Professional Documents
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nursing diagnosis
Nursing process
An organizing framework for professional
nursing practice
Step I – nursing assessment
Step II – making nursing diagnosis
Step III – planning
Step IV – implementation care
Step V – evaluation the nursing care has been
given
Step I: Assessment
Perfoming a thorough holistic nursing
assessment of client
Taking a medical history
Perfoming a physical assessment
Noting diagnostic test results
Step I: Assessment
To elicit as many symptoms as possible, the nurse
should use open-ended rather than yes/no questions.
Examples:
“Describe what you are feeling”
“How long have you been feeling this way?”
“When did the symptoms start?”
“Describe the symptoms”
This type of questions will encourage the client to give
more information about his or her situation.
Listen carefully for cues and record relevant information.
Step II: Nursing Diagnosis
A nursing diagnosis is a clinical judgment
about individual, family, or community
responses to actual or potential health
problems or life processes. Nursing
diagnosis provide the basis for selection of
nursing intervention to achieve outcomes
for which the nurse is accountable
(NANDA, 2003)
Step II: Nursing Diagnosis
A working of nursing diagnosis may have two or
three parts.
The three-part system consists of the nursing
diagnosis, the “related to” statement, and the
defining characteristics.
PES system:
P (problem) - The nursing diagnosis, the label; a concise
term or phrase that represent a pattern of related cues
E (etiology) – “Related to” phrase or etiology; related
cause or contributor to the problem
S (symptoms) –Defining characteristics phrase; symptoms
that the nurse identifted in the assessment
Step II: Nursing Diagnosis
Case study:
A 73-year-old man has been admitted to the
unit with a diagnosis of chronic obstructive
pulmonary disease (COPD). He states that he
has “difficulty breathing when walking short
distances”. He also states that his “heart feels
like it is racing” at the same time. He states
that he is “tired all the time”, and while
talking to you he is comtinually wringing his
hands and looking out the window.
Step II: Nursing Diagnosis
Part 1 (Problem)
Interpretation of information:
“difficulty breathing when walking short
distances”= dyspnea
“heart feels like it is racing”= dysrythmia
“tired all the time”= fatigue
P - Activity intolerance
E – “Related to” imbalance between oxygen
supply and demand
S – Verbal reports of fatique, exertional dyspnea
(“difficulty breathing when walking”), and
dysrythmia (“racing heart ”)
Step III: Planning (outcomes and
interventions)
Consists of writing measurable client outcomes and nursing
intervention to accomplish the outcomes. Before this can be done,
if the client has more than one diagnosis, the priority of the
nursing diagnoses must be determined.
Step III: Planning (outcomes and
interventions)
Outcomes are conceptualized as variable client
states influenced by nursing intervention. Thus
client outcomes represent patient states that vary
and can be measured and compared with a baseline
over time.