Chapter 7 Nursing Diagnoses - Vocabulary Flashcards

Diagnosis/Analysis

• Chapter focus: Analysis of cues and prioritizing hypotheses to guide nursing judgment.

• Nursing Diagnosis #1 (Overview)

  • The second phase of the nursing process.

  • Clinical judgment about the patient’s response to actual or potential health conditions or needs.

  • Expresses the nurse’s clinical judgment about the patient’s clinical status, response to treatment, or nursing care need.

  • Logically extends from the nurse’s assessment data and provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

  • Nursing diagnoses are not medical diagnoses; they focus on the patient’s response to their health condition or situation.

• Nursing Diagnosis #2 (Model)

  • Based on the National Council of State Boards of Nursing Clinical Judgment Measurement Model.

  • Purpose: identify problems and synthesize information gathered during nursing assessment.

  • Activities in synthesis: analyzed collected data, identified patient strengths, identified normal functional level and indicators of actual or potential dysfunction.

  • Outcome: formulate a diagnostic statement in relation to this synthesis.

• Nursing Diagnosis #3 (Process phases)

  • Diagnosis phase: identifies patterns.

  • Validates the diagnoses.

  • Formulates the nursing diagnostic statement.

Nursing Diagnosis: Taxonomy and Classification

• Classification systems include:

  • International Classification for Nursing Practice (ICNP) published by the International Council of Nurses (ICN, 2019).

  • Home Health Care Classification (HHCC) of Nursing Diagnoses (Flo et al., 2019).

  • North American Nursing Diagnosis-International Taxonomy II (Herdman et al., 2019).

Distinctions: Medical vs Nursing Diagnoses

• Medical diagnosis:

  • Describes disease or pathology of specific organs or body systems.

    • ex. pneumonia

• Nursing diagnosis:

  • Describes actual, risk, improved, or positive human response to health problem that nurses are responsible for treating independently.

    • ex. increased rick of tissue perfusion

  • Describes patient’s response to disease process, developmental stage, or life process.

  • Carries legal ramifications and defines scope of practice.

  • See Table 7-1 and Figure 7-2 for relationships between diagnoses and care.

Collaborative and Multidisciplinary Health Problems

• Collaborative health problems / multidisciplinary health problems:

  • Actual or potential physiologic complications that can result from disease, trauma, treatment, or diagnostic studies.

  • Require collaboration with other disciplines (speech therapy, physical therapy, medicine).

  • Incorporates both nursing and medical care.

  • See Table 7-1 and Figure 7-2.

Distinguishing Nursing Diagnoses from Other Healthcare Information

• Often confused with:

  • Procedures, medical terminology, symptoms, patient needs, and treatments.

• Example illustrating difference:

  • Medical diagnosis: pneumonia.

  • Nursing diagnosis: impaired airway clearance associated with thick tracheobronchial secretions.

  • Patient need: oxygenation.

  • Procedure: bronchoscopy.

  • Treatment: oxygen therapy.

Practice Question: True/False (Understanding scope)

• Question: Is the following statement true or false? A nursing diagnosis describes an existing or potential disease or pathology of specific organs or body systems.

• Answer: False

• Rationale: A nursing diagnosis describes an actual, risk, or wellness response to a health problem that nurses are responsible for treating independently. A medical diagnosis describes a disease or pathology of specific organs or body systems that guides medical treatment prescribed by authorized healthcare providers.

Components of a Nursing Diagnosis

• Diagnostic label:

  • Describes the essence of the problem using as few words as possible.

• Descriptors:

  • Used to add meaning to the nursing diagnosis.

  • ICNP examples include altered, conflicting, decreased, delayed, effective, impaired, improved, lack of, negative.

Associated Factors, Risks, and Indicators

• Associated factors:

  • Conditions, circumstances, or etiologies that contribute to the problem.

  • Phrases: associated with, related to, contributing to.

• Associated risk factors:

  • Clinical cues; variables that put the patient at risk.

• Indicators:

  • Observable and clustered cues and data that are manifestations of the diagnosis.

Diagnosis Activities

• Identify pattern:

  • Cue clustering.

  • Problems in cue clustering.

• Cluster interpretation:

  • Problems in cluster interpretation.

• Validate diagnosis:

  • Problems in diagnostic validation.

Formulating the Diagnostic Statement

• Diagnosis Activities (continued):

  • Formulating the diagnostic statement for:

  • Actual nursing diagnoses.

  • Risk nursing diagnoses.

  • Improved and positive diagnoses.

  • See Figure 7-4 and Table 7-2 for guidance.

Nursing Practice and Application

• Applying Nursing Diagnosis in the Clinical Setting:

  • It is a complex skill that requires practice to become proficient (Box 7-1).

• Significance of Nursing Diagnosis:

  • Provides a means of communicating nursing requirements for patient care.

  • Helps ensure patients receive quality nursing care.

  • Focuses attention on actual or potential health needs of patients.

Examples of Nursing Diagnoses

• Structure of nursing diagnoses:

  • Actual Nursing Diagnosis (3-part statement): Diagnostic Label + Associated Factors (etiology) + Indicators (signs and symptoms).

  • Risk Nursing Diagnosis (2-part statement): Diagnostic Label + Risk Factors.

  • Improved or Positive Diagnosis (1-part statement): Diagnostic Label.

• Example (3-part actual nursing diagnosis):

  • Stress incontinence of urine associated with weak pelvic muscles, obesity, and gravid uterus as indicated by urine dribbling when coughing.

• Example (2-part risk nursing diagnosis):

  • Risk for caregiver stress associated with discharge of family member with significant healthcare needs, economic instability, lack of respite care availability.

• Example (1-part improved/positive nursing diagnosis):

  • Readiness for effective parenting.

Validation and Patient Involvement

• Question #3: What is the main purpose of validating a nursing diagnosis?

  • Options included: derive the meaning of cues; identify individual cues; synthesize cue clusters; legitimize the nursing diagnosis.

• Answer: D. To legitimize the nursing diagnosis.

• Rationale: After selecting a nursing diagnosis, the nurse should validate it with the patient. Validation legitimizes the diagnosis and helps to discover its significance for the patient.