NUR304 - Adult Health - Exam 2 Study Guide - Nursing Process: Diagnosis

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Explain the importance of the correct etiology for a nursing diagnosis in terms of nursing interventions

Diagnosis is the second step of the nursing process. It is the phase in which you analyze your assessment data. Using your critical-thinking skills, you identify patterns in the data and draw conclusions about the client's health status, including strengths, problems, and factors contributing to the problems. Diagnosis is critical because it links the assessment step, which precedes it, to all the steps that follow it. Assessment data must be complete and accurate for you to make an accurate nursing diagnosis. Accuracy is essential because the nursing diagnosis is the basis for planning client-centered goals and interventions.

An etiology consists of the factors that are causing or contributing to the problem. Etiologies may be pathophysiological, treatment related, situational, social, spiritual, maturational, or environmental. It is important to correctly identify the etiology because it directs the nursing interventions

To identify the etiology of a health problem, use your theoretical knowledge (e.g., of psychology, physiology,
disease processes) and the patient data to answer ques-
tions such as the following:
■ What factors are known to cause this problem?
■ What patient cues are present that may be contributing to this problem?
■ How likely is it that these factors are contributing to the problem?
■ What past experiences do I have that support my judgment that these factors are linked to the problem?
■ Are these cues causing the problem, or are they merely symptoms of the problem?
An etiology is always an inference because you can never actually observe the "link" between etiology and problem. You can often be certain that the etiological factors are present. For example, in the Constipation diagnosis, you could measure (observe) the person's fiber intake. You could also observe infrequent, hard stools (Constipation). But you cannot observe that the lack of fiber is the cause of the Constipation. You have to infer that link based on your knowledge of normal elimination and your experiences with other patients. If the etiology is incorrect or incomplete, you might omit important nursing interventions. Suppose there are missing etiological factors in a skin diagnosis and that it should read: Risk for Impaired Skin Integrity r/t poor nutritional status and complete immobility 2° spinal cord injury. You can see that interventions to support mobility would not be adequate to prevent Impaired Skin Integrity.

Understand the importance of understanding the importance of reliable data to validate a clinical inference

Making inferences is a critical thinking skill. Recall that cues are facts (or data), whereas inferences are conclusions (judgments, interpretations) that are based on the data. An inference is not a fact, because you cannot directly check its truth or accuracy. Even though you cannot ever be completely sure that an inference is accurate, clearly some inferences are supported by more complete and reliable data than others. When you have enough data to support your inference, and you can be reasonably sure that it is accurate (valid). But remember, you can't be absolutely certain. For example, although it is unlikely, the patient might not be telling you the truth. Inference—even one that appears to be more valid than this one—is not a fact. This is an important point in diagnosing. Nursing diagnoses, because they are inferences, are only your reasoned judgment about a patient's health status. So try not to think of a diagnosis as right or wrong, but instead as more accurate or less accurate. Realize that you can never construct a "perfect" diagnosis, but strive to make your diagnostic statements as accurate as possible. Incorrect diagnoses result in ineffective care.

When writing a nursing diagnosis, know the type of information to use for the related to and as evidenced by.

To analyze and interpret data, follow three steps: (1) identify significant data, (2) cluster cues, and (3) identify data gaps and inconsistencies.
1. Identify Significant Data
Significant data (also called cues) are data that influence your conclusions about the client's health status. A cue should alert you to look for other cues that might be related to it (form a pattern).
2. Cluster Cues
A cluster is a group of cues that are related to each other in some way. The cluster may suggest a health problem. To help ensure accuracy, you should always derive a nursing diagnosis from data clusters rather than from a single cue.
3. Identify Data Gaps and Inconsistencies
As you cluster and think about relationships among the cues, you will identify the need for data that was not apparent before. In addition to missing data, look for inconsistencies
in the data.

When making a diagnosis using NANDA, what type of information do you use for the diagnostic label?

Each nursing diagnosis in the NANDA-I taxonomy has four parts: label, definition, defining characteristics, and related or risk factors. You must consider all four parts when formulating a nursing diagnosis.
■ The diagnostic label (title or name) is a word or phrase that represents a pattern of related cues and describes a problem or wellness response, such as Disturbed Body Image or Readiness for Enhanced Nutrition. Some labels include descriptors for time, age, and other factors (e.g., acute, deficient, delayed).
■ The definition explains the meaning of the label and distinguishes it from similar nursing diagnoses. For example, for a patient with a sleep problem, would you label the problem Sleep Deprivation or Disturbed Sleep Pattern? The following definitions can help you to decide:
Sleep Deprivation: Prolonged periods of time without
sleep
Disturbed Sleep Pattern: Time limited disruption of sleep amount and quality
Defining characteristics are the cues (signs and symptoms) that allow you to identify a problem or wellness
diagnosis. To use a problem label appropriately, a cluster of defining characteristics must be present in the patient data. For example, you cannot decide to use the label Sleep Deprivation merely by reading the definition. You must be sure the patient actually has some of the defining characteristics for Sleep Deprivation.
Related factors are the cues, conditions, or circumstances that cause, precede, influence, contribute to, or are in some way associated with the problem (label). They can be pathophysiological, psychological, social, treatment-related, situational, maturational, and so on. NANDA-I lists the related factors that are most often associated with each problem
label, but keep in mind:
1. The list is not exhaustive. Factors other than those listed by NANDA-I could also be associated with the problem. For example, imagine the vast number of factors that might cause someone to have Chronic Low Self-Esteem.
2. The problem may have more than one related factor. Human beings are complex, and their problems rarely have one single cause. Nursing diagnoses may have multiple factors as their etiology.
3. An individual patient will not have all the factors on the list in the NANDA-I Related Factors for his problem etiology.
Risk factors are events, circumstances, or conditions that increase the vulnerability of a person or group to a health problem. They can be environmental, physiological, psychological, genetic, or chemical. For example, ignoring the urge to defecate and being pregnant increase the risk a person will become constipated. The diagnostic statement would be: Risk for Constipation r/t pregnancy and habitually ignoring the urge to defecate.

Know Maslow's Hierarchy of Needs and how to prioritize care.

Even though it is not a nursing framework, many nurses use Maslow's hierarchy to prioritize nursing diagnoses. In Maslow's model, basic needs must be met before a person can focus on higher needs. Maslow (1970) ranks human needs on eight levels, beginning with the most basic needs. (Bottom of Pyramid first)

8. Transcendence: of self; helping others self-actualize (ND: Readiness for Enhanced Spirituality; Spiritual Distress)
7. Self actualization: Personal growth, reaching potential (ND: see 6)
6. Aesthetic: Symmetry, order, beauty (ND: It is unusual for nursing diagnoses to fall into this, or the two higher, categories.)
5. Cognitive: Knowledge, understanding, exploration (ND: Acute Confusion; Impaired Memory; Delayed Growth and Development)
4. Self-esteem: Pride, sense of accomplishment, recognition by others (ND: Chronic Low Self-Esteem; Social Isolation)
3. Love and belonging: Giving and receiving affection, meaningful relationships, belonging to group(s) (ND: Impaired Social Interaction; Ineffective Sexuality Pattern; Impaired Parent / Infant / Child Attachment)
2. Safety and security: Protection, emotional and physical safety and security, order, law, stability, shelter (ND: Risk for Falls; Fear; Risk for Self-Directed Violence)
1. Physiological: Food, air, water, temperature regulation, elimination, rest, sex, and physical activity (ND: Imbalanced Nutrition: Less Than Body Requirements; Impaired Gas Exchange)

Know the definition of nursing diagnosis - the use and a description

A nursing diagnosis is a statement of client health status that nurses can identify, prevent, or treat independently. It is stated in terms of human responses (reactions) to disease, injury, or other stressors, and it can be either a problem or a strength. Human responses can be biological, emotional, interpersonal, social, or spiritual.

In 1990, NANDA-I officially defined nursing diagnosis as "a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable" (NANDA-I, 2007, p. 332). This definition emphasizes the clinical judgment aspect of diagnosing.

➤ Nursing diagnosis is the unique obligation of the professional nurse; it cannot be delegated.

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➤ An accurate nursing diagnosis is the foundation for the plan of care because it directs the choice of client-centered goals and nursing interventions.

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➤ A nursing diagnosis is a statement of health status that nurses can identify, prevent, or treat independently.

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➤ A medical diagnosis describes a disease, illness, or injury. A nursing diagnosis, in contrast, more holistically describes human responses to disease, illness, or injury.

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➤ Collaborative problems are potential physiological complications of diseases, treatments, or diagnostic studies that nurses monitor and help to prevent but that cannot be treated primarily by independent nursing interventions.

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➤ You must determine the "status" of each nursing diagnosis—that is, actual, potential, or possible problem; wellness diagnosis; or syndrome—because each status requires (1) different wording and (2) different nursing interventions.

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➤ Diagnostic reasoning involves analyzing and interpreting data, verifying problems with the patient, and prioritizing the problems.

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➤ You can never be certain that an inference is accurate, but you can have more confi dence in an inference that is well supported by data.

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➤ A problem etiology consists of the factors causing or contributing to the problem.

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➤ You should involve patients in verifying and prioritizing their problems.

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➤ Sound diagnostic reasoning is based on critical thinking and good theoretical and self-knowledge.

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➤ A NANDA-I nursing diagnosis consists of a diagnostic label, a definition, defi ning characteristics, and related or risk factors.

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➤ To choose the correct NANDA-I problem label, match the patient's cue clusters to the NANDA-I definition and defining characteristics.

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➤ A diagnostic statement consists basically of "problem + etiology"; however, a variety of formats is needed to describe client health status.

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➤ In general, the problem side of the diagnostic statement directs the choice of goals; the etiology directs the choice of nursing interventions.

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➤ Diagnostic statements should be descriptive, accurate, clear, concise, and nonjudgmental.

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➤ One criticism of standardized diagnostic language is that it represents a threat to creative, holistic thinking.

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