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 persons problem and formulate a specific clear and individualised nursing diagnosis. A nursing diagnosis consists of the persons problem the related aetiology and supporting evidence (e.g. cues). There are two main types of nursing diagnosis:
1. 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.
2. 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.
Note: this information is adapted from: Levett-Jones T & Fagen A. (2015). Diagnosing. Berman A. Snyder S. J. Levett-Jones T. Dwyer T. Hales M. Harvey N. Stanley D. (ed.) Kozier and Erbs fundamentals of nursing (3rd Aust. ed.). Frenchs Forest Australia: Pearson. Chapter 13 pp.235-244
In this assessment item you are to:
1. 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)
2. 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).
3. 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.
4. For each risk nursing diagnosis describe three appropriate nursing actions to prevent the patient problem from occurring.
5. Discuss a clear rationale for each nursing action.
6. Explain how you would determine the effectiveness of your nursing actions. Outcome measures must be specific timely observable and/or measureable.
General guidelines for Assessment item 1
Your answers are to be well written and correct with respect to the clinical scenario/s presented.
Use the table provided on page 11-12.
Use full sentences and not bullet points.
Goals actions rationales and strategies for determining effectiveness must be supported by evidence from high quality sources such as nursing journal articles or textbooks.
At least six different high quality nursing references (including journals and textbooks) are required.
Answers are to be written in your own words (paraphrased) with accurate APA referencing (including a reference list) evident.
Use 11-12 point Arial or Calibri font and 1.5 line spacing.
A template with the cover page answer table and marking criteria will be provided in Blackboard > NURS2101 > Assessments.
Guidance for this assessment item will be provided in Tutorials and model answers will be provided in Blackboard > NURS2101 > Assessments.
In this assessment item the following definitions of directive terms will apply to your writing:
Aetiology Causal relationship between a problem and its related or risk factors
Actual diagnosis A problem that is present when the nurse assesses the patient
Describe Recall and provide details emphasising the most important points
Discuss Present a point of view that is supported by carefully chosen and authoritative evidence. This is likely to entail both description and interpretation.
Goal SMART objectives designed to address the patients problem (nursing diagnosis)
Explain To make plain and understandable; to make the cause or reason clear
Interpret Analyse data to come to an understanding; to explain the meaning of an event or situation.
Rationale An explanation reason or justification for why an action is warranted
Research A systematic inquiry that includes searching for analysing and synthesising information to address a particular question or problem.
Risk diagnosis A clinical judgment about a potential problem where the presence of risk factors indicates that a problem could develop
Four Nurse Diagnosiss are: 1/ Risk of pressure ulcers 2/Poorly managed type 2 diabetes 3/Hypovalemia 4/ Delayed wound healing.