Chapter 17: Nursing Diagnosis

Overview

• Nursing diagnosis is the second step in the nursing process.
• Critical thinking is crucial for making accurate nursing diagnoses.
• Purpose: Determine patient's response to illness in a consistent manner.

Types of Diagnoses

1. Medical Diagnosis

   • Identification of disease/illness through signs, symptoms, medical history, and test results.
   • Nurses do not treat medical diagnoses.

2. Nursing Diagnosis

   • Focuses on pathophysiological aspects and patient response to treatment.
   • Considers personal, environmental, and maturation factors.

3. Collaborative Problems

   • Require both medical and nursing interventions.
   • Nurses work with other professionals to manage these problems.

Nursing Process: ADPIE

• ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation.
• Institutions may use standardized terminology, but it's up to the nurse to identify relevant nursing diagnoses.

Types of Nursing Diagnoses

1. Problem-Focused Diagnosis

   • Identifies undesirable human response to existing problems.

2. Risk Diagnosis

   • Applied when there is increased potential for developing a problem (e.g., risk for falls).

3. Health Promotion Diagnosis

   • Identifies a patient's motivation to improve health through behavioral changes.

Diagnosis Process

• Assessment Data: Gather and validate comprehensive data.

• Interpretation: Identify patterns, cues, and clusters from data.

  • Compare data with normal/healthy standards.
  • Use experience and clinical judgment.

• Diagnostic Process

  • Order and organize data into meaningful clusters.
  • Recognize clinical patterns through experience.

Diagnosis Structure

• Problem-Focused Diagnosis: 3 parts - diagnosis label, related factors, major defining characteristics.
• Risk Diagnosis: 2 parts - diagnosis label and potential risk factors.
• Health Promotion Diagnosis: 2 parts - label and defining characteristics.

Importance of Standard Terminology

• Ensures clear communication between healthcare professionals.
• Accurate diagnoses are essential for personalized care plans.

Errors in Diagnosis

• Avoid premature or incorrect data clustering.
• Consider all available data and conflicting information.
• Seek assistance to verify data and prevent errors.

Prioritizing Nursing Diagnoses

• List diagnoses chronologically and prioritize based on patient's condition.
• Consider ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy.

Care Plan

• Provides a roadmap for care and accountability.
• Enhances interprofessional collaboration and communication.

Conclusion

• Successful intervention selection depends on accurate related factors.
• Standardized formats in EHRs aid in communication and care planning.