Safety Nursing Diagnosis and Nursing Plan - NurseStudy.Net (2023)

Nursing Care Plans for Diagnostics and Safety Interventions

Review of NCLEX Nursing Care and Safety Plans

Safety is a discipline dedicated to delivering medical care while minimizing risk, error, and patient injury.

It includes protocols, clear policies, and safety enhancements designed to minimize accidents, injuries, complications, and misdiagnosis. Clinical care involves all efforts by health professionals to avoid causing harm and limit all risks to patient safety.

Patient Safety: Environmental Safety and Basic Needs

  1. environmental security

Environmental safety encompasses the entire continuum of medical care, from rehabilitation, hospice, and palliative care. This includes nurse-patient interactions in hospitals, long-term care facilities, schools, homes, and clinics. Environmental modification is necessary to improve the lives and survival of vulnerable populations such as the elderly, newborns, children, people with disabilities, the impoverished and illiterate, and the sick.

  1. Basic needs

The safety and health of the patient can be affected or compromised if physiological demands such as adequate nutrition, oxygen and adequate temperature are not met.

  1. Oxygen. The most basic survival requirement is oxygen. A person's life will be cut short in a few minutes if his blood does not contain enough oxygen. In terms of environmental safety, it is critical to control it as it has the potential to further ignite the flames as it is a component of the fire. As a result, healthcare facilities restrict their use and adhere to correct handling and storage procedures. Due to the potential for ignition, household medical oxygen presents a risk ofBurnsand fire. Additionally, ventilation is a necessary component of any facility, as insufficient ventilation can lead to suffocation and increased work of breathing. Fuel-burning appliances can produce carbon monoxide, a toxic gas that reduces tissue oxygenation due to smoke and inadequate ventilation. Typical signs and symptoms of reduced oxygenation or hypoxia include the following:
    • Shortness of breath
    • nausea
    • Dizziness
    • Fatigue
    • Headache
    • Anxiety
  1. Nutritional intake. Meeting the nutritional needs and demands of the body is essential for life and survival. To maintain the body's homeostasis, one must consume adequate fluids while sufficient calories provide energy and boost immunity. In addition, it provides the body with the necessary components for its healing and recovery.

The nurse must assess patient safety, especially when the patient is seriously ill, lacks cognitive and physical function, or is included in susceptible populations. A patient's nutritional health can also be affected by their refusal to eat, insufficient nutrient intake, inability to swallow or chew, nausea and vomiting, food allergies, and overeating. The following are examples of supportive care that can help with proper nutrition and fluid intake:

  • Intravenous fluid infusion
  • intubation
  • oral feeding

In addition to physiological factors that affect nutritional status, food contamination also poses a health risk. A patient's risk of infection and food poisoning is increased if food is cooked, stored, or subjected to unsanitary conditions.

  1. Physical Risks and Accidents. Motor vehicles, poisoning, and falls are examples of hazards that can endanger the health and safety of a person.
  • Poisoning. This refers to any substance that can compromise the health and survivability of an individual when absorbed, ingested, or inhaled. Always exercise moderation in any substance or food, as too much can be debilitating, harmful, or toxic. Medicines, household disinfectants, personal hygiene products, detergents, cleaning products, gases and vapors are potential sources of poisoning. When it enters the body through various modes of transmission, it can damage or lead to organ failure. Accidental poisoning in the home and even in the healthcare setting is possible. If a patient or parent has questions about poison treatment, a poison control center is the best place to go.
  • Motor vehicles. Seat belts, child restraint systems, rear seat position, helmets and the type of car used reduce accidents and their devastating consequences.
  1. Fire. Smoking in the home is the leading cause of fire-related death, along with stoves, which are the leading cause of home fires and fire-related accidents due to negligent use. For this reason, fire extinguishers, smoke detectors, and carbon monoxide detectors should be located throughout the residence.
  1. Temperature regulation. Health, productivity and safety are negatively affected by extreme temperatures. Exposure to cold can induce unintentional frostbite and hypothermia. Extreme heat depletes the body's electrolytes and raises the body's core temperature, leading to heat stroke.

Risk factors for patient safety

  • Physical and cognitive state
  • Environmental factors (health care, hospitalization and home environment)
  • lifestyle choices
  • Knowledge
  • security awareness
  • Current level of development
  • Impaired physical and mental function.
  • Impaired senses and mobility.
  • Age
  • underlying infection
  • substance abuse
  • Smoke
  • Isolation
  • Unsafe housing and clothing
  • misdiagnoses
  • Lack of communication
  • language barrier
  • Safety issues in the workplace
  • Medicines
  • physical deficiency

Nursing Considerations for Patient Safety

  • Employ patient education on the importance of sticking with the procedure or plan of care.
  • Ask the patient to remove restrictive clothing and jewelry that may increase the risk of falls.
  • Monitor temperature to rule out infection.
  • Patients receiving digoxin should regularly monitor their serum digoxin level. Patients experiencing complications should be advised to immediately inform the treating physician of possibledigoxintoxicity. In addition, they should be encouraged to take the medication as directed.
  • Examine the skin and note its features.
  • Install handrails and safety sheets for patients with impaired cognitive and physical functions. Educate the patient in fall prevention techniques.
  • Help patients with visual and physical disabilities during activities of daily living (ADL).
  • Document parent-child interaction in case of suspected child abuse. Provide the opportunity to communicate and identify verbal and non-verbal cues that may indicate child abuse and neglect.

Nursing Process for Patient Safety (ADPIE)

  1. Assessment

The evaluation, the first stage of the Nursing Process (ADPIE), implies the collection of data and information.subjective or objectivedata. Subjective data is collected through the patient's verbal statement. Meanwhile, objective data is observable and measurable using all five (5) senses, such as vital signs, temperature, blood pressure, height, and weight. Nursing care plans are largely based on assessment, and if the assessment is wrong, the diagnosis will be inaccurate.

The patient safety assessment includes:

(Video) Nursing Diagnosis for Fall Risk and Fall Risk Nursing Diagnosis and Nursing Care Plans

  • patient identification
  • Communication and Consultations
  • risk assessment
  • Assessment of the effect of an underlying disease
  • Medical history

2. Diagnosis

A nursing diagnosis is developed from the information acquired during the assessment. Nursing diagnoses are developed to help plan and provide patient care. Furthermore, it should be developed using Maslow's Hierarchy of Needs as a framework. At this stage, the nurse diagnoses the patient's level of safety by identifying actual problems and potential problems or risks, such as risk of falls, risk of injury, risk of poisoning, poor knowledge, risk of trauma, and risk of suffocation.

3. Planning

Based on the nursing diagnosis, the health team plans to promote and maintain patient safety. Health professionals will work together to plan an appropriate treatment approach for the patient. When formulating care plans, nurses have specific goals (SMART) to ensure a favorable outcome. SMART goals stand for specific, measurable, achievable, realistic, and time bound. For nurses to develop SMART goals, they must communicate with patients about their concerns, preferences, self-care goals, and emotional state. This step includes establishing nursing goals, desired outcomes, and interventions.

4. Implementation

The implementation phase has commonly employed direct care and indirect care. Direct care is the relationship between a health professional and a patient. It involves the active participation and practical care of the health professional to help the patient achieve her goals to promote and maintain patient safety. On the other hand, indirect care services do not require presence or interaction with patients.

5. Evaluation

The evaluation is the step in which the health professional critically considers the results of the nursing action to know if the desired result has been achieved. Regarding patient safety, the main question to evaluate the nursing plan and the actions taken is: "Is the patient safe during the shift/at discharge?" During the evaluation phase, nurses determine whether their actions had a beneficial or negative effect on patient safety. A nursing plan and its implementation are considered effective if the plan of care is appropriate or beneficial to the patient's condition. On the other hand, if the patient's condition does not improve or worsens, the nursing procedure is ineffective. Some examples of patient safety assessments include:

  • The patient verbalizes understanding of safety risks.
  • The patient is free of injuries and complications.
  • Breathing is easy and discreet.
  • The patient minimizes exposure to toxic substances and harmful agents.

Safety Nursing Diagnosis

Safety Nursing Care Plan 1

risk of falls

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Nursing Diagnosis: Risk of Falls related to altered sensory perception and loss of muscle strength, secondary to the possible compromise of patient safety.

Desired Outcome: The patient will demonstrate the use of fall prevention techniques.

Nursing interventions for safetyJustification
Assess for any factors that increase the patient's likelihood of falling, especially when there is a change in physical or cognitive function.Both internal and environmental factors can estimate the risk of falling. Since falls can cause injury, risk assessment can identify whether or not patient safety is at risk. People suffering from decreased awareness and disorientation may not know their whereabouts. There is a chance that they will become disoriented and end up in a dangerous situation. Meanwhile, patients with visual and hearing impairments have difficulty perceiving and hearing potential hazards in their environment. Conversely, age-related macular degeneration makes older patients more prone to falls and other injuries.
Assess the patient's ambulation and note any movement difficulties.The evaluation will help in the management of the patient. It would also allow the nurse to tailor or adjust the plan of care to meet the specific needs of the patient.
Evaluate the use of mobility aids.Improper use of a cane or walker increases the risk of tripping and falling. Furthermore, it can lead to energy depletion, movement tremors, and even joint damage if used incorrectly. As a result, education programs on the proper functioning of ambulatory devices for activities of daily living (ADLs) should be available.
Examine unsafe clothingAn increased risk of falls can be attributed to ill-fitting or excessively tight clothing and footwear.
Observe the physical environment of the patient.People who are unfamiliar with their surroundings, such as when moving furniture and equipment, are more likely to trip and fall. Environmental hazards contribute significantly to falls due to exposure to fall hazards.

Safety Nursing Care Plan 2

risk of poisoning

Nursing Diagnosis: Poisoning risk related to insufficient knowledge and precautions, secondary to the possible compromise of patient safety.

Desired results:

  • The patient will be able to identify the symptoms of digitalis poisoning and the appearance of complications.
  • The patient will be free of drug or chemical toxicity/poisoning.
Nursing interventions for safetyJustification
Evaluate the environmental conditions of the patient. If necessary, protect potentially dangerous areas for children.For safety reasons, common cleaning products and medicines are kept out of the reach of children. For example, a 1-year-old patient has a tendency to put objects in his mouth. Pediatric patients will be less likely to be exposed to potentially hazardous substances if potentially hazardous areas are protected from children.
Remove or label all potentially toxic materials from the patient's home environment, including alcohol, disinfectants, pharmaceuticals, household cleaners, and pesticides.Notifying parents of potentially hazardous materials will effectively protect pediatric patients from exposure to harmful toxins.
Install carbon monoxide detectors in all areas of the patient's home.Carbon monoxide poisoning can occur seconds after inhaling toxic fumes.
For patients withcongenital heart failure (CHF)and cardiac arrhythmias:
Instruct the patient about the type of digitalis prescribed, how it is used therapeutically, and the risk of digitalis toxicity.There are numerous digitalis preparations, each with its unique name, dosage, mechanism of action, and onset of action. To avoid confusion, it is essential to describe the precise type of digitalis being administered to the patient. In addition, patient education contributes to the development of a fundamental understanding of the disease and its treatment.
Educate the patient about the consequences of changing medication doses.Dose increases or decreases will influence the activity, mode of action, and therapeutic effect of the drug and, in the worst case, lead to toxicity and complications.
Instruct the patient to report any signs or symptoms of poisoning as soon as they are noticed.The presence of nausea, diarrhea, lethargy, drowsiness, mental changes, blurred vision, dyspnea, and altered color perception may suggest the need for immediate intervention.

Safety Nursing Care Plan 3

choking hazard

Nursing Diagnosis: Asphyxiation risk related to inadequate air available for inhalation, secondary to possible compromised patient safety.

Desired Outcome: The patient will demonstrate preventative strategies to maintain a patent airway.

Nursing interventions for safetyJustification
Examine the patient for changes in skin color, severe dyspnea, lethargy, elevated pulse, and intercostal retractions during inhalation.It provides data on increasing airway blockage, which can increase the risk of choking. Also, obvious chest retractions and shortness of breath often denoteimpaired gas exchange.
Monitor the patient's oxygen levels and administer oxygen as needed.This prevents hypoxemia and promotes oxygen delivery.
Monitor for abnormal breath sounds (eg, gurgling, gurgling) and shortness of breath.Serious complications can be avoided if treated promptly.
Explain patient treatment and interventions in plain language, including the need for emergency intubation,Mechanic ventilationand tracheotomy.Patients with existing respiratory complications may require intubation devices and assisted ventilation to promote airway patency and ventilation. It also establishes the airway in respiratory failure and asphyxia, thus ensuring the well-being of the patient.
Place pregnant patients in semi-fowler and fowler positions to ensure adequate oxygenation.These positions ensure that the mother and fetus receive optimal oxygenation and circulation. It also relieves the symptoms of acid reflux, leading todyspnoeaand suffocation.

Safety Nursing Care Plan 4

risk of trauma

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Nursing Diagnosis: Risk of trauma related to situational exposure or encounter, secondary to possible compromise of patient safety.

Desired outcome: The patient will not be subjected to mistreatment or abuse.

Nursing interventions for safetyJustification
Assess parents' responses, expectations, and feelings about their children's behavior and assess their abilities to comfort them.Reveal potential exploits and abuses that endanger patient safety.
Assess the patient's environment. Add padding to the side rails and raise them while the bed is in the lowest position. Secure the brakes on the bed, stretcher or even the wheelchair.These actions promote safety and protect the patient from accidental or self-inflicted injuries. Patients with post-traumatic stress disorder (PTSD) or a traumatic childhood are more likely to self-harm.
Get a complete log of events and history.Provides information that can be used in legal proceedings related to allegations of abuse. In the event of a lawsuit, medical records must be as accurate, factual, and objective as possible. These include uncommented documents, impressions, and interpretations. Factual records include: health records, full description of condition, photographs documenting injuries, child's verbal responses to parents and others, description of behaviors and interactions.
Encourage positive behavior by providing occasional feedback and encouragement.This encourages good behavior and conduct, reducing the likelihood of re-trauma relapse.
Notify authorities of any suspected child abuse and neglect (CAN)Documentation and reporting of child abuse varies by state. It is mandatory to comply with state regulations and raise suspicions of CAN.
Foster a therapeutic environment.It encourages self-expression and helps patients make sense of their thoughts and feelings in order to deal more effectively with the aftermath of childhood abuse.
Support the child in coping with grief if they need a foster homeWhen a child is placed in foster care, they may experience mixed emotions of remorse, relief, and shame. A child's progress and development improves when health professionals help them through the grieving process.
Refer families to child protection and social service agencies for help.The type of abuse and the requirements of the parents are taken into account in the development of social activities, education and support. In addition, it helps to alleviate the cause of neglect.

Safety Nursing Care Plan 5

risk of injury

Nursing Diagnosis: Risk of Injury related to changes in mental and health status, secondary to possible compromise of patient safety.

Desired results:

  • The patient will maintain safe conditions without reporting injuries.
  • The patient will be free of injury and will modify the environment to ensure safety.
Nursing interventions for safetyJustification
Assess changes in health status and cognition.Injuries can occur when a patient's health situation changes. A postoperative patient may become disoriented or forgetful, putting them at risk of falling and injury. Loss or impairment of one or more senses can limit a person's response to environmental stimuli putting the patient at risk for falls and injury.
Determine the client's ambulation level and risk of falling using the Morse Fall Scale (MFS).Falls are more likely to occur when a person's mobility is impaired due to muscle weakness, paralysis, poor balance, or incoordination. Measuring your mobility using an assessment tool will help determine the degree of disability and the need for intervention.
Conduct a risk assessment of the patient environment.Dementia and other forms of cognitive dysfunction put patients at risk of injury from common hazards (including the home and care setting). The patient's environment can be inspected for items that put the patient at risk of injury, such as clutter and inadequate lighting. In addition, its objective is to identify objects or elements that can be used in suicidal hanging.
Protect the patient with a medical alarm system and watch out for alarm fatigueMedical alert systems are activated in emergencies to notify medical personnel that a patient is experiencing physiologic changes that require immediate treatment. Meanwhile, alarm fatigue or alert fatigue is a common safety issue in healthcare settings. This happens when someone is subjected to too many regular alarms (alerts) and overwhelms the healthcare professional, resulting in subsequent desensitization.
Refrain from using physical or chemical restraints.Physical restraints should only be used as a last resort when other, less restrictive methods have failed and the patient is at risk of injury to himself or others.
Recognize patient concerns about environmental hazards.Patients can feel validated when they receive verbal confirmation that the nurse has heard and understood their concerns. It also improves the relationship between the nurse and the patient.
Help visually impaired patients and their caregivers understand the importance of using labels in high-contrast colors, such as yellow or red, to mark critical areas in their environment (eg, stair edges, light switches).Visually impaired people can safely navigate the environment by assigning bright colors to objects because they are easier to perceive visually. Patients who have to wake up in the middle of the night may find it helpful to set lighting in certain areas to help with vision.

Nursing References

Ackley, B.J., Ladwig, G.B., Makic, M.B., Martinez-Kratz, M.R. y Zanotti, M. (2020).Nursing Diagnosis Manual: An Evidence-Based Guide to Care Planning. St. Louis, MO: on amazon

Gulanick, M. y Myers, J. L. (2022).Nursing care plans: diagnoses, interventions and results. St. Louis, MO: on amazon

Ignatavicius, D.D., Workman, ML, Rebar, C.R. y Heimgartner, N.M. (2018).Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: on amazon

Silvestri, LA (2020).Saunders Comprehensive Review for the NCLEX-RN Exam. St. Louis, MO: on amazon


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The medical information on this website is provided as an information resource only and is not to be used or misused for diagnostic or treatment purposes.

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This information is intended for nursing education and should not be used as a substitute for professional diagnosis and treatment.

Safety Nursing Diagnosis and Nursing Plan - NurseStudy.Net (1)


What is the difference between nursing care plan and nursing diagnosis? ›

Patient-centered care: Care plans help to ensure that patients receive evidence-based, holistic care. Nursing diagnoses are standardized to ensure quality care, but nursing interventions are tailored to meet the physical, psychological, and social needs of the individual patient.

How do I get a Nanda nursing diagnosis? ›

Nursing diagnoses must include the problem and its definition, the etiology of the problem, and the defining characteristics or risk factors of the problem. The problem statement explains the patient's current health problem and the nursing interventions needed to care for the patient.

What are the 3 different types of nursing problems diagnoses as defined by Nanda? ›

There are 4 types of nursing diagnoses according to NANDA-I. They are: Problem-focused. Risk.
  • Problem-focused diagnosis. A patient problem present during a nursing assessment is known as a problem-focused diagnosis. ...
  • Risk nursing diagnosis. ...
  • Health promotion diagnosis. ...
  • Syndrome diagnosis.

What are the 4 types of nursing diagnosis? ›

NANDA-I recognizes four categories of nursing diagnoses: problem focused diagnosis, risk diagnosis, health promotion diagnosis, and syndrome. Problem focused diagnoses, also known as actual diagnoses, are patient issues or problems that are present and observable during the assessment phase.

What are the 5 components of nursing care plan? ›

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.

What are the five types of nursing diagnosis? ›

There are five types of nursing diagnoses: problem-focused, risk, possible, health promotion, and syndrome. A problem-focused nursing diagnosis “describes human responses to health conditions/life processes that exist in an individual, family, or community.

What are 10 nursing diagnosis? ›

The following are nursing diagnoses arising from the nursing literature with varying degrees of authentication by ICNP or NANDA-I standards.
  • Anxiety.
  • Constipation.
  • Pain.
  • Activity Intolerance.
  • Impaired Gas Exchange.
  • Excessive Fluid Volume.
  • Caregiver Role Strain.
  • Ineffective Coping.

How do I write a NANDA nursing care plan? ›

How to Write a Nursing Care Plan
  1. Step 1: Assessment. The first step in writing an organized care plan includes gathering subjective and objective data. ...
  2. Step 2: Diagnosis. ...
  3. Step 3: Outcomes and Planning. ...
  4. Step 4: Implementation. ...
  5. Step 5: Evaluation.
Jul 19, 2022

Which is the best example of a nursing diagnosis? ›

Which is the best example of a nursing diagnosis? Ineffective Breastfeeding related to latching as evidenced by non-sustained suckling at the breast. The formulation of nursing diagnoses is unique to the nursing profession.

What is the difference between risk nursing diagnosis and actual nursing diagnosis? ›

An example of an actual nursing diagnosis is: Ineffective airway clearance related to decreased energy as manifested by an ineffective cough. Risk diagnosis - a statement about health problems that a client doesn't have yet, but is at a higher than normal risk of developing in the near future.

What is an example of a risk nursing diagnosis? ›

Risk-related diagnoses only contain a NANDA-I diagnosis and an as evidenced by statement because it is describing a vulnerability, not a cause. For example, a nurse may use a nursing diagnosis such as "risk for pressure ulcer as evidenced by lack of movement, poor nutrition, and hydration."

What are the three phases of nursing diagnosis? ›

The diagnosis phase of the nursing process involves three main steps: data analysis, identification of the patient's health problems, risks, and strengths, and formation of diagnostic statements.

What is a 3 part nursing diagnosis statement? ›

A nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis). BUILDING BLOCKS OF A DIAGNOSTIC STATEMENT. Components of an NDx may include problem, etiology, risk factors, and defining characteristics.

What are the 4 steps to diagnosis? ›

  • Step 1: Identify the Problem. ...
  • Step 2: Frame the Differential Diagnosis. ...
  • Step 3: Organize the Differential Diagnosis. ...
  • Step 4: Limit the Differential Diagnosis. ...
  • Step 5: Explore Possible Diagnoses Using History and Physical Exam Findings. ...
  • Step 6: Rank the Differential Diagnosis.

What are the three parts of a patient care plan? ›

Care plans are a way to strategically approach and streamline the nursing process.
Care Plan Fundamentals
  • The What: What does the patient suffer from? ...
  • The Why: Why does your patient suffer from this? ...
  • The How: How can you make this better?
Dec 7, 2021

What are the 6 C's of nursing? ›

The 6Cs of nursing are:
  • Care.
  • Compassion.
  • Competence.
  • Communication.
  • Courage.
  • Commitment.

What are the 4 P's in nursing care? ›

A structured approach involves addressing the “4 Ps” during each rounding visit:
  • Pain (Is it controlled?)
  • Personal Needs (Does the patient need hydration or nutrition, the restroom, etc.?)
  • Position (Is the patient comfortable?)
  • Placement (Are personal items and the call light within reach?

What are the 7 pillars of nursing? ›

The seven platforms:
  • Being an accountable professional.
  • Promoting health and preventing ill health.
  • Assessing needs and planning care.
  • Providing and evaluating care.
  • Leading and managing nursing care and working in teams.
  • Improving safety and quality of care.
  • Coordinating care.
Oct 21, 2022

What is NANDA 3 part format? ›

A care plan is then developed for that nursing diagnosis and is based on the North American Nursing Diagnosis Association (NANDA) evidence-based research. The nursing diagnosis is comprised of three parts: problem/definition, etiology, characteristics and risk factors.

What are the basic nursing diagnosis? ›

Definition of a Nursing Diagnosis

A nursing diagnosis is defined by NANDA International (2013) as a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community.

What are the categories of 21 nursing problems? ›

The 21 nursing problems fall into three categories: physical, sociological, and emotional needs of patients; types of interpersonal relationships between the patient and nurse; and common elements of patient care.

What is the nursing diagnosis priority order? ›

Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018).

How do you write a care plan example? ›

Every care plan should include:
  1. Personal details.
  2. A discussion around health and well being goals and aspirations.
  3. A discussion about information needs.
  4. A discussion about self care and support for self care.
  5. Any relevant medical information such as test results, summary of diagnosis, medication details and clinical notes.
Feb 14, 2022

What are the 5 smart goals in nursing? ›

What Are Nursing SMART Goals?
  • Be specific. Setting broad nursing goals allows them to be open for interpretation. ...
  • Keep it measurable. For goals to be effective, there must be some way to measure your progress. ...
  • Keep it attainable. ...
  • Be realistic. ...
  • Keep it timely.
Aug 3, 2018

What is a NANDA statement? ›

The function of NANDA is to standardize the language and procedures used to develop a nursing diagnosis. The goal of NANDA: Conduct and fund research to refine nursing diagnoses and outcomes. Develop standards in nursing care and diagnosis.

Can rn make nursing diagnosis? ›

A nurse making a diagnosis must be working under strict protocol or direct supervision of a physician. Any other diagnosis made by a nurse constitutes the unauthorized practice of medicine. The term nursing diagnosis is often used as the title of a nursing care plan.

What is the most common diagnosis in nursing homes? ›

The top condition on our list is essential (primary) hypertension, with 3.30% of claims. This makes sense since nearly one in two adults in the U.S. has hypertension.

What does NANDA define as a risk nursing diagnosis? ›

Risk Nursing Diagnosis

A clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.

How do you identify patient safety risks? ›

A number of research approaches can be used at stage 1 to identify risks and hazards including the use of medical records and administrative record review, event reporting, direct observation, process mapping, focus groups, probabilistic risk assessment, and safety culture assessment.

What is the nursing goal for safety? ›

These goals specify best clinical practice in a number of areas including: correct patient identification, communication among medical providers, the safe use of medications, infection prevention, patient safety risks, the prevention of surgical mistakes, fall prevention, and pressure ulcer prevention, among others.

What are the example of risk in health and safety? ›

physical - radiation, magnetic fields, pressure extremes (high pressure or vacuum), noise, etc., psychosocial - stress, violence, etc., safety - slipping/tripping hazards, inappropriate machine guarding, equipment malfunctions or breakdowns.

What are the three types of planning nursing? ›

Types of Nursing Care Plans

Formal - This is a written or computerized plan that organizes and coordinates the patient's care information and plan. Standardized - Nursing care for groups of patients with everyday needs. Individualized - A care plan tailored to the specific needs of the patient.

Who is responsible for making a nursing diagnosis? ›

Nursing diagnoses are developed by nurses, for use by nurses. For example, NANDA International (NANDA-I) is a global professional nursing organization that develops nursing terminology that names actual or potential human responses to health problems and life processes based on research findings.

What are the 3 C's in nursing? ›

Perspective: Consistency, Continuity, and Coordination—The 3Cs of Seamless Patient Care. Amid our efforts to improve health care quality, we can easily lose sight of the most basic questions. Consider evidence-based clinical guidelines, protocols, and pathways.

What are the 5 stages of the nursing process? ›

  • The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Assessment. ...
  • Diagnosis. ...
  • Outcomes / Planning. ...
  • Implementation. ...
  • Evaluation.

What are the NANDA domains? ›

Domain 1: health promotion. Domain 2: nutrition. Domain 3: elimination and exchange. Domain 4: activity/rest.

What are the 3 types of diagnosis? ›

Sub-types of diagnoses include: Clinical diagnosis. A diagnosis made on the basis of medical signs and reported symptoms, rather than diagnostic tests. Laboratory diagnosis.

What are the three levels of diagnosis? ›

Stages in reaching a diagnosis

We found that diagnostic reasoning can be split into a three stage model: initiation of diagnostic hypotheses; refinement of the diagnostic hypotheses; and defining the final diagnosis (fig 1)​ . Different strategies are used in each stage.

In what order do you write a diagnosis? ›

  1. Step One: Identify Presenting Problems, Symptoms, and Observations. ...
  2. Step Two: Cluster Related Symptoms, Observations, and Presenting Problems. ...
  3. Step Three: Identify Potential Diagnoses. ...
  4. Step Four: Locate the Diagnosis and Its Criteria Table in the DSM. ...
  5. Step Five: Apply Relevant Diagnostic Principles.

What are the 4 C's of patient centered care? ›

Background: The four primary care (PC) core functions (the '4Cs', ie, first contact, comprehensiveness, coordination and continuity) are essential for good quality primary healthcare and their achievement leads to lower costs, less inequality and better population health.

What are patient safety plans? ›

The Patient Safety Program is designed to enhance patient care delivery and prevent adverse outcomes of care by utilizing a systematic, coordinated and continuous approach to the improvement of patient safety.

What are key elements of a care plan? ›

Information that should be included within a comprehensive care plan can be grouped into eight components including:
  • Clinical assessment and diagnosis.
  • Goals of care.
  • Risk screening and assessment.
  • Planned interventions.
  • Activities of daily living.
  • Monitoring plans.
  • People involved in care.
  • Discharge planning.

What is nursing diagnosis in nursing care plan? ›

The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs.

What is meant by nursing diagnosis? ›

A nursing diagnosis is “a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

What is the difference between diagnosis and nursing diagnosis? ›

What is the difference between a medical diagnosis and a nursing diagnosis? A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes.

What is the meaning of nursing care plan? ›

What Is a Nursing Care Plan? A nursing care plan documents the process of identifying a patient's needs and facilitating holistic care, typically according to a five-step framework. A care plan ensures collaboration among nurses, patients, and other healthcare providers.

What are the five purpose of nursing diagnosis? ›

sharpen their problem-solving and critical thinking skills. The five stages of the nursing process are assessment, diagnosing, planning, implementation, and evaluation. In the diagnostic process, the nurse is required to have critical thinking.

Why is nursing diagnosis important? ›

The nursing diagnosis is a clinical judgment that identifies a health problem and is the basis for the nurse to describe the objectives and interventions to be performed [4,5].

What are the two types of nursing diagnosis? ›

The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.

Why is cough not a nursing diagnosis? ›

A cough is a symptom, rather than a diagnosis of disease. As such, many patients present for evaluation of the secondary or underlying effects of a cough rather than a cough itself. Essential components of the history taking session should include: Details about duration.

What are the two types of diagnosis? ›

Clinical diagnosis. A diagnosis made on the basis of medical signs and reported symptoms, rather than diagnostic tests. Laboratory diagnosis. A diagnosis based significantly on laboratory reports or test results, rather than the physical examination of the patient.

What are the 4 key steps to care planning? ›

Here are four key steps to care planning:
  • Patient assessment. Patient identified goals (e.g. walking 5km per day, continue living at home) ...
  • Planning with the patient. How can the patient achieve their goals? ( ...
  • Implement. ...
  • Monitor and review.

What are the three types of care plans? ›

They include; "nursing plan", "treatment plan", "discharge plan" and “action plan". While these terms refer to aspects of the care planning process, they do not include the concept of patient involvement and shared decision making, which is key to the care planning process.

What are the three components of a care plan? ›

A care plan consists of three major components: The case details, the care team, and the set of problems, goals, and tasks for that care plan.


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