CHAPTER 15

Recognizing Patterns or Clusters

-A data cluster is a grouping of patient data or cues that point to the existence of a health problem. Nursing diagnosis should always be derived from clusters of significant data rather than from a single cue.

Nursing Diagnosis

-A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable -Problem, strength, or risk identified for a patient, family, group, or community Focus: Monitoring human responses to actual and potential health problems

Parts of Nursing Diagnosis: Etiology

-The etiology identifies the contributing or causative factors of the problem -Identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related the problem as either a cause or contributing factor -Identifies the factors that are maintaining the unhealthy state or response (contributing or causative factors) -Suggests the appropriate nursing measures/interventions -Unless the etiology is correctly identified, nursing actions might be inefficient and ineffective.

in diagnosing step of nursing process

-nurse interprets and analyzes data gathered from the nursing assessment -identifies patient strengths -identifies resources the patient can use to resolve problems.

risk nursing diagnosis

A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation

Nursing Diagnosis Examples

A problem-focused nursing diagnosis for a patient who has experienced vomiting, diarrhea, and excessive diaphoresis for 3 days is Deficient fluid volume related to abnormal fluid loss. If the diarrhea persists and weakness interferes with the patient's normal perineal hygiene, the patient might be at risk for skin breakdown. This is written as the risk diagnosis, Risk for impaired skin integrity.

collaborative problems

certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse interventions to minimize the complications of the event -nurses working with other health care professionals

Risk Factor Diagnosis

clinical judgement concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes

medical diagnosis

identify health problems that are better treated by physicians

Purpose of Diagnosing

(1) identify how a person, group, or community responds to actual or potential health and life processes (2) identify factors that contribute to or cause health problems (etiologies) (3) identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems. -clarify the exact nature of the problems and risks that must be addressed to achieve the overall expected outcomes of care. -The conclusions you make during this phase affect the entire care plan.

No Problem

*No Problem* No nursing response is indicated. Reinforce the patient's health habits and patterns. Initiate health promotion activities to prevent disease or illness or to promote a higher level of wellness. Wellness diagnosis might be indicated.

Parenting with the Patient and Family

-Best source of information usually is an aware patient -patients want to play a leading role in identifying and treating their health problems -Be sure to ask patients what they believe their most important problems or issues are and have them confirm what your assessment reveals and helps you prioritize the resulting list of diagnoses/problems.

Collaborative problem

-Certain physiologic complications that nurses monitor to detect onset of changes in status Focus: Monitoring pathophysiologic responses of body organs or systems

Health Promotion Nursing Diagnosis

-Clinical judgement concerning motivation and desire to increase well being and to actualize human health potential -These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any state -Health promotion responses mat exist in an individual, family, group, or community

Risk factor

-Determinant (increase risk)

At-Risk populations

-Groups of people who share a characteristic that causes each member to be susceptible to a particular human response. These are characteristics that are not modifiable by the professional nurse.

Determining Patient and Family Strengths

-If a patient meets a standard, nurse concludes the patient has strength in that particular area, this strength contributes to patient's level of wellness -for example, a person with history of maintaining well balanced diet is usually better able to cope with illness than a person who has history of eating poorly -patient strengths include healthy physiologic functioning, emotional health, cognitive abilities, coping skills, interpersonal strengths, and spiritual strengths -Resources such as the presence of support people, adequate finances, and a healthy environment may all contribute to patient strengths -Many people take their strengths for granted and may not know how to use them effectively when responding to illness. -Discussing observed strengths with patients and counseling patients about ways to develop and use their strengths are important nursing measures.

predict, prevent, manage, and promote (PPMP)

-In the presence of known problems, predict the most common and most dangerous complications and take immediate action to (a) prevent them, and (b) manage them in case they cannot be prevented. -Whether problems are present or not, look for evidence of risk factors (things that evidence suggests contribute to health problems). If you identify risk factors, you aim to reduce or control them, thereby preventing the problems themselves. -In all situations, ensure that safety and learning needs are met, and promote optimum function and independence.

Associated conditions

-Medical diagnoses, injury procedures, medical devices, or pharmaceutical agents. These conditions are not independently modifiable by the professional nurse.

Parts of Nursing Diagnosis Statements

-Most are written as two part statements listing patient's problem and its cause or as three part statements that also include problems defining characteristics

Data interpretation and analysis

-Most experienced nurses begin the work of interpreting and analyzing data while they are still collecting (assessing) the data -The term cue is often used to denote significant data or data that influence this analysis -Significant data should "raise a red flag" for the nurse, who then looks for patterns or clusters of data that signal an actual or possible nursing diagnosis

Documenting Nursing Diagnoses

-Nurse documents validated nursing diagnoses in patient record -depending on doc system nursing diagnoses might be recorded in nursing care plan and on multidisciplinary problem list at the front of the patient record. -Nurses should use the terms recommended by their school, employer, or specialty organization

Determining Problems the Patient is Likely to Experience

-Nurses identify potential health problems. For example, a nurse notes that a patient has signs of a wound infection, but lab results show patient's WBC has not increased, as is usual when an infection is present. The nurse concludes the body is apparently not building up normal defenses to combat the infection -The nurse then predicts the problems this patient is likely to encounter, such as a longer-than-normal healing period. -Potential nursing diagnoses alert other caregivers to problems the patient may experience if certain trends in the patient's condition continue unreversed -prediction has implications for nursing care, such as the need for measures related to the patient's diet, fluid intake, urine output, and mobility.

Diagnostic Reasoning and Interpersonal Competence

-Nursing diagnoses are best used by nurses who have strong interpersonal and communication skills -these skills make it more likely that a patient will be able to trust you and talk about response to health and life processes -must be able to demonstrate your desire to listen to patients narrative to gain trust "Tell me your story." -best use of nursing diagnosis is in partnership with patients, families, groups, and communities. -To work in partnership, nurses need to speak to people with respect and care, listen effectively, respect opinions and views of others. and know how to validate perceptions with patients and families -learning these is a challenge so interpersonal aspects of nursing needs to be a integral part of learning to use nursing diagnosis

Identifying Potential Complications

-Pts may experience many complications related to their diagnoses, medications or treatment regimens, or invasive diagnostic studies -While new to nursing, you can more easily prevent potential complications—or at least make sure that they are detected early and managed well—if you research the potential complications associated with your patient's diagnoses, diagnostics, and treatment, and if you report all abnormal data. -For example, slurred speech, changes in skin color or moistness, inability to move an extremity or abnormal movement, and changes in levels of consciousness may all be indications of serious and life-threatening complications

Parts of Nursing Diagnosis: Problem

-Purpose of problem statement is to describe which health state or health problem of the patient as clearly and concisely as possible -Identifies what is unhealthy about the patient, indicating the need for change (clear, concise statement of the patient's health problem) -What the patient would like to change in his or her health status -Suggests the patient outcomes (expectations for change) -NANDA-I recommends the use of quantifiers or descriptors to limit or specify the meaning of a problem statement Example: -Bathing self-care deficit ↓ related to (R/T) ↓

Importance of Nursing Diagnoses in Electronic Health Records

-The goal of the EHR is to enable the interdisciplinary team caring for the patient to more easily view the patient's risks, health promotion possibilities, and actual long-term care problems. -documentation of nursing diagnoses is important for the patient and others providing care, and recommends that students use the EHR to: •view the patient's ongoing risks (e.g., Risk for aspiration, Risk for falls) and problems (e.g., Impaired gas exchange, Bowel incontinence) that others have identified and documented. •decide on and document new nursing diagnoses based on the patient assessment findings. •facilitate communication of the patient's actual problems (e.g., Urinary retention, Impaired skin integrity) with nurses and others on the care team. •use nursing diagnosis to make decisions about what mutual goals the patient desires (patient outcomes) and what can be done (nursing interventions). •determine and document when the nursing diagnoses (risk, health promotion, or actual problem) are resolved.

Parts of Nursing Diagnosis: Defining Characteristics

-The subjective and objective data that signal existence of actual or possible health problem are the third component of the nursing diagnosis NANDA-I has identified defining characteristics for each accepted nursing diagnosis; familiarity with these characteristics helps nurses recognize clusters of significant data. -important to remember that the defining characteristics are part of assessment. Although they are written last in the formal diagnosis, they are considered first.

Medical Diagnosis

-Traumatic or disease condition or syndrome validated by medical diagnostic studies -Correcting or preventing pathology of specific organs or body systems Focus: Correcting or preventing pathology of specific organs or body systems

nursing diagnosis

-When a health problem is identified, the nurse must decide which health care professional can best address the problem. -Actual or potential health problems that can be prevented or resolved by independent nursing intervention -nurse formulates, validates, and lists nursing diagnoses for each patient -provide the basis for selecting nursing interventions that will achieve valued patient outcomes for which the nurse is responsible -After a tentative nursing diagnosis is formulated, it should be validated.

Identifying Strengths and problems

-When analyzing data, determine patient's strengths and problems. -Helps to determine whether the patient agrees with the nurses identification of strengths and problems and is motivated to work towards problem resolution

syndrome

-a clinical judgement concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions -chronic pain syndrome is an example

Problem-Focused Nursing Diagnosis

-clinical judgement concerning vulnerability of an individual, family. group, or community for developing an undesirable human response to health conditions/life processes -this type has 4 components: label, definition, defining characteristics, and related factor

Assesment

-collecting data -Identifying cues and making infrences -validating (verifying) data -clustering related data -identifying patterns/testing first impressions -reporting and recording data

Diagnosis

-creating a running list of suspected problems/diagnosis -ruling out similar problems/diagnosis -naming actual and potential problems/diagnosis and clarifying what's causing or contributing to them -determining risk factors that must be managed -identifying resources, strengths, and areas for health promotion

nursing problem

-diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice

medical diagnosis vs nursing diagnosis

-identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. -describe problems for which the physician or advanced practice nurse directs the primary treatment, whereas nursing diagnoses describe problems treated by nurses within the scope of independent nursing practice. -A medical diagnosis remains the same for as long as the disease is present, whereas a nursing diagnosis may change from day to day as the patient's responses change. These distinctions reflect key differences in medical and nursing practices. -Myocardial infarction (heart attack) is a medical diagnosis. Examples of nursing diagnoses for a person with myocardial infarction may include Fear, Altered Health Maintenance, Deficient Knowledge, Pain, and Altered Tissue Perfusion.

benefits of nursing diagnosis

-individualization of patient care for patient -A prioritized list of nursing diagnoses enables nurses to direct their energies toward these differing patient priorities. use of nursing diagnoses also allows patients to be informed and willing participants in their care, as they validate their diagnoses and assist in prioritizing them. -The process of prioritizing nursing diagnoses is the first step in planning care -Improved communication between nurses and other health care professionals is probably the most important benefit of accurate, up-to-date diagnoses—expressed in well-defined and standardized terminology—for nurses and their patients -This communication aids in planning, charting, patient data retrieval, health team conferences, change-of-shift reports, and health care follow-up. It also promotes nursing accountability for the problems that nurses diagnose. -help in defining the domain of nursing for health care administrators, legislators, and other health care providers. This is important when seeking funding for nursing and reimbursement for nursing services

The nurse reaches one of four basic conclusions after interpreting and analyzing the patient data

-no problem -possible problem -Actual or Potential Nursing Diagnosis or Problem or Issue -Clinical Problem Other Than Nursing Diagnosis

standard

-norm, a generally accepted rule, measure, pattern, or model to which data can be compared to in the same class or category. -For example, when determining the significance of pt's BP reading, appropriate standards include normative values for the patient's age, group, race, and illness category. -Patient's own normal range is an important standard -A pressure of 150/90 mm Hg may be high for someone whos pressure is normally 120/70 mm Hg, but it may be normal for a person with hypertension

Unique focus of Nursing Diagnosis

-nurse expresses nursing's unique concern for a patient (i.e., what it is about the patient that gives rise to the need for nursing, as opposed to the need for medicine or for physical therapy) -written to describe patient problems or issues that nurses can treat independently, such as activity, pain and comfort, and tissue integrity and perfusion problems.

Nursing Diagnosis vs. Collabrative Problems

-nursing diagnoses and collaborative problems constitute the range of responses that nurses treat; as such, they define the unique nature of nursing. -Unlike medical diagnoses, collaborative problems are the primary responsibility of nurses. -Unlike nursing diagnoses, with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines. - When the nurse writes patient outcomes that require delegated medical orders for goal achievement, the situation is not a nursing diagnosis, but a collaborative problem. -Because collaborative problems involve potential complications, they must be identified early so that preventive nursing care can be instituted early

Determining Patient's Problem Areas

-person who does not meet a certain health standard probably has a limitation in that area and may benefit from professional care. -example- person with long history of constipation probably needs care to help overcome this problem -nurse decides whether the data represent a nursing diagnosis or a collaborative problem, or whether the data should be reported to the health care provider because they might lead to a medical diagnosis. -example: preparing to discharge 80 yr old patient with COPD home, lives alone with no one to help manage his diet meds and new therapies, you need to report his problem areas, or you can be sure you will see him quickly readmitted to hospital in crisis -you will be able to identify community resources that can be accessed to help him successfully transition home

Sources of Error when writing Nursing Diagnoses

-premature diagnoses based on an incomplete database -erroneous diagnoses resulting from an inaccurate database or a faulty data analysis -routine diagnoses resulting from the nurses -error of omission

Successful implementation of each step of the nursing process

-requires high-level skills in clinical reasoning. Nursing diagnoses are best used by nurses who have strong interpersonal and communication skills that allow them to gain patients' trust.

Diagnosing

-second step in the nursing process; begins after the nurse has collected and recorded the patient data -nurse interprets and analyzes data gathered from the nursing assessment -data help the nurse identify patient strengths and health problems. -formulate and validate nursing diagnosis -develop a prioritized list of nursing diagnosis -detect and refer signs and symptoms that may indicate a problem vetond nurse's experience

Diagnostic Thinking and Clinical Reasoning

-successful implementation of nursing process requires high-level skills in clinical reasoning To correctly diagnose health problems: -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 intuition, 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.

Recognizing significant data

-to avoid erroneously labeling selected patient health patterns as unhealthy (diagnostic error) when failing to detect an actual unhealthy behavior, nurses must be familiar with comparative standards to be used in data interpretation and analysis

health problems nurses should focus on

-to better understand their responsibilities relating to the diagnosis and management of health problems: -Recognizing safety and infection transmission risks and addressing these immediately -Identifying human responses—how problems, signs and symptoms, and treatment regimens affect patients' lives—and promoting optimum function, independence, and quality of life -Anticipating possible complications and taking steps to prevent them -Initiating urgent interventions—you do not want to wait to make a final diagnosis if there are signs and symptoms indicating the need for immediate treatment

Terminology for writing Nursing Diagnoses

-when a nurse recognizes a cluster of significant patient data indicating a health problem that can be treated with independent nursing interventions, a nursing diagnosis should be written - NANDA-I is resented in taxonomic order and includes basic components of a nursing diagnosis, definition and defining characteristics. Some include related factors, at risk population, and associated condition -There are distinct advantages to nurses use of common terminology when formulating nursing diagnoses. These range from communication advantages (everyone uses the same words to describe common problems) to promoting development of nursing science by facilitating research and the dissemination of research findings to establishing the foundation for any cost-benefit analysis for nursing practice

How standards can be used to identify significant cues

1. Changes in patient's usual health patterns that are unexplained by expected norms for growth and development. 2. Deviation from appropriate population norm 3. Behavior that is non productive in the whole-person context 4. Behavior that indicates a developmental lag or evolving dysfunctional pattern

Guidelines for writing Nursing Diagnoses

1. Phrase the nursing diagnosis (DX) as a patient problem or alteration in health state rather than as patient need 2. Check to make sure that the patient problem precedes the etiology and that the two are linked by the phase "related to" (R/T) 3. Consider when at-risk populations or associated conditions should be identified 4. 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" (AEB). 5. Write in legally advisable terms. 6. Use nonjudgmental language. 7. Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance). 8. Avoid using defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement. 9. Reread the diagnosis to make sure that the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing measures.

Questions to facilitate critical thinking during diagnostic reasoning

Are my data accurate and complete? Do the objective data support the subjective data? How do I know that this information is reliable? Have I correctly distinguished normal from abnormal findings and decided if abnormal data may be signs and symptoms of a specific health problem? Have I made and validated deductions or opinions that follow logically from patient cues? 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/resources the patient might use to avoid or resolve the problem? Have I followed facility guidelines to correctly document diagnostic statements in a way that clearly communicates patient problems to other health care professionals? Is this a problem that falls within nursing's independent domain, or does it signify a medical diagnosis or collaborative problem?

To write a diagnostic statement for a collaborative problem

focus on the potential complications of the problem

Actual or Potential Nursing Diagnosis or Problem or Issue

Begin planning, implementing, and evaluating care designed to prevent, reduce, or resolve the problem. If unable to treat the problem because the patient denies the problem and refuses treatment, make sure that the patient understands the possible outcomes of this stance.

Related factor

Cause or contributing factors (etiologic factors)

Possible Problem

Collect more data to confirm or disprove a suspected problem.

Clinical Problem Other Than Nursing Diagnosis

Consult with the appropriate health care professional and work collaboratively on the problem. Refer to medical or other services, as indicated.

Examples of nursing diagnoses that often are misused in labeling such cultural deviations

Impaired Verbal Communication, Impaired Social Interaction, and Noncompliance. -Nurses must provide culturally sensitive care and work collaboratively with the patient can avoid these problems

Medical Diagnosis Example

Sample Data Cluster 22-year-old woman; "Whenever I have to urinate, it burns terribly. I also feel like I have to go all the time—real bad." Small, frequent voidings, cloudy urine; T—100.8°F Diagnostic Statement Cystitis Select Nursing Response Report signs and symptoms to physician; obtain urine culture; report results to physician; administer appropriate physician-prescribed antibiotic.

Collaborative Problem Example

Sample Data Cluster 42-year-old woman; 1 hour after delivery, spinal anesthesia; 1,500-mL fluid infused in past 4 hours without patient voiding; unable to void Diagnostic Statement Potential complication: Urinary Retention related to fluid overload and effects of anesthesia Select Nursing Response Monitor for signs of increasing urine retention; offer bedpan, and encourage voiding with running water, warm water dripped over perineum, and so forth; if no result, administer physician-prescribed medication; if no result, perform physician-prescribed catheterization.

Nursing Diagnosis Example

Sample data cluster 56-year-old mother of seven; 5 ft 4 in, 167 lb; "Whenever I sneeze lately, I dribble urine. This is embarrassing." Diagnostic Statement Stress Urinary Incontinence related to degenerative changes in pelvic muscles and structural supports associated with advanced age, obesity, gravid uterus Selected Nursing Response Teach Kegel exercises to increase muscle tone; explore patient's willingness and motivation to pursue weight reduction and exercise program; evaluate need for bladder-training program.

ANA Standards of Practice: Diagnosis

The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, or issues. Competencies The registered nurse: identifies actual or potential risks to the health care consumer's health and safety or barriers to health, which may include but are not limited to interpersonal, systemic, cultural, or environmental circumstances. uses assessment data, standardized classification systems, technology, and clinical decision support tools to articulate actual or potential diagnoses, problems, and issues. verifies the diagnoses, problems, and issues with the individual, family, group, community, population, and interprofessional colleagues. prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health-illness continuum. documents diagnoses, problems, and issues in a manner that facilitates the determination of the expected outcomes and plans.

Common Errors in Writing Nursing Diagnoses

Writing diagnosis in terms of needs and response Making legally inadvisable statements Identifying as a problem a patient response that is not necessarily unhealthy Identifying as a problem signs and symptoms of illness Identifying as a patient problem or etiology what cannot be changed Identifying environmental factors rather than patient factors as a problem Reversing clauses Having both clauses say the same thing Including value judgments in the nursing diagnosis Including the medical diagnosis in the diagnostic statement

health problem

a condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness -actual or porential health problems that can be prevented or resolved by independent nursing interention are called nursing diagnosis

clinical reasoning

analyzing, synthesizing, reflecting, drawing conclusions

NANDA-I List

beginning list of suggested terms for health problems that might be identified and treated by nurses. Each of the diagnoses in NANDA International Nursing Diagnoses: Definitions and Classification, 2012-2014 is presented in taxonomic order and includes the basic components of a nursing diagnosis: definition, defining characteristics, and related factors or risk factors. -describes five types of nursing diagnoses: actual, risk, possible, wellness, and syndrome.

NANDA-I Nursing Diagnosis: Components

diagnostic label, definition, defining characteristics, related factors, associated condition

What is not a nursing diagnosis?

not a medical diagnosis: example diabetes mellitus medical pathology: example: hypoglycemia diagnostic tests, treatments, equipment example : Fasting blood glucose, Insulin therapy, Insulin syringe, Infusion pump therapeutic patient needs example: needs to learn the relation among diet, exercise, and insulin therapeutic nursing goals: example: to develop therapeutic diabetic self care behaviors a single sign or symptom example: after successfully administering own insulin for 3 days, patient tells nurse, "You give me my shot today." An invalidated nursing inference example: Above incident leads to the nursing inference: Noncompliance related to depression

nursing diagnosis, collaborative problem, medical diagnosis

nursing diagnosis is identified and successfully treated. In the next example, the nurse identifies a collaborative problem and initiates intervention within the scope of nursing practice. When this fails to resolve the problem, a health care provider is contacted to order medication or a catheterization. In this example, the nurse's early detection and reporting of the problem to the health care provider lead to the health care provider's prompt medical diagnosis of cystitis and successful antibiotic therapy.

Nursing Diagnoses benefits

powerful tool for individualizing patient care and ensures that nurses' energies are being used in the most efficient way to meet prioritized and holistic patients' needs. Nurses who are as concerned about the art and spirit of nursing as they are about its science are careful to avoid labeling patients in a way that objectifies them or limits the potential range of nurse-patient interactions.

Three types of Nursing Diagnoses

problem focused, risk, health promotion

collaborative and interdisciplinary problem

require a teamwork approach with other health care professionals to resolve the problem

Defining Characteristic

sign or symptom (objective or subjective cues)

Most nursing diagnoses are written as

two part statements listing the patient's problem and its cause or as three-part statements that also include the problem's defining characteristics.