Diagnosis: Process and Critical Thinking (Nursing)

by Samantha Rhea, MSN, RN

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    00:01 Hi guys! Talking about the nursing process, we're going to talk about the nursing diagnosis piece of ADPIE.

    00:08 Now, just to be honest here with you, this is usually the most confusing piece for nursing students, but we're going to explore this topic.

    00:17 So with our piece of the pie, the D is the diagnosis piece of the five step of the nursing process.

    00:24 So let's take a look and talk about nursing diagnosis.

    00:28 So we talk about diagnosis types.

    00:31 This is really important for us to differentiate.

    00:34 So of course, there's those medical diagnosis like diabetes, heart failure, pneumonia, for example.

    00:41 These are all identifying certain diseases.

    00:44 And this is all based on the physician assessment, keyword physician assessment, and diagnostic information like labs or X-rays, or CAT scan, for example.

    00:56 Now, the difference with a nursing diagnosis is this is our clinical judgment about the patient's actual or potential health problems.

    01:05 So usually, we gather this information, typically through our physical head to toe assessment.

    01:11 Now, just now with our patients, this is a collaborative problem, right? Any issue with our patient, we're going to have to work together with our physicians, because many times the nurses of the one that are monitoring the patients.

    01:25 So, if there's a change in condition, there's an issue that needs to be addressed.

    01:29 We work together with our physicians, and we report, so we can treat the issue.

    01:35 So why nursing diagnosis? This allows nurses to practice independently within their scope of practice.

    01:42 So if you remember diagnosis, such as pneumonia, diabetes, those are medical diagnosis and not within our scope of practice as a nurse to use.

    01:52 Therefore, we have the North American Nursing Diagnosis Association, otherwise known as NANDA.

    02:00 Named has developed for us refined and promoted the use of nursing diagnosis for use by all professional nurses.

    02:09 Now, before we get started, just know, literatures moving away from this a bit just because there's some confusion in regard to making a medical versus a nursing diagnosis statement.

    02:21 But however, this is still widely used.

    02:24 We also do this really organically in our clinical practice as well.

    02:28 So let's take a dive into nursing diagnosis and why we use it.

    02:33 So one of the reasons why we use a nursing diagnosis, it gives us precise definitions of those patient issues.

    02:40 Here's a great example.

    02:42 Impaired skin integrity. That's a NANDA nursing diagnosis.

    02:47 Now, just by saying, impaired skin integrity, you already know, right? The patient has skin issues here.

    02:55 Or another example is ineffective airway clearance.

    02:58 It's really precise here, right guys? We know the patient is having a hard time with their airway clearance.

    03:05 The other thing about this is that allows nurses, and other health care team members a common language.

    03:11 It's also really helpful between nurse to nurse communication.

    03:16 It also provides guidance for developing nursing interventions to treat our patients.

    03:21 So let's take a look at the diagnostic process.

    03:24 So how we get to that nursing diagnosis.

    03:27 If you remember, in the ADPIE piece, we start with A, our assessment.

    03:31 And this is where we validate our information, we gather all that data, and we interpret the patient's health status.

    03:39 Now, when we start with the diagnosis piece, we get that information, we cluster this.

    03:44 We identify key characteristics from our patient.

    03:48 Then work and identify our patient's needs.

    03:51 And therefore, we can formulate our nursing diagnosis.

    03:55 When we're talking about nursing diagnostic statements, these are sentences that provide specific, actual, or potential health problems.

    04:04 It also provides a common language among healthcare providers, such as nurses with physical therapy, occupational therapy, or the physician, for example.

    04:13 And again, this distinguishes the nurses role from the physician.

    04:18 So remember, we are working with our nursing diagnosis.

    04:21 And of course, this helps us focus on the nurses scope of practice.

    04:26 So we're talking about that diagnostic process.

    04:28 It's important here as a nurse as always, that we use critical thinking.

    04:33 So to get that nursing diagnosis and work through that process, we got to start with clustering information, using that information, and identifying the patient's health problem.

    04:44 Then we can formulate an appropriate nursing diagnosis.

    04:48 So we talk about information clustering.

    04:51 We got to bring all that information together in a logical way.

    04:55 We're looking for patterns as well with defining characteristics.

    04:59 So if you take a look at this image here, that's a great piece just to show you, hey, we have all this information that's gathered in an assessment.

    05:07 But it's important that we cluster that information, which leads to our nursing diagnosis.

    About the Lecture

    The lecture Diagnosis: Process and Critical Thinking (Nursing) by Samantha Rhea, MSN, RN is from the course Nursing Process – Assessment, Diagnosis, Planning, Interventions, and Evaluation.

    Included Quiz Questions

    1. A nursing diagnosis identifies an actual or potential health risk, while a medical diagnosis identifies a specific disease.
    2. A nursing diagnosis identifies a specific disease, while a medical diagnosis identifies an actual or potential health risk.
    3. A nursing diagnosis does not warrant any investigations or interventions, while a medical diagnosis does.
    4. A nursing diagnosis is typically made through assessing data collected from diagnostic tests and imaging, while a medical diagnosis is typically made through assessing data collected through the head-to-toe assessment.
    1. It provides precise definitions of the client’s problems.
    2. It provides a common language between nurses and other members of the healthcare team.
    3. It provides guidance for developing nursing interventions.
    4. It provides a way for nurses to order medications and tests independent of a medical doctor.
    1. “I need to organize the information I collected and group related data together.”
    2. “I need to verify that the information I collected is accurate before forming a diagnosis.”
    3. “I need to identify my client’s health problems before formulating a diagnosis.”
    4. “I need to look up my client’s symptoms, so I know what disease to diagnose them with.”

    Author of lecture Diagnosis: Process and Critical Thinking (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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