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Nursing Diagnoses in Psychiatric Nursing : Care Plans and Psychotropic Medications
Standardization of nursing actions and common terminology is important in the provision of consistent care over time, among nurses, across shifts, and even between different health- care agencies. This text incorporates the nomenclature of Taxonomy II that has been adopted by NANDA-I.There are those individuals who believe that NANDA’s list is incomplete. My intent is not to judge the completeness of this list but rather to suggest the need for clinical testing of what is available. NANDA encourages nurses to submit new diagnoses for consideration, after testing and research of that diagnosis has been conducted in the clinical setting.
There are three essential components in a nursing diagnosis, which comprise the
PES format. The “P” identifies the problem (or human issue of concern), the “E” represents the etiology (or cause) of the problem, and the “S” describes a cluster of signs and symptoms, or what has come to be known as “defining characteristics.” These three parts are combined into one statement by the use of “connecting words.” The diagnosis would then be written in this manner: Problem (or issue of concern) “related to” etiology “evidenced by” signs and symptoms (defining characteristics). The problem can be identifi
ed as the human response to actual or potential health problems as assessed by the nurse. The
etiology may be represented by past experiences of the individual, genetic infl
uences, current environmental factors, or pathophysiological changes. The defining characteristics describe what the client says and what the nurse observes that indicate the existence of a particular problem.
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