a clinical judgement based on information. You review info collected about a pt, see cues and patterns in the data, and identify the pts specific health care problems. Together nursing diagnoses and collaborative problems represent the range of pt conditions that require nursing care.
the identification of a disease condition based on a specific eval of physical signs, symptoms, the pts medical history, and the the results of diagnostic tests and procedures.
such as acute pain or nausea is a clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat.
an actual or potential physiological complication that nurses monitor to detect the onset of changes in a pts status. When collaborative problems develop, nurses intervene in collaboration with personnel from other health care disciplines. Nurses manage collaboration problems such as hemorrhage, infection, and paralysis using medical, nursing, and allied health interventions.
North American Nursing Diagnosis Association International (NANDA-I)
they put diagnosis into the nursing plan. before it was just assessment, planning, intervention and eval and now diagnosis makes ip the 5th component. The ANA paper scope of nursing practice which defines nursing as a diagnosis and treatment of human responses to health and illness, helped strengthen the definition of nursing diagnosis. The use of standard formal nursing diagnostic statements serves several purposes in nursing practice:
1. provides a precise definition of a pts problem that gives nurses and other members of the health care team a common language for understanding the pts needs
2. Allows nurses to communicate what they do among themselves with other health care professionals and the public
3. Distinguishes the nurses role from that of the physician or other health care provider
4. Helps nurses focus on the scope of nursing practice
5. Fosters the development of nursing knowledge
6. Promotes creation of practice guidelines that reflect the essence of nursing.
Critical thinking and the nursing diagnostic process
You need to know how to access the diagnoses definitions and interventions easily within the agency in which you work because the info is to much to remember. Sources of info about nursing diagnoses include faculty, advanced practice nurses, documentation settings, and in some settings practices and protocol. Experience also plays a role in becoming adept at nursing diagnosis. The diagnostic reasoning process involves using the assessment data you gather about a pt to logically explain a clinical judgement, in this case a nursing diagnosis. These steps include data clustering, identifying pt health problems, and formulating the diagnosis.
a set of signs or symptoms gathered during assessment that you group together in a logical way. Data clusters are patterns of data that contain DEFINING CHARACTERISTICS which is the critical criteria that are observable and verifiable. Each CLINICAL CRITERiON is an objective or subjective sign, symptom, or risk factor that when analyzed with other criteria, leads to a diagnostic conclusion. Working with similar pts over a period of time helps you recognize clusters of defining characteristics but remember that each pt is different.
Interpretation- Identifying Health Problems
usually from assessment to diagnosis you move from general info to specific. Often a pt has defining characteristics that apply to more than one diagnosis. Always examine the defining characteristics in your database carefully to support or eliminate a nursing diagnosis. To be more accurate, review all characteristics, eliminate irrelevant ones, and confirm the relevant ones.
a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis. A related factor allows you to individualize a nursing diagnosis for a specific pt.
types of nursing diagnoses
There are 3 types of nursing diagnoses: actual diagnoses, risk diagnoses, and health promotion diagnoses
Acutual nursing disgnosis
describes human responses to health conditions or life processes that exist in an individual, family, or community. defining characteristics support the diagnostic judgement. The selection of an actual diagnosis indicates that there are sufficient assessment data to establish the nuraing diagnosis. EX. of actual diagnoses include: stress urinary incontinence, acute pain, wandering, and impaired social interaction.
risk nursing diagnosis
describes human resources to health conditions of life processes that may develop in a vulnerable individual, family, or community. these diagnoses do not have defining characteristics or related factora because they have not occured yet. Has tisk factors. Risk factora are envirnomental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem. EX: open incision site has risk for hospital acquired infection. The risk factors help in planning preventive health care measures. ex: risk for loneliness and risk for acute confusion.
health promotion nursing diagnosis
a clinical judgement of a persons, familys, or communitys motivation, desire, and readiness to increase well being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise. Health promotion diagnoses can be used in any health state and do not require current levels of wellness. A persons readiness is supported by defining characteristics. EX: readiness for enhanced nutrition and readiness for enhanced family coping.
Components of a nursing diagnosis
it is important to use the language adopted within an agency. Most settings use a 2 part format in labeling a nursing diagnosis: the NANDA-I diagnostic label followed by a statememt of a related factor. The two part format provides a diagnosis meaning and televance for a particular pt.
Examples of NANDA international two part nursing diagnosis format:
1. Acute Pain: Biological, chemical, physical, or psychological injury agents (inflammation, edema, burn)
2. Anxiety: change (economic status, environment, health status, role) familial association, stress, threat of death
3. Impaired urinary elimination: anatomical obstruction, UTI, sensory motor impairment
4. impaired skin integrity: fluid retention, age extreme, hypothermia, meds, physical immobilization
the name of the nursing diagnosis as approved by NANDA International. It describes the essence of a pts response to health conditions in as few words as possible. The definition describes the characteristics of the human response identified. You refer yo definitions of nursing diagnoses to assist in identifying a pts correct diagnosis, which helps especially when selecting between two diagnoses with similar defining characteristics. The diagnostic labels include descriptors used to give additional meaning to the diagnosis. EX: pt A has anxiety about an upcoming surgery and pt B has anxiety about the loss of a job.
the related factor is associated with a change by using specific nursing interventions. Related factors for NANDA-I diagnoses include four categories: pathophysiological (biological or physical), a treatment related, situational (environmental or personal), and maturational.
or related factor of a nursing diagnosis is always within the domain of nursing practice and a condition that responds to nursing interventions.
The PES format
Some agencies prefer a three part nursing diagnostic label. It consists of the NANDA-I label, the related factor, and the defining characteristics. This makes the diagnostic even more pt specific. PES stands for:
1. Problem: NANDA-I label- EX: impaired physical mobility
2. Etiology: related factor- EX: incisional pain
3. Symptoms: defining characteristics- evidence by restricted turning and positioning
PES DIAGNOSTIC STATEMENT: impaired physical mobility related to incisional pain, evidence by restricted turning and positioning.
Concept mapping nursing diagnoses
As you proceed in applying each step of the nursing process, your concept map expands with more detail about planned interventions. A concept map promotes a critical thinking because you identify, graphically display, and link key concepts by organizing and analyzing info. The advantage of a concept map is its central focus on the pt rather than the pts disease or health alteration. This encourages nursing students to concentrate on pts specific health problems and nursing diagnoses. The focus also promotes pt participation with the eventual plan of care.
Sources of diagnostic errors
Errors may occur in the nursing diagnostic process during data collection, interpretation, clustering, and labeling of the diagnosis.
Sources of Diagnostic Error:
1. Collecting: lack of knowledge or skill, inaccurate data, missing data, and disorganization
2. Interpreting: Inaccurate interpretation of cues, failure to consider conflicting cues, using an insufficient number of cues, using unreliable or invalid cues, and failure to consider cultural influences or developmental stage
3. Clustering: Insufficient cluster of cues, premature or early closure, and incorrect clustering
4. Labeling: wrong diagnostic label selected, evidence that another diagnosis is more likely, condition a collaborative problem, failure to validate nursing diagnosis with pt, and failure to seek guidance.
errors in data clustering
occur when data are clustered prematurely, incorrectly, or not at all. Also if you make the diagnosis before clustering all the data together.
Documentation and Informatics
Once you identify a pts nursing diagnoses, enter them either on the written plan of care or in the electronic health info record of the agency. When making the care plan, organize the diagnoses with the high priority ones first and then the remaining. The computer will cluster together the similar defining characteristics and then select diagnoses and the computer also directs the nurse to intervention options to select for a pt.