Nursing Diagnosis: What It Is, What It Is Not
Learning Objectives
After reading the chapter, the following questions should be answered:
What is the bifocal clinical practice model?
How do nursing diagnoses differ from collaborative problems?
How are collaborative problems written?
Is monitoring an intervention?
As discussed in Chapter 2, the official NANDA-I definition of nursing diagnosis reads, “Nursing diagnosis is a clinical judgment about an individual, family, or community response to actual or potential health problems or life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability” (NANDA-I, 2009). But what about other clinical situations—those that nursing diagnosis does not cover, those that necessitates nursing intervention and medical interventions? Where do they fit within the scope of nursing practice? What about clinical situations in which both the nurses and physicians must prescribe interventions to achieve outcomes?
Collaboration With Other Disciplines
The practice of nursing requires three different types of nursing responsibilities:
Assessing for and validating nursing diagnoses, providing interventions for treatment, and evaluating progress
Monitoring for physiologic instability and collaborating with physicians/physician assistants and nurse practitioners, who determine medical treatment
Consulting with other disciplines (physical therapy, occupational therapy, social service, respiratory therapy, pharmacology) to increase the nurse’s expertise in providing care to a particular individual
When nurses collaborate with other disciplines such as physical therapy, nutrition, respiratory therapy, and social service, they may offer recommendations for the management of a problem. These recommendations can be either made informally to the nurse and added to the care plan at the discretion of the nurse or ordered by the discipline on the order record according to the institutional policies.
Carp’s CuesOther disciplines should not add interventions to the care plan unless it is a multidiscipline care plan. These interventions on a multidiscipline care plan would indicate what discipline is prescribing and providing care. When the care plan is not multidisciplinary and a physical therapist has recommendations for nursing interventions for an individual, the nurse and the physical therapist will determine whether these interventions are to be added to the care plan. This is the same as when a physician requests a specialist to see an individual. The specialist usually does not write orders for the individual but instead communicates recommendations in a consultation report.
Bifocal Clinical Practice Model
In 1983, Carpenito introduced a model for practice that describes the clinical focus of professional nurses in addition to NANDA-I nursing diagnoses. This bifocal clinical practice model identifies the two clinical situations in which nurses intervene: one as primary prescriber and the other in collaboration with medicine. This model not only organizes the focus of nursing practice, but also helps distinguish nursing from other health-care disciplines (Fig. 4.1).
 FIGURE 4.1 Domains of expertise of professional nurses and physicians. |
Carp’s CuesCollaborative problems are specifically defined as physiological; problems that are at risk to occur or have occurred that require both medicine and nursing interventions to treat. Collaboration with other disciplines (e.g., physical therapy, nutrition, respiratory therapy, and the use of nursing diagnosis) is discussed earlier.
Nursing derives its knowledge from various disciplines, including biology, medicine, pharmacology, psychology, nutrition, and physical therapy. Nursing differs from other disciplines in its broad range of knowledge. Figure 4.2 illustrates the varied types of this knowledge as compared with other disciplines. Certainly, the nutritionist has more expertise in the field of nutrition, and the pharmacist in the field of therapeutic pharmacology, than any nurse has. But every nurse brings knowledge of nutrition and pharmacology to individual interactions that is appropriate for most clinical situations. (Note that when a nurse’s knowledge is insufficient, nursing practice calls for consultation with appropriate disciplines.)
No other discipline has this wide knowledge base, possibly explaining why past attempts to substitute other disciplines for nursing have proved costly and ultimately unsuccessful. For this reason, any workable model for nursing practice must encompass all the varied situations in which nurses intervene while also identifying situations in nursing that nonnursing personnel must address.
Nursing prescribes for and treats individual and group responses to situations. These situations can be organized into five categories:
Pathophysiologic (e.g., myocardial infarction, borderline personality, burns)
Treatment-related (e.g., anticoagulant therapy, dialysis, arteriography)
FIGURE 4.2 Comparison of types of knowledge by discipline.
Personal (e.g., dying, divorce, relocation)
Environmental (e.g., overcrowded school, no handrails on steps, rodents)
Maturational (e.g., peer pressure, parenthood, aging)
The bifocal clinical practice model, diagrammed in Figure 4.3, identifies these responses as either nursing diagnoses or collaborative problems. Together, nursing diagnoses and collaborative problems represent the
range of conditions that necessitate nursing care. The major assumptions in the bifocal clinical practice model are as follows:
range of conditions that necessitate nursing care. The major assumptions in the bifocal clinical practice model are as follows:
 FIGURE 4.3 Bifocal clinical nursing model. (© 1985 by Lynda Juall Carpenito.) |
Client1
Has the power for self-healing
Continually interrelates with the environment
Makes health decisions according to individual priorities
Is a unified whole, seeking balance
Has individual worth and dignity
Is an expert on own health
Health
Is a dynamic, ever-changing state
Is defined by the individual
Is an expression of optimum physical, spiritual, and psychosocial well-being
Is the responsibility of the individual and the health-care system
Environment
Represents external factors, situations, and people who influence or are influenced by the individual
Includes physical and ecologic environments, life events, and treatment modalities
4. Nursing
Is accessed by the individual when he or she needs assistance to improve, restore, or maintain health or to achieve a peaceful death (Henderson & Nite, 1960)
Ensures the individual has the needed information for an informed consent
Supports the right of the individual to refuse recommendations
Engages the individual to assume responsibility in self-healing decisions and practices
Reduces or eliminates factors that can or do cause compromised functioning, for example, effects of diseases, relationship problems, comprehension barriers, financial issues
Understanding Collaborative Problems
Carpenito (1999) defines collaborative problems as
Certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nursing-prescribed interventions to minimize the complications of the events.
The designation certain clarifies that all physiologic complications are not collaborative problems. If the nurse can prevent the onset of the complication or provide the primary treatment for it, then the diagnosis is a nursing diagnosis. For example:
|
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
