Nursing Diagnosis

Nursing Diagnosis
• Second step of the Nursing Process
• Interpret & analyze clustered data
• Identify client’s problems and strengths
• Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis
Association)-Statement of how the client is RESPONDING to an actual or
potential problem that requires nursing intervention.
 Medical Nursing
Diagnosis Vs Diagnosis
• Within the scope of • Within the scope of
medical practice nursing practice
• Focuses on curing • Identify responses to
pathology health and illness
• Stays the same as long as • Can change from day to
the disease is present day
 Medical diagnosis Nursing diagnosis

Chronic obstructive Breathing patterns, ineffective

pulmonary disease

Cerebrovascular accident Activity intolerance

Appendectomy Acute Pain abdomen

Amputation Body image disturbance

Nursing Diagnosis
1. Medical Identification of a disease condition
diagnosis based on specific evaluation of signs
and symptoms

2. Nursing Clinical judgment about the patient

diagnosis in response to an actual or potential
health problem

3. Collaborative Actual or potential physiological

problem complication that nurses monitor to
detect a change in patient status
Types of Nursing Diagnoses
Actual Nursing Describes human responses to
Diagnosis health conditions or life
processes
Risk Nursing Describes human responses to health
Diagnosis conditions/life processes that may
develop
Health Promotion A clinical judgment of motivation,
Nursing Diagnosis desire, and readiness to enhance
well-being and actualize human
health potential
Types of Nursing Diagnoses

5 kinds of nursing diagnosis

• Actual
• Risk/ Potential nursing diagnoses
• Possible nursing diagnoses
• Wellness diagnoses
• Syndrome diagnoses
Formulating a Nursing Diagnosis

Composed of
3 parts:

Problem statement- the client’s

response to a problem

Etiology- what’s causing/contributing

to the client’s problem

Defining Characteristics- what’s the

evidence of the problem
 Nursing Diagnosis -Components
Problem( Diagnostic Label)-
based on your assessment of
client…(gathered information),
pick a problem from the NANDA
list...

Etiology- determine what the problem is

caused by or related to (R/T)...

Defining characteristics- then state as

evidenced by (AEB) the specific facts the
problem is based on...
Types of Nursing Diagnoses

Actual Wellness
Imbalanced nutrition; Risk Family coping:
less than body Risk for falls potential for
requirements R/T R/T altered gait growth R/T
chronic diarrhea, and generalized
nausea, and pain AEB unexpected
weakness birth of twins.
height 5’5” weight 78kg
Components of a Nursing Diagnosis
Diagnostic Label (NANDA-I) Definition
Related Factors/Etiology:
Treatment-related
Pathophysiological (biological or psychological)
Maturational
Situational (environmental or personal)
PES Format:
Problem
Etiology
Symptoms (or defining characteristics)
Values /descriptors:
• Disturbed Disproportionate
• Impaired Compromised
• Ineffective Anticipatory
• Imbalanced Enhanced
• Excessive Interrupted
• Decreased Perceived
• Deficient Readiness for
• Delayed Situational
• Disabled
• Disorganized
Example of Nursing Diagnosis
(NANDA only)

Ineffective therapeutic regimen management R/T

difficulty maintaining lifestyle changes and lack of
knowledge as evidenced by B/P= 160/90, dietary sodium
restrictions not being observed, and client statements of
“ I don’t watch my salt” “It’s hard to do and I just don’t
get it”.

Ineffective airway clearance/ related to physiologic

effects of pneumonia/ as evidenced by increased
sputum, coughing, abnormal breath sounds, tachypnea,
and dyspnea
1. Problem
a) Actual Diagnosis
• Client is already experiencing this nursing problem (see Carpenito’s defining
characteristics and criteria)
Contains three elements
• Imbalanced nutrition ; less than body requirements r/t impaired absorption of
nutrients; decreased oral intake 2° Crohn’s disease as evidenced by 10% body
weight loss and decreased serum albumin of 3.2 g/dl, decreased Hgb (8g/dl)
• Ineffective airway clearance related to fatigue as evidenced by ineffective
cough.
• Impaired skin integrity r/t immobility 2°to pain AEB 2cm erythematous sacral
lesion
 2. Etiology

(contributing factors, influencing or risk factors)

• These related factors have contributed to & influenced the

change in the health status (4 categories: pathophysiologic,
treatment related, situational, maturational)
• All etiologies should be included
• Be precise – may use ‘secondary to’ if helpful
• Do not state medical diagnosis unless using as ‘secondary to’ in
your etiology.
 Recognize mistake…………….
• Disturbed self-concept r/t multiple sclerosis –
incorrect!
• Disturbed self-concept r/t recent loss of role responsibilities 2° multiple
sclerosis AEB “my mother comes every day to run my house”

• Etiologies are included with actual or high risk problems but not for PC
(potential complication) diagnostic statements
3. DEFINING CHARACTERISTICS

These are the clinical criteria or assessment findings that

support a nursing diagnoses.
• Signs (objective data)
• Symptoms (subjective data)
• Other relevant data (ie. Lab data, test reports)
• Designated as Major or Minor (see Carpenito)
• Be specific – individualize
• Included with actual problems only
A complete nursing diagnosis
• Format:
• “ Problem related to cause of problem as evidenced by
symptoms of problem”
• “ Impaired gas exchange related to excessive secretions
as evidenced by O2 saturation 84%
 b) Risk Diagnosis

• Client does not experience the problem currently but is at high risk of
developing the problem
Contains two elements
• High risk for Imbalanced nutrition (less than body requirements) r/t nutritional losses
through diarrhea and vomiting .
• Risk for physical injury related to disorientation, and impaired mobility.

• High risk for impaired skin integrity r/t immobility.

• High risk for infection r/t interrupted skin integrity from surgical incision 2°abdominal
hysterectomy.
PC (POTENTIAL COMPLICATIONS):
• Require both physician prescribed and nursing prescribed
interventions – hence, are collaborative problems.
• One part statement.

(physiologic complications that nurses monitor to detect onset

of changes in status)
• Potential for Complication: Postpartum hemorrhage
• Potential for Complication : Atelectasis / Pneumonia
• Potential for Complication : Pulmonary Embolism
 Collaborative Problems
• Require both nursing interventions and medical interventions
EXAMPLE: Client admitted with medical dx of pneumonia
Collaborative problem = respiratory insufficiency
Nursing interventions: Raise head end of bed, Encourage
coughing and deep
breathing.
MD interventions: Antibiotics IV, O2 therapy
 Planning
Third step of the Nursing Process
• This is when the nurse organizes a nursing care plan based on the
nursing diagnoses.
• Nurse and client formulate goals to help the client with their
problems
• Expected outcomes are identified
• Interventions (nursing orders) are selected to aid the client reach
these goals.
 Remember :

• Once you have assessed a client’s condition & identified

appropriate nsg dx, a plan is developed for the client’s care.
• Planning involves establishing client goals & expected
outcomes and selecting nsg interventions
• plan of care is dynamic & will change as the client’s needs are
met or as new needs are identified
 Planning – Begin by prioritizing client
problems

• Prioritize list of client’s

nursing diagnoses using
Maslow
• Rank as high,
intermediate or low
• Client specific
• Priorities can change
NOW C
A
B
 Planning
Developing a goal and outcome statement
• Goal and outcome statements are
client focused.
• Worded positively
• Measurable, specific observable,
time-limited, and realistic
• Goal = broad statement
• Expected outcome =
objective criterion for
measurement of goal
EXAMPLE
• Goal:
Client achieves therapeutic
management of disease
process….
• Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and client
statement of understanding
importance of dietary
sodium restrictions by day
of discharge.
Planning- Types of goals
• Short term goals
• Long term goals
• Cognitive goals
• Psychomotor goals
• Affective goals
Developing expected outcome:
Goal:
Patient’s lung remains clear post operatively.
Expected outcomes:
• Sputum remains white
• Patient remains afebrile
• Lungs are clear on auscultation
Goals are patient-centered and
SMART
 Specific
 Measurable
 Attainable
 Relevant
 Time Bound
e.g.
Pt walks 50 ft.
Pt eats 75% of meal
Pt maintains HR<100
Pt states pain level is acceptable 6 (0-10)
Planning-select interventions
• Interventions are selected and written.

• The nurse uses clinical judgment and professional knowledge to

select appropriate interventions that will aid the client in reaching
their goal.

• Interventions should be examined for feasibility and acceptability

to the client.

• Interventions should be written clearly and specifically.

Examples of goals / outcomes
Problem statement of Nsg Goal/Expected outcome
Diagnoses
Pain Client reports
absence/diminished pain
Imbalanced nutrition more within 8 hrs
than body requirement Client reaches target weight of
Impaired physical mobility 60 kg within a week.
Client walks along the hallway
independently before
discharge
Interventions – 3 types
• Independent ( Nurse initiated )- any action the
nurse can initiate without direct supervision
• Dependent ( Physician initiated )-nursing actions
requiring MD orders
• Collaborative- nursing actions performed jointly
with other health care team members
Implementation
Implementation
• The fourth step in the Nursing Process
• This is the “Doing” step
• Carrying out nursing interventions (orders) selected during the planning step
• This includes monitoring, teaching, further assessing, reviewing NCP,
incorporating physicians orders and monitoring cost effectiveness of
interventions
• Utilize NIC as standard
Implementing
• Monitor VS q4h
• Maintain prescribed diet (2
Gm Na)
• Teach client amount of
sodium restriction, foods
high in sodium, use of
nutrition labels, food
preparation and sodium
substitutes
- “Doing”
• Teach potential
complications of
hypertension to instill
importance of maintaining
Na restrictions
• Assess for cultural factors
affecting dietary regime
Implementing – “Doing”
• Teach the client- hypertension can’t be cured
• Teach
but itclient
can beimportance
controlled.of
life style changes: (weight
• Remind the client to continue medication even though smoking
reduction, no S/S are present.
cessation, increasing
activity)
• Stress the importance of
ongoing follow-up care
even though the patient feels
well.
Evaluation- To determine effectiveness of
NCP
• Final step of the Nursing Process but
also done concurrently throughout client care
• A comparison of client behavior and/or response
to the established outcome criteria
• Continuous review of the nursing care plan
• Examines if nursing interventions are working
• Determines changes needed to help client reach
stated goals.
Evaluation
• Outcome criteria met? Problem resolved!
• Outcome criteria not fully met? Continue plan of care- ongoing.
• Outcome criteria unobtainable- review each previous step of NCP and
determine if modification of the NCP is needed.
• Were the nsg interventions appropriate/effective?
Evaluation
Evaluation
Factors that impede goal attainment:

• Incomplete database
• Unrealistic client outcomes
• Nonspecific nsg interventions
• Inadequate time for clients to achieve outcomes.