Nursing Diagnoses...

AgentBeast, MSN, RN · Jul 16, 2012

Every hospital that I have been at has had Nursing Diagnosis/ Care Plans. For the most part they are all preprinted and you either just check a box or write something in if you have to, but they are there and utilized. They aren't exactly in NANDA format though.

nurseprnRN, BSN, RN · Jul 16, 2012

i am a certified nurse life care planner and i use nursing diagnoses every day. in the legal world there's always some snotty attorney who say, "well, nurse grntea, you can't prescribe anything because you're not a doctor, isn't that right?" and i just enjoy the heck out of smiling sweetly and telling him (it's almost always a him) that yes i can, because my ana scope and standards of practice, nurse practice act, and nanda-i give me the tools and the legal obligation to do exactly that. i don't have prescriptive authority and i don't prescribe meds or other things that are the legal obligation of physicians/nps. i also don't confuse the idea that because an insurance company won't pay for something unless it's in a medical plan of care with the idea that therefore a physician must be the only one legally able to prescribe it. not so. did you know that physicians are not considered competent to prescribe hours of nursing care? why is that? because they aren't educated and licensed in nursing, that's why. you can look it up.

if you go to the nanda-i webpage (and i would strongly recommend that you do: faqs at http://www.nanda.org/nursingdiagnosisfaq.aspx, and all those questions answered, too) you'll learn that the dread "r/t and aeb" your faculty made you look up were for learning purposes and to teach you to observe, not just to pull a sexy-sounding diagnosis out of, um, the air. nanda-i wants you to know why you are making a diagnosis, mostly because if you don't then you don't know what to do about it and how you know if what you did do is working, but they do not insist on either their exact language nor on the "aeb" in the hands of a working, knowledgeable nurse.

we are knowledgeable about so much more than "alterations in comfort" and "knowledge deficit," as experienced nurses know. i think since because staff nurses are some of the least-empowered people on the planet, and often mostly because they think that's so, that they don't realize the real power they hold, based by science, the law, and a long tradition of activism. if you were in my shoes, you'd love having that power as much as i do. you have it now. use it.

nurseprnRN, BSN, RN · Jul 16, 2012

the nanda-i faq pages has this and many other useful links. students and new grads in particular should see the section on learning.

nursing diagnosis basics  nanda-i nanda international nursing diagnosis frequently asked questions

accessed 12/15/2011

what is a nursing diagnosis?

a nursing diagnosis is a clinical judgment about actual or potential individual, family, or community experiences/responses to health problems/life processes. a nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

why use nursing diagnosis?

a nursing diagnosis is used to determine the appropriate plan of care for the patient. the nursing diagnosis drives interventions and patient outcomes, enabling the nurse to develop the patient care plan. nursing diagnoses also provide a standard nomenclature for use in the electronic health record, enabling clear communication among care team members and the collection of data for continuous improvement in patient care.

why doesn’t nanda international provide a list of its diagnoses on its website?

there is no real use for simply providing a list of terms – to do so defeats the purpose of a standardized language. unless the definition, defining characteristics, related and/or risk factors are known, the label itself is meaningless. therefore, we do not believe it is in the interest of patient safety to produce simple lists of terms that could be misunderstood or used inappropriately in a clinical context.

should all of nursing practice related to patient care be named with nursing diagnoses?

not all nursing interventions or actions are based on nursing diagnoses. nurses intervene on conditions described by medical diagnoses as well as nursing diagnoses. we do not rename medical diagnoses or terms to create actual nursing diagnoses.

how specific should each nursing diagnosis be?

specificity - or granularity - differs by concept. it is important to look at each diagnosis based on the level of evidence available in the literature and to stay clinically focused in decision-making.

nursing diagnosis vs. medical diagnosis

does nanda-i provide a list of nursing diagnoses that go along with the most common medical diagnoses?

there are several books that use this format. however, we believe the individual nursing assessment is critical to the accurate nursing diagnosis for a patient. it can be helpful to consider nursing diagnoses that tend to cluster with a particular medical diagnosis. however, if nurses only use a “list” of nursing diagnoses with a particular medical diagnosis, they are missing the uniqueness of the patient for whom they are providing care – that is the risk of this approach. a nursing diagnosis must always be related to each individual patient’s nursing assessment, or we risk misdiagnosis and inappropriate interventions. remember that patient safety demands accurate nursing diagnosis!

what is the best nursing diagnosis to use for my patient with congestive heart failure (or any other) medical diagnosis?

using a medical diagnosis alone does not provide enough information to accurately diagnosis a patient from a nursing perspective. a holistic nursing assessment is critical for you to identify the potential nursing diagnoses. a medical diagnosis may be a related (or etiologic) factor for a nursing diagnosis, but you must identify defining characteristics of a nursing diagnosis during your assessment; it is impossible to make an accurate nursing diagnosis strictly from a medical diagnosis.

what is the difference between a medical diagnosis and a nursing diagnosis?

a medical diagnosis deals with disease or medical condition. a nursing diagnosis deals with human response to actual or potential health problems and life processes. for example, a medical diagnosis of cerebrovascular attack (cva or stroke) provides information about the patient’s pathology. the complimentary nursing diagnoses of impaired verbal communication, risk for falls, interrupted family processes and powerlessness provide a more holistic understanding of the impact of that stroke on this particular patient and his family – they also direct nursing interventions to obtain patient-specific outcomes.

learning and using nursing diagnosis

do i have to use the “nursing diagnosis…related to…as evidenced by” statement to write a diagnosis that is considered to be accurate by nanda-i?

no. while this is a good way of teaching the diagnostic reasoning process, it is not required by nanda-i. it is sufficient to provide the nursing diagnosis label (e.g., anxiety), and in fact, many computer systems do not allow the “related to…as evidenced by” model. however, it is important that nurses communicate the assessment data to support the diagnosis they make, so that others caring for the patient know why a diagnosis was selected.

how many diagnoses should my patient have?

students are often encouraged to come up with a list of every possible diagnosis that a patient might have – this is a learning method. however, in practice, it is important to prioritize nursing diagnoses, as these form the basis for nursing interventions. you should consider which diagnoses are the most critical – from the patient’s perspective as well as from a nursing perspective – and the resources and time available for treatment. other diagnoses may require referral to other health care providers or settings, e.g. home health care, a different hospital unit, skilled nursing facility, etc.

can i change a nursing diagnosis after it has been documented in a patient record?

absolutely! as you continue to assess your patient and collect additional data, you may find that your initial diagnosis wasn’t the best one – or your patient’s condition may have resolved. it is very important to continually evaluate your patient to determine if the diagnosis is still the most accurate for the patient at any particular point in time.

should licensed practical / vocational nurses or nursing technicians / assistants be taught to make nursing diagnoses?

the use of nursing diagnosis requires clinical judgment based on a holistic nursing assessment. because only professional nurses (rn’s in the usa, for example) are licensed to perform nursing assessments, it is not acceptable for a practical / vocational nurse or nursing technician / assistant to make a clinical judgment resulting in a nursing diagnosis. however, these individuals work with professional nurses to provide care to patients, by implementing a plan of care that is developed by the professional nurse. therefore, it is important they understand the nursing diagnoses just as much as the medical diagnoses, so the rationale is clear for the interventions they are asked to do.

standardized nursing language (snl) basics

what is standardized nursing language?

a commonly-understood set of terms used to describe the clinical judgments involved in assessments(nursing diagnoses), along with the interventions, and outcomes related to the documentation of nursing care.

how many standardized nursing languages are there?

the american nurses association recognizes 12 languages for nursing.

what are the differences among standardized nursing languages?

many nursing languages claim to be standardized; some are simply a list of terms, others provide definitions of those terms. nanda-i maintains that a standardized language that represents any profession should provide, at a minimum, an evidence-based definition, list of defining characteristics (signs/symptoms) and related factors (etiologic factors); risk diagnoses should include an evidence-based definition, and a list of risk factors. without these, anyone can define any term in his/her own way which obviously violates the purpose of standardization.

what is the connection between standardized nursing language and patient safety?

patient safety requires that clinicians quickly grasp the priority needs of a patient. use of language that requires a written narrative is no longer effective in today’s high acuity environment. just as the medical discipline uses standardized language to identify patient disease states – so that all caregivers of all professions understand what is meant by a “myocardial infarction” (heart attack) – it is also critical that when nurses use terminology such as “activity intolerance, “all health care providers clearly understand what is meant and the appropriate plan of care. lack of common definitions and defining characteristics (signs and symptoms) for nursing diagnosis language, leads to miscommunication and potentially, to mistreatment of patients. standardized language ensures consistent communication and clarity - and therefore a better direction for patient care.

is there any regulatory mandate that patient problems, interventions and outcomes included in an ehr, should be stated using nanda-i terminology?

there is no regulatory mandate; however nanda international nursing diagnoses are strongly suggested by standards organizations for inclusion into the ehr. several international expert papers and studies promote inclusion of the nanda-i taxonomy into the ehr based on several reasons:

•the safety of patients requires accurate documentation of health problems (e.g. risk states, actual diagnoses, health promotion diagnoses) and nanda-i is the single classification having a broad literature base (with some diagnoses evidence-based including loe formats). most important - nanda-i diagnoses are comprehensive concepts including related factors and defining characteristics. this is a major difference from other nursing terminologies.

•nanda-i concepts are included in snomed to assure data exchange and control.

•nanda-i, nic and noc (nnn) not only are the most frequently used classifications internationally; studies have shown these to be the most evidence-based and comprehensive classifications.

•nanda-i diagnoses and nic/noc are under continual refinement and development. these classifications are not single-author products – instead, they’re based on the work of professional nurses as members of nanda international and at the university of iowa center for nursing classification and clinical effectiveness. a majority of nanda-i members are nursing professors/ educators, nursing informaticists, nursing researchers and clinicians.

related studies:

•anderson, c. a., keenan, g., & jones, j. (2009). using bibliometrics to support your selection of a nursing terminology set. cin: computers, informatics, nursing, 27(2), 82-90.

•bernhard-just, a., hillewerth, k., holzer-pruss, c., paprotny, m., & zimmermann heinrich, h. (2009). die elektronische anwendung der nanda-, noc- und nic - klassifikationen und folgerungen für die pflegepraxis. pflege, 22(6), 443-454.

•keenan, g., tschannen, d., & wesley, m. l. (2008). standardized nursing teminologies can transform practice. jona, 38(3), 103-106.

•lunney, m. (2006). nanda diagnoses, nic interventions, and noc outcomes used in an electronic health record with elementary school children. journal of school nursing, 22(2), 94-101.

•lunney, m. (2008). critical need to address accuracy of nurses’ diagnoses. ojin: the online journal of issues in nursing, 13(1).

•lunney, m., delaney, c., duffy, m., moorhead, s., & welton, j. (2005). advocating for standardized nursing languages in electronic health records. journal of nursing administration, 35(1), 1-3.

•müller-staub, m. (2007). evaluation of the implementation of nursing diagnostics: a study on the use of nursing diagnoses, interventions and outcomes in nursing documentation. wageningen: ponsen & looijen.

•müller-staub, m. (2009). preparing nurses to use standardized nursing language in the electronic health record. studies in health technology and informatics: connecting health and humans, 146, 337-341.

•müller-staub, m., lavin, m. a., needham, i., & van achterberg, t. (2007). meeting the criteria of a nursing diagnosis classification: evaluation of icnp®, icf, nanda and zefp. international journal of nursing studies, 44(5), 702-713.

evidence-based practice and taxonomy

what is evidence-based nursing practice?

evidence based practice allows nurses to enrich their clinical training and experience through the utilization of up to date research. with the large amount of research and information that exists in the health care arena, learning the skills of evidence based practice allows nurses to search for, assess, and apply the literature to their clinical situations.*

* kessenich cr, "teaching nursing students evidence-based nursing." nurse educator, nov/dec 1997, 22(6): 25-29.

what is taxonomy?

taxonomy is the practice and science of categorization and classification. the nanda-i taxonomy currently includes 206 nursing diagnoses that are grouped (classified) within 13 domains (categories) of nursing practice: health promotion; nutrition; elimination and exchange; activity/rest; perception/cognition; self-perception; role relationships; sexuality; coping/stress tolerance; life principles; safety/protection; comfort; growth/development.

tokebi · Jul 17, 2012

GrnTea, I actually felt inspired by your post and thank you for the information. My opinion does not change, however, that nursing dx does not have a place in contemporary nursing, at least in acute care anyway. Even in institutions where nursing diagnoses and care plans are documented, they're mostly an afterthought and adds onto nurses' paperwork/computerwork burden while contributing little in the actual patient care. For a staff nurse, how useful is that "care plan" tab in the chart? Nurses constantly look up MD orders, progress notes, labs -- all vital in carrying out nursing responsibilities. How often do nurses refer to the care plan for any other reason than the fact that they have to document it just for the documentation's sake? How often do other disciplines refer to it in order to carry out patient care?

The ideas behind NANDA are great, but it's not useful in a fast-paced hospital environment. Sometimes I think we nurses (usually academics or leadership) hold onto it tenaciously because of the pride in what is inherently "ours" -- nurses'. But from a busy floor nurse's point of view, it's not needed. Today's healthcare is all about efficiency. Why not eliminate a practice that is not serving any useful purpose?

nurseprnRN, BSN, RN · Jul 17, 2012

"my opinion does not change, however, that nursing dx does not have a place in contemporary nursing, at least in acute care anyway. even in institutions where nursing diagnoses and care plans are documented, they're mostly an afterthought and adds onto nurses' paperwork/computerwork burden while contributing little in the actual patient care."

i beg to differ. how often does a patient have a problem that a savvy nurse has identified that is materially important to recovery/preventing readmission/ safety at home? how does that nurse communicate what should be done during the admission, from her expertise? how does that problem get communicated to the other nurses caring for this patient, so that they can also provide that intervention, all to the patient's benefit? "oh, that gets passed along in report." oh, really? how reliably, how consistently, how accurately?

we know the answer to this question. it's not that this wouldn't be helpful, it's just that nurses don't care enough to do it. let's not say it wouldn't contribute to patient care-- readmission rates, patient surveys that say they didn't feel prepared to be at home, patients who have no blessed clue why they are taking this drug or the other testify otherwise. it would. but why isn't there time or attitudinal support for better care?

nurses are so wrapped up in the rush of completing the medical plan of care (as we must) that they do not adequately provide for a nursing plan of care to go with it. i get it that many nurses aren't well-socialized to that aspect of what we do, that unless there's a cpt code for reimbursement there's no incentive for hospitals to help this aspect of patient care undergo a shift in attitudes such as yours, and that the documentation bites. but saying, as you do, that nursing diagnosis and care planning is irrelevant and has no place in contemporary patient care...well, that's pathetic. a profession that so devalues its own power and knowledge doesn't deserve better than it gets. unfortunately, it's the patients who get short shrift.

what would it look like if those things that get insufficiently "passed on in report" or at bedside nursing rounds were formally recognized for what they really are: a working model of the thing we all aspire to have in patient care? recognition for nursing's absolute, indispensable, irreplaceable place in care? how would that be?

"but from a busy floor nurse's point of view, it's not needed. today's healthcare is all about efficiency. why not eliminate a practice that is not serving any useful purpose?"

today's healthcare may or may not be "all about efficiency," and i have no doubt that today's busy floor nurse is less and less well-educated about what's needed in the overall scheme of patient care (not just the task list of what s/he has to accomplish this shift). so that's the reason we discard our professional identity and cede our power...and neglect patients in the bargain? does that sound ... efficient? because as a group we are poorly-invested in and only dimly aware of the essence of what nursing is, as opposed to what tasks nursing does? nursing professionalism doesn't serve any useful purpose? bite your tongue. pitiful, isn't it?

don't give up so glibly on a sound bite that bespeaks only resignation and the easy way out. if other nurses can make it work, why not ... you?

BrandonLPN, LPN · Jul 17, 2012

But why do we really need nursing dx??

I read your sources there and I still don't understand the point. I do understand the difference between medicine and nursing. Medicine has to do with the specific disease

process and how to treat it. Nursing is about treating the symptoms of the disease and any other ancillary discomforts/fears/misconceptions/ whatever the pt may have. Fine , I get that. But that doesn't change

the fact that most nursing dx are just re-worded medical dx. Plus they are always obvious, too.

I know a pt with COPD is going to have "impaired gas exchange". I know a pt with CHF is going to have a "fluid imbalance". The more intangible dx are obvious too. I know a pt with hypoxia will have extreme anxiety issues. I know the undereducated guy with uncontrolled type II DM probably has a "knowledge deficit".

Does any staff nurse anywhere on the face of the planet have time to do one of those stupid care plans

to "justify" and "define" multiple nursing dx? No! That's why in the hospital the nursing dx is just something that automatically prints out (99% of the time based solely on the medical dx) and stuffed in

the chart never to be looked at by anyone. Even in LTC, where care planning is more relevant and important, nursing dx are just an afterthought.

And I've done plenty of care plans where I work. I don't care what that

NANDA says, in LTC LPNs assess and do admissions, discahrges and pt teaching EVERY SINGLE DAY. For them to say otherwise just shows how out of touch with the real world of nursing they are.

The only place nursing dx has a useful role is in the purely abstract world of theory and research. In the REAL world it's just a redundant waste of time.

nurseprnRN, BSN, RN · Jul 18, 2012

i can assure you that in my very real world, it's not remotely redundant.

just noticed you're an lpn. of course lpns have ability to act as team members in assessment and care planning. however, the nurse practice act delegates the responsibility for comprehensive assessment and nursing diagnosis to rns only.

your post has, probably unwittingly, exemplified the very point i was trying, however imperfectly, to make, and for that i am grateful. when nurses see nursing diagnosis as "99%" related to medical diagnoses (because a computer-generated "care plan" says so), and limit their expectations to the obvious and student-level basics like impaired gas exchange, fluid imbalance, and knowledge deficit, of course they won't look at it twice. while real, and while certainly things that nursing has independent authority and actions to diagnose and treat, they are the cookie-cutter responses you see in the medical diagnosis-a-means-nursing-diagnosis-b lists that students flock to because they don't know any better, creating a mindset that real nurses should be able to see-- and practice-- beyond.

even medical plans of care "standing orders" for, say, chf admissions, make room for individualization. imagine what kind of medical care your mom would get if all the medical plan of care for her recurrent chf were for those routine lists. woe betide the physician who never looks more carefully for secondary and tertiary medical diagnoses that will affect the results of the plan of care for the first one(s). and more to the point, woe betide his patient.

but wait, you'd say, nobody asked her about the reasons she didn't take her meds at home. was it because she felt hopeless so what did it matter if she took them, because she felt that suffering was what she deserved for some reason, because she'd rather feed her cat than shell out the copay, because she felt that they changed her appearance (or didn't) in unacceptable ways, because she couldn't accept the help from your sister-in-law who laid out her pills in the morning, because they changed her sexual responsiveness (yes, old folks still notice things like this), because she didn't really think she needed them anyway? would you think these were significant enough for nursing to notice and work to address as a team? how do you think that would happen without nursing diagnosis (in the above list, you might consider hopelessness, powerlessness, decisional conflict, chronic low self-esteem, ineffective coping, disturbed body image, altered role function, sexual dysfunction, denial, noncompliance --and that's just off the top of my head) and targeted nursing intervention?

i would bet you dollars to doughnuts that not one of those potentially very significant factors in her ability to be as healthy as possible would show up in your computerized care plans; certainly nothing about them is specific to chf and would not show up in the usual medical h&p. they would show up in decent and ongoing nursing assessment, though. as a matter of fact, it would be pretty close to neglectful to ignore them because an rn thinks nursing diagnosis has no useful role in practice. if all you're doing is looking at the things your computer gives you, you are giving away your authority and power to help the woman with those very real problems. a real rn might want to rethink that.

MunoRN, RN · Jul 18, 2012

Just to clarify GrnTea, Nurses diagnosed long before NANDA and continue to today without utilizing NANDA. Asking a patient why they don't take their meds and addressing those issues can be done just fine without going through the step of pidgeonholing that patient into an inflexible categorization system. It's helpful for organizing patient's into a spreadsheet, although that's not where Nursing earns it's stripes, our value is in seeing patient's as individuals, not as diagnosis 302B.

(And by the way, the MD's I work with rarely fail to dig into why a patient's take their meds and get the proper interventions rolling).

In terms of the patient's care plan, no Nurse operates solely off of the medical care plan, each Nurse incorporates the medical plan into the patient's overall plan, which is completely possible (and actually more effective) without utilizing the NANDA system.

nurseprnRN, BSN, RN · Jul 19, 2012

this will come as a shock to some, but nanda-i does not insist on inflexibility. you can look it up. it was an attempt to develop a standardized language in the same way that medical dx has-- we no longer see the term "dropsy" for chf because it became obsolete and because at the time "congestive heart failure" more accurately reflected what was going on with the patient. older practitioners didn't know that fat feet and ankles was a reflection of cardiac insufficiency, but they knew that foxglove (active ingredient: digitalis) worked to make urine and shrink the swelling.

the diagnoses are precisely about individualization, in contrast to the computer-generated boilerplate that assumes every chf patient must have the same nsg dx too.

of course a nurse operates by integrating medical plan of care and nursing plan of care. however, how often have you come in after a few days off to discover that your plan of care hasn't been followed by the intervening shifts? why is that? absent a real change in situation, its because there's no standardized language to document it and pass it along to other caregivers. oh wait, there is. but it's immaterial?

what's the source of your assertion that incorporating the medical plan into the overall plan is more effective using standardized language? and could you explain what that means?