12 Diagnosing

Directory Classroom Response System Questions Lecture Note Presentation

Classroom Response System Questions

Question 1 The nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement? Assess the client’s needs. Delineate the client’s problems and strengths. Determine which interventions are most likely to succeed. Estimate the cost of several different approaches.

Question 1 Answer Assess the client’s needs. Delineate the client’s problems and strengths. Determine which interventions are most likely to succeed. Estimate the cost of several different approaches.

Question 1 Rationales Gathering data about client needs is assessment. Correct. In diagnosing, data from assessment are analyzed and problems, risks, and strengths are identified before diagnostic statements are established. Interventions are established in the planning phase and carried out in the implementation phase of the nursing process. Cost is an important consideration but would be estimated in the planning phase.

Question 2 In the diagnostic statement “Excess Fluid Volume related to decreased venous return as manifested by lower extremity edema (swelling),” the etiology of the problem is which of the following? Excess fluid volume Decreased venous return Edema Unknown

Question 2 Answer Excess fluid volume Decreased venous return Edema Unknown

Question 2 Rationales Excess Fluid Volume is the nursing diagnosis. Correct. Because the venous return is impaired, fluid builds up in lower extremities, resulting in swelling. Therefore, decreased venous return is the cause (etiology) of the problem. Edema of the lower extremity is the sign/symptom or critical attribute. The cause (impaired venous return) is known.

Question 3 Which of the following nursing diagnoses contains the proper components? Risk for Caregiver Role Strain related to unpredictable course of illness Risk for Falls related to tendency to collapse when having difficulty breathing Impaired Communication related to stroke Sleep Deprivation secondary to fatigue and a noisy environment

Question 3 Answer Risk for Caregiver Role Strain related to unpredictable course of illness Risk for Falls related to tendency to collapse when having difficulty breathing Impaired Communication related to stroke Sleep Deprivation secondary to fatigue and a noisy environment

Question 3 Rationales Correct. States the relationship between the stem (Caregiver Role Strain) and the cause of the problem. The diagnostic statement here says the same thing as the related factor (falls and collapse). It is inappropriate to use medical diagnoses such as stroke within a nursing diagnosis statement. Option D is vague. The statement must be specific and guide the plan of care (fatigue may be a result of sleep deprivation and does not direct intervention).

Question 4 Which of the following is a primary advantage of using a three-part diagnostic statement such as the problem-etiology-signs/symptoms (PES) format? Decreases the cost of health care Improves communication between nurse and client Helps the nurse focus on health and wellness elements Standardizes organization of client data

Question 4 Answer Decreases the cost of health care Improves communication between nurse and client Helps the nurse focus on health and wellness elements Standardizes organization of client data

Question 4 Rationales More efficient planning may or may not reduce health care cost. Nursing diagnostic statements should be confirmed with the client, but using PES does not ensure this. PES statements can be wellness or illness focused. Correct. The PES format assists with comprehensive and accurate organization of client data.

Question 5 A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis: If both medical and nursing interventions are required to treat the problem. When independent nursing actions can be utilized to treat the problem. In cases where nursing interventions are the primary actions required to treat the problem. When no medical diagnosis (disease) can be determined.

Question 5 Answer If both medical and nursing interventions are required to treat the problem. When independent nursing actions can be utilized to treat the problem. In cases where nursing interventions are the primary actions required to treat the problem. When no medical diagnosis (disease) can be determined.

Question 5 Rationales Correct. A collaborative (multidisciplinary) problem is indicated when both medical and nursing interventions are needed to prevent or treat the problem. If nursing care alone can treat the problem (in this case, independent nursing actions), a nursing diagnosis is indicated. If nursing care alone can treat the problem (whether that care involves independent or dependent nursing actions), a nursing diagnosis is indicated. If medical care alone can treat the problem, a medical diagnosis is indicated.

Lecture Note Presentation

Learning Outcomes Differentiate nursing diagnoses according to status. Identify the components of a nursing diagnosis. Compare nursing diagnoses, medical diagnoses, and collaborative problems. Identify basic steps in the diagnostic process.

Learning Outcomes (cont'd) Describe various formats for writing nursing diagnoses. List guidelines for writing a nursing diagnosis statement. Describe the evolution of the nursing diagnosis movement, including work currently in progress.

Nursing Diagnosis Prior step of nursing process leads up to formation of nursing diagnoses All other steps flow from nursing diagnoses Problems nurses identify and treat Taxonomy to categorize client problems or needs NANDA

Figure 12-1 Diagnosing. The pivotal second phase of the nursing process. 23

Diagnosing Diagnosing refers to the reasoning process Diagnosis -a statement or conclusion regarding the nature of a phenomenon Diagnostic labels are standardized NANDA names Nursing diagnosis - problem statement consisting of diagnostic label plus etiology

Types of Nursing Diagnoses Actual diagnosis Problem presents at the time of assessment Presence of associated signs and symptoms Health promotion diagnosis Preparedness to implement behaviors to improve their health condition Example: Readiness for Enhanced Nutrition

Types of Nursing Diagnoses (cont'd) Risk diagnosis Problem does not exist Presence of risk factors Wellness diagnosis Describes human responses to levels of wellness in individual, family, or community Example: Readiness for Enhanced Family Coping

Components of a Nursing Diagnosis Problem statement (diagnostic label) Describes the client’s health problem or response Qualifiers added to give additional meaning Etiology (related factors and risk factors) Identifies one or more probable causes of the health problem

Components of a Nursing Diagnosis (cont’d) Defining characteristics Cluster of existing signs and symptoms indicates “actual” diagnosis (clients have signs and symptoms). Cluster of factors that cause client to be more vulnerable to a problem indicates “risk for” diagnosis (no subjective or objective data exist at present).

Nursing Diagnosis A statement of nursing judgment based on education, experience, expertise and license to treat Describes human response, the client’s physical, sociocultural, psychological, and spiritual responses to an illness or health problem Changes when client’s responses change Independent nursing functions

Medical Diagnosis Made by a physician Refers to a disease process Remains the same as long as the disease process is present Dependent nursing functions (physician-prescribed therapies and treatments)

Collaborative Problems Use both independent and dependent (physician-prescribed) interventions Require monitoring of client’s condition and prevention of potential complications Occur when a particular disease or treatment is present

Figure 12-2 Decision tree for differentiating among nursing diagnoses, collaborative problems, and medical diagnoses.

Table 12-3 Comparison of Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems 33

Steps in Diagnostic Process Analyze data Compare data against standards (standard, norm) Cluster cues Identify gaps and inconsistencies Identify health problems, risks, and strengths Formulate diagnostic statements

Writing Nursing Diagnoses Basic Two-Part Statement Problem (P) Etiology (E) Basic Three-Part Statement Signs and symptoms (S)

Writing Nursing Diagnoses (cont’d) One-Part Statement Wellness (readiness for enhanced) Syndrome Variations Unknown etiology Complex factors Possible Secondary Other additions for precision

Table 12-6 Guidelines for Writing a Nursing Diagnostic Statement 37

Avoiding Errors in Diagnostic Reasoning Verify data Build a good knowledge base,acquire clinical experience Have a working knowledge of what is “normal” Consult resources Base diagnoses on patterns Improve critical-thinking skills

Evolution of Nursing Diagnoses First taxonomy was alphabetical Later version based on “human response patterns” Taxonomy II has three levels Domains Classes Nursing diagnoses

Evolution of Nursing Diagnoses (cont'd) Process for acceptance of new and modified labels reviewed biannually NIC (nursing interventions classification) NOC (nursing outcomes classification)

Figure 12-3 Taxonomy II. From NANDA Nursing Diagnoses: Definitions and Classifications, 2009–2011 (pp. 368–369), by NANDA International, 2009, Oxford, United Kingdom: Wiley-Blackwell. Reprinted with permission. 41

Figure 12-3 (continued) Taxonomy II Figure 12-3 (continued) Taxonomy II.From NANDA Nursing Diagnoses: Definitions and Classifications, 2009–2011 (pp. 368–369), by NANDA International, 2009, Oxford, United Kingdom: Wiley-Blackwell. Reprinted with permission. 42

Advantages of a Taxonomy of Nursing Diagnoses Development of standardized nursing language Includes NANDA nursing diagnoses Nursing interventions classification Nursing outcomes classification Nursing Minimum Data Set for computerized records