Diagnosing by Dr. Zyad Saleh PDF

Diagnosing By Dr. Zyad Saleh 0 © Pearson Education 2012  Nursing Diagnoses Definitions: Diagnosing: The reasoning process used to identify the nature of a client’s health problem....

Diagnosing By Dr. Zyad Saleh 0 © Pearson Education 2012  Nursing Diagnoses Definitions: Diagnosing: The reasoning process used to identify the nature of a client’s health problem. Diagnosis: A statement or conclusion regarding the nature of a phenomenon (client's health status). Components of Nursing Diagnoses: Diagnostic Label (Phrase): States the client’s problem. Etiology (Cause): Identifies the cause or contributing factors of the problem. Nursing diagnosis contains a diagnostic phrase or diagnostic label followed by an etiology phrase Purpose of Diagnostic Statements: To clearly communicate the patient's health problems and needs 1 © Pearson Education 2012  Domain of Nursing Diagnosis: Includes health states that nurses are educated and licensed to treat. Focuses on human responses to medical diagnoses (e.g., insufficient knowledge, inadequate nutrition). Nursing Diagnosis  Judgment Based on Data Collection Made after thorough, systematic data collection. Describes deviations from health, risk factors, and potential for personal growth. 2 © Pearson Education 2012  Types of Nursing Diagnoses Four Types: Actual Nursing Diagnosis Health Promotion Diagnosis Risk Nursing Diagnosis Syndrome Diagnosis 3 © Pearson Education 2012  Actual Nursing Diagnosis Definition: Also known as a problem-based diagnosis. Client problem that is present at the time of the nursing assessment. Key Point: Based on the presence of associated signs and symptoms. Examples: Altered respiratory status Impaired ability to cope 4 © Pearson Education 2012  Health Promotion Diagnosis Definition: Relates to clients' preparedness to implement behaviors for improving health. Key Phrase: Begins with "willingness to learn" or "willingness to change health practices." Examples: Willingness to learn about health maintenance Willingness to change health practices 5 © Pearson Education 2012  Risk Nursing Diagnosis Definition: A clinical judgment that a problem is likely to develop unless nurses intervene. Example: Risk for impaired breathing patterns Key Point: The problem does not exist yet but is likely to develop due to risk factors. 6 © Pearson Education 2012  Syndrome Diagnosis Definition: A clinical nursing judgment where a client has several similar nursing diagnoses. Example: Impaired respiratory status related to increased secretions and restricted airflow. Key Point: Involves multiple related nursing diagnoses. 7 © Pearson Education 2012  Nursing Diagnosis Components A nursing diagnosis consists of three main components: Problem (Diagnostic Label) Etiology (Related Factors and Risk Factors) Defining Characteristics 8 © Pearson Education 2012  Problem (Diagnostic Label) Definition: The diagnostic label describes the client’s health problem or response requiring nursing intervention. Purpose: Directs the formation of client goals and desired outcomes. Suggests possible nursing interventions. Qualifiers are words that are added to the nursing diagnosis to provide additional meaning to the diagnostic statement Examples of Qualifiers: inadequate in amount, quality, or degree; not sufficient; incomplete made worse, weakened, damaged, reduced, deteriorated lesser in size, amount, or degree not producing the desired effect vulnerable to threat. 9 © Pearson Education 2012  Etiology (Related Factors and Risk Factors) Definition: Identifies the probable cause(s) of the health problem. Purpose: Guides the required nursing therapy. Allows for individualized client care. Examples: Impaired activity (Problem (Diagnostic Label)) may be due to: Generalized weakness Sedentary lifestyle Lack of motivation 10 © Pearson Education 2012  Defining Characteristics Definition: A cluster of signs and symptoms indicating the presence of a specific diagnostic label. For Actual Nursing Diagnoses: Defined by the client’s observable signs and symptoms. For Risk Nursing Diagnoses: No signs and symptoms are present. Factors increasing vulnerability form the etiology. 11 © Pearson Education 2012  Example: Ineffective Breathing Pattern Diagnostic Label: Ineffective breathing pattern Etiology: Related to limited chest expansion, anxiety, and/or bronchial constriction. Defining Characteristics: Observable signs like dyspnea, increased respiratory rate, use of accessory muscles, and verbalization of difficulty breathing. 12 © Pearson Education 2012  Differentiating Nursing Diagnoses from Medical Diagnoses Nursing Diagnosis Definition: A nursing diagnosis is a clinical judgment about a human response to a health condition. Focuses on the client’s physical, sociocultural, psychological, and spiritual responses to an illness or health problem. Medical Diagnosis Definition: A medical diagnosis is made by a physician and identifies a specific disease process. Refers to pathophysiological responses that are relatively uniform among clients. 13 © Pearson Education 2012  Nursing Diagnosis: Changes as the client’s responses change. Medical Diagnosis: Remains the same as long as the disease process is present. Example: Rheumatoid Arthritis Case Study Case Study Overview: Mary Cain (70 years old): Accepts her condition as part of aging; responds with acceptance. Kristi Vidan (20 years old): Feels threatened by her condition; responds with anger and hostility. Key Point: The medical diagnosis (rheumatoid arthritis) is the same, but the nursing diagnoses differ due to each client's unique response. 14 © Pearson Education 2012  Nursing Responsibilities Nurses have responsibilities related to both medical and nursing diagnoses. Independent Functions: Related to nursing diagnoses and include unique aspects of nursing care. Example: Managing pain through non-pharmacological methods like guided imagery. Dependent Functions: Related to medical diagnoses and include carrying out physician-prescribed therapies. Example: Administering physician-ordered analgesics. 15 © Pearson Education 2012  What is a Collaborative Problem? Definition: A potential problem that requires both independent nursing interventions and physician-prescribed interventions. Characteristics: Present when a specific disease or treatment is present. Associated with specific complications that are always linked to a particular disease or treatment. Examples: Potential Complications of Pneumonia: Atelectasis, respiratory failure, pleural effusion, pericarditis, meningitis. 16 © Pearson Education 2012  Managing Collaborative Problems Role of Nurses: Independent Interventions: Monitoring and preventing complications. Dependent Interventions: Implementing physician- prescribed treatments. Example of Collaborative Management: A client with pneumonia: Nurse monitors for signs of complications (atelectasis, respiratory failure) and administers prescribed treatments. 17 © Pearson Education 2012  Nursing Diagnoses vs. Collaborative Problems in Practice Nursing Diagnoses: More individualized to specific client needs. Allow for independent nursing action based on observed human responses. Collaborative Problems: Require a multidisciplinary approach. Nurses coordinate with physicians to manage potential complications. 18 © Pearson Education 2012  Key Components of the Diagnostic Process Three Main Steps: Analyzing Data Identifying Health Problems, Risks, and Strengths Formulating Diagnostic Statements 19 © Pearson Education 2012  Analyzing Data Definition: Involves comparing data to standards, clustering cues, and identifying gaps. Examples of Significant Cues: Shortness of breath with activity. Not meeting developmental milestones, like an infant unable to sit alone at 9 months. Clustering Cues Definition: Grouping related data to identify patterns and determine significance. 20 © Pearson Education 2012  Identifying Health Problems, Risks, and Strengths Identifying Health Problems: Determining the main health issues affecting the patient. Recognizing Risks: Assessing potential health problems that could develop. Assessing Strengths: Identifying the patient’s abilities that can be used to improve their health. 21 © Pearson Education 2012  Identifying Gaps and Inconsistencies in Data Data should include a final check to ensure that data are complete and correct. 22 © Pearson Education 2012 23 © Pearson Education 2012  Formulating Diagnostic Statements Types of Nursing Diagnostic Statements: Two-Part Statements (PE): Problem (P): Statement of the client’s response. Etiology (E): Factors contributing to or probable causes of the response. Format: "Problem related to Etiology" Example: Nonadherence (diabetic diet) related to denial of having the disease. 24 © Pearson Education 2012  Three-Part Statements (PES): 1. Problem (P): Nursing diagnosis label (client’s response). 2. Etiology (E): Factors contributing to or probable causes of the response. 3. Signs and Symptoms (S): Defining characteristics manifested by the client. Format: "Problem related to Etiology as manifested by Signs/Symptoms" Example: Diagnosis: Nonadherence (diabetic diet) related to unresolved anger about diagnosis as manifested by: Subjective (S): "I forget to take my pills." "I can't live without sugar in my food." Objective (O): Weight 98 kg (215 lb) (gain of 4.5 kg [10 lb]), Blood pressure 190/100 mmHg. 25 © Pearson Education 2012 26 © Pearson Education 2012  When to Use Each Format: Two-Part Statements: Used when only the problem and its etiology are known. Three-Part Statements: Recommended for actual diagnoses where signs and symptoms are identified. 27 © Pearson Education 2012  Variations of Basic Diagnostic Formats 1. Unknown Etiology: 1. Used when the cause is not known. 2. Example: Nonadherence to medical regimen related to unknown etiology. 2. Complex Factors: 1. Used when there are multiple or complex causes. 2. Example: Chronic pain related to complex factors. 3. Possible Problems: 1. Used when further data is needed to confirm the problem or its cause. 2. Example: Possible low self-esteem related to loss of job. 28 © Pearson Education 2012  Variations of Basic Diagnostic Formats 1. Secondary To: 1. Divides etiology into more descriptive parts. 2. Example: Potential for impaired skin integrity related to decreased peripheral circulation secondary to diabetes. 2. Specificity Enhancement: 1. Adds details to make diagnoses more precise. 2. Example: Altered skin integrity (left lateral ankle) related to decreased peripheral circulation. 29 © Pearson Education 2012  Collaborative Problems Diagnostic Label: Format: All collaborative problems start with "Potential Complication (PC)." Example: PC of Head Injury: Increased Intracranial Pressure. PC of Pregnancy-Induced Hypertension: Seizures, Fetal Distress, Pulmonary Edema, Hepatic or Renal Failure, Premature Labor, CNS Hemorrhage. 30 © Pearson Education 2012  Example of Nursing Diagnosis Components Scenario: A patient has undergone abdominal surgery and is experiencing pain. Diagnostic Label (Phrase): Acute pain Etiology (Cause): Related to incisional pain Complete Nursing Diagnosis: Acute pain related to incisional pain. Explanation: Diagnostic Label: The patient is experiencing acute pain, which is a short-term, severe pain. Etiology: The pain is caused by the incision from the abdominal surgery. Another Example: Scenario: A patient with diabetes has a history of poor blood sugar control. Diagnostic Label (Phrase): Risk for impaired skin integrity Etiology (Cause): Related to chronic hyperglycemia Complete Nursing Diagnosis: Risk for impaired skin integrity related to chronic hyperglycemia. Explanation: Diagnostic Label: The patient is at risk of developing skin problems due to poor blood sugar control. Etiology: Chronic high blood sugar can lead to poor circulation and nerve damage, increasing the risk of skin ulcers. 31 © Pearson Education 2012