Chapter 17

Nurse diagnosis

nursing diagnosis, nurses make diagnostic conclusions and therefore the clinical decisions necessary for safe and effective nursing practice

Diagnostic Conclusions

Diagnostic conclusions include problems treated primarily by nurses (nursing diagnoses) and those requiring treatment by several disciplines (collaborative problems).

Collaborative Problem

A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status

Concept Map

A concept map diagrams the critical thinking associated with making accurate diagnoses. For each diagnosis you list defining characteristics and begin to see the connections or association among different diagnostic statements.

Additional guidelines to reduce errors in the diagnostic statement follow.

1Identify the patient's response, not the medical diagnosis (Carpenito-Moyet, 2009). Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. Change the diagnosis acute pain related to prostatectomy to acute pain related to trauma of an incision. 2Identify a NANDA-I diagnostic statement rather than the symptom. Identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. One symptom is insufficient for problem identification. For example, dyspnea alone does not definitively lead you to a diagnosis. However, the pattern of dyspnea, shortness of breath, pain on inspiration, and productive cough with thick secretions are defining characteristics that lead you to the diagnosis of ineffective breathing pattern related to increased airway secretions. 3Identify a treatable etiology or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention. An accurate etiology allows you to select nursing interventions directed toward correcting the etiology of the problem or minimizing the patient's risk. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat. A patient with fractured ribs likely has pain when inhaling; impaired chest excursion; and slower, shallow respirations. An x-ray film may show atelectasis (collapse of alveolar air sacs) in the area affected. The nursing diagnosis of ineffective breathing pattern related to shallow respirations is an incorrect diagnostic statement. Ineffective breathing pattern related to pain in chest is more accurate. 4 Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself. Patients experience many responses to diagnostic tests and medical treatments. These responses are the area of nursing concern. The patient who has angina and is scheduled for a cardiac catheterization possibly has a nursing diagnosis of anxiety related to lack of knowledge about cardiac catheterization. An incorrect diagnosis is anxiety related to cardiac catheterization. 5 Identify the patient response to the equipment rather than the equipment itself. Patients are often unfamiliar with medical technology. The diagnosis of deficient knowledge regarding the need for cardiac monitoring is accurate compared with the statement anxiety related to cardiac monitor. 6 Identify the patient's problems rather than your problems with nursing care. Nursing diagnoses are always patient centered and form the basis for goal-directed care. Potential intravenous complications related to poor vascular access indicates a nursing problem in initiating and maintaining intravenous therapy. The diagnosis risk for infection properly centers attention on patient needs. 7 Identify the patient problem rather than the nursing intervention. You plan nursing interventions after identifying a nursing diagnosis. The statement, "offer bedpan frequently because of altered elimination patterns," changes to the correct diagnostic statement, diarrhea related to food intolerance. This corrects the misstatement and allows proper implementation of the nursing process. More appropriate interventions are selected rather than a single intervention that will not solve the problem. 232233 8 Identify the patient problem rather than the goal of care. You establish goals during the planning step of the nursing process (see Chapter 18). Goals based on accurate identification of a patient's problems serve as a basis to determine problem resolution. Change the diagnostic statement, "Patient needs high-protein diet related to potential alteration in nutrition," to imbalanced nutrition: less than body requirements related to inadequate protein intake. 9 Make professional rather than prejudicial judgments. Base nursing diagnoses on subjective and objective patient data and do not include your personal beliefs and values. Remove your judgment from impaired skin integrity related to poor hygiene habits by changing the nursing diagnosis to read impaired skin integrity related to inadequate knowledge about perineal care. 10 Avoid legally inadvisable statements (Carpenito-Moyet, 2009). Statements that imply blame, negligence, or malpractice have the potential to result in a lawsuit. The statement, "recurrent angina related to insufficient medication," implies an inadequate prescription by the health care provider. Correct problem identification is chronic pain related to improper use of medications. 11 Identify the problem and etiology to avoid a circular statement. Circular statements are vague and give no direction to nursing care. Change the statement, "impaired breathing pattern related to shallow breathing," to identify the patient problem and cause, ineffective breathing pattern related to incisional pain. 12 Identify only one patient problem in the diagnostic statement. Every problem has different specific expected outcomes. Confusion during the planning step occurs when you include multiple problems in a nursing diagnosis. Restate pain and anxiety related to difficulty in ambulating as two nursing diagnoses such as impaired physical mobility related to pain in right knee and anxiety related to difficulty in ambulating. It is permissible to include multiple etiologies contributing to one patient problem, as in complicated grieving related to diagnosed terminal illness and change in family role.

Data Clusterings

A data cluster is a set of signs or symptoms gathered during assessment that you group together in a logical way.

health promotion nursing diagnosis

A health promotion nursing diagnosis is a clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise

Medical Diagnosis

A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history and the results of diagnostic tests and procedures.

Risk nursing diagnosis

A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. These diagnoses do not have related factors or defining characteristics because they have not occurred yet. Instead a risk diagnosis has risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.

actual nursing diagnosis

An actual nursing diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community.

Errors in Diagnostic Statement

Clinical reasoning leads to a higher quality of nursing diagnosis, which eventually leads to etiology-specific interventions and enhanced patient outcomes (Muller-Staub et al., 2008). The more competent you become in diagnostic reasoning, the more likely it is that you will correctly select diagnostic statements. This results in the appropriate selection of nursing interventions and patient outcomes during planning and implementation (see Chapters 18 and 19). Reduce errors by selecting appropriate, concise, and precise language using NANDA-I terminology.

Defining Characteristics

Data clusters are patterns of data that contain defining characteristics, the clinical criteria that are observable and verifiable. Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion

Error in Data Clustering

Errors in data clustering occur when data are clustered prematurely, incorrectly, or not at all. Premature closure of clustering occurs when you make the nursing diagnosis before grouping all data.

Errors in Interpretation and Analysis of Data

Following data collection, review your database to decide if it is accurate and complete. Review data to validate that measurable, objective physical findings support subjective data. For example, when a patient reports "difficulty breathing," you also want to listen to lung sounds, assess respiratory rate, and measure the patient's chest excursion. When you are not able to validate data, it signals an inaccurate match between clinical cues and the nursing diagnosis. Begin interpretation by identifying and organizing relevant assessment patterns to support the presence of patient problems. Be careful to consider conflicting cues or decide if there are insufficient cues to form a diagnosis.

Documentation and Informatics

In the clinical facility list nursing diagnoses chronologically as you identify them. When initiating an original care plan, place the highest-priority nursing diagnoses first. Date a nursing diagnosis at the time of entry. When caring for a patient, review the list and identify nursing diagnoses with the greatest priority, regardless of chronological order.

Nurse Diagnosis: Application to Care Planning

Nursing diagnosis is a mechanism for identifying the domain of nursing. Diagnoses direct the planning process and the selection of nursing interventions to achieve desired outcomes for patients.

Components of a nursing diagnosis

Most settings use a two-part format in labeling a nursing diagnosis: the NANDA-I diagnostic label followed by a statement of a related factor (Table 17-1). The two-part format provides a diagnosis meaning and relevance for a particular patient.

NANDA

NANDA-I (2012) identifies three types of nursing diagnoses: actual diagnoses, risk diagnoses, and health promotion diagnoses.

Nursing Diagnosis

Nursing diagnosis, the second step of the nursing process (Fig. 17-1), classifies health problems within the domain of nursing. A nursing diagnosis such as acute pain or nausea is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat

related factors

Related factors for NANDA-I diagnoses include four categories: pathophysiological (biological or psychological), treatment-related, situational (environmental or personal), and maturational

nursing diagnosis errors

Sometimes health care providers record medical diagnoses as the etiology of the nursing diagnosis. This is incorrect. Nursing interventions do not change a medical diagnosis. However, you direct nursing interventions at behaviors or conditions that you are able to treat or manage.

diagnostic label

The diagnostic label is the name of the nursing diagnosis as approved by NANDA International (see Box 17-2). It describes the essence of a patient's response to health conditions in as few words as possible. All NANDA-I approved diagnoses also have a definition. The definition describes the characteristics of the human response identified.

Diagnostic Process

The diagnostic process flows from the assessment process and includes decision-making steps (Fig. 17-2). These steps include data clustering, identifying patient health problems, and formulating the diagnosis.

Critical thinking and the nursing process

The diagnostic process requires you to use critical thinking (see Chapter 15). In the practice of nursing it is important for you to know nursing diagnoses, their definitions and the defining

etiology

The etiology or related factor of a nursing diagnosis is always within the domain of nursing practice and a condition that responds to nursing interventions.

Formulating a Nursing Diagnosis

To individualize a nursing diagnosis further, you identify the associated related factor. A related factor is a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis (NANDA International, 2012). A related factor allows you to individualize a nursing diagnosis for a specific patient. While focusing on patterns of defining characteristics, you also compare a patient's pattern of data with data that are consistent with normal, healthful patterns. Use accepted norms as the basis for comparison and judgment. This includes using laboratory and diagnostic test values, professional standards, and normal anatomical or physiological limits. When comparing patterns, judge whether the grouped signs and symptoms are expected for the patient and whether they are within the range of healthful responses. Isolate any defining characteristics not within healthy norms to allow you to identify a specific problem. A nursing diagnosis focuses on a patient's actual or potential response to a health problem rather than on the physiological event, complication, or disease

Interpretation

When interpreting data to form a diagnosis, remember that the absence of certain defining characteristics suggests that you reject a diagnosis under consideration.

Cultural Relevance of Nursing Diagnoses

When you select nursing diagnoses, consider your patients' cultural diversity. This includes knowing the cultural differences that affect how a patient defines health and illness and wants to be treated (Smith, 2007). It is important to consider your own cultural competence so you are more sensitive to a patient's health care problems and the implications.

Nursing Diagnostic Labels

there are two accepted nursing diagnostic labels for problems related to knowledge: deficient knowledge and readiness for enhanced knowledge.

PES Format

•P (problem)—NANDA-I label—Example: impaired physical mobility •E (etiology or related factor)—Example: incisional pain •S (symptoms or defining characteristics)—briefly lists defining characteristic(s) that show evidence of the health problem. Example: evidenced by restricted turning and positioning