Chapter 17

Front 1

Medical diagnosis

Back 1

Identification of a disease condition based on specific evaluation of signs & symptoms

Front 2

Nursing diagnosis

Back 2

Clinical judgment about the patient in response to an actual or potential health problem

Front 3

Collaborative problem

Back 3

Actual or potential physiological complication that nurses monitor to detect a change in patient status

Front 4

History of the Nursing Diagnosis

Back 4

1. First introduced in 1950
2. Fry proposed the formulation of a nursing diagnosis in 1953
3. First national conference was held in 1973
4. In 1980 & 1995, the ANA included diagnosis as a separate activity in it's publication Nursing: A Social Policy Statement
   
5. N.A.N.D.A was founded in 1982

Front 5

What is the nursing diagnostic process?

Back 5

A.) Assessment of patients health status:

• --Patient, family, & health care resources constitute database
  
• --Nurse clarifies inconsistent or unclear information
  
• --Critical thinking guides & directs line of questioning & examination to reveal detailed & relevant database
  

B.) Validate with other sources

C.) Is additional data needed? If so, reassess - if not, continue

D.) Interpret & analyze meaning of data

E.) Data Cluster:

--Group signs/symptoms

--Classify & organize

F.) Look for defining characteristics & related factors

G.) Identify patient needs

H.) Formulate nursing diagnosis & collaborative problems

Front 6

Nursing diagnostic statements

Back 6

• Provides a precise definition of a patients problem that gives nurses & other members of the health care team a common language for understanding patients needs
• Allows nurses to communicate what they do among themselves & with other health care professionals & the public
• Distinguishes the nurses role from that of the physician or other health care provider
• Helps nurses focus on the scope of nursing practice
  

Front 7

What does the diagnostic reasoning process involve?

Back 7

1. Using the assessment data gathered about a patient to logically explain a clinical judgment or nursing diagnosis
   
2. Nursing diagnosis & definitions
3. Choosing interventions suited for treating the diagnosis

Front 8

What are defining characteristics?

Back 8

1. Clinical criteria or assessment findings
   
2. Related factors pertinent to the diagnosis

Front 9

What is the reasoning for using Data Clustering?

Back 9

1. Show patterns of data that contain defining characteristics
2. Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion
   

Front 10

Interpretation related to identifying health problems:

Back 10

• Critical to select correct diagnostic label for patients needs
• Where you move from general to specific information throughout assessment to diagnosis
• Think of the problem identification phase in assessment as the general health care problem and the formulation of the nursing diagnosis as the specific health problem
• The absence of certain defining characteristics suggests that you reject a diagnosis under consideration
  

Front 11

What is a related factor?

Back 11

1. A condition, historical factor, or causative event that gives context for the defining characteristics & shows a type of relationship with the nursing diagnosis
   
2. Allows you to individualize a nursing diagnosis for a specific patient

Front 12

What does a concise nursing diagnosis allow?

Back 12

When you are ready to form a plan of care & select nursing interventions, this allows you to select suitable therapies

Front 13

Actual nursing diagnosis

Back 13

Describes human responses to health conditions or life processes

Front 14

Risk nursing diagnosis

Back 14

Describes human responses to health conditions/life experience processes that may develop

Front 15

Health promotion nursing diagnosis

Back 15

A clinical judgment of motivation, desire, & readiness to enhance well-being and actualize human health potential

Front 16

Components of a nursing diagnosis?

Back 16

Related factors/etiology

• -- treatment related
  
• --pathophysiological (biological or psychological)
  
• -- maturational
  
• -- situational (environmental or personal)
  

P. E. S. format:

P - problem

E - etiology

S - symptoms (or defining characteristics)

2 part diagosis:

1. Diagnostic label
2. R/T (etiology)

3 part nursing diagnosis:

1. Diagnostic label
2. R/T (etiology)
3. AEB

Front 17

Cultural relevance of nursing diagnosis

Back 17

• Consider patients cultural diversity when selecting a nursing diagnosis, ask questions such as:
  

--How has this health problem affected you & your family?

--What do you believe will help or fix the problem?

--What worries you most about the problem?

--Which practices within your culture are important to you?

• Cultural Awareness and sensitivity improve your accuracy in making nursing diagnoses.
  

Front 18

Sources of diagnostic error:

Back 18

1. Data collection
2. Data clustering
3. Labeling the diagnosis/diagnostic statement
4. Documentation & informatics
   

Front 19

Diagnostic Statement guidelines:

Back 19

1. Identify the patients response, not the medical diagnosis
   
2. Identify a NANDA-1 diagnostic statement rather than the symptom
3. Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention
4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself
5. Identify the patient response to the equipment rather than the equipment itself
6. Identify the patients problems rather than your problems with nursing care
7. Identify the patient problem rather than the nursing intervention
8. Identify the patient problem rather than the goal of care
9. Make professional rather than prejudicial judgments
10. Avoid legally indivisible statements
11. Identify the problem & it's cause to avoid a circular statement
12. Identify only one patient problem in the diagnostic statement

Front 20

Nursing diagnosis- application to care:

Back 20

• By learning to make accurate nursing diagnoses, your care plan will help communicate the patients health care problems to other professionals
• A nursing diagnosis will ensure that you select relevant & appropriate nursing interventions
  

Front 21

What is the purpose of using standard formal nursing diagnoses in clinical practices?

Back 21

• Provides a precise definition of a patients problems that gives nurses & other healthcare members a common language for understanding the patients needs
• Allows nurses to communicate (written & electronic) what they do among themselves with other health care professionals and the public
• Distinguishes the nurses role from that of the physician or other health care provider
  
• Fosters the development of nursing knowledge

Front 22

Examples of NANDA diagnosis defining characteristics r/t:

Acute Pain -

Back 22

1. Coded (scale of 0-10) report
   
2. Self-focus
3. Sleep disturbance
4. Verbal report of pain
5. Protective gestures
6. Guarding behavior
7. Change in bp
8. Diaphoresis
9. Expressive behavior
10. Positioning to avoid pain
11. Pupil dilation

Front 23

Examples of NANDA diagnosis defining characteristics r/t:

Chronic pain -

Back 23

1. Coded (scale of 0-10) report
2. Self-focusing
3. Changes in sleep pattern
4. Verbal report of pain
5. Observed protective behavior
6. Guarding behavior
7. Altered ability to continue previous activities
8. Atrophy of involved muscle group
9. Depression
10. Fatigue
11. Fear of reinjury

Front 24

Ex: Nursing diagnostic statement for a patient with a medical diagnosis of pneumonia

Back 24

Impaired gas exchange r/t decreased o2 saturation a.e.b. difficulty breathing & persistent cough

Front 25

Ex: etiology that could be interchanged for the medical diagnosis of COPD:

Back 25

1. Secondhand smoke
2. Smoke inhalation
3. Smoking
   

Front 26

Ex: Wellness diagnosis:

Back 26

Ready to care for self

Front 27

N. A. N. D. A.

Back 27

N - North

A - American

N - Nursing

D - Diagnosis

A - Association

** Initiated in 1973

Front 28

What is the purpose of concept mapping?

Back 28

A visual tool to graphically represent the connections between concepts & ideas that are related to a central subject

Front 29

What does data clustering mean?

Back 29

Clustering a set of signs/symptoms gathered during assessment that are grouped together in a logical way & analyzed to recognize the pattern of a problem

Front 30

AEB

Back 30

As Evidenced By - used in nursing diagnosis

Front 31

R/T

Back 31

Related To - used in nursing diagnosis