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

2. Purposes of the Diagnosing Step Identify how an individual, group, or community responds to actual or potential health and life processes. 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.

3. Diagnosing

4. 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

5. 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

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

7. 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

8. Types of Nursing Diagnoses Actual Risk Possible Wellness Syndrome

9. 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?

10. Validating Nursing Diagnoses (cont.) Is my tentative nursing diagnosis able to be prevented, reduced, or resolved by independent nursing action? Is my degree of confidence above 50% that other qualified practitioners would formulate the same nursing diagnosis based on my data?

11. 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. Determine and document when the nursing diagnoses are resolved.

12. 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

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

14. 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