3/24/2022 2.

Risk nursing diagnosis

- clinical judgment that a problem does not exist,
NURSING DIAGNOSIS but the presence of risk factors indicate that a
problem is likely to develop unless nurses
intervene
DIAGNOSING
● Interpret assessment data
E.g.
● Identify client strengths & problems

Risk for impaired skin integrity r/t immobility secondary

1. Data Analysis
to fractured hip
2. Problem Identification
3. Formulation of Nursing Diagnosis
3. Wellness diagnosis
- describes human responses to levels of
wellness in an individual, family or community
Nursing Diagnosis that have readiness for enhancement
● actual or potential health problem that
independent nursing intervention can prevent or E.g.
resolve
● client's problem statement consisting of the Readiness for enhanced spiritual well-being
diagnostic label & etiology
● describes a continuum of health status; Readiness for Enhanced Family Coping
deviations from health, presence of risk factors
and areas of enhanced personal growth
4. Possible Nursing Diagnosis
TYPES OF NURSING DIAGNOSES
1. Actual nursing diagnosis - Statements describing a suspected problem for
2. RISK nursing diagnosis which additional data are needed
3. Wellness diagnosis
4. Possible nursing diagnosis E.g.
5. Syndrome nursing diagnosis
Possible self-care deficit related to impaired ability to
1. Actual nursing diagnosis use left hand secondary to presence of intravenous
- client problem that is present at the time of the therapy.
nursing assessment
- problem that has been validated by the 5. Syndrome nursing diagnosis
presence of major defining characteristics - comprises a cluster of actual or risk nursing
diagnoses that are predicted to be present
E.g. because of a certain situation or event

Ineffective airway clearance r/t excessive and E.g.

tenacious secretions
Rape trauma syndrome
Imbalanced nutrition: more than body requirements r/t
excessive intake in relation to metabolic needs Post trauma syndrome
Components of Nursing Diagnosis
1. Problem (diagnostic label) and definition
- Problem Statement describes the client's health
problem/status or response
- diagnostic labels
- specific; when the word SPECIFY
follows a NANDA label, the nurse states
the area in which the problem occurs
2. Etiology
- (related factors & risk factors)
- identifies one or more probable causes of a
health problem, give direction to the required
nursing therapy & enables the nurse to
individualize the client's care
3. Defining characteristics
- clusters of signs & symptoms that indicate the
presence of a particular diagnostic label
STEPS OF DIAGNOSTIC PROCESS
1. Analyzing Data
a. Comparing data with standards
- identify significant cues
- Nurses draw on knowledge and
experiences to compare client data to
standards and norms and identify
significant & relevant cues.
b. Clustering cues
- process of determining the relatedness
of facts and determining whether any
patterns are present, whether the data
represents isolated incidents and the
data are significant
- grouping of data/cues that point to the
existence of a health problem
c. Identifying gaps and inconsistencies of
data
- include final check to ensure that data
are complete and correct
- Skillful assessment minimizes gaps and
inconsistencies of data
- possible sources of inconsistencies:
measurement error, expectations and
inconsistent or unreliable reports
2. Identifying Health Problems, Risks, &
Strengths
- identify problems that support tentative actual,
risk and possible diagnoses
- establish the client's strengths, resources and
abilities to cope
- must determine whether the client's problem is
a nursing diagnosis or a collaborative problem
3/25/2022
STEPS OF DIAGNOSTIC PROCESS
Formulating Diagnostic Statement
a. basic two-part statement
b. basic three-part statement
c. one-part statement
1. Basic Two-part Statement
● Problem (P)
○ statement of the client's health state or
response
○ diagnostic label
● Etiology (E)
○ factors contributing to or probable
causes of the responses
Problem + related to + etiology
E.g.
Hyperthermia r/t pyrogenic substances in blood
severe anxiety r/t threat to physiologic integrity:
possible CA diagnosis
 2. Basic three-part statement 4. Using secondary to to divide the etiology into two
● Problem (P) parts
○ statement of the client's health state or
response E.g.
○ diagnostic label Risk for impaired skin integrity r/t decreased peripheral
● Etiology (E) circulation secondary to diabetes
○ factors contributing to or probable
causes of the responses 5. Adding a second part to the general response or
NANDA label to make it more precise
● Signs and Symptoms (S)
○ Defining Characters manifested by the E.g.
client. Impaired Skin Integrity (left lateral ankle) r/t decreased
E.g. peripheral circulation
Situational low self-esteem r/t feelings of rejection by
husband as manifested by hypersensitivity to criticism
Nursing Diagnosis Medical Diagnosis
Altered dentition related to chronic use of tobacco as
manifested by tooth enamel discoloration statement of nursing made by physician
judgment
3. One-part statements
refers to a condition that refers to a condition that
● consist of a NANDA label only nurses by virtue of their only physician can treat
● wellness diagnoses & syndrome diagnoses education, experience,
and expertise are
E.g. licensed to treat
Rape-trauma syndrome
describes human refers to disease
Readiness for enhanced parenting
response, a client's processes
physical, socio-cultural,
Variations of Basic Format psychological & spiritual
responses to an illness
1. Writing unknown etiology when defining or a health problem
characteristics are present but the nurse does nursing actions - nursing actions -
not know the cause or contributing factors independen primarily dependent
2. Using complex factors when there are too many
etiologic factors
3. Using the word possible, to describe either the
problem or the etiology require more data about
the client's problem or etiology

E.g.
Possible low self esteem r/t loss of job and
rejection by family
Guidelines for Writing a Nursing Diagnosis
1. State in terms of a problem, not a need
E.g.
Fluid replacement /r/t fever
Deficient fluid volume r/t fever
2. Word the statement so that it is legally
advisable.
E.g.
Impaired skin integrity r/t improper positioning
Impaired Skin Integrity r/t immobility
3. Use nonjudgmental statements.
E.g.
X Spiritual distress r/t strict rules necessitating church
attendance
Spiritual distress r/t inability to attend church services
secondary to immobility
4. Make sure that both elements of the statement
do not say the same thing.
E.g.
Impaired skin integrity r/t ulceration of sacral area
Impaired skin integrity r/t immobility
5. Be sure that cause & effect are correctly stated.
E.g.
X Pain rit severe headache
Pain: severe headache r/t fear of demands of student
life
6. Word the diagnosis specifically and precisely to
provide direction for planning nursing
intervention.
E.g.
Impaired oral mucous membrane r/t noxious agent
Impaired oral mucous membrane r/t decreased
salivation secondary to radiation of neck
7. Use nursing terminology rather than medical
terminology to describe the client's response.
E.g.
X Risk for pneumonia
Risk for ineffective airway clearance r/t accumulation
of secretions in lungs
8. Use nursing terminology rather than medical
terminology to describe the probable cause of
the client's response.
E.g.
Risk for ineffective airway clearance r/t emphysema
Risk for ineffective airway clearance r/t accumulation
of secretions in lungs
Planning
Planning
- Developing a plan of care to assist the patient
to an optimum or improved level of functioning
in the problem areas identified in the nursing
diagnosis
Nurse works with the client to set goals/ outcomes to
prevent, correct or relieve health problems and
determine appropriate nursing interventions
Planning Process
1. Setting priorities
2. Establishing client goals/desired outcomes
3. Selecting nursing interventions
4. Writing individualized parsing interventions on
care plan
1. Setting priorities
- Determine which problems identified during the
assessment phase are in need of IMMEDIATE
attention and which problems may be dealt with
at a later time
Nursing diagnoses can be grouped as: Guidelines for Writing Goals
1. HIGH PRIORITY ● S - Specific
2. MEDIUM PRIORITY ● M-Measurable
3. LOW PRIORITY ● A - Attainable
● R - realistic
Nursing diagnoses can be grouped as: ● T - Time bounded
1. Maslow’s Hierarchy of Needs
2. ABC’s
3. Life Preservation 1. SPECIFIC GOAL

Consider: Nursing Dx: Self-care deficit r/t presence of cast in the

1. The most important problems to the patient left leg self
2. Effect of potential problems
3. Costs, resources available, personnel, time Goal: The patient will be able to perform bathing with
needed assistance of the nurse within the week.

2. Establishing client goals/desired outcomes 2. MEASURABLE GOALS

- describes a change in the patient's health The patient will be able to ambulate by tomorrow.
status or functioning
- desired outcome of nursing care that which you The patient will be able to ambulate with assistance
hope to achieve with your patient from bed to bathroom by tomorrow.
- expected outcome, predicted outcome,
outcome criterion, objective
3. ATTAINABLE AND REALISTIC GOALS
Goals can be:
The patient will be able to drink fluid amounting to
1. Short term
1200 mL within an 8-hour period.
2. Long term

The patient will be able to drink fluid amounting to

Long term and Short term goals 1200 mL within an hour.

Situation: Frail elderly man with a pressure ulcer on his 4. TIME BOUNDED
sacral area
The patient will be able to bathe with assistance within
Long term goal the period of hospitalization.
The patient's sacral area will exhibit no evidence of a
pressure ulcer in the next 2 weeks The patient will be able to ambulate with assistance
from bed to bathroom by tomorrow.
Short term goal
At the end of the 3 days, the patient's pressure ulcer
has decreased in size by 1 mm.
Guidelines for Writing Goals
- The goal is congruent with and supportive of
other therapies.
DOCTOR'S ORDER: CBR with BRP
Patient will ambulate along the corridors today
Patient will ambulate from bed to bathroom today.
- Whenever possible, the goal is important and
valued by the patient, the nurses, and the
physician.
- Whenever possible, the goal is important and
valued by the patient, the nurses, and the
physician.
- Derive each goal from only one nursing
diagnosis.
- Keep the goal short
Goal Statement
= patient's behavior
+criteria of performance
+ time
conditions (if needed)
Examples of Goal Statements
1. Nursing Diagnosis:
- Imbalanced Nutrition: more than body
requirements r/t poor eating habits
Goals:
- Will identify 10 low-calorie snacks he is
willing to try within 3 days
- Will lose 20 lbs. within 12 wks.
- Will reach a target wt. of 122 lbs. by
June. 20, 2022
2. Nursing Diagnosis
- Impaired physical mobility r/t general
muscle weakness
Goal:
- Before discharge, the patient will
ambulate the length of the hallway
independently.
3. Nursing Diagnosis:
- Hyperthermia r/t infectious process
Goal:
- Body temperature will decrease from
38.5°C to 37.5°C within 2 hours.
4. Nursing Diagnosis
- acute pain r/t post surgical incision
Goal
- verbalization of decreased pair from a scale of
2 to 1(where 3-severe, 2-moderate, 1-mild, 0=no
pain) within the shift
5. Nursing Diagnosis
- risk for infection r/t presence of open wound on
the right forearm
Goal
- will not manifest any sign of infection in the
next 7 days of hospitalization
Variables that Influence Goal Outcome
Achievement
a. patient variables
● patient's changing ability
● willingness to participate in the plan of care
● previous responses to nursing interventions
● progress towards goal
b. nurse variables
● nurse's level of expertise and creativity
● willingness to provide care
● available time
c. resources
● adequacy of staff, equipment and supplies
● financial resources of the patient
● adequacy of community-based resources
d. ethical and legal guides to practice
● laws and regulations
● ethical dimensions of clinical practice