NURSING

DIAGNOSIS
By: Neugene Rowan S. Cu, MAN, RN, RM, CNN,
CSSYB Faculty, FEU – Institute of Nursing
 Nursing Diagnosis
•  A clinical judgment about individual family
or community responses to health problem
processes
•  A complex decision-making process that
requires cognitive and intuitive skills,
experience and scientific knowledge
base.
 Nursing Diagnoses
•  Nurses are responsible for diagnosing
HUMAN RESPONSES to health related issues
and determine its effects on their daily living
 Nursing Care Plan
Cues Nursing Analysis Goals and Intervention Rationale Evaluation
Diagnosis Objective
Actual result
Subjective cues: (NANDA based) Explains the Short-term and Nursing Reason why a based
Objective cues: The condition seen nursing diagnosis. long term interventions to be particular on each
intervention
( Includes relevant based on cues (as Include reference/s (Specific, performed by the intervention will be given.
data such as vital stated in NANDA) May also present Measurable, student during her performed.
signs, laboratory Related to the underlying Attainable, duty To include
tests, observations) --- the immediate pathophysiology of Realistic and time- To include evidence why this
cause of the client’sthe patient’s bounded) evidence-based intervention must
condition condition. nursing practice be done.
Indicate references.

4
 Why Nursing Diagnoses?
1.  Contribute to the identity of nursing as a
profession
2.  Provide mechanism for professional
accountability
3.  Facilitate nurses’ autonomy in judgments about
client care
4.  Contribute to the knowledge
base of nursing as a science
 Why Nursing Diagnoses?
5.  Can be used as “key conceptual criteria
around which standards are developed”
6.  Used for communication of professional
judgment
7.  Contribute to continuity of care
8.  Demonstrate effectiveness of quality care
 Why Nursing Diagnoses?
9.  Promote collaboration among members of the
health care team
10.  Provide mechanism for costing out
nursing services
11.  Provide basis for generating computerized NCP
12.  Provide basis for intershift reporting
13.  Use as basis for quality assurance programs
 Nursing Diagnosis
•  Includes two phases: analysis and synthesis
–  Analysis is the categorization of the data
gathered and identification of gaps
–  Synthesis is determination of patterns, norms,
theories, models, health concerns and
delineation of relationships unique to the
patient
 Medical Diagnosis vs. Nursing Diagnosis

Medical Diagnosis Nursing Diagnosis

•  Focuses on illness, injury •  Focuses on RESPONSES to
or disease process ACTUAL or potential
health problems or life
processes
 Medical Diagnosis vs. Nursing Diagnosis

Medical Diagnosis Nursing Diagnosis

•  Remains constant until •  Changes as the client’s
a cure is effected response and/or the
health problem changes.
 Medical Diagnosis vs. Nursing Diagnosis

Medical Diagnosis Nursing Diagnosis

•  Identifies conditions the •  Identifies situations in
health care practitioner which the nurse is
is licensed and qualified licensed and qualified to
to treat intervene.
 NANDA means

North American
Nursing Diagnosis
Association
 DIFFERENT TYPES OF
NURSING DIAGNOSES

●  1. Actual Nursing Diagnosis

○  Problem present at the time the statement was made

○  Describe a clinical judgment that the nurse has validated

because of the presence of major defining characteristics.

○  Example: Ineffective Airway Clearance related to excessive

and tenacious secretions
 DIFFERENT TYPES OF
NURSING DIAGNOSES

●  2. High-Risk Nursing Diagnosis

○  A diagnosis that a patient is more vulnerable or

susceptible compared with others in the same situation

○  Example: Risk for Impaired Skin Integrity related to

immobility secondary to fractured hip.
 DIFFERENT TYPES OF
NURSING DIAGNOSES

●  3. Possible Nursing Diagnosis

○  There is an evidence of a health problem but the

causes are NOT fully understood

○  An option to indicate that some data are present to confirm

a diagnosis but are insufficient as of this time

○  Example: Possible Self Care Deficit related to impaired

ability to use left hand secondary to presence of
intravenous therapy.
 DIFFERENT TYPES OF
NURSING DIAGNOSES

●  4. Wellness Nursing Diagnosis

○  A positive statement
○  Indicate a healthy response
○  Examples:
● Potential for increased compliance related to increased
level of knowledge
● Potential for enhanced body image related to regular
exercise
● Potential for effective coping related to adequate
support systems
 DOMAINS OF NURSING DIAGNOSES

●  Key Concept!

○  It only includes health needs that a nurse is capable and

licensed to treat

○  The first taxonomy was alphabetical.

○  Later version based on “human response
patterns”
○  Taxonomy Ⅱ has three levels.
○ Domains (13)
○ Classes (47)
○ Nursing diagnoses