Diagnosing – Flashcards
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Diagnosing
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The second step in the nursing process—begins after the nurse has collected and recorded the patient data. The nurse interprets and analyzes data gathered from the nursing assessment. The data help the nurse identify patient strengths and health problems.
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The purposes of diagnosing
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(1) identify how a person, group, or community responds to actual or potential health and life processes (2) identify factors that contribute to or cause health problems (etiologies) (3) identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems.
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Health Problem
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A condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness.
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Concerns that are central to the role of a nurse
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(1) Recognizing safety and infection-transmission risks and addressing these immediately. (2) Identifying human responses—how problems, signs and symptoms, and treatment regimens impact on patients' lives—and promoting optimum function, independence, and quality of life (3) Anticipating possible complications and taking steps to prevent them (4) Initiating urgent interventions—you do not want to wait to make a final diagnosis if there are signs and symptoms indicating the need for immediate treatment.
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Nursing Diagnoses
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Actual or potential health problems that can be prevented or resolved by independent nursing intervention. The nurse formulates, validates, and lists nursing diagnoses for each patient. Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued patient outcomes for which the nurse is responsible
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Legal Implications of Using the Word Diagnosis
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The term diagnosis implies that there's a situation or problem requiring appropriate, qualified treatment. This means that if you identify a problem, you must decide if you are qualified to treat it and willing to accept responsibility for treating it. If you are not, you are responsible for getting help.
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ANA Standard of Practice: Diagnosing The registered nurse analyzes the assessment data to determine the diagnoses or issues.
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Competencies: 1.) Derives the diagnoses or issues based from assessment data. 2.) Validates the diagnoses or issues with the healthcare consumer, family, and other healthcare providers when possible and appropriate. 3.) Identifies actual or potential risks to the healthcare consumer's health and safety or barriers to health, which may include but are not limited to interpersonal, systematic, or environmental circumstances. 4.) Uses standardized classification systems and clinical decision support tools, when available, in identifying diagnoses. 5.) Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan.
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Nursing diagnoses are written to __________________________.
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describe patient problems or issues that nurses can treat independently, such as activity, pain and comfort, and tissue integrity and perfusion problems.
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3 activités for nurses using PPMP
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1.) In the presence of known problems, predict the most common and most dangerous complications and take immediate action to (a) prevent them, and (b) manage them in case they cannot be prevented. 2.) Whether problems are present or not, look for evidence of risk factors (things that evidence suggests contribute to health problems). If you identify risk factors, you aim to reduce or control them, thereby preventing the problems themselves. 3.) In all situations, ensure that safety and learning needs are met, and promote optimum function and independence.
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PPMP
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predict, prevent, manage, and promote (focus of nursing process)
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Medical diagnoses identify diseases, whereas nursing diagnoses...
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focus on unhealthy responses to health and illness.
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A medical diagnosis remains the same for as long as the disease is present, whereas a nursing diagnosis...
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may change from day to day as the patient's responses change.
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Medical diagnoses describe problems for which the physician directs the primary treatment, whereas nursing diagnoses...
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describe problems treated by nurses within the scope of independent nursing practice.
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Collaborative Problem
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Certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse interventions to minimize the complications of the event
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Responsibility of collaborative problems
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Unlike medical diagnoses, collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses, with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines. When the nurse writes patient outcomes that require delegated medical orders for goal achievement, the situation is not a nursing diagnosis, but a collaborative problem. Because collaborative problems involve potential complications, they must be identified early so that preventive nursing care can be instituted early.
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Writing a diagnostic statement for a collaborative problem
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To write a diagnostic statement for a collaborative problem, focus on the potential complications of the problem. Use "PC" (for potential complication), followed by a colon, and list the complications that might occur. For clarity, link the potential complications and the collaborative problem by using "related to." Example: "PC: Paralytic ileus related to anesthesia."
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Medical Diagnosis
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Traumatic or disease condition or syndrome validated by medical diagnostic studies
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Focus of Nursing Diagnosis vs. Collaborative Problem vs. Medical Diagnosis
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Nursing Diagnosis: Monitoring human responses to actual and potential health problems Collaborative Problem: Monitoring pathophysiologic responses of body organs or systems Medical Diagnosis: Correcting or preventing pathology of specific organs or body systems
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Standard (norm)
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A generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. The patient's own normal range, if known, is an important standard. A pressure of 150/90 mm Hg may be high for someone whose pressure normally is 120/70 mm Hg, but it may be normal for a person with hypertension.
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Examples of how standards can be used to identify significant cues:
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1.) Changes in a patient's usual health patterns that are unexplained by expected norms for growth and development: Example—An infant who took to breastfeeding easily as a newborn suddenly stops sucking when put to the breast and begins to lose weight. 2.) Deviation from an appropriate population norm: Example—A first-year college student begins to accelerate her exercise habits dramatically and starts inducing vomiting after binge eating. She rapidly loses weight. 3.) Behavior that is nonproductive in the whole-person context: Example—A college student breaks up with her boyfriend and begins to believe that she is "unfit" for any other relationship, withdrawing from her friends and social activities. 4.) Behavior that indicates a developmental lag or evolving dysfunctional pattern: Example—A 16-year-old single mother with a 6-month-old infant continues to "party hard" with her friends, hangs out at the mall, and shows no interest in caring for her son, who is repeatedly left with concerned family members.
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Recognizing Patterns or Cues
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- A data cluster is a grouping of patient data or cues that points to the existence of a health problem.
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Nursing diagnoses should always be derived from _______________________ rather than from a ______________.
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- Clusters of significant data, single cue - Example: Diagnosing a woman recovering from gallbladder surgery with Ineffective Coping solely on the basis of tears may misinterpret the patient's crying, which may be a healthy release of emotion. If the same patient begins to exhibit a cluster of significant cues, such as refusing to eat, preferring bed rest to scheduled ambulation, and reporting increasing discomfort, an unhealthy pattern is emerging.
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Determining Patient and Family Strengths
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- If a patient appears to meet a standard, the nurse concludes that the patient has strength in that particular area, and that this strength contributes to the patient's level of wellness.
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Patient strengths might include....
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- Healthy physiologic functioning, emotional health, cognitive abilities, coping skills, interpersonal strengths, and spiritual strengths. - Resources such as the presence of support people, adequate finances, and a healthy environment may all contribute to patient strengths. - Many people take their strengths for granted and might not know how to use them effectively when responding to illness. Discussing observed strengths with patients and counseling patients about ways to develop and use their strengths are important nursing measures.
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Determining the Patients Problem Areas
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A person who does not meet a certain health standard probably has a limitation in that area and may benefit from professional care. For example, a person with a long history of constipation probably needs care to help overcome this problem. As stated previously, the nurse decides whether the data represent a nursing diagnosis or a collaborative problem, or whether the data should be reported to the physician because they might lead to a medical diagnosis.
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Determining Problems the Patient is likely to experience
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Nurses also identify potential health problems. For example, a nurse notes that a patient has signs of a wound infection, but laboratory test results show that the patient's white blood cell count has not increased, as is usual when such an infection is present. The nurse concludes that the body apparently is not building up normal defenses to combat the infection. The nurse then predicts the problems this patient is likely to encounter, such as a longer-than-normal healing period. Potential nursing diagnoses alert other caregivers to problems the patient may experience if certain trends in the patient's condition continue unreversed. This prediction has implications for nursing care such as measures related to the patient's diet, fluid intake, urine output, and mobility.
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Identifying Potential Complications
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Patients may experience many complications related to their diagnoses, medications or treatment regimens, or invasive diagnostic studies. While new to nursing, you can more easily prevent potential complications or at least make sure that they are detected early and managed well if you research the potential complications associated with your patient's diagnoses, diagnostics, and treatment, and if you report all abnormal data. For example, slurred speech, changes in skin color or moistness, inability to move an extremity or abnormal movement, and changes in levels of consciousness may all be indications of serious and life-threatening complications
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4 Basic conclusions
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No Problem Possible Problem Actual or Potential Nursing Diagnosis Clinical Problem Other Than Nursing Diagnosis
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No Problem
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No nursing response is indicated. Reinforce the patient's health habits and patterns. Initiate health-promotion activities to prevent disease or illness or to promote a higher level of wellness. Wellness diagnosis might be indicated.
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Possible Problem
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Collect more data to confirm or disprove a suspected problem.
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Actual or Potential Nursing Diagnosis
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Begin planning, implementing, and evaluating care designed to prevent, reduce, or resolve the problem. If unable to treat the problem because the patient denies the problem and refuses treatment, make sure that the patient understands the possible outcomes of this stance.
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Clinical Problem Other Than Nursing Diagnosis
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Consult with the appropriate health care professional and work collaboratively on the problem. Refer to medical or other services, as indicated.
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Partnering with the Patient and Family
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Remember that your best source of information usually is an aware patient. While some patients still enter the health care system expecting physicians and nurses to tell them what is "wrong" and to "fix it," increasingly patients want to play a leading role in identifying and treating their health problems. Be sure to ask patients what they believe their most important problems or issues are and have them confirm what your assessment reveals and help you prioritize the resulting list of diagnoses.
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Five types of nursing diagnoses
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actual, risk, possible, wellness, and syndrome.
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Actual nursing diagnoses
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Represent problems that have been validated by the presence of major defining characteristics. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor.
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Risk nursing diagnoses
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Clinical judgments that a person, family, or community is more vulnerable to develop the problem than others in the same or similar situation.
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Possible nursing diagnoses
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Statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem.
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How many parts does a risk nursing Diagnoses have?
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A risk nursing diagnosis is a two-part statement consisting of a diagnostic label and risk factors. It does not include defining characteristics.
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How many parts does a health promotion nursing diagnosis have?
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Health-promotion diagnoses are one-part statements that include only the diagnostic label.
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How many parts does an actual nursing diagnosis have?
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An actual nursing diagnosis is a three-part statement that includes a diagnostic label, defining characteristics, and related factors.
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Wellness diagnoses
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- Clinical judgments about a person, group, or community in transition from a specific level of wellness to a higher level of wellness. - Wellness diagnoses are often more applicable in nursing settings that deal primarily with healthy patients. - Two cues must be present for a valid wellness diagnosis: - A desire for a higher level of wellness - An effective present status or function The diagnostic statement for wellness diagnoses is a one-part statement that contains the label Readiness for Enhanced, followed by the desired higher-level wellness. Related factors are not included.
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Syndrome nursing diagnoses
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Comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation; for example, Rape-Trauma Syndrome or Post-Trauma Syndrome.
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Parts of a Nursing Diagnosis
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1.) Defining characteristics are the observable "cues or inferences that cluster as manifestations of an actual illness or wellness health state." 2.) Related factors describe the condition, circumstances, or etiologies that contribute to the problem. 3.) Descriptors are words used to give additional meaning to a nursing diagnosis. 4.) Each approved NANDA-I nursing diagnosis has a definition that describes the characteristics of the human response under consideration Most nursing diagnoses are written either as two-part statements listing the patient's problem and its cause or as three-part statements that also include the problem's defining characteristics.
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Problem
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- The purpose is to describe the health state or health problem of the patient as clearly and concisely as possible. - Because this section of the nursing diagnosis identifies what is unhealthy about the patient and what the patient would like to change in his or her health status, it suggests patient outcomes. - NANDA-I recommends the use of quantifiers or descriptors to limit or specify the meaning of a problem statement. For example, the descriptor "anticipatory" placed before the concept "grieving" clarifies the nursing diagnosis for a pregnant couple informed prenatally that their child will most likely be stillborn and who are already grieving the death of their child.
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Etiology
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- Idenitifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. - Because the etiology identifies the factors that maintain the unhealthy patient state and prevent the desired change, the etiology directs nursing intervention. - Unless the etiology is correctly identified, nursing actions might be inefficient and ineffective. For example, a diabetic patient who is frequently admitted to the hospital with hyperglycemia and who has a poor history of dietary and pharmacologic management is diagnosed to be noncompliant. Mistakenly assuming that the noncompliance is related to a knowledge deficit, channeling all nursing activities and energies into teaching the patient how to manage the diabetes would be useless if the noncompliance was actually a result of the patient's decreased will to live, which would necessitate a different group of nursing interventions.
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Defining Characteristics
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- The subjective and objective data that signal the existence of the actual or possible health problem. - NANDA-I has identified defining characteristics for each accepted nursing diagnosis; familiarity with these characteristics helps nurses recognize clusters of significant data.
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Descriptors
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Words used to give additional meaning to a nursing diagnosis. They describe the change in condition, state of the client, or some qualification of the specific nursing diagnosis.
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related factors vs. defining characteristics vs. diagnostic label
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Related factors describe the conditions, circumstances, or etiologies that contribute to the problem. Defining characteristics are the observable "cues" or inferences that cluster as manifestations of an actual illness or wellness health state. The diagnostic label accurately reflects the specific client problem.
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Complicated
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Intricately involved, complex
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Situational
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Related to a particular circumstance
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Readiness for
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In a suitable state for an activity or situation
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Perceived
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Observed through the senses
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Organized
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Properly arranged or controlled
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Low
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Below the norm
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Interrupted
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Having its continuity broken
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Ineffective
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Not producing the intended or desired effect
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Impaired
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Damaged, weakened
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Imbalanced
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Out of proportion or balance
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Excessive
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Greater than necessary or desirable
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Effective
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Producing the intended or desired result
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Dysfunctional
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Not operating normally
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Disturbed
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Agitated, interrupted, interfered with
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Disproportionate
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Too large or too small in comparison with a norm
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Disorganized
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Not properly arranged or controlled
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Disabled
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Limited, handicapped
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Delayed
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Late, slow or postponed
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Deficient
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Insufficient, inadequate
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Decreased
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Lessened (in size, amount, or degree)
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Compromised
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Damaged, made vulnerable
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Problem: Definition, Purpose, Example
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- Identifies what is unhealthy about the patient, indicating the need for change (clear, concise statement of the patient's health problem) - Suggests the patient outcomes (expectations for change) - Bathing/Hygiene Self-Care Deficit ---> Related to ---->
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Etiology: Definition, Purpose, Example
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- Identifies the factors that are maintaining the unhealthy state or response (contributing or causative factors) - Suggests the appropriate nursing measures - Fear of falling in the tub and obesity--> as manifested by-->
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Defining characteristics: Definition, Purpose, Example
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- Identify the subjective and objective data that signal the existence of the problem (cues that reflect the existence of a problem) - Suggest evaluative criteria - Strong body and urine odor, unclean hair: "I'm afraid I'll fall in the tub and break something." (5′4″, 170 lb)
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Two-part diagnostic statement
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Bathing/Hygiene Self-Care Deficit related to fear of falling in tub and obesity
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Three-part diagnostic statement
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Bathing/Hygiene Self-Care Deficit related to fear of falling in tub and obesity, as manifested by strong body and urine odor, unclean hair, statement of fearing fall in tub, and height and weight: 5′4″, 170 lb
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Domain 1: Health Promotion
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Definition: The awareness of well-being or normality of function and the strategies used to maintain control of and enhance that well-being or normality of function. Approved Diagnoses: 1.) Deficient Diversional Activity 2.) Sedentary Lifestyle 3.) Deficient Community Health 4.) Risk-Prone Health Behavior 5.) Ineffective Health Maintenance 6.) Readiness for Enhanced Immunization Status 7.) Ineffective Protection 8.) Ineffective Self-Health Management 9.) Readiness for Enhanced Self-Health Management 10.) Ineffective Family Therapeutic Regimen Management
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Domain 2: Nutrition
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Definition: The activities of taking in, assimilating, and using nutrients for the purpose of tissue maintenance, tissue repair, and the production of energy Approved Diagnoses: 1.) Insufficient Breast Milk 2.) Ineffective Infant Feeding Pattern 3.) Imbalanced Nutrition: Less Than Body Requirements 4.) Imbalanced Nutrition: More Than Body Requirements 5.) Readiness for Enhanced Nutrition 6.) Risk for Imbalanced Nutrition: More Than Body Requirements 7.) Impaired Swallowing 8.) Risk for Unstable Blood Glucose Level 9.) Neonatal Jaundice 10.) Risk for Neonatal Jaundice 11.) Risk for Impaired Liver Function 12.) Risk for Electrolyte Imbalance 13.) Readiness for Enhanced Fluid Balance 14.) Deficient Fluid Volume 15.) Excess Fluid Volume 16.) Risk for Deficient Fluid Volume 17.) Risk for Imbalanced Fluid Volume
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Domain 3: Elimination and Exchange
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Definition: Secretion and excretion of waste products from the body Approved Diagnoses: 1.) Functional Urinary Incontinence 2.) Overflow Urinary Incontinence 3.) Reflex Urinary Incontinence 4.) Stress Urinary Incontinence 5.) Urge Urinary Incontinence 6.) Risk for Urge Urinary Incontinence 7.) Impaired Urinary Elimination 8.) Readiness for Enhanced Urinary Elimination 9.) Urinary Retention 10.) Constipation 11.) Perceived Constipation 12.) Risk for Constipation 13.) Diarrhea 14.) Dysfunctional Gastrointestinal Motility 15.) Risk for Dysfunctional Gastrointestinal Motility 16.) Bowel Incontinence 17.) Impaired Gas Exchange
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Domain 4: Activity/Rest
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Definition: The production, conservation, expenditure, or balance of energy resources Approved Diagnoses: 1.) Insomnia 2.) Sleep Deprivation 3.) Readiness for Enhanced Sleep 4.) Disturbed Sleep Pattern 5.) Risk for Disuse Syndrome 6.) Impaired Bed Mobility 7.) Impaired Physical Mobility 8.) Impaired Wheelchair Mobility 9.) Impaired Transfer Ability 10.) Impaired Walking 11.) Disturbed Energy Field 12.) Fatigue 13.) Wandering 14.) Activity Intolerance 15.) Risk for Activity Intolerance 16.) Ineffective Breathing Pattern 17.) Decreased Cardiac Output 18.) Risk for Ineffective Gastrointestinal Perfusion 19.) Risk for Ineffective Renal Perfusion 20.) Impaired Spontaneous Ventilation 21.) Ineffective Peripheral Tissue Perfusion 22.) Risk for Decreased Cardiac Tissue Perfusion 23.) Risk for Ineffective Cerebral Tissue Perfusion 24.) Risk for Ineffective Peripheral Tissue Perfusion 25.) Dysfunctional Ventilatory Weaning Response 26.) Impaired Home Maintenance 27.) Readiness for Enhanced Self-Care 28.) Bathing Self-Care Deficit 29.) Dressing Self-Care Deficit 30.) Feeding Self-Care Deficit 31.) Toileting Self-Care Deficit 32.) Self-Neglect
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Domain 5: Perception/Cognition
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Definition: The human information-processing system, including attention, orientation, sensation, perception, cognition, and communication. Approved Diagnoses: 1.) Unilateral Neglect 2.) Impaired Environmental Interpretation Syndrome 3.) Acute Confusion 4.) Chronic Confusion 5.) Risk for Acute Confusion 6.) Ineffective Impulse Control 7.) Deficient Knowledge 8.) Readiness for Enhanced Knowledge 9.) Impaired Memory 10.) Readiness for Enhanced Communication 11.) Impaired Verbal Communication
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Domain 6: Self-Perception
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Definition: Awareness about the self Approved Diagnoses Hopelessness Risk for Compromised Human Dignity Risk for Loneliness Disturbed Personal Identity Risk for Disturbed Personal Identity Readiness for Enhanced Self-Concept Chronic Low Self-Esteem Situational Low Self-Esteem Risk for Chronic Low Self-Esteem Risk for Situational Low Self-Esteem Disturbed Body Image
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Domain 7: Role Relationships
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Definition: The positive and negative connections or associations between people or groups of people and the means by which those connections are demonstrated Approved Diagnoses: Ineffective Breastfeeding Interrupted Breastfeeding Readiness for Enhanced Breastfeeding Caregiver Role Strain Risk for Caregiver Role Strain Impaired Parenting Readiness for Enhanced Parenting Risk for Impaired Parenting Risk for Impaired Attachment Dysfunctional Family Processes Interrupted Family Processes Readiness for Enhanced Family Processes Ineffective Relationship Readiness for Enhanced Relationship Risk for Ineffective Relationship Parental Role Conflict Ineffective Role Performance Impaired Social Interaction
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Domain 8: Sexuality
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Definition: Sexual identity, sexual function, and reproduction Approved Diagnoses Sexual Dysfunction Ineffective Sexuality Pattern Ineffective Childbearing Process Readiness for Enhanced Childbearing Process Risk for Ineffective Childbearing Process Risk for Disturbed Maternal-Fetal Dyad
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Domain 9: Coping/Stress Tolerance
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Definition: Contending with life events/life processes Approved Diagnoses Post-Trauma Syndrome Risk for Post-Trauma Syndrome Rape-Trauma Syndrome Relocation Stress Syndrome Risk for Relocation Stress Syndrome Ineffective Activity Planning Risk for Ineffective Activity Planning Anxiety Defensive Coping Ineffective Coping Readiness for Enhanced Coping Ineffective Community Coping Readiness for Enhanced Community Coping Compromised Family Coping Disabled Family Coping Readiness for Enhanced Family Coping Death Anxiety Ineffective Denial Adult Failure to Thrive Fear Grieving Complicated Grieving Risk for Complicated Grieving Readiness for Enhanced Power Powerlessness Risk for Powerlessness Impaired Individual Resilience Readiness for Enhanced Resilience Risk for Compromised Resilience Chronic Sorrow Stress Overload Autonomic Dysreflexia Risk for Autonomic Dysreflexia Disorganized Infant Behavior Readiness for Enhanced Organized Infant Behavior Risk for Disorganized Infant Behavior Decreased Intracranial Adaptive Capacity
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Domain 10: Life Principles
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Definition: Principles underlying conduct, thought, and behavior about acts, customs, or institutions viewed as being true or having intrinsic worth Approved Diagnoses: Readiness for Enhanced Hope Readiness for Enhanced Spiritual Well-Being Readiness for Enhanced Decision-Making Decisional Conflict Moral Distress Noncompliance Impaired Religiosity Readiness for Enhanced Religiosity Risk for Impaired Religiosity Spiritual Distress Risk for Spiritual Distress
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Domain 11: Safety/Protection
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Definition: Freedom from danger, physical injury, or immune-system damage; preservation from loss; and protection of safety and security Approved Diagnoses: Risk for Infection Ineffective Airway Clearance Risk for Aspiration Risk for Bleeding Impaired Dentition Risk for Dry Eye Risk for Falls Risk for Injury Impaired Oral Mucous Membrane Risk for Perioperative Positioning Injury Risk for Peripheral Neurovascular Dysfunction Risk for Shock Impaired Skin Integrity Risk for Impaired Skin Integrity Risk for Sudden Infant Death Syndrome Risk for Suffocation Delayed Surgical Recovery Risk for Thermal Injury Impaired Tissue Integrity Risk for Trauma Risk for Vascular Trauma Risk for Other-Directed Violence Risk for Self-Directed Violence Self-Mutilation Risk for Self-Mutilation Risk for Suicide Contamination Risk for Contamination Risk for Poisoning Risk for Adverse Reaction to Iodinated Contrast Media Latex Allergy Response Risk for Allergy Response Risk for Latex Allergy Response Risk for Imbalanced Body Temperature Hyperthermia Hypothermia Ineffective Thermoregulation
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Domain 12: Comfort
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Definition: Sense of mental, physical, or social well-being or ease Approved Diagnoses Impaired Comfort Readiness for Enhanced Comfort Nausea Acute Pain Chronic Pain Social Isolation
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Domain 13: Growth/Development
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Definition: Age-appropriate increase in physical dimensions, maturation of organ systems, and/or progression through the developmental milestones Approved Diagnoses Risk for Disproportionate Growth Delayed Growth and Development Risk for Delayed Development
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Guidelines for Writing Nursing Diagnoses
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1.) Phrase the nursing diagnosis as a patient problem or alteration in health state rather than as a patient need. 2.) Check to make sure that the patient problem precedes the etiology and that the two are linked by the phrase "related to." 3.) Defining characteristics, when included in the nursing diagnosis, should follow the etiology and be linked by the phrase "as manifested by" or "as evidenced by." 4.) Write in legally advisable terms. 5.) Use nonjudgmental language. 6.) Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance). 7.) Avoid using defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement. 8.) Reread the diagnosis to make sure that the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing measures.
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Common Error: Writing the diagnosis in terms of needs and not response
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Wrong: Needs assistance with bathing related to bed rest Correction: Write the diagnosis in terms of response rather than need. Right: Bathing/Hygiene Self-Care Deficit related to immobility
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Common Error: Making legally inadvisable statements
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Wrong: Noncompliance due to hostility toward nursing staff (the words duet imply a direct cause-and-effect relationship) Wrong: Spouse Abuse related to husband's immaturity and violent temper Wrong: Impaired Skin Integrity related to patient's lying on back all night Correction: Use "related to" rather than "due to" or "caused by" to link the etiology to the problem statement. Correction: Write diagnosis in legally advisable terms: statements that may be interpreted as libel or that imply nursing negligence are legally hazardous to all the nurses caring for the patient. Right: Noncompliance related to hostility toward nursing staff (denotes a relation between the problem and etiology but not necessarily a causal relation) Right: High Risk for Violence: Spouse Abuse related to husband's reported inability to control behavior Right: Impaired Skin Integrity related to mobility deficit
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Common Error: Identifying as a problem a patient response that is not necessarily unhealthy
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Wrong: Mild Anxiety related to impending surgery Correction: Include in the problem statement of the nursing diagnosis only patient responses that are unhealthy or that the patient wants to change. Right: No need for nursing diagnosis: mild anxiety before surgery is a healthy response that motivates preoperative self-care behavior
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Common Error: Identifying as a problem signs and symptoms of illness
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Wrong: Cough related to long history of smoking Correction: Avoid including signs and symptoms of illness in the problem statement of the nursing diagnosis. Right: Ineffective Airway Clearance related to 20-year history of smoking
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Common Error: Identifying as a patient problem or etiology what cannot be changed
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Wrong: Alterations in Bowel Elimination: Permanent Colostomy related to cancer of bowel Wrong Grieving related to death of spouse Correction: Express the problem statement and etiologic factors in terms that can be changed; otherwise, nursing energies are being directed to a hopeless task. Right: Self-Care Deficit: Care of Colostomy, related to severe anxiety about cancer and feelings of powerlessness Right: Dysfunctional Grieving related to inability to accept death of spouse
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Common Error: Identifying environmental factors rather than patient factors as a problem
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Wrong: Cluttered Home related to inability to discard anything Correction: Express the problem statement in terms of unhealthy patient responses rather than environmental conditions. Right: Risk for Injury related to cluttered home (inability to discard anything)
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Common Error: Reversing clauses
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Wrong: Deficient Knowledge related to alteration in parenting Correction: Avoid reversing the problem statement and etiologic statement. Right: Impaired Parenting related to knowledge deficit: child growth and development, discipline
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Common Error: Having both clauses say the same thing
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Wrong: Impaired Comfort related to pain (pain is the comfort alteration—what is contributing to the pain?) Correction: Be sure that the two parts of the diagnosis do not mean the same thing. Right: Unrelieved Incisional Pain related to fear of addiction
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Common Error: Including value judgments in the nursing diagnosis
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Wrong: Poor Home Maintenance related to laziness Correction: Write the diagnosis without value judgments; avoid words such as poor, inadequate, abnormal, unhealthy. Right: Impaired Home Maintenance related to low value ascribed to home safety and cleanliness
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Common Errors: Including the medical diagnosis in the diagnostic statement
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Wrong: Impaired Home Maintenance related to arthritis Correction: Do not include the medical diagnosis in the nursing diagnosis statement Right: Impaired Home Maintenance related to mobility, endurance, and comfort alterations
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A Nursing Diagnosis is not a Medical diagnosis
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Example: Diabetes mellitus Although there is nursing care associated with medical illnesses, the illness is not primarily amenable to nursing intervention. Nursing's concern is the person who has the illness and the effect of the illness on human functioning.
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A Nursing Diagnosis is not a Medical pathology
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Example: Hypoglycemia Nurses need to understand the pathology underlying disease states to plan appropriate nursing care, but once again, nursing's focus is the person, not the pathology. The person's response to hypoglycemia, how hypoglycemia affects human functioning—these are the domain of nursing diagnoses.
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A Nursing Diagnosis is not Diagnostic tests, treatments, equipment
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Examples: Fasting blood glucose Insulin therapy Insulin syringe Infusion pump Nursing's concern is the person's response to the diagnostic study, treatment, or equipment. If the need for insulin therapy reveals a deficient knowledge or self-care deficit, this becomes the nursing diagnosis, not insulin therapy in and of itself.
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Nursing Diagnoses are not Therapeutic Patient Needs
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Examples: Needs to learn the relation among diet, exercise, and insulin The diagnosis should be written as a patient health problem rather than a patient need. Example: Impaired Health Maintenance (Diabetic Care) related to lack of knowledge of relation among diet, exercise, and insulin.
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Nursing Diagnoses are not Therapeutic nursing goals
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Example: To develop therapeutic diabetic self-care behaviors The diagnosis should be written from the patient perspective rather than the nursing perspective and phrased as a patient health problem. Example: Self-Care Deficit: Diabetic Self-Care Behaviors, related to decreased value on life and decreased motivation to learn.
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Nursing Diagnsoses are not a single sign or symptom
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Example: After successfully administering own insulin for 3 days, patient tells nurse, "You give me my shot today." A nursing diagnosis is not developed until a pattern or cluster of significant cues is detected. The signs and symptoms lead to the identification of the problem statement but are not the problem statement. In this situation, no nursing diagnosis is indicated until further data collection, interpretation, and analysis take place.
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A Nursing Diagnosis is not an unvalidated nursing inference
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Noncompliance related to depression This is a premature nursing diagnosis that may not accurately reflect a patient problem. More data and the validation of the tentative nursing diagnosis (nursing inference) are needed before the diagnosis can be recorded.
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Questions to validate a tentative Nursing Diagnosis
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1.) Is my patient database (assessment data) sufficient, accurate, and supported by nursing research? 2.) Does my synthesis of data (significant cues) demonstrate the existence of a pattern? 3.) Are the subjective and objective data I used to determine the existence of a pattern characteristic of the health problem I defined? 4.) Is my tentative nursing diagnosis based on scientific nursing knowledge and clinical expertise? 5.) Is my tentative nursing diagnosis able to be prevented, reduced, or resolved by independent nursing action? 6.) Is my degree of confidence above 50% that other qualified practitioners would formulate the same nursing diagnosis based on my data?
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Common Sources that lead to Misdiagnosis
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1.) Premature diagnoses based on an incomplete database: For example—A diagnosis of Defensive Coping is made after the patient verbally attacks one nurse who was attempting to teach him self-care for his wound. 2.) Erroneous diagnoses resulting from an inaccurate database or a faulty data analysis: For example—A diagnosis of Dysfunctional Grieving is made in a patient observed crying after learning that her cancer had returned, before anyone had time to evaluate whether this was simply an appropriate response to bad news. 3.) Routine diagnoses resulting from the nurse's failure to tailor data collection and analysis to the unique needs of the patient: For example—A diagnosis of Deficient 4.) Knowledge is made in a diabetic patient who is frequently hospitalized with diabetes-related complications, when she actually has excellent knowledge of diabetes and related self-care demands, but has lacked the motivation to care for herself appropriately. 5.) Errors of omission: Failure to modify diagnoses and to identify new diagnoses as the patient's status changes may also be problematic. Failures in diagnosis lead to failures in nursing care.
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Examples of nursing diagnoses that often are misused in labeling cultural deviations as abnormal
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Impaired Verbal Communication, Impaired Social Interaction, and Noncompliance.
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Criticisms of Nursing Diagnoses
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• Nursing diagnoses apply limits to nursing practice. • Nursing diagnoses discourage innovative thinking. • Nursing diagnoses focus on negative client factors. • Nursing diagnoses promote a paternalistic attitude from health care providers. Nursing diagnoses deny the validity of cultural and health care beliefs and practices that are different from those of the nurse
