12. Diagnosing Learning Outcomes After Completing This Chapter, You Will

12. Diagnosing LEARNING OUTCOMES After completing this chapter, you will be able to: 1. Differentiate various types of nursing diagnoses. 2. Identify the components of a nursing diagnosis. 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems. 4. Identify basic steps in the diagnostic process. 5. Describe various formats for writing nursing diagnoses. 6. Describe the characteristics of a nursing diagnosis. 7. List guidelines for writing a nursing diagnosis statement. 8. Describe the evolution of the nursing diagnosis movement, including work currently in progress. 9. List advantages of a taxonomy of nursing diagnoses. KEY TERMS defining characteristics, 198 dependent functions, 198 diagnosis, 196 diagnostic label, 196 etiology, 196 independent functions, 198 norm, 199 nursing diagnosis, 196 PES format, 202 possible nursing diagnosis, 197 qualifiers, 197 risk factors, 197 risk nursing diagnosis, 197 standard, 199 syndrome diagnosis, 197 taxonomy, 196 wellness diagnosis, 197 INTRODUCTION Diagnosing is the second phase of the nursing process. In this phase, nurses use critical-thinking skills to interpret assessment data and identify client strengths and problems. Diagnosing is a pivotal step in the nursing process. Activities preceding this phase are directed toward formulating the nursing diagnoses; the care-planning activities following this phase are based on the nursing diagnoses (see Figure 12-1). The identification and development of nursing diagnoses began formally in 1973, when two faculty members of Saint Louis University, Kristine Gebbie and Mary Ann Lavin, perceived a need to identify nurses' roles in an ambulatory care setting. The First National Conference to identify nursing diagnoses was sponsored by the Saint Louis University School of Nursing and Allied Health Professions in 1973. Subsequent national conferences occurred in 1975, in 1980, and every 2 years thereafter. International recognition came with the First Canadian Conference in Toronto in 1977 and the International Nursing Conference in May 1987 in Calgary, Alberta, Canada. In 1982, the conference

group accepted the name North American Nursing Diagnosis Association (NANDA), recognizing the participation and contributions of nurses in the United States and Canada. The purpose of NANDA is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. A taxonomy is a classification system or set of categories arranged based on a single principle or set of principles. The members of NANDA include staff nurses, clinical specialists, faculty, directors of nursing, deans, theorists, and researchers. The group has currently approved more than 170 nursing diagnosis labels for clinical use and testing. In 2000, Taxonomy I was revised and is now referred to as Taxonomy II (see the list in Appendix C on page 1530). Figure 12-1. Diagnosing. The pivotal second phase of the nursing process. NANDA NURSING DIAGNOSES To use the concept of nursing diagnoses effectively in generating and completing a nursing care plan, the nurse must be familiar with the definitions of terms used, the types, and the components of nursing diagnoses. Definitions The term diagnosing refers to the reasoning process, whereas the term diagnosis is a statement or conclusion regarding the nature of a phenomenon. The standardized NANDA names for the diagnoses are called diagnostic labels; and the client's problem statement, consisting of the diagnostic label plus etiology (causal relationship between a problem and its related or risk factors), is called a nursing diagnosis. In 1990, NANDA adopted an official working definition of nursing diagnosis: ". . . a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable" (as cited in NANDA International, 2005, p. 277). This definition implies the following: • Professional nurses (registered nurses) are responsible for making nursing diagnoses, even though other nursing personnel may contribute data to the process of diagnosing and may implement specified nursing care. The American Nurses Association Nursing: Scope and Standards of Practice (2004) state that nurses are accountable for this phase of the nursing process. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires evidence of nursing diagnoses in clients' medical records as well (JCAHO, 2005). • The domain of nursing diagnosis includes only those health states that nurses are educated and licensed to treat. For example, generalist nurses are not educated to diagnose or treat diseases such as diabetes mellitus; this task is defined legally as within the practice of medicine. Yet nurses can diagnose and treat Deficient Knowledge, Ineffective Coping, or Imbalanced Nutrition, all of which are the human responses to the medical diagnosis of diabetes mellitus. • A nursing diagnosis is a judgment made only after thorough, systematic data collection. • Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth. Types of Nursing Diagnoses

The five types of nursing diagnoses are actual, risk, wellness, possible, and syndrome. 1. An actual diagnosis is a client problem that is present at the time of the nursing assessment. Examples are Ineffective Breathing Pattern and Anxiety. An actual nursing diagnosis is based on the presence of associated signs and symptoms. 2. A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client's health status. 3. A wellness diagnosis "Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement" (NANDA International, 2005, p. 277). Examples of wellness diagnoses would be Readiness for Enhanced Spiritual Well-Being or Readiness for Enhanced Family Coping. 4. A possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. A possible diagnosis requires more data either to support or to refute it. For example, an elderly widow who lives alone is admitted to the hospital. The nurse notices that she has no visitors and is pleased with attention and conversation from the nursing staff. Until more data are collected, the nurse may write a nursing diagnosis of Possible Social Isolation related to unknown etiology. 5. A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses (Carpenito-Moyet, 2006). Currently six syndrome diagnoses are on the NANDA International list. Risk for Disuse Syndrome, for example, may be experienced by long-term bedridden clients. Clusters of diagnoses associated with this syndrome include Impaired Physical Mobility, Risk for Impaired Tissue Integrity, Risk for Activity Intolerance, Risk for Constipation, Risk for Infection, Risk for Injury, Risk for Powerlessness, Impaired Gas Exchange, and so on. Components of a NANDA Nursing Diagnosis A nursing diagnosis has three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics. Each component serves a specific purpose. Problem (Diagnostic Label) and Definition The problem statement, or diagnostic label, describes the client's health problem or response for which nursing therapy is given. It describes the client's health status clearly and concisely in a few words. The purpose of the diagnostic label is to direct the formation of client goals and desired outcomes. It may also suggest some nursing interventions. To be clinically useful, diagnostic labels need to be specific; when the word Specify follows a NANDA label, the nurse states the area in which the problem occurs, for example, Deficient Knowledge (Medications) or Deficient Knowledge (Dietary Adjustments). Qualifiers are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement; for example: • Deficient (inadequate in amount, quality, or degree; not sufficient; incomplete) • Impaired (made worse, weakened, damaged, reduced, deteriorated) • Decreased (lesser in size, amount, or degree) • Ineffective (not producing the desired effect)

• Compromised (to make vulnerable to threat) Each diagnostic label approved by NANDA carries a definition that clarifies its meaning. For example, the definition of the diagnostic label Activity Intolerance is shown in Table 12-1. Etiology (Related Factors and Risk Factors) The etiology component of a nursing diagnosis identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care. As shown in Table 12-1, the probable causes of Activity Intolerance include sedentary lifestyle, generalized weakness, and so on. Differentiating among possible causes in the nursing diagnosis is essential because each may require different nursing interventions. Table 12-2 provides examples of problems that have different etiologies and therefore require different interventions. Defining Characteristics Defining characteristics are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label. For actual nursing diagnoses, the defining characteristics are the client's signs and symptoms. For risk nursing diagnoses, no subjective and objective signs are present. Thus, the factors that cause the client to be more vulnerable to the problem form the etiology of a risk nursing diagnosis. The NANDA lists of defining characteristics are still being developed and refined. Characteristics are listed separately according to whether they are subjective or objective in nature. Differentiating Nursing Diagnoses from Medical Diagnoses A nursing diagnosis is a statement of nursing judgment and refers to a condition that nurses, by virtue of their education, experience, and expertise, are licensed to treat. A medical diagnosis is made by a physician and refers to a condition that only a physician can treat. Medical diagnoses refer to disease processesspecific pathophysiologic responses that are fairly uniform from one client to another. In contrast, nursing diagnoses describe the human response, a client's physical, sociocultural, psychologic, and spiritual responses to an illness or a health problem. See how these responses vary among individuals: Seventy-year-old Mary Cain and 20-year-old Kristi Vidan both have rheumatoid arthritis. Their disease processes are much the same. X-ray studies show that in both clients, the extent of inflammation and the number of joints involved are similar, and both clients experience almost constant pain. Ms. Cain views her condition as part of the aging process and is responding with acceptance. Ms. Vidan, however, is responding with anger and hostility because she views her disease as a threat to her personal identity, role performance, and self-esteem. A client's medical diagnosis remains the same for as long as the disease process is present, but nursing diagnoses change as the client's responses change. Ms. Vidan's response to her illness may change over time to become more similar to that of Ms. Cain. Nurses have responsibilities related to both medical and nursing diagnoses. Nursing diagnoses relate to the nurse's independent functions, that is, the areas of health care that are unique to nursing and separate and distinct from medical management. It is possible that the nurse cannot prescribe all the care for a nursing diagnosis, but the nurse can prescribe most of the interventions needed for prevention or resolution. For example, most clients with a nursing diagnosis of Pain have medical orders for analgesics, but many independent nursing interventions can also alleviate pain (e.g., guided imagery or teaching a client to "splint" an incision). With regard to medical diagnoses, nurses are obligated to carry out physician-prescribed therapies and treatments, that is, dependent functions. See Chapter 13 dependent nursing interventions.

for a discussion of independent and

Differentiating Nursing Diagnoses from Collaborative Problems A collaborative problem is a type of potential problem that nurses manage using both independent and physician-prescribed interventions. Independent nursing interventions for a collaborative problem focus mainly on monitoring the client's condition and preventing development of the potential complication. Definitive treatment of the condition requires both medical and nursing interventions. Collaborative problems are present when a particular disease or treatment is present; that is, each disease or treatment has specific complications that are always associated with it. For example, a statement of collaborative problems is "Potential complication of pneumonia: atelectasis, respiratory failure, pleural effusion, pericarditis, and meningitis." Nursing diagnoses, by contrast, involve human responses, which vary greatly from one person to the next. Therefore, the same set of nursing diagnoses cannot be expected to occur with all persons who have a particular disease or condition; moreover, a single nursing diagnosis may occur as a response to any number of diseases. For example, all postpartum clients have similar collaborative problems, such as "Potential complication of childbearing: postpartum hemorrhage," but not all new mothers have the same nursing diagnoses. Some might experience Impaired Parenting(delayed bonding), but most will not; some might have Deficient Knowledge whereas others will not. Thus, the nurse uses nursing diagnoses rather than collaborative problems whenever possible, since nursing diagnoses are more individualized to a specific client and emphasize human responses to which the nurse can independently take action. Table 12-3 provides a comparison of nursing diagnoses, medical problems, and collaborative problems. THE DIAGNOSTIC PROCESS The diagnostic process uses the critical-thinking skills of analysis and synthesis. Critical thinking is a cognitive process during which a person reviews data and considers explanations before forming an opinion. Analysis is the separation into components, that is, the breaking down of the whole into its parts (deductive reasoning). Synthesis is the opposite, that is, the putting together of parts into the whole (inductive reasoning). See Chapter 10 reasoning.

to review the concepts of deductive and inductive

The diagnostic process is used continuously by most nurses. An experienced nurse may enter a client's room and immediately observe significant data and draw conclusions about the client. As a result of attaining knowledge, skill, and expertise in the practice setting, the expert nurse may seem to perform these mental processes automatically. Novice nurses, however, need guidelines to understand and formulate nursing diagnoses. The diagnostic process has three steps: • Analyzing data • Identifying health problems, risks, and strengths • Formulating diagnostic statements Analyzing Data In the diagnostic process, analyzing involves the following steps: 1. Compare data against standards (identify significant cues). 2. Cluster cues (generate tentative hypotheses). 3. Identify gaps and inconsistencies. For experienced nurses, these activities occur continuously rather than sequentially.

Comparing Data with Standards Nurses draw on knowledge and experience to compare client data to standards and norms and identify significant and relevant cues. A standard or norm is a generally accepted measure, rule, model, or pattern. The nurse uses a wide range of standards, such as growth and development patterns, normal vital signs, and laboratory values. A cue is considered significant if it does any of the following: • Points to negative or positive change in a client's health status or pattern. For example, the client states: "I have recently experienced shortness of breath while climbing stairs" or "I have not smoked for 3 months." • Varies from norms of the client population. The client's pattern may fit within cultural norms but vary from norms of the general society. The client may consider a patternfor example, eating very small meals and having little appetiteto be normal. This pattern, however, may not be healthy and may require further exploration. • Indicates a developmental delay. To identify significant cues, the nurse must be aware of the normal patterns and changes that occur as the person grows and develops. For example, by age 9 months an infant is usually able to sit alone without support. The infant who has not accomplished this task needs further assessment for possible developmental delays. Table 12-4 lists specific examples of client cues and norms to which they may be compared. Clustering Cues Data clustering or grouping cues is a process of determining the relatedness of facts and determining whether any patterns are present, whether the data represent isolated incidents, and whether the data are significant. This is the beginning of synthesis. The nurse may cluster data inductively (as in Table 12-5) by combining data from different assessment areas to form a pattern. Or the nurse may begin with a framework, such as Gordon's functional health patterns, and organize the subjective and objective data into the appropriate categories (see Box 11-4, page 190). The latter is a deductive approach to data clustering (see Chapter 10). Experienced nurses may cluster data as they collect and interpret it, as evidenced in remarks or thoughts such as "I'm getting a sense of . . ." or "This cue doesn't fit the picture." The novice nurse does not have the knowledge base or the clinical experience that aids in recognizing cues. Thus, the novice must take careful assessment notes, search data for abnormal cues, and use textbook resources for comparing the client's cues with the defining characteristics and etiologic factors of the accepted nursing diagnoses. Data clustering involves making inferences about the data. The nurse interprets the possible meaning of the cues, and labels the cue clusters with tentative diagnostic hypotheses. Data clustering or grouping for Amanda Aquilini is illustrated in Table 12-5, in which data are clustered according to standardized diagnosis labels. Identifying Gaps and Inconsistencies in Data Skillful assessment minimizes gaps and inconsistencies in data. However, data analysis should include a final check to ensure that data are complete and correct. Inconsistencies are conflicting data. Possible sources of conflicting data include measurement error, expectations, and inconsistent or unreliable reports. For example, a nurse may learn from the nursing history that the client reports not having seen a doctor in 15 years, yet during the physical health

examination he states, "My doctor takes my blood pressure every year." All inconsistencies must be clarified before a valid pattern can be established. See "Validating Data" in Chapter 11. Identifying Health Problems, Risks, and Strengths After data are analyzed, the nurse and client can together identify strengths and problems. This is primarily a decision-making process (see Chapter 10

).

Determining Problems and Risks After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnoses. In addition the nurse must determine whether the client's problem is a nursing diagnosis, medical diagnosis, or collaborative problem. See Figure 12-2 and Table 12-3. Significant cues and data clusters for Amanda Aquilini that were extracted from Figure 11-4 on page 188 and Box 11-7 on page 191 are shown in Table 12-5. In this example, the nurse and client identified eight tentative problems: Imbalanced Nutrition: Less than Body Requirements; Deficient Fluid Volume; Disturbed Sleep Pattern; Activity Intolerance; Acute Pain (Chest); Interrupted Family Processes; Anxiety; and Ineffective Airway Clearance. Note that some data may indicate a possible problem but when clustered with other data, the possible problem disappears. For example, the following data for Amanda Aquilini, "Decreased urinary frequency and amount × 2 days," suggests a possible urinary elimination problem. However, when these data are considered along with data associated with Deficient Fluid Volume, the nurse eliminates urinary elimination as a problem. Determining Strengths At this stage, the nurse and client also establish the client's strengths, resources, and abilities to cope. Most people have a clearer perception of their problems or weaknesses than of their strengths and assets, which they often take for granted. By taking an inventory of strengths, the client can develop a more well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and regenerative processes. A client's strength might be weight that is within the normal range for age and height, thus enabling the client to cope better with surgery. In another instance, a client's strengths might be absence of allergies and being a nonsmoker. A client's strengths can be found in the nursing assessment record (health, home life, education, recreation, exercise, work, family and friends, religious beliefs, and sense of humor, for example), the health examination, and the client's records. See Table 12-5 for the strengths identified for Amanda Aquilini. Formulating Diagnostic Statements Most nursing diagnoses are written as two-part or three-part statements, but there are variations of these. Basic Two-Part Statements The basic two-part statement includes the following: 1. Problem (P): statement of the client's response (NANDA label) 2. Etiology (E): factors contributing to or probable causes of the responses

The two parts are joined by the words related to rather than due to. The phrase due to implies that one part causes or is responsible for the other part. By contrast, the phrase related to merely implies a relationship. Some examples of two-part nursing diagnoses are shown in Box 12-1. For NANDA labels that contain the word Specify, the nurse must add words to indicate the problem more specifically. The format is still a two-part statement. For example, Noncompliance (Specify) would be Noncompliance (Diabetic Diet) related to denial of having disease. For ease in alphabetizing, many NANDA lists are arranged with qualifying words after the main word (e.g., Infection, Risk for). Avoid writing diagnostic statements in that manner; instead, write them as they would be stated in normal conversation (e.g., Risk for Infection). Basic Three-Part Statements The basic three-part nursing diagnosis statement is called the PES format and includes the following: 1. Problem (P): statement of the client's response (NANDA label) 2. Etiology (E): factors contributing to or probable causes of the response 3. Signs and symptoms (S): defining characteristics manifested by the client Actual nursing diagnoses can be documented by using the three-part statement (see Box 12-2) because the signs and symptoms have been identified. This format cannot be used for risk diagnoses because the client does not have signs and symptoms of the diagnosis. The PES format is especially recommended for beginning diagnosticians because the signs and symptoms validate why the diagnosis was chosen and make the problem statement more descriptive. The PES format can create very long problem statements, sometimes making the problem and etiology unclear. To minimize long problem statements, the nurse can record the signs and symptoms in the nursing notes instead of on the care plan. Another possibility, recommended for students, is to list the signs and symptoms on the care plan below the nursing diagnosis, grouping the subjective (S) and objective (O) data. The signs and symptoms are easily accessible, and the problem and etiology stand out clearly. For example: Noncompliance (Diabetic Diet) related to unresolved anger about diagnosis as manifested by S "I forget to take my pills." "I can't live without sugar in my food." O Weight 98 kg (215 lb) [gain of 4.5 kg (10 lb)] Blood pressure 190/100

BOX 12-1

Basic Two-Part Diagnostic Statement

Problem Related to Etiology Constipation related to prolonged laxative use Severe Anxiety related to threat to physiologic integrity: possible cancer diagnosis

One-Part Statements Some diagnostic statements, such as wellness diagnoses and syndrome nursing diagnoses, consist of a NANDA label only. As the diagnostic labels are refined, they tend to become more specific, so that nursing interventions can be derived from the label itself. Therefore, an etiology may not be needed. For example, adding an etiology to the label Rape-Trauma Syndrome does not make the label any more descriptive or useful.

NANDA has specified that any new wellness diagnoses will be developed as one-part statements beginning with the words Readiness for Enhanced followed by the desired higher level wellness (for example, Readiness for Enhanced Parenting).

BOX 12-2

Basic Three-Part Diagnostic Statement

Problem Related to Etiology As Manifested by Signs and Symptoms Situational related to feelings of as manifested by hypersensitivity to criticism; states "I Low (r/t) rejection by (a.m.b.) don't know if I can manage by myself" and husband rejects positive feedback Self-Esteem

Currently the NANDA list includes several wellness diagnoses. Some of these are Spiritual WellBeing, Effective Breastfeeding, Health-Seeking Behaviors, and Anticipatory Grieving. These are usually accepted as one-part statements but may be made more explicit by adding a descriptor, for example, Health-Seeking Behaviors (Low-Fat Diet). Variations of Basic Formats Variations of the basic one-, two-, and three-part statements include the following: 1. Writing unknown etiology when the defining characteristics are present but the nurse does not know the cause or contributing factors. One example is Noncompliance (Medication Regimen) related to unknown etiology. 2. Using the phrase complex factors when there are too many etiologic factors or when they are too complex to state in a brief phrase. The actual causes of chronic low self-esteem, for instance, may be long term and complex, as in the following nursing diagnosis: Chronic Low Self-Esteem related to complex factors. 3. Using the word possible to describe either the problem or the etiology. When the nurse believes more data are needed about the client's problem or the etiology, the word possible is inserted. Examples are Possible Low Self-Esteem related to loss of job and rejection by family; Altered Thought Processes possibly related to unfamiliar surroundings. 4. Using secondary to to divide the etiology into two parts, thereby making the statement more descriptive and useful. The part following secondary to is often a pathophysiologic or disease process or a medical diagnosis, as in Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to diabetes. 5. Adding a second part to the general response or NANDA label to make it more precise. For example, the diagnosis Impaired Skin Integrity does not indicate the location of the problem. To make this label more specific, the nurse can add a descriptor as follows: Impaired Skin Integrity (Left Lateral Ankle) related to decreased peripheral circulation. Collaborative Problems Carpenito-Moyet (2006) has suggested that all collaborative (multidisciplinary) problems begin with the diagnostic label Potential Complication (PC). Nurses should include in the diagnostic statement both the possible complication they are monitoring and the disease or treatment that is present to produce it. For example, if the client has a head injury and could develop increased intracranial pressure, the nurse should write the following: Potential Complication of Head Injury: Increased intracranial pressure

When monitoring for a group of complications associated with a disease or pathology, the nurse states the disease and follows it with a list of the complications: Potential Complication of Pregnancy-Induced Hypertension: seizures, fetal distress, pulmonary edema, hepatic/ renal failure, premature labor, CNS hemorrhage In some situations, an etiology might be helpful in suggesting interventions. Nurses should write the etiology when (a) it clarifies the problem statement, (b) it can be concisely stated, and (c) it helps to suggest nursing actions. See the examples in Box 12-3. Evaluating the Quality of the Diagnostic Statement In addition to using the correct format, nurses must consider the content of their diagnostic statements. The statements should, for example, be accurate, concise, descriptive, and specific. The nurse must always validate the diagnostic statements with the client and compare the client's signs and symptoms to the NANDA defining characteristics. For risk problems, the nurse compares the client's risk factors to NANDA risk factors. After writing nursing diagnoses, the nurse checks them against the criteria in Table 12-6. Avoiding Errors in Diagnostic Reasoning Some error is inherent in any human undertaking, and diagnosis is no exception. However, it is important that nurses make nursing diagnoses with a high level of accuracy. Nurses can avoid some common errors of reasoning by recognizing them and applying the appropriate critical-thinking skills. Error can occur at any point in the diagnostic process: data collection, data interpretation, and data clustering. The following suggestions help to minimize diagnostic error: • Verify. Hypothesize possible explanations of the data, but realize that all diagnoses are only tentative until they are verified. Begin and end the diagnostic process by talking with the client and family. When collecting data, ask them what their health problems are and what they believe the causes to be. At the end of the process, ask them to confirm the accuracy and relevance of your diagnoses. • Build a good knowledge base and acquire clinical experience. Nurses must apply knowledge from many different areas to recognize significant cues and patterns and generate hypotheses about the data. To name only a few, principles from chemistry, anatomy, and pharmacology each help the nurse understand client data in a different way. • Have a working knowledge of what is normal. Nurses need to know the population norms for vital signs, laboratory tests, speech development, breath sounds, and so on. In addition, nurses must determine what is usual for a particular person, taking into account age, physical makeup, lifestyle, culture, and the person's own perception of what his or her normal status is. For example, normal blood pressure for adults is in the range of 110/60 to 140/80. However, a nurse might obtain a reading of 90/50 that is perfectly normal for a particular client. The nurse should compare actual findings to the client's baseline when possible. • Consult resources. Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis. Professional literature, nursing colleagues, and other professionals are all appropriate resources. The nurse should use a nursing diagnosis handbook to determine whether the client's signs and symptoms truly fit the NANDA label chosen. • Base diagnoses on patternsthat is, on behavior over timerather than on an isolated incident. For example, even though Amanda Aquilini is concerned today about needing to leave her child with a

neighbor, it is likely that this concern will be resolved without intervention by the next day. Therefore, the admitting nurse should not diagnose Interrupted Family Processes. • Improve critical-thinking skills. These skills help the nurse to be aware of and avoid errors in thinking, such as overgeneralizing, stereotyping, and making unwarranted assumptions. See Chapter 10.

BOX 12-3

Collaborative Problems

Disease/Situation Complication Related to Etiology Potential complication of hemorrhage related to uterine atony retained childbirth: placental fragments bladder distention Potential complication of arrhythmia related to low serum potassium diuretic therapy:

Figure 11-3. Assessing. The assessment process involves four closely related activities. Figure 12-2. Decision tree for differentiating among nursing diagnoses, collaborative problems, and medical diagnoses. ONGOING DEVELOPMENT OF NURSING DIAGNOSES The first taxonomy of nursing diagnoses was alphabetical. This ordering was considered unscientific by some, and a hierarchic structure was sought. In 1982, NANDA accepted the "nine patterns of unitary man" (based on the nursing models of Sr. Callista Roy and Martha Rogerssee Chapter 3 ) as an organizing principle. In 1984, NANDA renamed the "patterns of unitary man" as "human response patterns" based more on the work of Marjorie Gordon (Kim, McFarland, & McLane, 1984), as listed in Box 12-4. Having undergone refinements, revisions, and acceptance of new diagnoses, the taxonomy is now called Taxonomy II (NANDA International, 2005). Taxonomy II has three levels: domains, classes, and nursing diagnoses (Figure 12-3). The diagnoses are no longer grouped by Gordon's patterns but coded according to seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology. In addition, diagnoses are now listed alphabetically by concept, not by first word.

BOX 12-4

Human Response Patterns

1. Exchanging: mutual giving and receiving 2. Communicating: sending messages 3. Relating: establishing bonds 4. Valuing: assigning relative worth 5. Choosing: selection of alternatives 6. Moving: activity

7. Perceiving: reception of information 8. Knowing: meaning associated with information 9. Feeling: subjective awareness of information

Review and refinement of diagnostic labels continue as new and modified labels are discussed at each biannual conference. Nurses submit diagnoses to the Diagnostic Review Committee, which reviews and "stages" the diagnosis according to how well developed and supported it is. The NANDA board of directors gives final approval for incorporation of the diagnosis into the official list of labels. Diagnoses on the NANDA list are not finished products but are approved for clinical use and further study. Many on the list have been studied only minimally. In 1997, NANDA changed the name of its official journal from Nursing Diagnosis to Nursing Diagnosis: The International Journal of Nursing Language and Classification. The subtitle emphasizes that nursing diagnosis is part of a larger, developing system of standardized nursing language. This system includes classifications of nursing interventions (NIC) and nursing outcomes (NOC) that are being developed by other research groups and linked to the NANDA diagnostic labels. NIC and NOC are discussed in greater detail in Chapter 13. Research groups are examining what nurses do from these three different perspectives (diagnoses, interventions, and outcomes) to clarify and communicate the role nurses play in the health care system. A standardized language will also enable nurses to implement a Nursing Minimum Data Set needed for computerized client records.

RESEARCH NOTE What New Nursing Diagnoses Are Being Researched? The International Journal of Nursing Terminologies and Classifications is a public forum for the publication of work currently conducted worldwide on the development of nursing diagnoses, outcomes, and interventions. In the paper by Lamont, the author reviewed published literature with the goal of establishing discomfort as a separate nursing diagnosis from pain. However, his review failed to provide clear evidence for this discrimination. He suggests that research be conducted to attempt to determine if pain and discomfort can be usefully separated. Lopes and Higa conducted interviews with 148 women who had complaints of urinary incontinence. Over half the women (57%) described incontinence with characteristics of both urge and stress incontinence. They suggest that this should lead to a new nursing diagnosis of mixed urinary incontinence so that clients are not treated for urge or stress incontinence when they truly require a plan related to both types. IMPLICATIONS Many nursing diagnoses are being studied in a variety of settings. This is important work to determine the reliability and validity of existing diagnoses, identify gaps in the current list, and establish usefulness of the diagnoses in everyday practice. Nurses should be familiar with the direction of this work as it progresses. Note: From "Discomfort as a Potential Nursing Diagnosis: A Concept Analysis and Literature Review," by S. C. Lamont, 2003, International Journal of Nursing Terminologies and Classifications, 14(4 Suppl), p. 5, and "Mixed Incontinence in Women: A New Nursing Diagnosis," by M. H. B.

Lopes and R. Higa, 2003, International Journal of Nursing Terminologies and Classifications, 14(4 Suppl), p. 49.

LIFESPAN CONSIDERATIONS

Diagnosing

CHILDREN Many developmental issues in pediatrics are not considered problems or illnesses, yet can benefit from nursing intervention. When applied to children and families, nursing diagnoses may reflect a condition or state of health. For example, parents of a newborn infant may be excited to learn all they can about infant care and child growth and development. Assessment of the family system might lead the nurse to conclude that the family is ready and able, even eager, to take on the new roles and responsibilities of being parents. An appropriate diagnosis for such a family could be Readiness for Enhanced Family Processes, and nursing care could be directed to educating and providing encouragement and support to the parents. ELDERS Elders tend to have multiple problems with complex physical and psychosocial needs when they are ill. If the nurse has done a thorough, accurate assessment, nursing diagnoses can be selected to cover all problems and, at the same time, prioritize the special needs. For example, if a client is admitted with severe congestive heart failure, prompt attention will be focused on Decreased Cardiac Output and Excess Fluid Volume, with interventions selected to improve these areas quickly. As these conditions improve, then other nursing diagnoses, such as Activity Intolerance and Deficient Knowledge related to a new medication regimen, might require more attention. They are all part of the same medical problem of congestive heart failure, but each nursing diagnosis has specific expected outcomes and nursing interventions. The client's strengths should be an essential consideration in all phases of the nursing process.

Critical Thinking Checkpoint Mr. H. has recently been diagnosed with lung cancer. Someone has written the nursing diagnosis of Anxiety on his care plan. 1. What data/defining characteristics would support this nursing diagnosis? 2. Which related factors might exist in his situation? 3. Which other nursing diagnoses might you expect to find in Mr. H.'s case? 4. Another nursing diagnosis on the care plan reads "Lung cancer related to smoking." Is this diagnosis written in an acceptable format? If not, why not? See Critical Thinking Possibilities in Appendix A.

Figure 12-3. Taxonomy II. Source: From Definitions and Classifications, 2003-2004 by NANDA International, 2003, Philadelphia, PA. Adapted with permission

CHAPTER 12 REVIEW CHAPTER HIGHLIGHTS • The purpose of the North American Nursing Diagnosis Association is to define, refine, and promote a taxonomy of nursing diagnostic terminology. • Diagnosis is a reasoning process that uses critical thinking. • Professional standards of care hold that registered nurses are responsible for making nursing diagnoses, even though others may contribute data or implement care. • A nursing diagnosis is a clinical judgment about the client's responses to actual and potential health problems or life processes. • A nursing diagnosis provides the basis for selecting independent nursing interventions to achieve outcomes for which the nurse is accountable. • There are various types of nursing diagnoses: actual, risk, wellness, possible, and syndrome. • A nursing diagnosis has three components: the problem (and its definition), the etiology, and the defining characteristics. Each component serves a specific purpose. • Nursing diagnoses differ from medical diagnoses and collaborative problems in orientation, duration, and nursing focus. • A collaborative problem is a type of potential problem that nurses manage using both independent and physician-prescribed interventions. • The three phases of the diagnostic process are data analysis; identification of the client's health problems, health risks, and strengths; and formulation of diagnostic statements. • In data analysis and processing, the nurse compares data against standards to identify significant cues, clusters the data, and identifies gaps and inconsistencies. • Significant cues are those that (a) point to change in a client's health status or pattern, (b) vary from norms of the client population, or (c) indicate a developmental delay. • It is important to identify client strengths as well as problems. • The basic format for a nursing diagnostic statement is "Problem related to etiology." However, there are several variations on this format. • The development of a taxonomy of nursing diagnosis labels is an ongoing process. • The organizing principles for the NANDA Taxonomy II are the seven axes: diagnostic concept, time, unit of care, age, potentiality, descriptor, and topology. • Work is progressing on a unified standardized nursing language that includes NANDA nursing diagnoses, a nursing interventions classification, and a nursing outcomes classification. TEST YOUR KNOWLEDGE 1. The nurse is conducting the diagnosing phase (nursing diagnosis) for a client with a seizure disorder. Which of the following elements exists

between data analysis and formulating the diagnostic statement? 1. Assess the client's needs 2. Delineate the client's problems and strengths 3. Determine which interventions are most likely to succeed 4. Estimate the cost of several different approaches 2. In the diagnostic statement "Excess fluid volume related to decreased venous return as manifested by lower extremity edema (swelling)," the etiology of the problem is which of the following? 1. Excess fluid volume 2. Decreased venous return 3. Edema 4. Unknown 3. Which of the following nursing diagnoses contains the proper components? 1. Risk for caregiver role strain related to unpredictable illness course 2. Risk for falls related to tendency to collapse when having difficulty breathing 3. Decreased communication related to stroke 4. Sleep deprivation secondary to fatigue and a noisy environment 4. One of the primary advantages of using a three-part diagnostic statement such as the problemetiology-signs/symptoms (PES) format includes which of the following? 1. Decreases the cost of health care 2. Improves communication between nurse and client 3. Helps the nurse focus on health and wellness elements 4. Standardizes organization of client data 5. A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis: 1. If both medical and nursing interventions are required to treat the problem 2. When independent nursing actions can be utilized to treat the problem 3. In cases where nursing interventions are the primary actions required to treat the problem 4. When no medical diagnosis (disease) can be determined See Answers to Test Your Knowledge in Appendix A. EXPLORE MEDIALINK WWW.PRENHALL.COM/BERMAN COMPANION WEBSITE • Additional NCLEX Review • Case Study: Selecting Nursing Diagnoses for Client with Pneumonia • Application Activity: Resources for a Chronically Ill Child

• Links to Resources READINGS AND REFERENCES SUGGESTED READINGS Kelly, J. H., Weber, J., & Sprengel, A. (2005). Taxonomy of nursing practice: Adding an administrative domain. International Journal of Nursing Terminologies and Classifications, 16(3/4), 74-80. In this article, the authors propose the addition of a fifth domain, Administrative, to the Taxonomy of Nursing Practice, and to introduce the related concept of organization nursing diagnoses. The current taxonomy does not include diagnoses that relate to the management/leadership roles of nurses. RELATED RESEARCH Junttila, K., Salantera, S., & Hupli, M. (2005). Perioperative nurses' attitudes toward the use of nursing diagnoses in documentation. Journal of Advanced Nursing, 52, 271-280. Keenan, G., Falan, S., Heath, C., & Treder, M. (2003). Establishing competency in the use of North American Nursing Diagnosis Association, nursing outcomes classification, and nursing interventions classification terminology. Journal of Nursing Measurement, 11, 183-198. REFERENCES American Nurses Association. (2004). Nursing: Scope and standards of practice. Kansas City, MO: Author. Carpenito-Moyet, L. J. (2006). Nursing diagnosis: Application to clinical practice (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Joint Commission on Accreditation of Healthcare Organizations. (2005). Accreditation manual for hospitals. Chicago: Author. Kim, M. J., McFarland, G. K., & McLane, A. M. (Eds.). (1984). Classification of nursing diagnoses: Proceedings of the fifth national conference. St. Louis, MO: Mosby. Lamont, S. C. (2003). Discomfort as a potential nursing diagnosis: A concept analysis and literature review. International Journal of Nursing Terminologies and Classifications, 14(4 Suppl), 5. Lopes, M. H. B., & Higa, R. (2003). Mixed incontinence in women: A new nursing diagnosis. International Journal of Nursing Terminologies and Classifications, 14(4 Suppl), 49. NANDA International. (2005). NANDA nursing diagnoses: Definitions and classification 2005-2006. Philadelphia: Author.

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Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care (7th ed.). St. Louis, MO: Elsevier Health Sciences. Alfaro-LeFevre, R. A. (2005). Applying the nursing process: Promoting collaborative care (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Alfaro-LeFevre, R. A. (2005). The nursing process made easy: Concept mapping and care planning for students. Philadelphia: Lippincott Williams & Wilkins. Doenges, M. E., & Moorhouse, M. F. (2003). Application of nursing process and nursing diagnosis: An interactive text for diagnostic reasoning (4th ed.). Philadelphia: F.A. Davis. Doenges, M. E., Moorhouse, M. F., & Geissler-Murr, A. C. (2005). Nursing diagnosis manual: Planning, individualizing, and documenting client care. Philadelphia: F. A. Davis. Gardner, P. (2003). Nursing process in action. Albany, NY: Delmar. Gordon, M. (1982). Historical perspective: The National Group for Classification of Nursing Diagnoses. In M. J. Kim & D. A. Moritz (Eds.), Classification of nursing diagnoses: Proceedings of the fourth national conference. New York: McGraw-Hill. Gordon, M. (2006). Manual of nursing diagnosis (11th ed.). St. Louis, MO: Mosby. Johnson, M., Bulechek, G. B., Butcher, H., Dochterman, J., Moorhead, S., Maas, M., et al. (Eds.). (2005). NANDA, NOC and NIC linkages: Nursing diagnoses, outcomes, and interventions (2nd ed.). St. Louis, MO: Elsevier Health Sciences. Ladwig, G. B., & Ackley, B. J. (2005). Mosby's guide to nursing diagnosis. St. Louis, MO: Elsevier Health Sciences. Seaback, W. (2005). Nursing process: Concept & application (2nd ed.). Albany, NY: Delmar. Wilkinson, J. M. (2005). Nursing diagnosis handbook: With NIC interventions and NOC outcomes (8th ed.). Upper Saddle River, NJ: Prentice Hall. Wilkinson, J. M. (2007). Nursing process & critical thinking (4th ed.). Upper Saddle River, NJ: Prentice Hall.