Nursing Diagnosis Formulation (간호 진단 수립)

NCLEX Review Guide: Nursing Process & Documentation

Nursing Process Overview

Five Steps of Nursing Process

Assessment: Systematic collection of subjective and objective data about client's health status
Diagnosis: Analysis of assessment data to identify actual or potential health problems
Planning: Development of goals and interventions to address identified problems
Implementation: Execution of planned nursing interventions
Evaluation: Assessment of client's response to interventions and goal achievement

Memory Aid: ADPIE

Assess → Diagnose → Plan → Implement → Evaluate

Key Points

Assessment is ALWAYS the first step - never skip data collection
The nursing process is cyclical and continuous throughout client care
Each step builds upon the previous one and informs subsequent steps

Nursing Diagnosis Formulation

Types of Nursing Diagnoses

Actual Diagnosis: Present problem supported by defining characteristics (signs/symptoms)
Risk Diagnosis: Potential problem with identified risk factors but no signs/symptoms yet
Health Promotion Diagnosis: Client's motivation to increase well-being and health potential
Syndrome Diagnosis: Cluster of actual or risk diagnoses predicted to occur together

Diagnosis Format Comparison

Type	Format	Example
Actual	Problem + Related to + Evidence	Acute Pain r/t surgical incision AEB grimacing, rating 8/10
Risk	Risk for + Problem + Risk Factors	Risk for Falls r/t weakness and confusion
Health Promotion	Readiness for Enhanced + Area	Readiness for Enhanced Nutrition

Clinical Example

Scenario: 68-year-old post-operative client, day 1 after hip replacement, reports pain 7/10, reluctant to move, shallow breathing

Nursing Diagnosis: Acute Pain related to surgical trauma as evidenced by verbal report of 7/10 pain, guarding behavior, and reluctance to move

Documentation Principles

Legal Documentation Requirements

Document immediately after providing care to ensure accuracy and legal protection
Use objective, factual language - avoid subjective interpretations or judgmental terms
Include date, time, and signature on all entries with credentials
Document client's exact words in quotation marks when recording subjective data

Documentation Memory Aid: FACT

Factual → Accurate → Complete → Timely

Key Points

Never document care before it's provided - this is falsification
Use approved abbreviations only - avoid dangerous abbreviations
Document client's response to interventions, not just the intervention itself

Commonly Confused Concepts

Assessment vs. Diagnosis

Assessment	Diagnosis
Data collection	Data analysis
"Client reports chest pain"	"Acute Pain r/t myocardial ischemia"
Objective: What you observe	Subjective: What you conclude

Common Pitfalls

Don't diagnose medical conditions - Focus on client's response to illness
Avoid circular reasoning - Don't use the problem as the cause (Pain r/t pain)
Don't use medical diagnoses as related factors - Use pathophysiology instead

Study Tips & Memory Aids

NCLEX Success Strategy

Always assess first unless client safety is at immediate risk
Look for ABC priority - Airway, Breathing, Circulation
Choose answers that demonstrate therapeutic communication
Remember: Safety first, then comfort

Quick Check Questions

□ Can I identify the difference between actual and risk nursing diagnoses?
□ Do I understand the proper format for writing nursing diagnoses?
□ Can I prioritize nursing diagnoses using Maslow's hierarchy?
□ Do I know when to assess vs. when to implement interventions?

다음 이론을 계속 학습하려면 로그인하세요.

로그인하고 계속 학습

제안하기

컨텐츠 수정하기

Nursing Diagnosis Formulation (간호 진단 수립)

NCLEX Review Guide: Nursing Process & Documentation

Nursing Process Overview

Five Steps of Nursing Process

Memory Aid: ADPIE

Key Points

Nursing Diagnosis Formulation

Types of Nursing Diagnoses

Diagnosis Format Comparison

Clinical Example

Documentation Principles

Legal Documentation Requirements

Documentation Memory Aid: FACT

Key Points

Commonly Confused Concepts

Assessment vs. Diagnosis

Common Pitfalls

Study Tips & Memory Aids

NCLEX Success Strategy

Quick Check Questions

성장을 멈추지 마세요

제안하기

컨텐츠 수정하기

Nursing Diagnosis Formulation (간호 진단 수립)

NCLEX Review Guide: Nursing Process & Documentation

Nursing Process Overview

Five Steps of Nursing Process

Memory Aid: ADPIE

Key Points

Nursing Diagnosis Formulation

Types of Nursing Diagnoses

Diagnosis Format Comparison

Clinical Example

Documentation Principles

Legal Documentation Requirements

Documentation Memory Aid: FACT

Key Points

Commonly Confused Concepts

Assessment vs. Diagnosis

Common Pitfalls

Study Tips & Memory Aids

NCLEX Success Strategy

Quick Check Questions