Diagnosing Group III

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    Polii, Paul

    Pontororing, Jonly

    Rompas, Heiber

    Retor, Wanlie

    Sepang, Geriel

    Selamat, Valentino

    Puni, Hizkia

    Preisilia Fristy

    Sinaulan, Finne

    Sriwidyawati Meida

    Sumanti, Lady

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    Learning Objectives

    Describe the term nursing diagnosis,distinguishing it from a collaborativeproblem and a medical diagnosis.

    Describe the four steps involved in data

    interpretation and analysis. Use the guidelines for writing nursing

    diagnoses when developing diagnosticstatements.

    Describe means to validate nursingdiagnoses.

    Describe the benefits and limitations ofnursing diagnoses.

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    Lady

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    Diagnosing

    After the nurse has collected and recorded thepatient data, the work of diagnosing begins (the second step in the nursing process ).

    The purpose of diagnosing is to:

    1. Identify how an individual, group orcommunity responds to actual or potentialhealth and life processes

    2. Identify factors that contribute to or causehealth problems (etiologies).

    3. Identify resources or strengths the individual,group or community can draw on to preventor resolve problems.

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    Cont...

    In the diagnosing step of the nursingprocess, the nurse interprets andanalyzes data gathered from the

    nursing assessment. The data helpthe nurse identify patient strengthsand health problems.

    A health problem is a condition that the

    necessitates intervention to prevent orresolve disease or illness or topromote coping and wellness.

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    Cont...

    Alfaro-LeFevre (2004), lists the following as the type of nursingconcerns that are clearly nursing responsibilities:

    1. Monitoring for change in health status.

    2. Promoting safety and preventing harm, detecting andcontrolling risks.

    3. Identifying and meeting learning needs.

    4. Tailoring treatment and medication regimens for eachindividual.

    5. Promoting comfort and managing pain.

    6. Promoting health and a sense of well being.

    7. Recognizing and addressing problem that impede the ability

    to be independent and live a healthy lifestyle.8. Determining human responses (how individuals, families or

    groups respond to health problems or life changes).

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    Cont...

    When a health problem is identified,the nurse must decide which

    healthcare professional can best treat

    the problem. Actual or potential healthproblems that can be prevented or

    resolved by independent nursing

    intervention are termed nursingdiagnoses.

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    Meida

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    Key elements in the evolution of nursing

    diagnosis as and integral component of

    nursing process include the following: In 1953, the term nursing diagnosis was

    introduce by V. Fry (1953) to describe a

    step necessary in developing a care plan.

    In 1972, the New York State Nurse Practice

    Act identified diagnosing as part of the legal

    domain of professional nursing.

    In 1973, The American Nurses AssociationsStandards of Practice include diagnosing as

    a function of professional nursing

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    Also in 1973, Gebbie and Lavin, of St.

    Louis University, called the First

    National Conference on Classification of

    Nursing Diagnoses, beginning a

    national effort to identify, standardize

    and classify health problem treated bynurses:

    In 1980, the ANA Social Policy

    Statement defined nursing as thediagnosis and treatment of human

    responses to actual or potential health

    problem.

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    In March 1990, at the Ninth Conference of

    NANDA, the General Assembly approved an

    official definition of nursing diagnosis:

    Nursing diagnosis is a clinical judgment

    about individual, family or community

    responses to actual or potential health

    problem/life processes. Nursing diagnosisprovides the basis for selection of nursing

    interventions to achieve outcome for which

    the nurse accountable.

    NANDA conferences are held every 2 years,and much progress continues to be made in

    defining, classifying and describing nursing

    diagnoses.

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    NURSING DIAGNOSIS

    VERSUS MEDICAL DIAGNOSIS Medical diagnoses identify diseases, whereas

    nursing diagnoses focus on unhealthy

    responses to health and illness.

    Medical diagnoses describe problems for which

    the physician directs the primary treatment,

    whereas nursing diagnoses describe problems

    treated by nurses within the scope of

    independent nursing practice.

    A medical diagnosis remains the same for as

    long as the disease is present, where a nursing

    diagnosis may change from day to day as the

    patients responses change. These distinctionsreflect key difference in medical and nursing

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    Heiber

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    Nursing Diagnosis Versus

    Collaborative Problems Carpenito defines collaborative

    problemsas certain physiologiccomplications that nurses monitor to

    detect onset or changes in status.Nurses manage collaborative

    problems using physician-prescribed

    and nursing-prescribed interventionsto minimize the complications of the

    event.

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    Cont...

    Unlike medical diagnoses, collaborativeproblems are the primary responsibilityof nurses.

    Unlike nursing diagnoses, withcollaborative problems, the prescriptionfor treatment comes from nursing,medicine, and other disciplines. When

    the nurse writes patient outcomes thatrequire delegated medical orders for goalachievement, the situation is not anursing diagnosis, but a collaborative

    problem.

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    Cont...

    Because collaborative problemsinvolve potential complications, they

    must be identified early so that

    preventive nursing care can beinstituted early.

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    Ovarian Cancer Radiotherapy ExploratoryLaparotomy

    Fi ure 13-4 Collaborative Problems

    Medical

    diagnosis/disea

    se

    Medical/Surgical

    Nursing

    Treatment

    Diagnostic

    Study

    PC: Cachectic

    syndrome

    related to

    disease process

    PC: Paralytic

    ileus related toanesthesia

    PC: Infection

    related to stageIII skin reaction

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    Wanlie

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    LEGAL ALERT: ALFAROS

    RULE

    The term diagnose and diagnosis have legalimplications. They imply that there is a specific

    problem that requires management by a qualified

    expert.

    If you make a diagnosis, it means that you accept

    accountability for accurately naming and managingthe problem.

    If you treat a problem or allow a problem to persist

    without ensuring that the correct diagnosis has been

    made, you may cause harm and be accused ofnegligence.

    You are accountable for detecting, identifying, or

    recognizing signs and symptoms that might indicate

    problems beyond your expertise. Example: staff

    nurses are not qualified to diagnose and manage

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    Cont...

    However, they are accountable for: Detecting and reporting signs and symptoms of

    pneumonia (for example, fever, productive cough,

    malaise).

    Diagnosing and managing risk factors forpneumonia (for example, weak breathing efforts

    due to surgical pain, spinal cord injury, or disease;

    in complicated cases, these risk factors may

    require medical management).

    Diagnosing and managing human responses to

    pneumonia (for example, fatigue and problems

    with airway clearance relates to pneumonia).

    Ensuring that the medical treatment plan is

    implemented as prescribed (Alfaro-LeFevre, 2004-

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    DIAGNOSTIC REASONING

    AND CRITICAL THINKING

    Selamat

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    . Be familiar with nursing diagnoses andother health problems; read professionalliterature and keep reference guides handy

    . Trust clinical experience and judgment, butbe willing to ask for help when the situationdemands more than your qualifications andexperience can provide.

    . Respect your clinical intuitions, but before

    writing a diagnosis without evidence,increase the frequency of your observationsand continue to search for cues to verifyyour intuitions.

    . Recognize personal biases and keep an

    To correctly diagnose health

    problems:

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    Hizkia

    Q ti t f ilit t iti l thi ki

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    Questions to facilitate critical thinking

    during diagnostic reasoning include:

    . Are my data accurate and complete? . Has the patient or the patients

    surrogates validated (if able to do so)that the these are important problems?

    . Have I given the patient or thepatients surrogate an opportunity toindentify problems that may have

    missed? . Is each diagnosis supported by

    evidence? Might these cues signify adifferent problem or diagnosis?

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    . Have I tried to identify what is causing

    the actual or potential problem and what

    strengths/resources the patient mightuse to avoid to resolve the problem?

    . Have a used agency guidelines to

    correctly document diagnosticstatements in a way that clearly

    communicates patient problems to other

    healthcare professionals? . Is this a problem that falls within

    nursings independent domain or does it

    signify a medical diagnosis or

    collaborative roblem.

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    Finne

    DATA

    INTERPRETATIONAND ANALYSIS

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    RECOGNIZING SIGNIFICANT

    DATA To avoid erroneously labeling selected

    patient health patterns as unhealthy

    (diagnostic error) while failing to detect

    an actual unhealthy behavior, nursesmust be familiar with comparative

    standards to be used in data

    interpretation and analysis.

    A standard, or a norm, is a generally

    accepted rule, measure, pattern, or

    model to which data can be compared in

    the same class or category.

    Examples of how standards can be used to

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    Examples of how standards can be used to

    indentify significant cues include the following

    (Gordon,1994):

    Changes in a patients usual healthpatterns that are unexplained by

    expected norms for growth and

    development. Deviation from an appropriate

    population norm.

    Behavior that indicates adevelopmental lag or evolving

    dysfunctional pattern.

    Behavior that is nonproductive in the

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    RECOGNIZING PATTERNS OR

    CLUSTERS

    A data cluster is a grouping of patient

    data or cues that points to the

    existence of a patient health problem. Nursing diagnoses should always be

    derived from clusters of significant

    data rather that from a single cue.

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    Preisilia

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    INDENTIFYING STRENGTHS AND

    PROBLEMS

    The next step in analyzing data is todetermine the patients strengths and

    problems.

    When determining a patientsstrengths and problems, it is helpful to

    determine whether the patient agrees

    with the nurses identification ofstrengths and problems and is

    motivated to work toward their

    resolution.

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    DETERMINING THE PATIENTS

    STRENGTHS

    If a patient appears to meet a

    standard, the nurse concludes that the

    patient has a strength in that particulararea, and that this strength contributes

    to the patients level of wellness.

    1

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    DETERMINING THE PATIENTS

    PROBLEM AREAS

    A person who does not meet a certainhealth standard probably has alimitation in this aspect of health statusand may benefit from professionalcare.

    the nurse decides whether the datarepresent a nursing diagnosis or a

    collaborative problem, or whether thedata should be reported to thephysician because they might lead toa medical diagnosis.

    2

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    DETERMINING PROBLEMS THE

    PATIENT IS LIKELY TO EXPERIENCE

    It is important for nurses to identifypotential health problems.

    3

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    REACHING CONCLUSIONS

    The nurse reaches one of four basicconclusions after interpreting and

    analyzing the patient data.

    4

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    Finne

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    Cont

    Different nursing responses are possiblefoe each conclusion:

    * No Problem

    No nursing response is indicated. Reinforce patients health habits and

    patterns

    Initiate health-promotion activities toprevent disease or illness or to promote

    a higher level of wellness.

    Wellness diagnosis might be indicated.

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    Cont

    *Possible Problem Collect more data to confirm or

    disprove suspected problem.

    *Actual Or Potential NursingDiagnosis

    Begin planning, implementing, and

    evaluating care designed to prevent,reduce, or resolve the problem.

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    Cont

    If unable to treat problem becausepatient denies problem and refusestreatment, make sure patientunderstands possible out-comes of this

    stance.*Clinical Problem Other Than Nursingdiagnosis

    Consult with appropriate healthcare

    professional and work collaboratively onproblem. Refer to medicine or other service as

    indicated.

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    FORMULATING AND

    VALIDATING NURSING

    DIAGNOSA

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    Writing nursing diagnoses

    When the nurse recognizes a clusterof significant patient data indicating ahealth problem that can be treated byindependent nursing intervention, anursing diagnosis should be written.

    Most nursing diagnoses are writteneither as two-part statements listing

    the patients problem and its cause oras three-part statement that alsoinclude the problems characteristics

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    Formulation of nursing

    diagnosis statements

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    problem purpose example

    Problem

    Etiology

    Defining

    characteristics

    Identifies what

    unhealthy aboutthe patient,

    indicating the

    need for

    change.

    Identifies the

    factors that are

    maintaining the

    unhealthy state

    or response.

    Identify the

    subjective andobjective data

    that signal the

    existence of the

    problem

    Suggests

    patient outcome

    Suggests the

    appropriate

    nursing

    measure.

    Suggests

    evaluativecriteria

    Bathing/hygiene

    self-care deficit.

    Related to

    Fear of falling in

    the tub and

    obesity.

    As manifested

    by

    Strong body and

    urine odor,

    unclean hair, Im

    afraid Ill fall inthe tub and

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    Examples

    Two-part diagnostic statement: Bathing/Hygiene Self-Care Deficit r/t fear

    of falling in tub and obesity.

    Three-part diagnostic statement: Bathing/Hygiene Self-Care Deficit r/t fear

    of falling in tub and obesity. As manifested

    by strong body and urine odor, unclean

    hair, statement of fearing in tub, and

    height and weight 54, 170 lb.

    Type of nursing

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    Type of nursing

    diagnoses NANDA describes five types of

    nursing diagnoses: actual, risk,

    possible, wellness, and syndrome

    1 A t lit i di

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    1. Actuality nursing diagnoses

    Actuality nursing diagnoses represent aproblem that has been validated by

    the presence of major defining

    characteristic. This type of nursingdiagnosis has four component: label,

    definition, defining characteristic, and

    related factor.

    2 Ri k i di

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    2. Risk nursing diagnoses

    Risk nursing diagnoses are clinicaljudgments that an individual, family, or

    community is more vulnerable to

    develop the problem than others in thesame or similar situation

    3 P ibl i di

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    3. Possible nursing diagnoses

    Possible nursing diagnoses arestatement describing a suspected

    problem for which additional data are

    needed.Additional data are used to confirm or

    rule out suspected problem.

    4 W ll di

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    4. Wellness diagnoses

    Wellness diagnoses are clinicaljudgments about an individual, group,

    or community in transition from a

    specific level of wellness to a higher ofwellness.

    Two cues must be present for a valid

    wellness diagnoses:A desire for a higher level of wellness

    An effective present status or function

    5 S d i di

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    5. Syndrome nursing diagnoses

    Syndrome nursing diagnosescomprise a cluster of actual or risk

    nursing diagnoses that are predicated

    to be present because of a certainevent or situation example: rape

    trauma syndrome or post-trauma

    syndrome.

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    Gerryl Sepang

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    Parts of Nursing Diagnoses

    Problem The purpose of the problem statement is to

    describe the health state or health or healthproblem of the patient as clearly andconcisely as possible.

    NANDA recommends use of the followingquantifiers when writing the problemsstatement: ability, anticipatory, balance,compromised, decreased, deficient,defensive, delayed, depleted,disproportionate, disabling, disorganized,disturbed, dysfunctional, effective,excessive, functional, imbalanced, impaired,inability, increased, ineffective, interrupted,low, organized, perceived, and readiness for

    enhanced

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    Cont

    Etiology The etiology identifies the physiologic,

    physiological, sociologic, spiritual, and

    environmental factors believed to berelated to the problem as either a causes

    or a contributing factor.

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    Cont

    Defining characteristic The subjective and objective data that

    signal the existence of the actual or

    potential health problem are the thirdcomponent of the nursing diagnosis

    Guidelines for writing nursing

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    Guidelines for writing nursing

    diagnoses

    - Remember the following to ensure thatyour diagnostic statement are

    correctly written

    1. Phrase the nursing diagnosis as apatient problem or alteration in health

    sate rather than as a patient need.

    2. Check to make sure that the patientproblem precedes the etiology and

    that the to are linked by the phrase

    related to

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    3. Defining characteristic, whenincluded in the nursing diagnosis,

    should follow the etiology and be

    linked by the phrase as manifestedby or as evidenced by.

    4. Write in legally advisable terms

    5. Use nonjudgmental language6. Be sure the problem statement

    indicates what is unhealthy about the

    patient or what the patient wants to

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    7. Avoid using defining characteristic,medical diagnoses, or something that

    cannot be change in the problem

    statement8. Reread the diagnosis to make sure

    the problem statement suggests

    patient outcomes and that etiology willdirect the selection of measure

    Validating nursing diagnoses

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    Validating nursing diagnoses

    After a tentative nursing diagnosis isformulated, it should be validated.

    An affirmative response to each of thefollowing question validates a tentativediagnosis:

    1. Is my database sufficient, accurate,and supported by nursing research?

    2. Does my synthesis of data(significant cues) demonstrate theexistence of a patter?

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    3.Are the subjective and objective data I usedto determine the existence of a patterncharacteristic of the health problem I defined?

    4. Is my tentative nursing diagnosis based on

    scientific knowledge and clinical expertise.5.Is my tentative nursing diagnosis able to be

    prevented, reduced, or resolved byindependent nursing action?

    6. Is my degree of confidence above 50% thatother qualified practitioners would formulatethe same nursing diagnosis based on mydata?.

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    Terry

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    Nursing Diagnosis: A Critique

    The current nursing diagnosis literaturecontains many examples of nurseswriting about how using nursingdiagnoses has improved their clinical

    practice.Articles also detail the many benefits

    nursing diagnosis brings to theprofession.

    Conversely, other articles point out thelimitations of nursing diagnosis and urgenurses to be cautious so that an

    uncritical use of nursing diagnosis does

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    Cont...

    The primary benefit that nursingdiagnosis offers the patient is the

    individualization of patient care.

    For example, nurses might be caring

    simultaneously for three women who had a

    modified radical mastectomy because of

    breast cancer. Although the postoperative

    nursing management of these women is

    similar, priorities of care may differ. A

    prioritized list of nursing diagnoses enables

    nurses to direct their energies toward these

    differing patient priorities.

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    Example

    Patient A Distubed Body Image

    Ineffective Coping

    Patient B Pain

    Bathing/Hygiene Self-Care Deficit

    Patient C Sexual Dysfunction

    Powerlessness

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    Cont...

    Improved communication among nursesand other health care professionals isprobably the most important benefit thataccurate, up to date diagnoses,

    expressed in well defined andstandardized terminology offer nurses.

    This communication aids in planning,charting, patient data retrieval, healthteam conferences, change of shiftreports, and healthcare follow up.

    It also promotes nursing accountability

    for the problems that nurses diagnose.

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    Cont...Among the other benfits of nursing

    diagnoses for the profession is help in

    defining the domain of nursing for helath

    care administrators, legislators, and other

    healthcare providers: this is important whenseeking funding for nursing and

    reimbursement for nursing services.

    Nursing diagnoses are also used to define

    curriculum content and to directspecialization and advancement in nursing

    and nursing research.

    When the diagnostic process is used

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    Common Sources of Error

    Premature diagnoses based on anincomplete database.

    Erroneous diagnoses resulting from

    an inaccurate database or a faultydata analysis.

    Routine diganoses resulting from the

    nurses failure to tailor data collectionand analysis to the unique needs of

    the patient.

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    Cont...

    Errors of omission: Failure to modifydiagnoses and to identify new

    diagnoses as the patients status

    changes may also be problems. Failures in diagnosis lead to failures in

    nursing care.

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    Conclusion

    In conclusion, nursing diagnosis hasbecome a valued and essential step inthe nursing process.

    Used correctly, it is a powerful tool for

    individualizing patient care and ensuresthat nurses energies are being used inthe most efficient way to meet patientsneeds.

    Nurses who are as concerned about theart and spirit of nursing as they are aboutits science are careful to avoid labelingpatients in a way that objectifies them orlimits the potential range of nurse-patient

    interactions.

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