Unit 4 Diagnosis and Outcome Development

Unit 4 Diagnosis and Outcome Development

Introduction Learning Outcomes Resources Information Instructional Activities Resources COPYRIGHT and Acknowledgements Copyright 2014 Registered Nurses Professional Development Centre and Department of Health & Wellness Nova Scotia Government. No part of this manual may be reproduced or transmitted in any form by any means, electronic or mechanical without permission in writing from the: Registered Nurses Professional Development Centre Room 231C, Bethune Building 1276 South Park Street Halifax, Nova Scotia B3H 2Y9 Page 2

Diagnosis and Outcome Development This unit continues with the steps of the nursing process and focuses on nursing diagnosis and outcome development. Like the pervious unit on assessment, this lesson is consistent with the second standard of the Canadian Standards for Psychiatric- Mental Health Nursing Practice, 4th ed. (2014), which states that, effective assessment, diagnosis and monitoring is central to the nurse s role (p. 8). The unit will start with a review of nursing diagnosis. There will also be an overview of the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system. At the end of this unit, you will be able to: 1. Define nursing diagnosis. 2. Define the components of a NANDA nursing diagnosis. 3. Differentiate between nursing diagnosis and collaborative problems. 4. Define outcomes. 5. Differentiate between a nursing diagnosis and DSM diagnosis. 6. Describe the steps in the DSM diagnostic process. Each of these will be presented at various points in the unit. Austin, W., & Boyd, M.A. (2015). Psychiatric & mental health nursing for Canadian practice, Third Edition. Philadelphia: Wolters Kluwer, p. 165-185. American Psychiatric Association. (2013). Highlights of changes from DSM-IV-TR to DSM-5. Retrieved from: http://www.dsm5.org/documents/changes%20from%20dsm-ivtr%20to%20dsm-5.pdf. Page 3

Case Study Susan Johnson is a 45-year-old woman who has be admitted to a psychiatric inpatient unit with suicidal ideation and a plan. She says, I d be better off dead., and has been thinking of locking herself in the garage with the car running to kill herself. Three months ago her husband of 25 years told her that he was having an affair and wanted a divorce. He has moved out of the house and left her with no financial support. Both of her children are away at university and she is alone. Her relationship with her son and daughter is very good, but she believes they have their own lives and should not be burdened by her problems. Prior to the separation Susan had a very active social life and was involved in several volunteer organizations but she has stopped these activities. She has several close friends who have tried to stay connected with her but she is reluctant to talk to them because she believes that they will all take her Husband s side. She repeatedly thinks about how she has been a bad wife, that the divorce is her fault, that she is not pretty enough. She reports feeling very irritable with reduced concentration, energy and motivation. Most days I find it hard to get out of bed. She also reports poor sleep, with difficulty initiating sleep and early awakening. She has a decreased appetite with a weight loss of 14 lbs. over the past two months. There is no prior psychiatric history, drug or alcohol abuse, or medical problems. Read: Austin, W., & Boyd, M.A. (2015). Psychiatric & mental health nursing for Canadian practice, Third Edition. Philadelphia: Wolters Kluwer, p. 165-185. What is nursing diagnosis? Generally speaking a nursing diagnosis is a classification system used for naming or labeling a phenomenon or group of phenomenon in order to improve communication and decrease the need for long communication (Ellis, 2009). Nurses have been involved in identifying the problems of persons in care since Florence Nightingale (Austin & Boyd, 2015). It wasn t until 1973, however, that nurses began the process of developing a classification system that laid the groundwork for nursing diagnosis. In 1982 the North American Nursing Diagnosis Association (NANDA) was created to bring together various groups that were working on nursing diagnosis. In 1986 NANDA created its first taxonomy of nursing diagnosis (Ellis, 2009). This unit will focus on NANDA approved nursing diagnosis, it is important to note, however, that not all psychiatric hospitals use NANDA approved diagnosis. Regardless of whether or not your Page 4

organization uses nursing diagnosis, as a psychiatric-mental health nurse, it is very important that you be able to identify issues of concern and specific outcomes for persons in care. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (NANDA, 1990 as cited in Austin & Boyd, 2015, p. 168). There are three distinct parts of a nursing diagnosis (problem, defining characteristics and related factors). 1. Problem The problem is a succinct statement of the person s actual or potential response to a health problem or life process. NANDA has a list of problem statements or diagnostic labels. The diagnoses are accompanied by a definition that helps to explain the health problem. Below is an example of a NANADA nursing diagnosis based on the case study of Susan Johnson. Example: NANDA Diagnosis: Coping Ineffective Definition: Inability to form a valid appraisal of the stressors; inadequate choices of practiced responses; or inability to use available resources. (Carpenito, 2013). 2. Defining Characteristics According to Austin & Boyd (2015), defining characteristics are key signs and symptoms that relate to each other and that confirm a nursing diagnosis. Defining characteristics are listed for each of the NANDA nursing diagnosis however; the defining characteristics can often be clarified by quoting the person in care. Whenever possible the defining characteristics should be individualized to represent the needs of the person being diagnosed. See the example below for some of the defining characteristics listed under the NANDA diagnosis for coping ineffective that relate to the case study of Susan Johnson. Example: Defining Characteristics o Verbalization of inability to cope. o I d be better off dead (persons own words) o Destructive behavior towards self (Expresses suicidal ideation or makes gestures and attempts). o Inability to meet role expectations. (Carpenito, 2013). Page 5

3. Etiology/ Related factors Etiology or related factors are those factors that influence or contribute to a person s health status or are considered the cause of the problem to the extent that a cause can be determined. Related factors are categorized as pathophysiological (psychological or biological), treatment related (medications, surgeries, diagnostic tests), situational (person, home, community, environment) or maturational (age related influences), (Carpenito-Moyet, 2010 as cited in Austin & Boyd, 2015). Etiologies or related factors require specific descriptions that represent the need of the person being diagnosed. These etiologies may be treated independently by the nurse or in collaboration with other health care professionals. The nursing plan of care should focus on managing or resolving both the etiologic/related factors and the health problem. Note that one nursing diagnosis can sometimes be used as etiology for another nursing diagnosis for example Anxiety related to powerlessness (Carpenito, 2013). Nurses are usually discouraged however, from using medical diagnosis as an etiology because the nursing diagnosis is primarily treated by nursing interventions (Fortinash & Holoday Worret, 2007). The example below gives some of the related factors/etiology for the NANDA diagnosis coping ineffective based on the case study of Susan Johnson. Example: Related Factors (Etiology) o Disruption of emotional bonds (separation or divorce) o Ineffective support system, actual or perceived o Disturbance in self-concept: feelings of worthlessness or inadequacy (Carpenito, 2013). Risk Nursing Diagnosis Risk factors are used to determine potential health problems. There are many potential health problems that could be given to a person whose health is already compromised. A determination of potential health problems needs to be done based on an assessment of the probability of a problem occurring. Is the person at greater risk than the general population? For example, any person started on an antipsychotic medication is at risk for weight gain. A person who is already over weight and who does not exercise or follow a healthy diet is however, at greater risk of weight gain than the general population of persons taking antipsychotic medications. Based on an assessment of these risk factors this person could be given a potential or risk nursing diagnosis Risk for imbalanced nutrition: more than body requirements. Note that a risk nursing diagnosis will only have two parts, the potential or risk problem and the risk factors. There will be no defining characteristic (signs and symptoms) because the problem has not actually occurred. Page 6

Nursing Diagnosis vs. Collaborative Problems Collaborative problems are physiologic complications that nurses monitor to detect onset or change in status. Nurses manage collaborative problems using physicianprescribed and nursing-prescribed interventions to minimize the complications of the event. (Carpenito, 2013). It is important to note however, that not all physiologic complications are collaborative problems. If the nurse can prevent the onset of the complication or can provide the primary treatment then this would be a nursing diagnosis not a collaborative problem. All collaborative problems begin with the diagnostic label Potential Complication, for example Potential Complication: Hypotension related to antipsychotic medication (Carpenito, 2000). Collaborative problems have nursing goals that indicate the responsibility of the nurse to monitor or detect changes in the status of the person in care and to co-manage with the physician; whereas, nursing diagnosis have goals of the person in care which represent the nurses responsibility to achieve or maintain a favourable status after nursing care (Carpenito, 1999). What are outcomes? Like problem identification, determining individual outcomes is not new to nursing. Outcomes are the individual s response to nursing care. An outcome is concise, stated in few words and in neutral terms. Outcomes are the end result of a process, a treatment, or a nursing intervention and should be monitored and documented over time and across clinical settings. (Austin & Boyd, 2015, p. 169). Outcomes can be specifically related to a nursing diagnosis and show that the nursing intervention resolved the problem or they can be non-specific outcomes. In this lesson we will focus on outcomes that are specific to the nursing diagnosis. Outcome statements should be measurable, have a time estimate for attainment and be mutually developed between the psychiatric-mental health nurse and the person in care. Outcome statements are a projection of the influence that nursing interventions will have on the person in care in relation to his/her identified problem and are used in the evaluation phase of the nursing process to determine if the problem is reduced or resolved. There are several outcome classification systems that are available to nurses that describe outcomes and their indicators. If using a classification system it is important that outcomes should be individualized and based on the needs of the person in care. An example of an outcome for the diagnosis coping ineffective based on the case study of Susan Johnson might be Identifies personal strengths and accepts support from friends before discharge (Carpenito, 2013). Page 7

1. Why is it important to involve the person in care in the development of the nursing care plan? 2. What is the purpose of developing outcomes for persons in care? Types of Diagnosis You have just read about nursing diagnoses, which are classified as dimensional diagnoses. We will now focus on DSM diagnoses, which use a categorical system (mental disorders are grouped into clusters or categories) for making a diagnosis. Diagnostic and Statistical Manual of Mental Disorders The need for a classification system for mental disorders has been recognized throughout the history of medicine, but there has been little agreement on which diagnoses to include and the best way to organize them. In the United States the first attempts at a classification system were done for the purpose of collecting statistical information. Over time, however, the classification system broadened and the American Psychiatric Association developed the first DSM classification system of mental disorders for use in clinical practice in 1952. The most recent version of this classification system, the DSM-5 was published in May, 2013. Page 8

Another common classification system is the International Classification of Disease (ICD), which was developed by the World Health Association. The most recent version ICD-10 was published in 1992. Unlike the DSM, the IDC-10 does not have a clinical focus but is used only to collect basic heath statistics. Those working on the DSM and IDC have, however, worked closely together and the codes and terms used in the DSM are compatible with the ICD-10. As most inpatient psychiatric-mental health nurses are not responsible for using diagnostic codes we will not go into detail on how to apply codes except to say that all DSM disorders have a numerical ICD code that is used for statistical purposes. The DSM includes explicit diagnostic criteria and a descriptive approach that group mental disorders into clusters or categories based on common symptoms and not based on a particular theory or etiology. Previous editions of the DSM used a multi-axial system, which involved an assessment from five different domains (Axis I-V). The DSM- 5 uses a new organizational framework. There is no longer a multi-axial system. Axis I, II & III are now combined. This allows multiple diagnoses to be assigned for those presentations that meet criteria for more than one DSM-5 disorder. Psychosocial and environmental factors (Axis IV) are not classified in the DSM-5 and Axis V that included the Global Assessment of Function (GAF) scale as been dropped from the DSM-5. The World health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is included instead. The WHODAS 2.0 assesses disability in 6 domains, including understanding and communicating, getting around, self-care, getting alone with people, life activities (i.e., household, work and /or school activities), and participations in society (See DSM-5, p.745-748 for more details). DSM-5 is organized in sequence with the developmental lifespan. This organization is evident in every chapter and within individual diagnostic categories, with disorders typically diagnosed in childhood detailed first, followed by those in adolescence, adulthood and later life. Disorders previously addressed in a single infancy, childhood and adolescence chapter are now integrated throughout the manual. Three additional disorder chapters have been added to DSM-5 to better classify the disorders based on known similarities to one another. Certain disorders come under more representative or comprehensive chapter headings. For example, Neurodevelopmental Disorders is a new heading that includes autism spectrum disorders, intellectual developmental disorder, attention-deficit/hyperactivity disorder and tic disorders, such as Tourette s Disorder. The chapter on substance-related disorders is now titled Substance Use and Addictive Disorders and includes gambling disorder as the only behavioral addiction. Other disorders have been broken out from their previous groupings based on new scientific understanding of their principal features. For example, because recent studies have shown that obsessive-compulsive disorder involves distinct neurocircuits, it and several related disorders now constitute their own chapter rather than be addressed in the chapter on anxiety disorders. Similarly, mood disorders are divided into two chapters for bipolar and related disorders and for depressive disorders. The DSM-5 replaces the Not Otherwise Specified (NOS) categories with two options: other specified disorder and Page 9

unspecified disorder. The first allows the clinician to specify the reason that the criteria for a specific disorder is not met; the second allows the clinician the option to forgo specification. The following is a listing of DSM-5 chapters: o Neurodevelopmental Disorders o Schizophrenia Spectrum and Other Psychotic Disorders o Bipolar and Related Disorders o Depressive Disorders o Anxiety Disorders o Obsessive-Compulsive and Related Disorders o Trauma-and Stressor-Related Disorders o Dissociative Disorders o Somatic Symptom Disorders o Feeding and Eating Disorders o Elimination Disorders o Sleep-Wake Disorders o Sexual Dysfunctions o Gender Dysphoria o Disruptive, Impulse Control and Conduct Disorders o Substance Use and Addictive Disorders o Neurocognitive Disorders o Personality Disorders o Paraphilic Disorders o Other Disorders The DSM-5 describes each disorder under the following headings. Diagnostic Criteria o Diagnostic criteria for each disorder is presented using the following system: Criterion A Cardinal Features. Theses are the symptoms that must be present for the diagnosis to be given. There is often a certain number of symptoms that must be present from a list of possible symptoms. Criterion B Distress and Dysfunction must be present. Criterion C Duration. Criterion D This criterion is used to exclude other diagnoses. Criterion E The disturbance is not attributable to the physiological effects of a substance or another medical condition Page 10

Criterion F - Other Subtypes and or Specifiers (help to make a more precise diagnosis) o Subtypes are mutually exclusive and jointly exhaustive phenomenological sub-groupings within a diagnosis for example; Delusional Disorder is subtyped based on the content of the delusion (i.e., Grandiose Type, Somatic Type, etc.). o Specifiers however, are not mutually exclusive or jointly exhaustive therefore more than one specifier can be given. Specifiers allow you to define a more homogeneous subgrouping of individuals who share common features (e.g., Major Depression, with Mixed Features). There are also severity and course specifiers that are listed after the diagnosis. The specifier mild, moderate, or severe are used if the full criteria for the disorder are currently met. In partial remission, in full remission, and prior history are used when the full criteria for the disorder is no longer met. Diagnostic Features, which clarifies the diagnostic criteria and often provides an example. Associated Features Supporting Diagnosis. Prevalence gives information on lifetime prevalence, incidence and lifetime risk. Development and Course provides a description of the typical lifetime course of the disorder. Risk and Prognostic Factors. Specific Culture, Age and Gender Features gives information about variations in the disorder that may be attributable to the person s culture, developmental stage or gender. Gender-Related Diagnostic Issues Suicide Risk Function Consequence Differential Diagnosis provides information on how to differentiate the disorder from other disorders that may have a similar presentation. Comorbidity, other disorders with which the disorder frequently co-ocurs Page 11

Read: American Psychiatric Association. (2013). Highlights of changes from DSM-IV-TR to DSM-5. Retrieved from: http://www.dsm5.org/documents/changes%20from%20dsmiv-tr%20to%20dsm-5.pdf. Steps in the Diagnostic Process Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Review assessment data or case study. Identify signs and symptoms then list on a work sheet. Group the signs and symptoms under every possible diagnostic cluster that might apply. Generate a list of possible diagnostic clusters that might apply to this case. Record your preferred diagnosis or diagnoses. Go to the DSM Classification (p. xiii in DSM-5). Locate the relevant diagnostic clusters. Read through the typical presentations to find those that most resemble your case. You may find the signs and symptoms belong to more than one presentation. Be sure to check the Cardinal Features. Compare the DSM Criteria for each of the preferred diagnoses with your cluster of signs and symptoms. Identify and make note of common comorbidities and any differential diagnoses. Record your Diagnosis including subtypes and specifiers as appropriate. Adapted with permission from Brainworks International Page 12

Use the above steps in the diagnostic process with the case study of Susan Johnson. 1. How many diagnostic groups do Susan s symptoms cluster into? 2. What is your preferred diagnosis? 3. What symptoms are essential for this condition? 4. How has the illness time course affected your diagnostic impression? 5. How would you assess Susan s functional level? 6. What factors in Susan s history are important to consider in order to rule out other diagnosis? Page 13

7. List your diagnosis for Susan Johnson. Page 14