Nursing Process: Nursing Diagnosis

1. Nursing Process: Nursing Diagnosis George Ann Daniels, MS, RN

2. Describes alterations in the client�s health status Identifies the client�s problems/needs, the cause of the problem/need (etiology), and the associated signs and symptoms that support the problem/need What changes have occurred in the client�s health Describes alterations in the client�s health status Identifies the client�s problems/needs, the cause of the problem/need (etiology), and the associated signs and symptoms that support the problem/need What changes have occurred in the client�s health

3. How do you make a NDX? Analyze collected data Identify the client�s strengths Identify the client�s normal functional level and indicators of actual or potential dysfunction Formulate a diagnostic statement in relations to this synthesis

4. Benefits of Nursing Diagnosis Gives nurses a common language Promotes identification of appropriate expected outcomes Provides acuity information Can create a standard for nursing practice Provide a quality improvement base Promotes improved communication between nurses. E.g.. Airway clearance, ineffective vs. poor breathing Uniform way to aid in choices of correct expected outcomes. E.G. high risk for infection vs presence of urinary catheter Client classification and 3rd party reimbursement. Impaired gas exchange vs acute urinary retention Provides a means to evaluate nursing practice Can determine, validate, and /or alter process of care deliveryPromotes improved communication between nurses. E.g.. Airway clearance, ineffective vs. poor breathing Uniform way to aid in choices of correct expected outcomes. E.G. high risk for infection vs presence of urinary catheter Client classification and 3rd party reimbursement. Impaired gas exchange vs acute urinary retention Provides a means to evaluate nursing practice Can determine, validate, and /or alter process of care delivery

5. NDX VS Medical Diagnosis Nursing Diagnosis Made by the nurse Describes clients response Responses vary between individuals Changes as client responses change Nurse orders interventions Medical Diagnosis Made by a physician Refers to the disease process Somewhat uniform between clients Remains same during disease process Physician orders interventions NDX describes the client�s response to actual or potential problems or conditions; changes from day to day within the legal scope of independent nursing practice Medical diagnosis identifies disease and organ dysfunction. Does not change as long as disease is present. Requires medical interventionsNDX describes the client�s response to actual or potential problems or conditions; changes from day to day within the legal scope of independent nursing practice Medical diagnosis identifies disease and organ dysfunction. Does not change as long as disease is present. Requires medical interventions

6. Steps Identify patterns Review data and look for cues Cluster cues (signs and symptoms) Synthesizing the cue clusters Three questions to ask self What are my concerns about this client Can I or am I doing something obout it Can the overall risk be decreased by nursing interventions

7. Synthesis the data Look at all data as a whole Validate the diagnosis Test for a fit Refer to the NANDA DX and defining characteristics Formulate the nursing diagnosis statement using nursing language NANDA

8. Types of Nursing Diagnosis Actual (3 parts) Can be documented from assessment Risk (2 parts) A clinical judgment that the client is more vulnerable to develop this problem than others in the same or similar situation Wellness (2 parts) Potential for enhancement of current well state Actual-a problem that is currently present and is manifested by signs and symptoms Risk- a problem/need the nurse believes could develop, but since it has not yer occurred, there are no signs of symptoms, only risk factors Error in choosing a NDX Overlooking cues making a diagnosis with insufficient database sterotypingActual-a problem that is currently present and is manifested by signs and symptoms Risk- a problem/need the nurse believes could develop, but since it has not yer occurred, there are no signs of symptoms, only risk factors Error in choosing a NDX Overlooking cues making a diagnosis with insufficient database sterotyping

9. Components of Nursing Diagnosis Diagnostic Label P Qualifier Etiology E Defining characteristics S

10. Diagnostic Label Problem Name of the nursing diagnosis as listed in the taxonomy Describes the problem using as few words as possible Qualifier Used to give additional meaning to the NDX Identified from the NANDA list of defining characteristics Reflects a change in the client�s health statis Identified from the NANDA list of defining characteristics Reflects a change in the client�s health statis

11. Problems to avoid in writing this part DO NOT use the medical diagnosis Must be a problem the nurse and/or client can change to do something about Relating the problem to an unchangeable situation Don�t confuse the etiology with the problem Focus on the human responses to the problem Avoid the use of one piece of assessment data as a NDX (EDEMA) Examples on handout for instructorExamples on handout for instructor

12. Be specific Don�t combine NDX Don�t relate one NDX to another. There is a different related to factor if this is a valid NDX Nursing interventions should not be included in the NDX Keep your language non-judgmental Don�t make assumptions or statements you can�t prove with assessment data Be sure your statement is legally advisable

13. Etiology This is the �related to, R/T� portion of the diagnosis. What caused the client to have the problem listed? Problems to avoid in writing this part DO NOT use the medical diagnosis Must be a problem the nurse and/or client can change to do something about Suspected cause or reason Suspected cause or reason

14. Defining Characteristics These are the major and minor clinical cues that validate the presents of an actual nursing diagnosis Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the NDX Provides the evidence that the problem Signs and symptoms identified in the assessment that substrantiates the NDX Use AEB to connect etiology to defining statement ID at least 3 signs and symptoms to verify NDX Provides the evidence that the problem Signs and symptoms identified in the assessment that substrantiates the NDX Use AEB to connect etiology to defining statement ID at least 3 signs and symptoms to verify NDX

15. Measurement criteria for ANA Standard II: Diagnosis: The nurse analyzes the assessment data in determining diagnosis. Diagnoses are derived from assessment data Diagnoses are validated with the patient, family, and HCP when possible and appropriate Diagnoses are documented in a manner that facilitates the determination of expected outcomes and plan of care Identifying Correct and incorrect NDX Practice 3-2 Go over handoutIdentifying Correct and incorrect NDX Practice 3-2 Go over handout