05/04/2011 Taxonomy of Nursing Diagnosess1-keperawatan.umm.ac.id/files/file/NANDA diagnosa Keperawatan... · The NANDA International Taxonomy ... Significant overlap of cues to diagnoses

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The NANDA International

Taxonomy

Taxonomy of Nursing Diagnoses

Dewi Baririet BarorohDepartement Keperawatan Dasar : Proses Dokumentasi Keperawatan

PSIK FIKES UMM

Nurse are diagnosticians “Health” of “human beings”

Health-related phenomena are complex because they involve human experiences

Nursing’s goal is to identify people’s experiences or responses in order to support them.

Significant overlap of cues to diagnoses

Contextual factors such as culture can change the perspective of “what is the diagnosis?”

Many studies have verified that interpretations of clinical cases have the potential to be less accurate than indicated by the data

(Lunney, 2007).

Nurse are diagnosticians

As foundation of nursing care.

2 basics development need of competencies to diagnose :

1. Requires intelectual, interpersonal, technical

2. Personal strength of tolerance for ambiguity and refelctive practice

Proposition # 1Skills/Competencies

Intellectual Knowledge related to:

Diagnoses, interventions, & outcomes

Thinking processesResearch findings

Human beings vary in thinking process abilities

Thinking process abilities can be improved

Crithical Thingking Find the core

Process to synthesize is good

Not just receiving knowledge or remember thing

Share with group or teacher or practitioner

Be confidence

U are whatever u thinking of yours

Generated by Foxit PDF Creator © Foxit Softwarehttp://www.foxitsoftware.com For evaluation only.

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Intellectual Skills:Critical Thinking (CT)

Thinking (CT) processes can be improved Stimulate to use

Expect use

Validate appropriate use

Demonstrate support & confidence in abilities

CT abilities -essential for accuracy of diagnoses & use of NOC & NIC

Intellectual Skills:What is CT in Nursing?Delphi study of 55 nurse experts

(Scheffer & Rubenfeld, 2000)

Purpose: Identify the components of CT that relate to nursing

Results- Definition for nursing7 Cognitive Skills

10 Habits of Mind

Cognitive Skills Analyzing

Applying Standards

Discriminating

Information Seeking

Logical Reasoning

Predicting

Transforming Knowledge

Habits of Mind

Confidence

Contextual perspective

Creativity

Flexibility

Inquisitiveness

Intellectual integrity

Intuition

Open-mindedness

Perseverance

Reflection

Intellectual Skills:CT Processes

CT involves continuous processing of data and inferences

In any situation, two or more cognitive skills are probably being used

Habits of mind support cognitive skills

The combination of CT abilities needed is unique to the situation

Proposition # 1 (cont.)Interpersonal Skills

Exquisite communicationPromote Trust

Work in partnership, share power

Validate perceptions

Accept that we do not “know” others


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Interpersonal First Impression

Not knowing anyone

Find someone by hearing them

Proposition # 1 (cont.)Technical Skills

Obtain valid and reliable dataHealth histories Comprehensive

Physical exams Focused

Perform nursing interventions

Technical aspects of using NNN

Shortcut to super_woman_run_md_wht.lnk

Proposition #2Personal StrengthsTolerate ambiguity FLEXIBELDecisions are relative to context & specific nature of

individuals

Multiple factors influence clinical situations

Human beings are complex and diverse

Ambiguity is the norm

Proposition #2(cont.)Personal Strengths

Reflect on practice experiences experienceAccept possible flaws Thinking

Interpersonal

Technical

Aim - develop & grow

Proposition # 2: Accurate Interpretations-Foundational

Cues/data may be incorrectExamples

Objective Data: Diagnostic tests Subjective Data

o Patients

o Families


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Proposition # 2: Accurate Interpretations-Foundational Use of NNN requires many decisions

All decisions are based on patient data

Data amounts are overwhelming

Short tem memory = 7 ± 2 bits of data

Data are converted to interpretations

Proposition #2: Accurate Interpretations -Foundational

Interpretations determine actions Additional data collection

Subsequent decisions

Possible outcomes to consider

Choices of interventions

High potential for inaccuracy Diagnosis and etiology

High Potential for Inaccuracy, e.g., Marian Hughes

16 y.o. Diabetic (#1)

Hospitalized, DKA (#2)

“did not follow prescribed diet” (#3)

NDX: Ineffective management of therapeutic regimen r.t. _______ (fill in the blank)

Possible Interpretation/Diagnosis

Knowledge deficitDisconfirming Cues:

Meals eaten at school are consistent with diet (#9)

Able to explain what she should be eating (12)

She can adjust her diet to her lifestyle (#13)

Conclusion: Low accuracy diagnosis

Teaching is waste of time, effort, & money

Highest Accuracy Diagnosis

Ineffective Management of Therapeutic Regimen related to communication difficulties between Marion and her mother

Patient Outcome (NOC): Communication = 3 (moderately compromised), Increase to 5 (not

compromised)

Nursing Intervention Communication enhancement

44 Diagnoses by 80 Nurses Examples

Communication difficulties mother/daughter Stressful mother/child relationship

Altered family dynamics Ineffective coping

Ineffective time management

Adolescent image Low self esteem

Denial Knowledge deficit


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Seven Levels of Accuracy+5 Highest level of accuracy

+4 Close to the highest level but not quite

+3 General idea but not specific enough

+2 Not enough highly relevant cues or not the highest priority

+1 Suggested by only one or a few cues

0 Not indicated by data

-1 Should be rejected, disconfirming cues

Diagnostic Accuracy Scores Communication difficulties between

mother and daughter +5

Stressful mother/child +4 Altered family dynamics +3

Ineffective coping +2 Ineffective time management +2

Adolescent image +1

Low self esteem +1 Denial 0

Knowledge deficit -1

Research Findings Studies: 1966 to present

Conclusions: Interpretations vary widely

All interpretations are not high accuracy

Influencing factors (Carnevali & Gordon): Nurse Diagnostician

Diagnostic Task

Situational Context

Research: Positive Influences Diagnostic Task

Lesser amounts and complexity of data

Nurse Diagnostician

Education related to nursing diagnoses

Knowledge of diagnostic process and concepts

Teaching aids for diagnostic reasoning

Variety of thinking processes

Experience specific to diagnostic task

Challenge: Achieving Accuracy

Puzzle: What is the Diagnosis?

Solving the Puzzle

Is it this? Or this? Or this?


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Accurate Interpretations-Foundational

Supporting Factors:

Acknowledge that data interpretations are probabilistic; question

accuracy

Use CT, interpersonal & technical skills

Develop tolerance for ambiguity

It’s OK not to have an answer

Accept that we might make mistakes

Develop reflective practice

5THING

about NURSING DIAGNOSE

DiagNoSa Keperawatan

TERSTANDARDiagNoSa Keperawatan

TERTENTU


TIDAK NGAWURDiagNoSa Keperawatan

TIDAK DIBUAT SENDIRI


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IDENTITAS

Why implement nursi diagnosis in clinical enviroment ?

Evidence based practise : integrating teory and practice

Electronic patients record

Leading the implementation

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)

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

PRINSIP diagnosa ∞ pengkajian Hipotesis diagnostik dipertimbangkan melalui proses pengkajian

dalam beberapa kejadian : data dasar pada pengkajian komprehensif/tak tentu waktu diagnosa harus segera dibuat dan di intervensi

Semua komponen dilibatkan : pasien, keluarga, komunitas

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)


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Diagnostic ProcessAssessment

Cluster cues / defining characteristics

Collect additional data to narrow list of potential diagnoses

Generate list of potential diagnoses

Implement plan of care based on identified diagnoses

Evaluate success of plan of care

Determine diagnosis/diagnoses to be treated

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

Cluster cues / defining characteristics

Collect additional data to narrow list of potential diagnoses

Generate list of potential diagnoses

Implement plan of care based on identified diagnoses

Evaluate success of plan of care

Assessment OR Identify Medical Diagnosis

Determine nursing diagnosis/diagnoses to be treated

Nursing Diagnosis: NANDA-I Definition

Adapted from a national, Delphi study by Dr. Joyce Shoemaker (1984) 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 (1997).

The Diagnoses

206 NANDA-approved nursing diagnoses as of 2008

Level of Evidence (LOE) Criteria Established for All New and Revised Diagnoses

Entry into the Taxonomy requires various levels of clinical evidence


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TaxonomyOxford English Dictionary American Nurses Association

/taksonnmi/

• noun chiefly Biology

1 the branch of science concerned with classification.

2 a scheme of classification.

ORIGIN from Greek taxis ‘arrangement’ + -nomia ‘distribution’

Classification according to presumed natural relationships among types and their subtypes

ANA, 1999

Definitions for Classification of Nursing Diagnoses

Classification

Systematic arrangement of related phenomena in groups or classes based on characteristics that objects have in common

Nomenclature

A system of designations (terms) elaborated according to pre-established rules

(ANA, 1999)

Definitions for Classification of Nursing Diagnoses Domain

A sphere of activity, concern, or function; a field: the domain of history

Class

A set, collection, group, or configuration containing members regarded as having certain attributes or traits in common; a kind or category.

o (http://www.thefreedictionary.com/domain)

Structure of Taxonomy II

Domains

Class

NDx NDx

Class

NDx NDx


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Code Structure

NANDA-I uses a 32-bit integer (or a 5-digit code) to enable growth & development of the taxonomy without having to change codes repeatedly to accommodate those changes

Code structure is compliant with the National Library of Medicine’s (USA) Unified Medical Language System (UMLS) concerning healthcare terminology codes

Structure of Taxonomy II

Registered with Health Level 7 (HL7)

Modeled into SNOMED-CT

Compliant with ISO terminology model for a nursing diagnosis

Working collaboratively with ICNP

Multiaxial System

7 axes within NANDA-I Taxonomy

Axis

A dimension of the human response that is considered in the diagnostic process

Allows for flexibility of the nomenclature

Allows for easy additions and modifications

1st step :

Look axis

NANDA-I AxesAxis 1

The Diagnostic Concept

Page. 446-447

Axis 2

Subject of the Diagnosis

(Individual, Family, Group, Community)

Axis 3

Judgment

(Decreased, Effective, Impaired, Situational,

etc.) page. 448

Axis 4

Location

(GI, Oral, Skin, etc.) page 449-450

Axis 5

Age

(Infant, Preschool Child, Adolescent, Adult, etc.)

Axis 6

Time

(Acute, Intermittent, Chronic, Continuous)

Axis 7

Status of the diagnosis

(Actual, Health Promotion, Risk,

Wellness)Required Optional

Variations of Nursing Diagnosis’: 1. Actual diagnosis: describes health conditions that exist

and supported by defining characteristics

2. Risk diagnosis: those which describe disease or other conditions that may develop and are supported by risk factors

3. Wellness diagnosis: describe levels of wellness and potential for enhancement to a higher level of functioning

4. health promotion : motivation to health and wellbeing

(NANDA, 2009) and (Denehy & Poulton, 1999)


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The NANDA-I Model of a Nursing Diagnosis

Diagnostic concept(Axis 1)

Judgment(Axis 3)

Location(Axis 4)

Subject of Diagnosis(Axis 2)

Time(Axis 6)

Status ofDiagnosis(Axis 7)

Age(Axis 5)

A NANDA-I Nursing Diagnosis Model: (Individual) Ineffective Coping

Coping(Axis 1)

Ineffective(Axis 3)

N/A(Axis 4)

[Individual](Axis 2)

N/A(Axis 6)[Actual]

(Axis 7)

N/A(Axis 5)

A NANDA-I Nursing Diagnosis Model:Compromised Family Coping

Coping(Axis I)

Compromised(Axis 3)

N/A(Axis 4)

Risk for(Axis 7)

N/A(Axis 6)

Family(Axis 2)

A NANDA-I Nursing Diagnosis Model: Readiness for Enhanced Family Coping

Coping(Axis 1)

Enhanced(Axis 3)

N/A(Axis 4)

Family(Axis 2)

N/A(Axis 6)

Readiness for(Axis 7)

N/A(Axis 5)

2nd step :

Look label and definition


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What is defining characteristic and rik factor ??

Related factor

Components of a Nursing Diagnosis

1. Label or Name and definition

2. Related Factors OR Risk Factors

3. Defining Characteristics

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).

Made a priority Base on basic human need : individu, family, community

Correlation with NIC and NOC

NNN NANDA, NIC, NOC linkage


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