2_Diagnosing (2).ppt

Diagnosing Learning Outcomes 1. Differentiate various types of nursing diagnoses. 2. Identify the components of a nursing diagnosis. 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems. 4. Identify basic steps in the diagnostic process. 5. Descr...

Diagnosing Learning Outcomes 1. Differentiate various types of nursing diagnoses. 2. Identify the components of a nursing diagnosis. 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems. 4. Identify basic steps in the diagnostic process. 5. Describe various formats for writing nursing diagnoses. Learning Outcomes 6. Describe the characteristics of a nursing diagnosis. 7. List guidelines for writing a nursing diagnosis statement. 8. Describe the evolution of the nursing diagnosis movement, including work currently in progress. 9. List advantages of a taxonomy of nursing diagnoses. Nursing diagnosis identified and developed in 1973 because nursing role in the ambulatory nursing setting needed to be identified In 1977 the international recognition of the nursing diagnosis is occurred In 1982 the name North American Nursing Diagnosis Association (NANDA) was accepted Purpose of it: to define, refine and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses The Nursing Process Nursing Diagnosis (According to NANDA) define as:  Clinical Judgment or conclusion about individual, family, or community response to actual or potential health problem  standardized NANDA names for the diagnosis (diagnostic label or patient problem statement) Nursing diagnosis compose of diagnostic label and etiology NANDA – North American Nursing Diagnosis Association Identifies nursing functions Creates classification system Establishes diagnostic labels  Status of the Nursing Diagnoses Actual Diagnosis ◦ Problem presents at the time of the assessment ◦ Based on presence of associated signs and symptoms Risk Diagnosis ◦ Problem does not exist  Presence of risk factors indicate that the problem is likely to develop unless nursing intervene  Types of Nursing Diagnoses Healthpromotion diagnosis relates to clients’ preparedness to implement behaviors to improve their health condition. These diagnosis labels begin with the phrase Readiness for Enhanced,as in Readiness for Enhanced Nutrition. Syndrome Diagnosis Describe a cluster of nursing diagnoses  that have similar interventions  Components of a Nursing Diagnosis Problem statement (diagnostic label) and definition ◦ Describes the client’s health problem or response ◦ Describe the client health status clearly and concisely ◦ Need to be specific ◦ Need qualifiers (words have been added to some NANDA label to give additional meaning) as: * Deficient: inadequate in amount, quality or degree, not sufficient * Impaired: weakened, damaged *Decreased: less in size, amount or degree * Ineffective: not producing the desired effect *compromised: to make vulnerable to threat. Components of a Nursing Diagnosis Etiology (related factors and risk factors) ◦Identifies one or more probable causes of the health problem ◦Possible causes should be differentiated because each may require different nursing intervention Components of a Nursing Diagnosis Defining characteristics ◦ Cluster of signs and symptoms indicating the presence of a particular diagnostic label (actual diagnoses) ◦ Factors that cause the client to be more vulnerable to the problem (risk diagnoses) Nursing and Medical Diagnosis, and Collaborative Problems Differences Based on ◦ Description ◦ Orientation ◦ Responsibility for diagnosing ◦ Treatment orders ◦ Nursing focus ◦ Nursing actions ◦ Duration ◦ Classification system  Nursing Diagnoses Statements of nursing judgment for a condition that the nurse are licensed to Rx Describes human responses to disease processes/health problems Oriented to the client Nurse responsible for diagnosing, treatment orders, actions May change frequently Classification system in development  Medical Diagnoses Describes disease and pathology Does not consider human responses Oriented to pathology Physician responsible for diagnosing and treatment orders Nurse implements orders and monitors client status Nursing actions dependent Diagnosis remains as long as disease present Well-developed and accepted classification Collaborative Problems Potential problem that nurses manage using independent and physician-prescribed intervention Involve human response mainly to Physiologic complications of disease, tests, treatments Oriented to pathophysiology Nurse and physician diagnose Physician orders definitive treatment Independent nursing action for monitoring and preventing Collaborative Problems Dependent nursing actions for treatment Present when disease/situation present No classification system Ex: Potetial complication of pneumonia: plural effusion, ,respiratory failure,atelecatsis Nursing Diagnosis Steps in Diagnostic Process 1. Analyzing Data ◦ Compare data against standards and norms (identifying significant cues) ◦ Cluster cues (generate hypothesis) ◦ Identify gaps and inconsistencies Compare Data: Cues considered significant if it does any of the following: 1. Point to +ve or –ve change in patient health status 2. Varies from norms of client population : the client may consider a pattern to be normal 3. Indicate development delay Cues and Inferences Cues = signs and Inference = what you think, symptoms a judgement about the cues Cues Inference Swollen finger Reddened Broken finger Painful  Cluster Cues: - Clustering: process of determining the relatedness of facts and determine whether any pattern present - Beginning of synthesis - Involve making inferences about data - May be deductive (start with a framework and cluster data into appropriate categories)or inductive (combining data from different assessment areas to form a pattern) approach Identify gaps and inconsistencies: - It should include final check up to ensure that data complete and correct - Source of conflict: measurement error, unreliable report - Data can be found in nursing assessment, patient history  Clustering according to Orem Model Air Requisite Activity & Rest Requisite Lungs clear Bed rest, full passive ROM RR 18 labored P.T.daily, Reddened skin O2, Chest X-ray shows on ankle & elbow, 40 degree pneumonia contracture on left leg, atrophy nonproductive cough of muscles Respiratory Problem Possible Skin Problem   Ineffective Airway Risk for Impaired Tissue Integrity 2. Identifying health problems, risks, and strengths: -Determine problems risks -Determine strength 3. Formulating diagnostic statements -Noncompliance (specify)  Writing Nursing Diagnoses Basic Two-Part Statement ◦ Problem (P) ◦ Etiology (E) Basic Three-Part Statement ◦ Problem (P) ◦ Etiology (E) ◦ Signs and symptoms (S)  Writing Nursing Diagnoses One-Part Statement ◦ Health promotion (readiness for enhanced) ◦ “Readiness for enhanced parenting”” readiness for enhanced heath seeking behavior” ◦ Syndrome  e.g. “Risk for disuse syndrome” is associated with clusters of diagnosis:  Impaired physical mobility, risk for impaired tissue integrity, risk for activity intolerance, risk for constipation, risk for infection…..etc Variations ◦ Unknown etiology: noncompliance to medication regimen ◦ Complex factors: low self-esteem RT complex factors ◦ Secondary: risk for impaired skin integrity RT decrease peripheral circulation secondary to diabetes ◦ Other additions for precision (descriptor addition): impaired skin integrity (left lateral ankle) RT decreased peripheral circulation Case Study Muna Ahmad is a 33-year-old nursing student. She is married and has a 13-year-old daughter and 5-year-old.son She is admitted to the hospital with an elevated temperature , productive cough, and rapid labored. respiration While taking the nursing history, the RN finds that Muna has had a “chest cold” for two weeks and has been experiencing shortness of breath upon exertion. Yesterday she developed an elevated temperature and began to.”experience “pain” in her “lungs Assessment ”Muna Stated “I cant breath, please help” I will never get caught up with my classes ”I’m worried about my children, I left them with my in laws, their father is out of town “ I could not sleep last night, I cant breath when I laydown” “Also, have this chest pain “ ”while I’m coughing I have no appetite since the cold, I have not eaten today anything, last thing entered my “ ”stomach was two spoons of chicken broth last night The chest pain I complain of is moderate 6/10 increase with coughing, and decrease “.”with rest The patient is coughing continuously, she has a productive cough, sputum is yellowish to greenish, orthopnea The patient is trying not to cough to avoid chest pain, puffy eyes, always talking to her kids over the phone … The patients does not eat very well, her food tray remain as is Diagnosis Ineffective airway clearance related to accumulation of secretion in the airways AMB----- Altered breathing pattern related to obstructed airways AMB--- Imbalanced nutrition: Less than body requirements related to decrease appetite and increased metabolism secondary to disease process AMB--- Diagnosis Disturbed sleep pattern related to ----cough, pan, orthopnea AMB Anxiety related to difficulty breathing and concerns overwork —and parenting role AMB As Manifested By ACTUAL DIAGNOSIS An actual diagnosis represents a state that has been clinically validated by identifiable major defining characteristics. Consists of a.label, related factors & defining characteristics Three Part Statement P E S P = Problem ( Precise qualifier / modifiers ) Altered High Risk Ineffective Decreased Deficit Excess Dysfunctional Disturbance Chronic Less than More than Anticipatory Diagnostic Label = Problem + modifier = Chronic Pain.Actual dx E = Related Factors Related factors are etiological or other contributing factors that have influenced the health status change. Etiology sometimes = Causes or factors of risk Chronic pain r/t Altered Tissue perfusion ………. secondary to Diabetes Pathophysiologic Alteration in skin Integrity r/t ( caused by) Compromised immune system Inadequate circulation Inadequate peripheral circulation Treatment-related Medications Diagnostic studies Anxiety r/t (caused by) lack of knowledge Surgery of how to dress his wound Treatments  Actual diagnosis P E Diagnostic Label Related factor I impaired Skin Integrity related to prolonged immobility S Defining characteristics as evidenced by a 2 cm sacral lesion A real problem exists !!!!!!!!  RISK DIAGNOSIS Is a clinical judgment that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation.. Two part statement.---------P ( problem) E ( related risk factors) No defining characteristics No signs or symptoms because No problem yet Risk dx Risk nursing diagnoses P E Diagnostic label Etiological risk factors Risk for Injury related to lack of awareness of hazards Factors present which present a risk situation for a problem to occur  Health promotion Diagnosis Is a clinical judgment about an individual, family or community in transition from a specific level of wellness to a higher level of wellness. Two cues must be present: 1. desire for a higher level of wellness 2. effective present status or function. One part statement beginning with Readiness for Enhanced Diagnostic Label Readiness for Enhanced Parenting SYNDROME DIAGNOSIS One part statement Diagnostic label Disuse syndrome. Comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation. Nursing Diagnoses Associated with Disuse Syndrome Risk for Constipation Risk for Altered Respiratory Function Risk for Infection Risk for Thrombosis Risk for Activity Intolerance Risk for Injury Risk for Altered Thought Processes INEFFECTIVE BREATHING PATTERNS DEFINITION Ineffective Breathing Patterns: State in which a person experiences an actual or potential loss of adequate ventilation related to an altered breathing pattern DEFINING CHARACTERISTICS Major (Must Be Present, One or More) Changes in respiratory rate or pattern (from baseline) Changes in pulse (rate, rhythm, quality) Minor (May Be Present) Orthopnea Tachypnea, hyperpnea, hyperventilation Dysrhythmic respirations. Splinted/guarded respirations  Diagnosis (P) Ineffective Breathing Patterns Related to (E) Immobility and chest pain r/t Secondary to abdominal surgery As evidenced by (S)  in respiratory rate from 12 to 22 pulse rate  88 to 104 and irregular  Bifocal Model---------collaborative problems Two practice situations Nurse is primary provider Nurse works in collaboration with others COLLABORATIVE PROBLEMS PC Physiological problems nurses monitor Watching for complications ……..Potential Complications bifocal All collaborative problems begin with the label POTENTIAL COMPLICATION (PC) Potential complication: Sepsis PC: Sepsis Usually occur in association with a specific pathology treatment Characteristics of a Nursing Diagnosis Have diagnostic labels Consist of the diagnostic label plus etiology Professional nurses responsible for making nursing diagnoses A judgment made only after thorough, systematic data collection Describes a continuum of health states  Guidelines for Writing a Diagnostic Statement State in terms of a problem, not a need. Word the statement so that it is legally advisable. Use nonjudgmental statements. Make sure that both elements of the statement do not say the same thing. Be sure that cause and effect are correctly stated. Word the diagnosis specifically and precisely Use nursing terminology rather than medical terminology to describe the client’s response and probable cause of client’s response  Avoid error in Diagnostic Reasoning Verify diagnoses by talking with the client and family Build a good knowledge base and acquire clinical experience Have a working knowledge of what is normal Consult resources Base diagnoses on patterns Improve critical-thinking skills Evolution of Nursing Diagnoses First Taxonomy Alphabetical Taxonomy II ◦ Domains ◦ Classes ◦ Nursing diagnoses ◦ Seven axes Taxonomy II Taxonomy II Advantages of a Taxonomy of Nursing Diagnoses Development of a standardized nursing language Nursing minimum data set