NURSING FOUNDATIONS I (N10) STUDY GUIDE THE NURSING PROCESS 1 (Part 2 .

1y ago
26 Views
8 Downloads
993.96 KB
17 Pages
Last View : Today
Last Download : 2m ago
Upload by : Philip Renner
Transcription

University of the Philippines ManilaTHE HEALTH SCIENCES CENTERCOLLEGE OF NURSINGWorld Health Organization Collaborating Center for Nursing Leadership and DevelopmentCommission on Higher Education Center of ExcellenceSotejo Hall, Pedro Gil St., Ermita, ManilaTel.: (632)523-1472 / Telefax: (632)523-1485NURSING FOUNDATIONS I (N10)STUDY GUIDETHE NURSING PROCESS 1 (Part 2) – Nursing DiagnosisIntroductionHello students!The demand for high quality, safe and effective nursing care increases particularly with growing newchallenges and issues related to individual or community health care. Faced with these challenges,the nursing profession ensures through education, research and practice that nurses are competentto respond to this demand and that future nurses (those enrolled in the BSN program) receive theneeded preparation to equip themselves to assume the duties and responsibilities of a competentand qualified professional nurse.Since its formal introduction in the 1960’s, the nursing process has remained a very importantframework and tool for both students and nurses to help ensure a consistent and strategic approachto client care in both hospital and community settings (Ead, 2019). The nursing process is describedas a deliberate activity in which the practice of nursing is approached in an orderly, systematicmanner, in a dynamic, continuous method to assist the client to achieve and maintain health, or torecover from illness. It provides a scientific approach and basis for the nurse’s activities in providingclient care in a safe and effective manner.The outlined content will guide you through the topics in this module. The activities (both offline andonline) will facilitate assimilation of the content in terms of knowledge, application and appreciationof the different phases of the nursing process in preparation for both simulated and actual applicationin client care. The practice sessions in the skills lab section will provide opportunities to improveyour application of the module content.Learning OutcomesAt the end of the module, you should be able to:1. Identify the major characteristics of the nursing process.2. Describe the phases of the nursing process and the purpose of each phase.3. Identify the major tasks or activities associated with each phase of the nursing process.4. Differentiate between the nursing process and the medical model.5. Differentiate among the various frameworks used for nursing assessment, the types ofassessment, types of data, and the methods of data collection6. Review the legal basis for documenting data.7. Differentiate nursing diagnosis according to types8. Identify the components of a nursing diagnosis9. Formulate a correct nursing diagnosis following the steps in the diagnostic process, theprescribed format and using the NANDA taxonomy.N-10, Sem2, AY 2021-20221

Concept OutlineThis is Part 2 of the Study GuideThe nursing process: DiagnosingA diagnosis is a statement or conclusion regarding the nature of aphenomenon. Generally, it refers to the science and art ofidentifying problems or conditions. The term is used acrossdifferent fields of knowledge in applying the problem-solvingapproach. In the health profession such as in medicine and innursing, the phenomenon in question is the health condition of theclient. Nursing diagnosis is defined as a clinical judgment aboutthe client’s responses to actual and potential health problemsor life processes.Definition and purpose of nursing diagnosis (NANDA-I)North American Nursing Diagnosis Association Taxonomy (NANDA – I) organizing principles.The purpose of the NANDA International organization is to define, refine, and promote a taxonomyof nursing diagnostic terminology (Herdman, Kamitsuru, & North American Nursing DiagnosisAssociation, 2018). Nursing diagnosis provides a standardized language in which the nurse canbase nursing actions. Thus, it provides the basis for selecting independent nursing interventions toachieve outcomes for which the nurse is accountable.Characteristics and purpose of a nursing diagnosis.The purposes of nursing diagnosis are tocommunicate the health care needs of individuals, families or communities among members of thehealth care team and within the health care delivery system; to facilitate individualized care of theclient, family, or community; and to empower the profession.From the nurses’ perspective, NANDA diagnoses help strengthen a nurse’s awareness, professionalrole, and professional abilities. It is not only beneficial for clients but for nurses as well. In addition,a nursing diagnosis is “a judgment based on a comprehensive nursing assessment.” Thisemphasizes the importance of a complete and correct assessment, thus, linking nursing diagnosisto nursing assessment.Just as nursing process is different from the medical model, thereexists a difference among nursing diagnosis, medical diagnosisand collaborative diagnosis. Try analyzing this diagram.Deepening Your UnderstandingInitially, it is not easy to differentiate these types of diagnoses. For more detailed examples,read or study Table 12-3, page 178 in Kozier’s Fundamentals of Nursing.Berman, A., Snyder, S., & and Frandsen, G. (2016). Kozier & Erb's Fundamentals ofNurisng: Concepts, Process, and Practice 10th ed., New Jersey: Pearson Education,Inc.N-10, Sem2, AY 2021-20222

You can also watch this short video.Medical vs. Nursing Diagnosis and Collaborative Problems: Know the difference andconnectionMedical diagnosis – refers to the clinical judgment by the physician that identifies or determines aspecific disease, condition, or pathologic state.Nursing diagnosis – refers to the clinical judgement by the professional nurse that identifies humanresponses (actual, risk, wellness or syndrome) of clients (individual, family, community, specialpopulations) to a health state, problem or condition.Collaborative problems – addressing these problems is shared between the physician (treatments)and nurse (monitoring and preventing)Then complete the Self-Assessment Activity below.Activity 1Given the following list, mark the appropriate type or category of diagnosisNDx Nursing DiagnosisMDx Medical DiagnosisColabDx Collaborative DiagnosisExamplesCongestive Heart FailureDeficient Fluid VolumeFocus on health promotion, disease prevention, comfortDisturbed Body ImagePotential complication of head injury: increasedintracranial pressureConcerned about disease and pathologyNDxMDxColabDxRemember: a nursing diagnosis focuses on the human responses of theindividual, family, or community to the identified health problems or conditions.Despite the professional distinction between nursing, medicine and other healthprofessions, it is clear that a lot of collaborative work goes into patient/client care. Thus, inaddition to nursing diagnoses that nurses can independently address, there are healthproblems or patient/client health responses that nurses address in collaboration with othermembers of the health team.The bifocal clinical practice model by Linda Carpenito (1985) identifies healthresponses as either nursing diagnoses or collaborative problems. Together, nursingdiagnoses and collaborative problems represent the range of conditions that necessitateN-10, Sem2, AY 2021-20223

nursing care. The major assumptions in the bifocal clinical practice model are shown in thediagram/image below.Classification of Nursing DiagnosesThe current approved nursing diagnoses are organized in 13categories (called domains) which align with the 11 Gordon'sFunctional Health Patterns (Gordon, 1982).Components of a NANDA Nursing Diagnosis: definition and examples1. Nursing diagnostic label: usually contains two parts: (1) descriptor or modifier and (2) focus ofthe diagnosis or the key concept of the diagnosis. Although some diagnosis may only haveone word, e.g., Constipation.Part of a Nursing Diagnostic LabelFrom: Nursing Diagnoses Definitions and Classification2.Defining characteristics: are observable cues/inferences that cluster as manifestations of adiagnosis (e.g., signs [objective cues] or symptoms [subjective cues]). These provide supportto the nursing diagnosis.3.Etiology: this describes the possible reasons for the problem or the conditions in which itdeveloped. Etiologies guide the choice of appropriate nursing interventions.a. Related factors – these are circumstances, facts, or influences that contribute to theproblem (not necessarily a direct cause of the problem)b. Risk factors – these are influences that increase the vulnerability of an individual,family, group, or community to an unhealthy event (e.g., environmental,psychological, genetic).Activity 2: WordscapeFamiliarization with common terminologies facilitate learning and application of these terms inpractice. Work on the following exercise and stimulate those neural conduits.N-10, Sem2, AY 2021-20224

DescriptionTermRelated factors that contribute or that haveinfluenced the change in health statusVariables that indicate that increased likelihood thata problem could ariseA cluster of signs and symptoms that indicate thepresence of a particular diagnostic labelA descriptor that qualifies the term or condition.A health patternA classification system or set of categoriesarranged based on a single principle or set ofprinciplesHuman responses to health conditionsTaxonomyDefining characteristicsCollaborative problemRisk factorsEtiologySyndromeModifierNursing diagnosisActivity-exerciseTypes of nursing diagnosis according to status of client responseThere are four types of nursing diagnoses, according to client’s response:Actual diagnosis - describes human responses to health conditions/life processes that exist in anindividual, family, or community. It is supported by defining characteristics (manifestations, signs,and symptoms) that cluster in patterns of related cues or inferences” (NANDA-I, 2009). These arecurrent and problem-focused nursing diagnoses.E.g., Acute Pain related to decreased myocardial flow as evidenced by grimacing, expression ofpain, guarding behaviorAcute Pain diagnostic labeldecreased myocardial flow etiology or related factorgrimacing, expression of pain, guarding behavior defining characteristics (objective andsubjective cues or signs and symptoms)Health promotion diagnosis - A clinical judgment concerning motivation and desire to increasewell-being and to actualize health potential. These responses are expressed by a readiness toenhance specific health behaviors, and can be used in any health state.E.g.,Readiness for Enhanced Spiritual Well BeingReadiness for Enhanced Family Processes-Note that the label begins with the phrase, “Readiness for Enhanced,” then followed bythe higher-level wellness desiredN-10, Sem2, AY 2021-20225

Risk nursing diagnosis - “human responses to health conditions/life processes that maydevelop in a vulnerable individual, family, or community. It is supported by risk factors thatcontribute to increased vulnerability” (NANDA-I, 2009)E.g., Risk for Falls as evidenced by muscle weakness-Risk nursing diagnoses have not etiology or related factors, only cues that suggest thepresence of the risk in the health condition.Syndrome diagnosis - a clinical judgment concerning with a cluster of problem or risk nursingdiagnoses that are predicted to present because of a certain situation or event.E.g., Chronic Pain Syndrome- Only the diagnostic label is included, no etiology or defining characteristics.Some references include another type of nursing diagnosis:Possible nursing diagnoses – are statements describing a suspected problem for whichadditional data are needed to confirm or rule out the suspected problem.E.g., Possible Chronic Low Self-Esteem- The qualifier “possible” is placed before the diagnostic labelDeepening Your UnderstandingRead Chapter 3, Types and Components of Nursing Diagnoses, pp. 11 – 18 (PDF), of theNANDA Nursing Diagnosis Classification.Herdman, H., Kamitsuru, S., & North American Nursing Diagnosis Association. (2018).NANDA International, Inc. nursing diagnoses : definitions & classification 2018-2020.New York: NANDA International, IncThe article provides a more detailed discussion on the types of nursing diagnoses. This isuploaded in the N10 VLE course site.The nursing diagnostic processThe diagnostic process involves critical thinking skills and synthesis. Once you have the data afterAssessment of the client, these has to be transformed into information.1. Analyzing data – these involves: compare data against standards or norms in order to identifysignificant cues, cluster the cues and look for patterns, identify gaps and inconsistencies.2. Identifying health problems, risks and strengths – this is done by the nurse and client together.If it’s a problem, is it nursing problem, collaborative or a medical problem.3. Formulating diagnostic statements – the nursing diagnostic statement has basic structures andwill depend on the type of nursing diagnosis (actual, risk, health promotion or a syndrome)N-10, Sem2, AY 2021-20226

3.1 Actual or Problem-focused Nursing Diagnosis (3-part statement or PES)Problem (P): the client’s response (NANDA label)Etiology (E): contributing or related factors; probable cause of the responseSigns and Symptoms (S): defining characteristics manifested by client (based onassessment cues)NANDA label related to (etiology or relatedfactors) as evidenced by (defining characteristicsor significant cues)E.g., Impaired Skin Integrity related to immobility secondary to pain as evidencedby 2-cm erythematous sacral lesion3.2 Risk Nursing Diagnosis (2-part statement or PE)Problem (P): the client’s response (NANDA label)Etiology (E): contributing or related factors; probable cause of the responseRisk for (NANDA label) related to(etiology or related factors)E.g., Risk for Infection related to incision and loss of protective skin barrierHealth Promotion Diagnosis (2-part statement or PS)Problem (P): the client’s response (NANDA label)Signs and Symptoms (S): the client’s expressed desire to enhanceReadiness for Enhanced (NANDA label) asevidenced by (the client’sexpressed desire or verbalization to enhance or improve)E.g., Readiness for Enhanced Health Promotion as evidenced by expressed desire“gusto kong malaman ang tungkol sa tamang ehersisyo na kaya ko.”Syndrome Nursing Diagnosis (1-part statement or P)Problem (P): the client’s response (NANDA label)No “related to” is needed with a syndrome diagnosis because the label includes theetiologyE.g., Unilateral Neglect Syndrome Impairment in sensory and motor response, mental representation, andspecial attention of the body, and the corresponding environmentcharacterized by inattention to one side and over-attention to theopposite side. Left-side neglect is more severe and persistent than rightside neglectN-10, Sem2, AY 2021-20227

Syndrome diagnoses encompass a cluster of nursing diagnoses, in thisexample: Self-Care Deficit, Anxiety, and Risk for Injury3.3 One-part statement (P)Problem (P): the client’s response (NANDA label)E.g.,Health Promotion DiagnosisReadiness for Enhanced ParentingSyndrome Nursing DiagnosisBattered Woman SyndromeDeepening Your UnderstandingYou can also read further and look at examples in this open educational resource, OpenResources for Nursing (OPEN RN), 4.4 Diagnosis, Nursing Fundamentals. This can beaccessed in: apter/2-4-diagnosis/Guidelines in writing nursing diagnostic statementsAvoiding Errors in Diagnostic ReasoningError can occur at anytime during the diagnostic process: data collection, data interpretation, anddata clustering.Deepening Your UnderstandingRead Chapter 12, Diagnosis, Table 12-6 p.185, Guidelines for Writing a NursingDiagnostic StatementBerman, A., Snyder, S., & and Frandsen, G. (2016). Stress and Coping. In Kozier &Erb's Fundamentals of Nurisng: Concepts, Process, and Practice (10th ed., pp. 972984). New Jersey: Pearson Education, Inc.The table summarizes guidelines and examples of errors in diagnostic statements.In addition to these, what specific actions can the nurse do to minimize these errors?Activity 3 – Chat Time: Learning LanguagesLanguage is defined as the principal method of human communication, consisting of wordsused in a structured and conventional way and conveyed by speech, writing, or gesture. TheNANDA nursing diagnoses is considered to provide a common language among nurses intheir professional practice.N-10, Sem2, AY 2021-20228

Answer the following question: What are the benefits of a uniform language in Nursing?Discuss and post your answers in the Discussion Forum in the N10 VLE course site.Comment on 1 or 2 of your groupmates’ posts. Cite your references using the APA format.SKILLS LABORATORY GUIDEFor this session, work on the Worksheets for Nursing Diagnosis. These are designed to developbeginning competency in the formulation of correct nursing diagnostic statements and theidentification of possible nursing diagnosis based on nursing history and physical examinationdata. It is recommended that the exercises be carried out in the proper sequence to maximizelearning.Worksheet 1: The Nursing ProcessWorksheet 2: Differentiating among Types of Nursing Diagnoses and Collaborative ProblemsWorksheet 3: Writing the Diagnostic Statement: Determining ErrorsThese exercises are uploaded separately in the course site and has to be accomplishedindividually. Post or upload the worksheets in the submission bin indicated in the N10 course site.The exercises will be discussed during the group plenary session.N-10, Sem2, AY 2021-20229

ReferencesBerman, A., Snyder, S., & and Frandsen, G. (2016). Stress and Coping. In Kozier & Erb'sFundamentals of Nurisng: Concepts, Process, and Practice (10th ed., pp. 972-984). NewJersey: Pearson Education, Inc.Doenges, M. E., Moorhouse, M. F., & Murrey, A. C. (2019). Nursing diagnosis manual: planning,individualizing, and documenting client care (6th ed.). F.A. Davis Company.Doenges, M. E., Moorhouse, M. F., & Murrey, A. C. (2014). Nursing care plans: guidelines forindividualizing client care across the life span. Edition 9. Philadelphia, PA: F.A. DavisCompanyEad, H. (2019, September 16). Application of the nursing process in a complex health careenvironment. Retrieved from Canadian-nurse.com: ess-in-acomplex-health-care-environmentHerdman, H., Kamitsuru, S., & North American Nursing Diagnosis Association. (2018). NANDAInternational, Inc. nursing diagnoses : definitions & classification 2018-2020. New York:NANDA International, Inc.Prepared by:Asst. Prof. Bettina D. Evio, RN, MANN-11 Course Coordinatorbdevio@up.edu.phN-10, Sem2, AY 2021-202210

Next slideN-10, Sem2, AY 2021-202211

Back to topN-10, Sem2, AY 2021-202212

Decision tree for differentiating among nursing diagnoses, collaborative problems, and medicalNext slideN-10, Sem2, AY 2021-202213

Back to topN-10, Sem2, AY 2021-202214

Back to topBifocal clinical nursing model. ( 1985 by Lynda Juall Carpenito.)N-10, Sem2, AY 2021-202215

Back to topN-10, Sem2, AY 2021-202216

N-10, Sem2, AY 2021-202217

Definition and purpose of nursing diagnosis (NANDA-I) North American Nursing Diagnosis Association Taxonomy (NANDA -I) organizing principles. The purpose of the NANDA International organization is to define, refine, and promote a taxonomy of nursing diagnostic terminology (Herdman, Kamitsuru, & North American Nursing Diagnosis Association, 2018).

Related Documents:

N10-006 Exam Dumps N10-006 Exam Questions N10-006 VCE Dumps N10-006 PDF Dumps Back to the Source of this PDF and Get More Free Braindumps -- www.comptiadump.com A. CAT5e cable B. Coax cable C. Fiber Optic cable D. CAT6 cable Answer: C QUESTION 1323 Joe, and administrator, is setting up three

N10-006 Exam Dumps N10-006 Exam Questions N10-006 VCE Dumps N10-006 PDF Dumps . bandwidth to reach performance objectives, and predict future capacity requirements. Changes in bandwidt

Texts of Wow Rosh Hashana II 5780 - Congregation Shearith Israel, Atlanta Georgia Wow ׳ג ׳א:׳א תישארב (א) ׃ץרֶָֽאָּהָּ תאֵֵ֥וְּ םִימִַׁ֖שַָּה תאֵֵ֥ םיקִִ֑לֹאֱ ארָָּ֣ Îָּ תישִִׁ֖ארֵ Îְּ(ב) חַורְָּ֣ו ם

CompTIA Network N10-006 course page online (and on your mobile device). 22. Printers Part 3 Maintenance and Troubleshooting 32 min. EXTRA MILE EXTRA MILE CompTIA Network N10-006 *Keep in mind that you’ve just started the training so you probably won’t ace the exam. This is just to establish a benchmark for future practice exam performance.File Size: 277KB

N10-007 - CompTIA Network pg. 2 Introduction to N10-007 Exam on CompTIA Network Use this quick start guide to collect all the information about CompTIA Network (N10-007) Certification exam. This study guide provides a list of objectives and resources that will help you prepare for items on the

Nursing 214 Intro to Medical Surgical Nursing 1 (9 weeks) 4 Nursing 571 Foundations of Nursing Skills Lab 0.5 MAJOR REQUIREMENTS (2nd Semester) Nursing 222 Nursing Care of Children & Families (9 weeks) 3.5 Nursing 224 Beginning Medical Surgical Nursing II 5 Nursing 226 N

for Nursing (69) Delaware Board of Nursing (12) District of Columbia Board of Nursing (75) Florida Board of Nursing (70) Georgia Board of Nursing (31) Guam Board of Nurse Examiners (87) Hawaii Board of Nursing (37) Idaho Board of Nursing (82) Illinois Board of Nursing (49) Indiana State Board of Nursing (48) Iowa Board of Nursing (60)

The Adventure Tourism Development Index (ATDI) is a joint initiative of The George Washington University and The Adventure Travel Trade Association (ATTA). The ATDI offers a ranking of countries around the world based on principles of sustainable adventure tourism