Nursing Process : NURSING DIAGNOSIS

BY : CATHERINE KUCKYT, RN

The nursing diagnosis is derived from data gatered during the assessment. Health problems or potential health problems are identified and formulated into nursing diagnosis. Nursing Diagnosis is the basis for planning nurisng interventions that help prevent, minimize or aleviate specific health issues.

A Medical Diagnosis is much different than nursing diagnosis, it is used to define etiology of the disease. It only focuses is on the function and malfunction of a specific organ system.

The two are very different.

A Nursing Diagnosis is written in a format called "PES ", devloped by NANDA(1).

* "P" stands for PROBLEM
* "E "satnds for ETIOLOGY or cause of problem
* "S "stands SIGNS and SYMPTOMS of problem

By usimg all of the components of the nursing diagnosis, the problem is clearly communicated to everyone involved in the clients care.
Measurement Criteria:(2)

1. Diagnosis are derived from the assessment data
2. Diagnosis is validated with the client.
3. Diagnosis is documented to aid in the expected outcomes and plan of care.

NOTE: For the purpose of examples of Nursing Process , I will be using the following Case Study through out this report.
Case Study:
Client with Liver Disease - Cirrhosis

Mr.K is a 45 year old polish male. Married with three children. He is currently unemployed. He has worked in the service industry for his entire life. He has been socially drinking since he was 13 yrs. He has a family history of alcoholism and diabetes. He has been admitted to ICU on three previous occassions for liver disease.
Sample Nursing Care Plan(1):
Nursing Diagnosis
Imbalance Nutrition:Less than Body Requirements related to anorexia, metabolic imbalance
Activity Intolerance related to fatigue
Risk for Impaired Skin Integrity related to edema, immobility, pruritis, hypoproteinemia
Ineffective Breathing Patterns related to ascites
Risk for Injury related to impaired coagulation
Disturbed Thought Processes related to elevated blood ammonia