1. Application of Nursing Process and Nursing Diagnosis: An Interactive Text for Diagnostic Reasoning Sixth Edition Copyright 2013 F.A. Davis Company

2. Chapter 3 The Diagnosis Step: Analyzing the Data (Need/Problem Identification)

3. The Diagnosis Step Purpose: To draw conclusions regarding a client’s specific needs or human responses so that effective care can be planned and delivered Nursing Diagnosis list Page 45

4. The Diagnosis Step These terms may be used interchangeably:  Analysis  Need (or problem) identification  Nursing diagnosis

5. The Diagnosis Step  What is Diagnosis? Forming a clinical judgment identifying a disease/condition or human response through scientific evaluation of signs/symptoms, history, and diagnostic studies.

6. Defining Nursing Diagnosis Nursing Diagnoses are:  Derived from the assessment data  Validated with the patient/others  Documented within a nursing plan of care

7. Medical vs. Nursing Diagnoses  Medical diagnoses illnesses/conditions; reflect alteration of the structure or function of organs/systems; verified by medical diagnostic studies  Nursing diagnoses address human responses to actual and potential health problems/life processes

8. TERMINOLOGY  NANDA - North American Nursing Diagnosis Association International  Ex:  Actual: Impaired Skin Integrity  Potential: Risk for Injury

9. Defining Nursing Diagnosis NANDA’s Definition  Nursing diagnosis is a clinical judgment about responses to actual and potential health problems.  Nursing diagnoses provide the basis for selecting nursing interventions to achieve results for which the nurse is accountable.

10. The Use of Nursing Diagnoses Benefits of the nursing diagnosis 1.Gives nurses a common language 2.Promotes identification of appropriate goals 3.Provides acuity information 4.Can create a standard for nursing practice 5.Provides a quality improvement base

11. Identifying Client Needs  During the Assessment step, the collection, clustering, and validation of client data flow directly into the Diagnosis step of the nursing process

12. Maslow’s Hiearchy of Neds

13. Analyzing the Client Database Six Steps in Problem Identification 1. Problem-Sensing 2. Rule-Out Process 3. Synthesizing the Data 4. Evaluating or Confirming the Hypothesis 5. Listing the Client’s Needs 6. Reevaluating the Problem List

14. Analyzing the Client Database Step 1: Problem-Sensing  Data are reviewed and analyzed to identify cues (signs and symptoms) suggesting patient needs. * See Box 3-1 pgs 50-55.

15. Analyzing the Client Database Step 2: Rule-Out Process  Alternative explanations considered  Compare and contrast relationships among data

16. Analyzing the Client Database Step 3: Synthesizing the Data  Looking at all the data as a whole  Creating a hypothesis

17. Analyzing the Client Database Step 4: Evaluating or Confirming the Hypothesis  Test hypothesis for fit by:  reviewing the nursing diagnosis definition  comparing the assessed data with NANDA’s related or risk factors  comparing the signs/symptoms with NANDA’s defining characteristics

18. Analyzing the Client Database Step 5: Listing the Client’s Needs  Combine the accurate nursing diagnosis label with the assessed etiology and signs/symptoms “PES” STATEMENT

19. Analyzing the Client Database Step 6: Reevaluating the Problem List  List all nursing diagnoses according to priority and classify according to status:  an actual need  a risk need

20. Identifying Client Problems: Other Considerations  The medical/psychiatric diagnosis can provide a starting point for identifying associated client needs.  Even if the need seems to exist only in the mind of the patient, it needs to be addressed and resolved.  Reduce the problem to its basic component to identify more clearly the appropriate interventions to be taken.

21. Writing a Client Diagnostic Statement  Nursing diagnoses identify client needs that can be positively affected, or possibly prevented, by nursing actions.  Some diagnoses permit greater independent function; others are more collaborative.

22. Writing a Client Diagnostic Statement  The extent of independent function is influenced by the nurse’s—  experience  expertise  work setting  established protocols

23. Writing a Nursing Diagnosis  P-E-S Statement – 3 part statement  Problem - Diagnosis according to NANDA  Etiology - the cause or risk factors, stated as “related to”-  Signs and symptoms – called defining characteristics, the evidence that showed your diagnosis or problem. Stated as “as evidenced by”   PROBLEM R/T ETIOLOGY AEB SIGNS AND SYMPTOMS.  (No “S” if potential problem)

24. Writing a Nursing Diagnosis  (P) Constipation R/T (E)use of opioid analgesics AEB (S) abdominal discomfort and hard, small stools.  Impaired verbal communication R/T aphasia AEB inability to communicate basic needs.  Imbalanced nutrition: Less than body requirements R/T vomiting AEB weight loss of 3 lbs over 2 days.

25. Writing a Nursing Diagnosis  Knowledge deficit of med administration R/T lack of recall AEB patient statement “I can never remember to take those pills”  Risk for fluid volume deficit R/T fluid loss secondary to NGT to continuous suction.

26. Writing a Client Diagnostic Statement  Collaborative problem: A need identified by another discipline that contains a nursing component requiring nursing intervention

27. Writing a Client Diagnostic Statement Common Errors :  Using the medical diagnosis: Self Care deficit r/t stroke  Confusing the etiology or signs/symptoms for the need: Postoperative lung congestion r/t bedrest  Use of a procedure instead of the “human response”: Catheterization r/t urinary retention

28. Writing a Client Diagnostic Statement Common Errors:  Lack of specificity: Constipation r/t nutritional intake  Combining two nursing diagnoses: Anxiety and Fear r/t separation from parents

29. Writing a Client Diagnostic Statement Common Errors:  Relating one nursing diagnosis to another: Ineffective coping r/t anxiety  Use of judgmental or value-laden language: Chronic pain r/t secondary/monetary gain

30. Writing a Client Diagnostic Statement Common Errors:  Making assumptions: Risk for impaired Parenting, risk factors of inexperience (new mother)  Writing a legally inadvisable statement: Impaired Skin Integrity r/t not being turned every 2 hours

31. Diagnostic Statement Using Medical Diagnosis: Self Care Deficient related to stroke. Incorrect

32. Diagnosis Statement  Self Care Deficit related to neuromuscular impairment as evidenced by inability to manipulate clothing and dress self. Correct

33. Diagnostic Statement Confusing the etiology or signs and symptoms with the need: Post Operative lung congestion related to ineffective cough Incorrect

34. Ineffective Airway clearance related to retained secretions as evidenced by adventitious breath sounds and ineffective cough. Correct

35. Using a Procedure instead of the “human response” Catheterization related to urinary retention. Incorrect

36. Urinary retention related to blockage/perineal swelling as evidenced by bladder distention and sensation of bladder fullness. Correct See a script or in a “nutshell” how to write nursing Diagnostic statements page 71-72.

37. Practice:  Identifying the PES Components of the Patient Diagnostic Statement  Practice Activity on Page 61 3-2  Work Page Activity Chapter 3  Page 75-76