Diagnosing

Learning Outcomes1. Differentiate various types of nursing diagnoses.2. Identify the components of a nursing diagnosis.3. Compare nursing diagnoses, medical diagnoses,

and collaborative problems.4. Identify basic steps in the diagnostic process.5. Describe various formats for writing nursing

diagnoses.

Learning Outcomes6. Describe the characteristics of a nursing diagnosis.7. List guidelines for writing a nursing diagnosis

statement.8. Describe the evolution of the nursing diagnosis

movement, including work currently in progress.9. List advantages of a taxonomy of nursing

diagnoses.

DIAGNOSINGDIAGNOSING

DIAGNOSING• In this phase, nurses use critical thinking skills to

interpret assessment data and identify client strengths and problems.

• Diagnosing is a pivotal step in the nursing process.

DIAGNOSING

DIAGNOSING HISTORY• Began formally in 1973• Two faculty members of Saint Louis University:

Kristine Gebbie and Mary Ann Lavin • The first national conference to identify nursing

diagnoses was sponsored by the Saint Louis University School of Nursing and Allied Health Professions in 1973.

• Subsequent national conferences occurred in 1975, in 1980, and every 2 years thereafter.

DIAGNOSING• The purpose of NANDA International:

– 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 based on a single principle or set of principles..

• The group has currently approved more than 200 nursing diagnosis labels for clinical use and testing.

NANDA Nursing DiagnosesNANDA Nursing Diagnoses

Definitions• DIAGNOSING

– refers to the reasoning process• DIAGNOSIS

– is a statement or conclusion regarding the nature of a phenomenon.

• DIAGNOSTIC LABELS – The standardized NANDA names for the diagnoses

• NURSING DIAGNOS – The client’s problem statement, consisting of the

diagnostic label plus etiology (causal relationship between a problem and its related or risk factors).

NURSING DIAGNOSIS

• A clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”… (1990, NANDA)

This definition is consistent with the following:

1. Professional nurses (registered nurses) are responsible for making nursing diagnoses

– nurses are accountable for analyzing data to determine diagnoses or issues.

– The standard also specifies that nurses should use standardized classification systems when naming diagnoses

2. The domain of nursing diagnosis includes only those health states that nurses are educated and licensed to treat..

This definition is consistent with the following:

3. A nursing diagnosis is a judgment made only after thorough, systematic data collection.

4. Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth.

Status of the Nursing DiagnosesStatus of the Nursing Diagnoses

Status of the Nursing Diagnoses

• “Status refers to the actuality or potentiality of the diagnosis or the categorization of the diagnosis”.(NANDA International)

The kinds of nursing diagnoses according to status are

• Actual• Health promotion• Risk • Wellness

Types of Nursing Diagnoses

1. Actual Diagnosis–Problem presents at the time of the

assessment–Presence of associated signs and

symptoms..

Examples are: Ineffective Breathing Pattern and Anxiety

Types of Nursing Diagnoses

2. Health Promotion Diagnosis – relates to clients’ preparedness to implement

behaviors to improve their health condition.– These diagnosis labels begin with the phrase

Readiness for Enhanced, as in Readiness for Enhanced Nutrition.

Types of Nursing Diagnoses

3. Risk Diagnosis– is a clinical judgment that a problem

does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene..

Example: –Risk for Infection

Types of Nursing Diagnoses

4. Wellness Diagnosis–“describes human responses to

levels of wellness in an individual, family or community”.

– Readiness for Enhanced Spiritual Well- Being or Readiness for Enhanced Family Coping.

Types of Nursing Diagnoses

•Possible Diagnosis–Evidence about a health problem

incomplete or unclear–Requires more data to either support

or to refute it•Syndrome Diagnosis

–Associated with a cluster of other diagnoses

Components of a NANDANursing Diagnosis

Components of a NANDANursing Diagnosis

Components of a NANDANursing Diagnosis

• A nursing diagnosis has three components: –(1) the problem and its definition–(2) the etiology–(3) the defining characteristics

• Each component serves a specific purpose.

Components of a Nursing Diagnosis

1. Problem (Diagnostic Label) and Definition• The problem statement, or diagnostic label,

describes the client’s health problem or response for which nursing therapy is given.

• It describes the client’s health status clearly and concisely in a few words.

• The purpose of the diagnostic label is to direct the formation of client goals and desired outcomes.

Components of a Nursing Diagnosis

1. Problem (Diagnostic Label) and Definition• To be clinically useful, diagnostic labels need

to be specific; when the word Specify follows a NANDA label, the nurse states the area in which the problem occurs,

• for example• Deficient Knowledge (Medications) or

Deficient Knowledge (Dietary Adjustments).

Components of a Nursing Diagnosis

1. Problem (Diagnostic Label) and DefinitionQUALIFIERS - are words that have been added to some

NANDA labels to give additional meaning to the diagnostic statement;

For example: ■ Deficient (inadequate in amount, quality, or degree; not

sufficient; incomplete) ■ Impaired (made worse, weakened, damaged, reduced,

deteriorated) ■ Decreased (lesser in size, amount, or degree)

■ Ineffective (not producing the desired effect) ■ Compromised (to make vulnerable to threat).

• Each diagnostic label approved by NANDAcarries a definition that clarifies its meaning. For example, the definition of the diagnostic label Activity Intolerance is shown in Table 12–1.

COMPONENTS OF NURSING DIAGNOSIS

DIAGNOSIS AND DEFINITION

RELATED FACTORS DEFINING CHARACTERISTICS

Activity Intolerance: Insufficientphysiological or psychological energy toendure or complete required or desireddaily activities

•Bed rest or immobility•Generalized weakness•Imbalance between oxygen supply/demand•Sedentary lifestyle

•Verbal report of fatigue or weakness•Abnormal heart rate or blood pressure response to activity•Electrocardiographic changes reflecting arrhythmias or ischemia•Exertional discomfort or dyspnea

Components of a Nursing Diagnosis

2. ETIOLOGY (RELATED FACTORS AND RISK FACTORS)

–The etiology component of a nursing diagnosis identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care

DIAGNOSTICLABEL

(PROBLEM) CLIENT ETIOLOGY

CLIENT ETIOLOGY

•Constipation Al Martinez Long-term laxative useJerry Wong Inactivity and insufficient fluidIntake

•Anxiety

•Al Martinez•Jerry Wong

Tanya Brown

Long-term laxative useJerry Wong Inactivity and insufficient fluidIntake

Threat to physiological integrity:possible cancer diagnosisCaitlin Shea Effects of aging (reducedhearing, vision, mobility)

Components of a Nursing Diagnosis

3. Defining characteristics– Cluster of signs and symptoms indicating the

presence of a particular diagnostic label (actual diagnoses)

– Factors that cause the client to be more vulnerable to the problem (risk diagnoses)

Differentiating Nursing Diagnoses

from Medical Diagnoses

Differentiating Nursing Diagnoses

from Medical Diagnoses

Differentiating Nursing Diagnosesfrom Medical Diagnoses

• NURSING DIAGNOSIS – is a statement of nursing judgment and refers to a

condition that nurses, by virtue of their education, experience, and expertise, are licensed to treat.

• MEDICAL DIAGNOSIS IS– made by a physician and refers to a condition that

only a physician can treat. – Medical diagnoses refer to disease processes—

specific pathophysiologic responses that are fairly uniform from one client to another.

• Nurses have responsibilities related to both medical and nursing diagnoses.

• Nursing diagnoses relate primarily to the nurse’s independent functions, that is, the areas of health care that are unique to nursing and separate and distinct from medical management.

• However, the nurse is still responsible for identifying and responding to data that indicate real or potential medical problems.

Differentiating Nursing Diagnosesfrom Collaborative Problems

• A collaborative problem is a type of potential problem that nurses manage using both independent and physician-prescribed interventions.

• Independent nursing interventions for a collaborative problem focus mainly on monitoring the client’s condition and preventing development of the potential complication.

• Collaborative problems are present when a particular disease or treatment is present; that is, each disease or treatment has specific complications that are always associated with it.

• For example, a statement of collaborative problems is “Potential complications of pneumonia: atelectasis, respiratory failure,

• pleural effusion, pericarditis, and meningitis.”

Nursing and Medical Diagnosis, and Collaborative Problems

• Differences Based on– Description– Orientation– Responsibility for diagnosing– Treatment orders– Nursing focus– Nursing actions– Duration– Classification system

Nursing Diagnoses • Describes human responses to disease

processes/health problems• Oriented to the client• Nurse responsible for diagnosing, treatment orders,

actions• May change frequently• Classification system in development

Medical Diagnoses • Describes disease and pathology• Does not consider human responses• Oriented to pathology• Physician responsible for diagnosing and treatment

orders• Nurse implements orders and monitors client status• Nursing actions dependent• Diagnosis remains as long as disease present• Well-developed and accepted classification

Collaborative Problems• Physiologic complications of disease, tests,

treatments• Oriented to pathophysiology• Nurse and physician diagnose• Physician orders definitive treatment• Independent nursing action for monitoring and

preventing• Dependent nursing actions for treatment• Present when disease/situation present• No classification system

The Diagnostic Process

• critical thinking, a person reviews data and considers explanations before forming an opinion

• Analysis is the separation into components, that is, the breaking down of the whole into its parts (deductive reasoning).

• Synthesis is the opposite, that is, the putting together of parts into the whole (inductive reasoning).

Steps in Diagnostic Process• Analyzing Data

– Compare data against standards– Cluster cues– Identify gaps and inconsistencies

• Identifying health problems, risks, and strengths• Formulating diagnostic statements

1. Comparing Data with Standards

• Nurses draw on knowledge and experience to compare client data to standards and norms and identify significant and relevant cues.

• A standard or norm is a generally accepted measure, rule, model, or pattern.

2.2 Clustering Cues

• Data clustering or grouping of cues is 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.

• This is the beginning of synthesis.

Identifying Gaps and Inconsistencies in Data

• Skillful assessment minimizes gaps and inconsistencies in data. However, data analysis should include a final check to ensure that data are complete and correct.

• Inconsistencies are conflicting data. Possible sources of

• conflicting data include measurement error, expectations, and inconsistent or unreliable reports.

Identifying Health Problems, Risks, and Strengths

Identifying Health Problems, Risks, and Strengths

Determining Problems and Risks

• After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnoses.

Writing Nursing Diagnoses

• Basic Two-Part Statement –Problem (P)–Etiology (E)• The two parts are joined by the words

related to rather than due to. The phrase due to implies that one part causes or is responsible for the other part. By contrast, the phrase related to merely implies a relationship.

• For NANDA labels that contain the word Specify, the nurse must add words to indicate the problem more specifically.

• The format is still a two-part statement. For example, Noncompliance (Specify) would be Noncompliance (Diabetic Diet) related to denial of having disease.

Writing Nursing Diagnoses

• Basic Two-Part Statement –Problem (P)–Etiology (E)

• Basic Three-Part Statement–Problem (P)–Etiology (E)–Signs and symptoms (S)

Writing Nursing Diagnoses • One-Part Statement

– Wellness (readiness for enhanced)– Syndrome

• Variations– Unknown etiology– Complex factors– Possible– Secondary– Other additions for precision

Characteristics of a Nursing Diagnosis

• Have diagnostic labels• Consist of the diagnostic label plus etiology • Professional nurses responsible for making nursing

diagnoses• A judgment made only after thorough, systematic

data collection• Describes a continuum of health states

Guidelines for Writing a Diagnostic Statement • State in terms of a problem, not a need.• Word the statement so that it is legally advisable.• Use nonjudgmental 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 • Use nursing terminology rather than medical terminology to

describe the client’s response and probable cause of client’s response

Improve Diagnostic Reasoning

• Verify diagnoses by talking with the client and family• Build a good knowledge base and acquire clinical

experience• Have a working knowledge of what is normal• Consult resources • Base diagnoses on patterns• Improve critical-thinking skills

Evolution of Nursing Diagnoses • First Taxonomy Alphabetical• Taxonomy II

– Domains– Classes– Nursing diagnoses– Seven axes

• Process for Acceptance on New Diagnosis• NIC• NOC

Taxonomy II

Taxonomy II

Advantages of a Taxonomy of Nursing Diagnoses• Development of a standardized nursing language • Nursing minimum data set

Post Test• Use your clickers to complete the following post test.

Question 1The nurse is conducting the diagnosing phases (nursing diagnosis) for a client with a seizure disorder. Which of the following elements exists between data analysis and formulating the diagnostic statement?

1. Assess the client’s needs.2. Delineate the client’s problems and strengths.3. Determine which interventions are most likely to succeed.4. Estimate the cost of several different approaches.

Rationales 1

1. This is assessment. 2. Correct. In diagnosing, data from assessment (option

1) are analyzed and problems, risks, and strengths are identified before diagnostic statements can be established.

3. Interventions are more commonly part of the planning and implementing phases of the nursing process.

4. Cost is an important consideration but would be estimated in the planning phase.

Question 2In the diagnostic statement “Excess fluid volume related to decreased venous return as manifested by lower extremity edema (swelling),” the etiology of the problem is which of the following?

1. Excess fluid volume.2. Decreased venous return.3. Edema.4. Unknown.

Rationales 2

1. Excess Fluid Volume is the nursing diagnosis.2. Correct. Because the venous return is impaired,

fluid is static, resulting in swelling. Therefore, decreased venous return is the cause (etiology) of the problem.

3. Edema of the lower extremity is the sign/symptom or critical attribute.

4. The cause is known.

Question 3Which of the following nursing diagnoses contains the proper components?

1. Risk for caregiver role strain related to unpredictable illness course.

2. Risk for falls related to tendency to collapse when having difficulty breathing.

3. Decreased communication related to stroke.4. Sleep deprivation secondary to fatigue and a noisy

environment.

Rationales 31. Correct. States the relationship between the stem

(caregiver role strain) and the cause of the problem.

2. The diagnostic statement says the same thing as the related factor (falls and collapse).

3. It is inappropriate to use medical diagnoses such as stroke within a nursing diagnosis statement.

4. Option 4 is vague. The statement must be specific and guide the plan of care (fatigue may be a result of sleep deprivation and does not direct intervention)

Question 4One of the primary advantages of using a three-part diagnostic statement such as the problem-etiology-signs/symptoms (PES) format includes which of the following?

1. Decreases the cost of health care.2. Improves communication between nurse and

client.3. Helps the nurse focus on health and wellness

elements.4. Standardizes organization of client data.

Rationales 4

1. More efficient planning may or may not reduce health care cost.

2. Nursing diagnostic statements should be confirmed with the client but using PES does not ensure this.

3. PES statements can be wellness or illness focused.4. Correct. The PES format assists with

comprehensive and accurate organization of client data.

Question 5A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis:

1. If both medical and nursing interventions are required to treat the problem.

2. When independent nursing actions can be utilized to treat the problem.

3. In cases where nursing interventions are the primary actions required to treat the problem.

4. When no medical diagnosis (disease) can be determined.

Resources• Audio Glossary• NDEC

A research team from the University of Iowa refined, extended, validated, and classified nursing diagnoses in collaboration with North American Nursing Diagnosis Association. Presents information obtained through this study.

• NANDA InternationalOfficial Web site of NANDA that offers information and links on nursing diagnosis.

Resources

• PDA cortexFreeware offered for students to download nursing diagnoses onto the computer

• Michigan Nurses Association: Standardized Nursing LanguageThe MNA's statement on the incorporation of nursing diagnoses into practice.

• The University of Iowa's Nursing ClassificationOverview and information on nursing classification and outcomes

• Guidelines for Composing a Nursing DiagnosisGuidelines and educational links on the development of nursing diagnosis

Question 1The nurse is conducting the diagnosing phases (nursing diagnosis) for a client with a seizure disorder. Which of the following elements exists between data analysis and formulating the diagnostic statement?

1. Assess the client’s needs.2. Delineate the client’s problems and strengths.3. Determine which interventions are most likely to succeed.4. Estimate the cost of several different approaches.

Rationales 11. This is assessment. 2. Correct. In diagnosing, data from assessment

(option 1) are analyzed and problems, risks, and strengths are identified before diagnostic statements can be established.

3. Interventions are more commonly part of the planning and implementing phases of the nursing process.

4. Cost is an important consideration but would be estimated in the planning phase.

Question 2

In the diagnostic statement “Excess fluid volume related to decreased venous return as manifested by lower extremity edema (swelling),” the etiology of the problem is which of the following?

1. Excess fluid volume.2. Decreased venous return.3. Edema.4. Unknown.

Rationales 2

1. Excess Fluid Volume is the nursing diagnosis.2. Correct. Because the venous return is impaired,

fluid is static, resulting in swelling. Therefore, decreased venous return is the cause (etiology) of the problem.

3. Edema of the lower extremity is the sign/symptom or critical attribute.

4. The cause is known.

Question 3Which of the following nursing diagnoses contains the proper components?

1. Risk for caregiver role strain related to unpredictable illness course.

2. Risk for falls related to tendency to collapse when having difficulty breathing.

3. Decreased communication related to stroke.4. Sleep deprivation secondary to fatigue and a noisy

environment.

Rationales 31. Correct. States the relationship between the stem

(caregiver role strain) and the cause of the problem.

2. The diagnostic statement says the same thing as the related factor (falls and collapse).

3. It is inappropriate to use medical diagnoses such as stroke within a nursing diagnosis statement.

4. Option 4 is vague. The statement must be specific and guide the plan of care (fatigue may be a result of sleep deprivation and does not direct intervention)

Question 4One of the primary advantages of using a three-part diagnostic statement such as the problem-etiology-signs/symptoms (PES) format includes which of the following?

1. Decreases the cost of health care.2. Improves communication between nurse and

client.3. Helps the nurse focus on health and wellness

elements.4. Standardizes organization of client data.

Rationales 4

1. More efficient planning may or may not reduce health care cost.

2. Nursing diagnostic statements should be confirmed with the client but using PES does not ensure this.

3. PES statements can be wellness or illness focused.4. Correct. The PES format assists with

comprehensive and accurate organization of client data.

Question 5A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis:

1. If both medical and nursing interventions are required to treat the problem.

2. When independent nursing actions can be utilized to treat the problem.

3. In cases where nursing interventions are the primary actions required to treat the problem.

4. When no medical diagnosis (disease) can be determined.

Rationales 51. Correct. A collaborative (multidisciplinary) problem is

indicated when both medical and nursing interventions are needed to prevent or treat the problem.

2. If nursing care alone (whether that care involves independent or dependent nursing actions) can treat the problem, a nursing diagnosis is indicated.

3. If nursing care alone (whether that care involves independent or dependent nursing actions) can treat the problem, a nursing diagnosis is indicated.

4. If medical care alone can treat the problem, a medical diagnosis is indicated.