UNIT 9 materi

NURSING DIAGNOSIS Lecture : Desy Natalia, M. Pd

EKA HARAP FOUNDATION PALANGKA RAYA INSTITUTE HEALTH AND SCIENCES PROGRAM STUDY OF NURSING ACADEMIC YEAR 2019/2020

1

i

Introduction After completing the nursing assessment, the nurse goes on to the nursing diagnosis, which is a clinical assessment of the response of an individual, family, or carcinoma to an actual or potential health problem or life process. Nursing diagnosis is a statement describing the client's actual or potential response to a health problem that the nurse has licensed and competent to overcome them. Nursing diagnoses provide a basis for selecting interventions to achieve outcomes that nurses are responsible for (NANDA, 1990; Carpenito, 1993). Outcomes and interventions are chosen in relation to certain nursing diagnoses (McCloskey & Bulechek, 1992). The reason for formulating nursing diagnoses after analyzing assessment data is to identify health problems involving the client and his family and to provide direction for nursing care. The statement of nursing diagnoses is the result of a diagnostic process during which nurses use critical thinking, nursing diagnoses developed for the client, family, or community and includes physical, intellectual, emotional, social and spiritual development data obtained during the assessment.

1

DISCUSSION Conversation: Diagnosing a New Patient Mrs.Smith come to see the doctor since is feeling unwell. Mrs.Smith : Good morning Doc. Doctor : Good morning. Mrs. Smith? Mrs. Smith : Yes, I’m. Doctor : Alright, sit down please. What seems to be the problem? Mrs. Smith : Okay, thank you I feel feverish, sweaty, and nauseous, Doc. I also shivered and got a bad headache. Doctor : Do you feel weary? Mrs. Smith :Yes Doc, I feel weary too. Doctor :Did you any blood transfusion recently? Mrs. Smith :No, I didn’t Doctor :Did you probably spend the night in a malaria endemic place? Mrs. Smith : Yeah... actually I did, doc. I spent the night there for around a week For taking the data of my research. Doctor : Okay, I see. Mrs. Smith : Is that someting serious, Doc? Doctor : We will know after yo do some tests in the lab. once you have finished the tests, you can come back here. And we can know more after the results have come in. Mrs. Smith : Okay Doc, thank you. Doctor : You’re very welcome. After doing some tests, Mrs. Smith comes back to the Doctor’s the room. Mrs. Smith : Good afternoon. Doctor : Good afternoon. Oh, Mrs. Smith, sit down, please. Mrs. Smith : Thank you, Doc. Doctor : Do you bring all the test results? Mrs. Smith : Yes, I do here they are. Doctor : Okay, let me take a look at the test result first. The Doctor reads the test result carefully. Doctor : Allright, Mrs. Smith. From the test results I can diagnose that you were infected by malaria parasite. Here it can be seen that you were positively infected by that parasite. Mrs. Smith : Yes, I see. Doctor : So, you should be hospialized, Mrs. Smith. In order that you can be treated intensively. Mrs. Smith : Okay Doc, I will take your suggestion. Thank you. Doctor : Okay good. Yes, you’re welcome.

2

Example for of expression in diagnosing phyisician  You’re test results have come in. “Hasil tes anda telah keluar.”  You have a long road to recovery. “Butuh waktu lama untuk pemulihan.” Patient  

I don’t understand what this means. “Saya tidak paham apa artinya ini.” Am I going to need surgery? “Apakah saya perlu dioperasi.?”

Patient Symptoms  

I’ve got a high temperature. “Saya demam tingg.i” I feel really exhausted. “Saya merasa sangat lelah.”

Medicine, Medical Equipments and Tools  

Pill ‘pil’ Capsule ‘kapsul’

Nursing Diagnosis : NANDA A nursing diagnosis is one nursing process. It is a medical judgement about individual, actual or potential health probelms. It also examines a problem response which presents during assessment. Nursing diagnosis is developed from data gained during nursing assessment. The North American Nursing Diagnosis Association (NANDA), a body of frofesional nurses, manages an official list of nursing diagnosis. The following is the list of the 16 new NANDA Nursing Diagnoses. Language Function: Simple Present, Simple Past, and Present Future Tense 1. Simple Present Tense Simple present tense is used to talk about things in general. It is also used to say that something happens all the time or repeatedly, or that something is true in general. We can say that the simple present us used express habitual or everyday activities.

3

  

Nurses look after patients in hospitals every day. Water consists of hydrogen and oxygen. He always studies hard every night.

Remember that if the subjects are he, she, and it add –s.  

I visit... but the visits... We teach... but my mother teaches...

2. Simple Past Tense Simple past tense is used for completed action that hapened at one specific time in the past.   

She went to school by motorcycle yesterday. I saw John in the garden this sfternoon. He studied Math last night.

3. Present Future Tense Present future tense expresess evebts or situation that will happen in the future.   

She will go to school by motorcycle tomorrow. I am going to visit my grandmother next week. He wiil study Math tonight.

4

5