Nursing Process Diagnosing

NURSING PROCESS

PREPARED AND PRESENTED BY

MRS.S.ANUKRISHNAN,

VICE PRINCIPAL CUM HOD OBG NURSING,

P.D.BHARATESH COLLEGE OF NURSING,

HALAGA, BELGAUM.

INTRODUCTION

Second phase of the Nursing Process.

Nurses use critical thinking skills to interpret assessment

data and identify client strengths & problems.

Diagnosing is the pivotal step in the nursing process.

All activities preceding this phase are directed toward

formulating the nursing diagnosis.

All the care planning activities following this phase are

based on the nursing Diagnoses.

The identification & development of nursing Diagnosing

began formally in 1973.

NORTH AMERICAN NURSING DIAGNOSING ASSOCIATION

NANDA: - is to define, refine & promote

taxonomy of Nursing Diagnostic terminology of

general use to professional nurses.

Taxonomy - is the classification system

Currently NANDA approved more than 150

Nursing Diagnosis labels for clinical use & testing.

In 2000 taxonomy I revised & now referred to as

Taxonomy II.

DEFINITION

“It is a clinical judgment about individual,

family or community responses to actual and

potential health problems/life processes.

Nursing diagnoses provide the basis for

selection of nursing interventions to achieve

outcomes for which the nurses are

accountable”.

TYPES OF NURSING DIAGNOSES

1. Actual Nursing Diagnosis

2. Risk Nursing Diagnosis

3. Wellness Diagnosis

4. Possible Nursing Diagnosis

5. Syndrome Diagnosis

ACTUAL NURSING DIAGNOSIS

Actual Nursing Diagnosis is a client problem that

is present at the time of the Nursing

assessment.

The actual Nursing Diagnosis is based on the

presence of associated signs & symptoms.

EXAMPLES OF ACTUAL NURSING DIAGNOSIS

Ineffective breathing pattern related to bacterial /

viral inflammatory Process.

Ineffective breathing pattern related to Tracheo-

bronchial obstruction

Anxiety related to changes in the environment and

routines, threat to socio economic status.

Anxiety related to change in health status and

situational crisis.

Body image disturbance related to temporary

presence of a visible drain/ tube.

RISK NURSING DIAGNOSIS It is a clinical judgment that a problem doesn’t

exist, but the presence of risk factors indicates

that a problem is likely to develop unless nurses

intervene.

Eg. A client with Diabetes Mellitus or a

compromised immune system is at high risk than

others.

Therefore the nurse would appropriately use the

label risk for infection to describe the client’s

health status.

WELLNESS DIAGNOSIS

Describes human responses to levels of wellness

in an individual, family or community that have a

readiness for enhancement.

Eg.

i) Readiness for enhanced spiritual well being

ii) Readiness for enhanced family coping.

POSSIBLE NURSING DIAGNOSIS is one in which evidence about a health problem

is incomplete or unclear.

For Eg. Elderly widow who lives alone admitted

in hospital have no visitors & is pleased with

attention and conversation from the nursing

staff. Until more data are collected, the nurse

may write a Nursing Diagnosis of :

i) Possible social Isolation Related to unknown

etiology.

A SYNDROME DIAGNOSIS

is a diagnosis associated with a Cluster of other

diagnoses.

Eg. Risk for disuse syndrome – experienced by

bed ridden patient.

1. Impaired physical mobility 2. Impaired gas

exchange 3. Risk for impaired tissue integrity 4.

Risk for Activity intolerance 5. Risk for constipation

6. Risk for infection 7. Risk for injury 8. Risk for

powerlessness

COMPONENTS OF NANDA NURSING DIAGNOSIS

A nursing Diagnosis has 3 components.

1. The problem and its definition

2. The etiology

3. The defining characteristics.

Each component serves a specific purpose.

1] THE PROBLEM (DIAGNOSTIC LABEL) AND ITS DEFINITION

Describes the clients health problem or response

for which nursing therapy is given.

It describes the client’s health status clearly &

concisely in few words.

Purpose is to direct the formation of client goals

and desired outcomes.

It may also suggest some nursing interventions.

To be clinically useful,

diagnostic labels need to be specific;

when the words specify follows a NANDA Label, the

nurse states the area in which the problem occurs.

For eg.

Deficient knowledge (specify) Medication

Deficient knowledge (Dietary adjustments).

Qualifiers are words that have been added to some NANDA

Labels to give additional meaning to the diagnostic

statement; for eg.

Deficient (inadequate in amount quality or degree not

sufficient, incomplete)

Impaired (Made worse, weakened, damaged, reduced,

deteriorated)

Decreased (lesser in size amount or degree)

Ineffective (not producing the desired coping)

Compromised (to make Vulnerable to threat)

Each Diagnostic label approved by NANDA carries a

definition that clarifies its meaning.

2] ETIOLOGY

The etiology component of a nursing diagnosis

identifies one or more probable cause of the health

problem,

gives direction to the required nursing therapy and

enables the nurse to individualize the client’s care.

Eg. of problems having different etiologies and

different interventions

Problem Client Etiology Nursing Intervention

Constipation

A Long termlaxative use

Gradual withdraw of laxatives- teach components of high fiber diet.

B Inactivity &insufficient fluid intake

- exercise information about daily schedule - types of fluid he likes - Plan to include sufficient amount of fluid in his diet.

Ineffective Breast Feeding

A Breast engorgement

-massage of breast before feeding- use hot packs- hot shower before nursing infant

B Inexperience and lack of knowledge

- Advice to feed infant on demand - Show her how infant is sucking & swallowing - demonstrate different holding positions for feedings.

3] DEFINING CHARACTERISTICS

Defining Characteristics are the client’s signs & symptoms.

That indicates the presence of a particular diagnostic

label.

For Actual Nursing Diagnosis the defining

characteristics are the client’s signs & symptoms.

For Risk Nursing Diagnosis no subjective & objective

signs are present.

Thus the factors that cause the client to be more than

“normally” vulnerable to the problem form the etiology of

a risk nursing diagnosis.

Characteristics are listed separately according to whether

they are subjective or objective in nature.

DIFFERENCE BETWEEN MEDICAL & NURSING DIAGNOSES

Sl No. Nursing Diagnoses Medical Diagnoses

1 It is a statement of Nursing judgment Medical Diagnoses is made by physician

2 Refers to a condition that Nurses are licensed to treat

Refers to a condition that only a physician can treat.

3 Nursing Diagnoses describe a client’s physical, socio-cultural, psychologic, and spiritual responses to an illness or health problem.

Medical Diagnoses refers to disease processes

4 It changes depend upon the response of the client to an illness & health problem.

Fairly uniform from one client to another

5 Nursing Diagnoses change as the client responses change.

Medical Diagnose remains same for as long as the disease process is present.

THE DIAGNOSTIC PROCESS

The Diagnostic Process uses critical thinking

skills of analysis and synthesis.

Critical thinking is a cognitive process during

which a person reviews data and considers

explanations before forming an opinion.

Analysis – is the separation into components that is

breaking down of the whole into its parts.

Synthesis – is the opposite that is the putting

together of parts into the whole.

The diagnostic process is used continuously by

most nurses.

An experienced nurse may enter a client’s room

and immediately observe significant data and

draw conclusions about the client.

As a result of attaining knowledge skill and

expertise in the practice setting, the expert nurse

may seem to perform these mental processes

automatically.

Novice nurses, however, need guidelines to

understand and formulate nursing diagnoses.

THE DIAGNOSTIC PROCESS

The diagnostic process has 3 steps:-

1] Analyzing data

2]Identifying health problems, risks and

strengths.

3] Formulating Diagnostic statements.

Assessing a. Collect datab. Organize datac. Validate datad. Document data

Diagnosinga. Analyze datab. Identify health

problems, risks and strength,

c. Formulating nursing diagnosis

1] ANALYZING DATA

In analyzing data following steps are

involved.

A. Compare data against standards (identify

significant cues)

B. Cluster cues (generate tentative hypotheses)

C. Identify gaps & inconsistencies.

For experienced nurses, these activities

occur continuously rather than sequentially.

A. COMPARING DATA AGAINST STANDARDS

A Standard or Norm is generally accepted

measure, model rule, or pattern.

Eg. of Standards

Growth and Development patterns

Normal vital signs

Laboratory values.

B. CLUSTER CUES

It is a process of determining the relatedness of

facts and determining whether data are

significant.

C. IDENTIFY GAPS & INCONSISTENCIES

Skillful assessment minimizes the gaps &

inconsistencies, conflicting data's.

Possible sources are measurement error,

expectation and unreliable report.

It helps to have final check to ensure the data are

complete and correct.

Eg. Patient reports not having seen a Doctor in 15

years, yet during Physical Examination he states “My

doctor takes my BP every year”.

All inconsistencies must be clarified before valid

pattern “Validating data”.

2] IDENTIFYING HEALTH PROBLEMS, RISKS & STRENGTHS

After data are analyzed, the nurse and client

can together identify strengths & problems.

That is after gaping and clustering the data, the

nurse and client together identify problems that

support tentative actual, risk, and possible

diagnoses.

EG. OF A CLIENT WITH PNEUMONIASl

No. Client cue clusters

1 a) No appetite since having “Cold”

b) Has not eaten today, Last fluids at noon today

c) Nauseated x 2 days

Imbalanced Nutrition: Less that Body Requirements related to decreased appetite & Nausea, & increased metabolism (Strength: - Normal Weight for Height.)



2 a) Last fluids at noon today

b) Oral temperature 39.40c (1030 F)

c) Skin lot & pale, checks flushed

d) Dry mucous membrane

e) Poor skin turgorf) Decreased Urinary

frequency x 2 days

Deficient fluid volume related to intake insufficient to replace fluid loss secondary to fever, diaphoresis, anorexia



3 Difficulty in sleeping because of cough, “Can’t breathe while lying down”

Disturbed sleep pattern related to cough, pain, orthopnea, fever, and diaphoresis.



4 a) States “I feel Weak” b) Short of breath on

exertionc) Radial pulses weak,

regulard) Pulse rate – 92 bt/mte) States “I can think

ok, just weak”

Activity Intolerance related to general weakness imbalance between O2 supply / demand

Strength: - No musculoskeletal impairment, normal energy level is Satisfactory, exercises regularly.



5 Reports pain in chest especially when coughing

Acute pain related to cough secondary to inflammation of lung parenchyma.Strength:-No cognitive or sensory deficits.



6 a) Husband out of town; will be back tomorrow afternoon b) Child with neighbor until husband returns.

Interrupted family processes related to mother’s illness & temporary unavailability of father to provide child care. Strength :- Neighbors available & willing to help.



7 a) Anxious :- “I can’t breathe”

b) Facial muscles tense,c) Tremblingd) States “I’ll never get

caught up”e) Husband out of town;

will be back tomorrow afternoon.

f) Child with neighbor house

g) Express “concern” & “Worry”

Anxiety related to difficulty breathing, inability to work, and child care.



8 a) Radial pulse weak, regular pulse rate 92 b) Skin hot, pale, and moistc) Respirations shallow, chest expansion, 3cm d) Productive cough e) Thick pale pink sputum f) Inspiratory crackles auscultated through out. Right upper & lower lungs. g) Diminished breath sounds an ® side h) Mucous membranes pale, dry

Ineffective Airway clearance related to viscous secretions & shallow chest expansion secondary to pain, fluid volume deficit & fatigue.

DETERMINING STRENGTHS

Eg. of strengths

Weight is with in normal as per age & Height –

Enables client to cope with surgery.

Absence of allergies & Non smoker.

It can be found in the nursing assessment record

(health, home life, Education, recreation,

exercise, work, family & friends religious beliefs,

sense of humour)

3] FORMULATING DIAGNOSTIC STATEMENTS

Most Nursing Diagnoses are written as two part

or three part statements, but there are variations

of these.

1. Basic two part statements

2. Basic three part statements

3. One part statements

4. Variations of Basic formats.

5. Collaborative problems.

BASIC TWO PART STATEMENTS

The basic two part statement includes the following.

1] Problem (P) :- Statement of the client’s response

(NANDA Label)

2] Etiology (E) :- Factors contributing to or probable

cause of responses.

The two parts are joined by the words related to rather

than due to.

The phrase due to implies that one part causes or is

responsible for the other part.

By contrast, the phrase related to merely implies a

relationship.

EG. OF TWO PART STATEMENTS

Problem Related to Etiology

Constipation Related to Prolonged

Laxative use

Ineffective

Breast Feeding

Related to Breast

engorgement

Some NANDA Labels contain the word specify. For these

the nurse must add words to indicate the problem more

specifically.

Eg. Noncompliance (specify)

Noncompliance (Diabetic Diet) related to denial of

having disease.

For ease in alphabetizing, many NANDA lists are

arranged with qualifying words after the main word (Eg.

Infection, Risk For).

Avoid writing Diagnostic statements in that manner

instead, write them as they would be stated in normal

conversation (Eg. Risk for infection)

BASIC THREE PART STATEMENTS

The three part Diagnostic Statements called the

PES format and includes the following:

1] Problem (P) :- Statement of the client’s response

(NANDA Label)

2] Etiology (E) :- Factors contributing to or probable

cause of the response.

3] S/S (S) :- Defining characteristics manifested by

the client.

Actual nursing diagnoses can be documented by

using the three part statement

because the signs & symptoms have been

identified.

This format cannot be used for risk diagnoses

because the client doesn’t have signs & symptoms

of the diagnosis.

EG. OF 3 PART STATEMENT Problem Related

ToEtiology As manifested

bySigns & symptoms

Situational Low Self Esteem

Related to Rejection by husband

As manifested by States that “I don’t know if I can manage by myself”Rejects positive feed back.

Hyperthermia Related to Bacterial infection As manifested by Elevated body temperature. 1000FIncreased pulse rate 92bt/mt Increased R.R 30br/mtDry lips . States Fatigue, tired.Feels so Hot Reduced Skin turgor.

Ineffective breathing pattern

Related to Viscious secretions

As manifested by Viscious secretions, shallow chest expansion.

ONE PART STATEMENTS

Wellness diagnoses and Syndrome nursing

diagnoses.

As the diagnostic labels are refined they tend to

become more specific, so that nursing interventions

can be derived from the label itself.

Therefore an etiology may not be needed.

The wellness diagnoses statement begins with

words Readiness for Enhanced (Parenting, Spiritual

well being, Effective breast feeding, Health seeking

behaviors, Anticipatory Grieving Low fat Diet.)

GUIDELINES FOR WRITING A NURSING DIAGNOSTIC STATEMENT

Sl No.

Correct statement Incorrect

1 State in terms of problem, not a need.

Deficient fluid volume related to fever

Fluid replacement (need) related to fever.

2 Word the statement so that it is legally advisable

Impaired skin integrity related to immobility (legally acceptable)

Impaired skin integrity related to improper positioning (implies legal liability)

3 Use nonjudgmental statements

Spiritual distress related to inability to attend church services secondary to immobility (Nonjudgmental)

Spiritual distress related to strict rules necessitating church attendance


Sl No.


4 Make sure that both elements of the statement don’t say the samething.

Impaired skin integrity (ulcer in sacral area) related to immobility.

Impaired skin integrity related to ulceration of sacral area.

5 Be sure that cause and effect are correctly stated (that is the etiology causes the problem)

Pain severe head ache related to fear of addiction to narcotics

Pain related to severe head ache.


Sl No.


6 Word the diagnosis specifically and precisely to provide direction for planning nursing intervention

Impaired oral mucus membrane related to decreased salivation secondary to radiation of neck. (specific)

Impaired oral mucus membrane related to noxious agent (vague)

7 Use nursing terminology rather than medical terminology to describe the client response & its cause.

Risk for ineffective airway clearance related to accumulation of secretions in lungs (nursing terminology)

Risk for pneumonia (Medical Terminology)

CONCLUSION Definition Types of Nursing Diagnoses –Actual, Risk, Wellness, Possible and

Syndrome

Components of NANDA nursing diagnosis- Problem, Etiology, Defining characteristics

Difference between medical and nursing diagnoses Diagnostic process-

Analyzing data - Compare data against standards (identify

significant cues), Cluster cues (generate tentative hypotheses) ,

Identify gaps & inconsistencies. Identifying health problems risk and its strengths

Formulating diagnostic statements - Basic two part, Basic three part,

One part, Variations of Basic formats, Collaborative problems.

Guidelines for writing a nursing diagnostic statement

Nursing Process Diagnosing

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