Nursing Diagnostic Applications Derived From National Academy of Clinical Biochemistry (NACB) Draft Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus

Brief: Nursing Diagnostic Applications Derived From National Academy of Clinical Biochemistry (NACB) Draft Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus

Lavin, Mary Ann

This brief indicates how methods used by the National Academy of Clinical Biochemistry (NACB) in the development of its guidelines and recommendation for the laboratory analysis in the diagnosis and management of diabetes mellitus may be applied to advance nomenclature, clinical practice, and research development within nursing. Specifically, human response diagnoses require the identification of accurate tests to confirm or reject the diagnoses. Each test needs to be described in terms of its use, rationale, analytical, and emerging considerations. Accurate test development will move nursing nomenclature, clinical practice, and research forward.

Search terms: Nursing diagnosis, human response, diagnostic tests, nomenclature, diabetes mellitus, laboratory, analysis.

doi: 10.1111/j.1744-618X.2008.00084.x

Introduction

NANDA International was invited to send a representative to the Arnold O. Beckman Conference held at the Renaissance Waverly hotel in Atlanta, Georgia, on November 19-21,2007, and to review and comment on the draft of the Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. Other professional organizations invited to attend were: Agency for Healthcare Research and Quality, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American Association of Diabetes Educators, American College of Obstetricians and Gynecologists, American College of Physicians, American Diabetes Association, Association of Clinical Biochemistry, Association of Public Health Laboratories, Centers for Disease Control and Prevention, College of American Pathologists, Department of Veterans Affairs, Diabetes UK, The Endocrine Society, European Association for the Study of Diabetes, Food and Drug Administration, International Diabetes Federation, International Federation of Clinical Chemistry and Laboratory Medicine, Juvenile Diabetes Research Foundation, NANDA International, and National Institute of Diabetes and Digestive and Kidney Diseases (of the National Institutes of Health).

This Conference is named after Arnold O. Beckman (1900-2004), who was born in Cullom, Illinois, 187 miles north-northeast of St. Louis and 73 miles south-southwest of Chicago. A graduate of the University of Illinois (BA in chemical engineering and MA in physical chemistry) and the California Institute of Technology (PhD), Beckman led an extraordinary life as academic chemist, teacher, and inventor (including the pH meter, spectrophotometer, and glucose analyzer) in addition to founding Beckman Instruments Inc. Fifty-seven years after their marriage, the Beckmans established the Arnold and Mabel Beckman Foundation and endowed the American Association of Clinical Chemistry with funds to support the Arnold O. Beckman Annual Conference in Clinical Chemistry. The 2007 Arnold O. Beckman Conference focused on the National Academy of Clinical Biochemistry Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. The guideline committee members were David B. Sacks, MB, ChB, Chair; Mark Arnold, PhD; George L. Bakris, MD; David E. Bruns, MD; Andrea Rita Horvath, MD, PhD; Sue M. Kirkman, MD; Ake Lernmark, MD; Loyd E. Metzger, MD; and David Nathan, MD.

Attendance at the Conference was a privilege and provided an exceptional opportunity to explore the applications of content to nomenclature development, clinical practice, and research. These applications are the subject matter of this report.

Nomenclature, Clinical, and Research Applications

Nomenclature Applications

The exquisite structure of the guidelines was a learning experience in nomenclature development in itself. This structure included the major topical sections, subsections, and boxed recommendations.

* Topical sections include: glucose, glucose meters, minimally invasive continuous glucose analysis, noninvasive glucose analyses, urinary glucose, oral glucose tolerance test (OGTT), gestational diabetes mellitus and OGTT, ketone testing, glycated (not glycosylated1) hemoglobin, genetic markers, autoimmune markers, and miscellaneous potentially important analytes (insulin and precursors, insulin antibodies, lipids).

* Each topical section was divided into the following subsections: Use, rationale, analytical (pre-analytical, analytical, and patient variable) considerations, interpretation, and emerging considerations.

* Boxed recommendations along with the respective levels of evidence fall within one or more of the subsections within each section.

This structure is applicable in whole or part in the development and evaluation of tests of human response diagnoses. The depth of the analyses points out the degree of sophisticated work required in developing and evaluating diagnostic tests for NANDA. The NACB Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellirus exemplify not only steps that need to be taken but also the end goal. This is not to say that laboratory analysis is a nursing method per se. It is to say that the analytic methods nursing science develops need to be analogous to laboratory measures in terms of defining their precision (reproducibility) and their diagnostic accuracy.

More explicitly, human response diagnoses may be determined clinically on the basis of their defining characteristics, the same way disease diagnoses are determined clinically on the basis of disease signs and symptoms. For example, polyuria, polydipsia, and polyphagia may establish a clinical diagnosis of diabetes mellitus. However, clinical disease diagnoses need to be confirmed. The clinical diagnosis of diabetes is “confirmed” by a fasting plasma glucose > 126 mg/dL. In a similar manner, confirmation of clinically determined nursing diagnoses requires more than the presence of defining characteristics. It requires the development of sensitive and specific diagnostic tests to confirm the clinically determined human response diagnoses. The NACB Guidelines and Recommendations provide an outstanding example of the study of the nuances involved in diagnostic testing and analysis.

Clinical Applications

The NACB Guidelines and Recommendations contain a myriad of applications that are appropriate for nursing and advanced nursing practice. Several examples of these clinical applications are illustrated in Table 1. To clarify the relevance of these examples for nursing, consider the first sentence in Table 1: “The test recommended for the diagnosis of diabetes mellitus is the fasting plasma glucose analysis (FPG).” This statement alerts the nursing community as a whole that:

* The more appropriate term for “fasting blood sugar” is “fasting plasma glucose.”

* The standard of practice for the diagnosis of diabetes mellitus is the fasting plasma glucose.

* In a manner analogous to the diagnosis of diabetes mellitus, the diagnosis of any one human response to illness/life processes requires accurate tests that confirm or reject the diagnosis.

Research Applications

In addition, several examples of nursing research applications are illustrated in Table 2. These applications are straightforward, hypothesis-generating examples of ways in which nurse researchers can contribute directly to applied clinical chemistry research in diabetes care and the management of the therapeutic regimen.

Conclusions

This report summarizes examples of nomenclature development and clinical and research applications derived from the 2007 Arnold O. Beckman American Association of Clinical Chemistry (AACC) Conference on the NACB Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. It is highly recommended that registered nurses, advanced practice nurses, educators, and researchers obtain a copy of the guidelines (http://www.aacc.org/AACC/members/nacb/LMPG), once published, to update their own clinical knowledge base and to inform their practice and research in accordance with the latest scientific directives.

1 For many in nursing, the HbA^sub 1^C is incorrectly referred to as “glucosylated” (or “glycosylated”) hemoglobin, when the correct term to describe the chemical reaction involved is “glycated” hemoglobin. The latter refers to any reaction that Unies a sugar with a protein of which hemoglobin is one; hence, “glycated hemoglobin.”

Mary Ann Lavin, ScD, RN, APRN, BC, FAAN

Mary Ann Lavin, ScD, RN, APRN, BC, FAAN, is Associate Professor, Saint Louis University School of Nursing, St. Louis, MO.

Author contact: lavinma@slu.edu

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