THE NURSING PROCESS

Chapter 3

The Diagnosis Step:

Analyzing the Data

Chapter 13

Fundamentals:

Diagnosing

Doenges, M. E., & Moorhouse, M. F. (2008). Application of nursing process and nursing diagnosis: An interactive text for diagnostic reasoning (5th ed.). Philadelphia: F. A. Davis.

Reference

Competencies for Chapter 3: The Diagnosis or Need Identification Step

By the end of this unit the student will:1. List 3 purposes of the nursing diagnosis2. Differentiate between nursing and

medical diagnoses3. Define 4 types of nursing diagnoses4. Define PES relating to parts of the

nursing diagnosis statement5. Identify the 6 steps involved in need

identification

Purpose of Diagnosing

To identify: Actual and potential problems in the

way the client responds to health or illness

Factors that contribute to or cause the problems (etiologies)

Strengths the client can draw on to prevent or resolve problems

Nursing Process:Diagnosing

1. Interpret and analyze client data to identify client strengths and health problems

If data indicates a health problem treatable by independent nursing intervention

2. Formulate and validate nursing diagnoses

Is there a health problem?

Which healthcare professional can best treat the problem?

What problems can be managed by nursing intervention?

Interpret/analyze client data

Focus of Nursing Diagnosis Medical Diagnosis – identify diseases,

describes problems, treated by a physician (narrow focus)

Nursing Diagnosis – focus on human response to disease process (holistic view)

The Nursing Diagnosis is a conclusion drawn from data with needs amenable to treatment by nurses

Interpret/Analyze Client Data Interpretation begins at assessment Diagnosis must be supported by data Look for clusters, strengths, problems,

potential problems Draw conclusions

No problem Possible problem Actual or potential nursing diagnosis

Formulate/Validate Nursing Diagnoses

Types of Nursing Diagnosis Actual Diagnoses Wellness Diagnoses Risk Diagnoses Resolved Diagnoses

P = Problem-describe the health state or problem of a client

E = Etiology-identifies the physiologic, psychological, sociologic, and spiritual and environmental factors

S = Signs/symptoms- defining characteristics – subjective and objective data that signal a problem and supports the diagnosis

PES: Parts of the Client Diagnostic Statement

Writing a Nursing Diagnosis

Consult NANDA Nursing diagnosis statements are

written in: Two-part statements (problem/cause) or Three-part statements

(problem/cause/problem’s defining characteristics)

Guideline for Writing a Nursing Diagnosis

P: Phrase patient problem (need) Link with phrase “related to”

E: Etiology (suspected cause for problem) Link with phrase “as evidenced by”

S: List signs/symptoms (cues identified in the assessment that substantiate the nursing diagnosis)

Nursing Process-2nd Step: Diagnosing

Step 1 - Problem SensingStep 2 - Rule out ProcessStep 3 - Synthesizing the DataStep 4 - Evaluating or Confirming the HypothesisStep 5 - List client needsStep 6 - Re-evaluate the Problem List

Remember:

Nursing Diagnosis – NOT – medical diagnosis Nursing Diagnosis change with the client’s

progress through various stages of illness Patients who are able to participate in their

care should be encouraged to validate the diagnosis

Nursing Diagnosis provides a common language to improve communication among nurses, and other healthcare providers

Examples of Nursing Diagnosis

Potential altered oral mucus membrane related to NPO state

Grieving related to recent job loss as manifested by statement of anger

Avoiding Errors

Identify client response, not medical diagnosis Correct: Anxiety related to fear of illness Incorrect: Anxiety related to myocardial

infarction

Avoiding Errors

Identify problem created by condition rather than the condition itself Correct: Ineffective individual coping

related to noncompliance with treatment regimen

Incorrect: Ineffective individual coping related to chronic illness

Avoiding Errors

Identify problem brought about by diagnostic study rather than the diagnostic study itself Correct: Anxiety related to lack of knowledge

about cardiac catheterization as evidenced by hyperventilation and profuse sweating each time cardiac catheterization is discussed

Incorrect: Anxiety related to cardiac catheterization

Avoiding Errors

Identify the diagnostic category rather than the symptom Correct: Altered breathing pattern related

to excessive mucus production as evidenced by coughing and drooling

Incorrect: Cough related to excessive mucus production

Avoiding Errors

Identify the patient response to the equipment or treatment rather than the equipment itself Correct: Impaired physical mobility

related to weakness and fatigue Incorrect: Impaired physical mobility

related to cast

Avoiding Errors

Identify associated factors, avoid legally inadvisable and judgmental statements Correct: Altered family processes related

to social deviance by family member Incorrect: Fear related to frequent

beatings by husband

Case Scenario

81 y.o. male S/P CVA admitted to ECF for custodial care. History includes:

Poor PO intake x 2 weeks No bowel movement x 3 days Unable to perform ADL’s independently

uses FWW in home or W/C on outing-last 2 weeks has had very limited ambulation related to viral illness

requires set-up for meals and encouragement with fluid intake

uses adult pads for bladder incontinence requires assistance with showers

Summary

The Nursing Diagnosis: Addresses human responses to actual

and potential health concerns Provides a common language for

nurses and other healthcare professionals and promotes identification of appropriate patient goals

Summary- (continued)

Is a conclusion drawn from data with patient needs amenable to treatment by nurses

Must be supported by data The nursing diagnosis changes as

patient progresses through various stages of illness

Summary- (continued)

There are six steps for diagnostic reasoning

Be specific when writing diagnosis and “related to” statement

Important to focus intervention on the roots of human response