Comparison of Medical Diagnoses and Nursing Diagnoses Medical DiagnosisNursing Diagnosis Focuses on the illness, injury, or disease process. Focuses on the responses to actual or potential health problems or life processes. Remains constant until a cure is effected. Changes as the client’s response and/or the health problem changes. Identifies conditions the health care practitioner is licensed and qualified to treat. Identifies situations in which the nurse is licensed and qualified to intervene.

THE STEPS IN THE NURSING PROCESS Outcome identification

Assessment Techniques The four assessment techniques used in physical examination are inspection, palpation, percussion, and auscultation.

THE STEPS IN THE NURSING PROCESS Outcome identification

Types of Nursing Diagnoses Analysis of the collected data leads the nurse to make a diagnosis in one of the following categories: Actual problems Potential problems (including those where risk factors exist and there are possible problems) Wellness conditions Collaborative problems

THE STEPS IN THE NURSING PROCESS Outcome identification

OUTCOME/GOAL IDENTIFICATION AND PLANNING AS A STANDARD COMPONENT OF CARE: ANA STANDARDS Outcome Identification The nurse identifies expected outcomes individualized to the client. Guidelines Outcomes should be: Based on diagnoses Documented in measurable terms Developed with the client and health care providers Realistic and achievable Planning The nurse develops a plan of care that prescribes interventions to attain expected outcomes. Guidelines Planning should: Be individualized to the client’s needs and status Be developed with the client, significant others, and health care providers Be documented Promote continuity of care SMART

THE STEPS IN THE NURSING PROCESS Outcome identification

Categories of Nursing Interventions Observation Treatment Prevention Health Promotion

THE STEPS IN THE NURSING PROCESS Outcome identification

EVALUATION AS A STANDARD COMPONENT OF CARE: ANA STANDARDS Evaluation The nurse evaluates the client’s progress toward attainment of outcomes. Guidelines Evaluation must: Be performed as a systemic process Occur on an ongoing basis Lead to revision of the plan of care when needed Involve the client, significant others, and other members of the health care team Be documented

No.Date/Time Nursing Diagnosis * Planning ImplementationEvaluation Goal*Interventions*Rationale* Form NCP (Nursing Care Plans) Pt. Name: Age: Room/Bed: Medical Diagnosis: Physician’s Name: *must be with reference(s)

No.Date/Time Nursing DiagnosisInterventionImplementationEvaluation Form NCP (Nursing Care Plans) Pt. Name: Age: Room/Bed: Medical Diagnosis: Physician’s Name:

Case Pada tanggal 6 juli 2012, Ny. Rita datang ke RSAM bagian darurat pada jam dengan keluhan rasa nyeri di abdomen bagian kanan bawah yang dialaminya sejak seminggu yang lalu. Setelah diperiksa dokter, ternyata pasien mengalami appendicitis. Kemudian pasien dibawa ke ruangan perawatan di kamar 203-1, oleh perawat ER untuk rawat inap. Kemudian pada jam Ns.Merry mengecek VS pasien dengan T= 38,5 o C, P=110x/m, R=24x/m BP=130/90mmHg. Pasien belum BAB sejak dua hari yang lalu, wajah pasien tampak kemerahan dan meringis kesakitan, badan pasien teraba hangat dan berkeringat, pt masih mengeluh nyeri pada abdomen kanan bawah skala nyeri 8 dari (0-10), pasien mengatakan nyeri terasa seperti ditusuk-tusuk benda tajam, nyeri menjalar dari abdomen sampai ekstrimitas bawah, nyeri dirasakan pada saat kaki ditekuk dan pada saat berdiri. Pada jam pasien di pasang infus NS 15 tetes per menit di tangan kanan dan jam pt di kompres air hangat oleh perawat dan pasien juga dianjurkan minum air hangat 250cc/jam. Pada jam pt di beri obat Sanmol 25 gram (PRN), Sumagesic 500 mg (PRN) sesuai order dokter. Kemudian pada jam pasien di pasang kateter no.18 dengan balon 15cc. Pada jam pengambilan VS oleh Ns.Merry T=37,5 o C, P=95x/m, R=21x/m Bp=130/90mmHg. Pasien sudah BAK belum BAB, pasien makan ½ porsi.