Understanding Nursing Diagnoses and Interventions in Healthcare

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Technologies in Nursing
Duquesne University
 
First introduced in 1950.
In 1953 Fry proposed the formulation of
nursing diagnosis.
In 1973, the first national conference
was held.
In 1982, NANDA was founded.
 
Diagnostic reasoning
A process of using assessment data to create
a nursing diagnosis
Defining characteristics
Clinical criteria or assessment findings
Clinical criteria
Objective or subjective signs and symptoms
 
 Problem
 Etiology
 Signs and Symptoms
 
By learning to make accurate nursing
diagnoses, your care plan will help
communicate the client’s health care
problems to other professionals.
A nursing diagnosis will ensure that you
select relevant and appropriate nursing
interventions.
 
Problem—the name or diagnostic label
identified from the NANDA list.  This may
be an actual problem, a risk (potential)
problem, or a wellness diagnosis.
 
The suspected cause or reason for
the response that has been
identified from the assessment
 
They are stated “as evidenced
by (A.E.B.)” or “as manifested
by”, followed by a list of
subjective and objective data.
“Risk” problems have no
evidence statement.
 
Ineffective Airway Clearance, related to
increased pulmonary secretions and
bronchospasm, evidenced by wheezing,
tachypnea, and ineffective cough.
Acute pain related to tissue distention and
edema as evidenced by reports of severe
colicky pain in right flank, elevated pulse and
respirations, and restlessness.
 
Hyperthermia related to increased metabolic
rate and dehydration as evidenced by
elevated temperature, flushed skin,
tachycardia, and tachypnea.
Risk for infection, related to broken skin,
traumatized tissues, decreased hemoglobin,
invasive procedures, increased environmental
exposure.
 
Risk for skin breakdown
related to immobility as
evidenced by stage III sacral
wound (7 X3 cm)
 
Pain related to myocardial
infarction as evidenced by
patient’s report of pain at 9 on
the 1-10 pain scale
 
Ineffective airway clearance
related to pneumonia as
evidenced by adventitious breath
sounds, sputum production, and
abnormal chest x-ray.
 
Fluid volume deficit related to
blood loss through wound as
evidenced by hemoglobin of 8
and hematocrit of 26%
 
Fluid volume deficit related to
NPO status as evidenced by
weight loss
 
Diarrhea related to C. Diff as
evidenced by 10 stool in one
day
 
Risk for infection related to
invasive procedure (surgery)
 
Readiness for enhanced
knowledge of disease process.
 
Based on a medical diagnosis
Examples:
Risk for pneumonia related to immobility
Risk for DVT related to immobility
Risk for myocardial infarction related to
inadequate tissue perfusion
 
Written in general terms
Not behavioral in nature
Patient centered
Example:  To enhance airway
clearance and improve
oxygenation
 
Actions that the nurse carries out for
the client or encourages the client to
do for themselves.
Include interdisciplinary actions, but
identify them as such.
Includes assessment
Includes teaching the client
Include the rationale for the
intervention.
 
Specific
Measurable
Attainable
Realistic
Time oriented
 
The patient will identify four
adaptive/protective measures for individual
situation by discharge.
The patient will maintain a patent airway,
ongoing.  (This outcome is stated as
“ongoing” and does not include a specific
timeframe other than discharge from care.
In this example, this is appropriate because
the situation may not resolve until the
patient’s condition or status changes or
discharge has occurred.)
 
 
The patient will be free of skin breakdown.
(This is another example of an ongoing
outcome).
The patient will demonstrate correct insulin
administration techniques within 48 hours.
The patient will attain pain relief identified as a
“3” on the 0-10 pain scale 30 minutes after
being medicated with pain medication.
The patient will maintain an oxygen saturation
of 92 or higher.
The patient will not incur a fall.
 
Should refer directly to the nursing diagnosis
and to the goal.
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Exploring the evolution of nursing diagnoses from the 1950s to the present day, this content highlights the importance of accurate diagnostic reasoning in creating effective care plans. It covers the types of nursing diagnoses, problem identification, etiology, and signs/symptoms, emphasizing the significance of clear communication and appropriate interventions in delivering quality healthcare.


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  1. Technologies in Nursing Duquesne University

  2. First introduced in 1950. In 1953 Fry proposed the formulation of nursing diagnosis. In 1973, the first national conference was held. In 1982, NANDA was founded.

  3. Diagnostic reasoning A process of using assessment data to create a nursing diagnosis Defining characteristics Clinical criteria or assessment findings Clinical criteria Objective or subjective signs and symptoms

  4. 1. Medical diagnosis A. Clinical judgment about the client in response to an actual or potential health problem B. The identification of a disease condition based on specific evaluation of signs and symptoms 2. Nursing diagnosis 3. Collaborative problem C. An actual or potential complication that nurses monitor to detect a change in client status

  5. 1. Actual Nursing Diagnosis A. Describe human responses to levels of wellness that have a readiness for enhancement 2. Risk Nursing Diagnosis B. Describes human responses to health conditions/life processes that may develop C. Describes human responses to health conditions or life processes 3. Wellness Nursing Diagnosis

  6. Problem Etiology Signs and Symptoms

  7. By learning to make accurate nursing diagnoses, your care plan will help communicate the client s health care problems to other professionals. A nursing diagnosis will ensure that you select relevant and appropriate nursing interventions.

  8. Problemthe name or diagnostic label identified from the NANDA list. This may be an actual problem, a risk (potential) problem, or a wellness diagnosis.

  9. The suspected cause or reason for the response that has been identified from the assessment

  10. They are stated as evidenced by (A.E.B.) or as manifested by , followed by a list of subjective and objective data. Risk problems have no evidence statement.

  11. Ineffective Airway Clearance, related to increased pulmonary secretions and bronchospasm, evidenced by wheezing, tachypnea, and ineffective cough. Acute pain related to tissue distention and edema as evidenced by reports of severe colicky pain in right flank, elevated pulse and respirations, and restlessness.

  12. Hyperthermia related to increased metabolic rate and dehydration as evidenced by elevated temperature, flushed skin, tachycardia, and tachypnea. Risk for infection, related to broken skin, traumatized tissues, decreased hemoglobin, invasive procedures, increased environmental exposure.

  13. Risk for skin breakdown related to immobility as evidenced by stage III sacral wound (7 X3 cm)

  14. Pain related to myocardial infarction as evidenced by patient s report of pain at 9 on the 1-10 pain scale

  15. Ineffective airway clearance related to pneumonia as evidenced by adventitious breath sounds, sputum production, and abnormal chest x-ray.

  16. Fluid volume deficit related to blood loss through wound as evidenced by hemoglobin of 8 and hematocrit of 26%

  17. Fluid volume deficit related to NPO status as evidenced by weight loss

  18. Diarrhea related to C. Diff as evidenced by 10 stool in one day

  19. Risk for infection related to invasive procedure (surgery)

  20. Readiness for enhanced knowledge of disease process.

  21. Based on a medical diagnosis Examples: Risk for pneumonia related to immobility Risk for DVT related to immobility Risk for myocardial infarction related to inadequate tissue perfusion

  22. Written in general terms Not behavioral in nature Patient centered Example: To enhance airway clearance and improve oxygenation

  23. Actions that the nurse carries out for the client or encourages the client to do for themselves. Include interdisciplinary actions, but identify them as such. Includes assessment Includes teaching the client Include the rationale for the intervention.

  24. Specific Measurable Attainable Realistic Time oriented

  25. The patient will identify four adaptive/protective measures for individual situation by discharge. The patient will maintain a patent airway, ongoing. (This outcome is stated as ongoing and does not include a specific timeframe other than discharge from care. In this example, this is appropriate because the situation may not resolve until the patient s condition or status changes or discharge has occurred.)

  26. The patient will be free of skin breakdown. (This is another example of an ongoing outcome). The patient will demonstrate correct insulin administration techniques within 48 hours. The patient will attain pain relief identified as a 3 on the 0-10 pain scale 30 minutes after being medicated with pain medication. The patient will maintain an oxygen saturation of 92 or higher. The patient will not incur a fall.

  27. Should refer directly to the nursing diagnosis and to the goal.

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