How to formulate

Nursing Diagnosis?
What is a Nursing Diagnosis?

A nursing diagnosis is a clinical judgment concerning a human

response to health conditions/life processes, or a vulnerability
to that response, by an individual, family, group, or community. A
nursing diagnosis provides the basis for selecting nursing
interventions to achieve outcomes for which the nurse has
accountability. Nursing diagnoses are developed based on data
obtained during the nursing assessment and enable the nurse to
develop the care plan

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So these are the steps on how to
formulate Nursing Dx:
Step 1: : Data Collection (Assessment)
Step 2: Data Analysis and Organization

This is the foundation. You'll gather information

Once you have the data, analyze it to identify patterns
through various methods:
and significant details. Here's how to organize:
Patient interview: Ask open-ended questions about
Cluster data by category: Group findings related to
their health history, current concerns, and lifestyle.
symptoms, medications, social history, etc.
Physical examination: Conduct a systematic
Identify abnormal findings: Look for deviations
examination to assess vital signs, body functions,
from normal ranges or expected responses.
and any abnormalities.
Consider the patient's perspective: Understand
Reviewing medical records: Look for existing
how their health problem impacts their daily life.
diagnoses, medications, lab results, and physician
notes.

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So these are the steps on how to
formulate Nursing Dx:
Step 3: Formulating Your Nursing Diagnoses Step 4: Writing the Diagnosis Statement
Use a standardized format to ensure clarity and
Use the data to identify actual or potential health consistency. The most common format is PES
problems. Here are the types of diagnoses you might (Problem-Etiology-Symptoms):
formulate: Problem: The actual or potential health problem
Problem-focused: These address current health using approved nursing terminology.
problems (e.g., Impaired Skin Integrity related to Etiology (related to): The factors contributing to the
pressure injury).
problem.
Risk-focused: These identify potential problems a
Symptoms (as evidenced by): The objective and
patient might develop (e.g., Risk for Imbalanced
subjective signs and symptoms supporting the
Fluid Volume related to excessive vomiting).
diagnosis.
Health Promotion: These focus on areas where a
patient can improve their well-being (e.g.,
Readiness for Enhanced Sleep Pattern).

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 For all purpose
Thank you
for listening!

For Presenration
Presented by: Jayson D. Calingacion, SN
Cyrus John C. Ancla, SN
2024 May 6