LEC 5.3: Nursing Process | Diagnosing

Diagnosis

Clinical judgment concerning the human response to health conditions/life processes or a vulnerability for that response, by an individual, family, group, or community (NANDA)

Provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability (NANDA - I Think Tank, 2009)

Diagnostic Labels

What are the standardized NANDA names for the diagnoses called?

“Impaired Gas Exchange”

Example of a Diagnostic Label

Etiology

What is the causal relationship between the client’s problem or risk factors?

IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS related to insufficient intake to meet metabolic demands

Identify the Diagnostic Label & Etiology for the following statement by CAPITALIZING the Diagnostic Label and lowercasing the Etiology:

Imbalanced Nutrition: less than body requirements related to insufficient intake to meet metabolic demands.

1. Diagnostic Label

2. Etiology

What does the typical Nursing Diagnosis consist of?

Imbalanced nutrition: less than body requirements related to insufficient intake to meet metabolic demands as manifested by a body mass index of 15.

Example of a Nursing Diagnosis

Status of Nursing Diagnosis

Refers to the actuality or potentiality of the problems/syndrome or categorization of the diagnosis as a health promotion diagnosis

1. Actual Diagnosis

2. Health Promotion Diagnosis

3. Risk Nursing Diagnosis

4. Syndrome Diagnosis

4 Kinds of Nursing Diagnosis Based on Status

Actual Nursing Diagnosis

One of the kinds of nursing diagnosis based on status

A client problem that is present at the time of the nursing assessment

Based on the presence of associated signs and symptoms

1. Ineffective breathing pattern

2. Anxiety

3. Impaired memory

Examples of Actual Nursing Diagnosis

Health Promotion Nursing Diagnosis

One of the kinds of nursing diagnosis based on status

Relates to the client’s preparedness to implement behaviors to improve their health condition

Begins with the phrase “readiness for enhanced…”

1. Readiness for enhanced nutrition

2. Readiness for enhanced knowledge

Examples of Health Promotion Nursing Diagnosis

Risk Nursing Diagnosis

One of the kinds of nursing diagnosis based on status

A clinical judgment that a problem does not exist but the presence of the risk factors indicates that a problem is likely to develop unless nurses intervene

1. Risk for Infection

2. Risk for Injury

Example of Risk Nursing Diagnosis

Syndrome Nursing Diagnosis

One of the kinds of nursing diagnosis based on status

Assigned by a nurse’s clinical judgment to describe a cluster of nursing diagnosis that have similar interventions

Relocation Stress Syndrome

Example of a Syndrome Diagnosis

1. Problem and its Definition

2. Etiology

3. Defining Characteristics

Components of NANDA Nursing Diagnosis

Problem (Diagnostic Label)

One of the components of NANDA Nursing Diagnosis

Describes the client’s health problem or response for which nursing therapy is given

Described the client’s health status clearly and concisely

Purpose is to direct the formation of client goals and desired outcomes

May also suggest nursing interventions

Has qualifiers, words that have been added to give additional meaning to the diagnostic statment

1. Deficient

2. Impaired

3. Decreased

4. Ineffective

5. Compromised

5 Examples of Qualifiers (part of the Problem (Diagnostic Label) component of the NANDA Nursing Diagnosis)

Deficient

One of the 5 Examples of Qualifiers (part of the Problem (Diagnostic Label) component of the NANDA Nursing Diagnosis)

Inadequate; not sufficient; incomplete

Impaired

One of the 5 Examples of Qualifiers (part of the Problem (Diagnostic Label) component of the NANDA Nursing Diagnosis)

Made worse, weakened, damaged, reduced, deteriorated

Decreased

One of the 5 Examples of Qualifiers (part of the Problem (Diagnostic Label) component of the NANDA Nursing Diagnosis)

Lesser in size, amount, or degree

Ineffective

One of the 5 Examples of Qualifiers (part of the Problem (Diagnostic Label) component of the NANDA Nursing Diagnosis)

Not producing the desired effect

Compromised

One of the 5 Examples of Qualifiers (part of the Problem (Diagnostic Label) component of the NANDA Nursing Diagnosis)

To make vulnerable to threat

Etiology (Related Factors/Risk Factors)

One of the components of NANDA Nursing Diagnosis

Identifies 1 or more probable causes of the health problem

Gives direction to the required nursing therapy

Enables the nurse to individualize the client’s care

Defining Characteristics

One of the components of NANDA Nursing Diagnosis

Cluster of signs and symptoms that indicate the presence of a particular diagnostic label

For Actual Nursing Diagnosis: Indicate the client’s signs and symptoms

For Risk Nursing Diagnosis: Cues - factors that cause the client to be more vulnerable to the problem

Actual Nursing Diagnosis

Is the following statement an Actual OR Risk Nursing Diagnosis?

Imbalanced nutrition: less than body requirements related to insufficient intake to meet metabolic demands as manifested by a body mass index of 15.

Risk Nursing Diagnosis

Is the following statement an Actual OR Risk Nursing Diagnosis?

Risk for infection related to impaired primary defense mechanism

cue/s: presence of 2 inch laceration at the right forearm

1. Analyzing Data

2. Identifying Health Problems

3. Formulating Diagnostic Statements

3 Steps of the Diagnostic Process

Analyzing Data

One of the steps of the diagnostic process

Consists of the following:

1. Comparing data with standards

2. Clustering cues

3. Identifying gaps and inconsistencies in data

Comparing data with standards

Component of Analyzing (the first step of the diagnostic process)

Cues are considered significant if they:

1. Point to negative or positive change in a client’s health status or pattern

2. Varies from norm of the client population

3. Indicates developmental delay

Clustering cues/Data clustering/Grouping of cues

Component of Analyzing (the first step of the diagnostic process)

Process of determining relatedness of facts and determining whether any patterns are present

May do so inductively or begin with a framework

Identifying gaps and inconsistencies in data

Component of Analyzing (the first step of the diagnostic process)

Should include a final check to ensure that data are complete and correct

Identifying Health Problems, Risks, and Strengths

One of the steps of the diagnostic process

Determine problems and risks: after data are analyzed, the nurse and client can work together to identify problems

Determine strengths: both nurse and client can establish client’s strengths, resources, and abilities to cope

Formulating Diagnostic Statements

One of the steps of the diagnostic process

Consists of either one of the following formats:

1. Basic two-part statement (PE): for Risk Nursing Diagnosis

2. Basic three-part statement (PES): for Actual Nursing Diagnosis

3. One-part statement (P): for Health Promotion Diagnosis & Syndrome Diagnosis

Basic Three-Part Statement (PES)

What is the format for Actual Nursing Diagnosis?

Basic Two-Part Statement (PE)

What is the format for Risk Nursing Diagnosis?

One-Part Statement (P)

What is the format for both Health Promotion & Syndrome Nursing Diagnosis?

Risk for Disused Syndrome

Examples of a “tricky” Syndrome Nursing Diagnosis

1. “Unknown Etiology”

2. “Complex Factors”

3. “Possible”

4. “Secondary”

5. Adding a second part to the NANDA label

5 Variations of Basic Formats (of Nursing Diagnoses)

Unknown Etiology

One of the variations from the basic formats (of nursing diagnosis)

Defining characteristics are present that the nurse doesn’t know the cause

Complex Factors

One of the variations from the basic formats (of nursing diagnosis)

When there are too many etiologic factors

Possible

One of the variations from the basic formats (of nursing diagnosis)

Describe either the problem or the etiology

Secondary

One of the variations from the basic formats (of nursing diagnosis)

Divides the etiology into 2 parts

Adding a second part to the NANDA label

One of the variations from the basic formats (of nursing diagnosis)

Usse for more precision, such as information about location

1. Verify

2. Build a Good Knowledge Base and Acquire Clinical Experience

3. Have a Working Knowledge of What is Normal

4. Consult Resources

5. Base Diagnosis on Patterns

6. Improve Critical Thinking Skills

6 Ways to Avoid Errors in Diagnostic Reasoning

Verify

One of the 6 Ways to Avoid Errors in Diagnostic Reasoning

Hypothesize possible explanations of the data but realize they are only tentative once verified

Talk to the client and family

Ask what their health problems are and causes

Confirm accuracy and relevance

Build a Good Knowledge Base & Acquire Clinical Experience

One of the 6 Ways to Avoid Errors in Diagnostic Reasoning

Apply knowledge from many different areas to recognize significant cues, patterns, and generate hypotheses about the data

Have a Working Knowledge of What is Normal

One of the 6 Ways to Avoid Errors in Diagnostic Reasoning

Need to know the population norms for vital signs, laboratory values, developmental milestones etc.

Need to know what is normal for a particular person

Consult Resources

One of the 6 Ways to Avoid Errors in Diagnostic Reasoning

Includes:

• Professional literature (like NANDA book)

• Nursing colleagues

• Other professionals

Base Diagnosis on Patterns

One of the 6 Ways to Avoid Errors in Diagnostic Reasoning

Diagnosis should be be based on behavior over time, not on an isolated incident

Example: A patient who regularly reports attending mass was unable to attend last Sunday. It is inapplicable to apply “impaired religiosity” to this patient based on that one incident.

Improve Critical Thinking Skills

One of the 6 Ways to Avoid Errors in Diagnostic Reasoning

Involves the review of data and considering of explanations before forming an opinion

Avoid overgeneralizing, stereotyping, and making unwarranted assumptions