What is Nsg Dx, and Why Should I Care?

[nurseprnRN, BSN, RN]

the following is from the nanda blog site, to which i commend your attention. http://nandainternational.typepad.com/nanda-international/

[h=3]what is nursing diagnosis - and why should i care?[/h] one of the most frequent questions we get goes something like this...."my patient has congestive heart failure. what is the highest priority/most likely nursing diagnosis?"

there is no right answer, because it's the wrong question! assigning a nursing diagnosis based on a medical diagnosis skips several steps essential to optimal and safe patient care. a medical diagnosis is only one piece of the puzzle; it does not by itself, provide the depth of information necessary to make an accurate nursing diagnosis.

what is a nursing diagnosis?

maybe the easiest thing is to start with what a nursing diagnosis is not.

a nursing diagnosis is not:

• merely a label that you make up that "sounds like" it explains what you are seeing in your patient.
  
• another way of explaining the medical diagnosis, or of renaming a medical condition.
  
• something that "goes with a particular medical diagnosis".
  

nursing diagnosis is defined as "a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. a nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability." (herdman, 2012, p. 515).

in other words, a nursing diagnosis is a judgment based on a comprehensive nursing assessment. the medical diagnosis provides one important piece of data, but it does not provide anywhere near the depth of information necessary for making an accurate nursing diagnosis.

why should you care?

because an accurate nursing diagnosis based on a thorough assessment results in more effective and safer patient care. period.

let's take a look at an example:

a man is admitted through the emergency department with a medical diagnosis of viral pneumonia with the following profile:

• age 78;
  
• dyspneic and demonstrating very shallow breathing;
  
• pulse oximeter is showing 90% on 4l of o2;
  
• history of copd.
  

what is the primary nursing diagnosis? did you think of impaired gas exchange? seems obvious, doesn't it, considering the data and medical diagnosis? however, the question the nurse should ask is this: "what is causing the low spo2?"

after completing a thorough assessment, the nurse discusses her findings with the patient, including the very shallow breathing. she learns the patient is breathing shallowly because he's in pain. he's suffering from postherpetic neuralgia as a result of a very painful course of shingles. in this example, the assessment-based, primary nursing diagnosis is chronic pain.

consider these two scenarios:

nursing diagnosis linked to the medical diagnosis

a care plan is developed to address the nursing diagnosis of impaired gas exchange, based on the medical diagnosis of viral pneumonia. the posthepatic neuralgia as a cause for shallow breathing is not identified and overlooked in treatment.

or

nursing diagnosis linked to nursing assessment and critical thinking

a care plan is developed to address the nursing diagnosis of chronic pain, with treatment designed to resolve this as the primary cause of the shallow breathing, and to prevent recurrence.

which scenario provides the best patient care and outcome? what do you think the relationship is - or is not - between medical diagnosis and nursing diagnosis?

learn more

nanda-i 2012 conference: may 23-26, 2012

nanda-i nursing diagnoses: definitions and classifcation 2012-2014

nanda-i frequently-asked questions

nanda-i fact sheet

[Altra, BSN, RN]

Interesting reading, GrnTea. But I can't climb on the "Yeah, NANDA" bandwagon. The scenario/example given in the blog appears to presume that the medical dx was derived from the most superficial data, with no history-taking or consideration for how the patient's pneumonia developed. And I just don't think that's realistic.

I don't think we do ourselves, our patients, or our physician colleagues any favors by pretending that nursing has a monopoly on care of the patient beyond procedures and pharmaceuticals.

[psu_213, BSN, RN]

I defnitely like the ideas expressed by NANDA, and I think their example is a very good one. However, how many nursing school exams (or the NCLEX) would just word questions like "What is the priority nursing dx. for at patient with viral PNA and a SpO2 of 88%?" In other words, critically thinking, the answer would be what is expressed in the blog post above. In the world of school and exams, we give the memorization answer: 'if airway is a choice, choose that. If oxygen/breathing is a choice, go with that next.'

In practice and in school we assess pt's. In school we take that assessment data and we use it to for diagnoses and we chose a priority diagnosis. On exams, we are reduced to 'spitting back' the answer without even considering assessment data. That is one reason why critical thinking does not have a place a nursing.

[netglow, ASN, RN]

Yes, NANDA is kind of like someone who continually wants to change the subject in order to ignore the elephant in the room. No, I'm not saying that we should be diagnosing. BUT, to be a nurse you need to be 75% there... you need to work with a medical model and be well on your way understanding differentials. MDs and RNs need to be on the exact same page. I left NANDA when I left the NCLEX testing center.

[dudette10, MSN, RN]

Nursing diagnoses in LTC are extremely important and they are formally written and acted upon in that setting. In acute care, nursing dx may very well be used, but in a much more informal and intuitive way, i.e. we don't even consciously realize we are making them. NANDA created a nursing language that no nurse wants to speak--and no other medical professional wants to learn--but the idea of a nursing diagnosis and the nursing process is there nonetheless in our work every day.

ETA: Altered sleep pattern r/t hospitalization as evidenced by pt stating "I can't sleep" and pt opening eyes during during rounds at night. Interventions: pulling privacy curtain, closing window blinds, turning off roommate's TV, closing room door, maintaining quiet at the nurse's station. Evaluation: Pt did not open eyes during subsequent rounds. Pt stated "I slept a little bit during the night" during final morning rounds and med pass.

Sounds stupid and a real "DUH!" moment when formally written, but that's what we do without thinking about it.

[nurseprnRN, BSN, RN]

"critical thinking does not have a place in nursing"

that's a joke, right?

of course we need to understand the medical model and differentials; we can use a lot of that data to bear on our model of care. and we also need to understand what we bring to the table, which is not merely slavish adherence to the medical model of care. we need to understand that what we bring to the table can be quantified, measured, and evaluated on its own merits.

as for leaving nanda behind when you took your nclex...well, i am in the middle of doing a case that is paying me every day, well, shall we say, more than i used to earn in a week just working as a medical model implementer, and it is based on the nursing process and nursing diagnosis. but hey.

[Vespertinas]

On exams, we are reduced to 'spitting back' the answer without even considering assessment data.

I don't know how your school was, but mine had exams with NO straight regurg questions and ALL critical thinking. Post-test answer review was a nightmare lol

[musu, RN]

interesting comments by all.

[jbluehorseh]

i found the whole nanda dx a bit ridicules because in practice it is not practicable. the nursing diagnosis is based on the patient medical history, diagnosis and current problems. the nurse uses that information to create a care plain. however another nurse with the same information can come up with a totally different diagnosis. unlike a nursing diagnosis a medical diagnosis has a defined criterion such as a mi or pneumonia where those diagnoses are defined in numbers and diagnostic tools. the nursing diagnosis has too much wiggle room and no defined parameters. moreover the nanda system does not cover all situations such as low magnesium level. i do acknowledge that it does make one more a where of what problems the patient can face. i am not going to come up with a whole nursing diagnosis just to sit the patient up and give o2 because he or she is short of breath, i just going to do it and reevaluate. in my facility we have a care plain which uses generic nanda, but it is greatly rejected because of the impracticability of the system. another point is the nana system does not translate well to doctors; one not going to call a doctor at 0220 in the morning to tell him or her that the patient is having ineffective tissue perfusion. no, you will give him or her facts, number and what you have done to improve the situation and then he or she will give further orders. this is why the medical model works best in nursing.

[SuesquatchRN, BSN, RN]

I think that NANDA was an attempt to codify nursing "intuition" into diagnoses. Unnecessary. The nursing process is the same with or without NANDA.

[MN-Nurse, ASN, RN]

I am in favor of NANDA and NANDA based care plans as teaching and learning tools.

However, until those bozos (who love to talk about "evidence based" practice) remove that "Disturbed Energy Field" and associated nonsense I will continue to ignore them.

[jbluehorseh]

So true