1. Differentiate nursing diagnoses according to status and explain.

Actual nursing diagnosis is a client problem that is present at the time

of the nursing assessment. A real or problem-based nursing diagnosis is
based on the presence of associated signs and symptoms. The Health
promotion diagnosis relates to the client’s preparedness to implement
behaviors to improve their health. Risk nursing diagnosis is a clinical
judgment that a problem does not exist, but the presence of it indicates that a
problem is likely to develop unless nurses intervene. While the Syndrome
diagnosis is a clinical nursing assessment is necessary when a patient has
many nursing diagnoses that are comparable, such as altered respiratory
status caused by increased secretion and restricted pulmonary airflow caused
by a lack of flexibility in the alveoli.

2. Identify the components of a nursing diagnosis and explain.

Problem and Definition

 It describes the client’s health problem or response to which

nursing therapy is given. The purpose of it is to direct the
formation of client goals and desired outcomes.

Etiology

 Identifies one or more probable causes of the health problem

and gives the direction to the required nursing therapy, and
enables the nurse to individualize the client’s care.

Defining Characteristics
  The cluster of signs and symptoms that indicate the presence of
a particular diagnostic label. It is a client’s sign and symptoms.
For risk nursing diagnosis no subjective and objective signs are
present. Thus the factor that causes the client to be more
vulnerable to the problem from the etiology of a nursing
diagnosis.

3. Compare and explain nursing diagnoses, medical diagnoses, and

collaborative problems.

A Nursing diagnosis provides a way to describe the client’s area of

concern. It is a statement of clinical judgment that concerns a human response to
a health condition that nurses, by virtue of their education, experience, and
expertise are licensed to treat. While the Medical diagnosis is made by a
physician and refers to a condition that only a physician can treat. It refers to
disease processes and specific pathophysiologic responses that are fairly
uniform from one client to another. Collaborative problem is a type of potential
problem that nurses manage using both independent and physician-prescribed
interventions. It focuses mainly on monitoring the client’s condition and
preventing the development of a potential complication.

4. Identify the basic steps in the diagnostic process, give examples at least 3
each.

Compare the data against standards

 The nurse draws on knowledge and experience to compare

client data to standards and norms and identify significant and
relevant cues.
 Example:

 The client states: “I have recently experienced shortness of breath

while climbing stairs”
 Eating very small meals and having a little appetite to be normal.
 By age 9 months an infant is usually able to sit alone without
support. The infant who has not accomplished this task needs
further assessment for possible development.

Cluster cues

 A process of determining the relatedness of facts and

determining whether any patterns are present, whether the data
represent isolated incidents, and whether the data are
significant.

Example:

 They collect and interpret it, as evidenced in remarks “ I’m

getting a sense of “ or “ This cue doesn’t fit the picture”

Identify gaps and inconsistencies.

 Are conflicting data. A possible source of conflicting data

includes measurement error, and expectations of unreliable
reports.

Example:

 A nurse may learn from the nursing history that the client
reports not having seen a health provider in 15 years, yet
during the physical health examination he states, “My doctor
takes my blood pressure every year”.

5. Describe various formats for writing nursing diagnoses and explain.

 Problem

 Statement of client response to which nursing therapy is given

concisely

Etiology

 Factors contributing to or probable causes of the response.

component of a nursing diagnosis label identifies one or more
probable causes of the health problem, are the conditions
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.

Signs and symptoms

 Defining characteristics manifested by the client.

6. List guidelines for writing a nursing diagnosis statement.

 state in terms of a problem, not a need.
 Word the statement so that it is legally advisable.
 Use nonjudgemental statements.
 Make sure that both elements of the statement do not say the
same thing.
 Be sure that cause and effect are correctly stated.
 Word the diagnosis specifically and precisely to provide direction
for planning nursing intervention.
 Use nursing terminology rather than medical terminology to
describe the client’s response.

7. Describe the evolution of the nursing diagnosis movement, including work

currently in progress.
 Nursing diagnoses were developed and assimilated into the traditional
APIE nursing process model. Nursing process evolved from a four-step process
(APIE) to a five-step model: assess, diagnose, plan, implement, and evaluate
(ADPIE).