Download - Nursing process(Diagnosis)
Diagnosing
• Activities preceding the diagnosing phase are directed toward forming the nursing diagnoses.
• All other steps flow from nursing diagnoses.
• Nurses use critical thinking skills to interpret assessment data and identify client strengths and problems.
• North American Nursing Diagnosis Association (NANDA) International Define, refine, and promote a taxonomy
of nursing diagnostic terminology• Taxonomy
Classification system or set of categories arranged based on principle(s)
Copyright © 2016, 2012, 2008Pearson Education, Inc.
All Rights ReservedKozier & Erb's Fundamentals of Nursing, Tenth EditionAudrey Berman | Shirlee Snyder | Geralyn Frandsen
Figure 12–1 Diagnosing—the pivotal second phase of the nursing process.
Diagnosis
A statement or conclusion regarding the nature of a phenomenon• Diagnostic labels
Standardized NANDA names for diagnoses
• EtiologyCausal relationship between problem and its related factors• Nursing diagnosisProblem statement consisting of diagnostic label plus etiology
• Nursing diagnosis This definition implies the following: Professional nurses responsible for
making Includes only those health states that
nurses are educated and licensed to treat Judgment made only after thorough,
systematic data collection Continuum of health states
Status of the Nursing Diagnoses
1- Actual diagnosis Problem presents at the time of
assessment. Presence of associated signs and
symptoms
2- Health promotion diagnosis Preparedness to implement behaviors to
improve their health condition Example: Readiness for Enhanced
Nutrition
3- Risk nursing diagnosis Problem does not exist. Presence of risk factors
4- Syndrome diagnosis Cluster of nursing diagnoses that have
similar interventions
Components of a NANDA Nursing Diagnosis
1- Problem (diagnostic label) and definition
Describes the client's health problem or response
May require specification Qualifiers added to give additional
meaning• Such as Deficient, Impaired, Decreased,
Ineffective, and Compromised
2- Etiology (related factors and risk factors)
Identifies one or more probable causes of the health problem
Gives direction to the required nursing therapy
Enables the nurse to individualize the client's care
3- Defining characteristics Cluster of existing signs and symptoms
indicates actual diagnosis• Clients have signs and symptoms.
Cluster of factors that cause client to be more vulnerable to a problem indicates "risk for" diagnosis
Differentiating Nursing Diagnoses from Medical Diagnoses
• Nursing diagnosis A statement of nursing judgment based on
education, experience, expertise and license to treat
Describes human response, the client's physical, sociocultural, psychological, and spiritual responses to an illness or health problem
Changes when client's responses change Independent nursing functions• Areas of health care that are unique to nursing,
separate and distinct from medical management
• Medical diagnosis physician Refers to a disease process Remains the same as long as the
disease process is present Dependent nursing functions (physician-
prescribed therapies and treatments)
Copyright © 2016, 2012, 2008Pearson Education, Inc.
All Rights ReservedKozier & Erb's Fundamentals of Nursing, Tenth EditionAudrey Berman | Shirlee Snyder | Geralyn Frandsen
Table 12–3 Comparison of Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems
The Diagnostic Process
• Critical thinking Reviewing data and considering
explanations before forming opinions• Analysis
Separation into components (deductive reasoning)
• Synthesis Putting together of parts into whole
(inductive reasoning
Copyright © 2016, 2012, 2008Pearson Education, Inc.
All Rights ReservedKozier & Erb's Fundamentals of Nursing, Tenth EditionAudrey Berman | Shirlee Snyder | Geralyn Frandsen
Figure 12–2 Decision tree for differentiating among nursing diagnoses, collaborative problems, and medical diagnoses.
Formulating Diagnostic Statements
1- Basic two-part statements Problem (P) Etiology (E) Joined by the words "related to"
2- Basic three-part statements PES format• Problem (P)• Etiology (E)• Signs and symptoms (S)
List signs and symptoms grouped by subjective and objective data
3- One-part statements Health promotion diagnoses beginning
with Readiness for Enhanced
Copyright © 2016, 2012, 2008Pearson Education, Inc.
All Rights ReservedKozier & Erb's Fundamentals of Nursing, Tenth EditionAudrey Berman | Shirlee Snyder | Geralyn Frandsen
Table 12–6 Guidelines for Writing a Nursing Diagnostic Statement
Avoiding Errors in DiagnosticReasoning
• Verify data• Build a good knowledge base and
acquire clinical experience• Have a working knowledge of what is
normal• Consult resources • Base diagnoses on patterns rather than
an isolated incident• Improve critical thinking skills