A simple example may help to clarify the diagnostic process for summa-rizing assessment data. The extensive description that follows takes the nurse approximately 2 minutes or less. Consider the case of Mr. G., whom the nurse sees during his routine visit to a physician’s office. The nurse notes that Mr. G.:
■Is a 45-year-old company executive.
■Has had a medical diagnosis of essential hypertension (high blood pressure) for 3 years.
Cues Recognized
■Exhausted appearance:
■ Dark circles under eyes.
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■ Slow gait.
■ States he is tired.
■ Reports trouble sleeping.
Hypotheses Generated (Possibilities)
The nurse generates the following hypotheses from the initial observations and conversation. She makes the hypotheses general in order to avoid premature closure or focusing on one specific problem too early in the assessment. The two hypotheses selected are:
■Sleep pattern disturbance.
■Cardiac problem.
A check of the physician’s note reveals the following: “no cardiac abnor-mality, pressure elevated, his company having financial difficulties.”
Hypotheses Revised
Based on the physician’s note, the nurse deletes the hypothesis of cardiac problem as a cause of his symptoms. Then the nurse reviews the diagnoses in the sleep-rest pattern to think about what sleep disturbances Mr. G. might have:
■Insomnia.
■Sleep deprivation.
■Sleep pattern reversal.
■Readiness for enhanced sleep.
With these in mind and a review of the data already collected (45-year-old male company executive whose company is experiencing financial difficulty is having difficulty sleeping), the nurse thinks about the likelihood of occur-rence:
■The diagnosis Sleep pattern reversal is reduced. This condition is more common in an elderly person who naps most of the day and workers changing shifts.
■The diagnosis Readiness for enhanced sleep is deleted. Generally, this diagnosis is used to promote a higher level of wellness when sleep is adequate.
■More information will clarify whether the problem is Delayed sleep onset as in insomnia or a prolonged problem as in Sleep deprivation.
■The nurse had checked the definition and defining characteristics of Sleep deprivation. They are more severe than those exhibited by Mr. G. The nurse recalls that Insomnia is the most frequently occurring sleep distur-bance in adults. This hypothesis is the most probable.
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Hypothesis Testing
One broad question will produce information on the probability of the two remaining hypotheses. Exploring with Mr. G. what “trouble sleeping”
means will:
■Provide information to narrow the possibilities to one.
■Provide data on the actual sleep disturbance.
■Yield information on the three remaining possibilities.
The nurse begins with an open-ended question:
Nurse: “You mentioned you were having trouble sleeping. Could you tell me more about that?”
Mr. G.: “I guess I keep thinking and can’t get to sleep right away. This has been going on for the last 4 weeks. I used to sleep so well.”
The nurse lets the patient know she has heard his concern and uses a focused question to get specific information:
Nurse: “That must be difficult for you and not good for your hypertension.
Have you noticed how long it takes to get to sleep?”
Mr. G.: “About 2 to 4 hours, and then I just get about 3 hours of sleep.”
The nurse looks for the reason for the insomnia:
Nurse: “Sometimes worries or problems can keep running through your mind when you try to get to sleep. Would that be a reason for your trouble?”
Mr. G: “For the last month, I have been trying to think of a way out, and then I can’t get to sleep; I am going to lose my company to bankruptcy, and there goes my job.”
The nurse begins to think about stress overload as a reason for insomnia.
The next response is an intervention, but it is appropriate here.
Nurse: “That certainly is a worry for you. Is there anyone who can help you manage this? Perhaps your bank?”
The nurse now has the following cues:
■45-year-old male.
■Company executive.
■Hypertension.
■Has trouble sleeping; keeps thinking.
■Thinking focused on: “Going to lose my company to bankruptcy, and there goes my job.”
■No sleep problems prior to this time.
■Delay in sleep onset for 2 to 4 hours for 4 weeks.
■Actual sleep time about 3 hours per night.
■Bankruptcy issues started 1 month ago.
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Review of Database and Judgments A check of the diagnostic manual reveals that:
■One characteristic of Insomnia is a 2- to 3-hour delay before falling asleep.
■Usually, inability to fall asleep after 30 to 45 minutes of expectation that sleep will come is diagnostic of insomnia.
Sleep deprivation is deleted; he is not “without sleep,” a characteristic of this diagnosis.
Another problem was identified during the assessment:
■Stress overload, defined as excessive amounts and types of demands that require action.
This diagnostic hypothesis was based on the following:
■“For the last month, I have been trying to think of a way out, and then I can’t get to sleep”
■“I am going to lose my company to bankruptcy, and there goes my job.”
■“I keep thinking and can’t get to sleep right away.”
■45-year-old company executive and owner
Structure and Content of the Diagnostic Statement The nurse identified two problems, Insomnia and Stress overload. Using theoretical knowledge, the nurse made the judgment that Stress overload was the reason for the Insomnia. The diagnostic statement is:
■Insomnia related to stress overload. This is supported by the signs and symptoms outlined above.
Using the Diagnostic Statement
Combining the two problems in a diagnostic statement provides a basis for:
■Outcome projection (based on Insomnia).
■Intervention planning (based on Stress overload).
Case Study Review
The nurse completed a full functional health pattern assessment with the following in mind:
■A careful reassessment of the role-relationship and coping-stress tolerance pattern to assess Mr. G.’s support system and coping effectiveness.
■The patterns important in his management of essential hypertension and prevention of future complications.
■The interaction of the nursing and medical diagnoses Stress overload and Hypertension.