DIAGNOSING - After identifying all of them, formulate
diagnostic statements.
• Nursing Process (Definitions)
- It is a rational and scientific method done by
nurses
- (1) Deliberate way of thinking by nurses
[done consciously; critical thinking is
needed] using (2) an organized systematic
framework of interrelated activities [ADPIE]
that is (3) a scientific problem-solving
approach (entails decision making in every
phase of the nursing process; what is the
best action and most appropriate nursing
diagnosis for the patient?) towards (4)
individualized, dynamic and continuing
interpersonal care (different patients,
different problems and approach;
collaborative management is needed: both
patient and client dapat) (5) for client’s
changing responses and needs (evaluate if
there’s improvement or if it worsens)
- Client-centered ADPIE (garbage in, garbage
out)
- Universal: can be applied to everyone - a
client or community; can be applied to all
cases or disease
- Critical thinking: in every phase of nursing
process
- Interpersonal: collaboration with patients
and other health professionals are needed
- Decision making: especially in the
implementing phase; choose the best action
towards the wellness and recovery of
patient
• Diagnosis (Steps)
- Second phase of nursing process
- Analyze and interpret the data gathered
(cluster them, what are the problems and
diagnosis?)
- Identify the health problems (Ano yung
problem? May signs of bleeding or infection
ba yung patient?)
- Identify health risks (patient may have no
actual problem but can have risk factors)
- Identify strengths (patients have no problem
but has strength; when they are step closer
towards high level of wellness)
• Diagnosing vs Diagnosis
a. Diagnosing
- Broad term relating to reasoning
process
- Process of critical thinking
b. Diagnosis
- Statement or conclusion from a
nurse or doctor about a nature of a
certain phenomena
- Problem seen in the patient
• Case Scenario
“A 65-year-old male patient admitted to Medical
Ward with a chief complaint of difficulty of
breathing”
▪ It is the nurse’s obligation to assess the patient
comprehensively
▪ Possible na sakit/Hypothesis/Judgement:
- Asthma
- Pneumonia
- Lung cancer
- Chronic Obstructive pulmonary disease
- Anything related to respiratory and
cardiovascular system
▪ Upon assessing the patient:
a. Skin: has bluish skin discoloration -
Cyanosis
b. Behavior: With cough
c. Respiratory Rate: 25 cpm; Tachypnea
- Normal RR: 12-20 cpm only
d. Auscultate thorax: Wheezing sounds
▪ Based on assessment: from the patient; don’t need to memorize but
a. Medical Diagnosis: Asthma be familiarized)
b. Nursing Diagnosis: Ineffective Breathing 1. Exchanging
Pattern related to spasm of the bronchial - Nursing diagnosis about the
tubes in response to inhaled irritants as physiological changes
evidence by difficulty of breathing happening in the body
- Ex: breathing (airway),
• Nursing Diagnosis circulation, metabolism,
- A statement of nursing judgement elimination; case analysis
- Nurses cannot diagnose and treat diseases kanina, high blood pressure
and illnesses but can prevent them 2. Communicating
- Nurses can make independent nursing - Includes only one nursing
actions in order to alleviate the condition of diagnosis which is the
the patient impaired verbal
- Focuses on the responses to actual or communication
potential health problems or life processes - Ex.: Patient with stroke have
(not only physiologic but also spiritual and difficulty in speech
psychological aspects.) 3. Relating
- Changes as the client’s response changes - Relating to people
- Identifies situations in which the nurse is - Ex.: Patient is always
qualified to intervene isolated, impaired social
interactions, ineffective
• Medical Diagnosis sexual patterns (with partner)
- A condition that only a physician can treat 4. Valuing
- Disease process - Spiritual aspect of patient
- Pathologic condition of the patient - Ex.: Spiritual distress, risk for
- Focuses on the illness, injury, or disease spiritual distress
process 5. Choosing
- Remains constant until it is cured (ex.: Yung - Coping mechanism and
asthma nandiyan pa rin kahit mawala na strategy of the patient
yung breathing problems) - Ex.: Nakapagcope ba siya o
- Identifies conditions the healthcare hindi? Nasa stages of denial
practitioner is qualified to treat pa rin ba siya?
6. Moving
• NANDA Book - Mobility and movement
- North American Nursing Diagnosis - Ex.: Impaired physical
Association mobility, impaired walking,
- Reference tool during nursing duty activity intolerance (di
- To know the appropriate diagnosis for the matolerate ng patients yung
patients paggawa ng ADL)
- Healthcare associations set the taxonomy 7. Perceiving
(classifications and categories of different - Self-perception of the patient
nursing diagnosis terminology) - Ex.: Patient has breast
- Includes the nursing diagnosis cancer, undergo ng
- A diagnostic system is organized around 9 Mastectomy (removal of
human response patterns: (Actually, there breast). She is problematic
are more than 170 nursing diagnoses to na nawala yung kanyang
choose from base on the data gathered isang breast since may
disturbed body image siya.
 8. Knowing
- Patient’s knowledge 3. Relating
- Ex.: Patient doesn’t know - Impaired social interactions
what medications to take and - social isolation
the right diet, knowledge - risk for loneliness
deficiency - ineffective role performance
9. Feeling - deficient parenting
- Pain or grieving process of - risk for deficient parenting
patient - risk for impaired parent/infant/child
- Among all the vital signs, the - attachment/sexual dysfunction
more subjective feeling is the - interrupted family processes
pain - caregiver role strain
- Ex.: Acute pain, chronic pain - risk for caregiver role strain
- dysfunctional family processes
• Examples of Nursing Diagnosis from NANDA - alcoholism parental role conflict
1. Exchanging - ineffective sexuality patterns
- Imbalanced nutrition: more than body
requirements 4. Valuing
- Imbalanced nutrition less than body - Spiritual distress
requirements - risk of spiritual distress
- Risk for imbalanced nutrition: more than - readiness for enhanced spiritual well-being
body requirements
- Risk for infection 5. Choosing
- Risk for altered body temperature - Ineffective coping
- hypothermia - impaired adjustment
- hyperthermia - defensive coping
- ineffective thermoregulation - ineffective denial
- autonomic dysreflexia - disabled family coping
- risk for autonomic dysreflexia - readiness for enhanced family coping
- Constipation - management
- perceived constipation - noncompliance
- diarrhea - decision conflict
- bowel incontinence - health seeking behavior
- risk for constipation
- impaired urinary elimination 6. Moving
- stress urinary incontinence - impaired physical mobility
- reflex urinary incontinence - fatigue
- urge urinary incontinence - sleep deprivation
- functional urinary incontinence - disturbed sleep pattern
- total urinary incontinence - impaired home maintenance
- risk for urge urinary incontinence - delayed surgical recovery
- urinary retention - adult failure to thrive
- ineffective tissue perfusion
- risk for fluid volume imbalance 7. Perceiving
- excess fluid volume - Disturb self-esteem
- etc - chronic low self esteem
- disturbed body image
2. Communicating - Hopelessness
- Impaired verbal communication - Powerlessness
 - unilateral neglect - ex.: Readiness for enhanced breastfeeding
- disturbed sensory perception (Paano ba magbreastfeeding? - patient has
- nestor personal identity eagerness to learn because she knows its benefits)
4. Possible Diagnosis
8. Knowing - Evidence about a health problem is incomplete or
- deficient knowledge unclear.
- impaired memory - ex.: Possible social isolation (Patient is elderly
- disturbed thought processes and widowed, mag-isa lang siya and no visitors na
- acute confusion pumupunta sa room; pedeng related to unknown
- impaired environmental interpretation cause or aging)
syndrome
5. Syndrome Diagnosis
9. Feeling - A diagnosis that is associated with a cluster of
- acute pain other diagnoses
- chronic pain - ex.: Risk for disuse syndrome (isa sa nursing
- nausea diagnosis na kapag nilagay mo ang dami nang
- dysfunctional grieving papasok na nursing diagnosis na under niya)
- ex.:Disuse: di na nagagamit ng katawan kapag
• Types of Nursing Diagnosis palaging nakahiga or immobility, can result to
1. Actual Diagnosis impaired physical mobility, risk for impaired skin
- Client problem that is present at the time of the integrity, constipation)
nursing assessment - pinakakaunti lang compare sa 170 nursing
- kung ano yung nakita mo sa pasyente diagnosis
- health status of patient
- ex.: ineffective breathing pattern, anxiety

2. Risk Diagnosis
- A problem does not exist, but the presence of risk
factors indicates that the problem is likely to
develop.
- Has no signs and symptoms
- ex.: Patient has normal vital signs but is an
elderly, bedriden, and has limited movement. He is
at risk for impaired skin integrity because he might
have pressure ulcers or bed sores later on.
- ex.: Patient has no problem but undergoes
chemotherapy. He has a low immune system and
high risk for infection.

* Prioritize first the actual diagnosis than the risk

diagnosis

3. Wellness Diagnosis
- Describes human responses to levels of wellness
in an individual, family, or community that have a
readiness for enhancement.
- health promotion
TYPES OF DIAGNOSIS
3 STEPS OF DIAGNOSTIC PROCESS
ACTUAL DIAGNOSIS- present at time of
assessment 1. Analyzing data
RISK DIAGNOSIS- risk factors present - compare data against standards
WELLNESS DIAGNOSIS- human response to - cluster cues
wellness - data clustering- or grouping of cues is a process
POSSIBLE DIAGNOSIS- not enough evidence of determining the relatedness of facts and
SYNDROME DIAGNOSIS- cluster of diagnosis determining whether any patterns are present,
whether the data represent isolated incidents , and
COMPONENTS OF A NURSING DIAGNOSIS whether the data is significant
1. Problem & Definition 2. Identifying health problems, risk and
- also known as “Diagnostic Label” strengths
- it describes the client’s health problem or - determining problems and risks
response for which nursing theraphy is given. - determining strengths
- Qualifiers- are words that have been added to 3. Formulating diagnostic statements
some NANDA labels to give additionla meaning to - one-part statement
the diagnostic treatment Ex. Wellness nursing diagnosis
Ex. ( readiness for enhanced parenting)
⚫ Deficient Syndrome nursing diagnosis
⚫ Impaired (risk for disuse syndrome)
⚫ Decreased - basic- two parts statements
⚫ Ineffective A. Problem (P) - statement of the client’s
⚫ Compromised response (NANDA label)
2. Etiology B. Etiology (E)- factors contributing to or
- also known as “Related factors” or Risk Factors probable causes of the responses
3.Defining Characteristics basic three parts statements
- these are the cluster of signs and symptoms that A. Problem (P)- statement of the client’s response
indicate the presence of a particular diagnostic (NANDA) label
label. B. Etiology( E)- factors contributing to or probable
causes of the responses
Diagnosis and definition C. Signs & Symptoms- defining characteristics
- activity tolerance manifested by the client
(insufficient physiological or psychological energy
to endure or complete required or desired daily VARIATIONS OF BASIC FORMAT
activities) - writing unknown etiology when the defining
Related Factors characteristic are present but the nurse does not
- bedrest or immobility know the cause or contributing factors
- generalized weakness - using the phrase complex factors when there are
- sedentary lifestyle too many etiologic factors or when they are too
Defining Characteristics complex to state in a brief phrase.
- verbal report of fatigue or weakness - using the word possible to describe either the
- abnormal heart rate or blood pressure problem or etiology
- using secondary to divide the etiology into two
THE DIAGNOSTIC PROCESS parts, thereby making the statement more
CRITICAL THINKING descriptive and useful
ANALYSIS - adding a second part to the general response
SYNTHESIS or NANDA label to make it more precise.

GUIDELINES FOR WRITING A NURSING
DIAGNOSTIC STATEMENT
1. State in terms of a problem, not a need
2. Word the statement so that it is legally advisable.
3. Use non judgemental statements
4. Make sure that both elements of the statement
do not say the same thing
5. Be sure that cause and effect are correctly stated
6. Word the diagnosis specifically and precisely to
provide direction for planning nursing intervention
7. Use nursing terminology rather then medical
terminology to describe the client’s response
8. Use nursing terminology rather than medical
terminology to describe the probable cause of the
client’s response.
AVOIDING ERRORS IN DIAGNOSTIC
REASONING
⚫ Verify
⚫ Build a good knowledge base & acquire clinical
experience
⚫ Have a working knowledge of what is normal
⚫ Consult resources
⚫ Base diagnoses on patterns
⚫ Improve critical thinking skills
PLANNING
- the nurse refers to the client’s assessment data
and diagnostic statements for direction in
formulating client goals and designing the nursing
interventions required to prevent , reduce, or
eliminate the clients health problems.
Nursing interventions
- any treatment, base upon clinical judgement and
knowledge, that a nurse performs to enhance
patient outcomes.
TYPES OF PLANNING
1. Initial Planning
- the nurse who performs the admission
assessment usually develops the initial
comprehensive plan of care
2. Ongoing Planning
- it is done by all nurses who work with the client
3. Discharge Planning
- the process of anticipating and planning for needs
after discharge
DEVELOPING NURSING CARE PLANS
Informal nursing care plan
- it is a strategy for action the exists in the nurse’s
mind
Formal nursing care plan
- it is a written or computerized guide that organizes
information about the clients care
Standardized care plan
- it is a formal plan that specifies the nursing care
groups of clients with common needs
Individualized care plan
- it is tailored to meet the unique needs of a specific
client- needs that are not addressed by the
standardized plan
THE COMPLETE PLAN OF CARE FOR A CLIENT
IS MADE UP OF SEVERAL DIFFERENT
DOCUMENTS THAT:
1. Describe the routine care needed to meet basic
needs.
2. Address the client’s nursing diagnosis and
collaborative problems
3. Specify nursing responsibilities in carrying out
the medical plan of care
STANDARDIZED APPROACHES TO CARE
PLANNING
Standards of care
- describing nursing actions for client with similar
medical conditions rather than individuals, and they
describe achievable rather than ideal nursing care
Standardized care plans
- these are predeveloped guides for the nursing
care of a client who has a need that arises
frequently in the agency
Protocols
-these are predeveloped to indicate the actions
commonly required for a particular group of clients.
Policies and procedures
- these are developed to govern the handling of
frequently occurring situations.
Standing order
- it is a written document about policies, rules,
regulations, or orders regarding client care.
 2. COMPUTERIZED CARE PLANS
FORMATS FOR NURSING CARE PLANS - The computer can generate both standardized
and individualized care plans. Nurses access the
⚫ Problem/nursing diagnosis client’s stored care plan from a centrally located
⚫ Goals/desired outcomes terminal at the nurse’s station or from terminals in
⚫ Nursing interventions client rooms.
⚫ Evaluation
3. MULTIDISCIPLINARY CARE PLANS
- it is a standardized plan that outlines the care
FOUR-COLUMN PLAN required for clients with common, predictable-
usually medical conditions.
⚫ Nursing Diagnosis - such plans, also referred to as collaborative care
⚫ Goals/ Desired outcomes/ Planning plans and critical pathways, sequence the care that
⚫ Nursing Interventions must be given on each day during the projected
⚫ Evaluation length of stay for the specific type of condition.

GUIDELINES FOR WRITING NURSING CARE

THREE COLUMN PLAN PLANS

⚫ Nursing Diagnosis ⚫ Date and sign the plan

⚫ Goals/Desired outcomes/ Planning/ Evaluation ⚫ Use category headings
⚫ Nursing Interventions ⚫ Use standardized/approved medical or english
symbols and key words rather than complete
sentences to communicate your ideas unless
FIVE COLUMN PLAN agency policy dictates otherwise.
⚫ Be specific
⚫ Assessment ⚫ Refer to procedure books or other sources of
⚫ Nursing Diagnosis information rather than including all steps on a
⚫ Goals/Desired outcomes/ Planning written plan.
⚫ Nursing Interventions ⚫ Tailor the plan to the unique characteristic of
⚫ Evaluation the client by ensuring that the client’s choices,
such as preferences about the times of care
and the method used, are included.
1. STUDENT CARE PLANS ⚫ Ensure that the nursing plan incorporates
preventive and health maintenance aspects as
⚫ Assessment well as restorative ones
⚫ Nursing Diagnosis ⚫ Ensure that the plan contains ongoing
⚫ Goals/ Desired outcomes/ Planning assessment of the client.
⚫ Nursing interventions ⚫ Include collaborative and coordination activities
⚫ Rationale in plan.
⚫ Evaluation ⚫ Include plans for the client’s discharge and
home care needs.
CONCEPT MAP
- it is a visual tool in which ideas or data are
enclosed in circles or boxes of some shape and
relationships between these are indicated by
connecting lines or arrows.
THE PLANNING PROCESS

⚫ Setting priorities
⚫ Establishing client goals/desired outcomes
⚫ Selecting nursing interventions and activities
⚫ Writing individualized nursing interventions on
care plans.

1. Setting Priorities
Priority setting
- it is a process of establishing a preferential
sequence for addressing nursing diagnosis and
interventions
High Priority
- life-threatening problems
Medium priority
- health-threatening problems
Low priority
- arises form normal developmental needs or that
requires only minimal nursing support

FACTORS WHEN ASSIGNING PRIORITIES

⚫ Client’s health values and beliefs
⚫ Client’s priorities
⚫ Resources available to the nurse and client
⚫ Urgency of the health problem
⚫ Medical treatment plan

ASSIGNING PRIORITIES TO NURSING

DIAGNOSES
- Ineffective Airway Clearance related to viscous
secretions as evidenced by productive cough

ESTABLISHING CLIENT GOALS/ DESIRED

OUTCOMES
- Observable client responses, what the nurse
hopes to achieve by implementing the nursing
interventions.
GOAL- BROAD
DESIRED OUTCOME- SPECIFIC