Nursing Diagnosis2019-2020

Chapter 17
Nursing Diagnosis
Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Diagnosis
 Analyzing the data

 Identifying health problems, risks and strengths
 Formulating diagnostic statements
Copyright © 2017, Elsevier Inc. All Rights Reserved. 2

Nursing Diagnosis
 Provides the basis for selection of nursing

interventions to achieve outcomes for which the
nurse is accountable
 Used to determine the appropriate plan of care

History of Nursing Diagnosis
 First introduced in 1950.

 In 1953, Fry proposed the formulation of a
nursing diagnosis.
 In 1973, first national conference held.
 In 1980 and 1995, the American Nurses
Association (ANA) included diagnosis as a
separate activity in its publication Nursing: a
Social Policy Statement.
 In 1982, North American Nursing Diagnosis
Association (NANDA) was founded.
Comparison
Medical Diagnosis Nursing Diagnosis

Disease, illness, Definition A clinical judgment about
injury, or condition individual, family, or
validated bys signs community responses to
and symptoms and treat a health problem
medical diagnostic
studies
disease, pathology, Focus Individual/person
and medical
treatments/proced
ures

Comparison

Describes disease Characteristics Holistic; describes
or pathology; does physiological,
not consider the psychological, social,
broader range of interpersonal, and
human responses spiritual responses
Physicians Who Professional nurse
diagnose?
Actual or possible Problem Actual, potential or
status possible

Comparison

Carry out medical Purpose Treat or prevent the
prescriptions for problems; relieve the
treatment, monitor symptoms
for improvement
or worsening of the
condition
Myocardial Example of ineffective denial r/t
infarction diagnostic difficulty coping with
statement new diagnosis of “heart
attack”

Comparison

cardiac enzyme Example of waited more than 6
levels elevated, has data to hours before coming to
had severe chest support the hospital, minimizes
pain, elevated diagnosis symptoms, refuses pain
WBC, ECG & medications. States “I've
echocardiogram got to get back to work.
diagnostic of I can't stay in the
cardiac muscle hospital.” laughing,
ischemia joking, saying,”It's
nothing.”

Case Study
 John is a first semester nursing student who is

particularly interested in heart disease since his
father died of a heart attack at age 48. John
decided to go into nursing because of his
father’s death. He wanted to select a career that
improves people’s lives.
 John is studying the steps of the nursing
process. He knows this information will help him
care for cardiac patients in the future.

Types of Nursing Diagnoses
 NANDA-I (2014) nursing diagnoses include:

 Problem-focused
 Risk
 Health promotion

 Problem-focused- describes a clinical judgment

concerning an undesirable human response to a
health condition/life process that exists in an
individual, family, or community
A problem focused nursing diagnosis should have:

a. Defining characteristics
b. Related factor

a. Defining characteristics - are observation

assessment cues that support each problem-
focused diagnosis.
 The selection of a problem focused nursing
diagnosis indicates sufficient assessment data

to to establish nursing diagnosis
b. Related factor -is an etiological or causative
factor for the diagnosis, and allows you to
individualize a problem-focused nursing diagnosis
for a specific patient need
Scenario
Mr. Lawson is having discomfort from the

colectomy incision. He rated pain at 7 on z 10-
point rating scale and was grimacing. He guarded
the incisional area that was tender. Mr. lawson
was also hesitant to move actively in bed.

 problem focused- Acute pain ( based on self
report of pain, guarding behavior and grimacing
experession)
 related factor- related to trauma of surgical incision

9allowing nurses to focus interventions at measures
to relieve ncisional pain.
Nursing diagnosis- Acute pain related to (r/t)

incisional trauma
 Impaired bed mobility
 Impaired skin integrity

• Risk- is a clinical judgment concerning the

vulnerability of an individual, family, group, or
community for developing an undesirable human
response to health conditions/life processes.
• No defining characteristics and related factor.

Instead a risk diagnosis has risk factors. Risk
factors are the environmental, physiological,
psychological, genetic, or chemical elements that
place a person at risk for a health problem.
Case Study
 In Mr. lawson's case, presence of his incision,
the separation of an area between the stitches,
and being hospitalized and exposed to sources
of infecton pose risks for hospital acquired
wound infections.
The rsk factors are the diagnostic related factors

that help in planning preventive health care
measures.
 Risk for infection
 Risk for loneliness

 Health promotion- is a clinical judgment concerning

motivation and desire to increase well-being and
actualize human health potential.
• These responses are expressed by a readiness to enhance
specific health behaviors and can be used in any health
state.
• Health promotion diagnoses may apply to an individual,
family, group, or community.
• The diagnoses have only defining characteristics, although a
related factor may be used to improve understanding of the
diagnosis.
 The nurse analyzes the information about Mr.
lawson and identifies that the patient has limited
knowledge about infoection with postoperative
wound care and freely asks questions with the
desire to enhance learning
 His desire to ask question is a critical defining
characteristics that leadss the nurse to select
“readiness for enhanced knowledge” a health
promotion diagnosis

 Possible Nursing diagnosis
 Isa clinical judgment that a problem does
not exist, but the presence of risk factors
indicates that a client is more vulnerable
to develop the problem
• E.g. Possible social isolation related to
unknown etiology/cause
 Syndrome Nursing Diagnosis
 Isa diagnosis that is associated with a
cluster of other diagnoses that occur
together & are best addressed together &
through similar interventions.
• E.g. Bedridden clients – Risk for
disuse syndrome --- Impaired physical
mobility, risk for impaired tissue
integrity, risk for activity intolerance
Case Study (Cont.)
 John reviews the phases of the nursing

process, and attempts to put them in the
correct order.

Critical Thinking and the
Nursing Diagnostic Process
 The diagnostic process requires you to use
critical thinking.
 Helps to be thorough, comprehensive, and
accurate when identifying nursing diagnoses that
apply to your patients.
 The diagnostic reasoning process involves
using the assessment data gathered about a
patient to logically explain a clinical judgment
or a nursing diagnosis.

Critical Thinking and the
Nursing Diagnostic Process
 Use critical thinking to:

 Analyze data
 Verify problems with the client
 identify health problems, risks, and strengths
 Draw conclusions about the clients health status
 Prioritize the problems
 Formulate diagnostic elements
 Record the diagnostic statement

Data Clustering
 A data cluster is a set of cues, the signs or

symptoms gathered during assessment.
 Data clusters are compared with standards to
reach a conclusion about a patient’s response to
a health problem.
 Each clinical criterion is an objective or
subjective sign, symptom, or risk factor that,
when analyzed with other criteria, leads to a
diagnostic conclusion.

Case Study (Cont.)
 Because of John’s interest in cardiac nursing, he

is familiar with the clinical criteria for heart
disease. He is helping Beth, another
fundamentals student, understand them as well.
She tells him, “Hypertension, fatigue, preferring
fried foods, and high cholesterol are all clinical
criteria for heart disease, right?”
 John shakes his head. “Not quite,” he says.

Data Interpretation
 It is critical to select the correct diagnostic label

for a patient’s need.
 When comparing patterns, judge whether the
grouped signs and symptoms are expected for a
patient (e.g., consider current condition, history)
and whether they are within the range of healthy
responses.
 By isolating any defining characteristics not within
healthy norms, you can identify a specific problem.

Formulating a Nursing
Diagnosis Statement
 Identify the correct
diagnostic label with
associated defining
characteristics or risk
factors and a related
factor.
 A related factor allows
you to individualize a
nursing diagnosis for
a specific patient.

 An accurate nursing diagnostic statements
requires identification of:
a. Diagnostic label
b. Definition
c. Defining characteristics
d. Related factors
e. Risks factors

 An accurate nursing diagnostic statements
requires identification of:
a. Diagnostic label- is the name of the nursing
diagnosis as approved by NANDA (see box 17:2)
 describes the essence of a patient's response to
health conditions in a few words as possible.

 is a word or phrase that represents pattern of
related cues and describes a problem or

wellness response
b. Definition
c. Defining characteristics
d. Related factors
e. Risks factors
a. Diagnostic label- is the name of the nursing
diagnosis as approved by NANDA (see box 17:2)
 describes the essence of a patient's response to

health conditions in a few words as possible.
 is a word or phrase that represents pattern of
related cues and describes a problem or
wellness response
Example:
Disturbed body image
Readiness for enhanced nutrition
b. definition- describes the characteristics of the
human response identified and helps to select the
correct diagnosis
 explains the meaning of the label and
distinguishes it from similar nursing diagnosis
Example:
Sleep deprivation: Prolonged periods of time
without sleep
Disturbed sleep pattern: time limited disruption

of sleep amount and quality
c. Defining characteristics- are observation
assessment cues that support each problem-
focused diagnosis.
d. Related factors- are associated with a

patient's actual or potential response to a health
problem and can change by using specific nursing
interventions (see table 17:1)
 the r/t is not a cause and effect statement. It
indicates that the etiology contributes to or is

associated with the patient's diagnosis.

e. Risk Factors
 These are events, circumstances, or conditions that
increase the vulnerability of a person or group to a
health problem
 They can be environmental, physiological,
psychological, genetic, or chemical
• E.g.
 Ignoring the urge to defecate and being pregnant increase the
risk that a person will become constipated
– Risk for constipation r/t pregnancy and habitually ignoring the urge
to defecate
Diagnosis Statement (Cont.)
2 part nursing diagnosis= NANDA diagnostic label+
statement of related factor
Ex: Acute pain r/t trauma of incision
3 part nursing diagnosis=NANDA diagnostic label +

related factor+ defining caracteristics
Ex: Ineffective breathing pattern r/tNeuromuscular

impairment As evidenced by C-6 spinal cord injury, poor
chest expansion Copyright © 2017, Elsevier Inc. All Rights Reserved. 34
One part nursing diagnosis
 readiness for enhanced knowledge

Two – part Statement
Component Example
Ineffective breathing
Problem Statement
pattern
Link R/T (related to)
Neuromuscular
Etiology
impairment
Three – part Statement
Component Example
Problem Statement Ineffective breathing pattern
Link R/T (related to)
Etiology Neuromuscular impairment
Defining Characteristics (signs & As evidenced by C-6 spinal cord

symptoms) injury, poor chest expansion
Diagnosis Statement (Cont.)
 Most settings use a two-part format in labeling
health promotion and problem-focused nursing
diagnoses.
 Some agencies prefer a three-part nursing
diagnostic label:
 Problem (diagnostic label)
 Etiology (cause of the problem)
 Symptoms

Case Study (Cont.)
 John is trying to remember the four types of

nursing diagnoses. He knows this is something
Beth has mastered, so he asks her about it, “Are
the four types of nursing diagnosis actual, risk,
wellness, and disease prevention?”

Cultural Relevance of
Nursing Diagnoses
 Consider patients’ cultural diversity when
selecting a nursing diagnosis. Ask questions
such as:
 How has this health problem affected you and your
family?
 What do you believe will help or fix the problem?
 What worries you most about the problem?
 Which cultural practices are important to you?
 Cultural awareness and sensitivity improve your
accuracy in making nursing diagnoses.

Case Study (Cont.)
 After his study session with Beth, John has a

better handle on nursing diagnoses. He knows
that a ______________ diagnosis is applied to
vulnerable populations.

Concept Mapping
Nursing Diagnosis
 A concept map helps you critically think about a
patient’s diagnoses and how they relate to one
another.
 Helps organize and link data about a patient’s multiple
diagnoses in a logical way.
 Graphically represents the connections among
concepts that relate to a central subject.

Sources of Diagnostic Error
 Errors occur during:

 Data collection
 Interpretation and analysis of data
 Clustering
 Diagnostic statement

Sources of Diagnostic Error (Cont.)
1. Identify the patient’s response, not the medical

diagnosis.
2. Identify a NANDA-I diagnostic statement rather than
the symptom.
3. Identify a treatable cause or risk factor rather than a
clinical sign or chronic problem that is not treatable
through nursing intervention.
4. Identify the problem caused by the treatment or
diagnostic study rather than the treatment or study
itself.
5. Identify the patient response to the equipment rather
than the equipment itself.

Sources of Diagnostic Error (Cont.)
6. Identify the patient’s problems rather than your problems

with nursing care.
7. Identify the patient problem rather than the nursing
intervention.
8. Identify the patient problem rather than the goal of care.
9. Make professional rather than prejudicial judgments.
10. Avoid legally inadvisable statements.
11. Identify the problem and its cause to avoid a circular
statement.
12. Identify only one patient problem in the diagnostic
statement.

Quick Quiz!
1. Concept mapping is one way to:

A. connect concepts to a central subject.
B. relate ideas to patient health problems.
C. challenge a nurse’s thinking about patient
needs and problems.
D. graphically display ideas by organizing data.
E. all of the above.

Quick Quiz!
2. For a student to avoid a data collection error, the

student should:
A. assess the patient and, if unsure of the finding, ask a
faculty member to assess the patient.
B. review his or her own comfort level and competency
with assessment skills.
C. ask another student to perform the assessment.
D. consider whether the diagnosis should be actual,
potential, or risk.

Documentation and Informatics
 Once you identify a patient’s nursing diagnoses,

enter them either on the written plan of care or in
the electronic health information record (EHR) of
the agency.
 Computer helps organize data into clusters
 Enhances ability to select accurate diagnoses
 When initiating an original care plan, place the
highest-priority nursing diagnosis first.

Nursing Diagnosis:
Application to Care Planning
 By learning to make accurate nursing
diagnoses, your care plan will help communicate
the patient’s health care problems to other
professionals.
 A nursing diagnosis will ensure that you select
relevant and appropriate nursing interventions.

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Chapter 17

Copyright © 2017, Elsevier Inc. All Rights Reserved.

 Analyzing the data

Copyright © 2017, Elsevier Inc. All Rights Reserved. 2

 Provides the basis for selection of nursing

 Used to determine the appropriate plan of care

Copyright © 2017, Elsevier Inc. All Rights Reserved. 3

 First introduced in 1950.

Medical Diagnosis Nursing Diagnosis

Copyright © 2017, Elsevier Inc. All Rights Reserved. 5

Medical Diagnosis Nursing Diagnosis

Copyright © 2017, Elsevier Inc. All Rights Reserved. 6

Medical Diagnosis Nursing Diagnosis

Copyright © 2017, Elsevier Inc. All Rights Reserved. 7

Medical Diagnosis Nursing Diagnosis

Copyright © 2017, Elsevier Inc. All Rights Reserved. 8

 John is a first semester nursing student who is

Copyright © 2017, Elsevier Inc. All Rights Reserved. 9

 NANDA-I (2014) nursing diagnoses include:

Copyright © 2017, Elsevier Inc. All Rights Reserved. 10

 Problem-focused- describes a clinical judgment

A problem focused nursing diagnosis should have:

Copyright © 2017, Elsevier Inc. All Rights Reserved. 11

a. Defining characteristics - are observation

diagnosis indicates sufficient assessment data

Mr. Lawson is having discomfort from the

Copyright © 2017, Elsevier Inc. All Rights Reserved. 13

 related factor- related to trauma of surgical incision

Nursing diagnosis- Acute pain related to (r/t)

 Impaired skin integrity

Copyright © 2017, Elsevier Inc. All Rights Reserved. 14

• Risk- is a clinical judgment concerning the

• No defining characteristics and related factor.

The rsk factors are the diagnostic related factors

 Risk for loneliness

Copyright © 2017, Elsevier Inc. All Rights Reserved. 16

 Health promotion- is a clinical judgment concerning

Copyright © 2017, Elsevier Inc. All Rights Reserved. 18

 John reviews the phases of the nursing

Copyright © 2017, Elsevier Inc. All Rights Reserved. 21

Copyright © 2017, Elsevier Inc. All Rights Reserved. 22

 Use critical thinking to:

Copyright © 2017, Elsevier Inc. All Rights Reserved. 23

 A data cluster is a set of cues, the signs or

Copyright © 2017, Elsevier Inc. All Rights Reserved. 24

 Because of John’s interest in cardiac nursing, he

Copyright © 2017, Elsevier Inc. All Rights Reserved. 25

 It is critical to select the correct diagnostic label

Copyright © 2017, Elsevier Inc. All Rights Reserved. 26

Copyright © 2017, Elsevier Inc. All Rights Reserved. 27

Copyright © 2017, Elsevier Inc. All Rights Reserved. 28

health conditions in a few words as possible.

related cues and describes a problem or

 describes the essence of a patient's response to

distinguishes it from similar nursing diagnosis

Disturbed sleep pattern: time limited disruption

d. Related factors- are associated with a

indicates that the etiology contributes to or is