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what is diagnosis
- 2nd step in nursing process
- phase in which I analyze assessment data
- using critical thinking skills-> identify patterns
- draw conclusions, strengths, problems, factors
involve patient in patient an d family
- diagnostic reasoning can start in assessment
- (e.g. renal failure-> imbalanced fluid volume?-> more data)
critical phase because it links assessment with all following actions
accuracy essential as it is the basis for planning client centered goals and interventions
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Which are the actions/steps in nursing diagnosis ?
- analyze and interpret data
- draw conclusions
- verify conclusions
- write diagnostic statement
- prioritize the problems
formal diagnostic statement of client's health status -> problem + etiology (factors contributing to the problem)-> create complete diagnostic statement
describes client's current health status
list of standardized terms (labels) used to write diagnostic statements- > problem labels , add etiology in order to create complete diagnostic statement
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history of nursing diagnosis
term "nursing diagnosis" was first used in 1953 to differentiate nursing from medicine (client's needs for nursing rather than for medical care)
1960 schools begin to teach nursing diagnosis
1973 developing of language to describe health problems treated by nurses
ANA included nurses diagnosis as one of the expectations of professional nurses
1980 nursing diagnosis as an exclusive responsibility of registered nurses (= analysis)
formal list of nursing diagnostic labels=health problems that can be addressed by independent nursing actions
2002 NANDA becomes NANDA-I = North American Nursing Diagnosis Association -> review and refine nursing diagnostic labels
- - approved for clinical use + further study
- - not finished product, only partially substantiated by research
- -encouragement to submit new aand revised diagnosis
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diagnosis (terminology)
- 2nd phase of nursing process
- reasoning process -> identify patient problems and strengths
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nursing diagnosis (terminology)
- end product of diagnostic reasoning process
- full diagnostic statement
- contains both: problem and etiology
standardized problem label by NANDA-I taxonomy
e.g nursing diagnosis: Fluid Excess Volume (label) secondary to renal failure
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what is a health problem?
any condition that requires intervention to promote wellness/ prevent / treat disease or illness
after identification-> decision how to treat it (independently or collaborative)-> nursing diagnosis/ medical diagnosis/ collaborative problem?
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nursing diagnosis
- clinical judgement about individual, family, community,...
- focuses on individual, human response (reaction) which nurse can identify/prevent/treat independently
- holistic view
- done by professional nurse
- treatment ordered by professional nurse
- problem status can be actual, potential or possible
- to treat/ prevent problem, relieve symptoms
e.g. Ineffective Denial related to difficulty coping with new diagnosis of "heart attack"
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medical diagnosis
disease, illness, injury or condition validated by signs and symptoms
focus on disease/pathology/ medical treatments
- describes illness/ injury
- diagnosed by physicians, advanced practice nurse, physician's assistants
- treatment ordere by physicians,..
- problem status is actual or possible (rule out)
carry out medical treatment, monitoring of improvement or worsening
e.g. myocardial infarction
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collaborative problem
certain potential physiological complications that are always associated with a disease/test/ treatment
focus on pathophysiology (complications caused by disease process)
not holistic, describes only physiological complications
diagnosed by nurses
ordered by physician or nurse
problem status always potential (if developed then it is medical)
monitor for development, preventive interventions
e.g. Potential Complication of myocardial infarction: congestive heart failure
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actual nursing diagnosis
a problem response that exists at the time of assessment
cues = signs or symptoms that are present
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risk nursing diagnosis
a problem response that is likely to develop if there is no intervention
risk factors,
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possible nursing diagnosis
intuition and experience -> suspect that a diagnosis is present, but enough data to support diagnosis -> alert other nurses, continue to collect data
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syndrome nursing diagnosis
several related problems are present
usually does not need an etiology
collection of nursing diagnoses that usually occur together
e.g. Disuse Syndrom -> represents all complications that can occur as a result of immobility (pressure ulcer, thrombosis, constipation, stasis of pulmonary secretion, body image disturbance)
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wellness nursing diagnosis
use when individual/ group/ community is in transition from one level of wellness to a higher level of wellness
client's present level of wellness is effective
client wants to move to a higher level
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What is diagnostic reasoning/analysis ?
enables to see the sense out of the data that were assessed
- use critical thinking to
- analyze and interpret data
- draw conclusions
- verify problems
- prioritize problems with patient
- record diagnostic statement
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Analyze and interpret data
- identify significant data
- cluster cues
- identify data gaps and inconsistencies
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identify significant data/ cues
data that influence conclusions about client's health status
cues can alert to look for other cues
cue is an unhealthy response
draw in theoretical knowledge and compare standards to assessment findings
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cluster cues
cluster cues that are related to each other some how-> may suggest a health problem, helps to ensure accuracy (rather than from a single cue),
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the following may indicate cues
- a deviation from population norm
- changes in usual patterns,
- indications of delayed growth and development
- changes is usual behaviors or relationships
- nonproductive and dysfunctional behavior
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draw conclusions about health status
- patient's strength
- no problem or wellness diagnosis
- possible problem- cues that suggest a problem but more cues are needed
- actual nursing diagnosis -> conclusion of problem that nurse can treat... independently
- risk/ potential nursing diagnosis-> cluster of risk factors that make nursing intervention necessary
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make inferences
- = judgements/ interpretations that are based on the data
- not a fact as it cannot directly be checked for accuracy
- you can't be absolutely certain
- think about more or less accurate (not right or wrong)
strive to make diagnostic statement as accurate as possible
incorrect-> ineffective care
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identify problem etiologies
consists of the factors that are causing or contributing to the problem
may be pathophysiological, treatment related, situational, social, spiritual, ...
e.g. constipation related to inadequate intake of dietary fiber
-> suggests to eat more fiber
- is etiology incomplete ? -> use theoretical knowledge and patient data
- are the cues causing the problem or are they symptoms of the problem
- an etiology is always an inference
- often certain that etiological factors are present
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verify problems with the patien
the patient's interpretations might differ
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prioritize problems
often more than one problem-> order of importance (see theoretical framework)->many use maslow's hierarchy of needs to give order
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problem urgency
ranking the problems according to the degree of threat/ immediacy treatment is needed
high priority : life threatening/ destructive effect on client (e.g. substance abuse)
medium priority: no direct threat to lifem but may cause destructive physical or emotional changes (e.g.Ineffective denial, Unilateral Neglect)
low priority: proplems that require minimal supportive nursing intervention (e.g. Risk for Delayed Delvelopment, Interrupted Breastfeeding, mild Anxiety)
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Future Consequences
- also consider the possible future consequences
- e.g. Ineffective Denial may lead to further problems with his treatment plan-> possible to assign high priority to this -> address it before teaching (Deficient Knowledge)
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Patient Preference
- give high priority to problems that patients think are important (if not in conflict to survival needs...),
- -> clients cooperate better
- -> might be more motivated
- (e.g. pain medication)
but also explain the importance of nurse priorities-> often patients come to agree with them
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documenting priorities
- -usually prioritized when documenting problems
- designate as high, medium, low
- ranking from highest to lowest
-> risk problems can have a higher priority than actual problems
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computer assissted diagnosing
- some systems allow to enter assessment data and the computer will generate a list of possible problems
- -> choose a problem label
- ->screen with definition, defining characters to compare to actual data
- -> accept diagnostic label-> choose etiologies
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Why reflecting critically on diagnostic reasoning?
- inaccurate diagnosis -> ineffective or even harmful
- complex and vulnerable to error
- implementation of electronic health records
- -> evaluate prioritized list for accuracy
- -> apply critical thinking to theoretical and self knowledge , patient data and situation
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think about your theoretical knowledge
- the better knowledge base the better the diagnostic reasoning
- -> diagnosis based on sound knowledge?
- -> do I have knowledge about defining characteristics associated with various nursing diagnoses
- -> interpreted data correctly?
- problem type correct?nursing interventions only?
- ->am I qualified to make this diagnosis, or shoul I ask for consultation
- knowledge to
- identify cues and patterns
- assoviate patterns to correct problem
- gives confidence in ability to reason
- keeps from reying to much on authorities
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think about self knowledge:
bias and stereotyping
- beliefs, values, experiences affect thinking
- bias-> slant judgement based on personal opinion or unfounded beliefs
- stereotypes->judgement and expectation based on belief about a group (e.g. men are unemotional)
- referring to a patient referring to their diagnosis or developmental group is a form of stereotyping (" the broken hip in 288")
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think about self knowledge: past experience
- did I rely too much on my past experience?
- -> is like stereotyping as conclusion based upon similar situations/ people...
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think about self knowledge: did I rely too much on the client's medical diagnosis/ setting/ what others say instead of on the data?
- medical diagnosis and statements from others can help to find possible explanations, but
- - can bias thinking
- -prevent from gathering own data
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think about your analysis and conclusions
- how was nursing process used?
- data was correct, patient's problems identified correctly, logically linked to etiologies
review interaction with patient, does diagnostic statements reflect his perception and priorities
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which step comes after diagnostic reasoning process?
record the strengths and problem statements:
select correct standardized problem labels and writing the diagnostic statements
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How are diagnostic statements written?
- standardized nursing languages -> terms carefully defined/ mean the same to all who use them
- to bring clarity to communication about nursing knowledge and nursing thinking
- -support electronic health records
- -define, communicate and expend nursing knowledge
- increase visibility of nursing intervention
- improve patient care
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What is taxonomy?
- system for classifying ideas or objects based on characteristics they have in common
- e.g. medication are classified in various ways
- -international classification of disease: names diseases
current procefural terminology (CPT) : used for reimbursement of physician services
NANDA-I
Clinical Care Classification (CCC): like NANDA-I for home health use but can be used in any setting
Omaha system : primarily used for community health use
Perioperative Nursing data set (PNDS): for use in perioperative nursing only, 64 nursing diagnoses, + interventions and outcomes (first nursing language)
- international classification for nursing practice (ICNP)
- diagnoses, outcomes, nursing actions- various clinical settings worldwide
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NANDA-I Taxonomy of diagnostic terminology
13 domains: area if activity, study, interest (e.g. healthpromotion, nutrition,...)
47 classes: subdivision of domain (e.g. digestion a class under nutrition)
-developed by nurses of all areas
-> diagnostic labels can be used in any setting or specialty
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Components of a NANDA-I Nursing Diagnosis
label, definition, defining characteristics, related or risk factors
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diagnostic label/ title/ name
word or phrase that represents a pattern or related cues and describes a problem or wellness response such Disturbed Body Image or Readiness for Enhanced Nutrition
some include descriptors for time, age, other factors (e.g. acute,...)
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the definition (NANDA-I)
explains the meaning of the label and distinguishes it from similar nursing diagnoses
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defining characteristics
are the cues/ signs/ symptoms that allow to identify a problem or wellness diagnosis
cluster of defining characteristics must be present-> nurse must be sure patient has some of the defining characteristics
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related factors
are the cues, conditions, circumstances, that cause, precede, influence, contribute or are in some way associated with the problem (label)
- the list is not exhaustive
- the problem may have more than one related factor
- an individual may not have all the factors on the list
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risk factors
events, circumstances, .... that increase the vulnerability to a health problem
- risk factors function as the defining factors
- must be present to make diagnosis
e.g. risk for ... related to pregnancy and ...
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how to know which lable to use?
1. identify broad topic/ domain that seems to fit the cue cluster
2. narrow search (to class or most likely labels)
3. using a nursing diagnosis handbook, compare definitions and defining characteristics of the diagnostic labels to your cue cluster -name alone does not explain what the label stands for
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formats of diagnostic statements
- consists of
- a problem
- an etiology
- linked by a connecting phrase
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problem
describes client's health status (or response to health problem) and identifies a response that needs to be changed
includes descriptors like acute, impaired, deficient,...
write with descriptor first (sentence like spoken)
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etiology
factors that cause, contribute, create a risk for the problem
may include NANDA label, releated factors, ...
may consist of several factors
do not use medical treatment or diagnosis as an etiology-> no nursingorder can change this
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connecting phrase/ related to
to connect problem to etiology
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basic 3 part statement
PES problem etiology symptom
problem r/t etiology AEB/AMB signs or symptoms
- longer cuest can be recordet in nurses' notes
- or signs and symptoms below nursing diagnosis
cannot be used for for risk nursing diagnosis, because symptoms not present when risk diagnose
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one part statement (without etiology)
syndrome diagnosis
wellness diagnosis
very specific labels -> imply etiology or only possible etiology is a medical diagnosis (death anxiety)
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specify
label is just useful if problem is discribed more specifically
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secondary to
when defining characters are vague-> need to add 2nd part of etiology
usually a disease process
this connection words make clear that nurse is not responsible for that part of the etiology.
use it only if it adds to understanding of diagnostic statement
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collaborative problem
do not use problem + etiology
instead:
Potential Complication of illness/ treatment: e.g.Pulmonary embolism
no etiology for a collaborative problem, but student statement might use one to clarify diagnostic statement
might alert for special actions
professional nurse NO ETIOLOGY
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how does nursing diagnosis relate to outcomes and interventions
problem suggests goal: Health status that needs to be changed
etiology suggests interventions: alter the factors contributing to the problem
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Guidelines for Judging the Quality of Diagnostic Statements
1. In choosing a NANDA-I label, do not rely on the definition alone
2.Include both problem and etiology, with cause and effect stated correctly
3. Be sure that the etiology does not merely restate the problem
4. Avoid using medical diagnoses and treatments as etiological factors (if hard to do, use secondary to instead of related to)
5. write statement clearly
- 6.write the statement concisely (kurz und klar): use "complex etiology" instead of listing lots
- signs and symptoms can also be noted under notes
7 statement is descriptive and specific
- 8 state problem as a patient response -> do not use the word need
- problem is a not a goal or action
- problem is not a medical test
9. use non judgmental language
10. avoid legally questionable language
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