DIAGNOSIS
- Formulating client’s problem
statement
- Process of data analysis
- Problem identification
- Form of decision making that the
nurse uses to arrive a judgment and
conclusion about client response
- And art of identifying disease from
it’s signs and symptoms
- A statement or conclusion
concerning the nature of some
phenomenon
- Also refer as the analysis of the
cause or nature of the condition,
situation or a problem
- Depends on the assessment phase
w/c may affect planning,
implementation and evaluation
TERMS USED :
Diagnosing - refers to the reasoning
process
Diagnosis - is a statement or conclusion
regarding the nature of a phenomenon
Diagnostic labels - the standardized NANDA
names for the diagnoses
NANDA - North American Nursing
Diagnosis Association
Nursing Diagnosis - the client’s problem
statement, consisting of the diagnostic label
+ etiology
NURSING DIAGNOSIS
- Is the client’s problem statement,
consisting of the diagnostic label +
etiology (causal relationship b/wn a
prob and its related / risk factors
- Clinical judgment about the
individual, family or community’s
response to actual or potential
health condition needs processes
- Provides basis for selection of
intervention to achieve outcomes for
w/c the nurse is accountable
- The statement of actual or potential
health status of a client:
-- is derived from nursing assessment w/c
requires intervention from domains of
nursing
-- Nurse can legally identify or pro which
they can prescribe primary intervention for
the treatment or intervention of disease
DIFFERENCE B/WN ND & MEDICAL
DIAGNOSIS
= based on an assessment of the client and
both are accompanied by expected clinical
outcomes and interventions
ND : -- address human responses to a
health state, problem, or condition
-- reflect nursing’s holistic philosophy
MD : -- are used by physicians to identify or
determine a specific disease, condition, or
pathologic state
-- label disease states
TYPES OF NURSING DIAGNOSIS
1.Actual Diagnosis
2.Risk D
3.Possible D
4.Wellness D
5.Syndrome D
1. ACTUAL DIAGNOSIS - is a client
problem that is present at the time of
the nursing assessment
- Present associated w/ S&S
- Problem identified by the nurse that
is already in existence
- EX. Ineffective breathing pattern
2. RISK 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
- Problem may occur but are not
currently in existence
- EX. A client w/ a compromised
immune system is at higher risk of
acquiring an infection
Therefore, the label RISK FOR
INFECTION is use to describe the
client’s health status
3. WELLNESS DIAGNOSIS -
describes human responses to
levels of wellness in an individual,
family or community that have a
readiness for enhancement
- Identifies the individual or aggregate
condition or state that may be
enhance by health promoting
activities
- EX. Readiness for enhanced
spiritual being or Readiness for
enhanced family coping
4. POSSIBLE DIAGNOSIS - Is one in
w/c evidence about a health problem
is incomplete or unclear
- It requires for a data to support or to
refute the diagnosis
- EX. An elderly widow who lives
alone is admitted. The nurse notices
she has no visitors and is pleased w/
attention and conversation from the
staff. Until data are collected, the
nurse may write a nursing diagnosis
of POSSIBLE SOCIAL ISOLATION
related to UNKNOWN ETIOLOGY.
5. SYNDROME DIAGNOSIS - Is a
diagnosis that is associated w/ a
cluster of other diagnosis
- Risk for Disuse Syndrome may be
experienced by long-term bedridden
clients. Cluster of diagnoses
associated w/ this syndrome include
Impaired Physical Mobility, Risk for
Impaired tissue integrity, Risk for
Activity Intolerance, Risk for
Constipation, Risk for Infection, etc.
COMPONENTS OF A NANDA NURSING
DIAGNOSIS
1. PROBLEM (DIAGNOSTIC LABEL)
- Title used in writing a nursing
diagnosis
- Taken from NANDA’s standardized
taxonomy of terms
- It describes the client’s response to
an actual, possible, and risk health
problem or to a wellness condition
2. ETIOLOGY (RELATED FACTORS &
RISK FACTORS)
- The causal relationship between a
problem and its related or risk
factors
- EX. Diagnostic label (Problem)
Constipation
- Etiology
Long-term laxative use
Inactivity and insufficient fluid intake
3. DEFINING CHARACTERISTICS - cluster
of S&S that indicate presence of particular
diagnostic label
- Types of Nsg. Diagnosis
Actual Nsg Dx
Risk Nsg Dx
- Defining characteristics
Client’s signs/sx
No subjective/objective signs are present
COLLABORATIVE PROBLEM - present
and seen w/ one disease but the human
response pattern in eerie individual differs
EX. PC (Potential Complication) of child
bearing: postpartum hemorrhage
DIAGNOSTIC PROCESS
-- Uses critical thinking skills of analysis &
synthesis
- Critical thinking skills : is a cognitive
process in w/c a person reviews data and
considers explanation before forming
opinion
- Analysis : separations into components
breaking down of whole into parts
- Synthesis : putting together of parts into a
whole
DIAGNOSTIC PROCESS HAS 3 STEPS:
1. Analyzing Data
2. Identifying health problems
3. Formulating diagnostic statement
1. ANALYZING DATA
Compare data against standards
Cluster cues
Identify gaps & inconsistencies
2. IDENTIFYING HEALTH
PROBLEMS, RISKS &
STRENGTHS
Determining problems and risks
Determining strengths
3. FORMULATING DIAGNOSTIC
STATEMENTS
Basic 2-part statements:
EX. Problem (P) + Etiology (E)
P: statements of the client’s
response (NANDA label)
E: factors contributing to or probable
causes of the responses
Two parts are joined by the words:
“related to” or “r/t”
EX. Ineffective airway clearance r/t
weak cough reflex
Basic 3-part statements
P+E+Signs/Sx (PES format)
P: statement of the client’s response
(NANDA label)
E: factors contributing to or probable
causes of the responses
S: defining characteristics
manifested by the client
3 parts are joined by the words: “As
Manifested By” or “AMB”
EX. Hypothermia r/t increased
metabolic rate AMB temp - 37.9°C,
skin warm to touch
1-part statements:
- For wellness diagnosis & syndrome
nursing diagnosis
- Consist of a NANDA label only
EX. A. Readiness for enhanced childbearing
process
B. Rape Trauma syndrome
Variations of the basic formats
1. Unknown etiology - defining
characteristics are present, contributing
factors unknown
EX. Pain r/t unknown etiology
2. Complex (etiology) factors - too many
etiologic factors/ too complex to state in a
brief phase
EX. Constipation r/t insufficient fiber intake,
insufficient oral fluid intake, pain upon
defecating
Constipation r/t complex factors
3. Possible (problem/etiology) - nurse
believes more data are needed about
client’s problem/etiology
EX. Possible situational low self-esteem r/t
loss of job & rejection by family
Complicated grieving possibility related to
lack of social support
4. Secondary to (2°) - used to divide the
etiology into 2 parts, making the statement
more descriptive and useful
-The part of ff a secondary to is often a
pathophysiologic or disease process or a
medical diagnosis
EX. Impaired skin integrity r/t immobility 2°
cast
5. Adding a 2nd part to the NANDA label -
adding a second part to the general
response to make it more precise
EX. Impaired skin integrity: pressure sore r/t
immobility 2° cast
Headache r/t increased cranial pressure
EXERCISES:
Hyperthermia
r/t increased metabolic rate
AMB Temp - 37.9°C, skin warm to touch
Says, “nahihirapan akong huminga”, RR -
28 bpm, orthopneic, nasal flaring, wheezing
heard upon auscultation, has Asthma
= Ineffective breathing pattern r/t
constriction of bronchioles 2° Asthma AMB
dyspnea, RR - 28bpm, orthopneic, nasal
flaring, wheezing heard upon auscultation
Has difficulty getting to toilet and carry out
proper toilet hygiene, needs assistance of
wife, says “I’m too weak to do it”
= Self care deficit (toileting) level 2 r/t
weakness AMB difficulty getting to toilet and
carry out proper toilet hygiene, needs
assistance of wife
GUIDELINES FOR WRITING ND
1.Uses legally advisable language
-should not affix or refer negatively to
aspects of pt care
X - Impaired skin integrity: pressure sores r/t
not being turned frequently enough
✔ - Impaired skin integrity: pressure sores r/t
inability to turn self
2.Uses nonjudgmental language
X - Risk for injury: falls r/t poor
housekeeping
✔- Risk for injury: falls r/t cluttered floors
3.Make sure that both elements of the
statement do not say the same thing
X - Chronic pain r/t headache
✔ - Chronic pain: headache r/t unknown
etiology
4.Precise & Clear - use terms generally
understood by other professional & avoids
abbreviations
X - Toileting self care deficit r/t inability to
get OOB w/o help
5. Cause & Effect are correctly stated
✔ - Impaired oral mucous membrane r/t
deficient fluid volume AMB oral lesions
X - Deficient fluid volume r/t altered oral
mucous membrane AMB oral lesions
6. Use nsg terminology rather than medical
terminology to describe probable cause of
the client’s response
✔ - Ineffective airway clearance r/t increased
tracheobronchial secretions
X - Ineffective airway clearance r/t
Pneumonia
7. NANDA labels can be used for both
problems & etiologies
✔ Self care deficit (Level 2) r/t activity
intolerance 2° ineffective airway clearance &
disturbed sleep pattern
✔ Hyperthermia r/t deficient fluid volume 2°
diarrhea
✔ Dressing/grooming self care deficit (level 2)
r/t activity intolerance (level IV) 2° heart disease
8. Concise - if etiology is wordy, use “...r/t
complex factors”