05/04/2011 taxonomy of nursing diagnosess1-keperawatan.umm.ac.id/files/file/nanda diagnosa...
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05/04/2011
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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
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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
DiagNoSa Keperawatan
TIDAK NGAWURDiagNoSa Keperawatan
TIDAK DIBUAT SENDIRI
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DiagNoSa Keperawatan
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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