THE NURSING PROCESS Chapter 3 The Diagnosis Step: Analyzing the Data Fundamentals: Diagnosing Chapter 3 The Nursing Process: The diagnosis or Need Identification Step: Analyzing the data Chapter 13 Fundamentals: Diagnosing

Reference Doenges, M. E., & Moorhouse, M. F. (2008). Application of nursing process and nursing diagnosis: An interactive text for diagnostic reasoning (5th ed.). Philadelphia: F. A. Davis.

Competencies for Chapter 3: The Diagnosis or Need Identification Step By the end of this unit the student will: List 3 purposes of the nursing diagnosis Differentiate between nursing and medical diagnoses Define 4 types of nursing diagnoses Define PES relating to parts of the nursing diagnosis statement Identify the 6 steps involved in need identification

Purpose of Diagnosing To identify: Actual and potential problems in the way the client responds to health or illness Factors that contribute to or cause the problems (etiologies) Strengths the client can draw on to prevent or resolve problems To diagnose means to determine the cause and nature of a pathological condition, to recognize a disease. Diagnosis means the use of scientific and skillful methods to establish the cause and nature of a sick person’s disease. The purpose of Diagnosing is to identify: actual and potential problems in the way the client responds to health or illness factors that contribute to or cause the problems (etiologies) strengths the client can draw on to prevent or resolve problems

Nursing Process: Diagnosing Interpret and analyze client data to identify client strengths and health problems If data indicates a health problem treatable by independent nursing intervention Formulate and validate nursing diagnoses Nursing Process-2nd Step: Diagnosing Interpret and analyze client data. Analysis is the process of examining and categorizing information to reach a conclusion about a client’s needs. Identify client strengths and health problems Formulate and validate nursing diagnoses Develop a prioritized list of nursing diagnoses

Interpret/analyze client data Is there a health problem? Which healthcare professional can best treat the problem? What problems can be managed by nursing intervention? Interpret and analyze client data You want to know: Is there a health problem? a condition that necessitates intervening to prevent or resolve disease or illness or to promote coping and wellness Which healthcare professional can best treat the problem? Nursing diagnosis – actual or potential health problems that can be prevented or resolved by independent nursing interventions

Focus of Nursing Diagnosis Medical Diagnosis – identify diseases, describes problems, treated by a physician (narrow focus) Nursing Diagnosis – focus on human response to disease process (holistic view) The Nursing Diagnosis is a conclusion drawn from data with needs amenable to treatment by nurses Medical Diagnosis – identify diseases, describes problems for which physician directs the primary treatment. A medical diagnosis remain the same for as long as the disease is present. Nursing Diagnosis – focus on unhealthy responses to health and illness, problems treated by nurses within the scope of independent nursing practice. A nursing diagnosis may change from day to day as the patient’s responses change. What it is about the patient that gives rise to the need for nursing as opposed to the need for medicine or for physical therapy. Nursing diagnoses are written to describe patient problems that nurses can treat independently. Example: Myocardial Infarction or Heart attack is a medical diagnosis. Fear, altered health maintenance, knowledge deficit, an pain are nursing diagnoses Collaborative problems – certain physiologic complications that nurses monitor to detect onset or changes in status or “when the nurse writes patient outcomes that require delegated medical orders for goal achievement, this situation is not a nursing diagnosis but a collaborative problem” (Carpenito, 1995) These problems require nursing and medical intervention. Collaborative problems are the primary responsibility of nurses but the prescription for treatment comes from both nursing and medicine. See table 13-1 Page 258 Fundamentals for comparisons

Interpret/Analyze Client Data Interpretation begins at assessment Diagnosis must be supported by data Look for clusters, strengths, problems, potential problems Draw conclusions No problem Possible problem Actual or potential nursing diagnosis Interpret and analyze client data Interpretation begins at assessments -you are interpreting and analyzing the data while you are still collecting it Look for cues (significant data or data that influence this analysis) A piece of data that raises a red flag so you begin to look for patterns that indicate an actual or potential problem. Look for: clusters(Data Cluster – grouping of patient data or cues that points to the existence of a patient health problem ), strengths (Determining strengths – healthy physiologic functioning, emotional health, cognitive abilities, coping skills, interpersonal strengths, and spiritual strengths), Problems (Determining problem areas – limitation in this aspect of health status and may benefit from professional care), potential problems (Potential problems – important for nurses to identify potential health problems) Compare to standards-changes, deviation, behavior. For example, need to know normal ranges for blood pressure and the client’s normal range to know if blood pressure is a deviation. Know that sorting out healthy data and not healthy data is not as clear cut as it appears. Draw conclusions Reaching conclusions No problem-no nursing response is indicated, reinforce health habits, initiate health promotion activities to prevent disease or illness or to promote a higher level of wellness Possible problem-collect more data to confirm or disconfirm suspected problem Actual or potential nursing diagnosis-begin planning, implementing and evaluating care designed to prevent, reduce or resolve the problem. Clinical problem other than nursing diagnosis-Consult with appropriate healthcare professional and work collaboratively on problem or refer to medicine.

Formulate/Validate Nursing Diagnoses Types of Nursing Diagnosis Actual Diagnoses Wellness Diagnoses Risk Diagnoses Resolved Diagnoses Formulate and validate nursing diagnoses Types of Nursing Diagnosis Actual Diagnoses human response to health conditions that currently exist Wellness Diagnoses actual diagnosis that has a wellness focus –opportunity to improve an aspect of health more than a need Risk Diagnoses potential responses in a vulnerable individual-risk factors Resolved Diagnoses no intervention needed-problem resolved-no diagnostic statement needed

PES: Parts of the Client Diagnostic Statement P = Problem-describe the health state or problem of a client E = Etiology-identifies the physiologic, psychological, sociologic, and spiritual and environmental factors S = Signs/symptoms- defining characteristics – subjective and objective data that signal a problem and supports the diagnosis P = Problem-to describe the health state or problem of a client as clearly as concisely as possible E = Etiology/Cause -identifies the physiologic, psychological, sociologic, and spiritual and environmental factors S = Signs/symptoms-Defining Characteristics – subjective and objective data that signal the existence of the actual or potential health problem. Sign – objective. Symptom – Subjective changes in the body Nursing Diagnosis – Noun – NANDA – identifying specific client needs Nursing Diagnosis – Verb 3 Part -Identifying the client’s need -Cause of the need -Associated signs/ symptoms

Writing a Nursing Diagnosis Consult NANDA Nursing diagnosis statements are written in: Two-part statements (problem/cause) or Three-part statements (problem/cause/problem’s defining characteristics) Writing a nursing diagnosis Consult NANDA for lists of health problems that may be identified and treated by nurses Write a nursing diagnosis if a health problem is identified that is treatable by independent nursing intervention Nursing diagnosis statements are written as two-part statements (problem/cause) or three-part statements (problem/cause/problem’s defining characteristics)

Guideline for Writing a Nursing Diagnosis P: Phrase patient problem (need) Link with phrase “related to” E: Etiology (suspected cause for problem) Link with phrase “as evidenced by” S: List signs/symptoms (cues identified in the assessment that substantiate the nursing diagnosis) Guideline for Writing a Nursing Diagnosis P: Phrase patient problem (need) Link with phrase “related to” E: Etiology (suspected cause for problem) Link with phrase “as evidenced by” S: List signs/symptoms (cues identified in the assessment that substantiate the nursing diagnosis) Remember: Indicates health problem or what patient wants to change Use non-judgmental language and legally advisable terms Avoid using defining characteristics or medical diagnosis in problem statement

Nursing Process-2nd Step: Diagnosing Step 1 - Problem Sensing Step 2 - Rule out Process Step 3 - Synthesizing the Data Step 4 - Evaluating or Confirming the Hypothesis Step 5 - List client needs Step 6 - Re-evaluate the Problem List Nursing Process-2nd Step: Diagnosing Step 1 – Problem Sensing-review and analyze data to identify cues (signs and symptoms) suggesting client needs that can be described by a nursing diagnosis Step 2 – Rule out Process-alternative explanations are considered for the identified cues to determine which nursing diagnosis is most appropriate. What are my concerns about this client? Can I do something about it? Can the overall risk be reduced by nursing intervention? Step 3 - Synthesizing the Data-view the data as a whole-include information collected by other members of the healthcare team to provide a comprehensive picture of the client Step 4 – Evaluating or Confirming the Hypothesis-compare NANDA nursing diagnosis with the assessed possible etiology Step 5 – List client needs-combine accurate nursing diagnosis label with the assessed etiology and signs/symptoms Step 6-Re-evaluate the Problem List-make sure all nursing diagnoses are identified and list them according to priority and classify them according to status, actual need, risk need or resolved need.

Remember: Nursing Diagnosis – NOT – medical diagnosis Nursing Diagnosis change with the client’s progress through various stages of illness Patients who are able to participate in their care should be encouraged to validate the diagnosis Nursing Diagnosis provides a common language to improve communication among nurses, and other healthcare providers Remember: Nursing Diagnosis – NOT – medical diagnosis Medical Diagnosis – identify diseases, describes problems for which physician directs the primary treatment Nursing Diagnosis – focus on unhealthy responses to health and illness, problems treated by nurses within the scope of independent nursing practice Collaborative problems – certain physiologic complications that nurses monitor to detect onset or changes in status Nursing Diagnosis change with the client’s progress through various stages of illness. Medical Diagnosis remains the same for as long as the disease is present. Validating – patients who are able to participate in their care should be encouraged to validate the diagnosis. Use of Nursing Diagnosis – common language – improved communication among nurses, and other healthcare providers

Examples of Nursing Diagnosis Potential altered oral mucus membrane related to NPO state Grieving related to recent job loss as manifested by statement of anger

Avoiding Errors Identify client response, not medical diagnosis Correct: Anxiety related to fear of illness Incorrect: Anxiety related to myocardial infarction

Avoiding Errors Identify problem created by condition rather than the condition itself Correct: Ineffective individual coping related to noncompliance with treatment regimen Incorrect: Ineffective individual coping related to chronic illness

Avoiding Errors Identify problem brought about by diagnostic study rather than the diagnostic study itself Correct: Anxiety related to lack of knowledge about cardiac catheterization as evidenced by hyperventilation and profuse sweating each time cardiac catheterization is discussed Incorrect: Anxiety related to cardiac catheterization

Avoiding Errors Identify the diagnostic category rather than the symptom Correct: Altered breathing pattern related to excessive mucus production as evidenced by coughing and drooling Incorrect: Cough related to excessive mucus production

Avoiding Errors Identify the patient response to the equipment or treatment rather than the equipment itself Correct: Impaired physical mobility related to weakness and fatigue Incorrect: Impaired physical mobility related to cast

Avoiding Errors Identify associated factors, avoid legally inadvisable and judgmental statements Correct: Altered family processes related to social deviance by family member Incorrect: Fear related to frequent beatings by husband

Case Scenario 81 y.o. male S/P CVA admitted to ECF for custodial care. History includes: Poor PO intake x 2 weeks No bowel movement x 3 days Unable to perform ADL’s independently uses FWW in home or W/C on outing-last 2 weeks has had very limited ambulation related to viral illness requires set-up for meals and encouragement with fluid intake uses adult pads for bladder incontinence requires assistance with showers See page 194 Nursing Process book for info on NANDA Constipation diagnosis

Summary The Nursing Diagnosis: Addresses human responses to actual and potential health concerns Provides a common language for nurses and other healthcare professionals and promotes identification of appropriate patient goals

Summary- (continued) Is a conclusion drawn from data with patient needs amenable to treatment by nurses Must be supported by data The nursing diagnosis changes as patient progresses through various stages of illness

Summary- (continued) There are six steps for diagnostic reasoning Be specific when writing diagnosis and “related to” statement Important to focus intervention on the roots of human response