Nursing Process

Nursing Diagnosis

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 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.
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 MEDICAL DIAGNOSIS
 Medical diagnosis – the identification of a disease
condition based on a specific evaluation of physical signs
and symptoms, a patient’s medical history, and the
results of diagnostic tests and procedures.

 A medical diagnosis stays constant as the condition

remains

 Physicians are licensed to treat diseases and conditions

described in medical diagnostic statements

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 NURSING DIAGNOSIS
 Nursing diagnosis - is a clinical judgement concerning a
human response to health conditions / life processes, or
vulnerability for that response by an individual, family , or
community that a nurse is licensed and competent to
treat.

 A nursing diagnosis can be problem focused or a state of

health promotion or potential risk.

 Nursing diagnoses are ever changing on the basis of a

patient’s needs.

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 Diagnosis
 What is the problem? Once the assessment is
completed, the nurse will take all the gathered
information into consideration and diagnose the
patient’s condition and medical needs. This
involves a nurse making an educated judgment
about a potential or actual health problem with a
patient. More than one diagnoses are
sometimes made for a single patient.
 Purpose
• To identify the client's health care needs and to
prepare diagnostic statements
• Nursing diagnosis- is a statement on client's
potential or actual alteration of health status. It
uses critical thinking skills of analysis and
synthesis
• Uses PRS/ PES format
• P- problem
• R- related factors
• S- signs and symptoms
• P- problem
• E- etiology
• S- symptoms and signs

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 Activities during Diagnosing
 Organize cluster or group data
• Pallor, dyspnea, weakness, fatigue oxygenation prob
• RBC=4 M/cu.mm, hgb= 10g/dl,
 Compare data against standards. Standards are
accepted norms, measures or patterns for purposes
of comparison
• Standard color of the sclera is white, the standard color or
urine is amber
 Analyze data after comparing with standards
 Identifying gaps and inconsistencies in data
 Determine the client’s health problems, health risks,
and strength
 Formulate nursing diagnosis statement
 Types of Nursing Diagnoses
 NANDA-I (2014) nursing diagnoses include:
 Problem-focused – includes a related factor (etiological or
causative factor)
 Example: Acute pain related to trauma of surgical incision

 Risk – has risk factors: environmental, physiological,

psychological, genetic or chemical elements placing a person at
risk for a health problem
 Example: Risk for infection

 Health promotion – concerns a patient’s motivation and desire

to increase well being and actualize human potential
 Example: Readiness for Enhanced knowledge
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 Nursing diagnosis are classified as high- priority,
medium priority, and low priority
• High- priority nursing diagnosis are those that are
potentially life-threatening and require immediate action- Ex.
Impaired Gas exchange, ineffective breathing pattern, self
directed risk for violence
• Medium- priority nursing diagnosis- are those that could
result to unhealthy consequences, such as physical or
emotional impairment but are not life threatening- Ex.
Fatigue, activity intolerance, ineffective coping, dysfunctional
grieving
• Low- priority nursing diagnosis- involves problems that
usually can be resolved easily with minimal interventions and
are unlikely to cause significant dysfunction- Ex. Sensation of
hunger in a client who is on NPO, in preparation for a
diagnostic procedure; minimal pain on the third postoperative
day, relate to ambulation
 Problem Nursing Diagnosis

 A problem diagnosis (or also called actual

diagnosis) is a client problem that is present at
the time of the nursing assessment. These
diagnoses are based on the presence of
associated signs and symptoms. Examples:
Ineffective Breathing Pattern and Anxiety,
Acute Pain, and Impaired Skin Integrity.
 Risk Nursing Diagnosis

 A risk nursing diagnosis is a clinical judgment that a

problem does not exist, but the presence of risk
factors indicates that a problem is likely to develop
unless nurses intervene.
 For example, all people admitted to a hospital have
some possibility of acquiring an infection; however, a
client with diabetes or a compromised immune
system is at higher risk than others. Therefore, the
nurse would appropriately use the label
Risk for Infection to describe the client’s health
status.
 Wellness Diagnosis

 Wellness Diagnoses (or also called health

promotion diagnosis) describe human
responses to levels of wellness in an individual,
family or community that have a readiness for
enhancement.
 Examples of wellness diagnosis would be
Readiness for Enhanced Spiritual Well Being or
Readiness for Enhanced Family Coping.
 Syndrome Diagnosis

 A syndrome diagnosis is associated with a

cluster of problem or risk nursing diagnoses that
are predicted to present because of a certain
situation or event. Example is RapeTrauma
Syndrome.
 Possible Nursing Diagnosis

 Possible nursing diagnoses are statements

describing a suspected problem for which
additional data are needed to confirm or rule out
the suspected problem. A possible nursing
diagnosis also provides the nurse the ability to
communicate to other nurses that a diagnosis
may be present but additional data collection is
indicated to rule out or confirm the diagnosis.
 Examples include Possible Chronic Low Self-
Esteem, Possible Social Isolation.
 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.

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 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.

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 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.

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 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.

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 Formulating a Nursing
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
 Etiology
 Symptoms

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 Nurse: “Mr. Lawson you said you had some questions. Can you tell me what they
are?”
 Patient: “ Well the doctor told me that I would not be able to lift anything heavy for a
while, and I’m not sure if I understand, the way my incision looks, will I need to do
something to it?”
 Nurse: “Let’s start with your question about lifting. First of all what types of things do
you lift regularly at home?”
 Patient: “ Well, when our grandchildren visit, they do liked to be picked up. We have a
pet, but he jumps up on the chair with me. My wife does the grocery shopping, but I
come out to unload the car.”
 Nurse: “ Ok about your incision, yes you will need to care for it. Do you know the
signs of infection?”
 Patient: “ Not sure I do, but I guess it would hurt more. Is infection common?”
 Nurse: “ No, but you need to know the signs so, if something happens once you
return home, you can call your doctor quickly. Has your doctor talked about ways to
care for your incision?”
 Patient: “ No, he hasn’t mentioned anything about that yet.”
 Nurse: “ Ok, I’ll explain everything you need to know. Do you learn best by reading
information or listening to explanations?”
 Patient: “ I think I do ok with both”

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 How to Write Nursing Diagnosis?
 Nursing diagnostic statements describe the
health status of an individual and the factors that
have contributed to the status.
 Diagnostic statements can be one-part, two-
part, or three-part statements.
 One-Part Nursing Diagnosis Statement
 Wellness nursing diagnoses are written as one-part
statements because related factors are always the
same: motivated to achieve a higher level of wellness.
Syndrome diagnoses also have no related factors.
 Examples include:
• Readiness for Enhance Breastfeeding
• Readiness for Enhanced Coping 
• Rape Trauma Syndrome
 Two-Part Nursing Diagnosis Statement
 Risk and possible nursing diagnoses have two-part
statements: the first part is the diagnostic label and
the second is the validation for a risk nursing
diagnosis or the presence of risk factors. It’s not
possible to have a third part for risk or possible
diagnoses because signs and symptoms do not exist.
 Examples include:
• Risk for Infection related to compromised host defenses
• Risk for Injury related to abnormal blood profile
• Possible Social Isolation related to unknown etiology
 Three-part Nursing Diagnosis Statement
 An actual or problem nursing diagnosis have three-part
statements: diagnostic label, contributing factor
(“related to”), and signs and symptoms (“as evidenced
by”). Three-part nursing diagnosis statement is also
called the PES format which includes the Problem,
Etiology, and Signs and Symptoms.
 Examples include:
• Impaired Physical Mobility related to decreased muscle control
as evidenced by inability to control lower extremities.
• Acute Pain related to tissue ischemia as evidenced by
statement of “I feel severe pain on my chest!” 
 Quick Activity

Forgetting to Risk for falls

use call bell Cognitive
status
“I can’t give Right side
Self care
myself a weakness
deficit
bath”
Crying and Spiritual Death of
withdrawal distress spouse
Compromised
Low WBC Risk for
immune
count infection
system

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 PROBLEM, ETIOLOGY, SIGNS &
SYMPTOMS
 Risk for falls r/t cognitive status aeb forgetting to
use call bell
 Self-care deficit r/t right side weakness aeb
patient stating “ I can’t give myself a bath”
 Spiritual distress r/t death of spouse aeb crying
and withdrawal
 Risk for infection r/t compromised immune
system aeb low WBC count

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 2 parts: NANDA & risk factors

 Risk for aspiration r/t inability to swallow

 Risk for falls r/t right sided paralysis

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 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.

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 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.

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 Sources of Diagnostic Error

 Errors occur during:

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

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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.

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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.

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