THE NURSING PROCESS

1. THE NURSING PROCESS Chapter 3 The Diagnosis Step: Analyzing the Data Chapter 13 Fundamentals: Diagnosing

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

3. Competencies for Chapter 3: The Diagnosis or Need Identification Step • By the end of this unit the student will: • List 3 purposes of the nursing diagnosis • Differentiate between nursing and medical diagnoses • Define 4 types of nursing diagnoses • Define PES relating to parts of the nursing diagnosis statement • Identify the 6 steps involved in need identification

4. 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

5. Nursing Process:Diagnosing • Interpret and analyze client data to identify client strengths and health problems • If data indicates a health problem treatable by independent nursing intervention • Formulate and validate nursing diagnoses

6. Interpret/analyze client data • Is there a health problem? • Which healthcare professional can best treat the problem? • What problems can be managed by nursing intervention?

7. 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

8. 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

9. Formulate/Validate Nursing Diagnoses Types of Nursing Diagnosis • Actual Diagnoses • Wellness Diagnoses • Risk Diagnoses • Resolved Diagnoses

10. PES: Parts of the Client Diagnostic Statement 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

11. 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)

12. 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)

13. Nursing Process-2nd Step: Diagnosing Step 1 - Problem Sensing Step 2 - Rule out Process Step 3 - Synthesizing the Data Step 4 - Evaluating or Confirming the Hypothesis Step 5 - List client needs Step 6 - Re-evaluate the Problem List

14. 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

15. 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

16. Avoiding Errors • Identify client response, not medical diagnosis • Correct: Anxiety related to fear of illness • Incorrect: Anxiety related to myocardial infarction

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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