Nursing Diagnosis Gail Ladwig, RN, MSN, CHTP Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

2 Process  How to develop a nursing diagnosis  Step one:  Assessment  Step two:  Analyze assessment information  Formulate nursing diagnosis

3 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step One ASSESSMENT

4 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment and Nursing Diagnosis  Step 1 of the nursing process: Assessment  Step 1 is the first step used to make a nursing diagnosis  Comprehensive assessment leads to an accurate nursing diagnosis

5 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment and Nursing Diagnosis (continued)  Collection of information about the client:  Holistic and detailed  Supports critical thinking  Determines problems and strengths  Beginning and ongoing during all phases of the nursing process

6 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment  Assess the client  Perform a thorough holistic nursing assessment  Use the format adopted by your facility or educational institution  Nursing assessments based on conceptual models:  Gordon’s functional health patterns  Orem’s self-care model  Roy’s adaptation model

7 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment Sources  Nursing assessment/health history: client  Physical assessment: client  Medical records  Diagnostic test results  Health team members  Significant others if appropriate

8 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Obtain an Accurate Health History  Ask open-ended questions:  “Describe what you are feeling.”  “Tell me how the symptoms you are describing affect your daily activities.”  “Describe measures that you use to alleviate the symptoms.”

9 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Physical Assessment  Perform a thorough physical assessment  Carefully assess each area for normal and abnormal findings.  Inspect, auscultate, palpate, and percuss. Medical model: Head to toe Head to toe -OR- -OR- Body system Body system

10 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking  Look for normal and abnormal findings.  Validate the data with the client:  “This is what I have noticed.”  “Does this describe how you feel?”  “Tell me more.”  “What can I do to help?”

11 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Immediate Reporting  Report and record information that requires immediate action.  Some examples:  Sharp, unrelenting pain  Vital signs greatly deviated from normal  Change in level of consciousness  When in doubt, ACT and report.

12 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Documentation  Record all information obtained from the health history and physical assessment.  Most places are placing this information on electronic record.

13 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Confidentiality  Share only information that is of benefit to the nursing and medical team for planning care.  Keep notes safe.  Do not leave notes at site of interview.

14 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Confidentiality (continued)  The client’s name should appear only on agency documents. (Do not put client’s name on any notes used for classroom work.)  Follow HIPAA (Health Insurance Portability and Accountability Act) guidelines regarding client confidentiality. HIPAA

15 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step Two Analyze Assessment Information Formulate Nursing Diagnosis  Identify diagnosis  Identify related factors  List defining characteristics

16 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Definition: Nursing Diagnosis  Clinical judgment  Individual, family, or community  Response to actual or potential health problems or life processes  Basis for outcomes and interventions  The nurse is accountable. (NANDA-International, 2009) (NANDA-International, 2009)

17 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnosis: Critical Thinking  Analyze information  2009 edition  203 Nursing Diagnoses  Does it fit the NANDA definition?  Are the defining characteristics in the assessment?  Can a change occur with a nursing intervention?

18 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Use of Assessment Information  Organize the information  Identify patterns in the assessment (highlight or underline the problems).  Make a list of all problems and potential problems.  Group like problems together.  Make initial inferences or impressions.  Prioritize the problems. Use Maslow’s hierarchy Use Maslow’s hierarchyMaslow’s hierarchyMaslow’s hierarchy  Report and record the information.

19 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study RJ, a 73-year-old male, has been admitted to the unit with an admitting medical diagnosis of COPD (chronic obstructive pulmonary disease). He states that he has “difficulty breathing when walking short distances.” He also states that his “heart feels like it is racing” at the same time. He states that he is “tired all the time,” and, while talking to you, he is continually wringing his hands and looking out the window.

20 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Identify Problems and Potential Problems: Critical Thinking  Highlight or underline the problem areas in the assessment.

21 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Highlight Problems Case Study: RJ, a 73-year-old male, has been admitted to the unit with an admitting medical diagnosis of COPD (chronic obstructive pulmonary disease). He states that he has “difficulty breathing when walking short distances.” He also states that his “heart feels like it is racing” at the same time. He states that he is “tired all the time,” and, while talking to you, he is continually wringing his hands and looking out the window.

22 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Problem Identification: Critical Thinking  Make a list of the problems that have been highlighted.

23 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. List of Problem Areas  COPD  “Difficulty breathing when walking short distances”  “Heart feels like it is racing”  “Tired all the time”  Continually wringing hands while talking

24 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Identify Similarities: Critical Thinking  Group or cluster similar problems.

25 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Clusters: Critical Thinking  COPD  “Difficulty breathing when walking short distances”  “Heart feels like it is racing”  “Tired all the time”  Wringing hands  Looking out the window

26 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. NANDA List: Critical Thinking  Check NANDA list  What diagnosis may these clusters indicate?

27 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnosis List  Select the appropriate nursing diagnosis for the client from NANDA’s approved list.  Nursing Diagnoses: Definitions and Classification  Ackley/Ladwig Nursing Diagnosis Handbook: A Guide to Planning Evidence-Based Care or at EVOLVE Care Plan Constructor website  List of 203 “approved nursing diagnoses”

28 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. 2. Time 3. Unit of Care 1. Diagnostic Concept (NANDA) 7. Topology 5. Health Status 4. Age 6. Descriptor Acute Chronic Intermittent Continuous Individual Family Group Community Fetus Old-Old Wellness Risk Actual Parts/Regions of body

29 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Selection of Appropriate Axes: Critical Thinking  Diagnosis/diagnostic concept (select appropriate axes based on the following questions [not all axes will be used]):  Is the problem acute, chronic, intermittent, or continuous?  Is the client an individual, family, group, or community?  What is the age of the client?

30 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnoses Axis 5: Select Appropriate Place on Continuum  Health status: position or rank on the health continuum of wellness to illness  Wellness: the quality of being healthy, especially as a result of a deliberate effort  Risk: vulnerability, especially as a result of exposure to factors that increase the chance of injury or loss  Actual: existing in fact or reality, existing at the present time (Nursing Diagnoses: Definitions and Classification )

31 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Selection of Appropriate Axes: Critical Thinking  What best describes the limits of the diagnosis?  Examples: anticipatory, compromised, decreased, deficit, impaired, increased, ineffective, readiness  What part/region of the body is involved?  Examples: auditory, bowel, cerebral, intracranial, oral, skin, visual

32 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. NANDA List  Activity intolerance  Activity intolerance, risk for  Adaptive capacity, decreased intracranial  Adjustment, impaired (delete these 2)  Adult failure to thrive (change to) Ineffective Activity Planning  Airway clearance, ineffective

33 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking  Select a diagnosis.  Read the NANDA definition.  Does the selected diagnosis fit the NANDA definition?  Is this what the client is demonstrating?  Does the client agree that this is what is a concern?  Is it an actual risk or a wellness diagnosis?

34 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Activity Intolerance Axis 5: Actual  NANDA definition  Insufficient physiological or psychological energy to endure or complete required or desired daily activities

35 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Analyze Client Symptoms: Critical Thinking  Compare the problems from the cluster to the defining characteristics of the nursing diagnosis.  Is this the correct diagnosis?  Are any other axes needed?  Can this diagnostic concept stand alone?

36 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Signs and Symptoms: Defining Characteristics of Critical Thinking  Is the information in the assessment?  Does it reinforce or clarify the related statement?  The phrase “as evidenced by” (AEB) may be used to connect them to the nursing diagnosis.

37 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Defining Characteristics: Activity Intolerance  Verbal report of fatigue or weakness  Abnormal heart rate or blood pressure response to activity  Exertional discomfort or dyspnea  Electrocardiographic changes reflecting dysrhythmias or ischemia

38 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Related Factors/Etiology: Critical Thinking  Select related factors  Related factors are what may be causing or contributing to the nursing diagnosis.  This is often referred to as the etiology.  Pathophysiological and psychosocial changes, such as developmental age and cultural and environmental situations, may be causative or contributing factors.

39 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Etiology: Related Factors Critical Thinking  Are they contributing to the nursing diagnosis?  Are they environmental, physiological, psychological, sociocultural, or spiritual?  Are they precise and accurate?  Will they help to direct nursing interventions?

40 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Related Factors: Activity Intolerance  Bed rest or immobility  Generalized weakness  Sedentary lifestyle  Imbalance between oxygen supply and demand

41 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnostic Statement  A working nursing diagnosis may have two or three parts. The two-part system consists of the nursing diagnosis and the “related to” statement. The three-part system consists of the nursing diagnosis, the “related to” statement, and the defining characteristics.

42 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking Check  The three-part diagnostic statement may be referred to as the PES system:  (P)roblem: nursing diagnosis label  (E)tiology: “related to” phrase  (S)ymptoms: defining characteristics

43 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnosis Label  P (Problem):  The nursing diagnosis—the label, a concise term or phrase that represents a pattern of related cues  Example:  Activity intolerance

44 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Etiology  E (Etiology):  “Related to" phrase (r/t) or etiology—related cause or contributor to the problem  Example:  R/t imbalance between oxygen supply and demand

45 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Defining Characteristics  S (Symptoms):  Defining characteristics phrase—symptoms that the nurse identified in the assessment  Example:  Verbal report of fatigue  Abnormal heart rate in response to activity “Heart feels like it is racing” “Heart feels like it is racing”  Exertional dyspnea “Difficulty breathing when walking short distances” “Difficulty breathing when walking short distances”

46 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Make a Nursing Diagnostic Statement: PES  Problem: nursing diagnosis  Etiology: related to statement  Signs and symptoms: defining characteristics

47 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Document the Selected Nursing Diagnosis on the Nursing Plan of Care

48 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnostic Statement  (P) Activity Intolerance  (E) Related to imbalance between oxygen supply and demand  (S) Verbal report of fatigue, abnormal heart rate in response to activity, “heart feels like it is racing,” exertional dyspnea, “difficulty breathing when walking short distances”

49 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Summary  Making a Nursing Diagnosis:  Assess the client  Analyze information from the assessment  Write three-part nursing diagnostic statement (P)roblem: nursing diagnosis label (P)roblem: nursing diagnosis label (E)tiology: “related to” phrase (E)tiology: “related to” phrase (S)ymptoms: defining characteristics (S)ymptoms: defining characteristics

50 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Complete the Nursing Process  Proceed to the planning phase of the nursing process.  Document all information.

51 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. References  North American Nursing Diagnosis Association – International. Nursing Diagnoses: Definitions and Classification Oxford, UK, Wiley, 2009