Name : Ardaninggar K.R.N.A.W.

NIM : 01.2.17.00594

Course : English

RESUME “NURSING DIAGNOSIS COMPONENT”

1. Nursing diagnosis is a clinical judgement about individual, family, or

community responses to actual or potential health problems/ life process. A
nursing diagnosis provides the basis for selection of nursing interventions to
achieve outcome for which the nurse’s accountable.
2. Based on SDKI and PPNI, nursing diagnosis can be divided into 5 category.
There are is physiology, psychology, behavior, relations, and environment.
And 14 sub category there are is respiraton, circulation, nutrition & liquid,
elimination, activity & rest, neurosensory, pain & comfort, ego identity, grow
& development, self hygiene, education & learning, social interaction, safety
& protection.
3. Characteristic of nursing diagnosis is :
a. It states clear and concisehealth problem
b. It derived from existing evidences about the client
c. It is potentially amenable to nursing therapy
d. It is the basis for planning and carrying out nursing care
4. Nursing diagnosis can be divided into 2 type, there are is negative and
positive. Negative nursing diagnosis can be divided into 2 type, there are is
actual (sign/symptom, major and minor), and risk (risk factor). Positive can be
divided into health promotion (sign/symptom, major and minor).
5. Actual nursing diagnosis : a clinical judgement about human experience/
responses to health conditions/ life processes that exist in an individual,
family or community. Actual client problem present at the time of assessment.
It is based on the presence of sign and symptoms. E.g: Ineffective breating
pattern, Disturbed sleep pattern.
6. Risk nursing diagnosis : a clinical judgementthat a problem doesn’t exist but
the presence of risk factors indicates that a problem is likely to develop unless
nurses intervene. No subjective or objective cues. E.g : A client with DM or
compromised immune system is at high risk than others.
a. Risk for infection
b. Risk for injury
7. Health promotion nursing diagnosis : describes human responses to level of
wellness in an individual, family, or community that have a readiness for
 enhancement. Clinical judgement about a person’s, families or communities
motivation and desire to increase well being. E.g: Readiness for enhanced
family coping, Readiness for enhanced self esteem.
8. Component of nursing diagnosis is :
a. Problem and it’s definition
b. The etiology
c. Defining character
9. Problem (diagnostic label)/definition : the problem statement describes the
client health. Problem or response for which nursing therapy is given. The
diagnostic label should be specific.
10. Etiology (Related Factors or Risk Factor) : Identifies one or more probable
cause of the health problem, gives directions to the required nursing therapy.
Enables the nurses to individualized client care. E.g problem : constipation,
etiology : long term laxative use, inactivity and insufficient fluid intake.
11. Defining characteristic : the cluster of signs and symptoms that indicate the
presence of a particular diagnostic label. Can be divided into :
a. Actual diagnosis : client signs and symptoms
b. Risk diagnosis : no subjective signs are present
12. Formulating diagnostic statement :
a. Basic two part statement :
1) Problem statement of the client response
2) Etiology factors contributing to or probable causes of the responses
‘related to’ phrase implies a relationship.
E.g : constipation related to insufficient fluid intake, pain related to
presence of surgical incision.
b. Basic three part statement :
1) Also calles PES (Problem, Etiology, Signs and symptoms) format.
2) Actual nursing diagnoses can be documented by using the three part
statement.
3) Not used for risk diagnosis
E.g : a.) Pain r/tsurgical incision as evidenced byverbalization
b.) Hypertermia r/tunderlying infectious process as evidenced by
temperature 100 F.
13. Errors in diagnostic reasoning :
a. Verify
b. Build a very good knowledge base and acquire clinical expertise
c. Have a working knowledgeof what is normal
d. Consult resources
e. Base diagnosis on pattern that is, on behaviour over time – rather than on
an isolated incident
f. Improving critical thinking skills

NURSING DIAGNOSIS VS MEDICAL DIAGNOSIS

NURSING DIAGNOSIS MEDICAL DIAGNOSIS

Care focused
Identifies risk and problems of the
patient
Focused on the signs and symptoms
on the patient and his/her care givers
Focused on the person and their
physiological / psychologic all
responses to illness
Eg : Ineffective denial related to
difficulty coping with new diagnosis
of “heart attack”
Etiology focused
Identifies as nearly possible the
specific clinical entity that is causing
illness
The medical diagnosis specify the
pathology
Focuses on illness
Eg : Myocardial infarction