Nursing Diagnosis
Gail Ladwig, RN, MSN, CHTP
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Process
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How to develop a nursing diagnosis
Step one:
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Assessment
Step two:


Analyze assessment information
Formulate nursing diagnosis
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Step One
ASSESSMENT
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Assessment and Nursing Diagnosis
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Step 1 of the nursing process: Assessment
Step 1 is the first step used to make a nursing
diagnosis
Comprehensive assessment leads to an
accurate nursing diagnosis
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Assessment and Nursing
Diagnosis (continued)

Collection of information about the client:

Holistic and detailed
 Supports critical thinking
 Determines problems and strengths
 Beginning and ongoing during all phases of the
nursing process
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Assessment

Assess the client
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Perform a thorough holistic nursing assessment
Use the format adopted by your facility or
educational institution
Nursing assessments based on conceptual
models:



Gordon’s functional health patterns
Orem’s self-care model
Roy’s adaptation model
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Assessment Sources
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Nursing assessment/health history: client
Physical assessment: client
Medical records
Diagnostic test results
Health team members
Significant others if appropriate
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Obtain an Accurate Health History

Ask open-ended questions:
“Describe what you are feeling.”
 “Tell me how the symptoms you are describing
affect your daily activities.”
 “Describe measures that you use to alleviate the
symptoms.”

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Physical Assessment

Perform a thorough physical assessment
Medical model:
Head to toe
-ORBody system


Carefully assess each area for normal and
abnormal findings.
Inspect, auscultate, palpate, and percuss.
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Critical Thinking
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Look for normal and abnormal findings.
Validate the data with the client:
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“This is what I have noticed.”
“Does this describe how you feel?”
“Tell me more.”
“What can I do to help?”
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Immediate Reporting
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Report and record information that requires
immediate action.
Some examples:
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Sharp, unrelenting pain
Vital signs greatly deviated from normal
Change in level of consciousness
When in doubt, ACT and report.
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Documentation
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
Record all information obtained from the
health history and physical assessment.
Most places are placing this information on
electronic record.
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Confidentiality
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Share only information that is of benefit to the
nursing and medical team for planning care.
Keep notes safe.

Do not leave notes at site of interview.
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Confidentiality (continued)
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
The client’s name should appear only on agency
documents. (Do not put client’s name on any
notes used for classroom work.)
Follow HIPAA (Health Insurance Portability and
Accountability Act) guidelines regarding client
confidentiality.
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Step Two
Analyze Assessment Information
Formulate Nursing Diagnosis
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Identify diagnosis
Identify related factors
List defining characteristics
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Definition: Nursing Diagnosis
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Clinical judgment
Individual, family, or community
Response to actual or potential health
problems or life processes
Basis for outcomes and interventions
The nurse is accountable.
(NANDA-International, 2009)
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Nursing Diagnosis: Critical Thinking
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Analyze information
2009 edition
203 Nursing Diagnoses
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Does it fit the NANDA definition?
 Are the defining characteristics in the
assessment?
 Can a change occur with a nursing intervention?
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Use of Assessment Information
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Organize the information
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Identify patterns in the assessment (highlight or
underline the problems).
Make a list of all problems and potential problems.
Group like problems together.
Make initial inferences or impressions.
Prioritize the problems.
• Use Maslow’s hierarchy
Report and record the information.
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Case Study
RJ, a 73-year-old male, has been admitted to
the unit with an admitting medical diagnosis of
COPD (chronic obstructive pulmonary disease).
He states that he has “difficulty breathing when
walking short distances.” He also states that his
“heart feels like it is racing” at the same time.
He states that he is “tired all the time,” and,
while talking to you, he is continually wringing
his hands and looking out the window.
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Identify Problems and Potential
Problems: Critical Thinking

Highlight or underline the problem areas in the
assessment.
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Highlight Problems
Case Study: RJ, a 73-year-old male, has been
admitted to the unit with an admitting medical
diagnosis of COPD (chronic obstructive
pulmonary disease). He states that he has
“difficulty breathing when walking short
distances.” He also states that his “heart feels
like it is racing” at the same time. He states that
he is “tired all the time,” and, while talking to
you, he is continually wringing his hands and
looking out the window.
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Problem Identification:
Critical Thinking

Make a list of the problems that have been
highlighted.
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List of Problem Areas
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COPD
“Difficulty breathing when walking short
distances”
“Heart feels like it is racing”
“Tired all the time”
Continually wringing hands while talking
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Identify Similarities: Critical Thinking
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Group or cluster similar problems.
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Clusters: Critical Thinking
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COPD
“Difficulty breathing when walking short
distances”
“Heart feels like it is racing”
“Tired all the time”
Wringing hands
Looking out the
window
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NANDA List: Critical Thinking
Check NANDA list
 What diagnosis may these clusters indicate?

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Nursing Diagnosis List
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Select the appropriate nursing diagnosis for
the client from NANDA’s approved list.
Nursing Diagnoses: Definitions and
Classification 2009-2010
Ackley/Ladwig Nursing Diagnosis Handbook:
A Guide to Planning Evidence-Based Care or
at EVOLVE Care Plan Constructor website
List of 203 “approved nursing diagnoses”
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7. Topology
Acute
1. Diagnostic
Concept
(NANDA)
2. Time
Chronic
6. Descriptor
Continuous
Intermittent
Individual
3. Unit of
Care
Family
Group
5. Health
Status
4. Age
Community
Fetus
Parts/Regions
of body
Actual
Risk
Wellness
Old-Old
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Selection of Appropriate Axes:
Critical Thinking

Diagnosis/diagnostic concept (select
appropriate axes based on the following
questions [not all axes will be used]):
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Is the problem acute, chronic, intermittent, or
continuous?
Is the client an individual, family, group, or
community?
What is the age of the client?
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Nursing Diagnoses Axis 5:
Select Appropriate Place on Continuum
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Health status: position or rank on the health
continuum of wellness to illness
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Wellness: the quality of being healthy, especially as a
result of a deliberate effort
Risk: vulnerability, especially as a result of exposure
to factors that increase the chance of injury or loss
Actual: existing in fact or reality, existing at the
present time
(Nursing Diagnoses: Definitions and Classification 2009-2011)
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Selection of Appropriate Axes:
Critical Thinking
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What best describes the limits of the
diagnosis?
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
Examples: anticipatory, compromised, decreased,
deficit, impaired, increased, ineffective, readiness
What part/region of the body is involved?

Examples: auditory, bowel, cerebral, intracranial,
oral, skin, visual
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NANDA List
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Activity intolerance
Activity intolerance, risk for
Adaptive capacity, decreased intracranial
Adjustment, impaired (delete these 2)
Adult failure to thrive (change to) Ineffective
Activity Planning
Airway clearance, ineffective
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Critical Thinking
Select a diagnosis.
 Read the NANDA definition.


Does the selected diagnosis fit the NANDA
definition?
 Is this what the client is demonstrating?
 Does the client agree that this is what is a
concern?
 Is it an actual risk or a wellness diagnosis?
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Activity Intolerance
Axis 5: Actual


NANDA definition
Insufficient physiological or psychological
energy to endure or complete required or
desired daily activities
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Analyze Client Symptoms:
Critical Thinking

Compare the problems from the cluster to the
defining characteristics of the nursing
diagnosis.

Is this the correct diagnosis?
 Are any other axes needed?
 Can this diagnostic concept stand alone?
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Signs and Symptoms: Defining
Characteristics of Critical Thinking
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Is the information in the assessment?
Does it reinforce or clarify the related
statement?
The phrase “as evidenced by” (AEB) may
be used to connect them to the nursing
diagnosis.
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Defining Characteristics:
Activity Intolerance
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Verbal report of fatigue or weakness
Abnormal heart rate or blood pressure response
to activity
Exertional discomfort or dyspnea
Electrocardiographic changes reflecting
dysrhythmias or ischemia
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Related Factors/Etiology:
Critical Thinking

Select related factors

Related factors are what may be causing or
contributing to the nursing diagnosis.
 This is often referred to as the etiology.

Pathophysiological and psychosocial
changes, such as developmental age and
cultural and environmental situations, may be
causative or contributing factors.
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Etiology: Related Factors
Critical Thinking
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

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Are they contributing to the nursing
diagnosis?
Are they environmental, physiological,
psychological, sociocultural, or spiritual?
Are they precise and accurate?
Will they help to direct nursing interventions?
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Related Factors: Activity Intolerance
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Bed rest or immobility
Generalized weakness
Sedentary lifestyle
Imbalance between oxygen supply and demand
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Nursing Diagnostic Statement

A working nursing diagnosis may have two or
three parts. The two-part system consists of
the nursing diagnosis and the “related to”
statement. The three-part system consists of
the nursing diagnosis, the “related to”
statement, and the defining characteristics.
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Critical Thinking Check
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The three-part diagnostic statement may be
referred to as the PES system:

(P)roblem: nursing diagnosis label
 (E)tiology: “related to” phrase
 (S)ymptoms: defining characteristics
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Nursing Diagnosis Label
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P (Problem):

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The nursing diagnosis—the label, a concise term
or phrase that represents a pattern of related cues
Example:

Activity intolerance
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Etiology
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E (Etiology):
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
“Related to" phrase (r/t) or etiology—related cause
or contributor to the problem
Example:

R/t imbalance between oxygen supply and
demand
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Defining Characteristics
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S (Symptoms):
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
Defining characteristics phrase—symptoms that the
nurse identified in the assessment
Example:

Verbal report of fatigue
 Abnormal heart rate in response to activity
• “Heart feels like it is racing”
 Exertional dyspnea
• “Difficulty breathing when walking short distances”
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Make a Nursing Diagnostic
Statement: PES
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Problem: nursing diagnosis
Etiology: related to statement
Signs and symptoms: defining characteristics
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Document the
Selected Nursing Diagnosis on the
Nursing Plan of Care
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Nursing Diagnostic Statement
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(P) Activity Intolerance
(E) Related to imbalance between oxygen
supply and demand
(S) Verbal report of fatigue, abnormal heart
rate in response to activity, “heart feels like it
is racing,” exertional dyspnea, “difficulty
breathing when walking short distances”
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Summary

Making a Nursing Diagnosis:

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Assess the client
Analyze information from the assessment
Write three-part nursing diagnostic statement
• (P)roblem: nursing diagnosis label
• (E)tiology: “related to” phrase
• (S)ymptoms: defining characteristics
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Complete the Nursing Process


Proceed to the planning phase of the nursing
process.
Document all information.
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References

North American Nursing Diagnosis
Association – International. Nursing
Diagnoses: Definitions and Classification
2009-2011. Oxford, UK, Wiley, 2009
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