Medical diagnosis

The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history and the results of diagnostic tests and procedures.

Nursing Diagnosis

(2nd step of the nursing process) 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. Ex: acute pain, nausea

Collaborative problem

Actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status.

NANDA-I

North American Nursing Diagnosis Association International- Known for its identification of over 80 nursing diagnoses.

ANA's paper Scope of Nursing Practice

Defined nursing as the diagnosis and treatment of human responses to health and illness, helped strengthened the definition of nursing diagnosis. Most state Nurse practice acts include nursing diagnosis as part of the domain of nursing practice.

The purpose of using a standard formal nursing diagnostic statement.

-Provides a precise definition of a patient's problem that gives nurses and other members of the health care team a common language for understanding the patient's needs.
-Allows nurses to communicate what they do among themselves with other health care professionals and the public.
-Distinguishes the nurse's role from that of the physician or other health care provider.
-Helps nurses focus on the scope of nursing practice.
-Fosters the development of nursing knowledge.
-Promotes creation of practice guidelines that reflect the essence of nursing.

Diagnostic process

The diagnostic process is a clinical judgement that involves reviewing assessment information, and identifying the patient's specific health care problems.

Nursing diagnostic process

-One purpose of nursing diagnosis is that it provides a precise definition of a patient's problem that gives nurses and other members of the health care team a common language for understanding the patient's needs.

-The nursing diagnosis process includes:

1. data clustering, 2. identifying patient needs or problems, and3. formulating the nursing diagnosis or collaborative problem.
1. Data clustering 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.

-Defining characteristics

The clinical criteria that are observable and verifiable.

-Clinical criteria

An objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion.

2. Interpretation-Identifying health problems

Analyze clusters of data
Interpret the information
Select the appropriate nursing diagnosis
-When interpreting data to form a diagnosis, remember that the absence of certain defining characteristics suggests that you reject a diagnosis under consideration.

3. Formulating a nursing diagnosis

To individualize a nursing diagnosis, you identify the associated related factor.
Related factor- A condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis. It allows you to individualize a nursing diagnosis for the specific patient.

Nursing diagnosis

-Provides the basis for selection of nursing interventions to achieve outcomes for which you, as a nurse, are accountable.
-Focuses on a patient's actual or potential response to a health problem rather than on the physiological event, complication, or disease.

Types of Nursing diagnosis

1. Actual nursing diagnosis- currently exists
2. Risk nursing diagnosis- (Potential) that may develop
3. Health promotion nursing diagnosis-

1. Actual nursing diagnosis

Describes human responses to health conditions or life processes that exist in an individual, family, or community. Defining characteristics support the diagnostic judgement.
Ex: Acute pain, wandering, impaired social interaction

2. Risk nursing diagnosis

(potential) Describes human responses to health conditions, or life processes that may develop in a vulnerable individual, family, or community.
These diagnoses do not have related factors or defining characteristics because they have not occurred yet. Instead a risk diagnosis has risk factors.
Ex: Risk for loneliness, Risk for acute confusion

-Risk factors

Environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.

3. Health promotion nursing diagnosis

A clinical judgement of a person's, family's, or community's 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.
Ex: Readiness for enhanced family coping, readiness for enhanced nutrition

Components of a Nursing diagnosis

When communicating a nursing diagnosis, it is important to use the language adopted within an agency.
-Most settings use a two-part format in labeling a nursing diagnosis: the NANDA-I diagnostic label followed by a statement of a related factor.
-Some agencies prefer a three-part nursing diagnostic label. NANDA-I label, the related factor, and the defining characteristics (PES)

-Diagnostic label

The name of the nursing diagnosis as approved by NANDA-I. It describes the essence of a patient's response to health conditions in as few words as possible.

-Related factor

Identified from the patient's assessment data and is the reason the patient is displaying the nursing diagnosis. Associated with a patient's actual or potential response to the health problem and can change by using specific nursing interventions.

Etiology

(aka related factor) of a nursing diagnosis is always with in the domain of nursing practice and a condition that responds to nursing interventions.

PES Format

3-part labeling
P (problem) - NANDA-I label
E (etiology) - Related factor
S (symptoms or defining characteristics)

The purpose of concept mapping a nursing diagnosis

Concept mapping a nursing diagnosis is a way to graphically represent the connections among concepts (nursing diagnosis) and ideas that are related to a central subject (patient's problems).

Sources of diagnostic errors

Errors may occur in the nursing diagnostic process during data collection, interpretation, clustering, and labeling of the diagnosis.

-Errors in Data Collection

*Lack of knowledge or skill
*Inaccurate data
* Missing data
* Disorganization

-Errors in Interpretation and Analysis of Data

* Inaccurate interpretation of cues
* Failure to consider conflicting cues
* Using an insufficient number of cues
*Using unreliable or invalid cues
* Failure to consider cultural influences or developmental stage.
Review data to validate that measurable, objective findings support subjective data.

-Errors in Data Clustering

* Insufficient cluster of cues
* Premature or early closure
* Incorrect clustering- occurs when you try to make a nursing diagnosis fit the signs and symptoms obtained.

Errors in the Diagnostic Statement/ Labeling

* Wrong diagnostic label selected
* Evidence that another diagnosis is more likely.
* Condition a collaborative problem.
* Failure to validate nursing diagnosis with patient.
* Failure to seek guidance

Guidelines to reduce errors when formulating the diagnostic statement

1. Identify the patient's response, not the medical diagnosis.
2. Identify a NANDA-I diagnostic statement rather than the symptom.
3. Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention.
4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself.
5. Identify the patient response to the equipment rather than the equipment itself.
6. Identify the patient's problems rather than your problems with nursing care.
7. Identify the patient problem rather than the nursing intervention.
8. Identify the patient problem rather than the goal of care.
9. Make professional rather than prejudicial judgments.
10. Avoid legally inadvisable statements.
11. . Identify the problem and its cause to avoid a circular statement.
12. . Identify only one patient problem in the diagnostic statement.

How would you document a patient's nursing diagnosis

Enter the nursing diagnosis either on a written plan of care or in the electronic health information record of the agency. List chronologically, placing the highest-priority nursing diagnosis first.
Date a nursing diagnosis at the time of entry.
Review the list and reevaluate the priority.