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Diagnosing

The pivotal second phase of the nursing process.

Mural interprets assessment data, identifies clients strengths and health

problems and formulates diagnosis statements.

Diagnosis

Clinical judgments about the clients response to actual or potential problem.

Purposes of Nursing Diagnosis

Provides for the basis for determination a plan of care to achieve the desired

outcome of the patients status.

NANDA (North American Nursing Diagnosis Association (1973)

To define, refine and promote taxonomy of nursing diagnostic terminology of

general use to professional nurses.

NANDA includes:

o Staff nurses

o Clinical specialists

o Faculty

o

Directors of Nursing

o Deans

o Theorists

o Researchers

150 Nursing diagnosis

TYPES OF NURSING DIAGNOSIS

1. ACTUAL DIAGNOSIS

o A client problem that is present at the time of the nursing assessment

Ex. Ineffective breathing pattern related to pain.

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Ineffective breathing pattern related to sticky phlegm along

trachea bronchial tree.

2. RISK NURSING DIAGNOSIS

o A clinical judgment that a problem does not exist, but presence of Risk

Factors indicates that a problem is likely to develop unless nurses

intervene.

Ex. Risk for infection related to surgery.

3. WELLNESS DIAGNOSIS

o Describe humans responses to levels of wellness in an individual,

family or community that have a readiness for enhancement.

Ex. Readiness for enhanced family coping related to adequate

information from family members.

4. POSSIBLES NURSING DIAGNONSIS

o One in which evidence about health problem is incomplete or unclear.

Ex. Possible social isolation related to unknown etiology.

5. SYNDROME DIAGNOSIS

o A diagnosis that is associated with a cluster of other diagnosis. (Long

term problem)

Ex. Risk for disuse syndrome related to lack of motor skills.

Components of NANDA Nursing Diagnosis

1. Problem and its definition

Statement or diagnosis label

Describes the clients health problem

Purpose

Direct the formation of clients goals and desired outcomes

o Ex: Deficient knowledge (Medication)

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o Factors contributing to or probable causes of the responses

2. Basic three-part statements (PES)

a. Problems

b. Etiology

c. Signs and symptoms

o Defining characteristics manifested by the client.

o Ex: Low self esteem related to rejection by husband as

manifested (a m b) hypersensitivity to criticism.

o Impaired urinary related to urinary tract infection as evidence

by (EB)

3. One-part statement for wellness diagnoses and syndrome

a. Diagnosis, consist of NANDA LABEL only, no etiology.

o Ex: Rape-Trauma Syndrome

Table 3-3 Examples of Nursing Diagnoses written as two and Three part

statements

Two-part statements Three-part statements

Toileting Self-care Deficit R/TNeuro-Muscular impairment

Impaired Swallowing R/Tmechanical obstruction

Impaired Urinary EliminationR/T urinary tract infection.

Impaired Memory R/T fluid andelectrolyte imbalance.

Impaired Home MaintenanceR/T individual /family member disease orinjury.

Toileting Self-care Deficit R/Tneuromuscular impairment AEB paralysisof the right side of the body

Impaired Swallowing R/T mechanicalobstruction AEB tracheotomy tube.

Impaired Urinary Elimination R/T urinarytract infection AEB inability to recallrecent or past events.

Impaired Memory R/T fluid andelectrolyte imbalanced AEB inability torecall recent or past events.

Impaired Home Maintenanceindividual/ family member disease orinjury AEB repeated lice infections.

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Variations of Basic Formats

1. Writing unknown etiology- The defining characteristics on signs and symptoms present but the

etiology or cause is unknown.- Ex. Non-compliance (Medication Regimen) related to unknown etiology

2. Using the phrase complex factors- When there are too many etiology factors or causes.- Ex: Chronic low-esteem related to complex factors

3. Using the word possible to described either problem or etiology. When nursebelieves more data are needed.

- Possible low self-esteem related to loss of job and rejection by family.4. Using secondary to divide the etiology into two parts, thereby making the

statement more descriptive and useful.- Secondary to is often pathophysiologic or disease process- Ex: Risk for Impaired skin integrity related to decrease peripheral

circulation secondary to diabetes.5. Adding secondary part the general response or NANDA LABEL to make it

more precise.- Ex: Impaired skin integrity (left lateral ankle) related to decreased

peripheral circulation

Collaborative Problems (Multi disciplinary problem)

- Problems begin with diagnostic label Potential Complication (P.C.)- Nurses include the diagnostic statement both possible complication

they are monitoring and the disease or treatment that is present toproduce it.

Ex: Potential complication of head injury: Increased intracranialpressure.

- Group of complications associated with a disease or pathology.

Ex: Potential complication of pregnancy-induced hypertension:seizures, fatal distress, pulmonary edena, hepatic/renal failure,premature labor CHS hemorrhage.

Table 17-3 Collaborative ProblemsDisease/ Situation

Potential

Complication ofChildren

Potentialcomplication ofdiuretic therapy

Complication

Hemorrhage

Arrhythmia

Related to

Related to

Related to

Etiology

Uterine atony

Retained placentalfragmentsBladder distentionLow serumpotassium

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