Taylor - Fundamentals Of Nursing - Adn 1 Exam #3 Chapter 13 - Diagnosing

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Diagnosing - the second step in the nursing process—begins after

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the nurse has collected and recorded the patient data.

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The purpose of diagnosing is to:

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(1) identify how an individual, group, or community responds to actual or potential health and life processes; (2) (etiologies)- identify factors that contribute to or cause health problems ;
(3) identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.

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In the diagnosing step of the nursing process, the nurse

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-interprets and analyzes data gathered from the nursing assessment .
-Through analysis of data, identifies patient strengths and health problems.
-Formulates and validates nursing diagnoses.
-Prioritizes the list of nursing diagnoses.
-detects and refers signs and symptoms that may indicate a problem beyond the nurse's experience.

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A health problem is:

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a condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness.

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Nurses need to understand and be concerned of the types of problems they should focus on to better understand their responsibilities relating to the diagnosis and management of health problems.these are:

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•Recognizing signs and symptoms of common health problems and those that may indicate the need for more expert diagnosis
•Predicting problems in those at risk and taking steps to manage risks and prevent complications.
•Identifying human responses and promoting optimum function, independence, and quality of life.
•Initiating actions and referrals in a timely way to ensure appropriate, qualified treatment.

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When a health problem is identified, the nurse must:

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decide which healthcare professional can best address the problem.

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Nursing diagnoses are written to describe:

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patient problems that nurses can treat independently.

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Medical Diagnoses identify:

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diseases. It remains the same for as long as the disease is present.

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Nursing Diagnoses focus on:

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the unhealthy responses to health and illness. these diagnoses may change from day to day as the patient’s responses change.

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collaborative problems

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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.

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The term cue is often used to denote

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significant data or data that influence the analysis. Significant data should “raise a red flag” for the nurse, who then looks for patterns or clusters of data that signal an actual, potential, or possible nursing diagnosis.

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A standard,or a norm, is

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a generally accepted rule,measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient’s blood pressure reading,appropriate standards include normative values for the patient’s age group, race, and illness category. The patient’s own normal range, if known, is an important standard.

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A data cluster is .

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a grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue.

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The NANDA list is

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a beginning list of suggested terms for health problems that might be identified and treated by nurses. Each of the diagnoses includes the basic components of a nursing diagnosis:
definition,
defining characteristics, and
related factors or risk factors

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NANDA describes five types of nursing diagnoses:

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Actual,
risk,
possible,
wellness, and
syndrome.

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Actual nursing diagnoses represent

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a problem that has been validated by the presence of major defining characteristics.This type of nursing diagnosis has four components:
label,
definition,
defining characteristics, and
related factor.
An actual 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.

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Risk nursing diagnoses

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are clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation.
If diarrhea persists and weakness interferes with the patient’s normal perineal hygiene, he might be at risk for skin breakdown:
Risk for Impaired Skin Integrity.

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Possible nursing diagnoses are

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statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem.
If the nurse suspects that a disturbance of self-concept is also present but lacks the necessary data (defining characteristics) to confirm this, it can be written as a possible diagnosis:
Possible Chronic Low Self-Esteem.
This alerts other nurses to the need to collect more data about the patient’s self-esteem.

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Wellness diagnoses are

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clinical judgments about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness.
Two cues must be present for a valid wellness diagnosis:
•A desire for a higher level of wellness.
•An effective present status or function.
Examples include:
Readiness for Enhanced FamilyCoping, Readiness for Enhanced Health Maintenance,
Readiness for Enhanced Parenting, and Readiness for Enhanced Self-Esteem.

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Syndrome nursing diagnoses

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comprise 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.

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nursing diagnoses are written either as

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

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FORMULATION OF NURSING DIAGNOSIS STATEMENTS
Problem

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identifies what is unhealthy about the patient, indicating the need for change (clear, concise statement of the patient’s health problem)
Suggests the patient outcomes (expectations for change).
Bathing/Hygiene Self-Care Deficit related to----

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FORMULATION OF NURSING DIAGNOSIS STATEMENTS
Etiology

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identifies the factors that are maintaining the unhealthy state or response (contributing or causative factors).
Suggests the appropriate nursing measures/interventions.
Fear of falling in the tub and obesity as manifested by--------

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FORMULATION OF NURSING DIAGNOSIS STATEMENTS

Defining Characteristics

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identify the subjective and objective data that signal the existence of the problem (cues that reflect the existence of a problem).
Suggest evaluative criteria.
Strong body and urine odor,unclean hair: “I’m afraid I’ll fall in the tub and break something.” (5'4" 170 lb)

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Common Descriptors used to clarify a Diagnostic Statement:
Anticipatory

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Realize beforehand, foresee

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Common Descriptors used to clarify a Diagnostic Statement:

Compromised

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Damaged, made vulnerable

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Common Descriptors used to clarify a Diagnostic Statement:

Decreased

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Lessened (in size, amount, or degree)

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Common Descriptors used to clarify a Diagnostic Statement:

Deficient

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Insufficient, inadequate

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Common Descriptors used to clarify a Diagnostic Statement:

Delayed

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Late, slow or postponed

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Common Descriptors used to clarify a Diagnostic Statement:

Disabled

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Limited, handicapped

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Common Descriptors used to clarify a Diagnostic Statement:

Disorganized

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Not properly arranged or controlled

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Common Descriptors used to clarify a Diagnostic Statement:

Disproportionate

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Too large or too small in comparison with a norm

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Common Descriptors used to clarify a Diagnostic Statement:

Disturbed

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Agitated, interrupted, interfered with

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Common Descriptors used to clarify a Diagnostic Statement:

Dysfunctional

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Not operating normally

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Common Descriptors used to clarify a Diagnostic Statement:

Effective

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Producing the intended or desired result

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Common Descriptors used to clarify a Diagnostic Statement:

Excessive

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Greater than necessary or desirable

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Common Descriptors used to clarify a Diagnostic Statement:

Imbalanced

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Out of proportion or balance

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Common Descriptors used to clarify a Diagnostic Statement:

Impaired

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Damaged, weakened

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Common Descriptors used to clarify a Diagnostic Statement:

Ineffective

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Not producing the intended or desired effect

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Common Descriptors used to clarify a Diagnostic Statement:

Interrupted

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Having its continuity broken

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Common Descriptors used to clarify a Diagnostic Statement:

Low

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Below the norm

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Common Descriptors used to clarify a Diagnostic Statement:

Organized

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Properly arranged or controlled

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Common Descriptors used to clarify a Diagnostic Statement:

Perceived

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Observed through the senses

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Common Descriptors used to clarify a Diagnostic Statement:

Readiness for

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In a suitable state for an activity or situation

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Common Descriptors used to clarify a Diagnostic Statement:

Situational

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Related to a particular circumstance

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Guidelines for Writing Nursing Diagnoses that ensure that your diagnostic statements are correctly written:

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1.Phrase the nursing diagnosis as a patient problem or alteration in health state rather than as a patient need.
2.Check to make sure that the patient problem precedes the etiology and that the two are linked by the phrase“related to.”
3.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.”
4.Write in legally advisable terms.
5.Use nonjudgmental language.
6.Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance).
7.Avoid using defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement.
8.Reread the diagnosis to make sure the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing measures.

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The nursing diagnosis statement is written in terms of

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a patient problem, alteration in health state, or patient strength for which nursing provides the primary therapy.
Nursing diagnoses are not medical diagnoses or statements of patient need.

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After a tentative nursing diagnosis is formulated, it should be validated.

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•Is my database 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?

In addition, patients who are able to participate in decision making should be encouraged to validate the diagnosis.