Enhancements

CRITICAL THINKING EXERCISE

Since Nursing diagnosis is a reasoning process and focuses on human responses it is
better to understand what are human reactions to an intent or stressors

Human Responses
•  Human Responses are human reactions to an event
or a stressor – goes to cellular to organism levels;
all change in that are human responses
Changes in Example
Body Posture; skin color
Appearance
Body function Inability to move joint, difficulty
swallowing
Symptoms Fever; body aches
Knowledge Knowledge of the basic food groups
Skills Ability to change own dressing
Emotions Anger; sadness
 Diagnostic Label Exercise
•  Problem + Etiology + Signs and Symptoms
NANDA Label + Causation + Defining characteristics
 What is wrong?
•  Myocardial Infarction (medical diagnosis) RT
high fat diet AEB chest pain

•  Fluid Volume deficit RT vomiting __ - no AEB

•  Sleep Pattern Disturbance AEB awakening 3

times per night – no etiology / RT
 Nursing Diagnosis
•  It should strictly follow the Problem + E1ology +
Signs and Symptoms (PES) format.
•  ALERT! Common Misuse: E1ology placed is a Medical
Diagnosis
–  X Acute Pain related to ILLNESS
–  X Hyperthermia related to SEPSIS
 E1ology – the contribu1ng or
influencing factor(s) of the health
concerns
•  Environment: odors, lightning, noises
•  Sociological: language, finances,
•  Support system
•  Spiritual: rituals, prac1ces, beliefs
•  Physiological: hypothermia, fluid deficit/excess
•  Psychological: fear, anxiety, low self-esteem
e.g. Impaired skin integrity related to physical immobiliza1on
(descrip1ve + e1ology)
 Situa1onal Analysis
•  IIR Strategy – Immediate, Intermediate, Root

I – The client verbalized the 3 basic food groups

but was not able to give examples properly and
says that he is not applying it in his diet.
O – Body Built is thin as compared to
height M – Height = 172.72cm, Weight =
50Kg IBW = 65.45Kg
 Situa1onal Analysis
•  IIR Strategy – Immediate, Intermediate, Root
Altered Nutri1on: Less than Body Requirements
related to Imbalanced Diet* as Evidenced by:
Faulty Dietary PaQerns**, Low Salience
on proper nutri1on***

*Immediate Cause; **Intermediate Cause;

***Root Cause
Evaluate the Quality of Your Dx Statement

•  STATEMENT IS CLEAR AND PRECISE

INC: Toile1ng Self Care RT inability to get OOB

w/o help

C: Toile1ng Self Care RT inability to get out of

bed w/o help
Evaluate the Quality of Your Dx Statement
•  STATEMENT IS CONCISE

INC: Self Esteem Disturbance RT longstanding feelings of

failure aggravated by recently being rejected by her
husband as manifested by being hypersensi1ve to
cri1cism sta1ng”…….

C: Self Esteem Disturbance RT complex factors

I – “I don’t know if I can manage myself”
O – Hypersensi1ve to cri1cism, rejects posi1ve
feedback, no eye contact
Evaluate the Quality of Your Dx Statement

•  STATEMENT IS DESCRIPTIVE AND SPECIFIC

INC: Pain RT Fear of addic1on to narco1cs

C: Pain: Severe Headache RT Fear of addic1on to

narco1cs
Evaluate the Quality of Your Dx Statement

•  CAUSE AND EFFECT ARE CORRECTLY STATED

Check this by trying to read your statement backwards,
If cause and effect are correctly stated, the sentence
will make sense.
Dysfunc1onal Grieving RT inability to accept
death of spouse

RB: Inability to accept death of spouse

caused Dysfunc1onal Grieving
Evaluate the Quality of Your Dx Statement

•  AT LEAST ONE SIDE OF STATEMENT IS DOABLE

FOR NURSING
INC: Sensory Percep1on Altera1on (Auditory) RT
Progressive hearing loss secondary to nerve
degenera1on
C: Impaired Social Interac1on RT
embarrassment at the inability to follow
conversa1ons due to progressive hearing loss
Evaluate the Quality of Your Dx Statement

•  STATEMENT IS NON-JUDGMENTAL

INC: Risk for Injury: Falls RT Poor housekeeping

C: Risk for Injury: Falls RT CluQered floors

Evaluate the Quality of Your Dx Statement

•  STATEMENT USES LEGALLY ADVISABLE

LANGUAGE
INC: Impaired Skin Integrity: Pressure Sores RT
not being turned enough frequently

C: Impaired Skin Integrity: Pressure Sores RT

Inability to turn self
Evaluate the Quality of Your Dx Statement

•  PROBLEM SIDE OF STATEMENT CONTAINS

ONLY ONE DX LABEL
INC: Risk for Fluid Volume Deficit and
Cons1pa1on RT inadequate fluid intake

C: Cons1pa1on RT inadequate fluid intake

Evaluate the Quality of Your Dx Statement

•  ETIOLOGY IS NOT MERELY REWORDING OF

THE PROBLEM

INC: Chronic Pain RT headache

C: Chronic Pain (Headache) RT unknown e1ology

 Summary
1.  The nursing diagnosis is NOT the medical
diagnosis.
2.  The nursing diagnosis is NOT the diagnos1c
test.
3.  The nursing diagnosis is NOT the medical or
surgical treatment
 Summary
4.  The nursing diagnosis is NOT the equipment
5.  The nursing diagnosis is NOT a single
diagnos1c label
6.  The nursing diagnosis is NOT a statement of
the nurse’s problem with the client.
 Summary
7.  The nursing diagnosis is NOT the nursing
goal.
8.  The nursing diagnosis is NOT a single
symptom.
THANK YOU FOR LISTENING!