NURSING DIAGNOSIS

- clinical judgment concerning a human response to health conditions/life processes

or vulnerability for that response by an individual, family, or community that a
nurse is licensed and competent to treat
- focuses on the responses to actual or potential health problems or life processes
- changes as the client's response and/or health problem changes
- identifies situations in which the nurse is licensed and qualified to intervene

MEDICAL DIAGNOSIS
- identification of a disease condition based on a specific evaluation of physical
s/s, a patient's medical history, and the results of diagnostic tests and
procedures
- stays constant as a condition remains/until a cure is effected
- focuses on illness, injury, or disease process
- uses medical terms
- identifies the condition the healthcare practitioner is licensed and qualified to
treat

NANDA (NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION)

- provides a precise definition of patient's responses to health problems that give
nurses and other members of the healthcare team a common language for understanding
a patient's need
- allows nurses to communicate what they do among themselves w/ other healthcare
professionals and the public
- distinguishes the nurse's role fr. that of other healthcare providers
- helps nurses focus on the scope of nursing practice
- fosters the development of nursing knowledge
- promote the creation of practice guidelines that reflect the essence and science
of nursing

TYPES OF NURSING DIAGNOSIS

1. PROBLEM-FOCUSED
- describes clinical judgment concerning an undesirable human response to a health
condition or life process that exists in an indi., fam, or community
- supported by:
a. Defining characteristics
> observable assessment cues
b. Related factor
> etiological or causative factor for the diagnosis
> allows nurse to individualize a problem-focused diagnosis for a
specific patient need
2. RISK
- concerning the vulnerability of an indi, fam, group, or community to developing
an undesirable human response to health conditions/life processes
- do not have to define characteristics/related factors because they have not yet
occurred
- supported by
a. Risk factors
> environmental, physiological, psychological, genetic, or chemical
elements that place a person at risk for a health problem
> diagnostic-related factors that help in planning preventive health
care measures
3. HEALTH PROMOTION
- concerning a patient's motivation and desire to increase well-being and actualize
human health potential
- used to clients in any health state that express readiness to enhance specific
health behaviors

COMPONENTS OF NURSING DIAGNOSIS

P > Problem, NANDA label
E > Etiology, related to...
S > S/S, as evidenced by...

PROBLEM (DIAGNOSTIC LABEL)

- describe's client's health problem or response to nursing therapy given
- purpose: to direct the formation of the client's goals and desired outcomes
- e.g. anxiety, pain, imbalanced body nutrition
- Qualifiers:
a. Deficient
> inadequate in amount, quality/degree; not sufficient; incomplete
b. Impaired
> made worse, weakened, damaged, reduced, deteriorated
c. Decreased
> lesser in size, amount, degree
d. Ineffective
> not producing the desired effect
e. Compromised
> to make vulnerable to the threat

ETIOLOGY (RELATED FACTORS/RISK FACTORS)

- identifies 1/more probable causes of health problem, gives direction to the
required nursing therapy, and enables the nurse to individualize nursing care
* Related factors
> etiological or causative factors for the diagnosis
* Risk factors
> environmental, physiological, psychological, genetic, or chemical elements
that place a person at risk for a health problem
- assessment cues that may indicate the existence of the problem

SIGNS AND SYMPTOMS (DEFINING CHARACTERISTICS)

- assessment cues that may indicate the existence of the problem

DIAGNOSTIC REASONING PROCESS

- Data Analysis > Data Interpretation > Formulation of Nursing Diagnosis

ANALYSIS OF DATA
A. Comparison of data against standards and norms
> done as in overlapping step on the transition b/n assessment and diagnostic
phase
- Ways of comparing cues:
a. deviation fr. population norms
b. dysfunctional behavior
c. development delay
d. changes in usual health status
e. changes in usual behavior

B. Clustering of cues
- combining data fr. diff. assessment areas to form a pattern & organizing
subjective & objective data into appropriate categories

C. Identifying gaps and inconsistencies in data

- final check to ensure that data are complete and correct
- possible sources: measurement error, expectations, and inconsistencies or
unreliable reports

D. Determining health problems, risks, and strengths

- based fr. clustered data, the nurse must draw inference from the client's
existing health conditions
E. Determining strengths
- problem: identified, taking inventory of strengths promotes self-concept and
self-image
- aid in mobilizing health and regenerative process

FORMULATION OF NURSING DIAGNOSIS

a. One-part statement (problem)
- consists of NANDA label only
b. Two-part statement (Problem + Etiology)
- joined by the words related to
c. Three-part statement (Problem + Etiology + s/s)
- joined by the word related to; and manifested by for the s/s

Variations of Basic Format

1. Unknown etiology
- does not know the cause
2. Complex factors
- too many etiologic factors
3. Possible
- nurse believes more data are needed about the client's prob/needs
4. Secondary to
- divide etiology into 2 parts:
a. More descriptive, useful
b. often pathophysiologic or disease process or medical diagnosis

POSSIBLE NURSING DIAGNOSIS

- evidence about a health prob is incomplete or unclear
- requires more data (to support or refuse it)
- suspected

SYNDROME DIAGNOSIS
- describing a specific cluster of nursing diagnoses that occur together, and are
best addressed together and through similar interventions

COMPONENTS OF NANDA NURSING DIAGNOSIS

1. Label
2. Definition
- provides a clear, precise description; delineates its meaning, and helps
differentiate it from similar diagnoses
- based on data collection
3. Etiology
- factors contributing to/causing the problem
- can't be a medical diagnosis
- must be modifiable by nursing interventions
4. Defining characteristics
5. Risk factors and related factors

NANDA MODIFIERS
1. Acute
> severe, serious, intense, critical
2. Chronic
> constant, persisting, ever-present
3. Depleted
> exhausted, tired, useless
4. Disturbed
> troubled, uneasy, unbalanced, bothered
5. Dysfunctional
> inability to function, organ/part of the body is unable to function
3 STEPS: DIAGNOSTIC PROCESS
a. Analyzing data
b. Identifying health problems, risks, and strengths
c. Formulating diagnostic statements

CLUSTER CUES
- a process of determining the relatedness of facts and determining whether data
are significant

SOURCES OF DIAGNOSTIC ERRORS

1. Data collection
2. Interpretation and analysis of data
3. Data clustering
4. Diagnostic statement
> identify a patient's response (not the med diagnosis)
> identify NANDA diagnostic statements (not the s/s)
> identify treatable factor (be realistic)
> identify actual cause of a prob
> identify problem and etiology