NURSING DIAGNOSIS

DEFINITION:
Nursing diagnosis is a statement of the high risk or actual problems in the patient’s
health status that the nurse is licensed and competent to treat.
There are three major components of Nursing Diagnosis:
1-Analysis and interpretation of the data by:
*Validation of data
*Cluster of data
2-indentification of the problem
3-Formulation of nursing diagnosis statement
Nursing Diagnosis is :
-derived from actual or potential problem
-derived from physiological, sociocultural, developmental and spiritual dimensions
of client
-focus to help the patient to achieve a maximal level of wellness
ADVANTAGES OF NURSING
DIAGNOSIS:
-For patient individualization of care ,appropriate selection of interventions,
establishment of goals.
-For nursing facilitates communication , documentation and continuity of care
among health care providers.
DIAGRAM OF NURSING
DIAGNOSIS :
This is the These are the
Patient’s Evidence
# priority Related to cause or signs or
problem d by
etiology symptoms

For example : pain related to open cholecystectomy (ablation of gall

bladder)evidenced by the pain scale 7 out of 10
PARTS OF NURSING
DIAGNOSIS:
oProblem
oModifiers
oRelated to
oEvidenced by
Problem
-Actual diagnosis supported by the nursing’s finding
-High risk has risk factors but does not have signs and symptoms
-Possible tentative additional data needed to confirm or rule out the health problem
Modifiers:
Impaired
Altered
Decreased
Ineffective
High risk
Related to:
Education about factors that contributes or causes the health problem
Indicate a relationship between the health problem and etiology
Must be modifiable by nursing intervention
Will be one of five categories :environmental, situational, phycological
Evidenced by or manifested by:
Signs and symptoms after nursing assessment that led to your nursing diagnosis.
For example:
Shortness of breath while walking
Constipations since 3 days
CASE STUDY 1

Joan Smith, 55 years of age, is a female patient who presents to the intensive care
unit with the diagnosis of intracranial hemorrhage. The patient stopped taking her
antihypertensives suddenly because of the cost of the medications and she recently
lost her job to outsourcing. The patient is slightly drowsy and complains of a
headache and blurred vision. The patient’s blood pressure is 220/130 mm Hg upon
presentation.
Mention 3 nursing diagnosis
CASE STUDY2
James Moorland, a 22-year-old fellow has suffered an accident 3 weeks ago and
bearing a compound fracture on his right femur. The patient was admitted in the
orthopedic department soon after the accident and 2 surgical operations were
conducted on his legs. The first operation was conducted for the internal fixation.

List 3 nursing diagnosis.

Thank you