00:01
Hi guys!
Talking about
the nursing process,
we're going to talk about the
nursing diagnosis piece
of ADPIE.
00:08
Now, just to be
honest here with you,
this is usually
the most confusing piece
for nursing students,
but we're going to explore this topic.
00:17
So with our piece of the pie,
the D is the diagnosis piece
of the five step
of the nursing process.
00:24
So let's take a look and talk about
nursing diagnosis.
00:28
So we talk about diagnosis types.
00:31
This is really important for us
to differentiate.
00:34
So of course,
there's those medical diagnosis
like diabetes, heart failure,
pneumonia, for example.
00:41
These are all identifying
certain diseases.
00:44
And this is all based on
the physician assessment,
keyword physician assessment,
and diagnostic information
like labs or X-rays, or CAT scan,
for example.
00:56
Now, the difference
with a nursing diagnosis
is this is our clinical judgment
about the patient's
actual or potential
health problems.
01:05
So usually,
we gather this information,
typically through our physical
head to toe assessment.
01:11
Now, just now
with our patients,
this is a collaborative problem,
right?
Any issue with our patient,
we're going to have
to work together
with our physicians,
because many times
the nurses of the one
that are monitoring
the patients.
01:25
So, if there's
a change in condition,
there's an issue
that needs to be addressed.
01:29
We work together
with our physicians,
and we report,
so we can treat the issue.
01:35
So why nursing diagnosis?
This allows nurses
to practice independently
within their scope of practice.
01:42
So if you remember
diagnosis,
such as
pneumonia, diabetes,
those are
medical diagnosis
and not within
our scope of practice
as a nurse to use.
01:52
Therefore, we have
the North American
Nursing Diagnosis Association,
otherwise known as
NANDA.
02:00
Named has developed for us
refined and promoted
the use of nursing diagnosis
for use by all professional nurses.
02:09
Now, before we get started,
just know,
literatures moving away
from this a bit
just because
there's some confusion
in regard to
making a medical
versus a nursing diagnosis
statement.
02:21
But however,
this is still widely used.
02:24
We also do this really organically
in our clinical practice as well.
02:28
So let's take a dive
into nursing diagnosis
and why we use it.
02:33
So one of the reasons
why we use a nursing diagnosis,
it gives us precise definitions
of those patient issues.
02:40
Here's a great example.
02:42
Impaired skin integrity.
That's a NANDA nursing diagnosis.
02:47
Now, just by saying,
impaired skin integrity,
you already know, right?
The patient has skin issues here.
02:55
Or another example is
ineffective airway clearance.
02:58
It's really precise here,
right guys?
We know the patient
is having a hard time
with their airway clearance.
03:05
The other thing about this
is that allows nurses,
and other health care team members
a common language.
03:11
It's also really helpful between
nurse to nurse communication.
03:16
It also provides guidance for
developing nursing interventions
to treat our patients.
03:21
So let's take a look
at the diagnostic process.
03:24
So how we get to that
nursing diagnosis.
03:27
If you remember,
in the ADPIE piece,
we start with A,
our assessment.
03:31
And this is where
we validate our information,
we gather all that data,
and we interpret
the patient's health status.
03:39
Now, when we start
with the diagnosis piece,
we get that information,
we cluster this.
03:44
We identify key characteristics
from our patient.
03:48
Then work and identify
our patient's needs.
03:51
And therefore, we can formulate
our nursing diagnosis.
03:55
When we're talking about
nursing diagnostic statements,
these are sentences
that provide
specific, actual, or potential
health problems.
04:04
It also provides a common language
among healthcare providers,
such as nurses
with physical therapy,
occupational therapy,
or the physician, for example.
04:13
And again, this distinguishes
the nurses role from the physician.
04:18
So remember, we are working
with our nursing diagnosis.
04:21
And of course, this helps us focus
on the nurses scope of practice.
04:26
So we're talking about
that diagnostic process.
04:28
It's important here as a nurse
as always,
that we use critical thinking.
04:33
So to get that nursing diagnosis
and work through that process,
we got to start with
clustering information,
using that information,
and identifying
the patient's health problem.
04:44
Then we can formulate an
appropriate nursing diagnosis.
04:48
So we talk about
information clustering.
04:51
We got to bring all that information
together in a logical way.
04:55
We're looking for patterns as
well with defining characteristics.
04:59
So if you take a look
at this image here,
that's a great piece
just to show you,
hey, we have all this information
that's gathered in an assessment.
05:07
But it's important that
we cluster that information,
which leads
to our nursing diagnosis.