-Take your textbooks (NANDA-I, NIC, NOC, or whatever you may be using)
-Look up the official terms for the problems write them down
-Look up outcomes and interventions that may align with what you wrote down
Transcribe
-Put the pieces together (problem + related to factors + defining characteristics/ "hows")
-Create your nursing diagnosis
-Use your S's and O's to place your subjective and objective data
-Write out your interventions and outcomes/evaluation
-Put your feet up - you're done!
Medical Diagnosis
Is a concept that defines a disease process or injury
Nursing Diagnosis
Describe human responses to potential or actual health problems and life processes; is
a clinical judgment about actual or potential individual, family, or community
experiences/responses to health problems/life processes; provides the basis for
selection of nursing interventions to achieve outcomes for which the nurse has
accountability
Why do we have nursing diagnosis?
It is used to determine the appropriate plan of care for the patient. The nursing
diagnosis drives interventions and patient outcomes, enabling the nurse to develop the
patient care plan. Nursing diagnoses also provide a standard nomenclature for use in
the Electronic Health Record, enabling clear communication among care team
members and the collection of data for continuous improvement in patient care - drives
the nursing care plan for the patient
How to write a nursing diagnosis?
-Rules
-Must use from the NANDA list
-Cannot add/remove "risk for" for any diagnosis- must use as written
Components of Nursing Diagnosis
-NANDA
-PATHO
-As evidenced by statement - evidence you see supporting your diagnosis
Variations (Actual vs. Risk)
-Risk for nursing Dx. has a r/t (related to) statement followed by risk factors
-Actual risk nursing Dx has a r/t (related to) statement followed by evidence statement
-To differentiate between evidence and risk factors you may use "risk factors"
Care Plan Building
-Nursing diagnoses are the foundation of care plans
-Review your nursing diagnosis book for details to assist you in building a solid plan
Care Plans Include
1. Assessment
2. Planning
3. Interventions
4. Evaluation
Assessment
Subjective/Objective information - complete head to toe and collect all assessment and
chart data needed. How do you know these things? Did you get the information with
your 5 senses (objective)? Or did the patient tell you about is (subjective)?
Planning
Short-term and long-term goals
Think of these as during shift or less and those things which go beyond your 12 hour
day
Interventions
What will you DO to achieve these goals?
, Evaluation
Why will you do these things? Did the things you did help your patient meet the goals?
Care Plan Steps
1. Collect Information
2. Analyze
3. Think About How
4. Translate
5. Transcribe
Collect Information
-Get information from all sources together
-Your head to toe assessment
-Conversations with patient and loved ones
-Observations (lab values, vital signs)
-Report (or your report sheet)
-Chart review and notes
-Discussions with healthcare team members
Analyze
-Look at all information
-What are areas in which this patient has trouble and therefore needs to progress in?
-Think about the ways you could see the patient improving and how you would know
they were improving
-Write down the general issues, how you would help them progress in that area, and
how would you know they were progressing
Think About How
-Think about how you knew these were issues
-How did you know he was in pain? Did he tell you? Did you observe it? Was he getting
pain medications?
-Look at each "how" and decide if it subjective (is this pain or something the patient told
you about?) or objective (did you gather this information with your 5 senses?)
-Write an S or an O next to them
-What could these issues be related to?
-A recent surgery, trauma, or disease process?
-Write all of your reasons (again in layman terms) under the problems you have
identified
-What would you do to make this better? (interventions)
-How would you know it got better? (evaluation)
Translate
-Take your textbooks (NANDA-I, NIC, NOC, or whatever you may be using)
-Look up the official terms for the problems write them down
-Look up outcomes and interventions that may align with what you wrote down
Transcribe
-Put the pieces together (problem + related to factors + defining characteristics/ "hows")
-Create your nursing diagnosis
-Use your S's and O's to place your subjective and objective data
-Write out your interventions and outcomes/evaluation
-Put your feet up - you're done!
