Evaluation of Admission Nursing Diagnoses

Ms. Minton is Staff Development and Outpatient Clinic Coordina- tor at Dr. John Warner Hospital in Clinton, Illinois. She is also a part-time clinical instructor for Parkland Community College in Champaign, Illinois.

Dr. Creason is Professor and Dean of the School of Nursing at Southern Illinois University at Edwardsville. She has been active in research on the validation of nursing diagnoses, particularly impaired physical mobility.

Both have contributed to the Pocket Guide to Nursing Diagnosis, by M.J. Kim, G.K. McFarland, and A.M. McLane.

Nursing Diagnoses Judy A. Minton, MS, RN, Nancy S. Creason, PhD, RN

Despite the interest and rcsearc h in nurwp; diagnosis, few studies have c i - aniined the incidence and qualitv of thr cliaposes. Specilit.ally. A 1;ic.k 0 1 knowledge exists regarding whiit nuning diagnoses are forinul;~trd o i l ii p - tient‘s admission to the hospital Ihla froni the charts o f 3 3 ;idtilt ortliolwoiic patients were evaluated for thr tvpr . frqiiency. and quality o f ;idmission nursing diagnoses. Of the 1 OG nursing diagnoses written. approxim;itdy two-thirds were on the acceptecl Id ol IIIC. North Anlcrican Nursing I)iag- nosis Asscxiation (NANDA) at i l u tinu 4 4 the study (1988). Alfrrcltrcni in c o m / i was the most prevalent d l d p t i i 1 . 1 1 ~ 1 . The quality 01 the tliagiosrs was evaluated using Ziegler’s (I!IM) tcud O n l y one diagnosis. potrnftnl alto- d u n in skiti i n t r p ’ f y related to &rlrd. met .ill 12 criteria. Nurses stlowed niorc’ difficulty in correctly identifyinK the rtiahtgy component tharl thr rcsponsc compnnent of the diagnostic s ~ ~ t c m c n t . t x t o r s that &ect the quality of nursing diagnoses and the need fnr tiu~l idineinent are discussed. and re- sedrch recommendations are nwtk.

Key Words: nursing diagnosis. patnil .idmission

Nursing diagnosis, the pivotal step in the nursing process, provides the basis for the plan of care. Despite resistance and some professional controversy about the issue of nursing diagnosis, influential organizations such as the American Nurses Association (ANA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the National League for Nursing (NLN), have adopted the nursing process language. Regardless of the clinical setting, ANA (1 973) requires that nursing diagnoses be derived from the health status data collected by registered nurses. Thus, formula- tion of nursing diagnoses by nurses is a professional responsibility- not an optional activity.

A nursing diagnosis generally consists of two components: the actual or potential unhealthful response joined to the etiology, when known, by the phrase, “related to” (Iyer, Taptich, & Bernocchi-Lo- sey, 1986; Shoemaker, 1985). According to Ziegler (1984), diagnostic statements that do not contain both components do not provide direction for patient care because patient goals are generated from the response component and independent nursing actions are di- rected at modifying the etiology component.

Nursing research on the prevalence, format, and quality of nursing diagnoses can influence the way nurses practice through the development of standardized care plans for particular populations (Halfmann & Pigg, 1984), the promotion of early case finding, and improved cue sensitivity to prevalent diagnoses for special populations (Fitzmaurice, 1987; Gordon, 1987a). Further evaluation of the

Nursing Diagnosis 119

use of NANDA and non-NANDA diagnoses can contribute to the refinement of the accepted list (Collard et al., 1987).

This study sought to describe the quality and prevalence of NANDA-accepted and non- NANDA nursing diagnoses as recorded on admission to the hospital on the nursing care plans of a sample of orthopedic patients.

Additional research questions that semed as guidelines for this study were: Does each nursing diagnosis identify a potential or an actual patient response and a related etiology? What percentage of admission nursing diagnoses are clearly supported by admission assessment data? Are the nursing diagnoses that were identified at assess- iiierit addressed on the nursing care plan?

Literature Review

Scholarly efforts related to nursing diagnoses have addressed a diverse range of topics, such as implementation, validation, use, and evaluation of diagnoses as well as the diagnostic reasoning pro- ws. Howe\er. few research projects have re- portrd the prevalence and distribution of nursing diagnoses as recommended by Brown (1 974). Studies of the incidence of diagnoses in various patient populations have been called epidemiologic studies (Gordon, 1987b; McI,ane, 1987).

I hree nursing diagnosis research studies have sampled spec3ic patient populations other than niedical-surgical subjects. In a study of the discharge diagnoses of 163 obstetric-gynecologic patients, 43% (241) of the diagnoses were on the NANDA-accepted list (McKeehan & Gordon, 19x2). In a similar- study, Lessow (1987) used a ct ratified random sampling technique to review care plans from 12 medical-surgical and 2 mater- nit\ units. The results showed that 50% of the diagnoses were written according to the NANDA list. Although the investigator noted a lack of N A N D A diagnoses that could be applicable to ma- ternity patients. nlteratinri in parenting, the most prevalent diagnosis in McKeehan and Gordon’s study, was not among the six most frequently written di;ignoses in Lessow’s review.

In a retrospective audit of nursing care plans of hospitalized patients with rheumatic disease, Halfinann and Pigg (1 984) found that 85% of the diagnoses were o n the NANDA list. The two most prevalent diaposes were alteration in comfort: pain (35%) and knorulrdge deficit (1 9%). This high per-

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centage could he attributed to the presence of the NANDA list in each patient’s folder. Collard et al. (1 987) investigated 3 16 nursing diagnoses generated by master’s candidates in ambulatory care settings and found that 84% of their diagnoses were on the approved list from the fourth NANDA conference.

Ziegler (1 984) examined nursing diagnoses that were formulated by graduate students using a self-constructed 12-criteria tool. Of the 168 diagnoses evaluated, only 10% met all 12 criteria. The main problem that was identified in the formula- tion of a diagnosis was improper identification of the etiology component.

In a related study that was performed to identify the terminology used by nurses who generate diagnoses, Myers and Spies (1987) found that of 33 1 diagnoses, 16 1 were one-part and 1 70 were two-part statements. Further analysis of the two- part statements showed that 31% were joined by “related to’’ and 38% by “due to.” Experts recom- mend the use of “related to” for- linking the components to avoid a direct cause and effect iniplica- tion between the two parts as implied by “due to” (Iver, Taptich, & Bernocch-Losey, 1986).

Miaskowski, Spangenberg, and Garofallou (1 984) examined the assessment findings of hospi- talked patients to determine whether the nursing diagnoses were supported by signs and symptoms, but they discovered that the data were difficult to e\ aluate because of a lack of specificity or because of incompleteness. Of the 4 1 I nursing diagnoses recorded, 73% (30 1) were written on admission, 24% (97) were written during hospitalization, and 3% (10) were written at discharge.

No investigation of nursing diagnoses for an orthopedic patient population was found in the literature. The paucity of studies done to determine the incidence and quality of NANDA- and non-NANDA-approved diagnoses indicates the need for additional research in these areas.

Methods A descriptive, retrmpective research design

was selected to determine the incidence and quality of nursing diagnoses generated by a sample of nurses. The nurses provided care to adult orthopedic inpatients in a 200-bed midwestern hospital. Verbatim nursing diagnoses were collected over a 30-day period from the charts of discharged patients and were transcribed onto a predeveloped

120 Volume 2. Number 3, July/September 1991

form by the investigator and a research assistant. A convenient nonrandom sample of 33 charts of men and women patients yielded 106 nursing diagnostic statements.

Instruments and Data Collection

The data collection instrument was developed to combine verbatim nursing assessment and care plan data on a single form. The instrument was constructed using the institution’s nursing admission assessment and care plan forms as a guide and it was pilot-tested for its utility. A doctorally pre- pared nurse with expertise in nursing diagnosis reviewed the instrument establish content validity. The investigator and the nurse research assistant, a doctoral student, transcribed the nursing care data, and interrater reliability was calculated at 93% on a subset of 3 charts.

All diagnoses that were dated the day of admission and the next day were included because the sponsoring institution allowed 24 hours to complete the nursing care plan after admission and entries were not timed. Etiologies, defining characteristics, and nursing care plans were reviewed and recorded.

Ziegler’s (1 984) instrument for evaluating the nursing diagnosis statements was used to determine the quality of each diagnostic statement. This tool consists of 12 criteria generated from desirable characteristics that were identified in the literature and that reflect the role diagnoses play in the nursing process. The first four criteria address the nursing diagnosis statement in general, criteria five through eight address the response component or problem statement, the last four criteria address the etiology component.

Data Analysis

Analysis of data included calculating the incidence and frequencies of diagnoses. The diagnoses were compared with the list of diagnoses accepted for clinical testing at the sixth NANDA Conference (each diagnosis was classified as an approved [NANDA] or nonapproved [non- NANDA] diagnosis). At the time of the data collection, the sixth conference listing was the most current list in use at the hospital and was selected as the standard for measurement.

Each diagnosis was evaluated using Ziegler’s tool. If the diagnostic statement did not meet the

first criterion, which requires both a response and an etiology component, it was coded into one of three categories: (1) only one component present; (2) two components present but both are response components; or (3) two components present, but both are etiology components. If the Statement was coded 1, no further coding took place. If the statement was coded 2 or 3, coding was continued for the second criterion and then discontinued. The remaining 11 criteria were judged as being met or not being met for each diagnostic statement. Intrarater reliability was calculated at 98% on a subset of 5 randomly selected charts.

NANDA diagnoses were judged as supported by assessment data if a critical defining character- istic or one or more of the defining characteristics associated with the diagnosis were noted on the nursing admission assessment form. If a diagnosis was found on the admission form, the nursing care plan was examined to determine whether the diagnosis was identified.

Results

Frequency

Registered nurses who provide care to 33 adult orthopedic patients recorded 106 admission nursing diagnoses, The number of admission diagnoses per patient ranged from 1-11, with a mean of 3.2. The 30 separate diagnoses identified and their associated frequencies are shown in Ta- ble 1. Seventy-three of the diagnoses (67%) were classified as accepted by NANDA. Alteration in comfort was the most frequently identified label. The second most frequently recorded diagnosis was a non-NANDA statement, potential alteration in neurovascular status.

Quality

Each nursing diagnosis was evaluated using Ziegler’s (1984) criteria (Table 2). Of the 106 diagnoses examined, only a single statement, potential alteration in skin integrity related to bedrest, met all of the criteria.

Twenty-five statements did not identify both response and etiology. Of these, 22 named a single component, e.g., ineffective airway clearance, whereas the other three consisted of two response components.

When the 84 nursing diagnoses composed of two components were examined for the presence


Table 1. Nursing Diagnoses Identified on Admission”

Frequency

NANDA Nursing Diagnoses

Comfort alteration in pain Knowledge deficit Mobiiity impairment of Skin integrity impairment of potential Bowel elimination alteration in potential Urinary eliniination alteration in potential Breathing pattern ineffective T SSIIP perfusion alteration in peripheral I w r y potential for Fluid volume alteration in excess Fluid volume deficit potential Tissue perfusion alteration in peripheral potentia! Skin integrity impairment of actual Airway clearance ineffective Gas exchange impaired potential Bowel elimination alteration in constipation Knowledge deficit potential Sen5ory-perceptuaI alteration in auditory Total NANDA Diagnoses

Non-NANDA Nursing Diagnoses

Intection potential for Neurovascular status alteration in potential Wound healing impaired Neurovascular status alteration in Self harm potential for Arelectasis potential for PJirnonary embolism/thrornbosis potential for Thrombuslphlebitis potential for Nausea/vorniting potential for Neurologic status alteration potential for Sdfety alteration potential Anaphylaxis potential Total Non NANDA Diagnoses

26 16 6 5 3 3 2 2 1 1 1 1 1 1 1 1 1 1

73

2 18

3 2 1 1 1 1 1 1 1 1

33

T07AL 106

*’ 5 !):,F. :tie !!nv ot i h s study j 1988). NANDA diagnostic !erminology has changed, and new diagnoses have been added to the accepted list

of’ “related to’’ as the joining phrase, 41 lacked this chai.ac.teristic. Instead, nurses used “due to’’ or “re:” t o link the diagnostic clauses. Sixty-three diagnoses sticcessfully met the criterion that the wsponse component must precede the etiology ci miponeri t . These diagnoses were evaluated against the remaining criteria. Eighteen state- nieiiis M‘VW classified as circular, i.e., the t w o c,laiises tvei-e synonymous, e.g., alteration in com- f o r t related 10 pain.

An unhealthy or potentially unhealthy patient response was identified in all of the 63 diagnoses in which the response was correctly stated first. Only two diagnostic statements did not meet the criterion that required that a single response be identified per diagnosis. Forty-four response components were judged specific enough to provide guidance to formulate measurable and observable patient goals. All 63 response clauses were judged amenable to change.

122 Volume 2, Number 3, July/September 1991

Table 2. Comparison of Research Findings with Ziegler’s (1 984) Study

Percent of Diagnoses Failing to Meet Criteria

Criterion Ziegler (1 984) N = 168 Minton (1 988) N = 108

Response Component The response is clearly unhealthy or written as a potentially unhealthful response Only one response is identified for each diagnosis statement The response is potentially modifiable The response is concrete enough to generate specific client goals

Etiology Component Only one etiology is identified for each diagnosis statement The etiology is potentially changeable The activity required to modify is within the boundaries of nursing‘s independent functions, nurse is capable and is legally and ethically expected to treat Etiology is concrete enough to generate specific nursing interventions

9 1 1 0

13

28 29

8

79

0 3 0

29

13 75

a7

67

NANDA versus Non-NANDA Diagnoses

To determine whether the NANDA-accepted diagnoses were supported by assessment data, the admission assessment data were compared to the NANDA defining characteristics. Of the 18 recorded NANDA diagnoses, critical defining characteristics were listed only alteration in tissue perfusion. Sixty-one of the remaining diagnoses were supported by one or more defining characteristics in the assessment data.

Care Plan Follow-Through

The final area of interest was how consistently the diagnoses listed on the admission assessment form were subsequently included in the nursing care plan. A combined total of 31 diagnoses were indicated on the 11 assessment forms. Of these 3 1 diagnoses, 14 were found in the nursing care plan.

Discussion

The finding that 69% of the diagnoses were on the NANDA-accepted list fell within the reported range of 43%-85% (McKeehan & Gordon, 1982; Halfmann & Pigg, 1987). Table 2 shows a comparison of the findings from Ziegler’s study with those of this study.

In this study, the finding that nurses could not clearly identify the etiology component of a diagnostic statement supports the work of Meade and Kim (1984) and Ziegler (1984). According to Ziegler et al. (1986), a single etiology identified per patient response best guides nursing care. They stated that, “if multiple etiologies are named, it is more difficult to link specific interventions to specific etiologies” (p. 91). Consensus has to be reached among nurses as to whether it is appropriate to limit the etiology component to one factor. It is not unusual for complex health problems to involve many factors, such as behav- ioral, cultural, and environmental influences (Derdiarian, 1987). Fitzpatrick (1 987) argues that narrowing the etiologic focus to one concern con- flicts with the holistic approach of nursing practice. Yet, nurses struggle to decrease their compli- cated experiences to simpler terms. Gordon (1987b) suggests, “nurses may select from multiple contributing factors the most probable etiologic or related factor that can be influenced by nursing intervention at a particular time” (p. 137). With conflicting interpretations of the term etiology among nursing leaders (Lunney, 1986), it is not surprising that clinicians have difficulty mastering the concept.

The finding that more than half of the nursing diagnoses found on the assessment form were not transferred to the nursing care plan is of concern.


Legal and ethical implications of recognizing a problem area and not providing a plan to resolve the problem exist. In addition, “incomplete or incorrect diagnoses can put the nurses at risk if they lead to an incorrect or a harmful care plan” (For- tin & Rabinow, 1979, p. 558).

The finding that the diagnosis alteratzon in corrrfrt: pazn was the most commonly identified diagnosis agrees with the findings of other literature (Ceccio, 1986; Crocker, 1986; Lessow, 1987;

With conflicting interpretations of the term etiology . . . it is not surprising that clinicians have

difficulty mastering the concept.

Martin & York, 1984). A joint publication by the .4NA and the National Association of Orthopae- dic Nurses (1987) acknowledged pain as a common orthopedic problem and identified process and outcome criteria for the nursing diagnoses pain and pain management dejicit. Process and outcome criteria were also identified for knowledge delficit, which was the second most commonly identified N,4NDA diagnosis in this study.

Conclusions

Despite the 4-year span between studies using Ziegler’s tool , the same problems in writing nursing diagnoses persist. Several issues regarding nursing diagnosis remain unclear. For instance, a statement component such as impaired mobility may be classified as a response component in the diagnosis and as an etiology in another.

Ziegler’s tool requires clarification to decrease investigator interpretation. h i explanation of the attribute in concrete terms for both the response and etiolog) components is needed. Also, the elimination of the circular diagnosis criteria is indicated unless specific distinctions between the statements composed of two responses or etiologm were clearly described.

Further research on the nursing problems of specific patient populations will provide informa- tioil on the prevalence and use of diagnoses. Pa- tierits will eventually benefit as nurses improve

their sensitivity to cues for more common diagnoses resulting in early case finding and problem prevention.

As the nursing diagnosis concept continues to evolve, modifications in the NANDA classification system will occur. Without periodic examination of the state of practice with nursing diagnoses, positive practices and deficits will be unrecog- nized. and the movement will lack direction.

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Evaluation of Admission Nursing Diagnoses