Student_15-Diagnosing

Copyright Information

  • Wolters Kluwer

  • Chapter 15: Diagnosing

  • Copyright © 2011 - 2019 Wolters Kluwer Health | Lippincott Williams & Wilkins

Purposes of the Diagnosing Step

  • Identify responses of individuals, groups, or communities to health processes.

  • Identify contributing factors or causes of health problems (etiologies).

  • Identify available resources or strengths for the prevention or resolution of problems.

Diagnosing Process

  1. Assessment

    • Collecting Data

    • Identifying Cues and Making Inferences

    • Validating (Verifying) Data

    • Clustering Related Data

    • Identifying Patterns / Testing First Impressions

    • Reporting and Recording Data

  2. Clinical Reasoning

    • Analyzing, synthesizing, reflecting, drawing conclusions

  3. Diagnosis

    • Creating a list of suspected problems/diagnoses

    • Ruling out similar diagnoses

    • Naming actual and potential problems/diagnoses and clarifying their causes

    • Determining risk factors for management

    • Identifying strengths and promoting health

Nursing Concerns and Responsibilities (Alfaro, 2014)

  • Recognizing safety and infection-transmission risks.

  • Identifying human responses to problems and their impact on patients' lives.

  • Anticipating complications and taking preventive action.

  • Initiating urgent interventions when necessary.

Predict, Prevent, Manage, and Promote (PPMP) (Alfaro-LeFevre, 2014)

  • In known problems, predict common complications to take immediate preventive action.

  • Look for risk factors, and aim to reduce or control them.

  • Ensure safety and learning needs are met, promoting optimum function and well-being.

Types of Diagnoses

  • Nursing Diagnosis: Problems that nurses can treat independently.

  • Medical Diagnosis: Problems directed by the physician as primary treatment.

  • Collaborative Problems: Managed with both physician and nursing interventions.

Diagnostic Reasoning and Clinical Reasoning

  • Familiarize with nursing diagnoses through professional literature.

  • Trust clinical experience and judgment, but seek help when necessary.

  • Validate clinical intuition through evidence and frequent observations.

  • Maintain objectivity, recognizing personal biases.

Four Steps of Data Interpretation and Analysis

  1. Recognizing significant data by comparing to standards

  2. Recognizing patterns or clusters of data

  3. Identifying strengths and problems

  4. Recognizing potential complications

  5. Reaching conclusions

Skills Needed to Work in Partnership

  • Communicate with respect and care.

  • Listen effectively.

  • Validate perceptions with patients and families.

Types of Nursing Diagnoses

  • Problem-focused

  • Risk (potential problem)

  • Health Promotion

Components of a Diagnosis

  • Problem Focused (3 parts): Problem, Etiology, Signs/Symptoms (Defining characteristics)

  • Risk (2 parts): Potential Problem (Risk), Risk Factor

  • Health Promotion (1 part): Label Only

Problem Focused Example

  • Wandering R/T Separation from familiar environment AEB: Long locomotion without clear destination.

Knowledge Deficiency Example

  • Deficient Knowledge: Seizures R/T Insufficient information AEB: “I am not sure what a seizure is.”

Risk Example

  • Risk for impaired tissue integrity R/T Imbalance nutritional state.

Health Promotion Example

  • Readiness for enhanced nutrition.

Common Errors in Writing Nursing Diagnoses #1

  • Writing in terms of needs and responses.

  • Legally inadvisable statements.

  • Identifying non-healthy patient responses as problems.

  • Using signs and symptoms of illnesses as problems.

  • Indicating unchangeable patient issues.

  • Misidentifying environmental factors in problems.

Common Errors in Writing Nursing Diagnoses #2

  • Reversing clauses.

  • Redundancy in clauses.

  • Including value judgments.

  • Incorporating medical diagnoses in nursing diagnoses.

Validating Nursing Diagnoses #1

  • Assess sufficiency and accuracy of patient database (assessment data).

  • Ensure data synthesis shows a pattern.

  • Verify subjective and objective data align with health problem defined.

  • Base the tentative diagnosis on scientific nursing knowledge.

Validating Nursing Diagnoses #2

  • Confirm that nursing actions can prevent, reduce, or resolve the diagnosis.

  • Ensure confidence level above 50% that another practitioner would agree with diagnosis.

Documentation of Diagnoses on EHR

  • Maintain continuity of care.

  • Track patient’s ongoing risks and problems.

  • Document new nursing diagnoses post-assessment findings.

  • Facilitate communication of patient’s issues across health care team.

  • Use nursing diagnoses for setting mutual patient goals and actions.

  • Record when nursing diagnoses are resolved.

Benefits of Nursing Diagnoses

  • Promote continuity of care.

  • Facilitate individual patient care.

  • Provide ancillary benefits.

  • Define nursing domain to healthcare administrators and legislators.

  • Assist in funding and reimbursement for nursing services.

Sources of Error When Writing Nursing Diagnoses

  • Premature diagnoses from incomplete data.

  • Erroneous diagnoses from inaccurate data or analysis.

  • Routine errors from failing to tailor data analysis to unique patient needs.

  • Omissions in data collection.

Case Study: Susan Ambrose

  • A 35-year-old single mother and nursing student struggling with sleep.

  • Increased insomnia affecting clinical duties and academic performance.

  • Facing stressors of a challenging semester and chronic illness in her child.