Chapter 12 Diagnosing Fundamental of nursing Dr. James Pelletier The Swain Department of Nursing The Citadel

Purposes of the Diagnosing Step Identify how an individual, group, or community responds to actual or potential health and life processes: disease process Identify factors that contribute to, or cause, health problems (etiologies). Identify resources or strengths on which the individual, group, or community can draw to prevent or resolve problems.

Diagnosing

Types of Diagnoses Nursing diagnosis: Describes patient problems nurses can treat independently Medical diagnosis: Describes problems for which the physician directs the primary treatment Collaborative problems: Managed by using physician-prescribed and nursing-prescribed interventions

Four Steps of Data Interpretation and Analysis Recognizing significant data: Comparing data to standards Recognizing patterns or clusters Identifying strengths and problems Identifying potential complications Reaching conclusions

Reaching Conclusions No problem Possible problem Actual or potential nursing diagnosis Clinical problem other than nursing diagnosis

Formulation of Nursing Diagnoses Problem—identifies what is unhealthy about patient Etiology—identifies factors maintaining the unhealthy state Defining characteristics—identify the subjective and objective data that signal the existence of a problem

Types of Nursing Diagnoses Actual Risk Possible Wellness Syndrome

Validating Nursing Diagnoses Is my patient database (assessment data) 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? Increase Hr, respiration, BP : trios. All of them should increase or decrease the same way.

Validating Nursing Diagnoses (cont.) Is my tentative nursing diagnosis able to be prevented, reduced, or resolved by independent nursing action?: if you can’t fix it on your own you need to corroborate with someone else, such as doctor. Is my degree of confidence above 50% that other qualified practitioners would formulate the same nursing diagnosis based on my data?

Documentation of Diagnoses on EHR View the patient’s ongoing risks and problems that others have identified and documented. Decide on and document new nursing diagnoses based on the patient assessment findings. Facilitate communication of the patient’s actual problems with nurses and others on the health care team. Use nursing diagnosis to make decisions about what mutual goals the patient desires and what can be done: must let them know what the deficits are. Determine and document when the nursing diagnoses are resolved. You need to know what is normal and what is not normal and what is a quick fix. When nursing gold resolve you should document as the gold are met. Electronic health record

Benefits of Nursing Diagnoses Individualizing patient care Defining domain of nursing to health care administrators, legislators, and providers Seeking funding for nursing and reimbursement for nursing services: private benefiter.

Limitations of Nursing Diagnosis If used incorrectly, patient might be misdiagnosed. Nursing practice might be restricted.

Sources of Error When Writing Nursing Diagnoses Premature diagnoses based on an incomplete database Erroneous diagnoses resulting from an inaccurate database or a faulty data analysis Routine diagnoses resulting from the nurse’s failure to tailor data collection and analysis to the unique needs of the patient Errors of omission : you forgot to write something down or you skip something.