Lecture Notes - Nursing Process and Diagnosis Phase

Introduction

• Presenter: Professor Hoffman
• Topic: Revision of learning objectives, focus on Topic 4
• Objective: Diagnosis step in the nursing process
• Reference: Chapter 4.4 in the text

Overview of the Nursing Process

• Six stages:
  1. Assessment
  2. Diagnosis
  3. Outcomes Identification
  4. Planning
  5. Implementation
  6. Evaluation

Diagnosis Phase

• Purpose: Analyze assessment data and determine actual/potential issues
• Connection: Links to ANA Standards of Professional Practice
• Process:
  • Analyze assessment data (subjective and objective)
  • Identify expected vs. unexpected results
  • Determine clinical relevance
  • Prioritize diagnoses
  • Formulate a plan structure

Analyzing Data in the Diagnosis Phase

• Data Types:
  • Subjective: Patient-reported symptoms
  • Objective: Vital signs, lab results, etc.
• Analysis Steps:
  1. Identify expected vs. unexpected results
  2. Determine if results are normal or abnormal
  3. Assess clinical relevance
• Clustering:
  • Group related cues
  • Formulate a hypothesis

Case Study Example

• Patient: Elderly female
• Symptoms:
  • Elevated blood pressure
  • Elevated respiratory rate
  • Abnormal lung sounds (crackles)
  • Recent weight gain
  • Edema in lower extremities
  • Shortness of breath
• Medical History: Heart failure
• Medication: Diuretic
• Hypothesis: Excess fluid volume or hypervolemia

Developing a Nursing Diagnosis

• Purpose: Verbalize a clinical judgment
• Application: Individual, family, community
• Examples:
  • Dyspnea (shortness of breath)
  • Anxiety related to symptoms

Responsibilities in the Nursing Process

• RN:
  • Analyze data
  • Develop diagnosis
• LPN:
  • Assist in data collection during assessment
  • Understand diagnosis and plan to assist in implementation
  • Continue ongoing assessment

Legal and Professional Standards

• ANA Standards: Guide nursing process
• Nurse Practice Act:
  • Defines boundaries and responsibilities for RNs, LPNs, and Advanced Practice RNs

Questions and Further Discussions

• Reach out for questions
• Open to discussions before the next exam