I Gathered Enough Assessment ???
1st level-subject and objective(4 senses)
2nd level- hx, etiology, other contributing problems
I Analyzed / Interpreted the Data???
What is it telling you?
What are you thinking? Feeling? About your client …..
I Validated the Assessment ??? (CT)
Do I have enough data to validate this?
Cluster your data!
More than 1 or 2 assessment findings? Yes or No?
Did you take your assessment findings / complaints and cluster them to make a nursing problem?
Ex: increased WBC count, temperature 101F, (+) chills, feeling
“weak and tired”, (+) blood cultures, ………… all abnormal assessments documented in the Protection Mode ………… nursing problem “Infection”
Take this nursing problem to you NANDA list and look under the mode of RAM.
Read the options for nursing diagnoses there. ……….
Do any of these NANDA and their definitions match your pt?
Choose a NANDA that you think explains your patient. Look up this NANDA in your Nursing Diagnosis Manual (Ackley) and read about the qualifiers?
the definition of the Nursing
Section III of Ackley
at the symptoms / characteristics common to the nursing diagnosis:
Ask yourself ……
“Does my client have these s/sx?”
“Is this diagnosis appropriate for the client?”
“Is there more assessment I need to justify it?” Compare
Have I related the 1st and 2nd level
Cause and effect? Make sense?
Do they show a “true relationship”? Does one really cause the other? (apples to apples and oranges to oranges?)
a look at your entire assessment database and make nursing problems and then NANDA diagnoses for all problems that you see existing in the Physiological and
Build a list – don’t get crazy!
Remember, no super nurse can plan and implement care for 20 problems!
Life Threatening / High Alert
▪ A – irway – non-patent / occluded / constricted
▪ B – reathing – labored / SOB / dyspnea
▪ C – irculation – bleeding / shock / clots
▪ Safety – falls / infection / aspiration / bleeding
▪ Life / Limb / Sight
Problems that threaten health or coping abilities
Don’t have a major effect if not dealt with today (or
maybe not even this week)
Won’t change the well-being of the client or delay discharge “Maslows
Hierarchy of Needs”
Ackley (Appendix A – pg. 905)
“If I do not address this first and
foremost, what will happen to my client?” “What can cause an immediate life threatening change in my client? In this shift? In the next few hours?”
Patients have many problems ….. what makes it a “priority problem”?
When it is the patient’s priority (pain, SOB, anxiety)
Keeps the patient from moving to the next phase of
wellness (fluid volume excess)
High probability for harm (infection risk, falls)
Delays discharge process
Day & Night shift may have different priorities
Ambulation vs. Sleep
To reduce physiological harm to your patients
Improve their physiological states
Stabilize their medical conditions
Support / minimize a decline in their overall state and rehabilitative process
Where am I spending the most of my “nursing hours and focus”? Example : My pt has been admitted with Heart
Failure – which problem do I pick?
What are the interventions that you are doing? Medical
Low Na diet?
Auscultating lung sounds?
Match a “nursing problem” closely with the interventions
Constantly re-assess your client’s
Problems are identified on admission, but can change throughout the hospitalization
AID….. PIE!!!!!! Yes – we are ready for pie!