NANDA nursing diagnosis essay/ care plan

NANDA nursing diagnosis essay/ care plan

What is a three-part nursing diagnosis?

Introduction
A three-part nursing diagnosis is a fundamental component of the nursing process. It represents a statement that highlights various potential issues a patient might encounter. This diagnosis guides nurses in identifying and addressing symptoms or health concerns, forming the basis for devising and executing a patient care plan.

Distinguishing Nursing Diagnosis from Medical Diagnosis

In contrast to a medical diagnosis, where a doctor identifies a specific disease or disorder, a nursing diagnosis focuses on problems observed during a nursing assessment, resulting from the underlying disease or disorder. For instance, while a doctor may diagnose chronic bronchitis and prescribe medication, a nurse may diagnose poor breathing and a cough during their assessment.

Steps in Developing a Three-Part Nursing Diagnosis

Creating a three-part nursing diagnosis involves three essential stages: data analysis, problem identification, and formulating the nursing diagnosis. These diagnoses can fall into four categories: actual nursing diagnosis, wellness or health promotion nursing diagnosis, risk nursing diagnosis, and syndrome diagnosis.

1. Actual Nursing Diagnosis

– Identifies a current health problem, such as inadequate airway clearance due to the inability to maintain proper oxygenation.

2. Wellness or Health Promotion Nursing Diagnosis

– Indicates a patient’s readiness to improve their well-being, like readiness for enhanced self-care to boost cardiac output after a pacemaker insertion.

3. Risk Nursing Diagnosis

– Flags situations where a patient might be at risk of developing additional health problems, such as infections.

4. Syndrome Diagnosis

– Describes a specific cluster of nursing diagnoses that frequently co-occur and require similar interventions, such as relocation stress syndrome.

The importance of Nursing Diagnosis

Nursing diagnosis enhances patient safety and the efficiency of care. It ensures the identification of all potential issues a patient might face and the documentation of vital signs and symptoms in detail. This meticulous approach can be crucial for delivering the right treatment and preventing continued illness or injury.

Correctly Writing a Nursing Diagnosis

When documenting a nursing diagnosis, following the North American Nursing Diagnosis Association (NANDA) guidelines is essential. The format varies depending on the type of diagnosis:
– Actual nursing diagnosis: Problem/diagnosis related to (r/t) x factor/cause as evidenced by data/observations.
– Risk nursing diagnosis: Problem/diagnosis related to (r/t) x factor/cause.
– Syndrome nursing diagnosis: Problem/diagnosis related to (r/t) x factor/cause.
– Wellness nursing diagnosis: Readiness to/for action.

Week 1: Comprehensive Integrated Psychiatric Assessment

Categories of NANDA Nursing Diagnosis

The NANDA-I system classifies nursing diagnoses into four categories:

1. Actual Diagnosis
– A clinical judgment regarding human experiences/responses to health conditions or life processes that currently affect an individual, family, or community. For example, sleep deprivation.

2. Risk Diagnosis
– Describes human responses to health conditions or life processes that might develop in a vulnerable individual, family, or community, supported by contributing risk factors. For instance, risk for shock.

3. Health Promotion Diagnosis
– A clinical judgment about a person’s, family’s, or community’s motivation to enhance well-being and achieve their health potential, as indicated by their readiness to improve specific health behaviors. An example would be readiness for enhanced nutrition.

4. Syndrome Diagnosis
– A clinical judgment defining a specific set of nursing diagnoses that coexist and require similar interventions, such as relocation stress syndrome.

NANDA Nursing Diagnosis Essay/Care Plan Process
The diagnostic process in nursing involves critical thinking and includes the following stages:

1. Assessment
– Gathering information about a patient’s psychological, physiological, sociological, and spiritual status through patient interviews, physical examinations, health history, and observation.

2. Diagnosis
– Making informed judgments about potential or existing health problems, including risk assessments and determining a patient’s readiness for health improvement.

3. Planning
– Developing an action plan in collaboration with the patient, prioritizing issues, and setting clear, measurable goals for desired outcomes.

4. Implementation
– Executing the action plan, monitoring the patient’s condition, providing care, educating the patient, and arranging follow-ups.

5. Evaluation
– Assessing whether the goals for patient wellness have been achieved and determining if the patient’s condition improved, stabilized, or deteriorated. If needed, the nursing process restarts.

In conclusion, the three-part nursing diagnosis plays a pivotal role in ensuring comprehensive patient care, and following standardized guidelines is essential for effective communication among healthcare professionals.