Kozier Erbs Fundamentals of Nursing Concepts Process and
Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice TENTH EDITION CHAPTER 12 Diagnosing Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Learning Outcomes 1. Differentiate nursing diagnoses according to status. 2. Identify the components of a nursing diagnosis. 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems. 4. Identify basic steps in the diagnostic process. continued on next slide Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Learning Outcomes 5. Describe various formats for writing nursing diagnoses. 6. List guidelines for writing a nursing diagnosis statement. 7. Describe the evolution of the nursing diagnosis movement, including work currently in progress. Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Introduction • Activities preceding the diagnosing phase are directed toward forming the nursing diagnoses. • All other steps flow from nursing diagnoses. • Nurses use critical thinking skills to interpret assessment data and identify client strengths and problems. Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Introduction • North American Nursing Diagnosis Association (NANDA) International § Define, refine, and promote a taxonomy of nursing diagnostic terminology • Taxonomy § Classification system or set of categories arranged based on principle(s) Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Figure 12– 1 Diagnosing—the pivotal second phase of the nursing process. Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Definitions • Diagnosing § Refers to the reasoning process • Diagnosis § A statement or conclusion regarding the nature of a phenomenon • Diagnostic labels § Standardized NANDA names for diagnoses Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Definitions • Etiology § Causal relationship between ad problem and its related factors • Nursing diagnosis § Problem statement consisting of diagnostic label plus etiology Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Definitions • Nursing diagnosis § Professional nurses responsible for making § Includes only those health states that nurses are educated and licensed to treat § Judgment made only after thorough, systematic data collection § Continuum of health states Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Status of the Nursing Diagnoses • Actual diagnosis § Problem presents at the time of assessment. § Presence of associated signs and symptoms Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Status of the Nursing Diagnoses • Health promotion diagnosis § Preparedness to implement behaviors to improve their health condition § Example: Readiness for Enhanced Nutrition Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Status of the Nursing Diagnoses • Risk nursing diagnosis § Problem does not exist. § Presence of risk factors • Syndrome diagnosis § Cluster of nursing diagnoses that have similar interventions Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Components of a NANDA Nursing Diagnosis • Problem (diagnostic label) and definition § Describes the client's health problem or response § May require specification § Qualifiers added to give additional meaning • Such as Deficient, Impaired, Decreased, Ineffective, and Compromised Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Components of a NANDA Nursing Diagnosis • Etiology (related factors and risk factors) § Identifies one or more probable causes of the health problem § Gives direction to the required nursing therapy § Enables the nurse to individualize the client's care Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Components of a NANDA Nursing Diagnosis • Defining characteristics § Cluster of existing signs and symptoms indicates actual diagnosis • Clients have signs and symptoms. § Cluster of factors that cause client to be more vulnerable to a problem indicates "risk for" diagnosis • No subjective or objective data exist at present Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Differentiating Nursing Diagnoses from Medical Diagnoses • Nursing diagnosis § A statement of nursing judgment based on education, experience, expertise and license to treat § Describes human response, the client's physical, sociocultural, psychological, and spiritual responses to an illness or health problem continued on next slide Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Differentiating Nursing Diagnoses from Medical Diagnoses • Nursing diagnosis § Changes when client's responses change § Independent nursing functions • Areas of health care that are unique to nursing, separate and distinct from medical management Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Differentiating Nursing Diagnoses from Medical Diagnoses • Medical diagnosis § Made by a physician § Refers to a disease process § Remains the same as long as the disease process is present § Dependent nursing functions (physicianprescribed therapies and treatments) Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Differentiating Nursing Diagnoses from Collaborative Problems • Use both independent and dependent (physician-prescribed) interventions • Require monitoring of client's condition and prevention of potential complications • Occur when a particular disease or treatment is present Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Table 12– 3 Comparison of Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
The Diagnostic Process • Critical thinking § Reviewing data and considering explanations before forming opinions • Analysis § Separation into components (deductive reasoning) • Synthesis § Putting together of parts into whole (inductive reasoning) Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Analyzing Data • Comparing data with standards § Standard or norm • Generally accepted measure, rule, model, or pattern § Cue considered significant if: • Points to negative, positive change in client's health status or pattern • Varies from norms of client population • Indicates a developmental delay Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Analyzing Data • Clustering cues § Determine relatedness of facts § Inductively or with a framework • Identifying gaps and inconsistencies in data § Conflicting data § All inconsistencies must be clarified before a valid pattern can be established. Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Table 12– 4 Comparing Cues to Standards and Norms Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Identifying Health Problems, Risks, and Strengths • Determining problems and risks § Problems that support tentative or actual risks and possible diagnoses § Determine whether problem is a nursing diagnosis, medical diagnosis, or collaborative problem Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Identifying Health Problems, Risks, and Strengths • Determining strengths § Resources and abilities to cope § Can be an aid to mobilizing health and regenerative processes § Can include home life, education, recreation, exercise, work, family and friends, religious beliefs, and sense of humor Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Figure 12– 2 diagnoses. Decision tree for differentiating among nursing diagnoses, collaborative problems, and medical Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Formulating Diagnostic Statements • Basic two-part statements § § Problem (P) Etiology (E) Joined by the words "related to" Add words if NANDA label contains the word Specify Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Formulating Diagnostic Statements • Basic three-part statements § PES format • Problem (P) • Etiology (E) • Signs and symptoms (S) § Recommended for beginning diagnosticians § List signs and symptoms grouped by subjective and objective data Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Formulating Diagnostic Statements • One-part statements § Health promotion diagnoses beginning with Readiness for Enhanced § Seven syndrome diagnoses • Variations of basic formats § Unknown etiology • Defining characteristics present but cause, contributing factors unknown Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Formulating Diagnostic Statements • Variations of basic formats § Complex factors • When too many etiologic factors to state briefly § Possible • Either problem or etiology continued on next slide Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Formulating Diagnostic Statements • Variations of basic formats § Secondary to • Divide etiology into two parts § Adding a second part to make it more precise • Indicate location, etc. Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Formulating Diagnostic Statements • Collaborative problems § Begin with Potential Complication (PC) § Etiology may be useful in some situations. • Evaluating the quality of the diagnostic statement § Validate with client § Compare signs and symptoms to NANDA defining characteristics Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Table 12– 6 Guidelines for Writing a Nursing Diagnostic Statement Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Avoiding Errors in Diagnostic Reasoning • Verify data • Build a good knowledge base and acquire clinical experience • Have a working knowledge of what is normal • Consult resources • Base diagnoses on patterns rather than an isolated incident • Improve critical thinking skills Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Ongoing Development of Nursing Diagnoses • The first taxonomy was alphabetical. • Later version based on "human response patterns" • Taxonomy II has three levels. § Domains § Classes § Nursing diagnoses Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
Ongoing Development of Nursing Diagnoses • Process for acceptance of new and modified labels reviewed biannually • Development of standardized nursing language § Includes NANDA nursing diagnoses § Nursing interventions classification § Nursing outcomes classification • Nursing Minimum Data Set for computerized records Kozier & Erb's Fundamentals of Nursing, Tenth Edition Audrey Berman | Shirlee Snyder | Geralyn Frandsen Copyright © 2016, 2012, 2008 Pearson Education, Inc. All Rights Reserved
- Slides: 37