Nama : Irena Siska Manalu

Nim :01.2.17.00610

Mata Kuliah : Bahasa Inggris

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A. Nursing Diagnosis

A clinical judgement about individual, family, or community responses to actual or

potential health problems/ life process’. A nursing diagnosis provides the basis for selection
of nursing interventions to achieve outcome for which the nurse’s accountable. Professional
nurses are responsible for making diagnosis. It derived from existing evidences about the
client It is potentially amenable to nursing therapy It is the basis for planning and carrying out
nursing

Nursing Diagnosis are divided into two. That is negative and positive.

a. Positive :
 Actual Nursing Diagnosis : A clinical judgement about human experience/
responses to health conditions/ life processes that exist in an individual,
family or community. Actual client problem present at the time of
assessment. It is based on the presence of sign and symptoms.
E.g: Ineffective breating pattern, Disturbed sleep patter.
 Risk Nursing Diagnosis : It is a clinical judgement that a problem doesn’t
exist but the presence of risk factors indicates that a problem is likely to
develop unless nurses intervene.’ No subjective or objective cues
E.g : A client with DM or compromised immune system is at high risk
than others. Risk for infection. Risk for injury
b. Negative :
 Health Promotion Nursing Diagnosis : Describes human responses to level
of wellness in an individual, family, or community that have a readiness
for enhancement’ Clinical judgement about a person’s, families or
communities motivation and desire to increase well being.
  E.g: -Readiness for enhanced family coping
-Readiness for enhanced self est.

B. Componen Nursing Diagnosis

1. Problem (Diagnostic Label) / Definition
The problem statement describes the client health problem or response for which
nursing therapy is given. The diagnostic label should be specific
2. Etiology (Related Factors or Risk Factors)
Identifies one or more probable cause of the health problem, gives directions to the
required nursing therapy. Enables the nurses to individualized client care.

Problem Etiology
Constipation Long term laxative use, inactivity and insufficient fluid
intake
Anxiety Threat to physiologic integrity Possible cancer diagnosis

3. Defining Characteristic
The cluster of signs and symptoms that indicate the presence of a particular diagnostic
label.
❖ Actual diagnosis 🡪 client signs and symptoms
❖ Risk diagnosis 🡪 no subjective signs are present

Basic Two Parts:

1. Problem 🡪 statement of the client response

2. Etiology 🡪 factors contributing to or probable causes of the responses ‘related to’ phrase
implies a relationship

E.g: -Constipation related to insufficient fluid intake

-Pain related to presence of surgical incision

Basic Three Parts :

Also calles PES (Problem, Etiology, Signs and symptoms) format. Actual nursing diagnoses
can be documented by using the three part statement. Not used for risk diagnosis.

E.g: - Pain r/t surgical incision as evidenced by verbalization

- Hypertermia r/t underlying infectious process as evidenced by temperature 100 F.

C. Errors In Diagnostic Reasoning

Nursing Diagnosis Vs Medical Diagnosis

Nursing Diagnosis Medical Diagnosis
Care focused Etiology focused
Identifies risk and problems of the patient Identifies as nearly possible the specific
clinical entity that is causing illness
Focused on the signs and symptoms on the The medical diagnosis specify the
patient and his /her care givers pathology
Focused on the person and their Focuses on illness
physiological / psychologic all responses
to illness
Eg : Ineffective denial related to difficulty Eg : Myocardial infarction
coping with new diagnosis of “heart
attack”