NCM 203 LECTURE: FUNDAMENTALS OF NURSING PRACTICE1
#1 Critical Thinking page_1
#2 Nursing Assessment page_3
#3 Nursing Diagnosis page_9
Nursing as a Science:
CRITICAL THINKING
NURSING PROCESS
● “A systematic, creative approach to thinking and doing that
nurses use to obtain, categorize and analyze patient data and to
plan actions to meet patient needs.”
● “A type of problem-solving process requiring the use of decision
making, clinical judgment and variety of critical thinking skills.”
PROBLEM SOLVING
● “The mental activity of identifying a problem (unsatisfactory
state) and finding a reasonable solution to it.”
● Requires decision making;
● May or may not require the use of critical thinking. (depends on
the nature of the problem and some requires decision-making)
CRITICAL THINKING
● “Goal-oriented, purposeful thinking that involves many mental
attitudes and skills, such as determining which data are relevant
and making inferences.
● “Essential when a problem is ill defined and does have a single
‘best’ solution.
DECISION MAKING
● The process of choosing the best action to take the action most
likely to produce the desired outcome. Involves deliberation,
judgment, and choice.
● Decision must be made whenever there are mutually exclusive
choices, but not necessarily problems.
● Important in all phases of the nursing process.
CLINICAL REASONING
● “Logical thinking that links thoughts together in meaningful
ways. Clinical reasoning is reflective, concurrent and creative
thinking about patients and patient care.”
REFLECTION/REFLECTIVE JUDGMENT
● “A kind of critical thinking that considers a broad array of
possibilities and reflects on the merits of each in a given
situation.
● ”Essential when a problem is complex and has no simple
“correct” solution.”
● Useful in decision-making and problem-solving
CLINICAL JUDGMENT
● “The use of values or other criteria to evaluate or draw
conclusion about information.”
● “Clinical judgments are conclusions and opinions about
patient’s health, drawn from patient data. They may or may not
be made using critical thinking.“
● There has to be accurate data in making a conclusion
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ANALYSIS/CRITICAL ANALYSIS
❖ Analysis:
● “The process of breaking down materials into
component parts and identifying the relationship among
them.”
❖ Critical analysis:
● “Is the questioning applied to a situation or idea to
determine essential information and ideas and discard
superfluous information and ideas.”
CRITICAL THINKING
● “The art of thinking about your thinking while you are thinking
so as to make your thinking more clear, precise, accurate,
relevant, consistent and fair.” (Paul, 1988)
● Nurses need to think critically because it is an applied discipline.
With all the rationale, we apply it in taking care of patients. And
nurses also deal with changes in the environment.
Are you a critical thinker?
★ Do you explore the thinking and assumptions that underlie your
emotions? (why do you feel that way?)
★ Do you base your judgments on facts and reasoning, not on
personal feelings, self-interest, or guesswork?
★ Do you suspend judgment until you have all the necessary
data? (by nature, we are judgemental, but if you are a critical
thinker, you gather all the necessary data before judging)
★ Do you support your view with evidence?
★ Do you ask for clarification when you don’t understand?
★ Do you turn your mistakes into learning opportunities? (by
determining what went wrong, and thinking of ways to avoid
these mistakes in the future)
CHARACTERISTICS OF CRITICAL THINKING
1. Rational and reasonable
● based on reasons; not on prejudice, preferences,
self-interest, fear
2. Involves conceptualization
● Concept – mental image of reality, ideas about events,
objects or relationship between them
3. Requires reflection
● Reflection – to ponder, contemplate or deliberate
something.
● Reflective thinking – integrates past experiences to
present to explore potential alternatives (you draw a
conclusion at the end, use if & then)
4. Involves both cognitive (thinking) and attitude (feelings) - you
must have thinking skills and motivations or desire to use them
5. Involves creative thinking
● It results in innovative ideas and products
● Think out of the box, be open and creative in thinking
6. Involves knowledge - affects your abilityI
❖ Nursing knowledge
● Scientific knowledge - facts, information,
principles, theories, research findings and
conceptual models

● Used to describe, explain, and predict.
● Ethical knowledge
● standard of conduct
● Obligation and what ought to be done, code of
ethics guide our actions
● Personal knowledge
● knowing and actualizing one’s self
● Enables the nurse to approach clients as people
rather than objects.
● Interacting from person to person and establishing
a therapeutic relationship
● Practice wisdom
● acquired from intuition, tradition, authority, trial
and error, clinical experience
CRITICAL THINKING ATTITUDES
INDEPENDENT THINKING
● Critical thinkers think for themselves.
● They consider a wide range of ideas, learn from them and make
their own judgments about them.
● Do not just simply go along with the crowd
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FAITH IN REASON .
● Implies that people can, and should learn to think logically for
themselves
● Not afraid of disagreement
FAIRMINDEDNESS .
● Making impartial judgments
● Treating all viewpoints alike, without reference to one’s own
feelings or vested interests, or those of one’s friends,
community or nation
● Consider everyone as equal
INTEREST IN EXPLORING THOUGHTS AND FEELINGS .
● The critical thinker knows that emotions can influence thinking
and that all thoughts create some level of feeling
● The feelings that you have in response to a situation would be
different if you had a different understanding of the situation
.
CRITICAL THINKING SKILLS

INTELLECTUAL HUMILITY
● Means being aware of the limits of your knowledge and
realizing that the mind can be self-deceptive
● Admitting lack of knowledge or skill can/will enable you to
grow professionally
● Rethinking conclusions in light of new knowledge
● Ex. New nurse and do not have the experience, leading to
feeling of insecurity & requesting for help from other nurses to
teach you
INTELLECTUAL COURAGE . only with health care workers
● Being willing to consider and examine fairly your own beliefs
and the views of others, especially those to which you may have
a strongly negative reaction
● Courage to deal with constant changes in the practice
environment
INTELLECTUAL EMPATHY
● The ability to imagine yourself in the place of others in order to
understand them and their actions and beliefs.
INTELLECTUAL INTEGRITY . ❖ Opinion - a view or judgment formed about
● Being consistent in the thinking standards you apply (e.g.
clarity, accuracy, completeness) – holding yourself to the same
rigorous standards of proof to which you hold others
INTELLECTUAL PERSEVERANCE .
● A sense of the need to struggle with confusion and unsettled
questions over an extended period of time to achieve
understanding and insight.
● Looking for the most effective solutions to patients’ problems
can be found if you do nursing research with perseverance.
INTELLECTUAL CURIOSITY
● An attitude of inquiry
● Having a mind filled with questions
● Examine statements to see if they are true or valid rather than
blindly accepting them.
● Asking what, how, why
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1. Using language
● Precise, specific
● Avoid cliches, jargon, euphemisms
● Do not use medical jargon with clients or patients, but
2. Perceiving
● Avoiding selective perception
● Recognizing differences in perception
● Using senses to experience the world
3. Believing and knowing
. ● Distinguishing facts from interpretation
● Supporting facts, opinions, beliefs and preferences
❖ Inference - a conclusion reached on the basis of
evidence and reasoning
something, not necessarily based on fact or
knowledge.
❖ Judgment - the ability to make considered decisions or
come to sensible conclusions.
4. Clarifying
● Questioning to clarify meaning of words and phrases
● Questioning to clarify issues, beliefs, and points of view
● Critical thinkers ask questions to clarify and understand
complex concepts, ideas, or situations
5. Comparing
. ● Noting similarities and differences
● Classifying
● Comparing and contrasting ideals and actual practice
● Transferring insights to new context
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6. Judging/Evaluating
● Providing evidence to support judgments
● Develop evaluation criteria Nursing as a Science:
● Evaluation requires first identifying the criteria or THE NURSING PROCESS
standards to be used and then decide to what extent
what you’re examining meet those criteria Nursing Process
● EX: Judgement- I like this music ● A method of problem identification and problem-solving
● EX: Evaluation- I like this music because it has a beautiful (Gordon, 1994)
melody and meaningful lyrics, pace… ● A key systematic method for taking independent nursing action
(Ralph & Taylor, 2014)
7. Reasoning
● Recognizing assumptions
Nursing Process (ANA, 2014)
● Distinguishing between relevant and irrelevant data
● Evaluating sources of information ● Cyclical
● Generating and evaluating solutions ○ Its components follow a logical sequence, but steps may
● Exploring implications, consequences, advantages or overlap because they are interrelated.
disadvantages ● Dynamic
○ It is flexible to meet the unique needs of clients, and open
“The essence of the independent mind lies not in what it thinks, but in how it to new information during its application.
thinks.” - Christopher Hitchens ● Interpersonal
○ It requires the nurse to communicate directly and
consistently with the client.
● Collaborative
○ It requires the nurse to collaborate, as a member of the
health care team, in a joint effort to provide quality client
care.
● Universal
○ It is applicable to individuals, families and communities.

Nursing Process (AACN, 2008)

● Framework for providing specific nursing care to individuals,
families and communities
● Orderly and systematic
● Interdependent
● Patient-centered using patient’s strengths
● Appropriate for use throughout life span
○ Applicable from womb to tomb
● Can be used in all settings
○ hospital setting
○ community setting

COMPONENTS OF THE NURSING PROCESS

Nursing Assessment .
● First phase of the nursing process, during which data are
gathered for the purpose of identifying actual or potential
health problems.
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○ Gather data about the patient that includes the individual ➢ Includes appraisal of any new, overlooked, or
patient, the family or the community that can be used in misdiagnosed problems
diagnosing, identifying outcomes, planning and ➢ Often, nurses assess patients for specific problems and
implementing care provide nursing care at the same time.
■ Ex. Admitting a patient with weakness in the
● Purposes:
lower extremity, the nurse can assess the patient’s
○ To establish baseline information on the patient
skin, muscular strength, and ability to perform
○ To determine the patient’s normal function
self-care activities.
○ To determine the patient’s risk of dysfunction
➢ Can be performed during nurse-patient interaction and to
○ To determine the presence or absence of dysfunction
identify specific problems or while doing activities or
○ To determine the patient’s strengths
observing the client’s behavior.
○ To provide data for diagnosis phase
● Time-lapse Assessment:
➢ Takes place after the initial assessment, to evaluate any
Types of Assessment changes in the patient’s health
➢ Nurses perform time-lapse assessments when substantial
Type Aim Time frame
periods of time have elapsed between assessments
Initial assessment Initial identification of Within the specified ■ Ex. Periodic Out-patient clinic visits, Home health
normal function, time frame after visits, health and developmental screenings
Also known as functional status, and admission to a ➢ Determine the status of problems already identified in
“Database collection of data hospital, nursing
the previous assessments
Assesssment” or concerning actual or facility, ambulatory
➢ LESS comprehensive compared to the initial assessment
“Comprehensive potential dysfunction healthcare center, or
Assessment” home healthcare ● Emergency Assessment:
Baseline for reference setting ➢ Takes place on life-threatening situations, in which the
and future comparison preservation of life is the top priority.
➢ Time is of the essence for rapid identification of and
Focus Assessment Status determination Ongoing process;
of a specific problem intervention for patient’s health problems.
Has a narrower identified during Integrated with ➢ Often, a patient’s difficulty involved airway, breathing,
scope and shorter previous assessment nursing care; circulatory problems (ABC), which are physiologic crisis
time frame ➢ Usually 2-7 seconds are taken to evaluate the heart,
To identify new A few minutes to a few lung, and neurologic status (it has to be done really fast)
problems hours between ➢ Abrupt changes in self-concept (ex. Suicidal thoughts), or
assessments
roles/relationships: these are examples of social conflict
To evaluate outcome
achievement & leading to violent acts that can initiate emergency
problem resolution assessment
➢ NOT comprehensive beacuse taking time to collect
Time-lapse Comparison of Several months information could delay treatment and pose serious risks
assessment patient’s current status (3, 6, or 9 months or
for the patient.
to baseline obtained more) between
Also called previously; assessments ➢ Once a patient’s status is stable, the nurse conducts a
“Reassessment” more comprehensive assessment
Detection of changes
in all functional areas ASSESSMENT SKILLS
after an extended
period of time has
(Data Collection Methods)
passed a. Observation
Emergency Identification of Anytime a physiologic, ● The act of noticing patient cues
assessment life-threatening psychological, or ● Involves using all senses to collect data
situation emotional crisis occurs ● Examples: Senses of smell, hearing, touch, taste, vision
● Vision - is used in a specialized manner; the nurse’s
● Initial Assessment: ability to survey how the patient looks (general
➢ Nurse is responsible for the completeness and accuracy appearance) “does the patient shows signs of distress or
of the initial assessment discomfort or grimacing, scowling, frowning, or holding a
➢ Joint commission (2019), each patient must have certain body part?”
documented nursing admission that follows institutional ○ Non-verbal behavior is noted during every
policies interaction; see signs of anger, suspicion, anxiety,
➢ Home care policies and other health care facilities has or hostility (the patient may deny any anxiety or
established policies in getting data apprehension about health problems but may
● Focus Assessment: have an anxious facial expression)
➢ If the status of the problem changed or not ● Smell - when observing the patient's breath or body
➢ If the problem worsen, improved or resolved odors may indicate an underlying physical condition.

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○ Ex. FOUL smelling breath = oral or pulmonary
infection
● Hearing - includes nurse’s ability to listen and hear what
Collection of Data .
the patient says; skill of active listening = one of the
♡ Subjective data
therapeutic communication skills (restating & clarifying
● Covert data
what the patient says)
● Symptoms
○ Ex. “I feel woozy when I take the medication” so
● Not measurable
the nurse clarifies what woozy means for the px
● Can be obtained only from what the client tells the nurse
● Touch - greet the patient (handshake) or to provide
(interview)
non-verbal communication and reassurance; perform
● Include client’s thoughts, beliefs, feelings, sensation,
preliminary appraisal of skin, temperature, and moisture;
perception of self, attitudes, values
○ be careful with using touch in considering different
○ Ex. “I haven’t felt good for the last couple of
cultural backgrounds of clients
months.”
b. Interview ● NOTE: Data from significant others and other health
● Interaction and communication process for gathering professionals may also be subjective if they consist of
data by questioning and information exchange opinion and perception rather than fact.
● To obtain accurate information, nurses must be effective ■ You may not always be able to obtain subjective
communicators; factors affecting interview’s quality and data.
comprehensiveness (nurse’s skill and information, and
patient’s willingness to share info)
♡ Objective data
● Signs
c. Physical examination ● Observable and measurable
● Analysis of bodily functioning using the techniques of ● Can be detected by someone other than the client
inspection, palpation, percussion & auscultation (IPPA) ● Obtained through observation and examination of the
client, measurement devices, health record, laboratory
NURSING INTERVIEW studies, radiologic tests, diagnostic procedures
● Purposeful, focused interaction EXAMPLES
● To obtain subjective data about the effects of the illness on SUBJECTIVE DATA OBJECTIVE DATA
patient’s daily functioning and ability to cope
● To obtain subjective data for nursing health history Description Covert data: Symptoms Overt data: Signs
○ What the patient says ○ Can be observed by
○ Can be perceived others
APPROACHES TO INTERVIEW ○ Verified only by the ○ Measured against a
❖ Directive interview patient standard
● Highly structured, controlled by nurse
Examples ○ Itching ○ Pulse rate of 100 bpm
● To obtain specific factual information (e.g. age, sex, ○ Pain ○ BP of 120/80 mmHg
analysis of symptoms) ○ Anxiety ○ Skin pale and cool to
○ “I am afraid” touch
❖ Nondirective interview
○ “I feel weak all ○ Urine output of 350
● Allow patient to control and to express
over” ml
● Time consuming ○ X-ray / laboratory
● Promote communication and rapport results
● Can apply all different techniques of communication to let ○ Skin turgor
client express themselves and figure out solution to own ○ Posture
problems
Identify the following data as subjective or objective:
NURSING ASSESSMENT ACTIVITIES ★ “I feel weak all over when I exert myself”
1. Collection of Data ➔ Subjective
2. Validation of Data ★ “BP 90/50; Apical pulse 104
3. Organization of Data ➔ Objective
★ Skin pale and diaphoretic
➔ Objective
★ Client states, “I feel sick to my stomach.”
➔ Subjective
★ Vomited 100 ml green-tinged fluid
➔ Objective
★ Abdomen firm & slightly distended
➔ Objective
★ Active bowel sounds auscultated in all four quadrants
➔ Objective

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★ “I’m short of breath” 4. Factors are present that interfere with accurate measurement.
➔ Subjective ○ Ex. Upon assessment, the environment is very noisy and
★ Lung sounds clear bilaterally; diminished in right lower lobe cannot hear well the different sounds needed to be
➔ Objective observed from the patient’s body, so validate it to check
★ Wife states, “He doesn’t seem so sad today” for accuracy in the data.
➔ Subjective
★ Client cried during interview Organizing Data .
➔ Objective ❖ Using Gordon’s 11 Functional Health Patterns to
organize/cluster the assessment data
SOURCES OF DATA ❖ Using Maslow’s Basic Human Needs to prioritize problem
❖ The NANDA - I taxonomy serves its intended purpose of
1. Primary data: the client
sorting/categorizing nursing diagnosis to help nurses locate
2. Secondary data: obtained from sources other than the client
nursing diagnosis within the taxonomy
a. Significant others (e.g. family, friends)
b. Other health care providers
● Various frameworks exist for the orderly collection and
c. Client’s written record, past, and present hospitalization
recording of assessment data.
● Frameworks serve as guide during the nursing interview and
NURSING HEALTH HISTORY physical examination.
● Refers to the data collected about the client’s current level of ● It also helps prevent the emission of pertinent information and
wellness, including a review of body systems, family and health foster data analysis in the diagnosis phase.
history, socio-cultural history, spiritual health, mental and
emotional reactions to illness.
Gordon’s Functional Health Patterns
● Obtained during an interview.
○ also done during initial assessment Patterns Description Examples

Health Perception Client’s perception of Compliance with

COMPONENTS OF NURSING HEALTH HISTORY / Health health and well-being medication regimen,
✔ Biographical data Management and how health is use of health
✔ Chief complaint managed promotion activities
■ reason for visit such as regular
Parameters: exercise, annual
✔ History of present illness
a. general survey of check ups.
■ how present illness has occurred
patient’s health
✔ Past health status status
■ client’s health history such as from childhood: b. usual health
immunizations and previous illnesses behavior
✔ Review of system and effects on functioning
Nutritional / Pattern of food and Condition of skin,
■ physical assessment Metabolic fluid intake relative to teeth, hair, nails,
✔ Social and family history metabolic need mucous membranes,
✔ Lifestyle, habits, daily living patterns indicators of local height, weight, fluid
✔ Spiritual well-being nutrient supply. and electrolyte
✔ Psychological data balance.
✔ Perception of health status and illness Parameters:
a. Eating habits
✔ Client’s expectation of caregivers
b. Appraisal of
appetite
Validation of Data . c. Weight loss/gain
● The act of “double-checking” or verifying data in order to: d. Appearance or
1. Ensure complete, accurate and factual information changes in skin,
2. Eliminate nurse’s own biases, errors and misperceptions hair, or nails
of the data Elimination Patterns of excretory Frequency of bowel
3. Avoid jumping to faulty conclusion, premature closure function (bowel, movement, voiding
bladder, and skin); pattern, pain on
A nurse must validate data when:
includes client’s urination,
1. Subjective and objective data, interview, physical examination perception of “normal” appearance of urine
do not agree. function. and stool.
○ There are discrepancies or inconsistencies in the data
gathered so validate it to check for accuracy Parameters:
2. The client’s statements differs at times in the assessment a. Usual bowel and
bladder elimination
○ We also need to assess the mental status and client’s
habits
orientation of the person, place, and time.
b. Last bowel
3. The data seem extremely abnormal. movement
○ Ex. if very high BP and labortory counts in diagnostics c. Laxative use

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d. Excretory functions Sexual / Patterns of satisfaction

Histories of
(perspiration or Reproductive and dissatisfaction with
pregnancy and
status of skin) sexuality; reproductivechildbirth; difficulties
pattern and stage with sexual
Activity / Exercise Patterns of exercise, Exercise, hobbies; functioning;
activity, leisure and may include Parameters: satisfaction with
recreation. cardiovascular and a. Patient’s appraisal sexual relationship
respiratory status, of his/her sexual
Parameters: mobility, and role and health
a. Mobility status activities of daily
b. Cardiovascular living
status Coping / Stress General coping pattern Client’s usual manner
c. Respiratory status Tolerance and effectiveness of of handling stress,
d. Exercise routine pattern in terms of available support
e. Leisure activites stress tolerance system, perceived
ability to control or
Parameters: manage situations.
Cognitive / Sensory-perceptual and Vision, hearing, taste,
a. Current stress level
Perceptual cognitive patterns touch, smell, pain
b. Client’s coping
perception and
ability
Parameters: management;
c. Ability to endure
a. Changes in cognitive cognitive functions
the stressors or
function such as language,
challenges of life
b. Client’s ability to memory and decision
d. Physiologic
hear, speak, see making
responses to stress
c. Client’s perception
(“how is the client’s
of pain, numbness,
vital signs when
and other
experiencing
sensations
stress?”)
Sleep / Rest Patterns of sleep, rest Client’s perception of
and relaxation quality and quantity Value-Belief Patterns of values, Religious affiliation,
of sleep and energy, beliefs (including what client perceives
Parameters: use of sleep aids, spiritual) and goals that as important in life,
a. Regular sleep habits routines client uses guide client’s choices or values/belief conflicts
b. Routines of rest and decisions related to health,
sleep special religious
Parameters: practices
Self-Perception / Client’s self-concept Body comfort, body a. Identification of
Self-Concept pattern and perceptions image, feeling state, valued people and
of self, emotional attitude about self, possessions
patterns perception of b. Sources of support
abilities, objective c. Client’s religious
Parameters: data such as body practices
a. Client’s description posture, eye contact,
of self voice tone
b. His/her physical Maslow’s Hierarchy of Needs
appearance
c. Effect of illness on ★ Physiological needs - needs that must be meet or least
the client partially met for survival
d. Major life ○ If not met, the client cannot go up to the higher needs /
accomplishments hierarchy
(abilities and self
○ Health, food, sleep
actualization
○ Ex. Temperature of 39 degree celcius, liquid stools 4x in
accomplishments)
one hour
Role/Relationship Client’s pattern of role Perception of current ★ Safety and Security needs - things that make a person feel
engagement and major role and safe and comfortable
relationships responsibilities (e.g. ○ Shelter, removal from danger
father, husband,
○ Ex. Sleeps with night light
Parameters: salesman);
a. Patient’s perception satisfaction with ★ Love and Belongingness - the need to give and receive love
of key relationships family, work, or social and affection
(like within family) relationship ○ Love, affection, being part of a group
b. Observation of
○ Ex. Mother and father are with Billy (hospitalized child)
interactions with
otehrs ★ Esteem needs - things that make feel good about themselves;
pride in abilities and accomplishments
○ Self-esteem, esteem from others
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○ Ex. “I just passed the nurse licensure examination”
★ Self Actualization needs - the need to continue to grow and
change; working towards the future goals
○ Achieving individual potential
○ Ex. “My children are grown with families of their own.
Raising them has been my biggest accomplishment.”

Recording Data .
● Record in ink on the form provided by the agency
○ In ink because it is a permanent document
● Write legibly and neatly
● Use acceptable and appropriate abbreviations
● Record subjective data in client’s own words
● Record cues not inferences
● Avoid vague generalities (e.g: good, normal)
● Data are recorded in a factual manner and not interpreted by
the nurse.
● Example: The nurse records a client’s breakfast intake:
■ “Coffee 240 ml, juice 120 ml, 1 egg, 1 slice of toast”
(objective)
■ “Appetite good” (judgment)
● To increase accuracy, the nurse records subjective data in the
client’s own words.
○ Using a framework or outline, the assessment data are
systematically recorded and became a permanent record
in the medical record (reason why it is in ink)
○ Institutions usually have a specific form for recording
data and facilitating its use by other nurses who are
caring for the patient.
○ Baseline assessment data are referred to periodically to
reaffirm assessment findings and to complete patient’s
current status with his/her initial condition.
○ 2 methods are used:
- Traditional Written Assessment Record (still
common in the present time)
- Computerized Assessment Record
○ Confidentiality or keeping information private is very
important in protecting confidentiality and discussed or
shared only with the health care professionals directly
involved in providing care for the patient.

“Nothing replaces two eyes, and using touch and hearing in nursing assessment.” -
Patrice Dillow, MSN, RN, CWOCN, APRN

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Comparison of Nursing Diagnoses with Collaborative Problems and
Medical Diagnoses
THE NURSING PROCESS:
Nursing Diagnoses Collaborative problems and
Nursing Diagnosis Medical diagnoses

Components of the Nursing Process Focus of Main focus is on Main focus is on monitoring
Assessment monitoring human for pathophysiologic
Activities responses to actual and response of body organs or
potential health systems.
problems
- Disease processes and
Nursing diagnosis are their associated signs &
statements that symptoms are the
describe the way that a essence of medical
patient responds to a diagnosis.
health problem of life
processes

Problem Nurse identifies and Nurse may identify problem

Identification validates but is required to refer to
NURSING DIAGNOSIS independently that physician for validation that
problem exists and can problem exists (may require
● A nursing diagnosis is a clinical judgment concerning a human
be treated legally by additional diagnostic studies
response to health conditions/life processes or vulnerability for nursing staff. to label problem.
that response, by an individual, family, group or community.
Nurse may not be qualified
(NANDA-I, 2013) - Within the scope of to diagnose exact nature of
our practice to problem but refers
Purposes of the nursing diagnosis address human abnormal data to physician.
responses
● A nursing diagnosis provides the basis for selection of nursing
interventions to achieve outcomes for which the nurse is Treatment Nurse legally initiates Nurse collaborates with
accountable. actions for treatment. physician to initiate
● The term nursing diagnosis serves as both the label for and the interventions for treatment.
*provided it is within
action of describing a client’s health problems.
the scope of practice Nurse may have standing
● Its purpose is to identify problems and synthesize the (eg. human response) orders from physician or
information gathered during the nursing assessment. institution to initiate
- The collection of assessment data provides the basis for diagnostic studies or
identifying the nursing diagnosis. So it is important to treatment interventions for
adequately and accurately collect data during the problem without physician’s
assessment. orders.

Key terms TYPES OF NURSING DIAGNOSIS

Terms Brief Description
1. PROBLEM - FOCUSED DIAGNOSIS .
♡ Nursing Diagnosis Problem, strength, or risk identified for ● A clinical judgment concerning an undesirable human response
a patient, family, group, or community to health condition/life process that exists in an individual,
family or community.
♡ Defining characteristic Sign or symptom (objective or
subjective cues) ● Problem-focused diagnosis should not be viewed as more
important than risk diagnosis
♡ Related factor Causes or contributing factors ● In the past, it was called the actual nursing diagnosis
(etiological factors)
● Example: Problem-focused NDx
♡ Risk factor Determinant (increase risk) ○ Ineffective breathing pattern related to hyperventilation
as evidenced by nasal flaring and RR of 30 cpm
♡ At-risk populations Groups of people who share a
○ Activity intolerance related to chronic pain as evidenced
characteristic that causes each
member to be susceptible to a by patient stating pain 10/10 with movement
particular human response. These are
characteristics that are not modifiable 2. RISK DIAGNOSIS .
by the professional nurse. ● A clinical judgment concerning the susceptibility of an
♡ Associated conditions Medical diagnoses, injury procedures, individual, family or community for developing an undesirable
medical devices, or pharmaceutical human response to health condition/life processes
agents. These conditions are not ● Sometimes, a risk diagnosis can be the diagnosis with the
independently modifiable by the highest priority for the patient.
professional nurse. ● Example: Risk NDx
○ Risk for falls related to impaired mobility

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○ Risk for hypothermia related to low environmental
temperature
3. HEALTH PROMOTION DIAGNOSIS . ■ Excess – an amount of something that is more than necessary,
● A clinical judgment concerning motivation and desire to
increase well-being and to actualize health potential.
● These responses are expressed by a readiness to enhance
specific health behavior, and can be used in any health state.
● Note: In case where individuals are unable to express their own
readiness, the nurse may determine that a condition for health
promotion exists and then act on the client’s behalf.
● Example: Health Promotion NDx
○ Readiness for enhanced comfort
○ Readiness for enhanced self-care
Components of a Nursing Diagnosis
1. Diagnostic label
● The name of the nursing diagnosis as listed in the
NANDA-I taxonomy.
● It describes the essence of the problem using as few
words as possible
- Nursing has a scientific body of knowledge, so
nursing process is our scientific base. To achieve
this scientific foundation, nursing requires a
taxonomy or classification system (in this case, we
are using the NANDA International Taxonomy)
- Taxonomy is the system for naming and organizing
themes into groups that share similar qualities.
● Example:
○ Stress Urinary Incontinence
○ Anxiety
2 Basic Parts of a Nursing Diagnostic label
a. Descriptor or modifier – are words used to give additional
meaning to a nursing diagnosis
b. Focus of the diagnosis or the key concept of the diagnosis
➢ The principal element/ fundamental & essential part/ the
root of the diagnostic concept
➢ Describes the “human response” that is the core of the
diagnosis
Examples: Parts of a diagnostic label...
Modifier Focus of the diagnosis
Ineffective Breathing pattern
Risk for Constipation
Deficient Fluid volume
Impaired Skin integrity
Readiness for enhanced Resilience
Examples of modifiers
■ Compromised – made vulnerable or to function less effectively
■ Decreased – smaller or fewer in size, amount, intensity, or
degree
■ Deficient/ Deficit – not having enough of a specified quality or
ingredient; insufficient or inadequate
■ Delayed – late, slow or postponed
■ Disproportionate – too large or too small in comparison with
the norm
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■ Disturbed – having had a normal pattern or function disrupted
■ Dysfunctional – not operating normally or properly
■ Effective – successful in producing a desired or intended result
permitted or desirable
■ Impaired – weakened or damaged
■ Ineffective – not producing any significant or desired effect
Note:
✔ Each nursing diagnosis has a label and a clear definition.
✔ It is critical to know the definition of the diagnoses
✔ Nurses must need to know the diagnostic indicators.
Diagnostic indicators
● The information that is used to diagnose and differentiate one
diagnosis from another
● Include:
1. Defining characteristics
2. Related factors
3. Risk factors
2. Defining characteristics
● are observable cues/inferences that cluster as
manifestations of a diagnosis (e.g, signs and symptoms)
● An assessment that identifies the presence of a number
of defining characteristics lends support to the accuracy
of the nursing diagnosis
3. Related factors
● An integral component of all problem-focused diagnoses
● Etiologies, circumstances, facts or influences that have
some type of relationship with the nursing diagnosis
● A review of the client history often helps to identify the
related factors
● Nursing intervention should be aimed at these factors to
remove underlying cause of the nursing diagnosis
● Example: cause, contributed facts
4. Risk factor
● Influences that increase the vulnerability of an
individual, family, group or community to an unhealthy
event
● Example: environmental, psychological, genetic
HOW TO WRITE A NURSING DIAGNOSIS
Problem-focused:
● Diagnostic label + related factor + defining characteristics
● Example: Ineffective breathing pattern related to
hyperventilation as evidenced by nasal flaring and RR of 30 cpm
○ Ineffective breathing pattern (Diagnostic label)
○ related to hyperventilation (related factor)
○ as evidenced by nasal flaring and RR of 30 cpm (defining
characteristics)
Risk Diagnosis:
● Diagnostic label + risk factor
● Example: Risk for falls related to impaired mobility
○ Risk for falls (Diagnostic label)
○ related to impaired mobility (risk factor)
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Health Promotion:
● Diagnostic label
● Diagnostic label + defining characteristics (if present)
● Example:
○ Readiness for enhanced comfort (Diagnostic label)

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