3/24/2022 2.

Risk nursing diagnosis

- clinical judgment that a problem does not exist,
NURSING DIAGNOSIS but the presence of risk factors indicate that a
problem is likely to develop unless nurses
intervene
DIAGNOSING
● Interpret assessment data
E.g.
● Identify client strengths & problems

Risk for impaired skin integrity r/t immobility secondary

1. Data Analysis
to fractured hip
2. Problem Identification
3. Formulation of Nursing Diagnosis
3. Wellness diagnosis
- describes human responses to levels of
wellness in an individual, family or community
Nursing Diagnosis that have readiness for enhancement
● actual or potential health problem that
independent nursing intervention can prevent or E.g.
resolve
● client's problem statement consisting of the Readiness for enhanced spiritual well-being
diagnostic label & etiology
● describes a continuum of health status; Readiness for Enhanced Family Coping
deviations from health, presence of risk factors
and areas of enhanced personal growth
4. Possible Nursing Diagnosis
TYPES OF NURSING DIAGNOSES
1. Actual nursing diagnosis - Statements describing a suspected problem for
2. RISK nursing diagnosis which additional data are needed
3. Wellness diagnosis
4. Possible nursing diagnosis E.g.
5. Syndrome nursing diagnosis
Possible self-care deficit related to impaired ability to
1. Actual nursing diagnosis use left hand secondary to presence of intravenous
- client problem that is present at the time of the therapy.
nursing assessment
- problem that has been validated by the 5. Syndrome nursing diagnosis
presence of major defining characteristics - comprises a cluster of actual or risk nursing
diagnoses that are predicted to be present
E.g. because of a certain situation or event

Ineffective airway clearance r/t excessive and E.g.

tenacious secretions
Rape trauma syndrome
Imbalanced nutrition: more than body requirements r/t
excessive intake in relation to metabolic needs Post trauma syndrome
Components of Nursing Diagnosis - Skillful assessment minimizes gaps and
inconsistencies of data
1. Problem (diagnostic label) and definition - possible sources of inconsistencies:
- Problem Statement describes the client's health measurement error, expectations and
problem/status or response inconsistent or unreliable reports
- diagnostic labels
- specific; when the word SPECIFY
follows a NANDA label, the nurse states 2. Identifying Health Problems, Risks, &
the area in which the problem occurs Strengths
- identify problems that support tentative actual,
2. Etiology risk and possible diagnoses
- (related factors & risk factors) - establish the client's strengths, resources and
- identifies one or more probable causes of a abilities to cope
health problem, give direction to the required - must determine whether the client's problem is
nursing therapy & enables the nurse to a nursing diagnosis or a collaborative problem
individualize the client's care

3/25/2022
3. Defining characteristics
- clusters of signs & symptoms that indicate the STEPS OF DIAGNOSTIC PROCESS
presence of a particular diagnostic label
Formulating Diagnostic Statement
STEPS OF DIAGNOSTIC PROCESS a. basic two-part statement
b. basic three-part statement
1. Analyzing Data c. one-part statement
a. Comparing data with standards
- identify significant cues 1. Basic Two-part Statement
- Nurses draw on knowledge and ● Problem (P)
experiences to compare client data to ○ statement of the client's health state or
standards and norms and identify response
significant & relevant cues. ○ diagnostic label
● Etiology (E)
b. Clustering cues ○ factors contributing to or probable
- process of determining the relatedness causes of the responses
of facts and determining whether any
patterns are present, whether the data Problem + related to + etiology
represents isolated incidents and the
data are significant E.g.
- grouping of data/cues that point to the Hyperthermia r/t pyrogenic substances in blood
existence of a health problem
severe anxiety r/t threat to physiologic integrity:
c. Identifying gaps and inconsistencies of possible CA diagnosis
data
- include final check to ensure that data
are complete and correct
 2. Basic three-part statement 4. Using secondary to to divide the etiology into two
● Problem (P) parts
○ statement of the client's health state or
response E.g.
○ diagnostic label Risk for impaired skin integrity r/t decreased peripheral
● Etiology (E) circulation secondary to diabetes
○ factors contributing to or probable
causes of the responses 5. Adding a second part to the general response or
NANDA label to make it more precise
● Signs and Symptoms (S)
○ Defining Characters manifested by the E.g.
client. Impaired Skin Integrity (left lateral ankle) r/t decreased
E.g. peripheral circulation
Situational low self-esteem r/t feelings of rejection by
husband as manifested by hypersensitivity to criticism
Nursing Diagnosis Medical Diagnosis
Altered dentition related to chronic use of tobacco as
manifested by tooth enamel discoloration statement of nursing made by physician
judgment
3. One-part statements
refers to a condition that refers to a condition that
● consist of a NANDA label only nurses by virtue of their only physician can treat
● wellness diagnoses & syndrome diagnoses education, experience,
and expertise are
E.g. licensed to treat
Rape-trauma syndrome
describes human refers to disease
Readiness for enhanced parenting
response, a client's processes
physical, socio-cultural,
Variations of Basic Format psychological & spiritual
responses to an illness
1. Writing unknown etiology when defining or a health problem
characteristics are present but the nurse does nursing actions - nursing actions -
not know the cause or contributing factors independen primarily dependent
2. Using complex factors when there are too many
etiologic factors
3. Using the word possible, to describe either the
problem or the etiology require more data about
the client's problem or etiology

E.g.
Possible low self esteem r/t loss of job and
rejection by family
Guidelines for Writing a Nursing Diagnosis 7. Use nursing terminology rather than medical
1. State in terms of a problem, not a need terminology to describe the client's response.
E.g.
Fluid replacement /r/t fever E.g.
Deficient fluid volume r/t fever X Risk for pneumonia
Risk for ineffective airway clearance r/t accumulation
2. Word the statement so that it is legally of secretions in lungs
advisable.
E.g. 8. Use nursing terminology rather than medical
Impaired skin integrity r/t improper positioning terminology to describe the probable cause of
Impaired Skin Integrity r/t immobility the client's response.

3. Use nonjudgmental statements. E.g.

Risk for ineffective airway clearance r/t emphysema
E.g. Risk for ineffective airway clearance r/t accumulation
X Spiritual distress r/t strict rules necessitating church of secretions in lungs
attendance
Planning
Spiritual distress r/t inability to attend church services
secondary to immobility Planning
- Developing a plan of care to assist the patient
4. Make sure that both elements of the statement to an optimum or improved level of functioning
do not say the same thing. in the problem areas identified in the nursing
diagnosis
E.g.
Impaired skin integrity r/t ulceration of sacral area Nurse works with the client to set goals/ outcomes to
Impaired skin integrity r/t immobility prevent, correct or relieve health problems and
determine appropriate nursing interventions
5. Be sure that cause & effect are correctly stated.
Planning Process
E.g.
X Pain rit severe headache 1. Setting priorities
Pain: severe headache r/t fear of demands of student 2. Establishing client goals/desired outcomes
life 3. Selecting nursing interventions
4. Writing individualized parsing interventions on
6. Word the diagnosis specifically and precisely to care plan
provide direction for planning nursing
intervention. 1. Setting priorities
- Determine which problems identified during the
E.g. assessment phase are in need of IMMEDIATE
Impaired oral mucous membrane r/t noxious agent attention and which problems may be dealt with
Impaired oral mucous membrane r/t decreased at a later time
salivation secondary to radiation of neck
Nursing diagnoses can be grouped as: Guidelines for Writing Goals
1. HIGH PRIORITY ● S - Specific
2. MEDIUM PRIORITY ● M-Measurable
3. LOW PRIORITY ● A - Attainable
● R - realistic
Nursing diagnoses can be grouped as: ● T - Time bounded
1. Maslow’s Hierarchy of Needs
2. ABC’s
3. Life Preservation 1. SPECIFIC GOAL

Consider: Nursing Dx: Self-care deficit r/t presence of cast in the

1. The most important problems to the patient left leg self
2. Effect of potential problems
3. Costs, resources available, personnel, time Goal: The patient will be able to perform bathing with
needed assistance of the nurse within the week.

2. Establishing client goals/desired outcomes 2. MEASURABLE GOALS

- describes a change in the patient's health The patient will be able to ambulate by tomorrow.
status or functioning
- desired outcome of nursing care that which you The patient will be able to ambulate with assistance
hope to achieve with your patient from bed to bathroom by tomorrow.
- expected outcome, predicted outcome,
outcome criterion, objective
3. ATTAINABLE AND REALISTIC GOALS
Goals can be:
The patient will be able to drink fluid amounting to
1. Short term
1200 mL within an 8-hour period.
2. Long term

The patient will be able to drink fluid amounting to

Long term and Short term goals 1200 mL within an hour.

Situation: Frail elderly man with a pressure ulcer on his 4. TIME BOUNDED
sacral area
The patient will be able to bathe with assistance within
Long term goal the period of hospitalization.
The patient's sacral area will exhibit no evidence of a
pressure ulcer in the next 2 weeks The patient will be able to ambulate with assistance
from bed to bathroom by tomorrow.
Short term goal
At the end of the 3 days, the patient's pressure ulcer
has decreased in size by 1 mm.
Guidelines for Writing Goals - Before discharge, the patient will
- The goal is congruent with and supportive of ambulate the length of the hallway
other therapies. independently.

DOCTOR'S ORDER: CBR with BRP 3. Nursing Diagnosis:

Patient will ambulate along the corridors today - Hyperthermia r/t infectious process
Patient will ambulate from bed to bathroom today. Goal:
- Body temperature will decrease from
- Whenever possible, the goal is important and 38.5°C to 37.5°C within 2 hours.
valued by the patient, the nurses, and the
physician. 4. Nursing Diagnosis
- acute pain r/t post surgical incision
- Whenever possible, the goal is important and Goal
valued by the patient, the nurses, and the - verbalization of decreased pair from a scale of
physician. 2 to 1(where 3-severe, 2-moderate, 1-mild, 0=no
pain) within the shift
- Derive each goal from only one nursing
diagnosis. 5. Nursing Diagnosis
- risk for infection r/t presence of open wound on
- Keep the goal short the right forearm
Goal
- will not manifest any sign of infection in the
Goal Statement
next 7 days of hospitalization
= patient's behavior
+criteria of performance
+ time Variables that Influence Goal Outcome
conditions (if needed) Achievement
a. patient variables
Examples of Goal Statements ● patient's changing ability
● willingness to participate in the plan of care
1. Nursing Diagnosis: ● previous responses to nursing interventions
- Imbalanced Nutrition: more than body ● progress towards goal
requirements r/t poor eating habits
Goals: b. nurse variables
- Will identify 10 low-calorie snacks he is ● nurse's level of expertise and creativity
willing to try within 3 days ● willingness to provide care
- Will lose 20 lbs. within 12 wks. ● available time
- Will reach a target wt. of 122 lbs. by
June. 20, 2022 c. resources
● adequacy of staff, equipment and supplies
2. Nursing Diagnosis ● financial resources of the patient
- Impaired physical mobility r/t general ● adequacy of community-based resources
muscle weakness
Goal: d. ethical and legal guides to practice
● laws and regulations
● ethical dimensions of clinical practice