Nursing Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation
Making accurate nursing diagnoses takes knowledge and practice. If the nurse uses a systematic approach to nursing diagnosis validation, then accuracy will increase. The process of making nursing diagnoses is difficult because nurses are attempting to diagnose human responses. Humans are unique, complex, and ever-changing; thus, attempts to classify these responses have been difficult.
Learning objectives
After studying this chapter, you should be able to:
Articulate the purpose of using a nursing diagnosis in the psychiatric–mental health setting.
Distinguish among the four types of nursing diagnoses.
State the use of the phrase possible nursing diagnosis.
State the rationale for using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) in the psychiatric–mental health setting.
Discuss the rationale for using outcome identification as part of the nursing process.
Compare and contrast the use of the following when developing a plan of care: clinical pathways, concept mapping, critical pathways, and evidence-based nursing practice.
Construct a plan of care in the psychiatric setting.
Interpret the nurse’s role when implementing nursing interventions.
Explain the rationale for the evaluation phase of the nursing process.
Key Terms
Actual nursing diagnosis
Clinical pathways
Concept mapping
Critical pathways
Cues
Decision trees
DSM-IV-TR
Evidence-based nursing practice
Expected outcomes
Inferences
Nursing diagnosis
Risk nursing diagnosis
Standardized nursing plans of care
Syndrome nursing diagnosis
Wellness nursing diagnosis
As stated in Chapter 9, the nursing process consists of six steps and uses a problem-solving approach. The first step, assessment, has already been covered in detail. This chapter focuses on the remaining five steps:
Nursing diagnosis
Outcome identification
Planning (formulation of a nursing plan of care)
Implementation of nursing actions or interventions
Evaluation of the client’s response to interventions
The nursing process has been referred to as an ongoing, systematic series of actions, interactions, and transactions.
Nursing Diagnosis
The nursing diagnosis is a statement of an existing problem or a potential health problem that a nurse is both competent and licensed to treat. The North American Nursing Diagnosis Association (NANDA) defines a nursing diagnosis as a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. A nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.
The psychiatric–mental health nurse analyzes the assessment data before determining which nursing diagnosis would be most appropriate. Analysis of the data involves differentiating cues from inferences, assuring validity, and determining how much data are needed. Cues are facts collected during the assessment process, whereas inferences are judgments that the nurse makes about cues. The inferences that nurses make are only as valid as the data used (Carpenito-Moyet, 2006).
Data, when valid, can be assumed to be factual and true. Validation of data may occur by rechecking data collected, asking someone to analyze the data, comparing subjective and objective data, or asking the client to verify the data. To determine if a sufficient number of valid cues are present to confirm a nursing diagnosis, the nurse should consult a list of defining characteristics for the diagnosis suspected (Carpenito-Moyet, 2006).
Nursing diagnoses are not to be written in terms of cues, inferences, goals, client needs, or nursing needs. Caution is advised regarding making legally inadvisable or judgmental statements as part of the nursing diagnosis. Finally, nursing diagnostic statements should not be stated or written to encourage negative responses by health care providers, the client, or the family.
Carpenito-Moyet (2006) classifies nursing diagnoses into actual, risk, wellness, and syndrome diagnoses (Table 10-1). An actual nursing diagnosis is based on the nurse’s clinical judgment on review of validated data. A risk nursing diagnosis is based on the nurse’s clinical judgment of the client’s degree of vulnerability to the development of a specific problem. A wellness nursing diagnosis focuses on clinical judgment about an individual, group, or community transitioning from a specific level to a higher level of wellness. A syndrome nursing diagnosis refers to a cluster of actual or high-risk diagnoses that are predicted to be present because of a certain event or situation.
The nurse may elect to use the phrase possible nursing diagnosis (eg, Possible Activity Intolerance related to obesity, Possible Loneliness related to hospitalization, Possible Noncompliance related to illiteracy) when a suspected problem requires additional data to confirm a diagnosis; however, it is not a type of diagnosis.
Diagnostic Systems
The NANDA diagnostic system was originally organized around nine human response patterns (exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling). In 2000, NANDA approved a new Taxonomy II, which addresses several domains (health promotion, nutrition, elimination, activity/rest, perception/cognition, self-perception, role relationships, sexuality, coping/stress tolerance, life principles, comfort, and growth/development) and 167 nursing diagnoses (NANDA, 2006). The psychiatric–mental health nursing (PMHN) diagnostic system is organized around eight human response processes (activity, cognition, ecological, emotional, interpersonal, perception, physiologic, and valuation). The psychiatric nursing community has agreed to use the existing NANDA classifications until further integration of the two models occurs (Boyd, 2002). Indeed, the American Nurses Association (ANA) Task Force continues to work on the development of a single
classification system that will incorporate psychiatric nursing diagnoses. Box 10-1 lists nursing diagnoses commonly seen in the psychiatric–mental health clinical setting.
classification system that will incorporate psychiatric nursing diagnoses. Box 10-1 lists nursing diagnoses commonly seen in the psychiatric–mental health clinical setting.
 Table 10.1 Classifications of Nursing Diagnoses | ||||||||||
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The following are two examples of NANDA nursing diagnoses identified by student nurses who assessed clients in the medical–psychiatric clinical setting:
A 52-year-old male was diagnosed with acute heart failure and metabolic acidosis. This man’s chief complaint was shortness of breath. History revealed two heart attacks, chronic constipation, and kyphosis. After completion of a psychosocial assessment, the student nurse analyzed the data, which included observations of clinical symptoms of anxiety and verification of the client’s statements. The student nurse validated the data with the clinical instructor and consulted a list of defining characteristics for the diagnoses suspected. The student nurse then noted the following nursing diagnoses pertaining to psychosocial needs of the client:
Anxiety, moderate level, related to physical condition and hospitalization as evidenced by tremulous voice, increased verbalization with pressured speech, tremors of hands when speaking, and diaphoresis
Ineffective Coping related to separation from family and home, change in physical status, and limited mobility
Disturbed Sleep Pattern related to anxiety secondary to physical illness as evidenced by the inability to fall asleep
Ineffective Sexuality Patterns related to fear and anxiety about sexual functioning secondary to physical illness
A 45-year-old female with chronic heart failure and lymphoma was admitted for chemotherapy. Chief complaints included shortness of breath, rapid weight loss, and fatigue. The student collected data regarding the client’s emotional response to her medical condition and her ability to cope with the diagnosis of a terminal condition. The student nurse then validated the psychosocial data with the head nurse and asked the client to verify her statements made during the assessment. After the defining characteristics for the nursing diagnoses were confirmed, the following nursing diagnoses were made:
Anticipatory Grieving related to terminal condition as evidenced by denial, anger, and the statement “I don’t have long to live”
Situational Low Self-Esteem due to alterations
of body image as evidenced by negative statements about self
Defensive Coping demonstrated by the increased use of suppression, projection, dissociation, and denial
Anxiety, acute, related to illness, hospitalization, and separation from spouse as evidenced by increased restlessness, rapid pulse, and increased questioning about illness
Box 10.1: Examples of Nursing Diagnoses in Psychiatric–Mental Health Nursing
Acute Confusion
Anticipatory Grieving
Anxiety
Bathing/Hygiene Self-Care Deficit
Decisional Conflict
Deficient Diversional Activity
Deficient Knowledge
Delayed Growth and Development
Disturbed Body Image
Disturbed Sleep Pattern
Dressing/Grooming Self-Care Deficit
Dysfunctional Grieving
Fear
Feeding Self-Care Deficit
Hopelessness
Imbalanced Nutrition: Less Than Body Requirements
Impaired Adjustment
Impaired Memory
Impaired Parenting
Impaired Social Interaction
Impaired Verbal Communication
Ineffective Coping
Ineffective Health Maintenance
Ineffective Role Performance
Ineffective Sexuality Patterns
Interrupted Family Processes
Noncompliance
Post-Trauma Syndrome
Powerlessness
Relocation Stress Syndrome
Risk for Injury
Risk for Loneliness
Risk for Other-Directed Violence
Risk for Self-Directed Violence
Social Isolation
Spiritual Distress
Toileting Self-Care Deficit
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR)
