Chapter 1 Nursing Diagnoses Issues and Controversies Copyright

Why Nurses Use Nursing Diagnoses • To describe client problems in sufficient detail to

Student Care Plans • Assist students in problem solving • Prioritize and individualize client

Question Is the following statement true or false? A nurse should never create a

Answer False Rationale: A nurse may create a care plan for another nurse to

Reasons Practicing Nurses Might Not Use Nursing Diagnosis • In the past there was

Domains of Expertise: Primary Care Nurse Practitioners vs. Primary Care Physicians Copyright © 2013

When Nursing Diagnosis May Be Viewed as a Negative Label • “When an individual’s

Nursing Diagnoses: Potential for Conflicts with Client Confidentiality • Certain recorded information may compromise

Question Is the following statement true or false? Nurses are not obligated to pass

Answer True Nurses are not obligated to pass on all of a client’s nursing

Nurses’ Obligation to the Client • Address applicable nursing diagnoses • Protect the client’s

Role of the Professional Nurse • Understand the pathophysiology of medical diagnoses and associated

Role of the Professional Nurse (cont. ) • Actively assist clients, families, or communities

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Why Nurses Use Nursing Diagnoses • To describe client problems in sufficient detail to provide continuing care for clients with special needs • To provide a standardized classification system to teach the science of nursing and communicate client problems to other nurses and disciplines • To properly describe all the client responses that nurses diagnose and treat Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Student Care Plans • Assist students in problem solving • Prioritize and individualize client care • Serve as directions for a student with a particular client • Describe standards of care for a client problem or situation • Allow for revision through additions or deletions Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer False Rationale: A nurse may create a care plan for another nurse to follow when it is necessary to alert that nurse to additional care that is needed beyond the standard of care. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Reasons Practicing Nurses Might Not Use Nursing Diagnosis • In the past there was little or no discussion of nursing diagnoses, and medical diagnoses guided future practice. – Nursing diagnosis became a documentation assignment rather than a guide to assessments and interventions. • Practicing nurses today may not understand the need to expertly diagnose and treat the client responses to medical diagnoses. – They may see themselves as the assistant of the physician, not as professionals in their own right. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

When Nursing Diagnosis May Be Viewed as a Negative Label • “When an individual’s definition of health is not consistent with the nurse’s the person’s health value is judged as ineffective, maladaptive, or dysfunctional. ” (Mitchell, 1991) • The nurse’s determination of a client’s response as ineffective, maladaptive, or dysfunctional should be based on the client’s perspective of the problem and the nurse’s knowledge and expertise. – An ineffective response is ineffective for the client, not the nurse. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Diagnoses: Potential for Conflicts with Client Confidentiality • Certain recorded information may compromise a client’s right to privacy, choice, or confidentiality. • Nurses must take measures to ensure diagnoses do no harm to the client. • Nurses must ascertain that there is permission to write, treat, or refer the diagnosis as appropriate. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question Is the following statement true or false? Nurses are not obligated to pass on all of a client’s nursing diagnoses to other nurses who will be caring for the client. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer True Nurses are not obligated to pass on all of a client’s nursing diagnoses to other nurses caring for the client as long as the nurse can assure that all the diagnoses are addressed. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nurses’ Obligation to the Client • Address applicable nursing diagnoses • Protect the client’s confidentiality • Nurses are not obligated to pass on all of a client’s nursing diagnoses as long as they are all addressed Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Role of the Professional Nurse • Understand the pathophysiology of medical diagnoses and associated complications and treatments • Monitor the patient’s responses • Detect early changes in physiologic status • Initiate appropriate treatments and/or consultations Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Role of the Professional Nurse (cont. ) • Actively assist clients, families, or communities to: – Reduce or eliminate problems – Reduce risk factors – Prevent problems – Promote healthier lifestyles Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins