Nursing Process: Nursing

Diagnosis
George Ann Daniels, MS, RN

Definition of Nursing
Diagnosis

A clinical judgment about

individual, family, or community
responses to actual or potential
health/life processes. Nursing
diagnoses provide the basis for
selection of nursing interventions
to achieve outcomes for which the
nurse is accountable

How do you make a NDX?

Analyze collected data

Identify the clients strengths
Identify the clients normal
functional level and indicators of
actual or potential dysfunction
Formulate a diagnostic statement
in relations to this synthesis

Benefits of Nursing
Diagnosis

Gives nurses a common language

Promotes identification of
appropriate expected outcomes
Provides acuity information
Can create a standard for nursing
practice
Provide a quality improvement base

NDX VS Medical Diagnosis

Nursing Diagnosis
Made by the nurse
Describes clients
response
Responses vary
between individuals
Changes as client
responses change
Nurse orders
interventions

Medical Diagnosis
Made by a physician
Refers to the disease
process
Somewhat uniform
between clients
Remains same during
disease process
Physician orders
interventions

Steps

Identify patterns

Review data and look for cues

Cluster cues (signs and symptoms)
Synthesizing the cue clusters
Three questions to ask self

What are my concerns about this client

Can I or am I doing something obout it
Can the overall risk be decreased by
nursing interventions

Synthesis the data

Validate the diagnosis

Look at all data as a whole

Test for a fit
Refer to the NANDA DX and defining
characteristics

Formulate the nursing diagnosis

statement using nursing language

NANDA

Types of Nursing Diagnosis

Actual (3 parts)

Risk (2 parts)

Can be documented from assessment

A clinical judgment that the client is more
vulnerable to develop this problem than
others in the same or similar situation

Wellness (2 parts)

Potential for enhancement of current well

state

Components of Nursing
Diagnosis

Diagnostic Label

Etiology

P
Qualifier
E

Defining characteristics

Diagnostic Label

Problem

Name of the nursing diagnosis as

listed in the taxonomy
Describes the problem using as few
words as possible

Qualifier

Used to give additional meaning to

the NDX

Problems to avoid in writing this part

DO NOT use the medical diagnosis

Must be a problem the nurse and/or client
can change to do something about
Relating the problem to an unchangeable
situation

Dont confuse the etiology with the

problem
Focus on the human responses to the
problem
Avoid the use of one piece of
assessment data as a NDX (EDEMA)

Be specific
Dont combine NDX
Dont relate one NDX to another. There
is a different related to factor if this is a
valid NDX
Nursing interventions should not be
included in the NDX
Keep your language non-judgmental
Dont make assumptions or statements
you cant prove with assessment data
Be sure your statement is legally
advisable

Etiology

This is the related to, R/T portion of

the diagnosis.
What caused the client to have the
problem listed?
Problems to avoid in writing this part

DO NOT use the medical diagnosis

Must be a problem the nurse and/or
client can change to do something about

Defining Characteristics

These are the major and minor

clinical cues that validate the
presents of an actual nursing
diagnosis
Must have at least the major defining
characteristics as listed in the
taxonomy and minor characteristics
will help support the NDX

Measurement criteria for

ANA
Standard II: Diagnosis: The nurse

analyzes the assessment data in

determining diagnosis.

Diagnoses are derived from assessment data

Diagnoses are validated with the patient,
family, and HCP when possible and
appropriate
Diagnoses are documented in a manner that
facilitates the determination of expected
outcomes and plan of care