Nursing Diagnosis Assessment

Assessment - Nursing Diagnosis

• Nurses make ongoing assessments throughout the nursing process.
• The assessment step establishes a database.
• Nursing history details patient health status, strengths, problems, risks, and need for care.
• A nursing physical examination may be conducted to gather data.
• Assess priorities based on patient condition and assessment purpose.

Types of Nursing Assessments

• First Assessment: Conducted after admission to a healthcare agency or service. Its purpose is to build a complete database for care planning. Data is collected on patient health and identified priorities for future assessments.

• Focused Assessment: Concentrates on a specific problem already identified. Helpful questions include those about the symptom(s), when they started, and what makes them better or worse. A focused assessment is regularly used to monitor changes in ongoing data collection and to recognize new or overlooked problems

• Emergency Assessment: Performed during a physiological or psychological crisis to identify life-threatening problems. Examples include choking, bleeding, or a patient in critical condition. Requires prompt action.

4- Time-Lapsed Assessment

• This assessment is scheduled to compare a patient's current status to baseline data collected earlier. A common example is taking vital signs every 4 hours.

Data Collection

• Data is collected to inform the assessment effectively.
• Structuring data collection is necessary for systematic organization.
• Guidelines facilitate effective patient focus during assessment.
• The Gordon's functional health patterns framework categorizes patient data.
• Maslow's hierarchy of five human needs provides another framework.

Types of Data: Subjective and Objective

• Subjective Data: Information perceived only by the affected person (e.g., feelings of nervousness, nausea, chills, pain).
• Objective Data: Observable and measurable data that can be seen, heard, or felt by someone else (e.g., elevated temperature, moist skin, refusal to eat).

Data Collection - Characteristics of Data

• Purposeful: The nurse decides the assessment approach (comprehensive, focused, emergency, time-lapsed) and plans accordingly.
• Complete: Collect all relevant data to understand the patient's health problems. consider if the weight loss is intentional or unintentional, and if there are related causes like eating or exercise changes or other health conditions.
• Factual and Accurate: Describe behavior precisely (e.g., "patient lies with face to the wall", rather than "patient is depressed").

Sources of Data

• Patient: Primary source; communication vital for appropriate care
• Family and Significant Others: Valuable information about the patient.
• Patient Record: Records compiled by various healthcare providers, helpful for understanding the patient's history and ongoing care.

Patient Record

• Includes medical history, physical examination, and progress notes.
• Includes reports of tests, therapies, consultations, and other observations by staff, helping to determine a treatment plan.

Nursing and Other Healthcare Literature

• Consulting relevant nursing and related literature enhances patient understanding.
• If the patient's issue is unfamiliar, thorough background knowledge ensures appropriate care.

Methods of Data Collection

• Nursing History: Collected as soon as possible after the patient presents for care. Identifies strengths, weaknesses, health risks (e.g., heredity, environment), and problems.
• Patient Interview: Planned communication; good interviewing skills are needed to establish a strong working partnership with the patient.
• Nursing Physical Assessment: Examination of the patient for objective data. Helps to define the patient's condition for care planning

Data Reporting and Recording

• Share collected data with other healthcare professionals.
• Important to report any critical changes in the patient's condition.
• Document the database on the designated forms on the date of admission.

Diagnosing

• Involves a continuous process of gathering and analyzing data of the patient's problem.

History of Nursing Diagnoses

• The first nursing diagnoses were identified in the 1950s, with a significant expansion in diagnoses in 1973
• NANDA-I is a leading organization in further developing nursing diagnoses.

Nursing Diagnosis vs Medical Diagnosis

• Medical diagnoses identify diseases.
• Nursing diagnoses focus on patient responses to health issues.

Data Interpretation and Analysis

• Experienced nurses analyze collected data promptly.
• "Cues" represent significant data influencing analysis.
• Significant data should raise concern for the nurse.

Recognizing Significant Data

• Sort healthy responses from unhealthy ones; be clear on what is normal for that patient's specific circumstances.
• Establish patient-specific norms.

Recognizing Patterns

• Nursing diagnoses should come from clusters of significant data, not just one single datum.

Identifying Strengths and Problems

• Identify patient strengths & how they affect well-being and illness.
• Define the problems the patient is likely experiencing (or is at risk of experiencing).

Identifying Potential Complications

• Observe for any developments that pose serious problems connected to the patient's current diagnosis and/or current plan of care.
• Consider possible complications from medication, prior procedures and/or current treatments, as well as interactions with other illnesses or treatments

Reaching Conclusions

• After comprehensively analyzing the data, the nurse concludes from four potential options: no problem; possible problem; actual or potential nursing diagnosis; or clinical problem aside from nursing diagnosis

Formulating and Validating Nursing Diagnoses

• NANDA defines five types of nursing diagnoses: actual, risk, possible, wellness, and syndrome.

Possible Nursing Diagnoses

• These diagnoses describe a suspected problem when more data are needed.

Syndrome Nursing Diagnoses

• A collection of diagnoses predicted to arise from a particular event or situation.

Writing Nursing Diagnoses

• Explain the problem clearly and concisely.
• Use quantifiers or descriptors to delineate problem specifics.

Etiology of Nursing Diagnoses

• Identify factors that contribute to the problem, whether as a cause or other contributing factor
• Accurate identification is necessary for appropriate interventions.

Defining Characteristics (Nursing Diagnoses)

• Subjective and objective data that clearly identify the presence of a problem, whether actual or potential

Nursing Diagnosis: A Critique

• Nurses often manage a complex caseload of patients requiring individualized care

Planning Nursing Care

• Outcome identification & planning is the third phase of the system.

Unique Focus of Nursing Outcome Identification and Planning

• Care plans are designed to prevent, reduce, or resolve health problems.

Identifying and Writing Outcomes

• Using established standards for creating relevant outcome-based plans.
• Identify measurable outcomes.

Identifying Nursing Interventions

• Interventions to help patients meet their outcomes.
• Types of interventions (nurse-initiated, physician-initiated, collaborative)

Nurse-Initiated Interventions

• Interventions under the nurse's authority.
• Focus on monitoring health, reducing risks, resolving, preventing or managing problems.
• Promoting self care, well being, etc

Physician-Initiated Interventions

• Interventions initiated by the physician, but carried out by the nurse.

Collaborative Interventions

• Interventions performed by the nursing team, multiple members of the health team.

Student Plans of Care

• Formats can vary across different nursing programs or institutions.
• Aims to assist nursing students in mastering the nursing process's five steps.

Implementing the Plan of Care

• Nurse actions are carried out as part of the plan.

Implementing the Plan of Care—Determining The Patient's Need

• Reassess the patient and review the plan of care.

Organizing Resources

• Ensures patient is prepared/visitors aware
• Determine if the nurse or other party should carry out the intervention.
• Ensure necessary tools/equipment is readily available.
• Evaluate the environment needed to meet the patient's privacy, dignity and safety needs

Implementing the Plan of Care—Promoting Self-Care

• Important plan to promote patient's self care skills and enhance independence

Implementing the Plan of Care—Assisting Patients to Meet Health Outcomes

• Nurse Variables: Expertise, creativity, time and willingness
• Resource Variables: Adequate personnel, equipment, supplies
• Research findings: The current research in the field.
• Ethical and legal Considerations: Nurses should be familiar with their professional codes and laws to ensure they operate ethically and legally.

Continuing Data Collection and Risk Management

• Ongoing data collection is necessary to determine if the interventions are effective.
• Monitoring patient responses is critical in managing risk.

When a Patient Does Not Cooperate with the Plan of Care

• Reasons for non-compliance, including a lack of support, understanding or ability to afford treatment, are frequently encountered
• Nurses should understand these reasons and communicate appropriately.

Evaluating

• Evaluate to determine success, based on patient responses.
• If successful, the plan of care is terminated
• If not met, the plan of care needs revision/modification.

Types of Outcomes

• Evaluate different outcome types (cognitive, psychomotor, affective, and physiologic)
• Evaluation methods differ depending on the outcome type (e.g., asking questions for cognitive).

Time Criteria

• Use of appropriate time-based considerations during the evaluation and determining intervention effectiveness.

Documenting Judgment

• The nurse documents the met, partially met, or unmet statuses of the patient outcomes.

Modifying the Plan of Care

• Modifying the plan of care when the outcomes have not been met, based on factors affecting achievement.