Tips for Teaching Nursing Diagnosis

and the Use of

NANDA International Terminology
Nursing Diagnosis: Definition
The NANDA-I definition of a nursing diagnosis was
adapted from a national, Delphi study by Dr.
Joyce Shoemaker (1984)
Nursing diagnosis is 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 (NANDA,
1997).
The Diagnoses
206 NANDA-approved nursing diagnoses will
be present in the Definitions & Classifications
book for 2009 - 2011
Level of Evidence (LOE) Criteria Established for
All New and Revised Diagnoses
Entry into the Taxonomy requires various levels of
clinical evidence
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)
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)
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
Nurses Are Diagnosticians
Diagnosticians interpret data within their fields of expertise in order to
provide needed services
A key element of data interpretations is that they are subject to error.
A good diagnostician must realize that there are always risks to the
accuracy of data interpretations
Becoming a nurse diagnostician requires development of professional
and personal skills and characteristics
Competencies in intellectual, interpersonal, and technical domains
Personal strengths of tolerance for ambiguity and use of reflective
practice

Teaching Methods
Review proper method to complete patient assessment to
determine the presence of defining characteristics
Clustering of defining characteristics is often misunderstood :
presence of one defining characteristic does not necessarily require a
diagnosis
All nursing interventions do not require a nursing diagnosis
Medication administration for a condition that is not a primary focus of
nursing care is related more to a medical diagnosis
Need to test hypotheses
Need to evaluate success of plan of care and reassess continually
Diagnostic Process
Assessment
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
Cue Generation and Nursing Diagnosis
Cues are analyzed in relation to possible diagnoses
Existing cues are matched with the expected cues for the
diagnoses being considered
During the evaluation of cues and related diagnoses, nurses
may decide that there are not enough data to make a
diagnostic decision or that there is enough evidence for one
or more likely diagnoses
If there are not enough data to make a diagnosis, then the next step involves a
focused search for additional cues
If there is enough supporting evidence, a diagnosis is made and then validated
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
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
Teaching Methods
Requiring students to develop and detail care plans
with every possible diagnosis creates resistance
Sets up situation that is not realistic
Cannot address every possible diagnosis in a short hospital stay
Becomes a thing to do rather than truly understanding
and applying diagnostic reasoning and differential
diagnosis
Students learn to just pick a diagnosis rather than making
decisions about the best explanation(s) for patient responses

Teaching Methods
Use of case studies can assist students in identifying
cues in patient situations that may be defining
characteristics of one or more nursing diagnoses
Hypothesis generation and differential diagnosis
skills can be developed through case studies, clinical
conference discussions and in skills lab scenarios
The List
Automating the electronic record to populate the
plan of care with nursing diagnoses when a particular
medical diagnosis is used
Becomes a documentation tool rather than an
individualized plan of care to direct nursing interventions
to meet important patient outcomes
Puts patients at risk / Negligence
May ignore or miss important diagnoses for patients
Plan of care does not address critical outcomes for patients
Reportable Quality Measures:
Where is Nursing?
Management of diabetes:
Percent of adults with diabetes who had a foot examination in past
year
Percent of adults with diabetes who had an influenza immunization in
past year
Percent of adults with diagnosed diabetes with HbA1c level > 9.0%
(poor control); < 7.0% (optimal)
Hospital admissions for short-term complications of diabetes per
100,000 population
The Role of Nursing in Patient Quality
Percent of adults with diagnosed diabetes
with HbA1c < 7.0% (optimal)
Readiness for enhanced family coping
Health-seeking behaviors
Readiness for Enhanced Self Health Management

The Role of Nursing in Patient Quality
Management of diabetes:
Hospital admissions for short-term complications
of diabetes per 100,000 population
Anxiety
Ineffective coping
Ineffective health maintenance
Risk for injury
Deficient knowledge
Ineffective Self Health Management

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).