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Fundamentals of Nursing

Chapter 17: Diagnosing

 

Learning Outcomes

·        Differentiate various types of nursing diagnoses

·        Identify the components of nursing diagnoses

·        Compare nursing diagnoses, medical diagnoses, and collaborative problems

·        Identify basic steps in the diagnostic process

·        Describe the characteristics of a nursing diagnosis

·        List common errors in writing diagnostic statements

·        Describe the evolution of the nursing diagnosis movement, including work currently in progress

·        List advantages of a taxonomy of nursing diagnoses

 

Chapter Highlights

·        The purpose of the North American Nursing Diagnosis Association is to define, refine, and promote a taxonomy of nursing diagnostic terminology

·        Diagnosis is a reasoning process that uses critical thinking

·        Professional standards of care hold that registered nurses are responsible for making nursing diagnoses, even though others may contribute data or implement care

·        A nursing diagnosis is a clinical judgment about the client’s responses to actual and potential health problems or life processes

·        There are various types of nursing diagnoses; actual, risk, wellness, possible, and syndrome

·        A nursing diagnosis has three components: the problem (and it’s definition), the etiology, and the defining characteristics.  Each component serves a specific purpose.

·        Nursing diagnoses differ from medical diagnoses and collaborative problems in orientation, duration, and nursing focus.

·        A collaborative problem is a type of potential problem that nurses manage using independent and physician prescribed interventions

·        The three phases of the diagnostic process are: data analysis, identification of the client’s health problems, health risks, and strengths, and formulation of diagnostic statements.

·        In data analysis and processing, the nurse compares data against standards to identify significant cues, clusters the data, and identifies gaps and inconsistencies.

·        Significant cues are those that

1.      point to change in a client’s health status or pattern

2.      vary from norms of the client population

3.      indicate a developmental delay

·        It is important to identify client strengths as well as problems

·        The basic format for a nursing diagnostic statement is “Problem related to etiology.” However, there are several variations of this form.

·        The development of a taxonomy of nursing diagnosis labels is an ongoing process

·        The organizing principles for the NANDA Taxonomy II are the seven axes: diagnostic concept, time, unit of care, age, potentiality, descriptor and topology.

·        Work is progressing on a unified standardized nursing language that includes NANDA nursing diagnoses, a nursing interventions classification, and a nursing outcomes classification

 

Diagnosing

·        interpret assessment data and identify client strengths and problems

·        North American Nursing Diagnosis Association (NANDA)’s purpose is to define, refine and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses

 

NANDA Nursing Diagnoses

Definitions

·        diagnosis: statement or conclusion regarding the nature of a phenomenon

·        diagnosing: the reasoning process

·        diagnostic labels: standardized NANDA names for diagnoses

·        etiology: causal relationship between a problem and its related or risk factors

·        nursing diagnosis: diagnostic label plus etiology

·        “a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes.  Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”

·        implies:

·        pro nurses responsible for making nursing diagnoses though other personnel contribute data to the process

·        domain of nursing diagnosis includes only those health states that nurses are educated and licensed to treat

·        nursing diag is judgment made after thorough assessment

·        nsg diag describes continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth

 

Types of Nursing Diagnoses

·        actual diagnosis: client problem present at time of assessment

·        risk nsg diag: clinical judgment that prob doesn’t exist, but risk factors present indicating problem is likely without intervention

·        wellness diag: human responses to levels of wellness in an individual, family, or community that have a readiness for enhancment

·        possible nsg diags: evidence about a prob is incomplete or unclear

·        syndrome diag: diag associated with a cluster of other diags

 

Components of a NANDA Nursing Diagnosis

Problem (Diagnostic Label) and Definition

·        describes the client’s health problem or response for which nursing therapy is given in order to direct the formation of client goals and desired outcomes

·        qualifiers: words added to NANDA labels to give additional meaning to diag statement

·        ex. deficient (inadequate amount, quality, or degree); impaired (made worse, weakened, damaged, reduced deteriorated); decreased (lesser in size, amount, or degree); ineffective (not producing the desired effect); compromised (to make vulnerable to threat)

 

Etiology (Related Factors and Risk Factors)

·        identifies cause(s) of the health problem, gives direction to required nsg therapy, and enables nurse to individualize client’s care

 

Defining Characteristics

·        cluster of signs and symptoms that indicate the presence of a particular diag label

 

Differentiating Nursing Diagnoses from Medical Diagnoses

·        nsg diag: statement of nsg judgment that refers to a condition that nurses are licensed to treat

·        describe client’s physical, sociocultural, psychologic, and spiritual responses to a health problem

·        medical diag: refer to disease processes fairly uniform from one client to the next

 

Differentiating Nursing Diagnoses from Collaborative Problems

·        collaborative problem: potential problem that nurses manage using independent and physician-prescribed interventions

 

The Diagnostic Process

·        uses analysis (separation into components) and synthesis (putting together into whole)

·        3 steps: analyze data, identify health problems, risk and strengths, and formulating diagnostic statements

 

Analyzing Data

Compare Data Against Standards

·        standard (norm): generally accepted measure, rule, or pattern

·        Cues are significant if one or more of following met:

·        points to negative or positive change in status

·        varies from norms of client population

·        indicates a developmental delay

 

Clustering Cues

·        process of determining the relatedness of data and determining if patterns are present

 

Identify Gaps and Inconsistencies

·        conflicting data possibly from measurement error, expectations, and inconsistent or unreliable reports

 

Identifying Health Problems, Risks, and Strengths

Determining Problems and Risks

·        nurse and client ID problems that support tentative actual, risk, and possible diags

·        nurse determines nsg diag, med diag, or collab prob.

 

Determining Strengths

·        establish client’s strengths, resources, and abilities to cope

 

Formulating Diagnostic Statements

Basic Two-Part Statements

·        include problem (NANDA label of statement of the client’s response) and etiology (factors or probable causes of the responses)

·        joined by “related to”

 

Basic Three-Part Statements

·        includes problem, etiology, and signs and symptoms

·        can be used for actual but not risk diagnoses

 

One Part Statements

·        usually wellness statements like “Readiness for enhanced parenting”

·        can be enhanced by adding a descriptor “Health-Seeking Behaviors (Low-Fat Diet)”

 

Variations of Basic Formats

·        writing unknown etiology

·        writing complex factors if there are too many or too complex etiologic factors for a short phrase

·        using possible to describe problem or etiology

·        using secondary to to divide etiology into two parts

·        adding second part to general response or NANDA label

 

Collaborative Problems

·        should begin with diag label: Potential Complication and include disease or treatment

·        if associated with a disease or pathology, should include list of complications

 

Evaluating the Quality of the Diagnostic Statement

·        must be accurate, concise, descriptive and specific

·        validate with client

 

Avoiding Errors in Diagnostic Reasoning

·        verify your diagnoses with the patient

·        build a good knowledge base and acquire clinical experience

·        have a working knowledge of what’s normal

·        consult resources

·        base diagnoses on patterns – behavior over time – rather than isolated incidents

·        improve critical-thinking skills

 

Ongoing Development of Nursing Diagnoses

·        currently, diags grouped by diagnostic concept, time, unit of care, age, health status, descriptor, and topology

·        alphabetically listed by concept instead of first word