DIAGNOSING - After identifying all of them, formulate
diagnostic statements.
• Nursing Process (Definitions)
- It is a rational and scientific method done by
nurses
- (1) Deliberate way of thinking by nurses
[done consciously; critical thinking is
needed] using (2) an organized systematic
framework of interrelated activities [ADPIE]
that is (3) a scientific problem-solving
approach (entails decision making in every
phase of the nursing process; what is the
best action and most appropriate nursing
diagnosis for the patient?) towards (4)
individualized, dynamic and continuing
interpersonal care (different patients,
different problems and approach;
collaborative management is needed: both
patient and client dapat) (5) for client’s
changing responses and needs (evaluate if
there’s improvement or if it worsens)
- Client-centered ADPIE (garbage in, garbage
out)
- Universal: can be applied to everyone - a
client or community; can be applied to all
cases or disease
- Critical thinking: in every phase of nursing
process
- Interpersonal: collaboration with patients
and other health professionals are needed
- Decision making: especially in the
implementing phase; choose the best action
towards the wellness and recovery of
patient
• Diagnosis (Steps)
- Second phase of nursing process
- Analyze and interpret the data gathered
(cluster them, what are the problems and
diagnosis?)
- Identify the health problems (Ano yung
problem? May signs of bleeding or infection
ba yung patient?)
- Identify health risks (patient may have no
actual problem but can have risk factors)
- Identify strengths (patients have no problem
but has strength; when they are step closer
towards high level of wellness)
• Diagnosing vs Diagnosis
a. Diagnosing
- Broad term relating to reasoning
process
- Process of critical thinking
b. Diagnosis
- Statement or conclusion from a
nurse or doctor about a nature of a
certain phenomena
- Problem seen in the patient
• Case Scenario
“A 65-year-old male patient admitted to Medical
Ward with a chief complaint of difficulty of
breathing”
▪ It is the nurse’s obligation to assess the patient
comprehensively
▪ Possible na sakit/Hypothesis/Judgement:
- Asthma
- Pneumonia
- Lung cancer
- Chronic Obstructive pulmonary disease
- Anything related to respiratory and
cardiovascular system
▪ Upon assessing the patient:
a. Skin: has bluish skin discoloration -
Cyanosis
b. Behavior: With cough
c. Respiratory Rate: 25 cpm; Tachypnea
- Normal RR: 12-20 cpm only
d. Auscultate thorax: Wheezing sounds
▪ Based on assessment: from the patient; don’t need to memorize but
a. Medical Diagnosis: Asthma be familiarized)
b. Nursing Diagnosis: Ineffective Breathing 1. Exchanging
Pattern related to spasm of the bronchial - Nursing diagnosis about the
tubes in response to inhaled irritants as physiological changes
evidence by difficulty of breathing happening in the body
- Ex: breathing (airway),
• Nursing Diagnosis circulation, metabolism,
- A statement of nursing judgement elimination; case analysis
- Nurses cannot diagnose and treat diseases kanina, high blood pressure
and illnesses but can prevent them 2. Communicating
- Nurses can make independent nursing - Includes only one nursing
actions in order to alleviate the condition of diagnosis which is the
the patient impaired verbal
- Focuses on the responses to actual or communication
potential health problems or life processes - Ex.: Patient with stroke have
(not only physiologic but also spiritual and difficulty in speech
psychological aspects.) 3. Relating
- Changes as the client’s response changes - Relating to people
- Identifies situations in which the nurse is - Ex.: Patient is always
qualified to intervene isolated, impaired social
interactions, ineffective
• Medical Diagnosis sexual patterns (with partner)
- A condition that only a physician can treat 4. Valuing
- Disease process - Spiritual aspect of patient
- Pathologic condition of the patient - Ex.: Spiritual distress, risk for
- Focuses on the illness, injury, or disease spiritual distress
process 5. Choosing
- Remains constant until it is cured (ex.: Yung - Coping mechanism and
asthma nandiyan pa rin kahit mawala na strategy of the patient
yung breathing problems) - Ex.: Nakapagcope ba siya o
- Identifies conditions the healthcare hindi? Nasa stages of denial
practitioner is qualified to treat pa rin ba siya?
6. Moving
• NANDA Book - Mobility and movement
- North American Nursing Diagnosis - Ex.: Impaired physical
Association mobility, impaired walking,
- Reference tool during nursing duty activity intolerance (di
- To know the appropriate diagnosis for the matolerate ng patients yung
patients paggawa ng ADL)
- Healthcare associations set the taxonomy 7. Perceiving
(classifications and categories of different - Self-perception of the patient
nursing diagnosis terminology) - Ex.: Patient has breast
- Includes the nursing diagnosis cancer, undergo ng
- A diagnostic system is organized around 9 Mastectomy (removal of
human response patterns: (Actually, there breast). She is problematic
are more than 170 nursing diagnoses to na nawala yung kanyang
choose from base on the data gathered isang breast since may
disturbed body image siya.
 8. Knowing
- Patient’s knowledge 3. Relating
- Ex.: Patient doesn’t know - Impaired social interactions
what medications to take and - social isolation
the right diet, knowledge - risk for loneliness
deficiency - ineffective role performance
9. Feeling - deficient parenting
- Pain or grieving process of - risk for deficient parenting
patient - risk for impaired parent/infant/child
- Among all the vital signs, the - attachment/sexual dysfunction
more subjective feeling is the - interrupted family processes
pain - caregiver role strain
- Ex.: Acute pain, chronic pain - risk for caregiver role strain
- dysfunctional family processes
• Examples of Nursing Diagnosis from NANDA - alcoholism parental role conflict
1. Exchanging - ineffective sexuality patterns
- Imbalanced nutrition: more than body
requirements 4. Valuing
- Imbalanced nutrition less than body - Spiritual distress
requirements - risk of spiritual distress
- Risk for imbalanced nutrition: more than - readiness for enhanced spiritual well-being
body requirements
- Risk for infection 5. Choosing
- Risk for altered body temperature - Ineffective coping
- hypothermia - impaired adjustment
- hyperthermia - defensive coping
- ineffective thermoregulation - ineffective denial
- autonomic dysreflexia - disabled family coping
- risk for autonomic dysreflexia - readiness for enhanced family coping
- Constipation - management
- perceived constipation - noncompliance
- diarrhea - decision conflict
- bowel incontinence - health seeking behavior
- risk for constipation
- impaired urinary elimination 6. Moving
- stress urinary incontinence - impaired physical mobility
- reflex urinary incontinence - fatigue
- urge urinary incontinence - sleep deprivation
- functional urinary incontinence - disturbed sleep pattern
- total urinary incontinence - impaired home maintenance
- risk for urge urinary incontinence - delayed surgical recovery
- urinary retention - adult failure to thrive
- ineffective tissue perfusion
- risk for fluid volume imbalance 7. Perceiving
- excess fluid volume - Disturb self-esteem
- etc - chronic low self esteem
- disturbed body image
2. Communicating - Hopelessness
- Impaired verbal communication - Powerlessness
 - unilateral neglect - ex.: Readiness for enhanced breastfeeding
- disturbed sensory perception (Paano ba magbreastfeeding? - patient has
- nestor personal identity eagerness to learn because she knows its benefits)
4. Possible Diagnosis
8. Knowing - Evidence about a health problem is incomplete or
- deficient knowledge unclear.
- impaired memory - ex.: Possible social isolation (Patient is elderly
- disturbed thought processes and widowed, mag-isa lang siya and no visitors na
- acute confusion pumupunta sa room; pedeng related to unknown
- impaired environmental interpretation cause or aging)
syndrome
5. Syndrome Diagnosis
9. Feeling - A diagnosis that is associated with a cluster of
- acute pain other diagnoses
- chronic pain - ex.: Risk for disuse syndrome (isa sa nursing
- nausea diagnosis na kapag nilagay mo ang dami nang
- dysfunctional grieving papasok na nursing diagnosis na under niya)
- ex.:Disuse: di na nagagamit ng katawan kapag
• Types of Nursing Diagnosis palaging nakahiga or immobility, can result to
1. Actual Diagnosis impaired physical mobility, risk for impaired skin
- Client problem that is present at the time of the integrity, constipation)
nursing assessment - pinakakaunti lang compare sa 170 nursing
- kung ano yung nakita mo sa pasyente diagnosis
- health status of patient
- ex.: ineffective breathing pattern, anxiety

2. Risk Diagnosis
- A problem does not exist, but the presence of risk
factors indicates that the problem is likely to
develop.
- Has no signs and symptoms
- ex.: Patient has normal vital signs but is an
elderly, bedriden, and has limited movement. He is
at risk for impaired skin integrity because he might
have pressure ulcers or bed sores later on.
- ex.: Patient has no problem but undergoes
chemotherapy. He has a low immune system and
high risk for infection.

* Prioritize first the actual diagnosis than the risk

diagnosis

3. Wellness Diagnosis
- Describes human responses to levels of wellness
in an individual, family, or community that have a
readiness for enhancement.
- health promotion