diagnosis

Differential diagnosis in advanced nursing practice

Heather Baid

dentifying a differential diagnosis has become a new responsibility in many advanced nursing roles. Increasingly, nurses are seeking professional growth and autonomy and are influenced externally by Department of Health (DH) initiatives to modernize the NHS through new ways of working (DH, 2000, 2002; DH and Royal College of Nurses (RCN), 2003). To assess the current status of advanced nursing practice, Ball (2005) surveyed 758 British nurses in the following advanced roles: nurse practitioner, clinical nurse specialist, nurse consultant, specialist nurse and advanced nurse practitioner. The results indicated that 81% of the respondents carry out a comprehensive health history as part of their nursing practice. Additionally 50% conduct a physical examination and 49% make diagnoses. The purpose of this article is to define the terminology surrounding diagnosis, to describe the process of formulating a differential diagnosis, and to illustrate the implications of using a differential diagnosis in advanced nursing practice through the use of a case study.

Differential diagnosis has become a key element of advanced nursing roles that are incorporating history taking and physical assessment into their remit of professional responsibilities. The aim of this article is to review the relevant definitions of different types of diagnoses, to describe the process of formulating a differential diagnosis including using clinical reasoning skills, and to use a case study as an example of differential diagnosis in advanced clinical practice. Key words: Diagnosis
n

Abstract

Patient assessment

Advanced practice

What is a medical diagnosis? the determination of the cause of a patients illness or suffering by the combined use of physical examination, patient interview, laboratory tests, review of the patients medical records, knowledge of the cause of observed signs and symptoms, and differential elimination of similar possible causes (p1066) Another related term worth defining is clinical reasoning which, according to Higgs and Jones (2000), is the thinking and decision-making processes associated with clinical practice (p3). Diagnostic reasoning, as a specific aspect of clinical reasoning, is described by Carnevali and Thomas (1993) as a series of clinical judgements made during and after data collection, culminating in informal judgements or formal diagnoses (p41). Some of the clinical reasoning theories which explain how a clinician processes the information gathered during an assessment are shown in Table 1. No single theory can be applied to every situation because of variances in past experience, role, training and situation (Offredy, 1998; Higgs and Jones, 2000). Carpenito-Moyet (2006) describes diagnostic statements as having either one part (diagnostic label), two parts (diagnostic label related to contributing factors), or three

Definitions
Diagnosis in British health care has traditionally only been utilized by the medical profession (Reveley, 2001). A nursing diagnosis was defined by the North American Nursing Diagnosis Association (NANDA) in 1973 and is well established in the nursing practice of North America (NANDA, 2005). Because the vocabulary and philosophy of diagnosis has varied greatly from country to country, the International Council of Nurses (ICN) has recently developed a standardized language in the form of the International Classification for Nursing Practice or ICNP (ICN, 2005). However, neither the NANDA nursing diagnosis nor the ICNP nursing phenomena have been incorporated into British nursing culture. With the development of advanced nursing practice in the UK, there has been a shift to include some of the terminology around this topic of diagnosis into advanced practice, indicating a need for clarification of the terms that are relevant for British nurses. Mosbys Medical, Nursing, and Allied Health Dictionary (2002) gives answers to the following questions: What is a nursing diagnosis? a statement of a health problem or a potential problem in the clients health status that a nurse is licensed and competent to treat (p1201) What is a differential diagnosis? the distinguishing between two or more diseases with similar symptoms by systematically comparing their signs and symptoms (p522)

Heather Baid is Work-Based Learning Facilitator (Physical Assessment), Surrey and Sussex Strategic Health Authority, Horley, Surrey Accepted for publication: June 2006

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Table 1. Clinical reasoning theories

Hypothetico-deductive reasoning (Elstein et al, 1978) Pattern recognition (Groen and Patel, 1985) Hypothesis is formed (inductive reasoning uses specific observations to form a generalization) Hypothesis is tested (deductive reasoning uses a generalization to confirm a specific case) Inductive reasoning used to interpret patterns through categorization (grouping of objects or events) and prototypes (clinical pattern is compared to the known typical example) Experts intuitively make decisions based upon past experiences Clinical reasoning has three core elements: disciplinespecific knowledge, cognitive skills (critical, creative, reflective, logical, and analytical thinking), and metacognition (being aware of cognitive processes) Other influencing dimensions include the clients input, environment, and the nature of the clinical problem

Intuition (Benner et al, 1996) Integrated, patientcentred model (Higgs and Jones, 2000)

parts (diagnostic label related to contributing factors as evidenced by signs and symptoms). The NANDA nursing diagnosis (2005) identifies the potential or actual response to a health problem in the diagnostic label. The following are examples of nursing diagnoses: fluid volume deficit, related to vomiting; risk for falls, related to decreased muscle strength to legs and impaired vision; and constipation, related to inadequate water intake, low fibre diet, and decreased activity. In these situations, the actual or potential response to a health problem has been identified in the diagnostic label (fluid volume deficit, risk for falls, and constipation). The subsequent contributing factors are then health problems that would benefit from the action of general nursing interventions. Contributing factors are issues that outline the cause of a clinical problem that a general nurse is able to act upon through the use of nursing interventions. For nurses working with an expanded scope of practice, this traditional nursing diagnosis model does not fully represent their ability to identify illness/injury, and therefore it cannot be used to plan interventions that fall outside of the general nursing domain. A differential or medical diagnosis will be more appropriate if the advanced nurse has the training, professional responsibility and competence, for example by prescribing medications or ordering investigations such as X-rays and bloodwork. A key concept to recognize is that a diagnosis can only be made if the professional is able to act upon the identified problem.

not correct in a nursing diagnosis because these diagnostic labels require medical interventions that do not fall within the staff nurses scope of practice. Pneumonia and pleural effusion are medical diagnoses. With the training and responsibility of advanced nursing practice, the night nurse practitioner is able to develop a differential diagnosis with a list of possible medical problems which then leads the practitioner to intervene with advanced nursing skills that will attempt to identify and resolve the medical problem. Because advanced nursing practice currently has no set national guidelines or standardization in the UK, each advanced nurse must have a clear understanding of which type of diagnosis is relevant for his/her practice. The case study from Table 2 was an example of a night nurse practitioner being able to develop a differential diagnosis because this particular practitioner did not have the training and professional responsibility to make or to be able to autonomously act upon a medical diagnosis. Only with adequate advanced clinical reasoning skills, training, experience and the professional scope of practice to definitively identify illness/injury can an advanced nurse investigate further to arrive at a medical diagnosis (Dimond, 2003). See Figure 1 for an overview of diagnosis in advanced nursing practice. Nurses working in advanced clinical practice who do have the ability to formulate a medical diagnosis, are then personally responsible for the corresponding interventions planned to solve the identified medical problem, because all nurses are professionally accountable for any action taken within his/her practice (Walsh, 2001a; Nursing and Midwifery Council (NMC), 2004).

Formulating a differential diagnosis

The nursing process used with advanced clinical practice can be adapted to incorporate advanced assessment and diagnostic skills including a differential diagnosis (Figure 2). The first step of assessment begins with taking a health history, which will not only reveal valuable subjective data, but will also provide direction for the extent and nature of the physical examination (Cox, 2004). By using the systematic approach of inspection, palpation, percussion, and auscultation, the nurse will be able to gather a great deal of objective clinical information during the physical examination (Bickley and Szilagyi, 2003). Other objective data can also be obtained from investigations such as blood work and radiology results. Throughout the assessment, there is an overlap of data collection and data analysis with judgments from the initial interpretations allowing for abnormality to be recognized which will subsequently influence decisions for further investigations (Carnevali and Thomas, 1993). Pieces of information or cues from the assessment are entered into working short-term memory and similar cues of abnormal findings are combined together into clusters. The cue cluster of highest priority is chosen for initial diagnosing, and knowledge from long-term memory and clinical reasoning skills are used to explain what is causing the problem of this particular cue cluster (Carnevali and Thomas, 1993; Gordon, 2002; Estes, 2006). When the practitioner is not able to

Case study
See Table 2 for an example of a comparison of the diagnoses and plan of care made by a general nurse, night nurse practitioner, and doctor for the same patient who was experiencing respiratory difficulties while recovering from abdominal surgery. The staff nurse in this case study is able to diagnose impaired gas exchange because general nursing interventions, such as giving oxygen, raising the head of the bed, and encouraging coughing, can be planned. Identifying the clinical problems of pneumonia and pleural effusion are

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Table 2. Case study comparing types of diagnoses

Staff Nurse NURSING DIAGNOSIS: Diagnosis Impaired gas exchange related to decreased ventilation and excessive secretions as evidenced by high respriratory rate, low O2 saturations, productive cough, use of accessory muscles, and nasal flaring. Subjective Data: Abnormal History of fever and productive cough clinical (yellow/green sputum) for 3 days findings Past medical history: bowel resection 5 days ago, myocardial infarction 5 yrs ago, angina Objective Data: Temp 39.5C Heart rate 110 beats/min Respiratory rate 35 breaths/min Blood pressure 100/50 mmHg O2 saturation 86% with O2 5 L/min via face mask Productive cough: thick, purulent sputum Laboured breathing with use of accessory muscles and nasal flaring, anxious Chest pain on inspiration but patient states is not the typical pain of his angina Change to non-rebreather face mask and increase O2 to keep saturation >92% Continuous O2 saturation monitoring Asses observations hourly Sit up in bed Encourage coughing up of sputum Refer to night nurse practitioner Inform charge nurse Refer to critical care team Refer to physiotherapy Reassure patient Speak to family Night Nurse Practitioner Doctor

DIFFERENTIAL DIAGNOSIS: MEDICAL DIAGNOSES: Acute respiratory failure related to: 1. Left lower lobe pneumonia ? pneumonia 2. Right pleural effusion ? pleural effusion ? pulmonary embolus ? cardiac cause Additional data: Mucous membranes to mouth cyanosed Minimal bilateral lower chest expansion Dullness percussed to bilateral lower lung fields Coarse crackles to bilateral upper/mid lung fields, bronchial breath sounds to left lower lung field, diminished breath sounds to right lower lung field Additional data: pO2 60 mmHg pCO2 55 mmHg HCO3 24 mmHg pH 7.32 White blood cells 20 X-ray infiltrates left lower lung, loss of costophrenic angles Ultrasound: fluid to lower right lung 12-lead ECG normal

Plan

External continuous positive airway pressure (CPAP) via face mask Prescribe antibiotics Provide reassurance and promote Insert right chest drain comfort with CPAP mask Consider intubation if Connect to 5-lead ECG monitor oxygenation does not Order chest X-ray, improve with external 12-lead ECG CPAP Send blood work: arterial blood gas full blood count, urea, creatinine, electrolytes, cardiac profile profile, blood cultures Discuss clinical findings and need for further investigation with doctor Speak to family

absolutely explain the cause of the clinical problem through analysis and interpretation of the assessment findings, a list of the most likely causes is developed, which is then the differential diagnosis. Szaflarski (1997) recommends the initial list of differentials to be exhaustive, to prevent prejudgment or bias from causing a diagnostic error. Szaflarski (1997) also suggests the importance of an organized, systematic approach to formulating a differential diagnosis which is achieved by arranging assessment data according to disease categories (congenital, environmental, endocrinologic, genetic, infectious, inflammatory, mechanical, neoplastic,

psychological, psychiatric, traumatic or unknown) or organ systems (neurological, pulmonary, cardiovascular, genitourinary, gastrointestinal, endocrine, integumentary, and psychological). The case study outlined in Table 2 can be used to demonstrate the process of preparing a differential diagnosis. The night nurse practitioner, with an understanding of the patients history, conducted a physical assessment which revealed abnormal respiratory findings. Past experiences with other patients in respiratory distress allowed pattern recognition and intuition to be used during the interpretation of the cause of the abnormalities. Advanced clinical practice training

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Figure 1. Overview of diagnosis in advanced nursing practice.

Advanced nursing practice

Nursing Diagnosis Clinical problem is a response to an actual or potential health problem General nursing interventions planned to achieve set outcomes

Differential Diagnosis List of possible causes of a health problem Advanced nursing interventions planned to resolve symptoms and identify actual vause of problem

Medical Diagnosis Actual cause of health problem identified (illness or injury) Advanced nursing interventions planned to achieve set outcomes

would have also provided information about prototypes of respiratory failure, as well as higher level cognitive skills, such as critical analysis and reflection. Having first identified abnormality in the form of respiratory failure, the night nurse practitioner was able to use clinical reasoning skills to hypothesize four possible causes for the respiratory problem (pneumonia, pleural effusion, pulmonary embolus, or a cardiac cause). This differential diagnosis was then the basis for clinical decision

making used in the advanced nursing care plan, which is the next step in the nursing process. The plan from a differential diagnosis will not only include interventions to solve the clinical problem as evidenced by set outcomes, but will also include tasks that will attempt to provide a definitive medical diagnosis. The plan in this case study included external continuous positive airway pressure (CPAP) to improve oxygenation; a chest X-ray to either identify or rule out infection, pulmonary oedema or pleural effusion;

Evaluation: Have outcomes been met? Yes: review at a later time No: return to assessment

Assessment: Subjective: history Objective: physical examination, lab results other investigations

Nursing process of advanced practice

Plan & implement: Interventions to achieve identified outcomes

Diagnosis: Nursing Differential Medical

Figure 2. Nursing process adapted to incorporate advanced assessment and diagnostic skills.

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and a 12-lead ECG to rule out myocardial ischaemia/ infarction. Blood work was also ordered to provide further diagnostic information.
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Conclusion
The development of advanced nursing practice has blurred the boundaries between medicine and nursing with many tasks, such as physical assessment and diagnosis, becoming a shared responsibility (McGee, 2003). By expanding the nursing profession to include diagnosis, a maxi-nurses vs mini-doctors debate has arisen (RCN, 2005). To maintain the nursing philosophy in advanced clinical practice, nurses incorporating diagnosis into their professional responsibilities must be clear about the definitions of diagnosis, understand their personal scope of practice for both identifying and acting upon a diagnosis, and consider diagnosis as a means of enhancing their caring role as a nurse rather than simply filling in the place of a doctor. Instead of viewing advanced nursing as physician replacement, Bryant-Lukosius et al (2004) recommend a patient-centred, health-focused, holistic nursing orientation to practice, otherwise the nursing components to advanced clinical practice will disappear. The case study presented in this article is an example of a differential diagnosis being used by an advanced nurse to provide efficient, effective care for a patient in respiratory failure while maintaining the essential caring and holistic aspects of nursing. The interventions planned and implemented as a result of this differential diagnosis allowed for an enhanced, multidisciplinary approach of the hospitalat-night team. Differential diagnosis, such as in this case study, is a new skill for many British nurses which highlights a need for research and study into the implications of using advanced diagnostic skills in the nursing process. There is also a need for professional regulation of advanced nursing skills which is due to commence once the NMC receives approval from the Privy Council to begin regulating BJN advanced nursing practice (NMC, 2006).

KEy POINTS
n Nurses working as advanced clinical practitioners who conduct physical assessment are now responsible for diagnosing. n The process of forming a differential diagnosis is to gather all subjective and objective clinical data, recognize and interpret abnormalities, and use clinical reasoning skills to identify clinical problems with their potential causes. n A differential diagnosis does not confirm an exact cause for a clinical problem but gives a list of potential causes. n A differential diagnosis will form the basis for clinical decision making that results in an action plan to help identify and solve the clinical problem. n Diagnosis in advanced nursing practice can be viewed as expanding the role of the nurse rather than physician replacement.

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