Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

BACHELOR OF SCIENCE IN NURSING

College of Health Sciences
1ST SEMESTER S/Y 2021-2022
NURSING PROCESS
Module 2: DIAGNOSING
Learning Outcomes:
After completing this module, you will be able to:
1. Differentiate nursing diagnoses according to status.
2. Identify the components of a nursing diagnosis.
3. Compare nursing diagnoses, medical diagnoses, and collaborative problems.
4. Identify the basic steps in the diagnostic process.
5. Describe various formats for writing nursing diagnoses.
6. List guidelines for writing a nursing diagnosis statement.
7. Describe the evolution of the nursing diagnosis movement, including work currently in progress.

Introduction
Diagnosing is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret
assessment data and identify client strengths and problems. Diagnosing is a pivotal step in the nursing process. Activities
preceding this phase are directed toward formulating the nursing diagnoses; the care planning activities following this
phase are based on the nursing diagnosis.

Definition
The term diagnosing refers to the reasoning process, whereas the term diagnosis is a statement or conclusion
regarding the nature of a phenomenon. The standardized NANDA names for the diagnoses are called diagnostic labels;
and the client’s problem statement, consisting of the diagnostic label plus etiology (causal relationship between a
problem and its related or risk factors), is called a nursing diagnosis.

Types of Nursing Diagnosis

1. Actual diagnosis is a client problem that is present at the time of the nursing assessment.

Examples: are Ineffective Breathing Pattern and Anxiety. An actual nursing diagnosis is based on the presence of
associated signs and symptoms.

2. Health promotion diagnosis relates to clients’ preparedness to implement behaviors to improve their health
condition. These diagnosis labels begin with the phrase Readiness for Enhanced, as in Readiness for Enhanced
Nutrition.
3. 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.

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.

Problem (Diagnostic Level) Definition

 The problem statement, or diagnostic label, describes the client’s health problem or response for which nursing
therapy is given.
 It describes the client’s health status clearly and concisely in a few words
  To be clinically useful, diagnostic labels need to be specific; when the word Specify follows a NANDA label, the
nurse states the area in which the problem occurs, for example, Deficient Knowledge (Medications) or Deficient
Knowledge (Dietary Adjustments).

Qualifiers
are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement,
for example:
 Deficient (inadequate in amount, quality, or degree; not sufficient; incomplete)
 Impaired (made worse, weakened, damaged, reduced, deteriorated)
 Decreased (lesser in size, amount, or degree)
 Ineffective (not producing the desired effect)
 Compromised (to make vulnerable to threat)

Etiology (Related Factors or Risk Factors)

The etiology component of a nursing diagnosis identifies one or more probable causes of the health problem,
gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care.

Differentiating Nursing Diagnosis from Medical Diagnosis

 Nursing diagnosis is a statement of nursing judgment and refers to a condition that nurses, by virtue of their
education, experience, and expertise, are licensed to treat.
 Medical diagnosis is made by a physician and refers to a condition that only a physician can treat. Medical
diagnoses refer to disease processes—specific pathophysiologic responses that are fairly uniform from one
client to another.

Formulating Diagnostic Statement

Most nursing diagnoses are written as two-part or three-part statements, but there are variations of these.

 Basic Two-Part Statements

The basic two-part statement includes the following:
 Problem (P): statement of the client’s response (NANDA label)
 Etiology (E): factors contributing to or probable causes of the responses.
 Basic Three-Part Statements
The basic three-part nursing diagnosis statement is called the PES format and includes the
following:
 Problem (P): statement of the client’s response (NANDA label)
 Etiology (E): factors contributing to or probable causes of the response.
 Signs and symptoms (S): defining characteristics manifested by the client.

2007–2008 NANDA-Approved Nursing Diagnoses

• Activity Intolerance
• Activity Intolerance, Risk for
• Airway Clearance, Ineffective
• Anxiety
• Anxiety, Death
• Aspiration, Risk for
• Attachment, Parent/Infant/Child, Risk for
• Impaired
• Autonomic Dysreflexia
• Autonomic Dysreflexia, Risk for
• Blood Glucose, Risk for Unstable
• Body Image, Disturbed
• Body Temperature: Imbalanced, Risk for
• Bowel Incontinence
• Breastfeeding, Effective
• Breastfeeding, Ineffective
• Breastfeeding, Interrupted
• Breathing Pattern, Ineffective
• Cardiac Output, Decreased
• Caregiver Role Strain
• Caregiver Role Strain, Risk for
• Comfort, Readiness for Enhanced
• Communication: Impaired, Verbal
• Communication, Readiness for Enhanced
• Confusion, Acute
• Confusion, Acute, Risk for
• Confusion, Chronic
• Constipation
• Constipation, Perceived
• Constipation, Risk for
• Contamination
• Contamination, Risk for
• Coping: Community, Ineffective
• Coping: Community, Readiness for Enhanced
• Coping, Defensive
• Coping: Family, Compromised
• Coping: Family, Disabled
• Coping: Family, Readiness for Enhanced
• Coping (Individual), Readiness for Enhanced
• Coping, Ineffective
• Decisional Conflict
• Decision Making, Readiness for Enhanced
• Denial, Ineffective
• Dentition, Impaired
• Development: Delayed, Risk for
• Diarrhea
• Disuse Syndrome, Risk for
• Diversional Activity, Deficient
• Energy Field, Disturbed
• Environmental Interpretation Syndrome, Impaired
• Failure to Thrive, Adult
• Falls, Risk for
• Family Processes, Dysfunctional: Alcoholism
• Family Processes, Interrupted
• Family Processes, Readiness for Enhanced
• Fatigue
• Fear
• Fluid Balance, Readiness for Enhanced
• Fluid Volume, Deficient
• Fluid Volume, Deficient, Risk for
• Fluid Volume, Excess
• Fluid Volume, Imbalanced, Risk for
• Gas Exchange, Impaired
• Grieving
• Grieving, Complicated
• Grieving, Risk for Complicated
• Growth, Disproportionate, Risk for
• Growth and Development, Delayed
• Health Behavior, Risk-Prone
• Health Maintenance, Ineffective
• Health-Seeking Behaviors (Specify)
• Home Maintenance, Impaired
• Hope, Readiness for Enhanced
• Hopelessness
• Human Dignity, Risk for Compromised
• Hyperthermia
• Hypothermia
• Immunization Status, Readiness for Enhanced
• Infant Behavior, Disorganized
• Infant Behavior: Disorganized, Risk for
• Infant Behavior: Organized, Readiness for
• Enhanced
• Infant Feeding Pattern, Ineffective
• Infection, Risk for
• Injury, Risk for
• Insomnia
• Intracranial Adaptive Capacity, Decreased
• Knowledge, Deficient (Specify)
• Knowledge (Specify), Readiness for Enhanced
• Latex Allergy Response
• Latex Allergy Response, Risk for
• Liver Function, Impaired, Risk for
• Loneliness, Risk for
• Memory, Impaired
• Mobility: Bed, Impaired
• Mobility: Physical, Impaired
• Mobility: Wheelchair, Impaired
• Moral Distress
• Nausea
• Neurovascular Dysfunction: Peripheral, Risk for
• Noncompliance (Specify)
• Nutrition, Imbalanced: Less than Body
• Requirements
• Nutrition, Imbalanced: More than Body Requirements
• Nutrition, Imbalanced: More than Body
• Requirements, Risk for
• Nutrition, Readiness for Enhanced
• Oral Mucous Membrane, Impaired
• Pain, Acute
• Pain, Chronic
• Parenting, Impaired
• Parenting, Readiness for Enhanced
• Parenting, Risk for Impaired
• Perioperative Positioning Injury, Risk for
• Personal Identity, Disturbed
• Poisoning, Risk for
• Post-Trauma Syndrome
• Post-Trauma Syndrome, Risk for
• Power, Readiness for Enhanced
• Powerlessness
• Powerlessness, Risk for
• Role Conflict, Parental
• Role Performance, Ineffective
• Sedentary Lifestyle
• Self-Care, Readiness for Enhanced
• Self-Care Deficit: Bathing/Hygiene
• Self-Care Deficit: Dressing/Grooming
• Self-Care Deficit: Feeding
• Self-Care Deficit: Toileting
• Self-Concept, Readiness for Enhanced
• Self-Esteem, Chronic Low
• Self-Esteem, Situational Low
• Self-Esteem, Risk for Situational Low
• Sexual Dysfunction
• Sexuality Pattern, Ineffective
• Skin Integrity, Impaired
• Skin Integrity, Risk for Impaired
• Sleep Deprivation
• Sleep, Readiness for Enhanced
• Social Interaction, Impaired
• Social Isolation
• Spiritual Distress
• Spiritual Distress, Risk for
• Spiritual Well-Being, Readiness for Enhanced
• Spontaneous Ventilation, Impaired
• Stress, Overload
• Sudden Infant Death Syndrome, Risk for
• Suffocation, Risk for
• Suicide, Risk for
• Surgical Recovery, Delayed
• Swallowing, Impaired
• Therapeutic Regimen Management: Community,
• Ineffective
• Therapeutic Regimen Management, Effective
• Therapeutic Regimen Management: Family,
• Ineffective
• Therapeutic Regimen Management, Ineffective
• Therapeutic Regimen Management, Readiness for
• Enhanced
• Thermoregulation, Ineffective
• Thought Processes, Disturbed
• Tissue Integrity, Impaired
• Tissue Perfusion, Ineffective (Specify: Cerebral,
• Cardiopulmonary, Gastrointestinal, Renal)
• Tissue Perfusion, Ineffective, Peripheral
• Transfer Ability, Impaired
• Trauma, Risk for
• Unilateral Neglect
• Urinary Elimination, Impaired
• Urinary Elimination, Readiness for Enhanced
• Urinary Incontinence, Functional
• Urinary Retention
 • Ventilatory Weaning Response, Dysfunctional
• Violence: Other-Directed, Risk for
• Violence: Self-Directed, Risk for
• Walking, Impaired
• Wandering
• Urinary Incontinence, Overflow
• Urinary Incontinence, Reflex
• Urinary Incontinence, Stress
• Urinary Incontinence, Total
• Urinary Incontinence, Urge
• Urinary Incontinence, Risk for Urge
Source: NANDA Nursing Diagnoses: Definitions and Classification, 2007–2008. Philadelphia: North American Nursing Diagnosis
Association. Used with permission

Prepared by:
Jocyl Darrel B. Abinal, R.M, R.N, MAN
Clinical Instructor

Source: Kozier and Erb’s FUNDAMENTALS OF NURSING, concept, process and practice 10th edition Unit 3, Chapter 12