Learning Objectives
By the end of this section, you will be able to:
- Analyze the foundational steps for clinical decision-making
- Recognize the difference between a nursing diagnosis and a medical diagnosis
- Identify how the nursing diagnosis can promote expected patient care outcomes
This section discusses the focus of nursing diagnosis. Just as the focus of each role for different healthcare clinicians varies, so does the focus of the nursing diagnoses. The primary focus is for the nurse to explain why the patient needs nursing care versus medical care. The diagnosis identifies nursing care that treats a patient’s problem or concern and can be performed independently by the nurse instead of the provider.
This section analyzes foundational steps for clinical decision-making using a model that focuses on preventing problems or issues. It also discusses the differences between nursing and medical diagnoses and explores how these differences highlight the uniqueness of each profession. This section also demonstrates how nursing diagnosis promotes the desired patient outcome.
Foundation for Clinical Decision-Making
Before the evolution of nursing diagnosis and the autonomy of the profession, the healthcare mindset was to have providers diagnose while nurses treat and care for patients. Hence, the foundation of the nursing profession is to care for those in need. Since the evolution of an autonomous profession that collaborates with other healthcare clinicians, the trend has shifted to place more value on the nurse, basing patient care on evidence-based research and incorporation of clinical decision-making.
The foundational steps for incorporating clinical decision-making for patient care are to predict, prevent, manage, and promote (PPMP). Through evidence-based interventions, nurses can address their patients’ needs by predicting potential problems, preventing problems before they start, managing problems when they do arise, and providing health promotion strategies.
Predict
In the presence of known problems, nurses must predict the most common and dangerous complications associated with each problem. This involves looking at the big picture and thinking about the best and worst possible outcomes. The best outcome will show signs and symptoms of the patient’s progress toward recovery. In contrast, the worst outcome will represent signs of patient deterioration and decompensation.
The nurse must always be thinking two steps ahead. While it sounds daunting, most people use this thinking in daily life without realizing it. For example, most people wouldn’t just hit the open roads on a road trip without thinking first about their destination or plan to get there. It takes a plan to make sure the trip is enjoyable and goes off without a hitch.
Prevent
The nurse has a primary role in keeping the patient safe. This responsibility means nurses are constantly looking for potential problems and determining how to prevent them from happening. Think of the road trip example again. Getting the car’s oil and tires checked, mapping out the route, and packing extra snacks and water in case of a breakdown on the road are all steps that can be taken ahead of time.
The same planning applies when using thinking skills in clinical decision-making. Nurses must think through the many possible scenarios that could happen to a patient and carefully put measures in place to prevent the worst scenarios from taking place. Nurses must be ready to take immediate action when a potential problem becomes an actual problem.
Manage
If a potential problem cannot be prevented, the nurse will initiate the management phase. This step includes managing the problem through interventions such as involving the patient in decision-making, using evidence-based sources and protocols, and asking other interdisciplinary team members to collaborate on care if needed. The nurse will organize monitoring of the patient to be watchful for signal changes in a patient’s condition or deterioration.
The road trip example applies here, too. What if a car’s tire blows out? Some people may change the tire themselves, while others would call a rescue service such as a tow truck company or a local mechanic. What they would not do is sit on the side of the road and wait for the tire to fix itself. The same goes for nursing care for identified patient problems. The nurse must manage the situation to prevent the patient’s situation from getting worse.
Promote
The nurse always ensures that the safety and learning needs of the patient are being met by promoting peak functioning and independence. Patients will not need nurses forever. The nurse will actively encourage a patient to heal and self-manage their disease or condition. Often, the most natural way to promote health is to include the patient in their care. A patient will become empowered to protect their own well-being by learning to identify the signs and symptoms of potential problems. While the nurse has knowledge about disease management, the patient has a front-row seat to the actual problem and the effects it has on their quality of life.
Just like a driver would promote their own safety and the safety of their passengers while on a road trip, safety is at the forefront of all nursing interventions regardless of outcome. The knowledge and experience gained from a specific patient scenario informs future scenarios and provides information for how to plan for, prevent, and manage any complications.
As the nurse starts interpreting and analyzing data to predict, prevent, manage, and promote, they may identify the need for collaborative care to ensure the best possible outcomes for a patient. For example, perhaps the provider will need to re-evaluate the patient’s medical diagnosis or order new diagnostics. Maybe other interdisciplinary team members need to initiate interventions such as wound care, physical therapy, or respiratory therapy. In such situations, the nurse is responsible for reporting their findings and working collaboratively with each discipline to resolve the identified patient problem.
Nursing Diagnosis versus Medical Diagnosis
A medical diagnosis identifies a disease or a condition and describes a problem toward which providers direct the treatment plan. Treatment plans focus on the etiology, the cause (or causes) of a specific disease state. A nursing diagnosis identifies a patient’s response to health and illness-related problems. The diagnosis process is performed independently within the nurse’s professional scope of practice. It is also fluid and ever-changing based on the patient’s response to interventions. These key distinctions reflect the differences between medical and nursing diagnoses (Table 13.1).
| Nursing Diagnosis (Care-Focused) |
Medical Diagnosis (Etiology-Focused) |
|
|---|---|---|
| Definition | Identifies the signs and symptoms of the disease stated by the patient and their caregiver(s) | Identifies the clinical process behind the disease itself and the pathophysiology responsible for its cause |
| Focus | Emphasis is on the person and their physiological and/or psychological response to the illness | Emphasis is on the illness or condition |
| Example 1 | Ineffective cardiac tissue perfusion related to reduced coronary blood flow | Myocardial infarction (heart attack) |
| Example 2 | Risk for aspiration related to altered sensory perception | Cerebrovascular accident (stroke) |
| Example 3 | Risk of deficient fluid volume related to gastrointestinal losses and NPO status | Small bowel obstruction |
It is important to remember that a nursing diagnosis is based on the patient as a whole person and includes physical, mental, and social factors. The patient’s response to the disease process affects all of these domains of their life, so they must be part of the plan of care. The nurse considers actual responses and potential risks. They also look at how areas of concern could affect psychosocial factors, such as family or community support, access to resources, healthcare access in general, and financial barriers to care.
The nurse must also be aware of their own potential biases when doing assessments. These biases can present with preconceived notions about particular groups or situations and may ultimately affect how nurses provide care. Poor outcomes could look like inadequate patient assessment, inappropriate diagnosis and treatment plans, or the lack of education and follow-up for the patient and family.
Actual Problems
Another important consideration is that disease processes do not affect all patients in the same way. As such, the same nursing diagnosis will not fit every patient with the same medical diagnosis. The nurse must ensure the diagnosis chosen is an actual problem or a problem the individual patient is or could potentially experience. Actual problems are discussed in the context of nursing assessment in [link to: Chapter 12, section 12.1 H4]Actual Problems[/link].
A common example of this would be the medical diagnosis of diabetes in two different patients. One patient goes home and asks their entire family for help, changes their diet, and begins to exercise every day. The second patient internalizes the medical diagnosis, feels depressed and ashamed, and keeps the diagnosis a secret from their family and friends. The patient goes for walks occasionally but gives up when the weather gets hot in the summer.
The first patient was energized and ready to learn how to manage the disease and change their life in response to it. Their plan of care might start with a nursing diagnosis, such as “readiness for enhanced knowledge.” The nurse could provide education related to disease management. The second patient is not coping well with the new diagnosis. They have isolated themselves by not involving family and will have less-than-optimum outcomes if they do not change their mindset. The patient’s response to the diagnosis must be addressed before the nurse can start to educate the patient on how to manage the disease. This patient’s plan of care might start with a nursing diagnosis of “ineffective coping.” The nurse would need to provide the patient with education on healthy coping mechanisms and how they affect disease progression. The nurse may connect the patient with community support and resources.
Nursing Diagnosis versus Collaborative Problem
A nursing diagnosis is also different from a collaborative problem. Collaborative problems require interdisciplinary team members to complete. Response to these problems can be initiated by the provider, the nurse, or another discipline, but the responsibility of ensuring the task is completed falls on the nurse.
When the nurse identifies an expected outcome or goal, if it cannot be initiated without a medical order, then it is not a nursing diagnosis. Rather, it is a collaborative problem. For example, perhaps the nurse is planning care for a patient who has just undergone a knee replacement. The nurse recognizes the patient has “impaired physical mobility” and recommends a goal of “the patient will walk to the nurses’ station and back without assistance before discharge.” This task cannot be completed without the provider writing an order for physical therapy (PT) to evaluate and treat the patient. Therefore, it is a collaborative problem and not a nursing diagnosis. If the patient reports severe pain and cannot tolerate PT, the nurses could write a nursing diagnosis of “impaired physical mobility related to pain” and would need to administer medication before physical therapists can work with the patient.
Collaborative problems and nursing diagnoses are often intertwined. Therefore, it is imperative that collaborative problems are identified early within the treatment plan so that preventive nursing care can be initiated sooner rather than later.
Another way to think of collaborative problems is as interdisciplinary problems. See Table 13.2 for a side-by-side comparison of nursing and medical diagnoses with collaborative problems. Any time another interdisciplinary team member is involved in a patient’s plan of care, it is a collaborative problem. Nurses can use nursing-prescribed actions within the scope of their license and skill set to carry out provider-prescribed orders. The focus of collaborative problem-solving is monitoring patients for changes in clinical status, understanding who can best address the identified problem, and recommending new interventions. Nurses not only utilize appropriate nursing interventions but can also implement treatments as prescribed by providers.
| Nursing Diagnosis | Collaborative Problem | Medical Diagnosis |
|---|---|---|
| Disturbed body image | Need for prosthetic: rehabilitation therapist to fit for prosthetic device |
Amputation |
| Ineffective airway clearance | Need for chest physical therapy (CPT): respiratory therapist to perform chest physiotherapy |
Pneumonia |
| Imbalanced nutrition | Need for specialized diet: dietician to evaluate and treat |
Malnutrition: failure to thrive |
| Ineffective activity tolerance | Potential complications related to respiratory failure: cardiopulmonary rehabilitation |
Chronic obstructive pulmonary disease (COPD) |
| Total self-care deficit | Potential complications related to deconditioning: occupational therapy (OT)/speech therapy (ST)/physical therapy (PT) to assist with activities of daily living |
Cerebrovascular accident (stroke) |
Potential Complications
It is important to remember that a nursing diagnosis is not based on a medical diagnosis—it’s based on a patient’s response or reaction to their condition or disease. Nurses use information gathered during the assessment process and analyze the data collected. Determining a healthy response from a nonhealthy response is not as easy as it sounds. To avoid making a diagnostic error or failing to identify a response as unhealthy, the nurse must incorporate common evidence-based comparative standards when interpreting and analyzing data.
Recognizing which data are significant data is an important first step in preventing potential complications. For example, a blood pressure of 136/88 mm Hg may be considered elevated for a patient without a history of high blood pressure. However, the same blood pressure could be considered normal for a patient with a medical diagnosis of hypertension. According to the National Institutes of Health (NIH), some common comparative standards to use when analyzing patient data include the following:
- Unexplained changes in normal health patterns such as growth and development.
- Example: A 7-year-old child suddenly develops an inability to control their bladder.
- Rationale: Most 7-year-old children have bladder control.
- A marked change from what is considered a population norm.
- Example: A previously social teenager suddenly becomes withdrawn and isolates themselves from peer interactions.
- Rationale: Depression is linked to a sudden change in social habits.
- Personal behavior that is described as nonproductive to the body as a whole (Young et al., 2023).
- Example: A college student suddenly loses weight and is seen binging food after being accepted to the cheerleading team.
- Rationale: Unhealthy nutritional habits and a negative self-perception are dysfunctional and have negative implications for one’s health.
Promotion of Expected Outcomes
Articulating outcomes is similar to goal setting when conducting patient and family education. Like planning goals, planning nursing outcomes from interventions should be clear, focused, and SMART—specific, measurable, achievable, relatable, and timely. The difference is that the outcomes are not measured solely on achieving a goal—rather, they are based on the progress toward attaining the desired outcomes.
Link to Learning
This article outlines SMART goals in nursing practice.
Many times, nurses will see several problems occurring for a patient at the same time. This means that one patient can have several nursing diagnoses. For example, they may have problems with pain, a wound, and a cough. The nurse must formulate these diagnoses and think about the common threads between them. It’s necessary to consider how the diagnoses are related and, subsequently, how interventions can be planned and implemented to address multiple diagnoses.