Purpose: In this report you will develop your ability to write an accurate nursing diagnosis, determine appropriate nursing goals and actions, and identify relevant evaluation criteria. Diagnosing is the fourth stage of the clinical reasoning cycle. An accurate nursing diagnosis is essential to safe patient care as the planning of nursing actions follows directly from this stage. Nurses collect and interpret objective and subjective cues to determine the person’s problem and formulate a specific, clear and individualised nursing diagnosis. A nursing diagnosis consists of the person’s problem, the related aetiology, and supporting evidence (e.g. cues). There are two main types of nursing diagnosis:
An actual diagnosis is a problem that is present when the nurse assesses the person. An actual nursing diagnosis has a specific aeitology and is based on the presence of associated cues (signs and symptoms etc). An actual nursing diagnosis is written in three parts: (1) problem; (2) aetiology; and (3) signs and symptoms. An example of an actual diagnosis is: dehydration related to post-operative nausea and vomiting evidenced by dry mucous membranes, oliguria, poor skin turgor, hypotension and tachycardia.
A risk nursing diagnosis is a clinical judgment about a potential problem where the presence of risk factors indicates that a problem could develop if the nurse fails to take appropriate action. For example, although all people admitted to a hospital have some possibility of acquiring an infection; a person with diabetes or a compromised immune system is at higher risk than others. A risk diagnosis is written in two parts (1) problem; and (2) aetiology. An example of a risk diagnosis is: risk of infection related to type 2 diabetes.
In this assessment item you are to:
Review the patient scenarios below and from them, identify two actual nursing diagnoses and two potential diagnoses. Consider physical, emotional and psychosocial problems. You can develop the four nursing diagnoses in relation to one patient scenario or four different patient scenarios.
Mr Cyril Smith (Blackboard: Wiimali and online clinical reasoning scenarios)
Jamie Lyons (Blackboard: Wiimali and Tutorial 4 resources)
Hayley Milangu (Clinical Reasoning Textbook – Chapter 11 and Tutorial 5 resources)
Michael Johnstone (Blackboard: Tutorial 6 resources)
Aneesh Ayman (Clinical Reasoning Textbook – Chapter 12)
For each nursing diagnosis identify an appropriate and person-centred goal of care (each goal is to be SMART (specific, measurable, achievable, realistic and timely).
For each actual nursing diagnosis describe three appropriate nursing actions to address the patient problem. Note: Referral to a member to the interprofessional team may be an appropriate nursing action is some situations.
For each risk nursing diagnosis describe three appropriate nursing actions to prevent the patient problem from occurring.
Discuss a clear rationale for each nursing action.
Explain how you would determine the effectiveness of your nursing actions. Outcome measures must be specific, timely, observable and/or measureable.