Standard 2. Diagnosis
Julie Stanik-Hutt PhD, ACNP-BC, CCNS, FAAN
Standard 2. Diagnosis. The registered nurse analyzes the assessment data to determine the diagnosis or the issues.
Definition and Explanation of the Standard
Diagnosis refers to the process of critically evaluating an issue or situation to identify and apply a name to the cause of the problem (Merriam-Webster Online Dictionary, 2011). Diagnostic processes are used by individuals in many occupations and professions. In addition to healthcare professionals, many others, including engineers, teachers, managers, automobile mechanics, and plumbers, diagnose problems within their areas of expertise. Healthcare professionals use the diagnostic process to identify and name the most likely cause of a patient’s signs and symptoms (Rakel, 2011). To make a diagnosis, the healthcare provider uses clinical judgment to draw conclusions regarding the nature or cause of the health problem on the basis of the available data. These problems, labeled as diagnoses, become the focus for planning care. In clinical practice, nurses use diagnosis to determine and name individual patient’s health problems. Nurses also use diagnosis to identify and name healthcare systems problems that interfere with effective delivery of high-quality healthcare services. In either case, the nurse recognizes a deviation from the expected, collects information about the deviation, interprets and analyses the assessment data, draws a conclusion, and labels the problem. Diagnosis is the second step of the nursing process.
Diagnoses serve several purposes. In clinical practice, diagnoses are used to identify a patient’s problems, which are the focus of attention by the healthcare provider. On the basis of that diagnosis, the provider develops a plan of care with established goals and selected effective therapeutic interventions. Diagnoses also facilitate communication among healthcare providers. By using standard diagnostic terms, multiple healthcare providers can understand the patient’s problems, can anticipate interventions that will be used to manage the problem, and can expect that certain data will be collected to reassess the patient’s condition and responses to care (Muller-Staub, Lavin, Needham, & van Achterberg, 2006). Diagnostic language can also be used as a system to organize research and practice evaluation processes, and it can be used to create a system of nomenclature for reimbursement for healthcare services (Rutherford, 2008).
Types of Diagnoses Used in Nursing
The type of diagnostic language used by nurses differentiates the practice focus of nursing and their professional role from those of other healthcare providers. Registered nurses (RNs) use nursing diagnoses to characterize and organize their professional work. In contrast, medical diagnoses label genetic and pathological conditions, illnesses, and syndromes. Medical diagnoses are used by APRNs nurse practitioners (NPs), nurse anesthetists (CRNAs), clinical nurse specialists (CNSs), physicians, nurse midwives (CNMs), and some other healthcare providers. Nurses in leadership and executive positions (clinical nurse specialists, nurse managers, nurse executives, nurse educators) also use critical thinking and problem-solving processes to identify and label (diagnose) problems that they encounter in their work. Although they may not always use a set of standardized diagnostic terms or labels, they are using similar processes to move from assessment of a situation to identification of a cause(s) before developing a plan of action to resolve or correct the problem. A nursing diagnosis is defined as an actual or potential response to a health problem experienced by a patient, family, or community, including health promotion needs and risks for health problems and syndromes. The North American Nursing Diagnosis Association International (NANDA-I) is one organization that has developed a diagnostic language commonly used in nursing. NANDA-I diagnoses are commonly used with two associated compendia, the Nursing Interventions Classifications (NIC) (Bulechek, Butcher, & Dochterman, 2008) and the Nursing Outcomes Classifications (NOC) (Moorhead, Johnson, Maas, & Swanson, 2007). The International Classification of Nursing Practice
(ICNP) and Perioperative Nursing Data Set (PNDS) are two other systems used to label patient healthcare problems addressed through nursing (ICN, 2009; Peterson, 2011). All three of these systems (NANDA-I with NIC and NOC, ICNP, and PNDS) integrate diagnostic terminology with nursing interventions and expected outcomes.
(ICNP) and Perioperative Nursing Data Set (PNDS) are two other systems used to label patient healthcare problems addressed through nursing (ICN, 2009; Peterson, 2011). All three of these systems (NANDA-I with NIC and NOC, ICNP, and PNDS) integrate diagnostic terminology with nursing interventions and expected outcomes.
Within the NANDA-I system, each diagnostic term includes a definition statement (diagnostic criteria), related factors (etiology of the problem, contributing or associated factors), and defining characteristics (symptoms) (Ackley & Ladwig, 2011). Consequently, a NANDA-I nursing diagnosis includes three parts: the problem, the etiology of the problem, and the symptoms. For example, a patient who has coronary artery disease and who grimaces and complains of 7/10 burning pain while pointing to the middle of his or her chest might have the nursing diagnosis of acute pain related to myocardial ischemia as evidenced by patient’s grimace and complaint of 7/10 burning pain. The information provided in the NANDA-I fully describes the diagnosis of interest. Categories included in the NANDA-I system include physical, psychological, sociocultural, and spiritual responses to health problems. The Omaha System and the Clinical Care Classification System also identify health problems and interventions used by nurses (Martin, 2005; Saba, 2006). The Omaha System includes categories for several domains: environmental, psychological, physiological, and health behaviors. It is commonly used by nurses in home health and public health settings. The Clinical Care Classification System includes diagnoses and interventions originally designed for nurses to use to describe and document home health care.
A medical diagnosis is used to label genetic or pathological conditions, illnesses, and syndromes. Advanced practice registered nurses (APRNs) are legally authorized to make medical diagnoses. Diagnostic criteria used to make medical diagnoses consist of the patient symptoms, physical and psychological examination findings, and results on selected diagnostic tests. Diagnostic labels used are found in the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) (WHO, 2007; American Psychiatric Association, 2000). The ICD is a taxonomy of diagnostic language used in medical diagnosis. It includes an exhaustive list of diagnoses and patient symptoms, signs, and injuries. The DSM is another system of diagnostic language used in medicine. It includes diagnostic criteria for and the standard diagnostic terminology used by all providers (NPs, psychiatric clinical nurse specialists [CNSs], MDs, psychologists, etc.) to identify psychiatric and mental health problems.
Two other systems, the International Classification of Functioning, Disability, and Health (ICF) and the Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT) are used with diagnostic languages, primarily to organize research and practice evaluation processes (WHO, 2011; Ruch, Gobeill, Lovis, & Geissbühler, 2008). The ICF system classifies “health and disability at both individual and population levels” (WHO, 2011). It is used alongside medical diagnostic language to describe an individual’s functional capacities, including performance of activities of daily living as well as one’s ability to interact with others. The ICF is not used in clinical practice in the United States, although it is used in Australia and Italy “to document functional status assessment, goal setting, and treatment planning and monitoring, as well as outcome measurement” (WHO, 2011). The ICF has been used more widely to describe the health status of a country’s population.
SNOMED CT is an exhaustive system of highly refined and technically specific clinical language used in clinical information systems to code, retrieve, and analyze information related to healthcare encounters. The system is integrated in such a way that varying labels for the same problem are linked. In this way, searches will retrieve all relevant cases so that care processes and outcomes can be examined. Although SNOMED CT includes diagnostic labels, it also includes much more specific technical terminology that is not generally used in practice to make nursing or medical diagnoses.
The Diagnostic Process
PATIENT-FOCUSED CARE
Assessment data (symptoms and physical exam findings) are the defining characteristics (diagnostic criteria) used to narrow the broad list of potential diagnoses to the one that is or ones that are the best match to the patient’s situation. More than one diagnosis may match the patient’s symptoms. After collecting assessment data, the nurse analyzes the patient’s historical data, symptoms, and physical examination findings are and organizes them into related groups or categories. A patient’s symptoms and signs can be grouped to create a cohesive picture of all associated data. For example, during the assessment process, a patient who complains of difficulty breathing would be asked questions that would further describe the symptom (e.g., onset, duration, and aggravating factors), and he or she would be examined for physical evidence related to breathing difficulty (e.g., respiratory rate and pattern, oximetry readings, breath sounds, color, and diaphoresis). All those data are
analyzed together to identify the diagnoses related to the patient’s complaint of difficulty breathing. Whenever possible, diagnoses are validated with the patient, family, or community (American Nurses Association, 2010; pg. 34).
analyzed together to identify the diagnoses related to the patient’s complaint of difficulty breathing. Whenever possible, diagnoses are validated with the patient, family, or community (American Nurses Association, 2010; pg. 34).
POPULATION-FOCUSED CARE
When an individual patient and his or her family are the focus in community-based care, nursing assessment and diagnoses are used as they are with any other individual or family (Rivera & Parris, 2002). When working with a community, a diagnosis is based on data from a focused or comprehensive community health assessment while using population-based health data, socioeconomic and crime statistics, data about family makeup and cultural groups, and the physical characteristics as well as the safety of the environment. The “10 Essential Public Health Services” might also be used to inform collection and analysis of assessment data (Public Health Functions Steering Committee, 1994; Smith & Bazini-Barakat, 2003; Satterfield, et al., 2004). Data from all these diverse sources are organized and analyzed to identify population-based health problems. Relevant diagnoses might include items such as ineffective community coping and health maintenance; risk prone behavior for injury and trauma, for poisoning, for impaired parenting, and similar items; deficient knowledge related to readiness for enhanced self-health management; social isolation; and so forth.
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