nursing process(diagnosis)

Diagnosing

• Activities preceding the diagnosing phase are directed toward forming the nursing diagnoses.

• All other steps flow from nursing diagnoses.

• Nurses use critical thinking skills to interpret assessment data and identify client strengths and problems.

• North American Nursing Diagnosis Association (NANDA) International Define, refine, and promote a taxonomy

of nursing diagnostic terminology• Taxonomy

Classification system or set of categories arranged based on principle(s)

Copyright © 2016, 2012, 2008Pearson Education, Inc.

All Rights ReservedKozier & Erb's Fundamentals of Nursing, Tenth EditionAudrey Berman | Shirlee Snyder | Geralyn Frandsen

Figure 12–1 Diagnosing—the pivotal second phase of the nursing process.

Diagnosis

A statement or conclusion regarding the nature of a phenomenon• Diagnostic labels

Standardized NANDA names for diagnoses

• EtiologyCausal relationship between problem and its related factors• Nursing diagnosisProblem statement consisting of diagnostic label plus etiology

• Nursing diagnosis This definition implies the following: Professional nurses responsible for

making Includes only those health states that

nurses are educated and licensed to treat Judgment made only after thorough,

systematic data collection Continuum of health states

Status of the Nursing Diagnoses

1- Actual diagnosis Problem presents at the time of

assessment. Presence of associated signs and

symptoms

2- Health promotion diagnosis Preparedness to implement behaviors to

improve their health condition Example: Readiness for Enhanced

Nutrition

3- Risk nursing diagnosis Problem does not exist. Presence of risk factors

4- Syndrome diagnosis Cluster of nursing diagnoses that have

similar interventions

Components of a NANDA Nursing Diagnosis

1- Problem (diagnostic label) and definition

Describes the client's health problem or response

May require specification Qualifiers added to give additional

meaning• Such as Deficient, Impaired, Decreased,

Ineffective, and Compromised

2- Etiology (related factors and risk factors)

Identifies one or more probable causes of the health problem

Gives direction to the required nursing therapy

Enables the nurse to individualize the client's care

3- Defining characteristics Cluster of existing signs and symptoms

indicates actual diagnosis• Clients have signs and symptoms.

Cluster of factors that cause client to be more vulnerable to a problem indicates "risk for" diagnosis

Differentiating Nursing Diagnoses from Medical Diagnoses

• Nursing diagnosis A statement of nursing judgment based on

education, experience, expertise and license to treat

Describes human response, the client's physical, sociocultural, psychological, and spiritual responses to an illness or health problem

Changes when client's responses change Independent nursing functions• Areas of health care that are unique to nursing,

separate and distinct from medical management

• Medical diagnosis physician Refers to a disease process Remains the same as long as the

disease process is present Dependent nursing functions (physician-

prescribed therapies and treatments)



Table 12–3 Comparison of Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems

The Diagnostic Process

• Critical thinking Reviewing data and considering

explanations before forming opinions• Analysis

Separation into components (deductive reasoning)

• Synthesis Putting together of parts into whole

(inductive reasoning



Figure 12–2 Decision tree for differentiating among nursing diagnoses, collaborative problems, and medical diagnoses.

Formulating Diagnostic Statements

1- Basic two-part statements Problem (P) Etiology (E) Joined by the words "related to"

2- Basic three-part statements PES format• Problem (P)• Etiology (E)• Signs and symptoms (S)

List signs and symptoms grouped by subjective and objective data

3- One-part statements Health promotion diagnoses beginning

with Readiness for Enhanced



Table 12–6 Guidelines for Writing a Nursing Diagnostic Statement

Avoiding Errors in DiagnosticReasoning

• Verify data• Build a good knowledge base and

acquire clinical experience• Have a working knowledge of what is

normal• Consult resources • Base diagnoses on patterns rather than

an isolated incident• Improve critical thinking skills