Clinical Diagnostic and Reasoning - week 1 PDF

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Clinical Diagnostic and Reasoning Diagnosis: -! 2nd phase of the nursing process -! Nurses use diagnostic reasoning to analyze data & dx -! Raw conclusions about the client’s health status Nurses: Verify conclusions with clients -! Select standardized labels -! Record in care plan -! What is the difference between diagnostic reasoning and nursing diagnosis? -! Depends on assessment phase (what happens in the assessment phase?) -! Quality of data collected affects accuracy of nursing diagnosis Two stages overlap -! Begin to interpret data at the same time as the nurse is collecting it Importance of Nursing Diagnosis Nursing Diagnosis: -! Facilitate individualized care -! Promote professional accountability & autonomy by defining and describing independent area of nursing practice -! Effective vehicle for communication among nurses & health care professionals -! Helps determine assessment parameters Diagnosis Health Status -! Purpose of diagnosis is to identify clients present health status -! A comprehensive care plan includes: 1.! Strengths 2.! Wellness diagnosis 3.! Actual, potential & possible nursing DX 4.! Collaborative Problems 5.! Medical problems (although nurses do not diagnose, they are expected to recognize & refer situations beyond expertise) Avoiding Diagnostic Errors 1.! Don’t jump to conclusions based on just a few facts 2.! Build a good knowledge base & acquire clinical experience 3.! Examine your beliefs & values 4.! Keep your mind open to all possible explanations of the data 5.! Validate all diagnosis with data, not intuition 6.! Develop cultural sensitivity 7.! Incomplete wording of nursing diagnosis Diagnostic Reasoning -! What is it? -! Explain the following -! Cues

-! Clustering of cues -! Data gaps -! Hunches or hypotheses -! What is involved in diagnostic reasoning Diagnostic reasoning: a critical thinking process used within the nursing process to identify patterns from the data and to draw conclusions about the health status of a client -! Cues are information collected through one of more of 5 senses (symptoms or signs) -! Clustering of cues is grouping together significant sues (ex. Dilated pupils, dry mouth, restlessness suggests anxiety) -! Data gaps are missing pieces of relevant data to support hunches -! Client strengths are those areas of normal, healthy functioning that will help the person to achieve higher levels of functioning, to prevent & overcome health problems Diagnostic Reasoning Involves 1.! Consider the organized data from the nursing framework and compare data to standards and norms (ex. Anatomy and physiology, nursing knowledge, developmental theory, lab values, etc.) 2.! Cluster significant cues from other categories and are also cluster cues that seem to be related (relationship between facts ) -! Identify patterns in the data -! Identify data gaps & inconsistencies Conclusions about present health Status -! Consider all possible explanations for each cue cluster -! Decide which hypothesis best explains it -! Determine causes of health problem -! Identify wellness & actual, potential and possible nursing diagnosis; and collaborative problems -! Identify strengths (pt and family) Nursing Diagnosis -! The end product of diagnostic reasoning -! a statement of health status of the client where nursing can intervene -! are NOT nurse problems -! NANDA statements that are individualized (standard problem label) with a… a)! “Related to” (R/T) clause and b)! “as evidenced by” (AEB) clause Components of Nursing Diagnosis A) Unhealthful/maladaptive human response (NANDA) that requires intervention by the nurse (healthy responses but can promote growth etc.)  B) “Related to” clause which identify contributing factors (etiologies) in individual client situation that are leading to the unhealthful response (NANDA dx.) 

C)” Secondary to” clause are factors nursing cannot intervene (eg., disease process, age)  D) “As evidenced by” clause which outlines the individual client situation data that supports A & B above (defining characteristics)  Types of Nursing Diagnosis -! Wellness Diagnosis: are statements of health that show client strengths however, interventions can be initiated to promote growth or to maintain the health response -! Actual Nursing Diagnosis: health concerns (maladaptive human response ) that are present now based on the presence of symptoms (subjective data from history) and signs (objective data, ex. Physical exam findings ) Nursing care is directed towards dealing with the diagnosis now. -! Potential Nursing Diagnosis: health concerns (maladaptive human responses) that are likely to develop if interventions are not initiated. Risk factors are present that make a person more likely to develop a health concern. Nursing care is directed towards preventing the development of these diagnosis -! Possible Nursing Diagnosis: you have a hunch that a health concern might exist because you have some data might exist because you have some data. You do not have enough data to confirm or to eliminate a nursing diagnosis so you identify a possible diagnosis so that monitoring will occur. Collaborative Problems -! Are complications of a disease, test, or treatment that the nurse cannot treat independently -! “related to” clause outlines the etiologist that are causing the health problems -! Eg. Deep vein thrombosis related to immobility and fractures femur Medical Diagnosis -! is a disease process that is usually identified by a physician and/or nurse practitioner? -! involves medical treatments to manage, and/or cure the disease -! some examples, migraine, headaches, hypertension, diabetes Some examples of Nursing Diagnosis 1.! constipation related to inactivity as evidenced by statement “it hurts too much to move,” pain in toes with ROM of the foot; “2 small hard stools” 2.! chronic pain in both feet related to lack of exercise secondary to osteoarthritis as evidences by Prioritizing Nursing Diagnosis -! decided on the basis of nurse’s judgement and client preferences -! prioritize from highest to lowest -! life threatening diagnosis are highest priority -! medium – priority dx. May produce destructive physical and/ or emotional changes -! low – priority dx- minimum nursing interventions are needed LOOK OVER EXAMPLE CASE STUDY...