Diagnosing Aubrey Y. Go, RN,MD

Nursing Diagnosis Definition: NANDA, 1990 Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

Diagnosis the second step in the nursing process begins after the nurse has collected and recorded the patient data

Purposes of the Diagnosing Step Identify how an individual, group, or community responds to actual or potential health and life processes Identify factors that contribute to, or cause, health problems (etiologies) Identify resources or strengths upon which the individual, group, or community can draw to prevent or resolve problems

Diagnosing

Nursing Diagnosis purpose - to clarify the exact nature of the problems and risk factors you need to achieve the overall expected outcomes of care. - If you do not completely understand the problems contributing to them, how are going to know what to do about them?

Nursing Diagnosis conclusions made during this phase affect the entire plan of care - if correct, your plan is likely to be on target - if not — operating on assumptions, rather than sound reasoning that is based on evidence— plan is likely to be flawed, maybe even dangerous.

Nursing Concerns and Responsibilities (Alfaro, 2004) Monitoring for changes in health status Promoting safety and preventing harm Identifying and meeting learning needs Promoting comfort and managing pain Promoting health and well-being Addressing problems that limit independence Determining human responses

Types of Diagnoses Nursing diagnosis Medical diagnosis Describes patient problems nurses can treat independently Medical diagnosis Describes problems for which the physician directs the primary treatment Collaborative problems Managed by using physician-prescribed and nursing-prescribed interventions Collaborative problems – “certain physiologic complications that nurses monitor to detect onset or changes in status. - primary responsibility of nurses; prescription for treatment comes from nursing, medicine, and other disciplines

Collaborative Problems Alfaro rule: “PC (potential for complications) followed by a colon, and list the complications that might occur. For clarity, link the potential complications and the collaborative problem by using “related to”

Critical Thinking and Nursing Diagnosis Be familiar with nursing diagnoses and other health problems; read professional literature and keep reference guides handy. Trust clinical experience and judgment, but be willing to ask for help when the situation demands more than your qualifications and experience can provide.

Respect your clinical intuitions, but before writing a diagnosis without evidence, increase the frequency of your observations and continue to search for cues to verify your intuition. Recognize personal biases and keep an open mind.

Questions to facilitate critical thinking during diagnostic reasoning Are my data accurate and complete? Has the patient or the patient's surrogates validated (if able to do so) that these are important problems? Have I given the patient or the patient's surrogate an opportunity to identify problems that I may have missed? Is each diagnosis supported by evidence? Might these cues signify a different problem or diagnosis?

Have I tried to identify what is causing the actual or potential problem, and what strengths or resources the patient might use to avoid or resolve the problem? Have I used agency guidelines to correctly document diagnostic statements in a way that clearly communicates patient problems to other healthcare professionals? Is this a problem that falls within nursing's independent domain or does it signify a medical diagnosis or collaborative problem?

Four Steps of Data Interpretation and Analysis Recognizing significant data Comparing data to standards Recognizing patterns or clusters Identifying strengths and problems Reaching conclusions

Question A nurse decides that a patient has a possible problem with high blood pressure. During which step of data interpretation would this most like be determined? A. Recognizing significant data B. Recognizing patterns or clusters C. Identifying strengths and problems D. Reaching conclusions

Answer Answer: D. Reaching conclusions Rationale: A possible problem, such as high blood pressure, is diagnosed as a conclusion of data interpretation. Recognizing significant data refers to the comparison of data to a standard or norm (e.g., normal blood pressure values). A data cluster is a grouping of patient data or cues that points to the existence of a problem (e.g., a series of readings). The nurse must then identify strengths and problems and determine if the patient is motivated to address them.

Reaching Conclusions No problem Possible problem Actual or potential nursing diagnosis Clinical problem other than nursing diagnosis

Question A patient who admits to smoking two packs of cigarettes a day is diagnosed with lung cancer based on his symptoms and a series of test results. Which of the following is the etiology in this scenario? A. Lung cancer B. Test results C. Smoking cigarettes D. The subjective and objective data

Answer Answer: C. Smoking cigarettes Rationale: The etiology is the factor that maintains the unhealthy condition (smoking cigarettes). Lung cancer is the problem, and the remaining factors are the distinguishing characteristics.

Formulation of Nursing Diagnoses Problem—identifies what is unhealthy about patient Etiology—identifies factors maintaining the unhealthy state Defining characteristics—identifies the subjective and objective data that signal the existence of a problem

Types of Nursing Diagnoses Actual a problem that has been validated by the presence of major defining characteristics Risk clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation

Types of Nursing Diagnoses Possible statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem. Wellness clinical judgments about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness.

Two cues must be present for a valid wellness diagnosis: A desire for a higher level of wellness An effective present status or function Readiness for enhanced…

Types of Nursing Diagnoses Syndrome comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation Rape-Trauma Syndrome Post-Trauma Syndrome.

PARTS OF A NURSING DIAGNOSIS

Parts of a Nursing Diagnosis Problem describe the health state or health problem of the patient clear and concise suggests patient outcomes NANDA quantifiers: 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

Parts of a Nursing Diagnosis Etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem either a cause or a contributing factor. directs nursing intervention to be efficient and effective

Parts of a Nursing Diagnosis Defining Characteristics subjective and objective data that signal the existence of the actual or potential health problem suggest evaluative criteria

Four Components of a NANDA Nursing Diagnosis Label Definition Defining characteristics Related factor

Four Components of a NANDA Nursing Diagnosis Label Imbalanced Nutrition: More Than Body Requirements (1975, 2000). Definition Intake of nutrients that exceeds metabolic needs.

Four Components of a NANDA Nursing Diagnosis Defining Characteristics Triceps skin fold greater than 25 mm in women, greater than 15 mm in men Weight 20% over ideal for height and frame Eating in response to external cues, such as time of day, social situation Eating in response to internal cues other than hunger (eg, anxiety) Reported or observed dysfunctional eating pattern (eg, pairing food with other activities) Sedentary activity level Concentrating food intake at the end of the day

Four Components of a NANDA Nursing Diagnosis Related Factors Excessive intake in relation to metabolic need.

GUIDELINES FOR WRITING NURSING DIAGNOSES

Guidelines for Writing Nursing Diagnoses Phrase the nursing diagnosis as a patient problem or alteration in health state rather than as a patient need. Check to make sure that the patient problem precedes the etiology and that the two are linked by the phrase “related to.”

Guidelines for Writing Nursing Diagnoses Defining characteristics, when included in the nursing diagnosis, should follow the etiology and be linked by the phrase “as manifested by” or “as evidenced by.” Write in legally advisable terms.

Guidelines for Writing Nursing Diagnoses Use nonjudgmental language. Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance).

Guidelines for Writing Nursing Diagnoses Avoid using defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement. Reread the diagnosis to make sure the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing measures.

VALIDATING NURSING DIAGNOSES

yes or no? Is my database sufficient, accurate, and supported by nursing research? Does my synthesis of data (significant cues) demonstrate the existence of a pattern? Are the subjective and objective data I used to determine the existence of a pattern characteristic of the health problem I defined?

yes or no? Is my tentative nursing diagnosis based on scientific nursing knowledge and clinical expertise? Is my tentative nursing diagnosis able to be prevented, reduced, or resolved by independent nursing action? Is my degree of confidence above 50% that other qualified practitioners would formulate the same nursing diagnosis based on my data?

Question Tell whether the following statement is true or false. A nursing diagnosis may be used to seek reimbursement for nursing services. A. True B. False

Answer Answer: A. True A nursing diagnosis may be used to seek reimbursement for nursing services.

Benefits of Nursing Diagnoses Individualizing patient care Allow patient to be informed and participate in their care Improve communication among nurses and healthcare professionals Defining domain of nursing to healthcare administrators, legislators, and providers

Benefits of Nursing Diagnoses Seeking funding for nursing and reimbursement for nursing services Define curriculum content and to direct specialization and advancement in nursing and nursing research

Limitations of Nursing Diagnosis If used incorrectly, patient might be “misdiagnosed” Nursing practice might be restricted

Question Which of the following nursing diagnoses is written correctly? A. Child Abuse related to maternal hostility B. Breast Cancer related to family history C. Deficient Knowledge related to alteration in diet D. Imbalanced Nutrition related to insufficient funds in meal budget

Answer Answer: D. Imbalanced Nutrition related to insufficient funds in meal budget Rationale: Answer A makes legally inadvisable statements, answer B is a medical diagnosis, and answer C reverses the clauses in the statement.

Common Sources of Error in Nursing Diagnoses Premature diagnoses based on incomplete database Erroneous diagnoses resulting from inaccurate or faulty database Routine diagnoses resulting from failure to tailor data to patient Errors of omission

Legal Alert: Alfaro's Rule The terms diagnose and diagnosis have legal implications. 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 managing the problem.

Legal Alert: Alfaro's Rule 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 of negligence.

Legal Alert: Alfaro's Rule 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 pneumonia independently.

However, they are accountable for: Detecting and reporting signs and symptoms of pneumonia (fever, productive cough, malaise) Diagnosing and managing risk factors for pneumonia (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 related to pneumonia) Ensuring that the medical treatment plan is implemented as prescribed (Alfaro-LeFevre, 2004, p. 77)