Diagnosis - Using the Nursing Process

DIAGNOSIS

The assessment component of the nursing process serves as the basis for identifying nursing diagnoses and collaborative prob-lems. Soon after the completion of the health history and the physical assessment, the nurse organizes, analyzes, synthesizes, and summarizes the data collected and determines the patient’s need for nursing care.

Nursing Diagnosis

Nursing, unlike medicine, does not yet have a complete taxon-omy, or classification system, of diagnostic labels. Classification of discrete items into meaningful categories organizes components of knowledge into coherent units of related information. Some rea-sons for establishing taxonomies are to help identify what is known about a field of study, to discover what gaps in knowledge exist, to provide a common language that enhances communica-tion among colleagues, and to facilitate the coding of standardized information for use in databases. Nursing diagnoses, the first tax-onomy created in nursing, have fostered the development of autonomy and accountability in nursing and have helped to de-lineate the scope of practice. Many state nurse practice acts include nursing diagnosis as a nursing function, and nursing diagnosis is included in the ANA’s Standards of Clinical Nursing Practice and the standards of many nursing specialty organizations.

The official organization that has assumed responsibility for de-veloping the taxonomy of nursing diagnoses and formulating nursing diagnoses acceptable for study is the North American Nursing Diagnosis Association (NANDA). NANDA has grouped diagnoses according to patterns of human responses (Chart 3-7). The diagnostic labels identified by NANDA have been generally accepted but require further validation, refinement, and expansion based on clinical use and research; they are not yet complete or mutually exclusive, and more investigation is needed to determine their validity and clinical applicability.

Choosing a Nursing Diagnosis

When choosing the nursing diagnoses for a particular patient, the nurse must first identify the commonalities among the assessment data collected. These common features lead to the categorization of related data that reveal the existence of a problem and the need for nursing intervention. The patient’s identified problems are then defined in the nursing diagnoses. The most commonly selected nursing diagnoses are compiled and categorized by NANDA in a taxonomy that is updated at least every 2 years. It is important to remember that nursing diagnoses are not medical diagnoses; they are not medical treatments prescribed by the physician; and they are not diagnostic studies. Nursing diagnoses are not the equip-ment used to implement medical therapy, and they are not the problems that the nurse experiences while caring for the patient. They are the patient’s actual or potential health problems that in-dependent nursing actions can resolve. Nursing diagnoses that are succinctly stated in terms of the specific problems of the patient will guide the nurse in the development of the nursing plan of care.

To give additional meaning to the diagnosis, the characteristics and the etiology of the problem must be identified and included as part of the diagnosis. For example, the nursing diagnoses and their defining characteristics and etiology for a patient who has rheumatoid arthritis may include

·      Impaired physical mobility related to pain and stiffness with joint movement

·      Self-care deficits (bathing/hygiene, dressing/grooming, feed-ing, toileting) related to fatigue and joint stiffness

·      Low self-esteem (chronic, situational, risk for situational) related to loss of independence

·        Imbalanced nutrition: Less than body requirements related to fatigue and inadequate food intake

Collaborative Problems

In addition to nursing diagnoses and their related nursing inter-ventions, nursing practice involves certain situations and inter-ventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team. The term collaborative problem is used to identify these situations.

Collaborative problems are certain physiologic complications that nurses monitor to detect changes in status or onset of com-plications. Nurses manage collaborative problems using physician-prescribed and nursing-prescribed interventions to minimize complications. A primary focus of the nurse when treating collaborative problems is monitoring the pa-tient for the onset of complications or changes in the status of ex-isting complications. The complications are usually related to the patient’s disease process, treatments, medications, or diagnostic studies. The nurse prescribes nursing interventions that are ap-propriate for managing the complications and implements the treatments prescribed by the physician. Figure 3-2 depicts the dif-ferences between nursing diagnoses and collaborative problems. After the nursing diagnoses and collaborative problems have been identified, they are recorded on the plan of nursing care.