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Chapter 12


Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

or community can draw to prevent or resolve problems. • Identify resources or strengths on which the individual. or cause. • Identify factors that contribute to. Copyright © 2015 Wolters Kluwer • All Rights Reserved . group. or community responds to actual or potential health and life processes. health problems (etiologies). group.Purposes of the Diagnosing Step • Identify how an individual.

independence. and treatment regimens impact on patients’ lives—and promoting optimum function. • Identifying human responses—how problems. • Anticipating possible complications and taking steps to prevent them. and quality of life. You should not wait to make a final diagnosis if there are signs and symptoms indicating the need for immediate treatment. signs and symptoms. • Initiating urgent interventions.Nursing Responsibilities Related to Diagnosis • Recognizing safety and infection-transmission risks and addressing these immediately. Copyright © 2015 Wolters Kluwer • All Rights Reserved .

thereby preventing the problems themselves. look for evidence of risk factors (things that evidence suggests contribute to health problems). Prevent. and Promote (PPMP) • In the presence of known problems.Predict. ensure that safety and learning needs are met and promote optimum function. Manage. • In all situations. and a sense of well-being. Copyright © 2015 Wolters Kluwer • All Rights Reserved . • Whether problems are present or not. If you identify risk factors. and (b) manage them in case they cannot be prevented. predict the most common and most dangerous complications and take immediate action to (a) prevent them. and independence. aim to reduce or control them.

Types of Diagnoses • Nursing diagnosis: Describes patient problems nurses can treat independently – Addresses the client’s response to healthcare and illness • Medical diagnosis: Describes problems for which the physician directs the primary treatment • Collaborative problems: Managed by using physicianprescribed and nursing-prescribed interventions – Primarily managed by nurses Copyright © 2015 Wolters Kluwer • All Rights Reserved .

increase the frequency of your observations and continue to search for cues to verify your intuition. • Trust clinical experience and judgment. but be willing to ask for help when the situation demands more than your qualifications and experience can provide. read professional literature and keep reference guides handy.Diagnostic Reasoning and Clinical Reasoning • Be familiar with nursing diagnoses and other health problems. Copyright © 2015 Wolters Kluwer • All Rights Reserved . • Recognize personal biases and keep an open mind. but before writing a diagnosis without evidence. • Respect your clinical intuition.

problems. and potential issues • Identifying potential complications • Reaching conclusions – Actual problem.Four Steps of Data Interpretation and Analysis • Recognizing significant data – Comparing data to standards or normal values – Note any changes • Recognizing patterns or clusters – Use multiple symptoms or results • Identifying strengths. potential problem. no problem Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Types of Nursing Diagnoses • Actual – An identified problem • Risk – Client is susceptible to a problem • Possible – Rule in or rule out a problem • Wellness – To improve level of wellness “Readiness” diagnoses • Syndrome – A group of diagnoses associated with a problem Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Formulation of Nursing Diagnoses • Problem – Identifies what is unhealthy about patient • Etiology – Identifies factors maintaining the unhealthy state • Defining characteristics – Identify the subjective and objective data that signal the existence of a problem Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Four Components of a Diagnosis • Label – Nursing diagnosis • Definition – Related to • Defining characteristics – Data collected by nurse that supports Dx • Related factors Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Validating Nursing Diagnoses • Is my patient database (assessment data) sufficient. reduced. accurate. or resolved by independent nursing action? • Is my degree of confidence above 50% that other qualified practitioners would formulate the same nursing diagnosis based on my data? Copyright © 2015 Wolters Kluwer • All Rights Reserved . and supported by nursing research? • Does my synthesis of data (significant cues) demonstrate the existence of a pattern? • Are the subjective and objective data I used to determine the existence of a pattern characteristic of the health problem I defined? • Is my tentative nursing diagnosis based on scientific nursing knowledge and clinical expertise? • Is my tentative nursing diagnosis able to be prevented.

Copyright © 2015 Wolters Kluwer • All Rights Reserved .Documentation of Diagnoses on EHR • View the patient’s ongoing risks and problems that others have identified and documented. • Use nursing diagnosis to make decisions about what mutual goals the patient desires and what can be done. • Facilitate communication of the patient’s actual problems with nurses and others on the health care team. • Determine and document when the nursing diagnoses are resolved. • Decide on and document new nursing diagnoses based on the patient assessment findings.

legislators.Benefits of Nursing Diagnoses • Individualizing patient care • Allows the patient to be knowledgeable and involved with their plan of care • Improves interaction between health care workers • Defining domain of nursing to health care administrators. and providers • Seeking funding for nursing and reimbursement for nursing services Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Limitations of Nursing Diagnosis • If used incorrectly. Copyright © 2015 Wolters Kluwer • All Rights Reserved . • Nursing practice might be restricted. patient might be misdiagnosed.

Common Errors in Writing Nursing Diagnoses • Writing diagnosis in terms of needs and response • Making legally inadvisable statements • Identifying as a problem a patient response that is not necessarily unhealthy • Identifying as a problem signs and symptoms of illness • Identifying as a patient problem or etiology what cannot be changed • Identifying environmental factors rather than patient factors as a problem • Reversing clauses • Having both clauses say the same thing • Including value judgments in the nursing diagnosis • Including the medical diagnosis in the diagnostic statement Copyright © 2015 Wolters Kluwer • All Rights Reserved .

Sources of Error When Writing Nursing Diagnoses • Premature diagnoses based on an incomplete database • Erroneous diagnoses resulting from an inaccurate database or a faulty data analysis • Routine diagnoses resulting from the nurse’s failure to tailor data collection and analysis to the unique needs of the patient • Errors of omission Copyright © 2015 Wolters Kluwer • All Rights Reserved .