305- Ch. 17- Nursing Diagnosis

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Objectives
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Discuss the purposes of using nursing diagnosis in practice. Differentiate among a nursing diagnosis, medical diagnosis, and collaborative problem. Discuss the relationship of critical thinking to the nursing diagnostic process. Describe the steps of the nursing process. Explain how defining characteristics and the etiological process individualize a nursing diagnosis. Describe differences among health promotion, problem-focused, and risk nursing diagnoses. Describe sources of diagnostic errors.
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Medical Diagnosis
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Identification of a disease through diagnostic findings. Stays constant as the condition remains.
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Nursing Diagnosis
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Clinical judgment concerning a human response to health conditions based on information that the nurse is licensed to treat. The nursing diagnostic process is unique in that it involves patients (individual, family, or community) where ever possible in the process. Diagnostic Conclusions Include: Problems treated primarily by nurses (nursing diagnosis) Problems requiring treatment by several disciplines (collaborative problems)
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History of Nursing Diagnosis
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1950- First introduced in literature 1953- Nursing dx and individualized nursing care plan introduced to make nursing more creative Emphasized the nurse’s independent practice (patient education and sx relief) compared with the dependent practice (physicians orders) 1955- Not accepted by ANA and excluded from Model Nurse Practice Act of the ANA 1967- Theory of the Nursing Process developed by Yura & Walsh (1967): Assess, (no Diagnose), Plan, Implement, & Evaluate 1973- First national conference held identifying the health conditions of concern to nursing: 80 nursing diagnosis were defined 1980- ANA included dx as a separate activity in its publication Nursing: a Social Policy Statement.
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Nursing Diagnostic Statements: Purpose
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Provide precise definition to a patient problem using a common language Allows nurses to communicate what they do among themselves with other disciplines and the public Distinguishes the nurse’s role from physician or other health care provider Helps nurses focus on their scope of practice Fosters the development of nursing knowledge Promotes creation of practice guidelines that reflect the essence of nursing
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Three Types of Nursing Diagnosis
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Actual Diagnosis: Response to an existing condition in a patient, family, or community. Risk Diagnosis: Response to health conditions that may develop in a vulnerable patient, family, or community. There are no defining characteristics because they have not occurred (NO AEB b/c then it would be actual) Health Promotion Diagnosis: Clinical judgment of a person’s, family’s or community’s motivation and readiness to increase human health potential.
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Elements of a Nursing Diagnosis
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Problem focused Diagnosis Clinical judgement concerning an undesirable response to a health condition. Related factor (etiology) Causative factor for the diagnosis Individualized for a particular patient Defining Characteristics (as evidenced by) Subjective and/or objective assessment cues/data such as patient behavior or physical signs that support the diagnostic statement.
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The Nursing Diagnostic Process
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Diagnostic reasoning involves using the assessment data gathered on a patient to logically explain a clinical judgment- the nursing diagnosis.
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Data Clustering
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A set of signs or symptoms gathered during your assessment that share a common thread.
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Defining Characteristics (AEB)
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The clinical criteria that are observable and verifiable (ex. Guarding, incr. grimacing, BP, pain 7 out of 10)
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Clinical Criteria:
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Objective or subjective data that when analyzed with other criteria, leads to a diagnostic conclusion (ex. Diagnostic conclusion from above defining characteristics is “acute pain”)
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Components of a Nursing Diagnosis
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Diagnostic Label: The name of the nursing diagnosis B. 17-2 p. 228-9 Stated in as few words as possible. Include “descriptors” Ex. Compromised, Decreased, Deficient, Delayed, Impaired, Imbalanced Related Factors: The reason the patient is displaying the nursing diagnosis. Includes 4 categories: Pathophysiological (biological or psychological) Treatment-related Situational (environmental or personal) Maturational
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Formulating a Nursing Diagnosis
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Related factor: A condition or etiology that gives a context for the defining characteristics. Shows a relationship with the nursing diagnosis. Ex. Acute pain (nursing diagnosis) related to (R/T) incisional trauma (related factor) as evidenced by (AEB) patients guarding and reluctance to move (defining characteristics). Allows for individualized nursing diagnosis The nursing diagnosis focus may be an actual or potential response to a problem rather than on the physiological event, complication, or disease. Ex. “acute pain related to incisional trauma” NOT “acute pain related to cholecystectomy”
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Nursing Diagnosis Stated in PES Format
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P=Problem (nursing diagnosis) E=Etiology (or related factor) R/T S=Symptoms (defining characteristics) AEB Example: Impaired physical mobility (diagnosis) R/T incisional pain (related factor), AEB restricted turning and positioning (defining characteristics).
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Cultural Relevance
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Consider the patient’s cultural diversity. Cultural awareness and sensitivity improve your accuracy in making nursing diagnoses. Examples of interview questions: What do you expect from your hospital stay to help maintain some of your cultural practices? What do you believe will help or fix the problem? What worries you the most about this problem? Will being in the hospital affect your ability to practice your religion?
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Concept Mapping
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Graphically represents the connections between concepts (nursing diagnosis) and ideas that are related to the patients health problems. Focus is on the patient. Promotes critical thinking- key concepts are linked by organizing and analyzing information. Incorporates: Clinical reasoning Intuition Past experiences with patients Patterns seen in similar situations Reference to institutional standards and procedures.
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Sources of Diagnostic Error read pp. 234-36
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Errors in Data Collection Errors in Interpretation and Analysis of Data Validate that measureable, objective physical findings support subjective data Errors in Data Clustering An incorrect nursing diagnosis affects quality of patient care Errors in the Diagnostic statement Reduce errors by selecting appropriate, concise, and precise language using NANDA terminology
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Nursing Diagnosis of “Breathing Pattern Ineffective”The patient reports difficulty breathing. Improper or incomplete data collect can drastically change the necessary interventions to aid your patient.
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Psychological Dyspnea Normal pulse o2 Anxiety Tingling in extremities Clear lungs Increased respiratory rate Palpitations Rx: Ativan, breath into a paper bag, coach patient to slow their breathing Physiological Dyspnea Decreased pulse o2 Lung sounds with rales, wheezes or rhonchi Use of accessory muscles Confusion Cyanosis Rx: O2, diuretics, nebulizer rx, teach pursed-lip breathing
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Documentation
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Document in the written plan of care or in the electronic record Place the highest-priority nursing diagnosis first Date and time the nursing diagnosis entry Accurate documentation assures clear communication with other health care professionals and assures relevant and appropriate nursing interventions have been selected

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