Panduan Penulisan Diagnosa Keperawatan Sesuai SDKI

Summary

In this video, the speaker explains the process of determining accurate nursing diagnoses. Key points include the importance of analyzing patient symptoms and comparing them with established diagnostic criteria, focusing on the 80% rule for validation. The speaker covers the three types of nursing diagnoses: actual, risk, and health promotion, providing guidelines for writing them correctly. Specific emphasis is placed on the use of major and minor signs, etiologies, and symptoms, with a strong focus on accuracy and understanding the differences between types of diagnoses. The goal is to improve the accuracy of nursing diagnoses and prevent common mistakes.

Takeaways

• 😀 Nursing diagnoses are based on symptoms (manifestations) rather than etiology, unlike medical diagnoses.
• 😀 The process of nursing diagnosis starts with data analysis, including both objective and subjective data, followed by identifying problems.
• 😀 Nursing diagnosis types include actual diagnosis, risk diagnosis, and health promotion diagnosis.
• 😀 Actual diagnoses follow the format: Problem related to Etiology as evidenced by Symptoms (P-E-S).
• 😀 Risk diagnoses focus on potential issues and are written as: Risk of Problem related to Etiology (P-E). No symptoms are involved.
• 😀 Health promotion diagnoses emphasize encouraging patients to improve their health, formatted as: Readiness for Problem as evidenced by Symptoms (P-S).
• 😀 For actual diagnoses, symptoms should match at least 80% of the major signs listed in the diagnostic criteria for the diagnosis to be considered accurate.
• 😀 In writing actual diagnoses, only one etiology (cause) should be chosen; multiple etiologies are not allowed in a single diagnosis.
• 😀 Symptoms in actual diagnoses can include both major and minor signs, but major signs hold more weight in confirming the diagnosis.
• 😀 Diagnoses are validated when symptoms align with at least 80% of the major signs, ensuring accuracy in diagnosis formulation.
• 😀 When writing risk diagnoses, no symptoms are included as they refer to potential issues that have not yet occurred but could happen.

Q & A

What is the primary focus when determining the accuracy of a nursing diagnosis?

The primary focus is ensuring that the symptoms observed in the patient align with the major signs of the diagnosis, with at least 80% similarity.

What are the three main types of nursing diagnoses discussed in the script?

The three main types of nursing diagnoses are actual diagnosis, risk diagnosis, and health promotion diagnosis.

How is an 'Actual Diagnosis' structured according to the script?

An actual diagnosis follows the formula: Problem (P) related to Etiology (E), as evidenced by Symptoms (S).

What is the key difference between an actual diagnosis and a risk diagnosis?

The key difference is that an actual diagnosis includes specific signs and symptoms, while a risk diagnosis identifies potential problems without visible symptoms.

What does 'S' stand for in the formula for actual diagnosis and what are the requirements for it?

'S' stands for Symptoms, which include both major and minor signs. Major symptoms are crucial, while minor symptoms are supportive but not required for validation.

What is the role of major symptoms in validating a diagnosis?

Major symptoms are essential for validating a diagnosis. A diagnosis is considered accurate if the patient's symptoms match at least 80% of the major symptoms associated with the diagnosis.

How should 'Etiology' (E) be treated in an actual diagnosis?

In an actual diagnosis, only one etiology should be identified. Multiple etiologies cannot be used in the same diagnosis.

What is the correct way to write a risk diagnosis?

A risk diagnosis is written as: Problem (P) related to Etiology (E) or risk factor, with no symptoms or signs (S) included, as the problem has not yet manifested.

What are the requirements for a health promotion diagnosis according to the script?

A health promotion diagnosis is structured as: Problem (P) with Symptoms (S), without any Etiology (E), and focuses on the patient’s readiness to improve or change a behavior.

How are minor symptoms treated when forming a nursing diagnosis?

Minor symptoms are considered supplementary to the major symptoms and can be used to support the diagnosis, but they are not the primary basis for validating the diagnosis.