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NURSING AND USING NURSING DIAGNOSIS

A. Definitions of nursing diagnosis


according Gordon (1976)
Nursing diagnosis is the actual or potential health problems which nurses, by education and
experience, is able to and has permission to handle it.
to make a diagnosis nursing, nurses must be able to:
1. Collecting valid data and related
2. Analyze the data into groups
3. Distinguishing collaborative nursing diagnosis of problems
4. Formulate diagnoses priority

Nursing Diagnosis "Wellness"


Nursing diagnosis is a clinical judgment about the welfare state of the individual, family, or
society in transition from a certain degree of prosperity to a higher level of prosperity
(NANDA).
There are two keys that must be present:
a) Something fun on a higher level of well-being.
b) There is a status and function effectively.
Written statement of nursing diagnosis is "the potential for improvement ..". it should be
noted that this category of nursing diagnoses contain elements "related factors".

Example: Potential increase in family relationships Expected results include:


a) Eat breakfast together for five days / week
b) Mrlibatkan child in family decision making
c) Maintain confidentiality of each member of the family

Nursing diagnosis "syndrome"


Nursing diagnosis is a diagnosis syndrome consisting of a group of actual or risk nursing
diagnoses are thought to exist because of a particular situation or event. Benefits syndrome
nursing diagnosis is that nurses are always alert and require the expertise of nurses in each
review and nursing actions.
According to NANDA nursing diagnoses syndrome there are two:

a) rape trauma syndrome (Rape trauma syndrome) In the above nursing diagnoses is more
indicative of a group of signs and symptoms in a group of nursing diagnoses. Signs and
symptoms include: Anxiety, fear, sadness, rest and sleep disorders, and pain when
performing high-risk sexual intercourse.
b) Risk Syndrome abuse (Risk for disuse syndrome)
The risk of constipation
The risk of changes in respiratory function
Risk of infection
The risk of thrombosis
The risk of disruption of activity
Risk of injury
Physical Damage mobilization
The risk of disruption thought process
The risk of body image disturbance
Risk of powerlessness (powerlessness)
Risk of damage to the integrity of the network.

B. Types And Conditions Nursing Diagnosis


Nursing diagnoses according Carpenito (2001) can be divided into 5 categories:
1. Actual
an actual nursing diagnosis describes the clinical judgment of nurses must be validated
because of the major defining characteristics.
a) Terms: Enforcing the actual nursing diagnoses should be no element of PES.
Symptom (s) must meet the major criteria (80% -100%) and most of the minor
criteria guidelines NANDA diagnosis. For example, there are the data: vomiting,
diarrhea, and poor turgor for 5 days.
b) Diagnosis: Lack of body fluid volume associated with abnormal fluid losses (taylor,
lilis, and Lemoni, 1988, p.283)
c) If the problem is getting ugly and disturbing health "perineal", the client will occur
the risk of skin damage, and disebu as "risk diagnosis".
2. Risk
The risk of nursing diagnoses describe clinical judgment in the individual to which or
groups are more prone to problems compared to others in the same or similar
circumstances.

a) Terms: Enforce existing risk nursing diagnosis of PE elements (problem and


etiology) use of the term "risk and high risk" depending on the severity /
susceptibility to problems.
b) Diagnosis: "impaired skin integrity risk associated with diarrhea that continues".
If the nurse suspects a disorder of self-concept, tetepi lack sufficient data to support
(the definition of the characteristics / signs and symptoms) to ensure the problem, it
can be stated as: "probable diagnosis".
3. Possible
Nursing diagnosis is a statement that might explain the problems that allegedly require
additional data. it is un fortunate that many nurses have been socialized to avoid
appearing tentative. in scientific decision making, a tentative approach is not a sign of
weakness or doubt, but an important part of the process. nurses must delay the final
diagnosis until he or she has collected and analyzed all the information necessary to
arrive at a scientific conclusion.physicians showed tentativeness with the rules of a
statement out (R / O). Nurses also must adopt a tentative position until they have
completed the data collection and evaluation and can confirm or rule.
a) Terms: enforce any possibility of nursing diagnoses response elements (problem)
and factors that may cause the problem but no.
b) Diagnosis: possible interference of self-concept: low self-esteem / terilosasi
associated with diarrhea. Keperawat required to think more critically and to collect
additional data related to konbsep themselves.

C. Components Nursing Diagnosis


1. Problem (problem)
The purpose of writing is to explain the problem statement or the health status of the
client's health problems clearly and possible. Because in this part of the nursing
diagnosis to identify what is unhealthy about the client and what should be changed
about the client's health status and also provide guidelines on the purpose of nursing
care. By using the standard of NANDA nursing diagnosis has a significant advantage.
a) Helping nurses to communicate with each other by using the term is commonly
understood.
b) Facilitating the use of computers in nursing, because nurses will be able to access
the nursing diagnosis.
c) As a method to identify differences existing nursing problems with medical
problems.

d) All nurses can work together to examine and define the categories of diagnostic
criteria in identifying nursing assessment and intervention in improving nursing
care.

2. The etiology (cause)


The etiology (cause) is a clinical and personal factors that can change the status or
influence the development of the problem's Health. Etiology identify the physiological,
psychological, sociological, spiritual and environmental factors are believed to relate to
the problem either as a cause or risk factor. Because the etiology identify factors that
support the client's health problems, the etiology as a guide or a direct target of nursing
interventions. If errors are made in determining the cause of the nursing action becomes
ineffective and inefficient. For example, a client with diabetes mellitus hospitalized with
hiperglikeni and usually have a history that is not good about diet and medication
(insulin) was diagnosed with "disobedience". Katakana was the disobedience
kuramgnya knowledge related to nursing actions prioritized kien and teaches clients
how to cope with diabetes mellitus and does not work, if such disobedience causes
because clients are desperate for a living. Writing etiology of nursing diagnoses include
elements PSMM
P = Pathophysiology of disease
S = Situational (state of the environment of care)
M = Medication (treatment given)
M = maturation (maturity level / maturity client)
The etiology, risk factors and support, including:
a) Pathofisiologi:
All the processes of disease, acute and chronic, which can lead to or support issues,
such as the problem of "powerlessness" Common causes:
inability to communicate (CV A, intubation)
inability to perform daily activities (CV A, Cervical trauma, pain, IMA)
inability to meet its responsibilities (surgery, trauma, and arthritis)
b) Situational (Personal, enfironment)
Lack of knowledge, social isolation, lack of explanation of health workers, lack of
client participation in decision mengabil, relocation, cost of incapacity, sexual
harassment, removal of social status, and changes in personal territory.
c) Medication (treatment-related)
Limitations institution or hospital: not able to provide care and there are no secrets.

d) Maturational
Adolescent: dependence in a group, independent of the family Young
adult: married, pregnant, parents
Adults: career pressure, and signs of puberty
Elderly: the lack of sensory, motor loss (money, other factors)

3. Sign / symptoms (signs / symptoms)


Identification of subjective data and objective as a sign of trouble nursing. Requires
evaluation criteria, for example: the smell of "urine", never in shampooing the hair. "I
was afraid to walk in shower and breaking things".

D. DETERMINATIONS OF DIAGNOSIS PRIORITY


By determining the nursing diagnosis, it can be seen where the diagnosis will be done or
addressed first or soon be conducted to determine the priority order of the opinion there are
several priorities, including:
1. Based on the level of severity (life-threatening)
Determination of priority based on the level of severity or life-threatening background
of the principle of first aid is to divide the priority among several high priority, medium
priority and low priority.
a) High Priority: reflects the life-threatening situation (one life) that need to be taken
in advance as road clearance respirating problems.
b) Priorities were: describe a situation that is not life threatening and does not threaten
the client's life like hygiene problems someone.
c) Low priority: describe situations that are not directly related to the prognosis of a
disease specific such as financial problems or other diagnoses.

2. Based on the needs Maslow


Maslow determination diagnosis priority will be planned based on the needs of such
physiological needs of safety and security, love and have, self-esteem and selfactualization, which can be described as follows: For a diagnosis to be planned priority
Maslow divide the sequence based on the sequence of basic human needs such as:
a) Physiological Needs, including respiratory problems, circulation, temperature,
nutrition, pain, fluid, skin care, mobility, elimination.
b) The need for security and safety, including environmental issues, living conditions,
shelter, clothing, free of infection and fear.

c) The need to love and be loved, covering issues of love, sexuality, group affiliation,
human relationships.
d) The need for self-esteem, including the respect of family problems, feelings of selfrespect
e) The need for self-actualization issues, including satisfaction with the environment.

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