Nursing Process: Diagnosis

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Diagnosing

Use critical thinking to identify patterns in the data and draw conclusions about the client's health status

Includes strengths, problems, and factors contributing to the problems

Critical because it links assessment to all the steps that follow it

Assessment data must be complete and accurate for an accurate diagnosis

Evolution of Nursing Diagnosis

1980s: State practice acts designate nursing diagnosis as an exclusive responsibility to RNs

Differentiating Diagnoses

Medical Diagnosis

Describes a disease, illness or injury so that appropriate treatment can be given

Narrowly focused

Cannot be used to predict a nursing diagnosis

Nursing Diagnosis

A statement of client health status that nurses can identify, prevent or treat independently

Can have multiple nursing diagnoses for one medical diagnosis

Clients can have the same medical diagnosis but different nursing diagnoses

Can be treated right away

Holds us accountable for interventions

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Health Problems

Any condition that requires intervention in order to promote wellness or to prevent/resolve disease/illness

Decide how to treat it: Independently or Collaboratively

Accountability

Provides the basis for selection of nursing interventions to achieve the outcomes for which the nurse is accountable

Collaborative Problems

Physiological complications of disease, medical treatments or diagnostic studies

Clients with certain diseases/treatments are at risk for developing the same complications

Always a potential problem

if you can prevent the complication with independent nursing interventions alone, it is not a collaborative problem.

Collaborative problems require both medical and independent nursing interventions to prevent them or minimize the complications.

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Type of Nursing Diagnosis

Actual

If patient has enough signs and symptoms for a specific nursing diagnosis

Next step is to determine etiology and then intervene

Risk

Potential

Describes a problem response that is likely to develop if no intervention happens

Possible

Exists when intuition and experience direct you to suspect a diagnosis is present

Not enough data to support the diagnosis

Continue assessing

Syndrome

Collection of nursing diagnoses that usually occur together

Wellness

Used when individual, group/ community in transition to a higher level of wellness

Client's present level of wellness is effective

Client wants to move to a higher level of wellness

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Diagnostic Reasoning:

Use critical thinking to

Analyze and interpret data

Draw conclusions

Verify problems

Prioritize problems

Record diagnostic statements

Analyzing Data

Significant data (also called cues)

Data that influence your conclusions about the client’s health status.

A cue should alert you to look for other cues that might be related to it (form a pattern).

Cluster

Group of cues that are related to each other in some way

The cluster may suggest a health problem.

To help ensure accuracy, you should always derive a nursing diagnosis from data clusters rather than from a single cue.

Identify data gaps and inconsistencies

As you cluster and think about relationships among the cues, you will identify the need for data that were not apparent before and also look for inconsistencies in the data.

Drawing conclusions about health status

Strengths as well as problems.

Make inferences

It is a critical-thinking skill

Whereas inferences are conclusions (judgments, interpretations) that are based on the data

Identify problem etiologies

An etiology consists of the factors that are causing or contributing to the problem.

Etiologies may be pathophysiological, treatment related, situational, social, spiritual, maturational, or environmental.

Directs the nursing interventions.

An etiology is always an inference.

Verify problems with the patient

The patient’s interpretations may differ from yours.

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Prioritizing Problems

Problems are in order of importance

Does not mean you have to resolve one before attending the other

Determined by the theoretical framework you use

Problem Urgency

High Priority = Life Threatening

Medium Priority = Not a direct threat to life but can be destructive physically or emotionally

Low Priority = requires minimal supportive nursing intervention

Self Knowledge

1. Realize that your beliefs, values, and experiences affect your thinking and can be misleading.

2. A bias is the tendency to slant your judgment based on personal opinion or unfounded beliefs, as the nurse did in the preceding example. Stereotypes are judgments and expectations about an individual based on the personal beliefs you have about this group.

3. This is like stereotyping in that you draw conclusions about an individual based on what you know about people in similar situations.

4. Medical diagnoses and statements from others can help you to think of possible explanations for your data, but they can also bias your thinking and prevent you from gathering your own data.

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NANDA-I Nursing Diagnosis: Components

Diagnostic label:

The diagnostic label (title or name) is a word or phrase that represents a pattern of related cues and describes a problem or wellness response.

Definition:

Explains the meaning of the label and distinguishes it from similar nursing diagnoses.

Defining characteristics:

The cues (signs and symptoms) that allow you to identify a problem or wellness diagnosis are called defining characteristics.

To use a problem label appropriately, a cluster of defining characteristics must be present in the patient data.

Related factors:

The cues, conditions, or circumstances that cause, precede, influence, contribute to, or are in some way associated with the problem (label) are called related factors.

They can be pathophysiological, psychological, social, treatment-related, situational, maturational, and so on.

Risk factors:

Events, circumstances, or conditions that increase the vulnerability of a person or group to a health problem

They can be environmental, physiological, psychological, genetic, or chemical.

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How to Choose a NANDA-I Label

Identify the broad topic (or domain) that seems to fit the cue cluster.

Narrow your search (to the class or most

likely labels).

Use a nursing diagnosis handbook; compare definitions and defining characteristics of the diagnostic labels with your cue cluster.

How Nursing Diagnosis Relates to Outcomes and Interventions

The problem suggests the goal.

The etiology suggests interventions.

Criticisms of the NANDA-I System

Too abstract

Not well reasearched

Some say not to use any standardized language to describe nursing knowledge and nursing work

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Writing Quality Statements

In choosing a NANDA-I label, do not rely on the label definition alone.

Always compare patient data to the defining characteristics of the label as well as to the definition.

Include both problem and etiology.

A quick check of this is to read your statement backwards: “Etiology causes problem,” and see if it makes sense.

Be sure that the etiology does not merely restate

the problem.

Avoid using medical diagnoses and treatments as etiological factors.

The nurse should be able to provide interventions to change or remove the etiological factors.

Write the statement clearly.

Write the statement concisely.

Be descriptive and specific.

State the problem as a patient response.

Use nonjudgmental language.

Avoid legally questionable language.