NANDA-I International Nursing Diagnoses (eBook)

1 Nursing Diagnosis Basics

T. Heather Herdman, Susan Gallagher-Lepak, Camila Takáo Lopes

1.1 A Brief Introduction to Diagnosing

We begin this discussion by exploring the concept of diagnosing, which encompasses the process of determining a patient’s diagnosis. It’s crucial for nurses to comprehend the skill of not merely assessing and documenting findings, but also engaging in a coherent process of assessment leading to an accurate diagnosis. It is insufficient to complete an assessment and swiftly transition to an electronic health record screen or paper record to haphazardly “select” a diagnosis, devoid of any logical connection to the completed assessment.

This chapter will offer a brief exploration of the nursing discipline and the nursing process before delving into the subject of nursing diagnosis. It will emphasize the significance of distinguishing between the act of diagnosing and the subsequent act of documenting, highlighting the need for a logical linkage between assessment and diagnosis in nursing practice.

Diagnosis, a fundamental responsibility of professional nurses, unfolds during the nurse’s interactions with the patient and their family. This process encompasses an in-depth assessment, extensively detailed in a separate chapter, where nurses conduct physical examinations and conduct a health history to uncover potential health concerns. They gather comprehensive data encompassing the patient’s medical and family history, along with current signs and symptoms.

Data collection involves scrutinizing patient records, including laboratory and diagnostic test results, medications, and progress notes from various disciplines. Additionally, crucial data is gleaned through dialogue with the patient, family, or significant others. By meticulously analyzing data acquired through these multifaceted methods, nurses bergin recognizing patterns, identifying anomalies, and ideally uncovering the patient’s strengths relevant to their healthcare journey.

Leveraging disciplinary expertise, the nurses employ critical thinking to transform raw data into informed inferences. They embark on formulating hypotheses about potential nursing diagnoses possibly present in the patient, demonstrating a strategic and analytical approach to clinical decision-making.

What is meant by an inference? An inference refers to a conclusion or deduction drawn from evidence and logical reasoning, extending beyond explicit or directly presented data or statements. Essentially, it represents a reasoned interpretation or explanation that goes beyond the surface of the provided raw data. Inferences are crafted by combining existing data – consisting of facts and observations – with prior knowledge derived from nursing theory and disciplinary expertise, along with clinical experience.

This process allows for the formulation of a fresh understanding or interpretation that surpasses the initial data set. Inferences often entail making well-informed conjectures or predictions based on available evidence. The ability to derive accurate inferences stands as a pivotal facet of critical thinking, problem-solving, and the diagnostic process in nursing practice.

Drawing upon the analysis of inferences, nurses proceed to diagnose the patient responses inferred from the data. They may engage in collaboration with patients, families, colleagues, and professionals from other disciplines to validate their inferences. This collaborative process aims to confirm or challenge their diagnostic hypotheses, facilitating a comprehensive understanding of the human responses evident in the patient.

However, without a grasp of the underlying concepts and theories within the nursing discipline, accurately deriving inferences from raw data becomes a challenging task. Understanding these foundational principles and theories is crucial for nurses to make accurate inferences and derive meaningful insights from the data obtained during patient assessments.

For example, James, a new nurse in the neonatal intensive care unit (NICU), gathers the following data from the patient record and during care and feeding of Baby Samuel:

As a novice nurse in the NICU, James might not immediately identify signs such as yawning, finger splaying, hiccoughing, and desaturation as stress responses in neonates. Recognizing these requires a deep understanding of neurodevelopmental organization in this patient population. He may perceive weight gain as positive without realizing that it falls below norms for this age group, indicating that Baby Samuel expends more calories than he consumes.

However, equipped with knowledge about neonatal growth and neurodevelopment, James would discern these stress responses and growth concerns. These indicators suggest that the infant struggles to tolerate feeding and lacks adequate calorie intake for normal growth. Accurate inferences arising from this insight might prompt James to consider diagnoses related to neurodevelopmental behavior, stress response, and nutrition, among others, prompting further data collection.

Arriving at a diagnosis in this context necessitates holistic data collection, informed interpretation (inferences), application of clinical expertise, and comprehensive disciplinary knowledge, underscoring the complexity of neonatal care in the NICU environment.

The process of diagnosing stands distinct from the act of documenting the diagnosis. Diagnosing involves a cognitive process, while documenting serves as a mechanism for nurses to convey clinical reasoning and judgment (diagnosis) in a standardized manner, facilitating seamless communication across the interdisciplinary healthcare team.

Standardized terms play a pivotal role in ensuring that all members of the care team comprehensively understand the nursing concerns for each patient, along with the treatment plan, which can be uniformly documented. Utilizing standardized and coded terms also bolsters research endeavors by enabling the study of patient responses that possess identical definitions and diagnostic indicators across various sites, care settings, and even countries.

The adoption of standardized terminology to delineate clinical judgments and interventions maintains consistency across multiple healthcare disciplines, including nursing, medicine, physical therapy, psychology, and others. This unified approach ensures effective communication and fosters a common understanding of patient care across diverse healthcare settings.

1.2 Nursing as a Discipline

Nursing practice revolves around evaluating, diagnosing, and addressing actual or potential individual, family, or community responses to health issues or life processes. These clinical judgments, known as nursing diagnoses, form the foundation for selecting nursing interventions aimed at achieving outcomes for which nurses have accountability. While most people are familiar with medical diagnoses – the identification of diseases, illnesses, or injuries explaining an individual’s signs and symptoms (Hansbauer, 2021)– many are unaware that nurses also establish diagnoses. Interestingly, in contemporary practice, some nurses may assert their disuse of nursing diagnoses, opting instead to strictly adhere to physician directives or follow established protocols, perceiving this as a form of professional autonomy. However, this trend might stem from misconceptions surrounding the teaching of the nursing process and nursing diagnosis over time, as well as the lack of standardized systems within healthcare organizations to support the implementation of nursing diagnosis.

Despite this, many countries mandate that nurses utilize the nursing process, which encompasses the identification of nursing diagnoses as a fundamental framework for delivering nursing care. Research demonstrates that nursing diagnoses, when appropriately employed, possess greater predictability than medical diagnoses alone in critical aspects such as length of stay and hospital readmissions (Zeffiro et al., 2020; D’Agostino et al., 2019; Sanson et al., 2019; D’Agostino et al., 2017; Sanson et al., 2017).

Emphasizing that patients are the focal point of nursing practice extends beyond addressing their diseases or injuries. It encapsulates nurses’ attention on how individuals, families, and communities respond to life processes or health issues and their proactive efforts to enhance their health and prevent such problems. Nurses play a pivotal role in patient safety, offering education, imparting skills to improve health, and lending an empathetic ear to understand patients’ unique experiences. They stand at the forefront of advocating for patient well-being and fostering holistic care.

1.3 The Nursing Process

The nursing process serves as a foundational topic in nearly every nursing program, often introduced as one of the initial courses in the curriculum. This structured approach hinges upon clinical reasoning, which, in turn, draws heavily upon understanding crucial concepts within the nursing discipline. However, when embarking on your nursing education, you might lack familiarity with these concepts crucial for your future practice. It’s challenging to effectively employ clinical reasoning in practical scenarios without first hand exposure to...