3. NURSING DIAGNOSIS
INTRODUCTION
Diagnosis is the second phase of nursing process. It is
often referred to as analysis as well as problem
identification or nursing diagnosis. It provide the basis
for the selection of nursing intervention to achieve the
outcome for which the nurse is accountable.
4. DEFINITION
Diagnosing refers to the reasoning process.
Diagnosis A statement or conclusion regarding the
nature of phenomenon.
Nursing diagnosis definition by NANDA (1990):-
A nursing diagnosis is a clinical judgement about
individual, family or community response to actual and
potential health problems/ life process. Nursing diagnosis
provides the basis for selection of nursing intervention to
achieve the outcome for which the nurse is accountable.
5. PURPOSE
 Identify how an individual, group or
Community responds to actual or potential
health and life processes.
 Identify factors that contribute to or cause
health problems (etiologies).
 Identify resources or strengths the
individual, group or community can draw on
to prevent or resolve problems.
6. Development of Nursing diagnosis
Began in 1973 by faculty members of Saint Louis University,
Kristine Gebbie & Mary Ann Lavin.
In 1977 International recognition came with the first
Canadian Conference in Toronto & the International
Nursing Conference in 1987, Canada.
1982 The Conference group accepted the Name North
American Nursing Diagnosis Association
(NANDA), (Nurses in Canada & US.)
7. PURPOSE OF NANDA
o To define, refine and promote a taxonomy of
Nursing diagnostic terminology of general use to
Professional Nurses.(Taxonomy is a classification
system or set of categories arranged on the basis of
single principle or set of principles).
o Members of Nanda Staff Nurses, Clinical
Specialists, faculty, Directors of
Nursing, Deans, Theorists & Researchers.
8. In 2000 NANDA approved new Taxonomy
II, which has 13 Domains, 106 classes and 155
Diagnosis.
Taxonomy II Domains
Domain 1 : Health Promotion.
2 : Nutrition
3 : Elimination
4 : Activity / Rest
5 : Perception / Cognition
6 : Self – perception
7 : Role relationships
8 : Sexuality
9 : Coping / Stress tolerance
10 : Life principles
11 : Safety / Protection
12 : Comfort
13 : Growth / Development.
9. NURSING DIAGNOSIS VERSES MEDICAL DIAGNOSIS
Medical diagnosis Nursing diagnosis
 Identify disease.  Focuses on unhealthy responses
to health and illness.
 Describe problems for  Describe problems treated by
which the physician directs nurses within the scope of
the primary treatment independent Nursing practice.
 May change from day to day as
the patients’ response change
 Remains the same as long
as the disease is present.  Example of Nursing diagnosis for
a person with myocardial
infarction
 Example of Medical  Fear
diagnosis
ď‚— Altered health maintenance
Myocardial infarction (heart ď‚— Pain
attack)
ď‚— Knowledge deficit
Altered tissue perfusion.
10. TYPES OF NURSING DIAGNOSIS
Actual Nursing
Diagnosis
Risk Nursing Possible Nursing
Diagnosis Diagnosis
Syndrome Wellness Nursing
Nursing Diagnosis Diagnosis
11. Actual Nursing Diagnosis:
It is judgement about the client
response to a health problem that is
present at a time of nursing
assessment.
Eg: Ineffective breathing pattern &
anxiety
12. Risk Nursing Diagnosis
It is a clinical judgement that a client is
more vulnerable to develop the problem
than others in the same or similar
situation.
Eg: Risk for impaired skin integrity
related to surgery.
13. Possible Nursing Diagnosis
It describe a suspected problem for
which current and available data are
insufficient to validate the problem.
Eg: Possible social isolation related to
unknown etiology.
14. Syndrome Nursing Diagnosis
It is a cluster of nursing diagnosis that
frequently go together and present a
clinical picture.
Eg: Rape Trauma Syndrome
15. Wellness Nursing Diagnosis
It is clinical judgement about an
individual, group or community in
transition from a specific level of
wellness to a higher level of wellness.
Eg: Family coping: potential for growth
related to unexpected birth of twins.
16. COMPONENT OF NURSING
DIAGNOSIS
Problem Statement
Defining
Etiology
Characterstics
17. Problem Statement (Diagnostic Label):
It describe the client health problem or
response for which nursing therapy is given
clearly and concisely in a few words.
Eg: Knowledge deficit(medications)
Some Qualifier are also added to give
additional meaning to the statement such as
Impaired, Decreased, Ineffective, Acute, Chron
ic.
18. Etiology (Related Factors & Risk
Factors):
This component identifies one or more probable
causes of health problem. It help the nurse to give
individualized patient care.
Eg: Anxiety related to hospitalization.
19. Defining Characterstics:
These are the clusters of signs and symptoms that
indicate the presence of a particular diagnostic
lebel.
Eg: Fluid volume deficit related to decreased oral
intake manifested by dry skin and mucus
membranes.
20. Nursing Diagnostic process
Assess the client health status
Validate data with other resources
Reasses
Is additional data needed?
s
No
Yes
Interpret and analyses of
data
21. Data clustering, group
sign & symptoms, classify
& organize
Look for defining
characterstics
Identify client needs
Formulate nursing diagnosis
& collaborative problems
22. FORMULATION OF NURSING DIAGNOSTIC
STATEMENT
The basic format for a diagnostic
statement is “ problem related to
etiology” however nurses must be able
to write one , two, three and four part
diagnostic statement, as well as some
variation of each.
23. BASIC TWO PART STATEMENT
The basic two part statement is used for
actual, high risk, and possible nursing
diagnosis.
It includes the following:
1. PROBLEM (P) : statement of client
response
2. ETIOLOGY(E) : Factors contributing
to or probable causes of responses.
24. The two part joined by the words
related to, or associated with rather
than due to.
e.g.1. Noncompliance ( diabetic diet)
related to denial of having disease.
2. Pain related to surgery
25. BASIC THREE PART STATEMENT
The basic three part statement is called the
PES
1.PROBLEM (P): Statement of client
response.
2.ETIOLOGY (E): Factors contributing to or
probable causes of responses.
3.SIGN AND SYMPTOMS(S) : defining
characteristics manifested by the client.
26. 4.Using “secondary to” divided the etiology into
two parts thereby making the statement more
descriptive and useful.
e.g. High risk for impaired skin integrity related to
decreased peripheral circulation secondary to
diabetes.
27. 5.Adding a second part to the general response or
NANDA label to make it more precise
e.g.
PROBLEM DESCRIPTER RELATED TO ETIOLOGY
Impaired physical inability to work related to knee joint stiffness
mobility and pain secondary to
muscle atrophy
28. FOUR PART STATEMENT
These statement are the
combination of basic statement
and variation 4 and 5 discuss
above
e.g.
1. High risk for impaired skin
integrity
2. Pressure sore related to
3. Immobility
4. Secondary to presence of
traction and casts.
29. ADVANTAGES
COMMUNICATION
CHARTING QUALITY
IMPROVEMENT
30. LIMITATION
LIMIT
NURSING
PRACTICE
IMPRESICE
LANGUAGE
LIMITED TO
NURSING
PROFESSIONAL
