Chapter 35 Nursing Diagnosis and Planning

Writing the Diagnostic Statement

. The first two parts of the statement are linked by related to, sometimes abbreviated R/T. The last two parts are linked by as evidenced by, sometimes abbreviated AEB. • Ineffective Airway Clearance related to physiologic effects of pneumonia as evidenced by increased sputum, coughing, abnormal breath sounds, tachypnea, and dyspnea.

**The Diagnostic Statement**

A comprehensive diagnostic statement: Airway clearance ineffective manifested by shortness of breath on exertion Problem: It describes—clearly and concisely—a health problem a client is having; general label (e.g., airway clearance, ineffective). Etiology: The cause of the problem; specific, related factors such as excessive mucus or foreign body obstruction Signs and symptoms: Summarizes the data collected during assessment; specific, defining characteristics, such as shortness of breath on exertion

What are the three components of the nursing diagnosis KC

A nursing diagnosis has three components: P—Problem (diagnostic label) E—Etiology (cause) S—Signs and symptoms (the objective and subjective information observed and documented)

How is a nursing diagnosis stated? KP

A nursing diagnosis is stated in terms of a problem (a statement approved by NANDA-I), its etiology, and signs and symptoms.

What is the difference between a short term objective and a long term objective?

A short-term objective is an expected outcome or goal that a client can reasonably meet in a matter of hours or a few days A short-term objective is an expected outcome or goal that a client can reasonably meet in a matter of hours or a few days

A nurse is required to plan the care of a client. In what order should the following steps be performed when planning care? A- Establishing expected outcomes B- Setting priorities C-Writing a nursing care plan D- Selecting nursing interventions *

ABCD BADC BDAC DCAB BADC

What are the basis of the nursing plan written? KP

After establishing the nursing diagnosis, the planning of nursing care begins. A nursing care plan is written based on priorities, expected outcomes, and selected nursing interventions.

Which fact must the nurse keep in mind when creating a nursing care plan to meet the requirements of agencies such as the joint commission, nursing home regulators, and medicare? *

All data relating to clients have to be computerized No changed should be made tot he original nursing care plan The nursing care plan should be written on Kardex files The nursing care plan should be available within 12-24 hours after admission The nursing care plan should be available within 12-24 hours after admission

Why do we use NANDA-1

Analysis of the data reveals that the priorities of nursing care are to address specific problems related to the client's airways. Subjective and objective data has become more understandable, as it has been adapted by all nursing units at the various types of clinical facilities. Most healthcare facilities have their specific version of the current NANDA-I.

Assessment Versus Nursing Diagnosis CMA

Assessment is analyzing data that has been collected in order to arrive at the nursing diagnosis. The nursing diagnosis is a statement about actual or potential problems.

What are Actual/Potential health problems

Assessment is analyzing data that has been collected in order to arrive at the nursing diagnosis. The nursing diagnosis is a statement about actual or potential problems.

A nurse is preparing the nursing diagnosis for a client who has just been admitted to the healthcare facility. The nurse knows that a nursing diagnosis is prepared for which of the following reasons? Select all that apply *

Determine the cause and nature of the disease Identifying the client care problems Stating the prognosis or projected client outcome Directing interventions for the client's priority needs Providing a common platform for the entire healthcare team Directing interventions for the client's priority needs Providing a common platform for the entire healthcare team Identifying the client care problems

A nurse is preparing the goal of the nursing plan. Which of the following points should the nurse keep in mind when formulating the expected outcome statements? Select all that apply *

Ensure that the outcome is client oriented Generalize the statement to include any new outcome The outcome should be within the cline's capacity and abilities The outcome should include whether or not client is feeling better The outcome should be observable and measurable Ensure that the outcome is client oriented The outcome should be within the cline's capacity and abilityes The outcome should be observable and measurable

What are the excepted outcomes KC

Expected outcomes are client oriented, specific, reasonable, and measurable Client-oriented, specific, reasonable, measurable

Writing a Nursing Care Plan The nursing team often holds a nursing care conference to develop a nursing care plan for a client with complex healthcare needs.

Ideally, the entire nursing team formulates the nursing care plan at a meeting called a nursing care conference or team conference (Fig. 35-3). Sometimes one or two nurses may create the care plan. The initial care plans are written to provide instructions and guidelines for the total healthcare team to use for direction and communication.

When caring for a client, a nurse has analyzed data regarding the client's chief concern. Which would the nurse include in the diagnosis? *

Identification of the disease The medical treatment plan Identification of the nursing care problem The cause of the disease Identification of the nursing care problem

**Purposes of the Nursing Diagnosis*

Identifying nursing priorities Directing nursing interventions to meet the client's high-priority needs Directing nursing interventions to meet the client's short-term and long-term goals Directing nursing interventions to meet the client's needs for discharge planning, educational needs, or post-discharge follow-up Communicating in a common language Integrating actions and goals between the nursing professionals and the healthcare team Forming a process to evaluate the benefits of nursing care Providing assistance when determining the client's acuity level or the client's needs for nursing care

A nurse is formulating the diagnostic statement for a client who had a bicycle accident. the healthcare facility when the nurse works uses a three-part diagnostic statement. The client has multiple laceration and bruises on her right arm and is unable to make movements using that arm. Which is an example of a correct diagnostic statement? *

Impaired mobility of right arm R/T multiple lacerations, bruises, and swelling AEB biking accident Impaired mobility of right arm R/T biking accident AEB multiple lacerations, bruises, and swelling Impaired mobility of right arm AEB multiple lacerations, bruises, and swelling Impaired movement of the client's right arm related to a bike accident Impaired mobility of right arm R/T biking accident AEB multiple lacerations, bruises, and swelling

A nurse is preparing a two-part diagnostic statement for a client with renal failure. Which is the most appropriate way of phrasing the problem in the diagnostic statement?

Impaired urinary elimination Chronic renal disorder Problem in voiding Caused by diabetes Chronic renal disorder

A nurse is preparing the care plan for an 8-year-old child with asthma. Which nursing intervention should the nurse perform to help the client meet the treatment goals? *

Interact with client regularly to prevent loneliness Change dosage if cline's condition worsens Set long-term goals to motivate the client Administer corticosteroids as ordered by the healthcare provider Administer corticosteroids as ordered by the healthcare provider

What are Independent nursing actions

It is when a nursing diagnosis is formulated and orders of the physician are not obstructing the staff do there job

Medical vs Nursing diagnosis? KP

Medical diagnoses are concerned with the disease process. Nursing diagnoses are concerned with the client and how the disease affects that person's ability to function.

Nursing Diagnosis and Planning What is the importance of this step?

Nursing diagnoses are concise, clear, client-centered, and client-specific statements. a statement about the actual or potential health concerns of the client that can be managed through independent nursing interventions The nursing diagnosis is a statement about actual or potential problems It is a statement about the actual or potential health concerns of the client that can be managed through independent nursing intervention. It is an approved label that identifies the client's problems in nursing terminology. Data collected during assessment is analyzed to obtain a nursing diagnosis. Client care is planned based on the problems or diagnoses identified.

What does nursing diagnosis identify? KP

Nursing diagnoses help identify nursing priorities and the goals that are established to maintain quality and continuity of care.

Nursing Diagnosis

Nursing diagnoses look at nursing observations and actions and how nursing care can affect the needs of the client, such as an individual's ability to function, to cope with specific problems, or to learn how to care for a problem

What is the statement for nursing diagnosis? KP

Nursing diagnosis is a statement about the client's actual or potential health concerns that can be managed through independent nursing interventions.

Nursing Diagnosis Versus Medical Diagnosis Who determines the medical diagnosis? **Medical Diagnosis**

Physicians arrive at a medical diagnosis by studying the physiologic manifestations of the illness and establishing its cause and nature. Medical diagnosis Identifies the disease a person has or is believed to have Physicians arrive at a medical diagnosis by studying the physiologic manifestations of the illness and establishing its cause and nature. Provides a basis for prognosis and medical treatment decisions Nursing focuses on the person—the individual's response to his or her health

PLANNING CARE

Planning is the development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals. The development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals. **Setting priorities** Nursing diagnoses are ranked in order of importance. Survival, safety, social, and psychological needs

What are the steps in planning the nursing diagnosis KC

Planning is the development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals. Remember the following steps involved in planning: • Setting priorities • Establishing expected outcomes • Selecting nursing interventions • Writing a nursing care plan

Establishing a Nursing Care Plan

Selecting nursing interventions or orders or actions Activities that will most likely produce the desired outcomes (short-term or long-term) Interventions are based on the scientific rationale or reason for using them. Writing a nursing care plan Formulated at a nursing care conference by the entire nursing team; includes nursing diagnoses, expected outcomes, and nursing orders

A nurse is planning the care of a client with severe diarrhea. The nurse knows that which diagnosis result should assume the highest priority? *

Significant water loss Abdominal pain Fever Nausea Significant water loss

Writing a Nursing Care Plan/concept map What resources are needed to create one?

Sometimes it is hnd written These days they are replaced with computerized versions Computerized medical information systems Medical and nursing data is inputted into the system and the nursing data is recorded

Nursing Diagnosis What would the LVN do with the nursing diagnosis?

The LVN's would assist in the planning, implementing and evaluating process of the nursing diagnosis Practical/vocational nurses may not make nursing diagnoses. However, all nurses must understand the meaning of a nursing diagnosis and how it is used to plan and to implement nursing care.

Describe Planning Care

The development of goals to prevent, reduce, or eliminate problems and identify nursing interventions that will assist clients in meeting these goals

Writing the Diagnostic Statement

The diagnostic statement connects problem, etiology, and signs and symptoms. The first two parts of the statement are linked by "related to," sometimes abbreviated R/T. The last two parts are linked by "as evidenced by," sometimes abbreviated AEB. Examples : Ineffective Airway Clearance related to physiologic effects of pneumonia as evidenced by increased sputum, coughing, abnormal breath sounds, tachypnea, and dyspnea.

What is The Diagnostic Statement

The diagnostic statement is a detailed description of the client's statement from the nurse. Problem Etiology Signs and Symptoms This is the format of the statement and the nurse states in an alphabetical format.

Who provides the Nursing Diagnosis???

The duty of the RN is the one who makes the nursing diagnosis One of the duties of the RN is to make the nursing diagnoses.

NANDA-Approved Nursing Diagnosis, why are they important?

The nomenclature, criteria, and categories developed by NANDA are commonly referred to as nursing diagnosis. They have updated terminology and revised categories every years.

What is NANDA-I,

The nomenclature, criteria, and categories developed by NANDA-I are commonly referred to as nursing diagnoses. In the past decades, NANDA-I has provided updated terminology and revised categories every 2 years. Subjective and objective data, which nurses collect to communicate effective nursing care for all types of clients, became more understandable as it was adapted by all nursing units at the various types of clinical facilities. Nursing diagnosis is stated in terms of a problem (a statement approved by NANDA-I), its etiology, and signs and symptoms.

Setting Priorities

The nursing diagnoses associated with these situations are given a higher priority than those not connected to survival needs . The most important, that is, priority needs must be identified and addressed first. On the nursing care plan, nursing diagnoses are prioritized; that is, nursing diagnoses, goals, and actions must be listed in order of importance. Survival needs or imminent life-threatening problems take the highest priority.

Nursing Diagnosis Versus Medical Diagnosis, Why are they both important?

The nursing diagnosis focuses on the person, The medical diagnosis identifies the disease and diagnoses that. Both important in treating the client and medically and holistically

What is the nursing diagnosis KC

The nursing diagnosis is a statement about the client's actual or potential health concerns that can be managed through independent nursing interventions. It contains the following steps: • Establishing significant data • Writing a two- or three-part diagnostic statement

Written or Electronic Nursing Care Plans

The written care plan is kept in several ways. Most hand-written information systems concerning clients have been replaced with computerized versions, also known as computerized medical information systems. Documentation of a nursing care plan is a requirement of agencies such as the Joint Commission, nursing home regulators, and Medicare. An ideal nursing care plan is individualized for each client.

Can there be more than one problem?

There can be, but there needs to be another diagnosis written

Nursing Diagnosis Versus Medical Diagnosis, How are they different?

They are different in that the medical diagnosis is impersonal in many ways. A nursing diagnosis is personal and the person is involved with being a part of the nurses care. Nursing diagnosis A nursing diagnosis is based on nursing observations and data collection about the client. It recognizes the client's ability for self care.T The diagnosis suggests nursing actions and interventions

Writing a Nursing Care Plan/concept map What needs to be included and how is it formatted?

This directs the nursing staff to provide client care, sometime a nursing care conference is called, other times one or two nurses may create the care plan. Provides instructions and guidelines for the total healthcare team to use for direction and communication It includes nursing diagnoses or client problems short and long term objective goals The plan is an ever-changing guide which is updated frequently Within a certain time frame the nursing care plan has to be completed or the hospital will be cited.

A nurse is caring for a client with multiple fractures in his leg and arms. Which should the nurse plan as the client's long-term objective? *

Walk around the room after 2 days Resume playing for college football team Absence of any pain or discomfort after discharge Perform light exercises Resume playing for college football team

Nursing Diagnosis, NANDA-1

Whether or not you make a nursing diagnosis yourself or this step is considered the providence of the RN, all nurses must understand the meaning of a nursing diagnosis and how it is used to plan and to implement nursing care. NANDA-I's 2015-2017 nursing diagnoses are printed on the inside back cover of this textbook. NANDA-I's terminology is the basis for accepted nursing diagnoses and is a required facet of nursing care by multiple accrediting agencies.

Setting Priorities How do you do this

With setting priorities the highest needs are the needs of survival and that is air, water, and food After the physiological needs are met, the priority is safety Then social and psychological love self-esteem companionship fulfillment This follows Maslow's hierarchy of human needs

Does care plans evolve, explain KC

Writing nursing care plans is a process that continually evolves. It is important that the contemporary nurse document according to his or her licensure limitations and within the guidelines of the employing institution.

3. The nurse is assisting the team with planning goals for a client in the long-term care facility. What does the nurse determine is the first step in the planning process?

a. Establish expected outcomes. b. Select the nursing intervention. c. Set priorities. d. Write the care plan.

1. The nurse is caring for a client admitted to the hospital with aspiration pneumonia. What diagnostic label is a priority for this client?

a. Gas Exchange, Impaired b. Aspiration, Risk for c. Mobility, Impaired d. Anxiety

2. Which nursing diagnostic category is the highest priority for an older adult client who is dehydrated, has a 3 × 2 cm wound on the lower extremity, and is anxious about living alone?

a. Social Isolation b. Anxiety c. Skin Integrity, Impaired d. Fluid Volume, Deficient

5. The nursing care team is setting short-term goals for a client with end-stage chronic obstructive pulmonary disease. Which short-term goal is most realistic for this client?

a. The client will ambulate 10 ft with oxygen 2 L/min via nasal cannula without a decrease in oxygen saturation by day 3. b. The client will be able to perform all activities of daily living without dependency on oxygen. c. The client will be able to live independently without assistance. d. The client will be free of shortness of breath.

4. Which priority nursing intervention will assist the client confined to bed with meeting the goal of prevent contractures?

a. The nurse will turn the client every 2 hours. b. The nurse will perform passive range-of-motion exercises every 2 hours. c. The nurse will assist the client with activities of daily living. d. The nurse will encourage fluid intake every 2 hours.

Explain Establishing Expected Outcomes

is a measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care. It may also be called a goal or objective.

What is the nursing diagnosis

is a statement about the actual or potential health concerns of the client that can be managed through independent nursing interventions Nursing diagnoses are concise, clear, client-centered, and client-specific statements.

short-term objective long-term objective

is an expected outcome or goal that a client can reasonably meet in a matter of hours or a few days (e.g., "The client will walk for 20 minutes longer each day for the first 3 postoperative days"). is an outcome that the client ultimately hopes to achieve, but which requires a longer period of time to accomplish. Sometimes, the longer period means that the client will not still be in the healthcare facility when the objective is achieved. Short-term objective helps the client understand an expected outcome that can be met in a matter of hours or a few days Long-term objective may be achieved after the client is discharged from the healthcare facility

Describe medical diagnosis

is obtained from a list of accepted medical problems compiled in a major database known as the International Statistical Classification of Diseases and Related Health Problems.

What is Etiology

is part of the diagnosis statement It is the cause of the problem May be physiologic, pathophysiologic, psychological, sociologic, spiritual or environmental.

What is collaborative problem

means that you will work together with the physician or other healthcare providers. For instance, the physician will prescribe the medication, but the nurse will decide whether or not to administer a PRN (as needed) medication at bedtime.

Establishing Expected Outcomes

measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care. It may also be called a goal or objective. Establishing expected outcomes (goal or objective) An expected outcome is a measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care

Selecting Nursing Interventions Explain the process

nursing interventions are selected because scientific research has demonstrated that these actions are effective. The interventions are based on the scientific rationale or reason for using them. Eg; Offering fluids Positioning the client with the head of the bed elevated for optimum breathing Teaching deep breathing exercise if the problem is respiratory Monitor vital signs Administering Oxygen as ordered by the physician

Nursing interventions

nursing orders or nursing actions, are nursing activities that will most likely produce the desired outcomes (short term or long term). nursing interventions are selected because scientific research has demonstrated that these actions are effective.

problem portion

of a statement describes—clearly and concisely—a health problem a client is having. The use of one of the NANDA-I-approved nursing diagnostic labels communicates the problem to other nurses.

Explain Nursing priorities

priorities of nursing care are to address specific problems related to the client's condition

What is the etiology of the nursing diagnosis

statement is the cause of the problem. Etiology may be physiologic, pathophysiologic, psychological, sociologic, spiritual, or environmental.

Problem, explain How do you identify the problem

the problem describes a health problem the client is having

Signs and symptoms of the nursing diagnosis

third part of the diagnostic statement summarizes these data. You may need to include several signs and symptoms.

Remember these facts about a medical diagnosis:

• A medical diagnosis identifies the disease a person has or is believed to have. • Physicians arrive at a medical diagnosis by studying the physiologic manifestations of the illness and establishing its cause and nature. • A medical diagnosis provides a basis for prognosis (projected client outcome) and medical treatment decisions.

Remember these general concepts relating to the nursing diagnosis:

• A nursing diagnosis is based on nursing observations and data collection. • A nursing diagnosis suggests nursing actions or nursing interventions. • A nursing diagnosis recognizes the client's ability for self-care, to cope with specific problems, or to respond to existing or potential conditions.

three compartments of the diagnostic statement for the purpose of definition and demonstration:

• A three-part diagnostic statement consists of the problem, etiology, and signs and symptoms. • Sample Nursing Diagnostic Statement. Airway clearance is ineffective // related to excessive mucus production // as evidenced (manifested) by shortness of breath on exertion. • A two-part diagnostic statement consists of the problem and signs and symptoms. • Sample Nursing Diagnostic Statement. Airway clearance // is ineffective as evidenced (manifested) by shortness of breath on exertion.

An expected outcome has the following characteristics:

• Client-oriented: The client, not the nurse, is expected to meet this outcome. For instance, "the client will walk around the room at least once per shift." • Specific: Everyone, including the client, knows what is to occur. For instance, "the client will walk up and down the hall for 5 minutes." • Reasonable: The outcome should be within the client's capacity and abilities, considering the confines of his or her condition. For example, if the client is having trouble breathing, walking may be limited to trips to the bathroom. • Measurable: The behavior can be observed and measured. For example, nursing staff can observe a client walking, or the client can state that he or she walked for 5 minutes.

Examples of Verbs Used in Expected Outcome Statements

• Cough • Demonstrate • Describe • Discuss • Express • Has a decrease in • Has an absence of • Has an increase in • Identify • List • Perform • Relate • Share • Sit • Stand • State • Use • Verbalize • Walk

The nursing diagnosis serves the following specific purposes:

• Identifying nursing priorities • Directing nursing interventions to meet the client's high-priority needs • Directing nursing interventions to meet the client's short-term and long-term goals • Directing nursing interventions to meet the client's needs for discharge planning, educational needs, or post-discharge follow-up • Communicating in a common language • Integrating actions and goals between the nursing professionals and the healthcare team • Forming a process to evaluate the benefits of nursing care • Providing assistance when determining the client's acuity level or the client's needs for nursing care

To achieve this outcome, you would select nursing interventions such as the following examples:

• Offering fluids frequently • Positioning the woman with the head of the bed elevated for optimum breathing • Teaching the woman deep-breathing exercises • Monitoring vital signs frequently • Encouraging correct use of the incentive spirometer • Administering oxygen as ordered by the physician • Ensuring that Respiratory Therapy is administering nebulizer treatments as ordered

The three-part nursing diagnostic statement consists of the following components:

• Problem: General label (e.g., airway clearance, ineffective). Notice that the nursing diagnosis is written alphabetically with the descriptive noun (airway clearance) followed by a comma, followed by the specific problem of airway clearance (ineffective). • Etiology: Specific, related factors such as excessive mucus or foreign-body obstruction. Note that the etiology is obtained from a nursing observation (excessive mucus). • Signs and symptoms: Specific, defining characteristics (signs or symptoms) written in the following format: as evidenced by (AEB) or as manifested by objective or subjective data such as shortness of breath on exertion, or abnormal lung sounds (crackles, wheezes, rhonchi), or ineffective cough. Note that the signs and symptoms are specific events or issues that have developed from the basic etiology.