Chapter_007 Yoost

Chapter 7: Nursing Diagnosis

Overview of Nursing Diagnosis

• Nursing diagnosis involves the comprehensive analysis and systematic clustering of related assessment data to identify patient needs effectively, considering both physiological and psychosocial aspects.

• The nursing diagnosis framework enhances communication of patient needs among healthcare providers, fostering coordinated and individualized patient care.

• Nursing diagnoses not only promote professional accountability but also support the autonomy of nurses in their practice, allowing them to act as advocates for their patients.

Taxonomies of Nursing Diagnosis

• NANDA International, Inc. (NANDA-I): A globally recognized standardized classification system for nursing diagnoses, providing a comprehensive list of nursing diagnoses that can be adapted across various healthcare settings.

• International Classification for Nursing Practice (ICNP): Developed by the International Council of Nurses (ICN), this universal classification system is designed to improve international nursing practice and research through consistent terminology.

• International Council of Nurses (ICN): This organization plays a crucial role in representing nursing on a global level, advocating for nursing practice and shaping healthcare policy.

• Clinical Care Classification System (CCC): This system classifies not only nursing diagnoses but also the interventions associated with them, helping to standardize nursing care and documentation in electronic health records.

LO 7.1 Nursing Diagnosis Methodology

Differentiating Between Diagnoses

• Medical Diagnoses: Focus on identifying diseases and medical conditions based on a patient's symptoms and medical history, often requiring medical intervention and treatment.

• Nursing Diagnoses: Concentrate on holistic patient care, addressing non-medical aspects of patient needs, including their emotional, social, and spiritual well-being alongside physiological concerns.

LO 7.2 Nursing Taxonomies

Evolution of Nursing Taxonomies

• NANDA International (NANDA-I): Continually evolving to reflect the changing landscape of nursing practice and healthcare needs, ensuring relevancy and applicability.

• ICNP Taxonomy: Enhanced to support global nursing practice and improve communication among nurses in different countries through a common language.

• Cycle of Revision: Taxonomies are reviewed and updated every 1 to 3 years, incorporating feedback from nursing professionals and trends in patient care to maintain their relevance.

LO 7.3 NANDA-I Nursing Diagnostic Statements

Types of Diagnostic Statements

• Problem-Focused: Intended to address current issues or specific needs of the patient, such as pain, anxiety, or risk for infection.

• Risk: These statements identify potential complications or problems that the patient may be vulnerable to, allowing for preventive measures to be taken.

• Health Promotion: Focus on encouraging behaviors that enhance well-being or promote better health outcomes, such as exercise and dietary changes.

Diagnostic Statement Flow

1. Identify if there are identifiable patient or group responses to a current need, issue, or life process.

2. Determine if the patient is vulnerable to developing complications that are not currently present.

3. Assess if there is a desire for improved health or behavioral changes.

4. Select appropriate diagnostic labels based on thorough assessments and identified needs.

Related Factors and Risk Factors

• Start with a problem-focused nursing diagnosis label based on observational data gathered from the patient.

• Identify risk factors that substantiate risk nursing diagnoses, which may include patient history and environmental factors.

• Recognize patient behaviors that are relevant to health promotion nursing diagnosis labels, reflecting their readiness for change.

• Cluster both subjective and objective data to validate diagnostic statements, ensuring a holistic view of the patient's condition.

LO 7.4 Components of NANDA-I Nursing Diagnostic Statements

Structure of Diagnostic Statements

• Diagnosis Label: A concise and specific term that encapsulates a pattern of related data, such as "Impaired Mobility" or "Chronic Pain."

• Related Factors: These are the underlying causes or contributing factors associated with the diagnosis, providing context to the presentation of symptoms.

• Defining Characteristics: These include specific environmental, physical, psychological, or situational concerns observable in the patient that support the diagnosis, such as limited range of motion or patient reports of pain.

LO 7.5 Nursing Diagnosis in the Electronic Medical Record

• Electronic Medical Record (EMR): Modern EMRs often utilize dropdown lists to facilitate the identification and selection of nursing diagnoses, making it easier for nurses to accurately document patient needs.

• Nurses have the option to select from standardized diagnoses or manually enter the signs and symptoms associated with the diagnosis, ensuring comprehensive patient records.

LO 7.6 Steps for Identification of Accurate Nursing Diagnoses

Identification Process

• Data Clustering: The technique of grouping patient assessment data based on similarities and potential relationships, which aids in synthesizing information for diagnosis.

• Diagnostic Validity: Ensuring the correctness of the diagnosis through a meticulous review of selected options in EMR or using the NANDA-I taxonomy for accurate alignment with patient conditions.

LO 7.7 Avoiding Problems in the Diagnostic Process

Key Considerations

• Emphasize accurate data collection while focusing on correctly clustering the data to avoid diagnostic errors.

• Ensure that related factors are formulated correctly and identify the appropriate causes of the patient's condition.

• Concentrate on one problem at a time to minimize confusion and enhance the clarity of the diagnosis.

LO 7.8 Application to Patient Care

• Clear and concise nursing diagnostic statements are essential for developing effective and individualized patient care plans, allowing nurses to prioritize care based on patient needs.

• Nursing diagnoses are a vital component of the planning phase, wherein prioritization occurs to address the most pressing patient issues first.

• Nurses hold substantial accountability for formulating accurate diagnoses, thereby directly influencing the success of implemented interventions and the overall quality of patient care.