this is chapter 17 nursing diagnosis so nursing diagnosis is the second step of our nursing process as a nurse we deliberately use critical thinking when we're making the nursing diagnosis because we need to accurately determine the patient's response to an illness so are you able to identify with john have you maybe had a situation in your own life that caused you to think about coming into nursing when we as nurses make a diagnosis we use a clear label or term that is familiar to everyone that's involved within the patient's care so they can understand the patient's needs in the nursing pro practice we have three types of diagnoses or problem statements a medical diagnosis is the identification of a disease or an illness that is based on a specific evaluation of physical signs and symptoms patients medical history and the results of any tests or procedures nurses cannot treat medical diagnoses our nursing diagnoses we look at the pathophysiological aspects so how are they handling their um heart attack or the um how are they um how are they handling their treatment so if they're taking an anticoagulant um how how are they being affected in their personal lives related to the death of maybe their friend environmentally you know do they have any maybe safety barriers that we can help with at home or when we look at their maturation level we're thinking about maybe are they impending parents do they you know under do they understand what they need to be doing and where their focus needs to be so collaborative problems these are problems that require medical and nursing interventions so as a nurse we will practice with other professionals to manage some different types of collaborative problems these problems will use physician prescribed and nursing prescribed interventions okay um all of the patients physiologic complications are not considered as collaborative problems if we as a nurse can prevent the onset of some complication or provide primary treatment for it then the nursing then the diagnosis is definitely a nursing diagnosis so what are the different processes or phases of the nursing process that go along with the acronym adpie so healthcare institutions they work with vendors that have electronic records right they want they want a standardized language or terminology that's unique to their institution sometimes these terminologies are only based on medical diagnoses as a nurse i understand that nursing diagnosis our terminology may or may not be part of the institutions when it isn't integrated it is up to the actual nurse to specifically identify the patient's relevant nursing diagnoses as it pertains to the patient's current health condition in addition to improving communication amongst all the providers using standard nursing terminology creates a greater scientific knowledge base for our profession problem-focused diagnoses identify an undesirable human response to some existing problem or a patient concern a risk diagnoses these are applied when there is an increased potential or vulnerability for a patient to develop a problem or even a complication so think of risk for falls health promotion this is a positive diagnosis to it identifies an individual's desire or their motivation to improve their prove their health status through some positive behavioral change so we want to make sure that we're able to use the nursing process accurately and appropriately critical thinking when we use apply our knowledge experience our own critical thinking attitudes and our intellectual standards when we are doing a collection of a comprehensive assessment database this will help improve the way we can diagnose the patient's situation so we use patient assessment data during the diagnostic reasoning process this helps us logically explain a clinical judgment and this would be our explaining our nursing diagnosis as a nurse we gather a comprehensive set of data or information we validate that data and we add additional information if there's not adequate information so we'll go asking questions or digging then we will interpret our data we will identify different cues or cluster and we'll cluster all this information together that could help form a pattern that could lead to a specific nursing diagnosis or other problem the diagnostic process it actually goes from the assessment and includes decision making steps so a nurse's review and analysis of the assessment data we are critically organizing all parts of the information into meaningful clusters or sets of assessment findings and defining characteristics so a set of assessment findings is no more than a group of data pieces of information these are signs or symptoms that we gathered during our assessment each specific piece of information is either objective or subjective and it is either a sign a symptom or a risk factor that can help the nurse make a diagnostic conclusion when as a nurse we're looking for a pattern we are comparing the patient's information with that that is consistent with a normal or a healthy pattern so we're looking at lab test values we're looking at professional stem standards we're looking at maslow's lowest hierarchy his physiologic needs we then will find some information clustered together to help us think about specific individual information and instead we'll start looking at a pattern our ability to recognize a pattern or a cluster it it evolves over time with clinical experience and um reflective practice remember that clinical criteria these consist of the data objective and subjective signs and symptoms or risk factor that will lead to a diagnosis or conclusion hypertension fatigue and high cholesterol these are all clinical data or signs and symptoms for heart disease where food preference is not a sign or symptom for heart disease so interpretation means that we're putting a label on a pattern or a cluster so we can hopefully identify a patient's response to their health problems we will select the diagnosis this is not a casual or an intuitive process we use critical thinking we want to make sure that we interpret data clusters or patterns and that it leads to the selection of different nursing diagnoses that will apply to our patients so it's vital that we actually compare the information in the cluster with different standards for a diagnosis to co to come to become a reasoned conclusion about the patient's response to their health problem so when we are comparing the assessment data with the standards it doesn't matter the diagnostic system used we will still compare the data that we find with the data with the assessment finding standard for different nursing diagnosis to select one specific diagnosis that will fit our patient when we recognize the data in a logical cluster or pattern this will reveal the nursing diagnosis and how a patient is responding to a health condition or a life process so there is a relationship between the nursing diagnosis in the really related factor or the etiology the way the nurse phrases or words the nursing diagnosis statement will affect how the nurse communicates the patient's problems which in nursing interventions will be chosen and how the patient's outcomes will be evaluated we need to make sure as nurses we are using clarity and precision when we form a diagnosis each diagnosis has a different format a problem-focused nursing diagnosis has three parts it has the diagnosis label the related factors are related to which is your etiology and then major defining characteristics which are signs and symptoms the risk nursing diagnosis it has two parts so it has the label the diagnosis and any associated potential risk factors preceded by the phrase as evidenced by so these would be signs and symptoms remember risk nursing diagnosis has not happened yet okay there's just the potential that it could happen a health promotion diagnosis are written with only two sections it has a label and it has the defining characteristics or the assessment information um unless we use the exact format for the nursing diagnosis the label that we put on the patient's situation has no meaning and it can be easily misunderstood so we want to make sure that we are extremely clear and precise so when you read this slide beth understands that there's four types of nursing diagnoses there are actual diagnoses the risk diagnoses a wellness diagnosis and then a health promotion diagnosis so disease prevention is not a nursing diagnosis so before we identify a nursing diagnosis we need to look at neander one or the international council of nursing to look at the actual statements to make sure that they're accurate this is essential for good communication standard terminology are used in electronic health records when we use the nursing diagnosis accurate nursing diagnoses are the foundation so we can develop effective personalized care plan for our patients and we as nurses need to thoroughly interpret all of the assessment findings so we can have a broad picture of the patient's various health responses so we need to understand the nursing diagnoses that applies to a vulnerable population oftentimes a risk nursing diagnosis will describe the human response to health conditions or life situations that develop within a vulnerable individual or community during the assessment phase as a nurse i want to make sure i'm knowledgeable thorough and skillful i want to avoid not having all the accurate or missing data and i need to be make sure i need to make sure i'm willing to confirm a finding with another nurse or another professional errors occur if we don't cluster data and if we do it prematurely incorrectly or not at all premature clustering will occur if we make a diagnosis before we group all of the exact data during the analysis and interpretation a nurse needs to be careful to consider any conflicting data and determine whether there's enough data to form a diagnosis a single symptom is not sufficient for selecting a nursing diagnosis clinical reasoning could lead to an accurate nursing diagnosis and this will eventually help make an individualized specific and effective nursing care plan with interventions so by successful selection of the interventions this will depend on having the correct related or ideologic factors or risk factor for the nursing diagnosis an accurate statement with relative relevant assessment findings will guide the nurse and the patient to select the appropriate patient outcomes so what did i not for a student to avoid a data collection error the student should assess the patient and if unsure of the finding ask a faculty member to assess the patient review his or her his or her own comfort level and competency with assessment skills ask another student to perform the assessment consider whether the diagnosis should be actual potential or a risk so the answer is a the data collection is an art that as a nurse we get better at with experience so asking assistance from someone to ensure that we have all of the appropriate data can help ensure that the patient has the right diagnostic statement so standardized formats that are used in ehr electronic health records this will enable nurses and other health care individuals to share information all right so the use of standardized and familiar terminology provides nurses better um ease at selecting the nursing diagnosis and the interventions whenever we're planning care we want to make sure that all of the nursing diagnoses are listed chronologically when we identify them when we initiate an original care plan we want to place the highest priority nursing diagnosis first this will always depend on the patient's condition and the nature of the diagnosis so if you're thinking about highest priority we start with abc which is airway breathing circulation then we go to safety and then we go to maslow's physiologic or basic needs to sustain human life a nursing diagnosis provides a universal and a standardized format for nurses to communicate between each other and then across with other healthcare individuals a care plan for us is a roadmap to deliver our care and demonstrates accountability for the patient care it enhances our interprofessional collaboration the diagnosis will direct the planning process and the selection of nursing interventions to achieve the best patient outcomes