Polii, Paul Pontororing, Jonly Rompas, Heiber Retor, Wanlie Sepang, Geriel Selamat, Valentino Puni, Hizkia Preisilia

Fristy Sinaulan, Finne Sriwidyawati Meida Sumanti, Lady

Learning Objectives
Describe the term nursing diagnosis, distinguishing it from a collaborative problem and a medical diagnosis. Describe the four steps involved in data interpretation and analysis. Use the guidelines for writing nursing diagnoses when developing diagnostic statements. Describe means to validate nursing diagnoses. Describe the benefits and limitations of nursing diagnoses.

Lady

Diagnosing
After the nurse has collected and recorded the patient data, the work of diagnosing begins ( the second step in the nursing process ). The purpose of diagnosing is to: 1. Identify how an individual, group or community responds to actual or potential health and life processes 2. Identify factors that contribute to or cause health problems (etiologies). 3. Identify resources or strengths the individual, group or community can draw on to prevent or resolve problems.

Cont...
In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment. The data help the nurse identify patient strengths and health problems. A health problem is a condition that the necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness.

Cont...
Alfaro-LeFevre (2004), lists the following as the type of nursing concerns that are clearly nursing responsibilities: 1. Monitoring for change in health status. 2. Promoting safety and preventing harm, detecting and controlling risks. 3. Identifying and meeting learning needs. 4. Tailoring treatment and medication regimens for each individual. 5. Promoting comfort and managing pain. 6. Promoting health and a sense of well being. 7. Recognizing and addressing problem that impede the ability to be independent and live a healthy lifestyle. 8. Determining human responses (how individuals, families or groups respond to health problems or life changes).

Cont...
When a health problem is identified, the nurse must decide which healthcare professional can best treat the problem. Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses.

Meida

Key elements in the evolution of nursing diagnosis as and integral component of nursing process include the following: In 1953, the term nursing diagnosis was introduce by V. Fry (1953) to describe a step necessary in developing a care plan. In 1972, the New York State Nurse Practice Act identified diagnosing as part of the legal domain of professional nursing. In 1973, The American Nurses Associations Standards of Practice include diagnosing as a function of professional nursing

 Also

in 1973, Gebbie and Lavin, of St. Louis University, called the First National Conference on Classification of Nursing Diagnoses, beginning a national effort to identify, standardize and classify health problem treated by nurses: In 1980, the ANA Social Policy Statement defined nursing as the diagnosis and treatment of human responses to actual or potential health problem.

In March 1990, at the Ninth Conference of NANDA, the General Assembly approved an official definition of nursing diagnosis: Nursing diagnosis is a clinical judgment about individual, family or community responses to actual or potential health problem/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcome for which the nurse accountable. NANDA conferences are held every 2 years, and much progress continues to be made in defining, classifying and describing nursing diagnoses.

NURSING DIAGNOSIS VERSUS MEDICAL DIAGNOSIS

Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Medical diagnoses describe problems for which the physician directs the primary treatment, whereas nursing diagnoses describe problems treated by nurses within the scope of independent nursing practice. A medical diagnosis remains the same for as long as the disease is present, where a nursing diagnosis may change from day to day as the patients responses change. These distinctions reflect key difference in medical and nursing

Heiber

Nursing Diagnosis Versus Collaborative Problems

Carpenito defines collaborative problems as certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nursing-prescribed interventions to minimize the complications of the event.

Cont...

Unlike medical diagnoses, collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses, with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines. When the nurse writes patient outcomes that require delegated medical orders for goal achievement, the situation is not a nursing diagnosis, but a collaborative problem.

Cont...

Because collaborative problems involve potential complications, they must be identified early so that preventive nursing care can be instituted early.

Medical diagnosis/disea se

Medical/Surgical Nursing Treatment

Diagnostic Study

Ovarian Cancer Laparotomy

Radiotherapy

Exploratory

PC: Cachectic syndrome related to disease process

PC: Infection related to stage III skin reaction

PC: Paralytic ileus related to anesthesia

Figure 13-4 Collaborative Problems

Wanlie

LEGAL ALERT: ALFAROS RULEdiagnose and diagnosis have legal The term
implications. They imply that there is a specific problem that requires management by a qualified expert. If you make a diagnosis, it means that you accept accountability for accurately naming and managing the problem. If you treat a problem or allow a problem to persist without ensuring that the correct diagnosis has been made, you may cause harm and be accused of negligence. You are accountable for detecting, identifying, or recognizing signs and symptoms that might indicate problems beyond your expertise. Example: staff nurses are not qualified to diagnose and manage

Cont...

However, they are accountable for: Detecting and reporting signs and symptoms of pneumonia (for example, fever, productive cough, malaise). Diagnosing and managing risk factors for pneumonia (for example, weak breathing efforts due to surgical pain, spinal cord injury, or disease; in complicated cases, these risk factors may require medical management). Diagnosing and managing human responses to pneumonia (for example, fatigue and problems with airway clearance relates to pneumonia). Ensuring that the medical treatment plan is implemented as prescribed (Alfaro-LeFevre, 2004-

DIAGNOSTIC REASONING AND CRITICAL THINKING

Selamat

To correctly diagnose health problems:

. Be familiar with nursing diagnoses and other health problems; read professional literature and keep reference guides handy . Trust clinical experience and judgment, but be willing to ask for help when the situation demands more than your qualifications and experience can provide. . Respect your clinical intuitions, but before writing a diagnosis without evidence, increase the frequency of your observations and continue to search for cues to verify your intuitions. . Recognize personal biases and keep an

Hizkia

Questions to facilitate critical thinking during diagnostic reasoning include: . Are my data accurate and complete? . Has the patient or the patients surrogates validated (if able to do so) that the these are important problems? . Have I given the patient or the patients surrogate an opportunity to indentify problems that may have missed? . Is each diagnosis supported by evidence? Might these cues signify a different problem or diagnosis?

. Have I tried to identify what is causing the actual or potential problem and what strengths/resources the patient might use to avoid to resolve the problem? . Have a used agency guidelines to correctly document diagnostic statements in a way that clearly communicates patient problems to other healthcare professionals? . Is this a problem that falls within nursings independent domain or does it signify a medical diagnosis or collaborative problem.

Finne

DATA INTERPRETATION AND ANALYSIS

RECOGNIZING SIGNIFICANT DATA

To avoid erroneously labeling selected patient health patterns as unhealthy (diagnostic error) while failing to detect an actual unhealthy behavior, nurses must be familiar with comparative standards to be used in data interpretation and analysis. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category.

Examples of how standards can be used to indentify significant cues include the following (Gordon,1994):

Changes in a patients usual health patterns that are unexplained by expected norms for growth and development. Deviation from an appropriate population norm. Behavior that indicates a developmental lag or evolving dysfunctional pattern. Behavior that is nonproductive in the

RECOGNIZING PATTERNS OR CLUSTERS

A data cluster is a grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather that from a single cue.

Preisilia

INDENTIFYING STRENGTHS AND PROBLEMS

The next step in analyzing data is to determine the patients strengths and problems. When determining a patients strengths and problems, it is helpful to determine whether the patient agrees with the nurses identification of strengths and problems and is motivated to work toward their resolution.

DETERMINING THE PATIENTS STRENGTHS

If a patient appears to meet a standard, the nurse concludes that the patient has a strength in that particular area, and that this strength contributes to the patients level of wellness.

DETERMINING THE PATIENTS PROBLEM AREAS A person who does not meet a certain health standard probably has a limitation in this aspect of health status and may benefit from professional care. the nurse decides whether the data represent a nursing diagnosis or a collaborative problem, or whether the data should be reported to the physician because they might lead to a medical diagnosis.

DETERMINING PROBLEMS THE PATIENT IS LIKELY TO EXPERIENCE

It is important for nurses to identify potential health problems.

REACHING CONCLUSIONS

The nurse reaches one of four basic conclusions after interpreting and analyzing the patient data.

Finne

Cont
Different nursing responses are possible foe each conclusion: * No Problem No nursing response is indicated. Reinforce patients health habits and patterns Initiate health-promotion activities to prevent disease or illness or to promote a higher level of wellness. Wellness diagnosis might be indicated.

Cont
*Possible Problem Collect more data to confirm or disprove suspected problem. *Actual Or Potential Nursing Diagnosis Begin planning, implementing, and evaluating care designed to prevent, reduce, or resolve the problem.

Cont
If unable to treat problem because patient denies problem and refuses treatment, make sure patient understands possible out-comes of this stance. *Clinical Problem Other Than Nursing diagnosis Consult with appropriate healthcare professional and work collaboratively on problem. Refer to medicine or other service as indicated.

FORMULATING AND VALIDATING NURSING DIAGNOSA

Writing nursing diagnoses

When the nurse recognizes a cluster of significant patient data indicating a health problem that can be treated by independent nursing intervention, a nursing diagnosis should be written. Most nursing diagnoses are written either as two-part statements listing the patients problem and its cause or as three-part statement that also include the problems characteristics

Formulation of nursing diagnosis statements

problem
Problem Identifies what unhealthy about the patient, indicating the need for change. Identifies the factors that are maintaining the unhealthy state or response. Identify the subjective and objective data that signal the existence of the problem

purpose

example

Suggests Bathing/hygiene patient outcome self-care deficit. Related to Suggests the appropriate nursing measure.

Etiology

Fear of falling in the tub and obesity. As manifested by

Defining characteristics

Suggests evaluative criteria

Strong body and urine odor, unclean hair, Im afraid Ill fall in the tub and

Examples

Two-part diagnostic statement:

Bathing/Hygiene Self-Care Deficit r/t fear of falling in tub and obesity.

Three-part diagnostic statement:

Bathing/Hygiene Self-Care Deficit r/t fear of falling in tub and obesity. As manifested by strong body and urine odor, unclean hair, statement of fearing in tub, and height and weight 54, 170 lb.

Type of nursing diagnoses

NANDA describes five types of nursing diagnoses: actual, risk, possible, wellness, and syndrome

1. Actuality nursing diagnoses

Actuality nursing diagnoses represent a problem that has been validated by the presence of major defining characteristic. This type of nursing diagnosis has four component: label, definition, defining characteristic, and related factor.

2. Risk nursing diagnoses

Risk nursing diagnoses are clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation

3. Possible nursing diagnoses

Possible nursing diagnoses are statement describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out suspected problem.

4. Wellness diagnoses
Wellness diagnoses are clinical judgments about an individual, group, or community in transition from a specific level of wellness to a higher of wellness. Two cues must be present for a valid wellness diagnoses: A desire for a higher level of wellness An effective present status or function

5. Syndrome nursing diagnoses

Syndrome nursing diagnoses comprise a cluster of actual or risk nursing diagnoses that are predicated to be present because of a certain event or situation example: rape trauma syndrome or post-trauma syndrome.

Gerryl Sepang

Parts of Nursing Diagnoses

Problem

The purpose of the problem statement is to describe the health state or health or health problem of the patient as clearly and concisely as possible. NANDA recommends use of the following quantifiers when writing the problems statement: ability, anticipatory, balance, compromised, decreased, deficient, defensive, delayed, depleted, disproportionate, disabling, disorganized, disturbed, dysfunctional, effective, excessive, functional, imbalanced, impaired, inability, increased, ineffective, interrupted, low, organized, perceived, and readiness for enhanced

Cont

Etiology
The etiology identifies the physiologic, physiological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a causes or a contributing factor.

Cont

Defining characteristic
The subjective and objective data that signal the existence of the actual or potential health problem are the third component of the nursing diagnosis

Guidelines for writing nursing diagnoses

- Remember the following to ensure that your diagnostic statement are correctly written 1. Phrase the nursing diagnosis as a patient problem or alteration in health sate rather than as a patient need. 2. Check to make sure that the patient problem precedes the etiology and that the to are linked by the phrase related to

3. Defining characteristic, when included in the nursing diagnosis, should follow the etiology and be linked by the phrase as manifested by or as evidenced by. 4. Write in legally advisable terms 5. Use nonjudgmental language 6. Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to

7. Avoid using defining characteristic, medical diagnoses, or something that cannot be change in the problem statement 8. Reread the diagnosis to make sure the problem statement suggests patient outcomes and that etiology will direct the selection of measure

Validating nursing diagnoses

After a tentative nursing diagnosis is formulated, it should be validated. An affirmative response to each of the following question validates a tentative diagnosis: 1. Is my database sufficient, accurate, and supported by nursing research? 2. Does my synthesis of data (significant cues) demonstrate the existence of a patter?

3.Are the subjective and objective data I used to determine the existence of a pattern characteristic of the health problem I defined? 4. Is my tentative nursing diagnosis based on scientific knowledge and clinical expertise. 5.Is my tentative nursing diagnosis able to be prevented, reduced, or resolved by independent nursing action? 6. Is my degree of confidence above 50% that other qualified practitioners would formulate the same nursing diagnosis based on my data?.

Terry

Nursing Diagnosis: A Critique

The current nursing diagnosis literature contains many examples of nurses writing about how using nursing diagnoses has improved their clinical practice. Articles also detail the many benefits nursing diagnosis brings to the profession. Conversely, other articles point out the limitations of nursing diagnosis and urge nurses to be cautious so that an uncritical use of nursing diagnosis does

Cont...

The primary benefit that nursing diagnosis offers the patient is the individualization of patient care.
For example, nurses might be caring simultaneously for three women who had a modified radical mastectomy because of breast cancer. Although the postoperative nursing management of these women is similar, priorities of care may differ. A prioritized list of nursing diagnoses enables nurses to direct their energies toward these differing patient priorities.

Example

Patient A
Distubed Body Image Ineffective Coping

Patient B
Pain Bathing/Hygiene Self-Care Deficit

Patient C
Sexual Dysfunction Powerlessness

Cont...

Improved communication among nurses and other health care professionals is probably the most important benefit that accurate, up to date diagnoses, expressed in well defined and standardized terminology offer nurses. This communication aids in planning, charting, patient data retrieval, health team conferences, change of shift reports, and healthcare follow up. It also promotes nursing accountability for the problems that nurses diagnose.

Cont...
Among the other benfits of nursing diagnoses for the profession is help in defining the domain of nursing for helath care administrators, legislators, and other healthcare providers: this is important when seeking funding for nursing and reimbursement for nursing services. Nursing diagnoses are also used to define curriculum content and to direct specialization and advancement in nursing and nursing research. When the diagnostic process is used

Common Sources of Error

Premature diagnoses based on an incomplete database. Erroneous diagnoses resulting from an inaccurate database or a faulty data analysis. Routine diganoses resulting from the nurses failure to tailor data collection and analysis to the unique needs of the patient.

Cont...

Errors of omission: Failure to modify diagnoses and to identify new diagnoses as the patients status changes may also be problems.
Failures in diagnosis lead to failures in nursing care.

Conclusion

In conclusion, nursing diagnosis has become a valued and essential step in the nursing process. Used correctly, it is a powerful tool for individualizing patient care and ensures that nurses energies are being used in the most efficient way to meet patients needs. Nurses who are as concerned about the art and spirit of nursing as they are about its science are careful to avoid labeling patients in a way that objectifies them or limits the potential range of nurse-patient interactions.