Topic: The Nursing Process: Diagnosis

Instructor: A. Besong
Course Code: NURS 2051
24-26/9/2019
At the end of 1 hours session the students will be able
to:
1. Define nursing diagnosis

2. Understand NANDA list of nursing diagnosis

3. Differentiate between medical and nursing

diagnosis

4. Describe and formulate a nursing diagnosis

statement

5. Understand how to prioritize nursing diagnosis

1. Assessment
 Collecting
 organize
 Validating and document data
2. Diagnosing
 Analyzing data
 Identify health problems, risks and
strengths
 Formulating nursing diagnosis
3. Planning
 Prioritize problems/diagnosis
 Formulate goals/desired outcomes
 select nursing interventions
 Write nursing interventions
4. Implementation
 Take action
 giving nursing care
 using support systems available
resources
 Document nursing activities
5. Evaluating
 Collect data related to outcomes
 Compare data with outcomes
 Relate nursing actions to clients
goals/outcomes
 Draw a conclusions about problem
status
 Continue, modify, terminate the
client’s care plan (revise the plan
of care)
second Phase of the  Providesthe basis for
nursing process selecting independent
nursing interventions
Diagnosis: is a statement to achieve outcomes
or conclusion regarding
the nature of a
phenomenon

Nursing Diagnosis: is a
clinical judgment about
the client’s response to
an actual or potential
health problems or life
processes.
Nursing Diagnosis Medical Diagnosis

1. Focuses on identifying 1. Focuses on identifying

human responses to diseases (pathology)
health and illness

2. Describe problems
treated by nurses within 2. Describe problems for
the scope of which the physician
independent nursing direct primary
practice treatment

3. May change from day to 3. Remains the same as

day as the client’s long as the disease is
responses change present
North American Nursing Diagnosis Association
(NANDA) adopted an official working definition of
the nursing process in 1990.

The purpose of NANDA international is to define,

refine, and promote a taxonomy (classification) of
nursing diagnostic terminology. (NANDA update
every 2 years)
Types of diagnosis (according to the client status):

1. An actual diagnosis
2. A Health promotion diagnosis
3. A risk nursing diagnosis
4. A wellness diagnosis

Note: Status refers to the actual or potential diagnosis.

Risk Nursing Diagnosis: Diagnosis label use Risk
for to describe the
Is a clinical judgment clients health status.
that a problem does
not exist, but the
presence of a risk
indicates that a
problem is likely to
develop unless the Example: Risk for
nurse intervene infection
A wellness Diagnosis:
Diagnosis label use
same as for Health
This describes promotion.
human response to Readiness for
level of wellness in enhanced-----
an individual,
family, or
Example: Readiness
community.
for enhanced
spiritual well being
An actual diagnosis: This type of diagnosis is
associated with the
Problem that is present presence of signs and
at the time of symptoms .
assessment.

Example: Ineffective Example: shallow

breathing pattern. breathing, nasal
flaring, abdominal
breathing etc..
Health promotion  Thesediagnosis label
Diagnosis: begin with the phrase
Readiness for
enhanced
Relates to the client’s
preparedness to
implement behavior
to improve their Example: Readiness for
health condition. enhance nutrition
In the diagnosis process, analyzing involves the
following steps:

1. Compare data against standards

2. Cluster the cues

3. Identify gaps and inconsistencies

This include establishing the client’s strength,
resources, and abilities to cope.

strengths can be found in the following:

 Nursing assessment records (health, home

life, recreation, education, exercise, work,
family and friends, religious belief,)

 Health examination

 Client records
components of a nursing e the following:

1. The problem

2. The etiology

3. The defining characteristics

Each component serves a specific purpose.

This can be written in P and E are joined by
two or three part the words related to
statements: rather due to.

Basic two parts include:

1. Problem (p):
statement of the
client response Example: constipation
(NANDA label). (p) related to
prolonged laxative
use (E).
2. Etiology (E): factors
contributing to or
probable cause of the
responses
The three part statement E.g. Noncompliance
is called the PES (diabetic diet) related to
format. unresolved anger about
1. Problem (p): diagnosis as manifested
Statement of the by
client response S: “I forgot to take my
(NANDA label) pill.”
“ I cant live without sugar
2. Etiology (E): Factors in my food.”
contributing to or
probable cause of the O: Weight 98kg (215lbs)
response blood pressure 190/100
3. Signs and symptoms Reminder: etiology is
(S): characteristics linked to S by writing As
manifested or evidenced/manifested by
evidence by the client
Are used in wellness diagnosis and syndrome
diagnosis, consisting of a NANDA label only.

e.g. Readiness for enhanced ------spiritual well being,

childbearing, parenting.

A nursing label is specific hence, an etiology may not

be needed.
1. Unknown etiology: Altered 4. Secondary to: risk for
comfort level (pain) impaired skin integrity
related to unknown related to decreased
etiology (the nurse does peripheral circulation
not know the cause or secondary to diabetes
contributing factors). (divide the etiology into 2
parts make it more
descriptive and useful)
2. Complex factors: Chronic (secondary is often a
low-self esteem related to pathophysiologic or
complex factors (multiple disease process).
related etiologic factors).
5. Adding a second part to
3. Possible: possible low self- the general response:
esteem related to loss of Impaired skin integrity
job and rejection by (left lateral ankle)
family.(more data is related to decreased
needed the client problem peripheral circulation
or the etiology).
 High priority – greatest
threat to well-being
 Medium priority – non-life
threatening
Diagnostic statement should
be : accurate, concise,
descriptive, and specific

 Low priority – diagnoses

that are not specifically
related to the current
illness and prognosis. Student activity: Review
Common Errors in Writing
Nursing Diagnoses and
Prioritizing Guideline: recommended corrections
1) Maslow’s BHN
2) ABC’s
3) Client Preference
4) Anticipated of future
Berman, A., Synder, S.J. (2012) Kozer & Erb’s
Fundamentals of nursing: Concepts, process,
& practice. (8th ed.). New Jersey: Pearson
Education

Potter, P.A. & Perry. A.G. (2005). Fundamentals of

nursing. (6th ed.). St..Louise, MO: Mosby.