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Diagnosis – Second Step in the Nursing Process

Definition 

  • Is the 2nd step of the nursing process.
  • the process of reasoning or the clinical act of identifying problems


Purpose 

  • To identify health care needs and prepare a Nursing Diagnosis.
  • To diagnose in nursing
  • It means to analyze assessment information and derive meaning from this analysis.


Nursing Diagnosis 

  • Is a statement of a client’s potential or actual health problem resulting from analysis of data.
  • Is a statement of client’s potential or actual alterations/changes in his health status.
  • A statement that describes a client’s actual or potential health problems that a nurse can identify and for which she can order nursing interventions to maintain the health status, to reduce, eliminate or prevent alterations/changes.
  • Is the problem statement that the nurse makes regarding a client’s condition which she uses to communicate professionally.
  • It uses the critical-thinking skills analysis and synthesis in order to identify client strengths & health problems that can be resolves/prevented by collaborative and independent nursing interventions.
    • Analysis – separation into components or the breaking down of the whole into its parts.
    • Synthesis – the putting together of parts into whole

Student Resources: Nursing Diagnoses

Image Courtesy: http://allnurses.com
Three Activities in Diagnosing: 

  1. Data Analysis
  2. Problem Identification
  3. Formulation of Nursing Diagnosis


Characteristics of Nursing Diagnosis 

  1. It states a clear and concise health problem.
  2. It is derived from existing evidences about the client.
  3. It is potentially amenable to nursing therapy.
  4. It is the basis for planning and carrying out nursing care.

Components of A nursing diagnosis (PES or PE) 

  1. Problem statement/diagnostic label/definition = P
  2. Etiology/related factors/causes = E
  3. Defining characteristics/signs and symptoms = S
  •   *Therefore may be written as 2-Part or a 3-Part statement.

Types of Nursing Diagnosis 

1. Actual Nursing Diagnosis – a client problem that is present at the time of the nursing assessment. It is based on the presence of signs     and symptoms.

Examples: 

  • Imbalanced Nutrition: Less than body requirements r/t decreased appetite nausea.
  • Disturbed Sleep Pattern r/t cough, fever and pain.
  • Constipation r/t long term use of laxative.
  • Ineffective airway clearance r/t to viscous secretions
  • Noncompliance (Medication) r/t unknown etiology
  • Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis
  • Acute Pain (Chest) r/t cough 2nrdary to pneumonia
  • Activity Intolerance r/t general weakness.
  • Anxiety r/t difficulty of breathing & concerns over work

2. Potential Nursing diagnosis – one in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it; or the causative factors are unknown but a problem is only considered possible to occur.

Examples: 

  • Possible nutritional deficit
  • Possible low self-esteem r/t loss job
  • Possible altered thought processes r/t unfamiliar surroundings

3. Risk Nursing diagnosis – is a clinical judgment that a problem does not exist, therefore no S/S are present, but the presence of RISK FACTORS is indicates that a problem is only is likely to develop unless nurse intervene or do something about it. No subjective or objective cues are present therefore the factors that cause the client to be more vulnerable to the problem are the etiology of a risk nursing diagnosis.

Examples: 

  • Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in diabetes.
  • Risk for interrupted family processes r/t mother’s illness & unavailability to provide child care.
  • Risk for Constipation r/t inactivity and insufficient fluid intake
  • Risk for infection r/t compromised immune system.
  • Risk for injury r/t decreased vision after cataract surgery.


Formula in writing nursing diagnosis (PES or PE) 

  1. Actual nursing diagnosis = Patient problem + Etiology – replace the (+) symbol with the words “RELATED TO” abbreviated as r/t. = Problem + Etiology + S/S
  2. Risk Nursing diagnosis = Problem + Risk Factors
  3. Possible nursing diagnosis = Problem + Etiology

Qualifiers – words added to the diagnostic label/problem statement to gain additional meaning.

  • “deficient” – inadequate in amount, quality, degree, insufficient, incomplete
  • “impaired” – made worse, weakened, damaged, reduced, deteriorated
  • “decreased” – lesser in size, amount, degree
  • “ineffective” – not producing the desired effect

Activities during diagnosis: 

  1. Compare data against standards
  2. Cluster or group data
  3. Data analysis after comparing with standards
  4. Identify gaps and inconsistencies in data
  5. Determine the client’s health problems, health risks, strengths
  6. Formulate Nursing Diagnosis – prioritize nursing diagnosis based on what problem endangers the client’s life

Situation: Functional Health Pattern – Activity/Exercise 

  • Anna, 35 years of laundry woman seeks consultation at the Philippine General Hospital due to fever 2 days prior to admission PTA. She verbalizes: “Bigla na lang ako giniginaw, masakit ang ulo at mainit ang pakiramdam pagkatapos kong maglaba sa kabilang kanto. “(“I suddenly felt cold, headache and warm after I done laundry”). She has 3 children she walks off to school everyday before she goes to work

Vital Signs 

  • Temperature (T) =39.2°C Respiratory Rate (RR) = 35 P = 96; with flush skin and warm to touch, teary eyed and with dry lips and mucous membrane.

Nursing Diagnosis 

  • Hyperthermia [related to (r/t)] environmental condition AMB T = 39°C, flush skin, warm to touch, teary eyed and dry lip and mucous membrane.


Situation: Functional Health Pattern = Nutritional/Metabolic 

  1. States, “No appetite since having cough”
  2. Has not eaten today; last fluids at noon today
  3. Has lost 8 lbs in past 2 weeks
  4. Nauseated x 2 days

Nursing Diagnosis 

  • Imbalanced Nutrition: Less than body Requirements r/t decreased appetite and nausea 2ndary to disease process/cough

Situation: Functional Health Pattern = Activity/Exercise

  1. Difficulty sleeping because of cough
  2. States, “Can’t breath lying down”
  3. Report pain on chest when coughing

Nursing Diagnosis 

  • Disturbed Sleep Pattern r/t a disease process, orthopnea and pain. Acute Pain (chest) r/t pathologic condition 2ndary to pneumonia


Situation: Functional Health Pattern = Coping/Stress 

  1. Anxious
  2. State, “I can’t breath”
  3. Facial muscles tense, trembling
  4. Expresses concern and worry over leaving daughter with neighbors
  5. Husband out of town, will be back next week.

Nursing Diagnosis 

  • Anxiety r/t difficulty of breathing and concerns over parenting roles.

Source:

http://www.rnpedia.com/home/notes/fundamentals-of-nursing-notes/diagnosis—second-step-in-the-nursing-process

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