The nursing diagnosis is derived from data gathered during the assessment. Health
problems or potential health problems are identified and formulated into
nursing diagnosis. Nursing Diagnosis is the basis for planning nursing
interventions that help prevent, minimize or alleviate 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 ", developed by NANDA.
By using all of the components of the nursing diagnosis, the problem is
clearly communicated to everyone involved in the clients care.
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 an diabetes. He has been admitted to ICU on three previous occasions for liver disease.
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 |
Nursing Process: Definition |
Critical Thinking
| Guidelines
Critical Thinking:
Characteristics
| Skills, Elements, Standards
Nursing Process: Assessment
| Nursing
Diagnosis | Planning | Implementation | Evaluation
John
Philip Tiongco, MD