Chapter 12

Collecting data Identifying cues and making inferences Validating data clustering related data identifying patterns/testing first impressions reporting and recording data They are all a part of:

Assessing

Wellness nursing diagnosis

Clinical judgments about a person, group, or community in transition from a specific level of wellness to a higher level of wellness

Risk nursing diagnosis

Clinical judgments that a person, family, or community is more vulnerable to develop the problem than others in the same or similar situation.

analyzing synthesizing reflecting drawing conclusions They are all a part of:

Clinical reasoning

Four Components of a Diagnosis

Label (Imbalanced Nutrition) Definition (Intake of nutrients) Defining characteristics- signs/ symptoms Related factor (excessive intake)

If used incorrectly, patient might be misdiagnosed. Nursing practice might be restricted.

Limitations of Nursing Diagnosis

Collaborative problems

Managed by using physician-prescribed and nursing-prescribed interventions are the primary responsibility of nurses

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 nurse's failure to tailor data collection and analysis to the unique needs of the patient Errors of omission

Actual nursing diagnosis

Represent problems that have been validated by the presence of major defining characteristics There are 4 components: label, definition, defining characteristics and related factor

Whether problems are present or not, look for evidence of:

Risk factors If you identify risk factors, aim to reduce or control them, thereby preventing the problems themselves.

Documentation of Diagnoses on Electronic Health Records View the patient's... Decide on and document... Facilitate communication of... Use nursing diagnosis to... Determine and document...

ongoing risks and problems that others have identified and documented. new nursing diagnoses based on the patient assessment findings. the patient's actual problems with nurses and others on the health care team. make decisions about what mutual goals the patient desires and what can be done. when the nursing diagnoses are resolved.

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

Evolution of Nursing Diagnosis: ____ - When it first appeared ____ - NY State Nurse Practice Act identified diagnosing as part of the legal domain of professional nursing ____ -ANA standards included diagnosing as a function of professional nursing ____ -ANA social policy statement-defined nursing as the diagnosis & treatment of human response to actual or potential health problems

1950s 1972 1973 1980

a condition that necessities intervention to prevent or resolve disease or illness or to promote coping & wellness

A health problem

Types of Nursing Diagnoses

Actual Risk Possible Wellness Syndrome

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

Common Errors in Writing Nursing Diagnoses

Individualizing patient care Defining domain of nursing to health care administrators, legislators, and providers Seeking funding for nursing and reimbursement for nursing services

Defining benefits of nursing diagnosis

Nursing Diagnosis

Describes patient problems nurses can treat independently Focuses on unhealthy responses to health and illness

Creating a list of all suspected problems/diagnoses Ruling out similar problems Naming actual and potential problems and clarify what is causing them Determine risk factors that need to be managed Identifying resources, strengths, and areas for health promotion They are all a part of:

Diagnosing

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.

Diagnostic Reasoning and Clinical Reasoning

T/F: The nursing diagnosis Risk for Imbalanced Nutrition: Less Than Body Requirements is an example of a risk diagnosis.

False Rationale: The nursing diagnosis Risk for Imbalanced Nutrition: Less Than Body Requirements is an example of a possible diagnosis.

Medical diagnosis

Identifies diseases and describes problems that the physician primarily treats

more than body requirements related to excessive intake of nutrients as evidenced by weight 20% over ideal body weight, eating late at night, sedentary life

Imbalance nutrition

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

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.

Reaching Conclusions: No problem- Possible Problem- Actual or potential nursing diagnosis- Clinical problem other than nursing diagnosis- Always partner with patient & family

No problem-no nursing response is indicated, reinforce health habits Possible problem-collect more data to confirm or disprove a suspected problem Actual or potential nursing diagnosis-begin planning, implementing & evaluating care to prevent, reduce or resolve the problem Clinical problem other than nursing diagnosis-consult with the appropriate health care professional

Recognizing safety and infection-transmission risks and addressing these immediately. Identifying human responses—how problems, signs and symptoms, and treatment regimens impact on patients' lives—and promoting optimum function, independence, and quality of life. Anticipating possible complications and taking steps to prevent them. Initiating urgent interventions. You should not wait to make a final diagnosis if there are signs and symptoms indicating the need for immediate treatment.

Nursing Concerns and Responsibilities in Diagnosing

Formulation of Nursing Diagnoses

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

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 on which the individual, group, or community can draw to prevent or resolve problems.

Purposes of the Diagnosing Step

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

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 to determine if the patient is motivated to address them.

Four Steps of Data Interpretation and Analysis

Recognizing significant data: Comparing data to standards (generally accepted rule), BP of 140/90 is normal for a pt with HTN, but not normal in a normal pt Recognizing patterns or clusters ( data cluster) Identifying strengths and problems (Identifying potential complications- slurred speech, change in skin color, etc) Reaching conclusions

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

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.

Possible nursing diagnosis

Statements describing suspected problems for which additional data is needed

T/F: A nursing diagnosis may be used to seek reimbursement for nursing services.

True

Is my patient database (assessment data) 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? 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?

Validating Nursing Diagnoses

Syndrome nursing diagnosis

a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation; for example, Rape-Trauma Syndrome or Post-Trauma Syndrome.