Tips for Teaching Nursing Diagnosis and the Use of NANDA International Terminology

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Tips for Teaching Nursing Diagnosis and the Use
of NANDA International Terminology
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Nursing Diagnosis Definition

• The NANDA-I definition of a nursing diagnosis was
  adapted from a national, Delphi study by Dr.
  Joyce Shoemaker (1984)
• Nursing diagnosis is a clinical judgment about
  individual, family, or community responses to
  actual or potential health problems/life
  processes. Nursing diagnoses provide the basis
  for selection of nursing interventions to achieve
  outcomes for which the nurse is accountable
  (NANDA, 1997).

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The Diagnoses

• 206 NANDA-approved nursing diagnoses will be
  present in the Definitions Classifications book
  for 2009 - 2011
• Level of Evidence (LOE) Criteria Established for
  All New and Revised Diagnoses
• Entry into the Taxonomy requires various levels
  of clinical evidence

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Clinical Decision Making

• Health care professionals face complex decisions
  daily regarding patient care and must do so with
  decreased resources
• What is the area of concern that nurses can
  treat/prevent/monitor? (Diagnosis)
• What is an appropriate goal for this patient?
  (Outcome)
• What treatment is most effective? (Intervention)

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Critical Thinking

• Nurses need knowledge of diagnoses, definitions
  and defining characteristics, especially those
  common to the populations with which they work
  and the diagnostic processes that are used to
  interpret patient data
• Skills of analyzing, logical reasoning, and
  applying standards are thinking processes
  required for accurate diagnosis in nursing
• These skills are developed through
• Discussions of how data should be clustered to
  generate accurate diagnoses
• Relation of data clusters to diagnoses
• Comparisons of existing data to expected data
  based on research findings.
• Lunney (2009)

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Diagnosis Requires Assessment

• Identifying human responses that are related to
  medical diagnosis without a complete assessment
  to determine the presence of defining
  characteristics
• Lack of instruction on clustering assessment data
  to derive a list of potential diagnoses
• Lack of hypothesis testing to determine best
  diagnoses for each patient

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Nurses Are Diagnosticians

• Diagnosticians interpret data within their fields
  of expertise in order to provide needed services
• A key element of data interpretations is that
  they are subject to error.
• A good diagnostician must realize that there are
  always risks to the accuracy of data
  interpretations
• Becoming a nurse diagnostician requires
  development of professional and personal skills
  and characteristics
• Competencies in intellectual, interpersonal, and
  technical domains
• Personal strengths of tolerance for ambiguity and
  use of reflective practice

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Teaching Methods

• Review proper method to complete patient
  assessment to determine the presence of defining
  characteristics
• Clustering of defining characteristics is often
  misunderstood presence of one defining
  characteristic does not necessarily require a
  diagnosis
• All nursing interventions do not require a
  nursing diagnosis
• Medication administration for a condition that is
  not a primary focus of nursing care is related
  more to a medical diagnosis
• Need to test hypotheses
• Need to evaluate success of plan of care and
  reassess continually

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Diagnostic Process
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Cue Generation and Nursing Diagnosis

• Cues are analyzed in relation to possible
  diagnoses
• Existing cues are matched with the expected cues
  for the diagnoses being considered
• During the evaluation of cues and related
  diagnoses, nurses may decide that there are not
  enough data to make a diagnostic decision or that
  there is enough evidence for one or more likely
  diagnoses
• If there are not enough data to make a diagnosis,
  then the next step involves a focused search for
  additional cues
• If there is enough supporting evidence, a
  diagnosis is made and then validated

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Quality Nursing Care

• Accurate Assessment and Diagnosis
• Defining characteristics
• Related factors
• Risk factors
• Identify Attainable Patient Outcomes
• Efficiency
• Utilize Proven Interventions
• Effective
• Least resource-intensive

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Quality Nursing Care

• Accurate Assessment and Diagnosis
• Defining characteristics
• Related factors
• Risk factors
• Identify Attainable Patient Outcomes
• Efficiency
• Utilize Proven Interventions
• Effective
• Least resource-intensive

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Incorrect Diagnostic Process
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Teaching Methods

• Requiring students to develop and detail care
  plans with every possible diagnosis creates
  resistance
• Sets up situation that is not realistic
• Cannot address every possible diagnosis in a
  short hospital stay
• Becomes a thing to do rather than truly
  understanding and applying diagnostic reasoning
  and differential diagnosis
• Students learn to just pick a diagnosis rather
  than making decisions about the best
  explanation(s) for patient responses

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Teaching Methods

• Use of case studies can assist students in
  identifying cues in patient situations that may
  be defining characteristics of one or more
  nursing diagnoses
• Hypothesis generation and differential diagnosis
  skills can be developed through case studies,
  clinical conference discussions and in skills lab
  scenarios

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The List

• Automating the electronic record to populate the
  plan of care with nursing diagnoses when a
  particular medical diagnosis is used
• Becomes a documentation tool rather than an
  individualized plan of care to direct nursing
  interventions to meet important patient outcomes
• Puts patients at risk / Negligence
• May ignore or miss important diagnoses for
  patients
• Plan of care does not address critical outcomes
  for patients

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Reportable Quality Measures Where is Nursing?

• Management of diabetes
• Percent of adults with diabetes who had a foot
  examination in past year
• Percent of adults with diabetes who had an
  influenza immunization in past year
• Percent of adults with diagnosed diabetes with
  HbA1c level gt 9.0 (poor control) lt 7.0
  (optimal)
• Hospital admissions for short-term complications
  of diabetes per 100,000 population

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The Role of Nursing in Patient Quality

• Percent of adults with diagnosed diabetes with
  HbA1c lt 7.0 (optimal)
• Readiness for enhanced family coping
• Health-seeking behaviors
• Readiness for Enhanced Self Health Management

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The Role of Nursing in Patient Quality

• Management of diabetes
• Hospital admissions for short-term complications
  of diabetes per 100,000 population
• Anxiety
• Ineffective coping
• Ineffective health maintenance
• Risk for injury
• Deficient knowledge
• Ineffective Self Health Management

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Diagnostic Difficulties

• Significant overlap of cues (Defining
  Characteristics) to diagnoses
• Contextual factors such as culture can change the
  perspective on diagnosis
• Many studies have verified that interpretations
  of clinical cases have the potential to be less
  accurate than indicated by the data
• (Lunney, 2007).