Diagnosing
Learning Outcomes
1.
2.
3.
4.
5.
Differentiate various types of nursing
diagnoses.
Identify the components of a nursing
diagnosis.
Compare nursing diagnoses, medical
diagnoses, and collaborative problems.
Identify basic steps in the diagnostic process.
Describe various formats for writing nursing
diagnoses.
Learning Outcomes
6.
7.
8.
9.
Describe the characteristics of a nursing
diagnosis.
List guidelines for writing a nursing diagnosis
statement.
Describe the evolution of the nursing
diagnosis movement, including work currently
in progress.
List advantages of a taxonomy of nursing
diagnoses.
Nursing diagnosis identified and developed in 1973
because nursing role in the ambulatory nursing
setting needed to be identified
 In 1977 the international recognition of the nursing
diagnosis is occur
 In 1982 the name North America Nursing
Diagnosis Association (NANDA) was accepted
 Purpose of it: to define, refine and promote a
taxonomy of nursing diagnostic terminology of
general use to professional nurses

The Nursing Process
Nursing Diagnosis (According to
NANDA) define as:
Clinical Judgment or conclusion about individual,
family, or community response to actual or
potential health problem
 standardized NANDA names for the diagnosis
(diagnostic label or patient problem statement)
 Nursing diagnosis compose of diagnostic label and
etiology

NANDA – North American Nursing
Diagnosis Association
 Identifies nursing functions
 Creates classification system
 Establishes diagnostic labels
Types of Nursing Diagnoses
Actual Diagnosis
◦ Problem presents at the time of the assessment
◦ Based on presence of associated signs and
symptoms
◦ Ineffective breathing pattern
 Risk Diagnosis
◦ Problem does not exist
 Presence of risk factors indicate that the problem
is likely to develop unless nursing intervene
 Risk for infection

Types of Nursing Diagnoses
Wellness Diagnosis
◦ Readiness for enhanced family coping
 Possible Diagnosis
◦ Evidence about a health problem incomplete
or unclear
◦ Requires more data to either support or to
refuse it
 Syndrome Diagnosis
◦ Associated with a cluster of other diagnoses

Components of a Nursing Diagnosis

Problem statement (diagnostic label)
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Describes the client’s health problem or response
Describe the client health status clearly and concisely
Need to be specific
Need qualifiers (words have been added to some NANDA
label to give additional meaning) as:
* Deficit: inadequate in amount, quality or degree, not
sufficient
* Impaired: weakened, damaged
*Decreased: less in size, amount or degree
* Ineffective: not producing the desired effect
*compromised
Components of a Nursing Diagnosis

Etiology (related factors and risk factors)
◦ Identifies one or more probable causes
of the health problem
◦ Possible causes should be differentiated
because each may require different
nursing intervention
Components of a Nursing Diagnosis

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)
Nursing and Medical Diagnosis, and
Collaborative Problems

Differences Based on
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Description
Orientation
Responsibility for diagnosing
Treatment orders
Nursing focus
Nursing actions
Duration
Classification system
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Identifies conditions the
MD is licensed &
qualified to treat
Identifies situations the
nurse is licensed &
qualified to treat
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Identifies conditions the
MD is licensed &
qualified to treat
Identifies situations the
nurse is licensed &
qualified to treat
Focuses on illness,
injury or disease
processes
Focuses on the clients
responses to actual or
potential health / life
problems
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Remains constant
until a cure is
effected
Changes as the clients
response and/or the health
problem changes
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Remains constant
until a cure is
effected
Changes as the clients
response and/or the health
problem changes
i.e. Breast cancer
i.e. Knowledge deficit
Powerlessness
Grieving, anticipatory
Body image disturbance
Individual coping, ineffective
Diangosis
Nursing diagnosis
Medical diagnosis
Breathing patterns,
ineffective
Activity intolerance
Chronic obstructive
pulmonary disease
Cerebrovascular accident
Pain
Appendectomy
Body image disturbance
Amputation
Body temperature, risk for
altered
Strep throat
Collaborative Problems
Involve human response mainly to
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

Diagnostic process
Steps in Diagnostic Process

Analyzing Data
◦ Compare data against standards and norms
(identifying significant cues)
◦ Cluster cues (generate hypothesis)
◦ Identify gaps and inconsistencies
Compare Data:
Cues considered significant if it does any of the
following:
1. Point to +ve or –ve change in patient health status
2. Varies from norms of client population
3. Indicate development delay
Cues and Inferences
Cues = signs and
symptoms
Cues
Inference = what you think,
a judgement about the cues
Inference
Swollen finger
Reddened
Painful
Broken finger
Cluster Cues:
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Clustering: process of determining the relatedness
of facts and determine whether any pattern present
Beginning of synthesis
Involve making inferences about data
Identify gaps and inconsistencies:
It should include final check up to ensure that data
complete and correct
Source of conflict: measurement error, unreliable
report
Data can be found in nursing assessment, patient
history
Identifying health problems, risks, and
strengths:
- Determine problems risks
- Determine strength
 Formulating diagnostic statements

Writing Nursing Diagnoses

Basic Two-Part Statement
◦ Problem (P)
◦ Etiology (E)
Writing Nursing Diagnoses

Basic Three-Part Statement (PES format)
◦ Problem (P)
◦ Etiology (E)
◦ Signs and symptoms (S)
Problem
Related
to
Etiology
As
manifested
by
S&S
Situational low
self-esteem
r/t
Feeling of
rejection by
husband
a.m.b
a.e.b
Hypersensitivity to
criticism; stated ‘I
don’t know if I can
manage by myself’ and
reject positive feedback
Noncompliance (diabetic diet) related to
unresolved anger about diagnosis as
manifested by
S- ‘I forgot to take my pills’
‘I can’t live without sugar in my food’
O- weight 98kg (gain of 4.5kg)
blood pressure 190/100 mmHg
Writing Nursing Diagnoses

One-Part Statement
◦ Wellness (e.g. readiness for enhanced parenting)
◦ Syndrome: a diagnosis that is associated with a
cluster of other diagnoses:
 Risk for Disuse syndrome (experienced by long-term
bedridden. Clusters of diagnoses associated with this
syndrome include:
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Impaired physical mobility
Risk for impaired tissue perfusion
Risk for activity intolerance
Risk for constipation
Risk for infection
Risk for injury…….etc
Example of Nursing Dx

Ineffective therapeutic regimen
management
R/T difficulty maintaining lifestyle changes
and lack of knowledge
AEB 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”.
Guidelines for Writing a Diagnostic
Statement
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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
INEFFECTIVE BREATHING PATTERNS
DEFINITION
Ineffective Breathing Patterns: State in which a person
experiences an actual or potential loss of adequate
ventilation related to an altered breathing pattern
DEFINING CHARACTERISTICS
Major (Must Be Present, One or More)
Changes in respiratory rate or pattern (from baseline)
Changes in pulse (rate, rhythm, quality)
Minor (May Be Present)
Orthopnea Tachypnea, hyperpnea, hyperventilation
Dysrhythmic respirations. Splinted/guarded
respirations
Diagnosis
(P)
Related to
r/t
(E)
As evidenced by
Ineffective Breathing Patterns
Immobility and chest pain
Secondary to abdominal surgery
(S)  in respiratory rate from 12 to 22
pulse rate  88 to 104 and irregular