Diagnosing Group III
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Transcript of Diagnosing Group III
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Polii, Paul
Pontororing, Jonly
Rompas, Heiber
Retor, Wanlie
Sepang, Geriel
Selamat, Valentino
Puni, Hizkia
Preisilia Fristy
Sinaulan, Finne
Sriwidyawati Meida
Sumanti, Lady
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Learning Objectives
Describe the term nursing diagnosis,distinguishing it from a collaborativeproblem and a medical diagnosis.
Describe the four steps involved in data
interpretation and analysis. Use the guidelines for writing nursing
diagnoses when developing diagnosticstatements.
Describe means to validate nursingdiagnoses.
Describe the benefits and limitations ofnursing diagnoses.
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Lady
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Diagnosing
After the nurse has collected and recorded thepatient data, the work of diagnosing begins (the second step in the nursing process ).
The purpose of diagnosing is to:
1. Identify how an individual, group orcommunity responds to actual or potentialhealth and life processes
2. Identify factors that contribute to or causehealth problems (etiologies).
3. Identify resources or strengths the individual,group or community can draw on to preventor resolve problems.
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Cont...
In the diagnosing step of the nursingprocess, the nurse interprets andanalyzes data gathered from the
nursing assessment. The data helpthe nurse identify patient strengthsand health problems.
A health problem is a condition that the
necessitates intervention to prevent orresolve disease or illness or topromote coping and wellness.
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Cont...
Alfaro-LeFevre (2004), lists the following as the type of nursingconcerns that are clearly nursing responsibilities:
1. Monitoring for change in health status.
2. Promoting safety and preventing harm, detecting andcontrolling risks.
3. Identifying and meeting learning needs.
4. Tailoring treatment and medication regimens for eachindividual.
5. Promoting comfort and managing pain.
6. Promoting health and a sense of well being.
7. Recognizing and addressing problem that impede the ability
to be independent and live a healthy lifestyle.8. Determining human responses (how individuals, families or
groups respond to health problems or life changes).
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Cont...
When a health problem is identified,the nurse must decide which
healthcare professional can best treat
the problem. Actual or potential healthproblems that can be prevented or
resolved by independent nursing
intervention are termed nursingdiagnoses.
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Meida
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Key elements in the evolution of nursing
diagnosis as and integral component of
nursing process include the following: In 1953, the term nursing diagnosis was
introduce by V. Fry (1953) to describe a
step necessary in developing a care plan.
In 1972, the New York State Nurse Practice
Act identified diagnosing as part of the legal
domain of professional nursing.
In 1973, The American Nurses AssociationsStandards of Practice include diagnosing as
a function of professional nursing
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Also in 1973, Gebbie and Lavin, of St.
Louis University, called the First
National Conference on Classification of
Nursing Diagnoses, beginning a
national effort to identify, standardize
and classify health problem treated bynurses:
In 1980, the ANA Social Policy
Statement defined nursing as thediagnosis and treatment of human
responses to actual or potential health
problem.
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In March 1990, at the Ninth Conference of
NANDA, the General Assembly approved an
official definition of nursing diagnosis:
Nursing diagnosis is a clinical judgment
about individual, family or community
responses to actual or potential health
problem/life processes. Nursing diagnosisprovides the basis for selection of nursing
interventions to achieve outcome for which
the nurse accountable.
NANDA conferences are held every 2 years,and much progress continues to be made in
defining, classifying and describing nursing
diagnoses.
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NURSING DIAGNOSIS
VERSUS MEDICAL DIAGNOSIS Medical diagnoses identify diseases, whereas
nursing diagnoses focus on unhealthy
responses to health and illness.
Medical diagnoses describe problems for which
the physician directs the primary treatment,
whereas nursing diagnoses describe problems
treated by nurses within the scope of
independent nursing practice.
A medical diagnosis remains the same for as
long as the disease is present, where a nursing
diagnosis may change from day to day as the
patients responses change. These distinctionsreflect key difference in medical and nursing
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Heiber
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Nursing Diagnosis Versus
Collaborative Problems Carpenito defines collaborative
problemsas certain physiologiccomplications that nurses monitor to
detect onset or changes in status.Nurses manage collaborative
problems using physician-prescribed
and nursing-prescribed interventionsto minimize the complications of the
event.
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Cont...
Unlike medical diagnoses, collaborativeproblems are the primary responsibilityof nurses.
Unlike nursing diagnoses, withcollaborative problems, the prescriptionfor treatment comes from nursing,medicine, and other disciplines. When
the nurse writes patient outcomes thatrequire delegated medical orders for goalachievement, the situation is not anursing diagnosis, but a collaborative
problem.
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Cont...
Because collaborative problemsinvolve potential complications, they
must be identified early so that
preventive nursing care can beinstituted early.
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Ovarian Cancer Radiotherapy ExploratoryLaparotomy
Fi ure 13-4 Collaborative Problems
Medical
diagnosis/disea
se
Medical/Surgical
Nursing
Treatment
Diagnostic
Study
PC: Cachectic
syndrome
related to
disease process
PC: Paralytic
ileus related toanesthesia
PC: Infection
related to stageIII skin reaction
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Wanlie
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LEGAL ALERT: ALFAROS
RULE
The term diagnose and diagnosis have legalimplications. They imply that there is a specific
problem that requires management by a qualified
expert.
If you make a diagnosis, it means that you accept
accountability for accurately naming and managingthe problem.
If you treat a problem or allow a problem to persist
without ensuring that the correct diagnosis has been
made, you may cause harm and be accused ofnegligence.
You are accountable for detecting, identifying, or
recognizing signs and symptoms that might indicate
problems beyond your expertise. Example: staff
nurses are not qualified to diagnose and manage
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Cont...
However, they are accountable for: Detecting and reporting signs and symptoms of
pneumonia (for example, fever, productive cough,
malaise).
Diagnosing and managing risk factors forpneumonia (for example, weak breathing efforts
due to surgical pain, spinal cord injury, or disease;
in complicated cases, these risk factors may
require medical management).
Diagnosing and managing human responses to
pneumonia (for example, fatigue and problems
with airway clearance relates to pneumonia).
Ensuring that the medical treatment plan is
implemented as prescribed (Alfaro-LeFevre, 2004-
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DIAGNOSTIC REASONING
AND CRITICAL THINKING
Selamat
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. Be familiar with nursing diagnoses andother health problems; read professionalliterature and keep reference guides handy
. Trust clinical experience and judgment, butbe willing to ask for help when the situationdemands more than your qualifications andexperience can provide.
. Respect your clinical intuitions, but before
writing a diagnosis without evidence,increase the frequency of your observationsand continue to search for cues to verifyyour intuitions.
. Recognize personal biases and keep an
To correctly diagnose health
problems:
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Hizkia
Q ti t f ilit t iti l thi ki
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Questions to facilitate critical thinking
during diagnostic reasoning include:
. Are my data accurate and complete? . Has the patient or the patients
surrogates validated (if able to do so)that the these are important problems?
. Have I given the patient or thepatients surrogate an opportunity toindentify problems that may have
missed? . Is each diagnosis supported by
evidence? Might these cues signify adifferent problem or diagnosis?
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. Have I tried to identify what is causing
the actual or potential problem and what
strengths/resources the patient mightuse to avoid to resolve the problem?
. Have a used agency guidelines to
correctly document diagnosticstatements in a way that clearly
communicates patient problems to other
healthcare professionals? . Is this a problem that falls within
nursings independent domain or does it
signify a medical diagnosis or
collaborative roblem.
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Finne
DATA
INTERPRETATIONAND ANALYSIS
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RECOGNIZING SIGNIFICANT
DATA To avoid erroneously labeling selected
patient health patterns as unhealthy
(diagnostic error) while failing to detect
an actual unhealthy behavior, nursesmust be familiar with comparative
standards to be used in data
interpretation and analysis.
A standard, or a norm, is a generally
accepted rule, measure, pattern, or
model to which data can be compared in
the same class or category.
Examples of how standards can be used to
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Examples of how standards can be used to
indentify significant cues include the following
(Gordon,1994):
Changes in a patients usual healthpatterns that are unexplained by
expected norms for growth and
development. Deviation from an appropriate
population norm.
Behavior that indicates adevelopmental lag or evolving
dysfunctional pattern.
Behavior that is nonproductive in the
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RECOGNIZING PATTERNS OR
CLUSTERS
A data cluster is a grouping of patient
data or cues that points to the
existence of a patient health problem. Nursing diagnoses should always be
derived from clusters of significant
data rather that from a single cue.
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Preisilia
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INDENTIFYING STRENGTHS AND
PROBLEMS
The next step in analyzing data is todetermine the patients strengths and
problems.
When determining a patientsstrengths and problems, it is helpful to
determine whether the patient agrees
with the nurses identification ofstrengths and problems and is
motivated to work toward their
resolution.
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DETERMINING THE PATIENTS
STRENGTHS
If a patient appears to meet a
standard, the nurse concludes that the
patient has a strength in that particulararea, and that this strength contributes
to the patients level of wellness.
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DETERMINING THE PATIENTS
PROBLEM AREAS
A person who does not meet a certainhealth standard probably has alimitation in this aspect of health statusand may benefit from professionalcare.
the nurse decides whether the datarepresent a nursing diagnosis or a
collaborative problem, or whether thedata should be reported to thephysician because they might lead toa medical diagnosis.
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DETERMINING PROBLEMS THE
PATIENT IS LIKELY TO EXPERIENCE
It is important for nurses to identifypotential health problems.
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REACHING CONCLUSIONS
The nurse reaches one of four basicconclusions after interpreting and
analyzing the patient data.
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Finne
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Cont
Different nursing responses are possiblefoe each conclusion:
* No Problem
No nursing response is indicated. Reinforce patients health habits and
patterns
Initiate health-promotion activities toprevent disease or illness or to promote
a higher level of wellness.
Wellness diagnosis might be indicated.
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Cont
*Possible Problem Collect more data to confirm or
disprove suspected problem.
*Actual Or Potential NursingDiagnosis
Begin planning, implementing, and
evaluating care designed to prevent,reduce, or resolve the problem.
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Cont
If unable to treat problem becausepatient denies problem and refusestreatment, make sure patientunderstands possible out-comes of this
stance.*Clinical Problem Other Than Nursingdiagnosis
Consult with appropriate healthcare
professional and work collaboratively onproblem. Refer to medicine or other service as
indicated.
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FORMULATING AND
VALIDATING NURSING
DIAGNOSA
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Writing nursing diagnoses
When the nurse recognizes a clusterof significant patient data indicating ahealth problem that can be treated byindependent nursing intervention, anursing diagnosis should be written.
Most nursing diagnoses are writteneither as two-part statements listing
the patients problem and its cause oras three-part statement that alsoinclude the problems characteristics
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Formulation of nursing
diagnosis statements
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problem purpose example
Problem
Etiology
Defining
characteristics
Identifies what
unhealthy aboutthe patient,
indicating the
need for
change.
Identifies the
factors that are
maintaining the
unhealthy state
or response.
Identify the
subjective andobjective data
that signal the
existence of the
problem
Suggests
patient outcome
Suggests the
appropriate
nursing
measure.
Suggests
evaluativecriteria
Bathing/hygiene
self-care deficit.
Related to
Fear of falling in
the tub and
obesity.
As manifested
by
Strong body and
urine odor,
unclean hair, Im
afraid Ill fall inthe tub and
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Examples
Two-part diagnostic statement: Bathing/Hygiene Self-Care Deficit r/t fear
of falling in tub and obesity.
Three-part diagnostic statement: Bathing/Hygiene Self-Care Deficit r/t fear
of falling in tub and obesity. As manifested
by strong body and urine odor, unclean
hair, statement of fearing in tub, and
height and weight 54, 170 lb.
Type of nursing
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Type of nursing
diagnoses NANDA describes five types of
nursing diagnoses: actual, risk,
possible, wellness, and syndrome
1 A t lit i di
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1. Actuality nursing diagnoses
Actuality nursing diagnoses represent aproblem that has been validated by
the presence of major defining
characteristic. This type of nursingdiagnosis has four component: label,
definition, defining characteristic, and
related factor.
2 Ri k i di
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2. Risk nursing diagnoses
Risk nursing diagnoses are clinicaljudgments that an individual, family, or
community is more vulnerable to
develop the problem than others in thesame or similar situation
3 P ibl i di
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3. Possible nursing diagnoses
Possible nursing diagnoses arestatement describing a suspected
problem for which additional data are
needed.Additional data are used to confirm or
rule out suspected problem.
4 W ll di
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4. Wellness diagnoses
Wellness diagnoses are clinicaljudgments about an individual, group,
or community in transition from a
specific level of wellness to a higher ofwellness.
Two cues must be present for a valid
wellness diagnoses:A desire for a higher level of wellness
An effective present status or function
5 S d i di
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5. Syndrome nursing diagnoses
Syndrome nursing diagnosescomprise a cluster of actual or risk
nursing diagnoses that are predicated
to be present because of a certainevent or situation example: rape
trauma syndrome or post-trauma
syndrome.
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Gerryl Sepang
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Parts of Nursing Diagnoses
Problem The purpose of the problem statement is to
describe the health state or health or healthproblem of the patient as clearly andconcisely as possible.
NANDA recommends use of the followingquantifiers when writing the problemsstatement: ability, anticipatory, balance,compromised, decreased, deficient,defensive, delayed, depleted,disproportionate, disabling, disorganized,disturbed, dysfunctional, effective,excessive, functional, imbalanced, impaired,inability, increased, ineffective, interrupted,low, organized, perceived, and readiness for
enhanced
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Cont
Etiology The etiology identifies the physiologic,
physiological, sociologic, spiritual, and
environmental factors believed to berelated to the problem as either a causes
or a contributing factor.
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Cont
Defining characteristic The subjective and objective data that
signal the existence of the actual or
potential health problem are the thirdcomponent of the nursing diagnosis
Guidelines for writing nursing
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Guidelines for writing nursing
diagnoses
- Remember the following to ensure thatyour diagnostic statement are
correctly written
1. Phrase the nursing diagnosis as apatient problem or alteration in health
sate rather than as a patient need.
2. Check to make sure that the patientproblem precedes the etiology and
that the to are linked by the phrase
related to
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3. Defining characteristic, whenincluded in the nursing diagnosis,
should follow the etiology and be
linked by the phrase as manifestedby or as evidenced by.
4. Write in legally advisable terms
5. Use nonjudgmental language6. Be sure the problem statement
indicates what is unhealthy about the
patient or what the patient wants to
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7. Avoid using defining characteristic,medical diagnoses, or something that
cannot be change in the problem
statement8. Reread the diagnosis to make sure
the problem statement suggests
patient outcomes and that etiology willdirect the selection of measure
Validating nursing diagnoses
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Validating nursing diagnoses
After a tentative nursing diagnosis isformulated, it should be validated.
An affirmative response to each of thefollowing question validates a tentativediagnosis:
1. Is my database sufficient, accurate,and supported by nursing research?
2. Does my synthesis of data(significant cues) demonstrate theexistence of a patter?
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3.Are the subjective and objective data I usedto determine the existence of a patterncharacteristic of the health problem I defined?
4. Is my tentative nursing diagnosis based on
scientific knowledge and clinical expertise.5.Is my tentative nursing diagnosis able to be
prevented, reduced, or resolved byindependent nursing action?
6. Is my degree of confidence above 50% thatother qualified practitioners would formulatethe same nursing diagnosis based on mydata?.
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Terry
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Nursing Diagnosis: A Critique
The current nursing diagnosis literaturecontains many examples of nurseswriting about how using nursingdiagnoses has improved their clinical
practice.Articles also detail the many benefits
nursing diagnosis brings to theprofession.
Conversely, other articles point out thelimitations of nursing diagnosis and urgenurses to be cautious so that an
uncritical use of nursing diagnosis does
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Cont...
The primary benefit that nursingdiagnosis offers the patient is the
individualization of patient care.
For example, nurses might be caring
simultaneously for three women who had a
modified radical mastectomy because of
breast cancer. Although the postoperative
nursing management of these women is
similar, priorities of care may differ. A
prioritized list of nursing diagnoses enables
nurses to direct their energies toward these
differing patient priorities.
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Example
Patient A Distubed Body Image
Ineffective Coping
Patient B Pain
Bathing/Hygiene Self-Care Deficit
Patient C Sexual Dysfunction
Powerlessness
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Cont...
Improved communication among nursesand other health care professionals isprobably the most important benefit thataccurate, up to date diagnoses,
expressed in well defined andstandardized terminology offer nurses.
This communication aids in planning,charting, patient data retrieval, healthteam conferences, change of shiftreports, and healthcare follow up.
It also promotes nursing accountability
for the problems that nurses diagnose.
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Cont...Among the other benfits of nursing
diagnoses for the profession is help in
defining the domain of nursing for helath
care administrators, legislators, and other
healthcare providers: this is important whenseeking funding for nursing and
reimbursement for nursing services.
Nursing diagnoses are also used to define
curriculum content and to directspecialization and advancement in nursing
and nursing research.
When the diagnostic process is used
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Common Sources of Error
Premature diagnoses based on anincomplete database.
Erroneous diagnoses resulting from
an inaccurate database or a faultydata analysis.
Routine diganoses resulting from the
nurses failure to tailor data collectionand analysis to the unique needs of
the patient.
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Cont...
Errors of omission: Failure to modifydiagnoses and to identify new
diagnoses as the patients status
changes may also be problems. Failures in diagnosis lead to failures in
nursing care.
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Conclusion
In conclusion, nursing diagnosis hasbecome a valued and essential step inthe nursing process.
Used correctly, it is a powerful tool for
individualizing patient care and ensuresthat nurses energies are being used inthe most efficient way to meet patientsneeds.
Nurses who are as concerned about theart and spirit of nursing as they are aboutits science are careful to avoid labelingpatients in a way that objectifies them orlimits the potential range of nurse-patient
interactions.
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