Learning and using nursing diagnosis

Diagnosis means reaching a definite conclusion regarding the

patient’s strengths and human responses. This diagnostic process is
complex and utilizes aspects of intelligence, thinking,and critical
thinking
The North American Nursing Diagnosis Association International
(NANDA-I), formerly the National Conference Group for
Classification of Nursing Diagnosis, has been meeting since 1973 to
identify, develop, and classify nursing diagnoses.
The definition of nursing diagnosis distinguishes nursing diagnosis
from medical diagnosis. For example, nursing diagnosis is different
from medical diagnosis in its focus. nursing diagnoses focus on
patient response, whereas medical diagnoses focus on the disease
process.
There are five steps, or phases, in the nursing process:
assessment,diagnosis, planning, implementation, and evaluation.
These steps are not distinct; rather, they overlap and build on each
other.
1. ASSESSMENT
 The first step, or phase, of the nursing process is assessment.
During this phase, you are collecting data (factual
information) from several sources. The collection and
organization of these data allow you to:
2. DIAGNOSIS
Diagnosis means reaching a definite conclusion regarding the
patient’s strengths and human responses. This diagnostic
process is complex and utilizes aspects of intelligence,
thinking, and critical thinking.
3. PLANNING
Planning involves three subsets: setting priorities, writing
expected outcomes, and establishing target dates. Planning
sets the stage for writing nursing actions by establishing where
we are going with our plan of care.
4. IMPLEMENTATION
Implementation is the action phase of the nursing process.
Recent literature has introduced the concept of nursing
interventions, which are defined as treatments based on
clinical judgment and knowledge that a nurse performs to
enhance patient outcomes.
5. EVALUATION
Evaluation simply means assessing what progress has been
made toward meeting the expected outcomes; it is the most
 ignored phase of the nursing process. The evaluation phase is
the feedback and control part of the nursing process.
Evaluation requires continuation of assessment that was begun
in the initial assessment phase.
6. DOCUMENTATION
Just as development of the nursing process as a framework for
practice has evolved, so documentation of that process has
become an essential link between the provision of nursing care
and the quality of the care provided. Several nursing
documentation systems
LEARNING AND USING NURSING DIAGNOSIS

MADE BY
GROUP 3
JUWITA PUSPITA YAMIN
NI LUH GEDE ANGEL
ANGGRIVINI
FITRIANA

SEKOLAH TINGGI ILMU KESEHATAN

PROGRAM STUDI ILMU KEPERAWATAN
2018