Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide of breath with activity, difficulty in breathing, and abnormal lung sounds is seen by a physician and a nurse. The medical diagnosis of the physician might be pneumonia. A nursing diagnosis established by the nurse might be “activity intolerance.” The physician will typically only deal with actual problems, while the nurse will focus on both actual and potential problems. In 1973, a conference on nursing diagnosis was held that began to identify the knowledge specific to nursing and a system for classifying that knowledge. Over the next several years, the diagnosis development group, North American Nursing Diagnosis Association (NANDA), worked to develop the NANDA Taxonomy of Nursing Diagnoses. The purposes of this list is to: • Provide all nurses with a standardized language that allows communication amongnurses • Provide a classification system that describes the scientific foundation of nursing practices • Provide a system that can be translated for computer and reimbursement use Other nursing diagnosis classifications exist but the American Nurses Association (ANA) has sanctioned NANDA as the organization to develop the classification system. Developing the Nursing Diagnoses List The process for developing the nursing diagnosis list is: • Identification of the patient problems: In the example of the previous section, the patient with a medical diagnosis of pneumonia was identified as having a problem of “activity intolerance” by the nurse. For potential problems, this part of the nursing diagnosis can be prefaced by “at risk for.” If activity intolerance was only a potential problem, the nurse would document the problem as, “at risk for activity intolerance”. • Identification of the probable cause or etiology of the problem: In the example of the patient with pneumonia, the activity intolerance is caused by or is related to the patient’s shortness of breath. In the context of the nursing diagnosis, the problem and etiology are usually linked by the words “related to” (sometimes abbreviated as “R/T”). In this case, the developing nursing diagnosis would be, “activity intolerance related to imbalance between oxygen supply/demand.” • Identification of any defining characteristics of the problem: The final piece of the nursing diagnosis is the identification of any defining signs or symptoms of the problem. In the patient with pneumonia, the symptommight be the patient’s shortness of breath. In the context of the nursing diagnosis, the problem and etiology are usually linked to the signs and symptoms by the words “as evidenced by” (sometimes abbreviated as “AEB”). In this case, the final nursing diagnosis would be, “activity intolerance related to imbalance between oxygen supply/demand, as evidenced by shortness of breath when walking.” Steps to developing a nursing diagnosis:

AEB Signs & Symptoms

R/T Etiology

Nursing Diagnosis

Problem

©2018

Achieve

Page 12

of 134