NURSING DIAGNOSIS (LECTURE # 4)
NURSING DIAGNOSIS
• Identified PRIORITIZED problems will become basis for client’s plan of care • Identified strengths will be invaluable when choosing effective interventions
What is a Nursing Diagnosis?
• It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
• It is focused on client-centered (holistic) problems
PURPOSES
• Contributes to the professional status of nursing as a discipline • Provides a means for effective communication • Facilitates holistic client, family & community-focused care
NANDA DEFINITION
North American Nursing Diagnosis Association • Clinical judgment about clients’ responses to actual or potential health problems or life processes • Identifies problems for which the nurse is accountable and is capable of diagnosing & treating independently
Comparison: Medical vs. Nursing Diagnosis
• Medical: terminology used for a clinical judgment by the physician. Identifies or determines a specific disease, condition, or pathological state.
• Nursing: clinical judgment that identifies the client’s responses to a health state, problem or condition.
Taxonomy ??
• System of identification, naming & classification • Drawn from human responses: both physiological (Maslow’s) as well as behavioral aspects • Data clustered to human needs
MAKING SENSE..
• COMPONENTS: – LABEL – DEFINITION – SET OF DEFINING CHARACTERISTICS – GROUP OF RELATED FACTORS OR RISK FACTORS
FORMATS
• Different formats may be used to structure (write) the diagnosis statement • 1 part = “wellness” • 2 part = “at risk for” • 3 part = “actual”
• Both 2 & 3 part statements have:
– label: a problem statement – etiology: a related cause or a contributor to the problem identified (related to = r/t)
• 3 part will also have list of defining characteristics (as manifested by = amb; as evidenced by = aeb)
The difference is… A 2 part statement
• identifies that which the nurse may anticipate or needs to monitor…problem does not currently exists Risk for ineffective airway clearance r/t history of smoking for 20 years.
Versus a 3 part statement…..
• identifies a priority need/problem that is actual. Ineffective airway clearance r/t increased production of secretions amb (as manifested by) or aeb (as evidenced by) client’s cough, presence of crackles in lung bases.
THE LABEL
• Remember - you “cluster” the data & prioritize client’s needs (think holistic!) • Label - may include a qualifier:
– impaired, altered, decreased, acute, chronic, ineffective – (refer to NANDA list after you cluster & prioritize your collected data)
What does the Diagnosis look like?
LABEL / DEFINITION (1)
• Concise description of the prioritized problem. Example: IMPAIRED PHYSICIAL MOBILITY
Etiology (2)
• The related cause or contributor to the identified problem….. Example: IMPAIRED PHYSICAL MOBILITY R/T (related to) PRESCRIBED BEDREST
DEFINING CHARACTERISTICS (3)
• Collected data (objective & subjective) known as signs & symptoms or clinical manifestations that support the existence of the problem. Example: IMPAIRED PHYSICAL MOBILITY R/T PRESCRIBED BEDREST AMB DECREASED ROM TO LOWER EXTREMITIES
• (1) IMPAIRED PHYSICAL MOBILITY • (2) R/T PRESCRIBED BEDREST • (3) AMB (OR AEB) DECREASED ROM
TO LOWER EXTREMITIES
SO THE DIFFERENCE IS….
• 2 PART (RISK FOR): Risk for impaired physical mobility r/t bedrest • versus • 3 PART (ACTUAL): Impaired physical mobility r/t bedrest amb decreased ROM to lower extremities
Let’s review the types...
• ACTUAL (3 PART): describes the human responses to health conditions or life processes that actually exist in the client, their family, or the community.
• RISK FOR (2 PART): describes human responses that may develop in a vulnerable client, family, or community.
Things to think about..
• Identify appropriate Nursing Diagnoses • Determine the related factor/factors • Identify actual defining characteristics for 3 part statement
• DISCUSS THE DIAGNOSES WITH THE CLIENT TO FORMULATE PLAN OF NURSING CARE
POTENTIAL ERRORS
• Use of medical diagnosis – Leads to premature termination of data collection – Nurse cannot address independently
More Potential Errors …
• • • • • Lack of nurses’ holistic approach Inadequate data collection Inadequate assessment Including a nurse’s personal judgement Data clustering errors
– inadequate data – poor critical thinking
INTERPRETATION ERRORS
• CUES OR CLUSTERED DATA ARE INTERPRETED INCORRECTLY • ASSESSMENT DATA IS AMBIGUOUS • DATA LEADS YOU TO 2 OR MORE POSSIBLE DIAGNOSES
• Don’t forget to include the family ! • Don’t under or over diagnose ! • COMING ATTRACTIONS ..To be presented in Medical Surgical Nursing … COLLABORATIVE PROBLEMS! In contrast to independent nursing diagnoses - those problems which require interdependency with health care team (hemorrhage /shock)