Unit 3

DIAGNOSIS

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LEARNING OUTCOMES
At the end of this session student will be able to:
1. Define NANDA.
2. State purpose of nursing diagnosis.
3. Define medical diagnosis and nursing diagnosis.
4. Differentiate between medical and nursing
diagnosis.
5. State Four types of Nursing diagnosis.
6. State definition of diagnostic Axes.
7. List Seven diagnostic Axes for nursing diagnosis.
8. Explain Three components of Nursing diagnosis.
9. State formulating diagnostic statement.
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NANDA International (NANDA-I)
• NANDA–International earlier known as
the North American Nursing Diagnosis
Association (NANDA) is the principal
organization for defining, distribution and
integration of standardized nursing
diagnoses worldwide.

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NANDA International (NANDA-I)
• Nurses can submit diagnoses to the Diagnostic
Review Committee for review.
• The NANDA-I board of directors give the final
approval for incorporation of the diagnosis into
the official list of labels.
• As of 2019, NANDA-I has approved 244
diagnoses for clinical use, testing, and
refinement.

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Purposes of Nursing
Diagnosis
1.Helps identify nursing priorities and help direct nursing
interventions based on identified priorities.
2.Helps the formulation of expected outcomes for quality
assurance requirements of third-party payers.
3.Nursing diagnoses help identify how a client or group
responds to actual or potential health and life processes
and knowing their available resources of strengths that can
be drawn upon to prevent or resolve problems.
4.Provides a common language and forms a basis for
communication and understanding between nursing
professionals and the healthcare team.
5.Provides a basis of evaluation to determine if nursing care
was beneficial to the client and cost-effective.
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 DEFINITION OF NURSING
DIAGNOSIS
A nursing diagnosis is a clinical judgment concerning a
human response to health conditions/life processes, or
a vulnerability for that response, by an individual,
family, group or community. A nursing diagnosis
provides the basis for selection of nursing
interventions to achieve outcomes for which the nurse
has accountability.

(Approved at the ninth NANDA Conference; amended

in 2009 and 2013.)
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 KEY WORD
Vulnerability
the quality or state of being exposed to the
possibility of being attacked or harmed, either
physically or emotionally.

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Differentiate between Medical and
Nursing Diagnoses
• The term nursing diagnosis is associated with
three different concepts. It may refer to the
distinct second step in the nursing
process, diagnosis.
• Also, nursing diagnosis applies to the label
when nurses assign meaning to collected data
appropriately labelled with NANDA approved
nursing diagnosis.

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Difference between Medical and
Nursing Diagnoses… cont’s
• The term nursing diagnosis is associated
with three different concepts. It may refer to
the distinct second step in the nursing
process, diagnosis.
• Also, nursing diagnosis applies to the label
when nurses assign meaning to collected
data appropriately labelled with NANDA
approved nursing diagnosis.

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Difference between Medical and
Nursing Diagnoses.. Cont’s
• For example, during the assessment, the
nurse may recognize that the client is
feeling anxious, fearful, and finds it difficult
to sleep.
• It is those problems which are labelled with
nursing diagnoses: respectively, Anxiety,
Fear, and Disturbed Sleep Pattern.
• Lastly, a nursing diagnosis refers to one of
many diagnoses in the classification system
established and approved by NANDA.

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Difference between Medical and
Nursing Diagnoses.. Cont.'s
• In this context, a nursing diagnosis is based
upon the response of the patient to the
medical condition.
• It is called a ‘nursing diagnosis’ because
these are matters that hold a distinct and
precise action that is associated with what
nurses have autonomy to take action about
with a specific disease or condition.
• This includes anything that is a physical,
mental, and spiritual type of response. Hence,
a nursing diagnosis is focused on care.

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Difference between Medical and
Nursing Diagnoses.. Cont.'s
• A medical diagnosis, on the other hand,
is made by the physician or advance
health care practitioner that deals more
with the disease, medical condition, or
pathological state only a practitioner can
treat.

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Difference between Medical and
Nursing Diagnoses.. Cont.'s
• Moreover, through experience and know-how, the
specific and precise clinical entity that might be
the possible cause of the illness will then be
undertaken by the doctor, therefore, providing the
proper medication that would cure the illness.
• Examples of medical diagnoses are Diabetes
Mellitus, Tuberculosis, Amputation, Hepatitis,
and Chronic Kidney Disease.
• The medical diagnosis normally does not change.
Nurses are required to follow the physician’s
orders and carry out prescribed treatments and
therapies.

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Four Types of Nursing Diagnoses
• The four types of NANDA nursing
diagnosis are:
1. Problem-Focused/ Actual
2. Risk
3. Health promotion
4. Syndrome

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Here are the four categories of nursing
diagnosis provided by the NANDA.

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 Definition of
Problem-focused Nursing Diagnosis
• A clinical judgment concerning an undesirable human
response to health conditions/life processes that exists
in an individual, family, group, or community.
• In order to make a problem-focused diagnosis, the
following must be present: defining characteristics
(manifestations, signs, and symptoms) that cluster in
patterns of related cues or inferences.
• Related factors (etiological factors) that are related to,
contribute to, or antecedent to the diagnostic focus are
also required.

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1. Problem-Focused Nursing Diagnosis
• A problem-focused diagnosis (also known as actual
diagnosis) is a client problem that is present at the
time of the nursing assessment.
• These diagnoses are based on the presence of
associated signs and symptoms.
• Actual nursing diagnoses should not be viewed as
more important than risk diagnoses.

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1. Problem-Focused
Nursing Diagnosis… cont.'s
• There are many instances where a risk
diagnosis can be the diagnosis with the highest
priority for a patient.
• Problem-focused nursing diagnoses have three
components:
(1) nursing diagnosis
(2) related factors
(3) defining characteristics

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1. Problem-Focused Nursing
Diagnosis… cont.'s
Examples of actual nursing diagnosis are:
• Ineffective Breathing Pattern
• Anxiety
• Acute Pain
• Impaired Skin Integrity.

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2. Risk Nursing Diagnosis
• Definition: A clinical judgment concerning
the vulnerability of an individual, family,
group, or community for developing an
undesirable human response to health
conditions/life processes.
• In order to make a risk-focused diagnosis,
the following must be present: supported by
risk factors that contribute to increased
vulnerability.

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2. Risk Nursing Diagnosis… cont.'s
• For example, an elderly client with diabetes and
vertigo has difficulty walking refuses to ask for
assistance during ambulation may be
appropriately diagnosed with Risk for Injury.
• Components of a risk nursing diagnosis include:
a. risk diagnostic label
b. risk factors
Examples are:
1. Risk for Falls
2. Risk for Injury
3. Risk for Infection
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3. Health-promotion Nursing
Diagnosis
• Definition : A clinical judgement concerning
motivation and desire to increase well-being and to
actualize human health potential.
• These responses are expressed by a readiness to
enhance specific health behaviours, and can be used
in any health state. Health promotion responses may
exist in an individual, family, group, or community.
• In order to make a health-promotion diagnosis, the
following must be present: defining characteristics
which begin with the phrase, “Expresses desire to
enhance…”.
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3. Health Promotion Diagnosis
• Components of a health promotion diagnosis
generally include only the diagnostic label or a
one-part-statement.
• Examples are:
1. Readiness for Enhanced Spiritual Well
Being
2. Readiness for Enhanced Family Coping
3. Readiness for Enhanced Parenting

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4. Syndrome
• Definition: A clinical judgment concerning a
specific cluster of nursing diagnoses that occur
together, and are best addressed together and
through similar interventions.
• In order to make a syndrome diagnosis, the
following must be present: two or more
nursing diagnoses must be used as defining
characteristics.
• Related factors may be used if they add clarity
to the definition, but are not required.
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4. Syndrome Diagnosis
• Examples of a syndrome nursing diagnosis are:
1. Chronic Pain Syndrome
2. Post-trauma Syndrome
3. Frail Elderly Syndrome

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Diagnostic Axes
Definition of Axis
An axis is operationally defined as a
dimension of the human response that is
considered in the diagnostic process.
There are seven axes which parallel the
International Standards Reference Model for
a Nursing Diagnosis.

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Diagnostic Axes… cont.'s
7 axes which parallel the International Standards
Reference Model for a Nursing Diagnosis.
Axis 1: the diagnostic focus
Axis 2: subject of the diagnosis (individual,
caregiver, family, group, community)
Axis 3: judgment (impaired, ineffective, etc.)
Axis 4: location (bladder, auditory, cerebral, etc.)
Axis 5: age (infant, child, adult, etc.)
Axis 6: time (chronic, acute, intermittent)
Axis 7: status of the diagnosis (problem-focused,
risk, health promotion).
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Axis 1: the diagnostic focus
• The diagnostic focus is the principal element or the
fundamental and essential part, the root, of the diagnostic
concept.
• It describes the “human response” that is the core of the
diagnosis.
• The diagnostic focus may consist of one or more nouns.
When more than one noun is used (for example, Activity
intolerance), each one contributes a unique meaning to the
diagnostic focus, as if the two were a single noun; the
meaning of the combined term, however, is different from
when the nouns are stated separately.
• Frequently, an adjective (Spiritual) may be used with a noun
(Distress) to state the diagnostic focus Spiritual Distress.

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Axis 2: Subject of the Diagnosis
The person(s) for whom a nursing diagnosis is determined.
The values in Axis 2 which represent the NANDA-I
definition of “patient” are:
1.Individual: a single human being distinct from others, a
person.
2.Caregiver: a family member or helper who regularly
looks after a child or a sick, elderly, or disabled person
3.Family: two or more people having continuous or
sustained relationships, perceiving reciprocal obligations,
sensing common meaning, and sharing certain
obligations toward others; related by blood and/or choice.
4.Group: a number of people with shared characteristics
5.Community: a group of people living in the same locale
under the same governance. Examples include
neighbourhoods andDNNP cities.
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Axis 3 : Judgment
A descriptor or modifier that limits or specifies the
meaning of the diagnostic focus.
The diagnostic focus together with the nurse’s
judgment about it forms the diagnosis.

Notes: The values in Axis 3 are found in the

NANDA-I Nursing Diagnoses: Definitions and
Classifications book, Chapter 4, Table 2.

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Axis 4: Location
• Describes the parts/regions of the body and/or
their related functions – all tissues, organs,
anatomical sites, or structures.
• For the locations in Axis 4, see the NANDA-I
Nursing Diagnoses: Definitions and
Classifications book, Chapter 4, Table 3.

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 Axis 5 : Age
Refers to the age of the person who is the subject of the
diagnosis (Axis 2).
Malaysian context of age:
1. Fetus: an unborn human more than 8th weeks after
conception, until birth.
2. Neonate: a child < 28 days of age
3. Infant: a child > 28 days and <1 year of age
4. Child: person aged 1 to 9 years, inclusive
5. Adolescent: person aged 10 to 17 years, inclusive
6. Adult: a person older than 18 years of age unless national
law defines a person as being an adult at an earlier age
7. Older adult: a person > 60 years of age

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Axis 6: Time
Describes the duration of the diagnostic concept
(Axis 1).
The values in Axis 6 are:
1. Acute: lasting <3 months
2. Chronic: lasting >3 months
3. Intermittent: stopping or starting again at
intervals, periodic, cyclic
4. Continuous: uninterrupted, going on without
stop.

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Axis 7: Status of the Diagnosis
• Refers to the actuality or potentiality of the
problem/syndrome or to the categorization of
the diagnosis as a health promotion diagnosis.
• The values in Axis 7 are:
1. Problem-focused
2. Health Promotion
3. Risk
4. Syndrome

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Components of a Nursing
Diagnosis
• A nursing diagnosis has commonly three
components:
1. Problem and its definition
2. Aetiology
3. Defining characteristics

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Problem and Definition
• The problem statement, or the diagnostic
label, describes the client’s health problem or
response for which nursing therapy is given as
concisely as possible.
• A diagnostic label usually has two parts: qualifier
and focus of the diagnosis. Qualifiers (also called
modifiers) are words that have been added to
some diagnostic labels to give additional
meaning, limit or specify the diagnostic
statement.
• Exempted in this rule are one-word nursing
diagnoses (e.g., Anxiety, Fatigue, Nausea) where
their qualifier and focus are inherent in the one
term.
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Problem and Definition… cont’s
Qualifier Focus of the Diagnosis

Deficient/Deficit/ Fluid volume

Excess
Imbalanced Nutrition: Less Than Body
Requirements
Impaired/Altered Gas Exchange
Ineffective Tissue Perfusion
Risk for Injury
Risk for Infection
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Definition of etiology
1: CAUSE, ORIGIN
specifically : the cause of a disease or abnormal
condition

2: a branch of knowledge concerned with

causes
specifically : a branch of medical science
concerned with the causes and origins of diseases

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Etiology related to Nursing
Diagnosis
• The etiology, or related factors and risk factors,
component of a nursing diagnosis label identifies
one or more probable causes of the health
problem/status of condition.
• It involved in the development of the problem,
gives direction to the required nursing therapy,
and enables the nurse to individualize the client’s
care.
• Nursing interventions should be aimed at
etiological factors in order to remove the
underlying cause of the nursing diagnosis.
• Etiology is linked with the problem statement with
the phrase “as related to”.
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Defining Characteristics
• Defining characteristics are the clusters of signs and
symptoms that indicate the presence of a particular
diagnostic label.
• In actual nursing diagnoses, the defining
characteristics are the identified signs & symptoms of
the client.
• For risk nursing diagnosis, no signs and symptoms are
present therefore the factors that cause the client to
be more susceptible to the problem form the etiology
of a risk nursing diagnosis.
• Defining characteristics are written “as evidenced by”
or “as manifested by” in the diagnostic statement.
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Formulate/Write a Nursing Diagnosis
• In writing nursing diagnostic statements, describe
the health status of an individual and the factors
that have contributed to the status.
• Do not need to include all types of diagnostic
indicators.
• Diagnostic statements can be one-part, two-part,
or three-part statements.
• A common format used when writing or
formulating nursing diagnosis is the PES format.

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Variations on Basic Statement
Formats
Variations in writing nursing diagnosis statement
formats include the following:
• Using “secondary to” to divide the etiology into two
parts to make the diagnostic statement more
descriptive and useful.
• Following the “secondary to” is often a
pathophysiologic or diseases process or a medical
diagnosis.
For example:
Risk for Decreased Cardiac Output related to
reduced preload secondary to myocardial infarction.

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Variations on Basic Statement
Formats
• Using “complex factors” when there are
too many etiologic factors or when they
are too complex to state in a brief
phrase.
• For example, Chronic Low Self-Esteem
related to complex factors.

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Variations on Basic
Statement Formats
• Using “unknown etiology” when the defining
characteristics are present but the nurse does not
know the cause or contributing factors.
For example : Ineffective Coping related to unknown
etiology.
• Specifying a second part to the general response or
NANDA label to make it more precise.
For example : Impaired Skin Integrity (Right Anterior
Chest) related to disruption of skin surface secondary
to burn injury.

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 Formulation Diagnosis
Statements for Nursing Diagnosis
• Rule for making diagnostic statements are as
follows:
(a) Actual Nursing Diagnosis (Three part
statement)

i. Use PES (Problem, Etiology, Signs & Symptoms)

or
Use PRS (Problem, Related Factors, Signs &
Symptom) format.

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Formulation Diagnosis Statements for
Nursing Diagnosis… cont.'s
• Rule for making diagnostic statements are as follows:
(a) Actual Nursing Diagnosis (Three part statement)

ii. Use “ related to " to link the problem and the

etiology or related factors to support that nursing
diagnosis is present.

Example : Pain related to surgery

(Appendectomy)

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Formulation Diagnosis Statements for
Nursing Diagnosis… cont.'s
• Rule for making diagnostic statements are as
follows:
b) Risk Nursing Diagnosis (two part statement)
i. Use PE (Problem , Etiology)
or
Use PR (Problem, Related (Risk) factors)
format.

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Formulation Diagnosis Statements for
Nursing Diagnosis… cont.'s
• Rule for making diagnostic statements are as
follows:
b) Risk Nursing Diagnosis (two part statement)
ii. Use “related to "to link the potential problem with
the related (risk) factors present

Example : Risk for bleeding related to an open

wound.

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Formulation Diagnosis Statements for
Nursing Diagnosis… cont.'s

Acute pain related PROBLEM ETIOLOGY EVIDENCED

to abdominal SIGN &
Surgery. SYMPTOM

Pain Surgery of Pain scale

Subjective Data : abdomen and
Patient discomfort discomfort of
patient

Objective Data:
pain scale = 7/10
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 Instruction:
1. Practice identifying problems, aetiology and
signs and symptoms (PES).
2. Study the nursing diagnosis below and circle
the problem, underline the aetiology and
highlight the signs as well as symptoms.

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 Exercise 1:
Which of the following is TRUE/FALSE in
formulation nursing diagnosis?

1. Risk for fall and fainted related to anemia.

2. Constipation related to poor diet and fluid intake.
3. Anxiety related to impeding surgery.
4. Increased susceptibility to falling related to
impaired mobility as evidence by patient’s
unsteady gait.
5. Hyperthermia related to disease process.
6. Impaired physical mobility related to fracture
tibial and fibula.
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 Other Examples:
DIAGNOSIS PROBLEMS
Self concepts Disturbance in body image related to
limb amputation
Cognition Knowledge deficit related home care
management (Diabetes)

Affect Sleep pattern disturbance related to

unfamiliarity with the hospital.

Coping Anxiety related to poor knowledge of

Mechanism diabetes
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Guidelines: Avoiding errors when
making diagnostic statements
The following are guidelines on how to avoid errors,
when making diagnostic statements:
1. Do not write diagnostic statement is such a way
that it may be legally incriminating.
Example:
Incorrect : Risk for infection related to staff’s poor
hand washing.
Correct : Risk for Infection related to Low white
count.

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Guidelines: Avoiding errors when
making diagnostic statements
The following are guidelines on how to avoid errors,
when making diagnostic statements:
2. Do not “rename” a medical problem to make it
sounds like a nursing diagnosis,
Example:
Incorrect : Anemia related to disease process as
evidenced by low hemoglobin.
Correct : Lethargic related to low haemoglobin as
evidence by poor activity tolerance and laboratory
result (Hb = 7gm/l)

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Guidelines: Avoiding errors when
making diagnostic statements
The following are guidelines on how to avoid errors,
when making diagnostic statements:
3. Do not write nursing diagnosis based on value
judgements.
Example:
Incorrect :
1. Risk of high blood sugar related to being and Asian.
2. Hyperthermia related to aircond dysfunction.
Correct :
1. Risk of high blood sugar related to high sugar intake
diet.
2. Hyperthermia related to disease process.
3. Hyperthermia related to dehydration.
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Guidelines: Avoiding errors when
making diagnostic statements
The following are guidelines on how to avoid errors,
when making diagnostic statements:
4. Do not state nursing diagnosis using medical
terminology. Focus on the person’s response to the
medical problem.
Example:
Incorrect : Mastectomy related to cancer
Correct :
1. Risk of self concept disturbance related to effects of
mastectomy.
2. Low Self Esteem related to Mastectomy.
3. Body image disturbance related to Mastectomy.
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Guidelines: Avoiding errors when
making diagnostic statements
The following are guidelines on how to avoid errors,
when making diagnostic statements:
5. Do not state two problems at the same time.
Example:
Incorrect : Pain and fear related to diagnostic
procedures as evidenced by facial expressions and
verbalisations from patient.
Correct :
1. Acute pain related to diagnostic procedure.
2. Fear related to diagnostic procedure.

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STUDENT ACTIVITY

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 Case Study
• Mr Ahmad, 35 years old and a Manager in Johor
Bahru. He is admitted to the medical unit from the
emergency department with severe muscle weakness
all over body and complaint of nausea 3/7 but no
vomiting. He also informed having diarrheal for 3/7.
• Other finding show, having coughing 3/7 with
productive cough, thick, greenish as informed by
patient.
• The Full blood count show platelet 70 microliter (μl) of
blood. Physical Examination show, abdomen soft,
rashes presence of both lower limb. Minor gum
bleeding seen 2/7.
• Vital signs – Temperature 38°C, Pulse 98 bpm, BP
145/90 mmHg, Respiration: 24/min
• Pain score : 6/10
• Other body part : Normal
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Instruction:
1. Formulate nursing diagnosis related to this
cases study.
2. Identify the subjective and objective data
from this case.

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THANK YOU

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