NUR1010 Nursing process: diagnosis

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NUR1010 Nursing process: diagnosis
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2014-03-03 09:48:37
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NUR1010 Nursing process diagnosis
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NUR1010, Nursing process: diagnosis
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  1. 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
  2. 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
  3. 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
  4. diagnosis (terminology)
    • 2nd phase of nursing process
    • reasoning process -> identify patient problems and strengths
  5. 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
  6. 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?
  7. 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"
  8. 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
  9. 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
  10. actual nursing diagnosis
    a problem response that exists at the time of assessment

    cues = signs or symptoms that are present
  11. risk nursing diagnosis
    a problem response that is likely to develop if there is no intervention

    risk factors,
  12. 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
  13. 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)
  14. 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
  15. 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
  16. Analyze and interpret data
    • identify significant data
    • cluster cues
    • identify data gaps and inconsistencies
  17. 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
  18. 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),
  19. 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
  20. 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
  21. 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
  22. 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
  23. verify problems with the patien
    the patient's interpretations might differ
  24. prioritize problems
    often more than one problem-> order of importance (see theoretical framework)->many use maslow's hierarchy of needs to give order
  25. 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)
  26. 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)
  27. 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
  28. 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
  29. 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
  30. 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
  31. 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
  32. 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")
  33. 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...
  34. 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
  35. 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
  36. which step comes after diagnostic reasoning process?
    record the strengths and problem statements:

    select correct standardized problem labels and writing the diagnostic statements
  37. 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
  38. 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
  39. 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
  40. Components of a NANDA-I Nursing Diagnosis
    label, definition, defining characteristics, related or risk factors
  41. 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,...)
  42. the definition (NANDA-I)
    explains the meaning of the label and distinguishes it from similar nursing diagnoses
  43. 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
  44. 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
  45. 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 ...
  46. 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
  47. formats of diagnostic statements
    • consists of
    • a problem
    • an etiology
    • linked by a connecting phrase
  48. 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)
  49. 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
  50. connecting phrase/ related to
    to connect problem to etiology
  51. 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
  52. one part statement (without etiology)
    syndrome diagnosis

    wellness diagnosis

    very specific labels -> imply etiology or only possible etiology is a medical diagnosis (death anxiety)
  53. specify
    label is just useful if problem is discribed more specifically
  54. 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
  55. 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
  56. 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
  57. 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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