CLASS 7 : Selection & manipulation of client cues to produce nursing diagnoses

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Class material and assignments related to CLASS 7 will be tested in CLASS 8.

 

TOPIC: ORGANIZING ASSESSMENT DATA

 

TOPIC: ORGANIZING A NURSING ASSESSMENT

  • Looking for a matrix for unexpected findings
  • What is a relevant finding? - the elephant's high heels
  • The value of detail - orientation in nursing
  • Using Nursing and Diagnosis books
  • Types of data
  • Group work:  Dividing data into subjective or objective lists.

* Cox, HC, Hinx, MD, et. al.(1997).Clinical Foundations of Nursing
Diagnosis (3rd ed.). Philadelphia:F.A. Davis.

 

TOPIC: A Nurse's Focus on the Client

There is nothing static about health care. Everything is evolving: the condition of the client, the options for treatment, the economic backdrop for delivering care, and the roles of the Health Care Team members. As soon as a set of guidelines for nursing practice is adopted, challenges occur – challenges trying to restrict a nurse's practice and other challenges to expand it. Before you graduate expect to witness significant changes in the opportunities for nurses to deliver care to their clients.

Every health care discipline has a unique point of view, and a special area of expertise. The physician focuses on pathology, the physical therapist on movement, the chaplain on spiritual needs, and so forth. Despite differences in focus, coordination and mutual respect between team members grows increasingly vital. The nurse is often the coordinator of the team. As such, s/he can not ignore the concerns of the other disciplines. Medicines must be explained; specialists must be called in for consults; records must be kept. All of these actions serve the client and as such are reasonable aspects of the nurse's role. Some territorial arguments about who can do what become moot as health care power fractures, moving away from the physician and hospital and toward clients and those financing care.

Nurses focus on the client as a whole, inseparable from their particular life situation. Can you even imagine a health problem you experienced without remembering your situation at the time – your environment, those who helped you, or your attitude about the problem. In writing a nursing diagnosis contextual information may very well become part of the diagnostic statement.

Nurses also focus on the emergent nature of a client's needs. Student nurses need to keep this in mind as they learn to formulate nursing diagnoses. The data that support a diagnosis should have a longitudinal aspect to them. Monitoring, reassessment, and updating are central to a nurse's actions. A cross-sectional view of a person at one point in time will not do. All current measured perimeters, such as a temperature, blood pressure, mood or energy level must be accompanied by baseline information.


TOPIC: INTRODUCTION TO NURSING DIAGNOSTIC STATEMENTS

A nursing diagnosis has 3 parts:

The first part is the human response of the client to illness, injury or significant change. This response could be an actual problem, an increased risk of developing a problem, or an opportunity or intent to increase the client's health.

The second part of the diagnostic statement names the factors related to the response. Usually there is more than one factor. The diagnostic statement does not necessarily claim a cause-and-effect link between these factors and the response, only that there is a connection between them.

The third part of the diagnostic statement lists the clues/ cues/ evidence/ data that supports the nurse's claim that this diagnosis is true.

10 RULES FOR WRITING A NURSING DIAGNOSIS

  1. State a human response not a client's need.
  2. Start the diagnostic statement with the human response.
  3. Connect the first (human response) part to the second (etiology) part with "related to" not "due to" or "caused by".
  4. Be sure that the first two parts are not restatements of each other.
  5. Do not mention a medical diagnosis in either of the first two parts.
  6. Several factors may be involved in the etiology (part 2) of the human response. Include them.
  7. Select an etiology (part 2) that can be changed by nursing intervention.
  8. Avoid judging the client as bad in any part of the diagnostic statement.
  9. Avoid suggesting that some member of the health care team is not doing her/ his job.
  10. Put the cues that led to the diagnosis in the third part (defining characteristics)


TOPIC: EXAMPLE OF FORMULATING A NURSING DIAGNOSIS FROM A CASE STUDY

Example: Person A is about to have surgery to repair a fractured wrist. She says she is very afraid of having surgery as she starts to hyperventilate. Hyperventilating makes her even more panicked. Even though she is breathing fast (26/ minute; baseline reading 18/ minute) she says she feels short of breath, and says, " Everything is getting dark."

  1. In a Nursing Diagnosis book try to find a NANDA diagnosis that labels A's human response to her situation. There may be several diagnoses that seem to describe her experience. Pick a diagnosis that matches Defining Characteristics for this case study.

    For Person A an appropriate nursing diagnosis could be the actual problem, Breathing Pattern, Ineffective
  2. Now check the Related Factors under this diagnosis to see if an etiological event is listed there that matches this case study. Related to will be abbreviated as "r/ t".

    For Person A, Anxiety is one of the Related Factors of Breathing Pattern, Ineffective
  3. The third part of a Nursing Diagnosis is a list of the Defining Characteristics divided into a Subjective List and an Objective List. What did she say that could go into a subjective list? In the case study what observable cues demonstrated to you that Person A was having the human response that you diagnosed?

    For Person A the Subjective List includes "Everything is getting dark." and her reports of being afraid and short of breath. The Objective List includes her respiratory rate, the expression of fear on her face, and her fact that she is about to have surgery.
  4. Write the three parts as one statement.

For Person A the diagnosis would read, Breathing Pattern, Ineffective r/t anxiety over impending surgery as evidenced by saying that she is short of breath and "everything is getting dark" plus a respiratory rate of 26, a fearful facial expression, and surgery scheduled in an hour.


TOPIC: DIAGNOSTIC WORDING

  • Discriminating between medical and nursing Dx
  • Group work: Real life examples of the differences

 


TOPIC: FORMULATE YOUR OWN 3-PART NURSING DIAGNOSIS TO E-MAIL TO YOUR TEACHER

You will need a Nursing Diagnosis Book to do the 2 class 9 assignments: (The Cox, Hinx, (1997)Clinical Foundations of Nursing Diagnosis book is a good choice. There are many others.)

  1. RECALL an illness experience that you (or someone close to you) had. Write about it in detail. Be sure to identify the medical diagnosis, plus a human response you had to the illness. Keep in mind that the human response can be an actual problem, a potential problem, or an opportunity to increase one's level of wellness.
  2. In a Nursing Diagnosis book try to find a NANDA diagnosis that labels your human response to your illness. There may be several diagnoses that seem to describe your experience. Pick the diagnostic label whose Defining Characteristics best match your signs and symptoms.
  3. Now check the Related Factors of the diagnosis you selected to see if an etiological event is listed there that matches your own situation. Related to is abbreviated as "r/ t".
  4. The third part of a Nursing Diagnosis lists the Defining Characteristics divided into a Subjective List and an Objective List. In your illness experience what observable cues demonstrated to others that you were having the human response that you did? What did you say?
  5. Write the three parts as one statement. Check your diagnostic statement against the 10 rules above and fix any errors in stating your nursing diagnosis.
  6. Be sure that your E-mail submission identifies you and..
  • describes your illness experience in detail including your human response.
  • includes a correctly stated 3-part nursing diagnosis

 


TOPIC: EXERCISE TO RECOGNIZE INCORRECTLY STATED NURSING DIAGNOSES

Each of the following violates one or more of the 10 Rules. Identify the broken rules.

Post your answers on nurs1100@majordomo.fdu.edu by stating the number of the diagnosis and the number of the broken rules. Be sure to identify yourself.

Example: #1 breaks 3 rules: Potential for injury due to open-heart surgery as evidenced by temperature of 100.2 (baseline 98) and surgery on 11/2

Submit: " Hi this is Jane. #1 breaks rules 3, 5, & 7"

Note: All of the following diagnostic statements have a shortened version of Part 3, In any nursing diagnoses that you write Part 3 should provide a long list of evidence supporting the diagnosis.

#2 breaks 1 rule: Alteration in comfort: pain related to gastritis as evidenced by the client saying,"My stomach hurts."

#3 breaks 1 rule: Self –care deficit: hygiene related to laziness as evidenced by a strong foot odor

#4 breaks 2 rules: Inability to learn because of a learning disability as evidenced by failing grades on first grade tests and complaints of the letters "dancing" on the page

#5 breaks 1 rule: Needs help turning related to pain as evidenced by red area on back and lack of spontaneous movement

#6 breaks 1 rule: Spiritual distress related to separation from cultural ties as evidenced by fever and infection

#7 breaks 2 rules: Ineffective coping related to cancer as evidenced by shouting and crying

#8 breaks 2 rules: Fever and chills related to infection as evidenced by body temperature, altered.

#9 breaks 1 rule: Potential for injury related to insufficient nurse-patient ratio as evidenced by 1 nurse for 20 patients

#10 breaks 1 rule: Post trauma response related to sexual assault as evidenced by nightmares, guilt feelings, and flashbacks

TOPIC: Assignments:

Assignments to prepare for CLASS 8