Nursing diagnosis is a crucial step in the nursing process that aids in determining a patient’s health issues, potential hazards, and strengths. It is a systematic approach that allows nurses to create a comprehensive care plan for their patients.
Nursing diagnosis is important in delivering quality patient care, as it gives a framework for developing individualized interventions based on the patient’s particular requirements.
In this article, our team at my homework help will explore some nursing diagnosis examples and case studies that will assist you comprehend the process and the significance of nursing diagnosis in patient treatment.
Table of Contents
Definition Of Nursing Diagnosis
A nursing diagnosis is assessment of a client’s requirements or current or anticipated health issues.
It is based on an analysis of subjective and objective data gathered during a comprehensive health assessment and acts as the foundation for creating a plan of treatment.
Introduction To Nursing Diagnoses
Nursing diagnoses are a crucial element of the nursing process, which is a problem-solving framework used by nurses to give patient-centered care. In order to create a nursing care plan, a nursing diagnosis must be made about the patient’s reaction to present or potential health issues or life processes.
Nursing diagnoses are based on a complete evaluation of the patient’s physical, emotional, psychological, and social needs and are aimed at determining the patient’s actual or potential health issues.
The goal of nursing diagnoses is to direct the nursing care of patients by giving a standardized language for nurses to communicate with each other and other healthcare professionals. They assist to determine the patient’s health problems and strengths, prioritize the nursing interventions, asses the effectiveness of the nursing interventions, and support patient-centered care.
The background of nursing diagnoses can be tracked back to the 1950s, when nurses first start to create their own terminology to describe the patient’s health problems. The concept of nursing diagnoses was first put forth by a nursing theorist by the name of Martha Rogers in the 1970s, and it was later codified by the North American Nursing Diagnostic Association (NANDA) in the 1980s. Today, NANDA is the top organization for the creation and standardization of nursing diagnoses.
Nursing diagnoses distinct from medical diagnoses in that they concentrate on the patient’s reaction to actual or potential health issues rather than the disease or medical condition itself. Medical diagnoses are made based on clinical signs and symptoms, laboratory results, and medical imaging, and are used at determining the illness the disease or medical condition that is causing the patient’s symptoms.
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Types Of Nursing Diagnosis
As a nurse, one of the crucial elements of your clinical practice is making correct nursing diagnoses. Nursing diagnoses are a crucial section of the nursing process and assist guide patient care and treatment plans.
There are three forms of nursing diagnoses that you need to be familiar with: actual, risk, and wellness.
1. Real Nursing Diagnoses
Actual nursing diagnoses are made when a patient is dealing current health problems or issues. These diagnoses are based on the patient’s current signs and symptoms, as well as medical history, lab tests, and other related data. Impaired movement, severe discomfort, and an inadequate respiratory pattern are a few examples of real nursing diagnoses.
2. Risk Nursing Diagnoses
Risk nursing diagnoses are made when a patient is at risk for developing a health problem or concern. These diagnoses are based on the patient’s present health status and risk factors. Examples of risk nursing diagnoses contain risk for falls, risk for infection, and risk for impaired skin integrity.
3. Wellness Nursing Diagnoses
Wellness nursing diagnoses are made when a patient is in good health but needs support to maintain or enhance their health status. These diagnoses center on improving health and preventing illness and are based on the patient’s health objectives. Examples of wellness nursing diagnoses involve readiness for enhanced nutrition, readiness for improved sleep, and readiness for improved coping.
When making nursing diagnoses, it’s crucial to use critical thinking skills and collect all the necessary information to make an appropriate diagnosis. You should also use the Problem, Etiology, and Symptoms (PES) format to write your nursing diagnoses. The concern describes the patient’s health issue, the etiology refers the underlying cause of the problem, and the symptoms describe the patient’s signs and symptoms.
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Sample Nursing Diagnosis Case Studies
Case Study #1
Choose a patient case study that shows the employ of nursing diagnoses in clinical practice. to an article on Nursing diagnosis examples and case study
Case Study #1: Mrs. Smith
Mrs. Smith is a 65-year-old woman who was admitted to the hospital with shortness of breath, chest pain, and fatigue. She has a history of hypertension and type 2 diabetes, and she takes medications to contain these conditions. Upon admission, Mrs. Smith’s vital signs were stable, but she was noted to have crackles in her lungs and decreased oxygen saturation levels. First, pulmonary edema was seen on a chest X-ray.
Nursing Diagnosis
Impaired Gas Exchange relevant to pulmonary edema as evidenced by shortness of breath, chest pain, and lower oxygen saturation levels.
Rationale: Impaired gas exchange brought on by pulmonary edema might result in hypoxemia and respiratory discomfort. Nursing interventions are necessary to increase oxygenation and avoid complications such as respiratory failure.
Nursing Interventions
- Administer supplemental oxygen as directed to increase oxygenation.
- Keep an eye oxygen saturation levels and respiratory rate to assess for enhancement or deterioration in gas exchange.
- Administer diuretics as directed to lessen pulmonary edema and enhance gas exchange.
- Inform the patient and family about the significance of managing hypertension and diabetes to avoid further complications.
Outcome
Mrs. Smith’s oxygen saturation levels increased and she reported feeling less out of breath after 24 hours of nursing care. Her chest X-ray showed lower pulmonary edema, and she was able to leave the hospital with follow-up care
Here is a case study on a patient with a different medical condition and symptoms:
Case Study #2
Patient with Diabetic Foot Ulcer
Medical History: Mr. S is a 63-year-old male with a history of type 2 diabetes mellitus. He availed to the clinic with a wound that wasn’t healing on his left foot. His right foot had already been amputated owing to a wound similar to this one. Mr. S also had a history of hypertension, hyperlipidemia, and peripheral vascular illness.
Assessment Data: upon examination, Mr. S had a big, deep ulcer on the plantar surface of his left foot. The wound was surrounded by erythema and had a bad smell. The foot felt cool to the touch and peripheral pulses were few. Mr. S reported painful and numbness in the affected foot.
Nursing Diagnoses
- Impaired Tissue Integrity associated with diabetic foot ulcer
- possibility for Infection relevant to open wound
- inefficient Peripheral Tissue Perfusion associated with peripheral vascular illness
Nursing Interventions
- Maintain the wound clean and dry
- Apply sterile dressings to the wound and replace them frequently
- Provide antibiotics as directed by the physician
- Keep an eye for signs and symptoms of infection
- Motivate the patient to raise his foot to increase blood flow
- Teach the patient on proper foot care and diabetic management to stop future wounds.
Outcome
With the above interventions, Mr. S’s wound began to heal, and the erythema and foul odor resolved. Peripheral pulses increased and the patient reported decreased pain and numbness. The wound eventually healed, and the patient was referred for diabetic foot care education to stop future wounds.
The nursing diagnoses gave a framework for creating a comprehensive care plan for Mr. S. The treatment plan covers the immediate wound care needs, as well as the underlying conditions adding to the wound. It assisted in directing the nursing actions to enhance peripheral tissue perfusion, promote healing, and avoid infection. By covering all of this element of care, the patient was able to achieve a positive outcome.
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Writing Nursing Diagnosis
Sure, here are some tips and guidelines for writing effective nursing diagnoses employing the PES format:
- Begin with the patient’s concerns: start by determining the patient’s problem or health concern. This could be a symptom, an abnormal lab tests, or a condition that needs nursing intervention. Be precise and concise in your description of the issue.
Example: Impaired mobility related to muscle weakness and decreased range of motion secondary to stroke.
- Determine the root cause: Next, determine the issue’s etiology or underlying cause. This could be a disease process, a medical condition, or a contributing element that is exacerbating the problem. Employ evidence-based knowledge and clinical judgment to identify the most likely cause.
Example: Impaired mobility related to muscle weakness and decreased range of motion secondary to stroke.
- Describe the patient’s symptoms: lastly, discuss the patient’s symptoms or evidence of the issue. This could involve physical signs, lab results, or subjective information from the patient or caregiver. Utilize specific and measurable terms to describe the symptoms.
Example: Impaired mobility relevant to muscle weakness and reduced range of motion secondary to stroke, as evidenced by difficulty standing, poor balance, and decreased capacity to perform activities of daily living.
Additional pointers for creating strong nursing diagnoses are provided below:
- Speak in plain, simple terms that are simple to comprehend for others.
- Refrain from using medical jargon or technical terms that may be not familiar to patients or caregivers.
- Ensure your nursing diagnosis is precise and related to the patient’s current condition and needs.
- Employ evidence-based knowledge and clinical judgment to back up your diagnosis.
- Collaborate with other healthcare providers to make sure a comprehensive and coordinated treatment plan.
In general, using the PES format can assist you write successful nursing diagnoses that direct patient care and improve outcomes. By following these tips and guidelines, you can be sure that your nursing diagnoses are accurate, related, and evidence-based.
Key Takeaways
Finally, nursing diagnoses play an important role in clinical practice. They enable nurses to determine patient problems and create individualized care plans that cover these issues.
Throughout this article, we have covered the different kind of nursing diagnoses, including actual, risk, and wellness diagnoses. We have also looked at case studies that show how nursing diagnoses are used in clinical practice, emphasizing how crucial these diagnoses are for directing patient care and treatment.
It’s crucial to note that writing successful nursing diagnoses needs careful assessment and critical thinking skills. Nurses must be able to gather and analyze patient information, identify issues, and create appropriate interventions to cover those issues.
Overall, nursing diagnoses contribute to ensuring that patients receive comprehensive, patient-centered care that takes into account their particular needs and concerns. By incorporating nursing diagnoses into their practice, nurses can enhance patient outcomes and assist promote general health and well-being.
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What If Want to Offer Nursing Diagnosis Services?
If you want to offer nursing diagnosis services, you could think about writing a section about the advantages of having a professional nurse handle nursing diagnosis. You could emphasize the expertise and experience that a professional nurse brings to the table and how they can assist in determining potential problems and develop effective care plans.
To prevent making any false claims, you should also make sure that you are transparent about the qualifications and certifications of your team members. This assist to build trust with possible clients and set credibility for your service.
In addition, you may want to highlight the significance of collaboration between the healthcare team and the patient. Collaboration is crucial in making sure that the nursing diagnoses correctly reflect the patient’s needs, and that the care plan is efficient and tailored to the patient’s unique situation.
Generally speaking, the purpose of your blog article should be to inform readers about nursing diagnosis and how they can benefit patients. You may also want to give tips for patients on how to effectively communicate their symptoms and concerns with their healthcare team to make sure that the nursing diagnoses are correct and accurate.
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Frequently Asked Questions (FAQs)
A nursing diagnosis is a clinical judgment made by a nurse to determine a patient’s health issue or possible health problems, and the root causes or risk element.
A nursing diagnosis concentrates on the patient’s response to health issues, while a medical diagnosis concentrates on determining a disease or medical condition.
The three kinds of nursing diagnoses are actual, risk, and wellness. Real nursing diagnoses determine existing health issues, risk nursing diagnoses determine potential health problems, and wellness nursing diagnoses determine the patient’s possible for health promotion and avoiding of health problems.
A nursing diagnosis contains three parts: the problem, the etiology (or cause), and the defining features (or symptoms). To draft a nursing diagnosis, first determine the patient’s problem or health issue, then determine the root cause or risk element, and finally, list the patient’s symptoms or signs that backs up the diagnosis.
The goal of a nursing diagnosis is to pinpoint the patient’s current or anticipated health issues, direct the nursing care plan and interventions, and to assess the effectiveness of nursing interventions.
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