05.03 Nursing Process – Diagnose

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Overview

  1. Nursing Diagnosis
    1. Nursing Diagnosis Defined
    2. Analyzing Data
    3. Make a Decision
    4. Using Nursing Diagnosis in Practice

Nursing Points

General

  1. Nursing Diagnosis – Defined
    1. Diagnosis definition
      1. Nursing Diagnosis is the analyzing of data in the nursing process
      2. How the nurse thinks about a response to what a patient is going through
    2. 2nd phase of Nursing Process
    3. Differs from medical diagnosis
      1. “Diagnosis” is not literal
      2. Meant to be used to “identify a problem or risk”
  2. Nursing Diagnosis Terminology
    1. Common Terms/Acronyms
      1. ADPIE – Assessment, Diagnosis, Planning, Implementation, Evaluation
      2. APIE – Assessment, Planning, Implementation, Evaluation
        1. Excludes “diagnosis”
      3. SOAPIE – Subjective, Objective, Analysis, Planning, Implementation, Evaluation
      4. All terminology references the nursing process
    2. NANDA
      1. Professional organization
      2. Created common terminology and nomenclature
      3. Nursing programs differ in their use of NANDA diagnosing
    3. Terminology varies
      1. Important fact to remember: “Diagnosis”  is finding out what the problem is
  3. Analyze Data
    1. Helps form planning phase
    2. Use info available
      1. Medical Diagnosis
      2. Tap into knowledge base
  4. Make a Decision
    1. What is the primary problem?
    2. Use the information available
      1. Refer to primary and secondary sources for info
        1. Primary – from the patient
        2. Secondary – anywhere else
    3. Plain language
      1. Avoid NANDA nomenclature
      2. Use plain language to identify and document
    4. Identify risks
      1. Identify risks associated with the current complaint or problem
    5. Begin thinking of plan
      1. Planning stage begins here.
      2. Begin to think of interventions, both appropriate and inappropriate
        1. i.e. what works and what doesn’t work

Nursing Concepts

  1. Professionalism
  2. Clinical Judgment

Reference Links

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Video Transcript

Now, we’re going to talk about the diagnosis phase of the nursing process.

So let’s talk really quickly about what it is and define kind of what the diagnosis process is. The nursing diagnosis phase is really the analyzing of data in the nursing process. Where did we get all that data? We got all the data from our assessment phase. So, we’re now analyzing all this data that we’ve collected. This is really how the nurse thinks about a response to what the patient is going through, okay? Again, it’s the second phase of the nursing process, and it differs from a medical diagnosis, okay? It’s not a medical diagnosis. So in that sense, diagnosis is not literal. Meaning, it’s not meant to be a literal diagnosis. It really pertains to our plan and our planning, okay?

So it’s meant to be used to identify a problem or a risk that our patient has. We’re just identifying a problem, or an issue, or risk. That’s kind of where diagnosis plays in. We’ve got all of our data. So we’re analyzing that data to assess is there a problem, is there a risk that my patient is having. All right. So there are some common terms or acronyms used to kind of … and that’s going to vary by program, and some of us glue the term diagnosis all together. So first, we have ADPIE, which is what we talk about Assess, Diagnose, Plan, Implement, and Evaluate. And then we have APIE or Assess, Plan, Implement, and Evaluate, that kind of leave out diagnosis, but that’s supposed to kind of be done here in the assessment phase when you collect and then assess that data.

And then you have the SOAPIE, which really is Subjective, Objective, Analysis, Planning, Implement, and Evaluate, where here is where you’re doing this diagnosis. All right. Now, there’s this organization called NANDA. You probably heard the term NANDA diagnosis. So what is NANDA? Like I said, it’s a professional organization. What does it do? They try to create common terminology and nomenclature around this idea of nursing diagnosis, okay? That was its goal. Now, nursing programs differ in their use of a NANDA diagnosis, so may or may not be used in your program. But the idea behind NANDA is we say, “Okay, here’s a list of 180 or so different diagnosis that you can say that your patient has. And so, when you make your care plans and clinical, you have to use one of these and your patient has to have one of these.

Now, we’re going to talk about that in just a little bit more. So, this terminology varies and it’s an important fact to remember that diagnosis is finding out what the problem is no matter what we call it. We have all of our data together and the diagnosis is finding out what that problem is. So don’t focus too much on ADPIE, or SOAPIE, or NANDA, or whatever. Just realize that we’re finding out what the problem is that our patient has. So we’re analyzing data. This really helps as we start preparing for the planning phase in the nursing process. In the diagnosis phase, the RM begins to identify areas of planning because this is when we figure out what problems the patient is actually facing.

So we have to use all the information that we can find. We use all information available. Refer to all this to make a more sound clinical decision. So we have our medical diagnosis saying your patient has DKA. So we’re trying to see what the problems are that this patient is going to have, and we tap into our knowledge base that we’ve gained. We refer to all of the knowledge that we’ve gained from our books, from our assessment, from our observation, from our labs, from everything. And then we also have to use some intuition. So with DKA, I know my patient is going to need fluids. I know what’s going on here. So we start to use intuition and we try to put pieces together. And so here’s what problems my patient has.

And then we must employ more investigation. If things don’t look or feel right, if we say, “This is what I’m seeing, but that just doesn’t seem right. I think more needs to be done,” okay? Then once we’ve done that, we start to make a decision. What is the primary problem or risk that my patient is facing. So we’ve used the information available. We use things from primary sources, which would be from the patient themselves, or we can use secondary sources. That’s from anywhere else. Okay. Now, we make this decision, we write it down in normal language, all right? We write a list down in normal language. We avoid using the NANDA terminology and we write it down in plain language.

The reason we avoid using NANDA at this phase and this is … I’m talking in real life, if you have a clinical paperwork, where you have to use NANDA, fine. But if you’re taking care of a DKA patient, I want you to avoid using NANDA language because what NANDA really does is it really boxes you in to I have to say that my patient has this one problem, or one, or two, or three problems, and I write it out, and I say exactly what’s going to happen. I don’t want you to do that because I want you to look at your DKA patient and say, “Here’s everything that my DKA patient has going on. This is all the different things that I need to do. So use plain language, all right? Use plain language. Say what the patient has, say what risks and what problems they’re going to have because of this medical diagnosis. That starts to get you leading towards your planning phase of how you’re going to then address these issues that your patient has going on.

So start identifying these risks with the current complaint or problem that the patient has, and begin to think of your plan. Your planning starts right now. Begin to think of those interventions with the appropriate ones, the ones you shouldn’t do, what shouldn’t I do for a patient with a low blood pressure. Should I be giving them narcotics? What should I do for a patient with low blood pressure, get them fluids, get them pressors, et cetera. You start thinking of this thing. So while NANDA is fine in school to help pass your class, I don’t want you to necessarily use it now because I want you to think more holistically of your patient and what’s actually going on so you could start to address these things, all right? What works and what won’t work for a patient.

So what are some of the nursing concepts. It’s going to be professionalism and, of course, clinical judgment. How do we work in the clinical setting. One of the ways we do that is following the nursing process and creating diagnosis for the patients, analyzing all the data we’ve assessed.
Now, we’re getting here to diagnose. So we’re analyzing all this data that we got and we’re finding the risks and the problems that our patient currently has. So with nursing diagnosis and in the diagnosis phase realize it’s not a medical diagnosis. It’s part of the nursing process to identify complaints, risks, and issues that our patient has. It’s the second phase of the nursing process. You have to use your knowledge. You got to tap in to this knowledge and this knowledge bank that you’re acquiring, working on clinical, reading your books, studying.

You have to start tapping in to all those things that you’re learning, and then you have to analyze your data. Look at the data, and your patient, and let those start to guide you and guide your decision-making, then you must make a decision. Look at the big picture and now it’s time to say what’s wrong. If your patient is at risk for skin breakdown related to impaired skin integrity, that means what, what are you going to do? He’s at risk for skin tears because of his bad skin. So what can I do to keep that from happening? Start making some decisions and go with what you’ve analyzed and what you’ve decided. All right, guys, that’s diagnosis. I want you, guys, to study this, to realize this, and to start acting on this in clinical on tests and in the hospital.

All right, make sure you’re looking all the resources attached with this, make sure you watch all the other lessons associated with the nursing process. Now, it’s time to go out and be your best selves today. Happy nursing.

Read more

  • Question 1 of 8

A 35-year-old client is being seen for anxiety and sleep problems secondary to reports of elevated stress levels. The client tells the nurse that she has been restless and has problems concentrating. Which nursing diagnosis would be most appropriate for this client?

  • Question 2 of 8

A nurse is caring for a client who was recently diagnosed with diabetes and is receiving treatment for hypoglycemia. The nurse gives the client a nursing diagnosis of Fear related to the diabetes diagnosis based on the client’s behavior and sense of anxiety when she talks about managing her disease. What type of nursing intervention is most applicable for this nursing diagnosis?

  • Question 3 of 8

A 69-year-old client has been diagnosed with cardiomyopathy. The nurse gives the client a nursing diagnosis of powerlessness because the client has said that she feels sad and angry about what she will miss out on with her diagnosis. Which nursing intervention is most appropriate for this nursing diagnosis?

  • Question 4 of 8

A client with a history of heart disease and obesity is being seen in the primary care clinic. The nurse notes that the client has a nursing diagnosis of Ineffective Tissue Perfusion related to his cardiac disease. Upon assessment of the client’s lower extremities, the nurse notes a brownish discoloration of the skin. This sign is most likely associated with which of the following conditions?

  • Question 5 of 8

A patient has been given a nursing diagnosis of Alteration in Comfort related to a back injury. Which nursing intervention would be most appropriate in this situation?

  • Question 6 of 8

A nurse has given her patient a nursing diagnosis of Fluid Volume Deficit related to inadequate oral fluid intake because of his medical treatment. The patient requires TPN. Which of the following nursing interventions is most appropriate in this situation? Select all that apply.

  • Question 7 of 8

A nurse is caring for a patient with a nursing diagnosis of ‘Pain related to a back injury’. In addition to asking the client to rate their pain intensity, the nurse monitors for changes in vital signs and other appearances of pain from the patient. Which of the following describes the best rationale for this?

  • Question 8 of 8

A nurse has given a client a nursing diagnosis of Ineffective Coping because of her response to an injury. The nurse helps the client to recognize individual strengths in this situation. Which outcome would most likely be expected as a result of these interventions?

Module 0 – Fundamentals Course Introduction

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