The Nursing Process (Diagnosis)

PROF. FRANCIS VINCENT ACENA, MAN, RN, RM

 Objectives

Organize
Differentiate the
assessment data as
various types of
to the taxonomy of
nursing diagnoses.
nursing diagnoses.

Compare nursing Identify the

diagnoses & medical components of a
diagnoses nursing diagnoses.
Nursing Diagnosis
This is a clinical judgment
concerning human response to
health condition/s, life
processes or vulnerability for
that response by an individual ,
family, or community that a
nurse is licensed and competent
to treat.
 MEDICAL DIAGNOSIS
(Doctor)
• Focuses on illness, injury or
disease process
• Focuses on curing Pathology
• Stays the same as long as the
disease is present
NURSING DIAGNOSIS
(Nurse)
• Focuses on the responses to actual
or potential health problems or life
processes.
• Identify responses to health and
illness
• Can change from day to day
Medical Diagnosis: Nursing Diagnosis:
Cholecystitis (Inflammation - Hyperthermia (fever)
of the gallbladder) - Acute pain
- Nausea & Vomiting

e.g. Pneumonia; Asthma • Ineffective breathing

 Purposes of
Nursing Diagnosis
 Helps identify nursing priorities and
01 help direct nursing interventions based
on identified priorities.

Provides a common language and forms a

Purposes of 02 basis for communication and
Nursing Diagnosis understanding between nursing
professionals and the healthcare team

For nursing students, nursing diagnoses

03 are an effective teaching tool to help
sharpen their problem-solving and
critical thinking skills.
 TYPES OF NURSING
DIAGNOSIS
(Recognized by NANDA-I)

1. Problem-focused Nursing
diagnosis
2. Risk Nursing diagnosis
3. Syndrome Nursing diagnosis
4. Health Promotion Nursing
diagnosis

*NANDA: North American Nursing Diagnosis Association- Int’l

 PES-FORMAT
1. Problem-focused
Nursing Diagnosis
• AKA “ Actual diagnosis”
01
+ 02
+ 03
NANDA Label Related factors Defining characteristics
• is a client problem that is
(Problem) (Etiology) (Signs & Symptoms)
present at the time of the
nursing assessment.
Basis for standard
Nursing Diagnosis
(NANDA-I)
North
American
Nursing
Diagnosis
Association- International
 Domains of NANDA
Domain 1: Health Promotion
Domain 2: Nutrition
Domain 3: Elimination & Exchange
Domain 4: Activity/ Rest
Domain 5: Perception/ Cognition
Domain 6: Self-perception
Domain 7: Role Relationships
Domain 8: Sexuality
Domain 9: Coping/ Stress tolerance
Domain 10: Life Principles
Domain 11: Safety/ Protection
Domain 12: Comfort
Domain 13: Growth/ Development
NANDA Based Standard Nursing Diagnosis
How are nursing diagnoses listed, arranged
or classified?
(NANDA-Taxonomy II was adopted, which was based from the
Functional Health Patterns assessment framework of Dr. Mary Joy
Gordon)

(13) Domains

(47) Classes

Nursing
diagnoses
Example: *fever
Formula: PES

P E S
Hyperthermia r/t dehydration AEB Increase
in body temperature,
increased pulse rate,
increased Respi. Rate,
skin warm to touch.
Domain 11 (Safety/Protection) : Class 6
 2. Risk Nursing
Diagnosis
01
+ 02

Risk diagnostic label Related factors

• These are clinical
(Problem) (Etiology)
judgment that a problem
does not exist, but the
presence of risk factors [1] Risk for falls r/t muscle weakness
indicates that a problem is
[2] Risk for injury r/t altered mobility
likely to develop unless
nurses intervene. Formula is only [Problem+ Risk factors]
* No AEB since the problem has not yet
developed
 3. Health Promotion
Diagnosis
• AKA “wellness diagnosis”
• is a clinical judgment about
motivation and desire to
increase well-being.
01
Diagnostic label
(*Components of a health promotion diagnosis
generally include only the diagnostic label or a one-
part-statement.)
Examples;
[1] Readiness for Enhanced Spiritual Well Being
[2] Readiness for Enhanced Parenting
 NANDA-I Approved Syndrome diagnosis
4. Syndrome Nursing
Diagnosis 1. Disuse syndrome
2. Impaired environmental interpretation
• Is used when a cluster of syndrome
assessment findings or
3. Post-trauma syndrome
nursing diagnosis occur
together, showing a specific 4. Relocation stress syndrome
clinical pattern. It can be 5. Rape Trauma syndrome
actual or risk diagnosis.. 6. Sudden Infant death syndrome
Patient #1 Patient #2 Patient #3
Arrange the following in
order of priority;

• Acute pain r/t surgical tissue trauma

• Risk for infection r/t surgical incision
• Ineffective breathing pattern r/t effects of general
anesthesia
THANK
YOU!
PROF. VINZ ACENA, MAN, RN, RM
OLFU Valenzuela