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Nursing Diagnosis
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Nursing Diagnosis
Terms
- Medical diagnosis- identification of disease condition based on specific evaluation of physical signs, symptoms, medical history, and result of diagnostic tests and procedures.
- Nursing diagnosis – clinical judgement concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat.
- Collaborative Problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s health status.
- Nursing diagnosis – clinical judgement concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat.
- Medical diagnosis- identification of disease condition based on specific evaluation of physical signs, symptoms, medical history, and result of diagnostic tests and procedures.
History of Nursing Diagnosis
- 1967 Yura and Walsh 4 part process
- Diagnosis was added, you cannot plan and intervene correctly for patients if you do not know the problems with which you are dealing.
- ANA defines nursing as the diagnosis and treatment of human responses to health and illness strengthening the definition of nursing diagnosis.
- NCLEX exam defines nursing process as scientific, clinical reasoning approach to patient care that includes assessment, analysis, planning, implementation, and evaluation. Note analysis instead of diagnosis. Types of Nursing Diagnoses
- ANA defines nursing as the diagnosis and treatment of human responses to health and illness strengthening the definition of nursing diagnosis.
- Diagnosis was added, you cannot plan and intervene correctly for patients if you do not know the problems with which you are dealing.
- 1967 Yura and Walsh 4 part process
Types of Diagnosis
- Problem-focused nursing diagnosis – clinical judgement concerning undesirable response t health condition/life
- Risk nursing diagnosis clinical judgement concerning vulnerability of individual, family, group, or community for developing undesirable human response to health conditions/life processes.
- Related factor etiological or causative factor for the diagnosis
- Risk nursing diagnosis clinical judgement concerning vulnerability of individual, family, group, or community for developing undesirable human response to health conditions/life processes.
- Problem-focused nursing diagnosis – clinical judgement concerning undesirable response t health condition/life
Critical thinking and the diagnostic process
- Data clustering Organize patient’s data into meaningful usable data clusters. Set of cues, signs or symptoms gathered during assessment.
- Data interpretation Comparison of characteristics or risk factors in database. Move from generalized to more specific Compare patient’s data with normal, healthy patterns.
- A nursing diagnosis focuses on a patient’s actual or potential response to a health condition rather than on the physiological event, complication, or disease
- Data interpretation Comparison of characteristics or risk factors in database. Move from generalized to more specific Compare patient’s data with normal, healthy patterns.
- Data clustering Organize patient’s data into meaningful usable data clusters. Set of cues, signs or symptoms gathered during assessment.
Formulating a Nursing Diagnostic Statement
- "related to" phrase is not cause-effect.
- Two part = diagnosis meaning and relevance.
- Three part includes related to factor
- Three part, PES, problem, etiology, symptom
- Three part includes related to factor
- Two part = diagnosis meaning and relevance.
- "related to" phrase is not cause-effect.
Cultural relevance
- Important to consider patient’s culture and own cultural competence to identify health care problems.
Concept mapping
- help critically think about patients diagnoses and how they related to one another.
- Organizes and links info to see holistic complexity of patient care
- Central focus is on patient rather than disease or alteration in health.
- Organizes and links info to see holistic complexity of patient care
- help critically think about patients diagnoses and how they related to one another.
Sources of Diagnostic errors
- Errors in Data collection
- Errors in Analysis of Data
- Errors in Data Clustering
- Errors in Diagnostic statement
- Errors in Data Clustering
- Errors in Analysis of Data
- Errors in Data collection
Documentation and informatics
- Once diagnosis entered, outcome and intervention options are available (computer based)
- List chronologically as you identify them
- Care plan- highest priority diagnosis first
- Review in order of priority not chronologically
- Care plan- highest priority diagnosis first
- List chronologically as you identify them
- Once diagnosis entered, outcome and intervention options are available (computer based)
Application to care planning
- Care plan is a map for nursing care
- Demonstrates accountability for nursing diagnosis, patient's health care problems.
- Care plan is a map for nursing care