Tips for Teaching Nursing Diagnosis
and the Use of
NANDA International Terminology
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).
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
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)
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)
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
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
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
Diagnostic Process
Assessment
Cluster cues / defining characteristics
Generate list of potential diagnoses
Collect additional data to narrow list of potential diagnoses
Determine diagnosis/diagnoses to be treated
Implement plan of care based on identified diagnoses
Evaluate success of plan of care
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
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
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
Incorrect Diagnostic Process
Assessment OR Identify Medical Diagnosis
Cluster cues / defining characteristics
Generate list of potential diagnoses
Collect additional data to narrow list of potential diagnoses
Determine nursing diagnosis/diagnoses to be treated
Implement plan of care based on identified diagnoses
Evaluate success of plan of care
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
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
“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
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 > 9.0%
(poor control); < 7.0% (optimal)
– Hospital admissions for short-term complications of diabetes per
100,000 population
The Role of Nursing in Patient Quality
• Percent of adults with diagnosed diabetes
with HbA1c < 7.0% (optimal)
– Readiness for enhanced family coping
– Health-seeking behaviors
– Readiness for Enhanced Self Health Management
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
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).