Nursing Diagnosis NUR3056

How do we interpret data clusters? How does interpreting a data cluster help us reach a nursing diagnosis?

- Involves placing a label on your data pattern or cluster to clearly identify a patient's response to health problems. - Compare the data in a cluster with the data standard - The recognition of data in a logical cluster or pattern reveals the nursing diagnoses, how a patient is responding to a health condition or life process.

What are the common terminologies used in the electronic health record (5)?

- NANDA International (NANDA-I) - Nursing Intervention Classification (NIC) - Nursing Outcome Classification (NOC) - Omaha System - SNOMED CT for clinical terminology - International Classification for Nursing Practice (ICNP®)

What roles do nurses have?

- Nurses continuously collect assessment data. - The nurse constantly observes, interacts and applies physical examination techniques to gather information about a patient's condition.

What are the different types of nursing diagnostic statements (3)?

- Problem-focused - Risk diagnosis - Health promotion

How can data clusters help us gain experience in nursing?

- Finding a data cluster helps you think less about individual data points and instead focus on pattern recognition. - When assessment data reveal risk factors, you will recognize patterns.

What is a major assessment finding and how does it influence how you create a diagnostic statement?

- Further clarity is added to a diagnostic statement if you list major assessment findings or defining characteristics that were used to select a diagnosis. - Highlighting a patient's major assessment findings offers guidelines for how you will evaluate the efficacy of nursing care

What is a collaborative problem and how do we treat one?

A problem that requires both medicine and nursing interventions to treat

When is a nursing diagnosis made?

- A nursing diagnosis is made when a nurse identifies a health-related problem or the potential to develop a problem based on patient data. - Nursing diagnosis is the second step of the nursing process.

What are related factors and how do they help us form a diagnostic statement?

- A patient's response to a health problem is related to a set of conditions that caused or influenced the response. - Related factors are etiologies, circumstances, facts, or influences that have a relationship with the nursing diagnosis (the underlying cause of the patient's problem)

How can we ensure diagnostic validity? Why is this important?

- Before identifying a diagnosis, refer to the official ICNP ® or NANDA-I list to ensure accuracy of the diagnostic statement. - This is essential for clear communication with all health care team members. - Standard diagnostic terminology must be used in any electronic health record using nursing diagnosis because accurate nursing diagnoses are foundational to the development of an effective, personalized plan of care.

Where can diagnostic errors occur (4)?

- Data collection - Clustering - Analysis and interpretation of data - Diagnostic statement

How does a nursing diagnosis affect a patient's care plan (2)?

- Diagnoses direct the planning process and the selection of nursing interventions to achieve desired outcomes for patients. - By making accurate nursing diagnoses, your subsequent care plan communicates a patient's health care responses to the health care team.

What components go into forming a diagnostic statement?

- Diagnostic label - Related factors - Major assessment findings

How does using an electronic health record (EHR) aid in the process of making a nursing diagnosis? How do we use an EHR?

- The use of standard, familiar terminology in an EHR can provide nurses greater ease in their selection of nursing diagnoses and interventions in planning patient care. - Once you identify a patient's nursing diagnoses, enter them in the EHR of the agency. - The agency information system will dictate how the diagnosis is disseminated throughout the record. - List nursing diagnoses chronologically.

What are the four types of nursing diagnoses?

- actual diagnoses - risk diagnoses - wellness diagnoses - health promotion diagnoses

How do we use subjective data to support a nursing diagnosis? What about objective data?

- ex: nursing diagnosis is: risk for falls related to weakness secondary to pneumonia - supporting subjective data: pt. said "i feel weak" or "i left my glasses at home" - supporting objective data: low spO2, needs help ambulating to the bathroom

When formulating a nursing diagnosis, we assess a patient's health status. What kind techniques do we use when we do this (3)?

- gather patient, family, and health care resources (info for the database) - clarify unclear information - use critical thinking to guide interview questions

What is a data cluster and how do we use it when formulating a nursing diagnosis?

- is a set of assessment findings/defining characteristics. - Compare a patient's data with information that is consistent with normal, healthy patterns.

How is concept mapping useful to nurses (4)?

- it connect concepts to a central subject. - it relates ideas to patient health problems. - it challenges a nurse's thinking about patient needs and problems. - it graphically displays ideas by organizing data.

medical diagnosis vs nursing diagnosis

- medial diagnosis: the identification of a disease condition based on a specific evaluation of physical signs and symptoms, a patient's medical history, and the results of diagnostic tests and procedures - nursing diagnosis: a clinical judgment made by a nurse to describe a patient's response or vulnerability to health conditions or life events that a nurse is licensed and competent to treat

How do we construct a nursing diagnosis?

- nursing diagnosis + related to [a condition] + secondary to [medical diagnosis] - ex: risk for falls related to weakness secondary to pneumonia

What are the different types of nursing diagnoses (5)?

- pathophysiological (e.g., myocardial infarction, borderline personality) - treatment-related (e.g., anticoagulant therapy, dialysis) - personal (e.g., dying, divorce) - environmental (e.g., overcrowded school, safety barriers in home) - maturational (e.g., peer pressure, parenthood).

What is a diagnostic label or diagnosis? Why do we use certain systems / medical terms in the diagnostic label / diagnosis?

- the name of a nursing diagnosis approved by NANDA-I, ICNP, or any other system used by your institution. - these systems offer definitions for each diagnosis to describe the characteristics of the human response identified.

Are all physiological complications collaborative problems? Why or why not?

- they are not - If a nurse can prevent the onset of a complication or provide the primary treatment for it, then the diagnosis is a nursing diagnosis.

How do we formulate a nursing diagnosis (8)?

1. Assess a patient's health status 2. Validate data with other sources 3. Are additional data needed? If so, go back to step 1 4. Interpret and analyze the meaning of the data 5. Data clustering / patterns 6. look for assessment findings and related factors 7. identify patient needs 8. formulate nursing diagnoses and collaborative problems

What elements are involved in developing the nursing diagnosis?

1. knowledge 2. experience 3. standards 4. attitudes

What "standards" are involved in developing a nursing diagnosis?

ANA scope of nursing practice, intellectual standards of measurement, patient-centered care

What are the benefits of collaboration (medicine and nursing)?

Collaboration will better manage the multiple factors that influence the health of individuals, families, and communities.

How does culture affect a patient diagnosis?

Consider your patients' cultural diversity, including ethnicity, values, beliefs, language, and health practices when developing a care plan.

risk diagnosis

Diagnoses that apply when there is an increased potential or vulnerability for a patient to develop a problem or complication

problem-focused diagnosis

Identify an undesirable human response to existing problems or concerns of a patient

health promotion diagnosis

Identify the desire or motivation to improve health status through a positive behavioral change

Why do we use standardized terminology when constructing a nursing diagnosis?

Using standardized terminology is essential for diagnostic clarity and effective team communication.

What "attitudes" are involved in developing a nursing diagnosis?

critical thinking

What "experience" is involved in developing a nursing diagnosis?

previous patient care experience, validation of assessment findings, observation of assessment techniques

actual diagnosis

problem that currently exists aka problem diagnosis

wellness diagnosis

situation in which a healthy person obtains nursing assistance to maintain his or her health or perform at a higher level

What "knowledge" is involved in developing a nursing diagnosis?

underlying disease process, normal growth/development, normal physiology/psychology, normal health assessment findings, health promotion