NURSING DIAGNOSIS

"The nurse analyzes the assessment data in determining diagnoses"

DIAGNOSING
⁃ process of data analysis & problem identification
⁃ a form of decision making that the nurse uses to arrive at judgments
and conclusions about patients' responses to actual or potential health problems
NURSING DIAGNOSIS
⁃ the specific result of diagnosing & is the problem statement that
nurses use to communicate professionally
⁃ it refers to a problem statement that nurse makes regarding a patient's
condition
⁃ the judgment or conclusion which occurs as a result of nursing ---
Gebbie (1975)
⁃ a clinical judgment about an individual, family, or community which is
derived through a deliberate systematic of data collection and analysis
⁃ it provides the basis for prescriptions for definitive therapy for
which the nurse is accountable
⁃ it is expressed concisely and includes the etiology of the condition
when known
⁃ a clinical judgment about the patient's response to actual or potential
health conditions or needs

KEY TERMS RELATED TO DIAGNOSIS

COMPETENCY - having the knowledge and skills to identify problems and risks and to
perform actions safely & efficiently in various situations
QUALIFIED - being competent and having the authority to perform an action or give a
professional option
NURSING DOMAIN - actions a nurse is legally qualified to perform
MEDICAL DOMAIN - activities and actions a physician is legally qualified to perform
depending on state regulations, APN are also legally qualified to perform some
things in the medical domain.
ACCOUNTABLE - being responsible and answerable for something
DEFINITIVE INTERVENTIONS + most specific actions or treatments required to prevent,
resolve, or manage a health problem
OUTCOME - the result of prescribed interventions. Usually referred to as desired
result of interventions, includes a specific time frame when the outcome is
expected to be
achieved
SIGNS - objective (observable data) known to suggest a health problem
SYMPTOMS subjective (reported) data known to suggest a health problem
CUES - signs and symptoms that prompt you to suspect the presence of a health
problem or desire to improve health
DEFINITIVE DIAGNOSIS - most specific, most correct diagnosis that clearly
identifies both the problem and the cause
DEFINING CHARACTERISTICS
- a cluster of signs and symptoms, and related factors usually seen with a specific
nursing diagnosis
RULE OUT » to decide that a certain problem is NOT present
RELATED FACTOR
⁃ something known to be associated with a specific health problem
⁃ ( history of frequent falls is a related factor to (RISK FOR INJURY)
RISK FACTOR OR ETIOLOGY
⁃ something known to cause, or contribute to a diagnosis
⁃ (Decreased vision is a related Yactor for
RISK FOR INJURY)

PURPOSE OF NURSING DIAGNOSIS

⁃ to provide the basis for determination of a plan of care to achieve
expected outcomes for a patient's health statu
⁃ " to clarify the exact nature of the problems and risk factors to
achieve the overall expected outcomes of care .
⁃ the conclusions you make during this phase affect the entire plan of
care
The accuracy & relevancy of the entire plan depends on your ability to clarify the
problems and what factors are causing or contributing to them if you make errors in
this phase, your whole plan may be USELESS, even DANGEROUS.

DIAGNOSES - Use DIAGNOSES when referring to very specific problems that are CLEARLY
DEFINED and require very specific or long term solutions

DISORDERS, PROBLEMS, OR ISSUES- Use DISORDERS, PROBLEMS, OR ISSUES when the problem
is LESS CLEAR or when there's a simple or quick solution

ACTIVITIES IN DIAGNOSIS
⁃ Creating a list of suspected problems
⁃ Ruling out similar problems
⁃ Naming actual & potential problems and clarifying what's causing or
contributing to them
⁃ Determining risk factors that must be managed
⁃ Identifying resources, strengths, and areas for health promotion

TYPES OF NURSING DIAGNOSES

ACTUAL NURSING DIAGNOSES
⁃ Present or existing problem that may or may not necessitate immediate
concern
RISK (POTENTIAL) NURSING DIAGNOSES
⁃ A health problem that may develop into a problem if preventive actions
are not taken
POSSIBLE NURSING DIAGNOSES
⁃ You suspect a diagnosis /problem is present but the person's data need
more clarifying before you can decide whether the diagnosis/problem is present
WELLNESS DIAGNOSES
⁃ Human response to levels of wellness to individual, family or community
that have a READINESS FOR ENHANCEMENT (pre-fix for wellness diagnosis)
SYNDROME DIAGNOSES
⁃ compare patient signs and symptoms with the related factor and defining
characteristics of the syndrome diagnosis you suspect
Nurses growing responsibilities as
DIAGNOSTICIANS:
⁃ Monitoring for changes in health status
⁃ Promoting safety and preventing harm
⁃ Identifying and meeting learning needs
⁃ Promoting comfort and managing pain
⁃ Promoting health and well-being
⁃ Addressing problems that limit independence
5 MAJOR IMPACT ON YOUR DIAGNOSTIC
ROLE TODAY
1. The shift from diagnose & treat (DT) to predict, prevent, manage &
promote (PPMP)
2. More emphasis on the importance of multidisciplinary practice and
disease management (use of nurses to help people manage chronic disease by
themselves at home)
3. The development and refinement of critical pathways (also called
critical paths, clinical paths, Care Maps)
4. Information (use of computers to process and manage information) and
computer assigned diagnosis.
5. More awareness that nursing scope of practice has flexible boundary
that responds to the changing needs of society.

CRITICAL PATHWAYS
DISADVANTAGES
⁃ You may be influenced by knowing major diagnosis & predict care in
advance that it's easy to become. complacent, thinking , "I already know the
problem so I don't have to worry about too much assessment.
⁃ It's not unusual for patient's to be experiencing other important
problems that aren't covered by the path

ADVANTAGES
⁃ Gives outcome focused, evidence based approaches
⁃ Alert you to frequently encountered problems & predicted care for
situation.
⁃ Help you learn the usual treatment course for common problems through
repeated experience using the path with different patients

Using Standards or
Recognized Terminologies
• NANDA - North American Nursing Diagnosis Association
• NIC - Nursing Intervention Classification
• NOC - Nursing Sensitive Outcomes ClassificationANA - American Nurses
Association
• PNDS - Peri-operative Nursing Data Set
• HHCC - Home Health Care Classifications
• ICNP - International Classifications in Nursing Practice

HOW TO USE STANDARD LANGUAGE

• Be sure you understand conceptually the relationships
• Determine information resources (books)
• When you're in a new setting
• Check with instructor or supervisor
• Before you take any test, find out what terminology will be used

Good afternoon doc, ang ma shahsare ko po mgayon na talagang natandaan ko po is

yung using of standard language po.

COMPUTER- ASSISTED DIAGNOSIS

⁃ the soft ware of such computer is specifically designed to support
clinical decision making
BENEFITS :
1. Store large amount of data, keeping them available for recall as
needed.
2. Process large amount of data aster than humans can.
3. Perform at a consistent level (not affected by human factors like
fatigue, environmental distractions, boredom or complacency)
4. Prompt you to enter data, improving accuracy and completeness of
documentation and diagnosis.
5. Spot trends and flag potential problems or mistakes, such as drug
interaction or incorrect doses.
6. Facilitate diagnostic reasoning by suggesting possible diagnosis,
depending on matching assessment data.
LIMITATION:
• Assumed that enter data are true, simply shuffling the information
around.
• May not be up-to-date with minute-to-minute changes with patient
status.
• Don't replace humans; they require humans to analyze and interpret the
information they generate in context of current situations.
 • Don't relieve you of the responsibility of recognizing when computers
make obvious mistakes.

DIAGNOSIS
COMPETENT - Act in your patient's best interest, and protect yourself from legal
problems, you must understand the key terms to DIAGNOSIS.
WRITING NURSING DIAGNOSES
• FORMULA
Actual Nursing Diagnosis =
Patient problem + Causes if known
• PES APPROACH
Nursing Diagnosis =
Problem + Etiology + Signs and Symptoms
• At Risk / High Risk Nursing Diagnosis"= Problem + Risk Factors
• Possible Nursing Diagnoses = an incomplete problem statement because
the purpose of this diagnosis is to assure continued data collection
Guidelines in Writing a Nursing Diagnosis
1. Write the diagnosis in terms of the person's response rather than
nursing need.
2. Use "RELATED TO" rather than
3. Write the diagnosis in LEGALLY advisable terms.
4. Write the diagnosis WITHOUT value judgments.
5. Be sure that the two parts of the diagnosis do not mean the same thing.
6. Express the problems and related factors in terms that can be changed.
7. State the diagnosis CLEARLY & CONCISELY.
FUNDAMENTAL PRINCIPLES AND RULES OF DIAGNOSTIC REASONING
• Know your qualifications and limitations. o People have the right to be
assessed by a qualified health care professional.
• - Although you may feel that you have the knowledge to do an assessment
and diagnose the problems, you must determine (for your patient and your own legal
protection) whether you have the authority to do so.
• Keep an open mind. - Prevents you from seeing problems from a narrow
perspective, a common critical thinking error
• Making a diagnoses involves comparing your patient's cues (signs &
symptoms) with the "textbook picture" of the diagnoses you suspect. - You make a
definitive diagnosis, when your patient's data closely match the "textbook picture"
of the diagnosis you suspect.
• Name problems by using the labels that most closely match assessment
cues. -Diagnosis is based on recognizing when patient cues match the signs and
symptoms or defining characteristics of a specific diagnosis.
• When you suspect a specific problem, look for other signs, symptoms,
and risk factors commonly associated with the problem. - "More than one cue, more
likely it's TRUE. More than one source, more likely of course."
• When you make a diagnosis, back it up with evidence. - Cues are like
"key puzzle pieces", if you don't have them, you can't complete the puzzle and
label the problem.
• Include problems from patient's perspectives. - Patients know
themselves best, and must be included in the diagnostic process. - Things that the
patient sees as problems should be given a high priority.
• Patients often present complaining of two or more related problems. -
Often one problem creates another.

CAUSED OF DIAGNOSTIC ERRORS

⁃ Over valuing the probability of one explanation or failing to consider
all of the data because of a narrow focus.
⁃ Continuing to analyze when you should be acting to get help
⁃ Failing to recognize personal biases or assumptions.
⁃ Making a diagnosis that's too general (not being specific enough in
choosing a diagnostic label to name the problem)
 ⁃ Failing to include the correct diagnosis in the initial list of
possible problems.
⁃ Rushing to get done, either when collecting or analyzing data.

RISKS OF DIAGNOSTIC ERRORS

⁃ Initiating interventions that are harmless but wasteful of everyone's
time and energy.
⁃ Influencing others that problems exist as described incorrectly.
⁃ Placing yourself in danger of legal liability.

AVOIDING ERRORS IN
WRITING NURSING DIAGNOSIS
• Don't write the diagnostic statement in such a way that it may be
legally incriminating.
x - Risk for Injury related to lack of side rails on bed.
- Risk for Injury related to disorientation and attempts to get out from bed.
• Don't "rename" a medical problem to make it sound like a nursing
diagnosis.
x - Imbalanced hemodynamics related to hypovolemia
- Risk for deficient fluld related to increase blood loss.
• Don't make a nursing diagnosis out of a physician's order or a
collaborative problem.
x - Imbalanced Nutrition related to being on NPO.
⁃ Consider being on NPO to be a physician's order.In this case, you
monitor for the potential complication
• Don't write a nursing diagnosis based on value judgments.
x - Spiritual Distress related to Atheism as evidenced by statements that she has
never believed in God.
- Spiritual Distress related to loneliness as evidenced by self- alienation.
• Don't make a medical diagnosis a nursing diagnosis. Focus on the
person's response to the medical problem.
x - Mastectomy related to cancer.
- Risk for Self-concept Disturbance related to effects of mastectomy.
• Don't use two problems at the same time.
x - Pain & Fear related to the diagnostic procedure.
-Fear related to unfamiliarity with diagnostic
procedures
- Pain related to movement in X-ray.

CHECKLIST FIR WRITING THE DIAGNOSIS

Is the statement:
⁃ Based on evidence from the nursing assessment?
⁃ Descriptive of both the problem & its cause o Is the problem written
before the "related to" and the cause written after?
⁃ For actual diagnosis, have you added "
⁃ asevidenced by...."?
⁃ Specific & clear
⁃ Reflective of a problem that nursing has been authorized to manage?
⁃ Written with accepted terminology? o Free of legally inadvisable and
judgmental language?

(INSERT TABLE)MAIN FOCUS OF:

MEDICAL DIAGNOSIS :
⁃ The impact of disease, trauma or life changes upon patient and families
(human responses)
⁃ Problems with functioning independently (ADL)
⁃ Quality of life issues (pain, ability to do desired activities)
NURSING DIAGNOSIS
⁃ Quality of life tissues (pain, ability to do desired activities, but to
a lesser extent than nursing
⁃ they often refer this problem to other disciplines.
⁃ Allows opportunity to ramble and get off track.
⁃ Disease, trauma and pathophysiology

PRIMARY MANAGER OF THE PROBLEM

MEDICAL DIAGNOSIS:
⁃ Nurse (may use other resources such as physical therapy or physician
expertise, but the nurse accepts primary responsibility for monitoring status and
allocating resources
⁃ Definitive Diagnosis
⁃ Authority to diagnose is within the nursing domain
NURSING DIAGNOSIS
⁃ Physician or Advanced Practice Nurse
⁃ Definitive Diagnosis
⁃ Nursing is required to seek physician or APN diagnosis.

NURSING RESPONSIBILITIES
MEDICAL DIAGNOSIS
1. Identification of signs, symptoms and risk factors
2. Early detection of actual or potential problem.
NURSING DIAGNOSIS
1. Identification of risk factors, anticipating potential complications
2. Monitoring to detect and report early signs and symptoms or potential
complications or change in status

DIAGNOSIS
MEDICAL DIAGNOSIS
1. identifies pathologic basis for liliness
2. Focuses on the physical condition of the client
3. Addresses actual existing problems
4. Not validated with the client
5. Uses standardized goals & freatments
6. May not be resolvable
NURSING DIAGNOSIS
1. identifies response to illness
2. Focuses on the physical, psychosocial & spiritual needs of the client
3. Addresses actual & potential problems
4. Validated with the client, if possible
5. Uses INDIVIDUALIZED goals & Interventions
6. usually resolvable