Nursing Diagnosis Concepts

• Nursing as a Science: Nursing Process is the lesson title.
• The topics covered are nursing assessment, nursing diagnosis, and planning.

Learning Outcomes

• Types of assessments and data are described.
• Patient-centered interviews and techniques are explained.
• The components of a nursing history are described.
• The steps of the nursing diagnostic process are described.
• The differences among health promotion, problem-focused, and risk nursing diagnoses are described.
• Sources of diagnostic errors are described.
• The relationship of assessing planning and nursing diagnoses is explained.
• Criteria used in priority setting is discussed.
• The difference between a goal and an expected outcome is discussed.
• Explain the SMART and correctly write an outcome for a goal of care are described.
• A plan of care from a nursing assessment is developed.
• The process of selecting nursing interventions during planning is discussed.
• The consultation process is described.

The Nursing Process

• Nurses use critical thinking to apply the best available evidence for caregiving, promoting human functions, and addressing responses to health and illness.
• The nursing assessment helps nurses define patient problems, which then helps with planning and implementing nursing interventions and evaluating outcomes.
• The nursing process is standard of practice, which protects nurses against legal issues if followed correctly.
• The nursing process is essential to provide timely and appropriate patient care.
• Assessment consists of gathering and analyzing information about a patient's health status, then clinical judgments are made to identify the patient's response to health problems in the form of nursing diagnoses.
• Planning includes setting goals, expected outcomes, and choosing nursing and collaborative interventions tailored to the patient's nursing diagnoses.
• Implementation involves performing the planned interventions, and evaluation determines their effectiveness based on the patient's response.
• The steps can be repeated and are dynamic.

Nursing Assessment

• Assessment involves collecting and interpreting information from the patient and secondary sources to form a database.
• Two stages include collecting/verifying data and analyzing data.
• Sources of data include patients and/or family, the healthcare team, and medical records.
• Data from patients comes from interviews, observation, and physical examination.
• Data collection may include patient- centered interviews for health history, physicals, and periodic assessments.
• A cue is information obtained through the senses, while an inference is a judgment or the interpretation of cues.
• Subjective data includes the patient’s description of their problems, and often reflects physiological changes.
• Objective data consists of measurements of a patient’s health status based on accepted standards.
• Critical thinking standards like clarity, precision, and consistency are required when collecting objective data,
• The patient-centered interview requires motivational interviewing and effective communication and includes preparation, orientation/agenda setting, a working phase, and termination.
• Observation, open-ended questions, leading questions, back channeling, and direct closed-ended questions are all interview techniaues.

Components of the Nursing Health History

• Biographical information and patient expectations are components of the nursing health history.
• Diagnostic and lab data help to explain alterations identified from health history and physical examination.
• Assessment data must be interpreted and validated to ensure it's complete, which leads to the next step of the nursing process.
• Data is documented using clear, concise, and terminology that is appropriate so that there is a base line for care.
• Visual representations show the connections among a patient’s many health problems through concept mapping.

Nursing Diagnosis

• A nursing diagnosis involves a clinical response from an individual/community that a nurse is licensed and competent to treat and is ever evolving.
• Collaborative problems are actual and/or potential physiological complications that nurses monitor.
• Inter professional collaboration is a health care team partnership with a participatory approach for shared decision making around health issues.

History of Nursing Diagnosis

• Nursing diagnosis was were first introduced in 1950.
• In 1953 Fry proposed the formulation of a nursing diagnoses.
• The first national conference was held in 1973.
• The American Nurses Association included diagnosis in its 1980 and 1995 publications.
• In 1982, the North American Nursing Diagnosis Association (NANDA) was founded.

Types of Nursing Diagnoses

• Nursing diagnoses include problem-focused, risk, and health promotion-related.
• A data cluster comes from the signs or symptoms gathered during assessment.
• Conclusions about a patient’s response compared with standard data clusters.
• Critical to correctly select the diagnostic label, assess whether the grouped signs/symptoms are as expected for the patient, and isolate characteristics not within healthy norms.

Planning and Setting Goals

• After a medical diagnosis, a healthcare provider chooses interventions and communicates the plan to the healthcare team.
• The plan of care should be individualized and requires communication with the patient, and ongoing consultations.
• Nursing diagnoses determine nursing interventions as well as goals and outcomes.
• Classifications of priorities are High-Emergent, Intermediate-non-life-threatening, and Low-Affect (patient's future well-being).
• Priority setting requires knowing the patients needs, values and expressed needs.

Critical Thinking In Setting Goals and Expected Outcomes

• Goals should be broad statements that describe the desired change in a patient's behavior, condition or perceptions, and expected outcomes should be measurable.
• Goals are the aim, intent, or end, and outcomes must be achieved to reach for the goals.
• Patient-centered goals target the highest possible wellness/independence based on the patient's needs/abilities.
• Nursing-sensitive patient outcomes measure the patient's perception of an intervention
• NOC links outcomes to NANDA-I nursing diagnoses.
• SMART acronyms should be use to define goals and expected outcomes.

Types of Interventions

• The three types of interventions are nurse-initiated (independent), health care provider initiated (dependent), or collaborative (interdependent).
• Six factors to consider when selecting interventions are desired outcomes, the nursing diagnosis, research-based knowledge, and acceptability to the patient, the competency of the nursing staff, and feasibility.
• The NIC model includes three levels ( domains, classes, interventions) for ease of use.
• Nursing diagnoses, goals, outcomes, and interventions create a plan that enables and supports quick assessment of a patient’s situational needs.

Hand-Off Reporting

• This is when nurses transfer information that ensures continuity of quality assistance and prevents delays.
• It requires confirmed answers and clarification of the patient’s information
• Student care plans help apply knowledge gained from the nursing and medical literature, and the classroom to a practice situation
• Planning care for patients in community-based settings involves educating the patient/family about care, and guiding them to assume more of the care over time.
• Consultation with specialists is vital for planning implementing and managing therapies.

Concept Maps

• These are visual presentations that organize and categorize nursing concepts.
• This gives holistic views for more sound medical decisions.

Explore nursing diagnosis: formal recognition, diagnosis types, and cue clustering. Learn about identifying deviations and the 'related to' component in diagnosis statements.