DIAGNOSING- IS REASONING PROCESS.

- A STATEMENT OR CONCLUSION
REGARDING THE NATURE OF A
PHENOMENON.

Types:
- Actual diagnosis
- Risk nursing diagnosis
- Wellness diagnosis
- Possible nursing diagnosis
- Syndrome diagnosis

Actual diagnosis- a client problem that is present at

the time of nursing assessment.

Ex. Ineffective breathing pattern

Anxiety

Risk Diagnosis- a clinical judgment that even a

problem does not exist, it is likely to develop.

Ex. Risk for Infection

Wellness Diagnosis- describes human responses to

levels of wellness in an individual, family, or
community.

Ex. Readiness for enhanced spiritual well-being

Readiness for enhanced family coping

Possible Nursing Diagnosis- evidence about a health

problem is incomplete or unclear.

Ex. Possible social isolation

Syndrome Diagnosis- a diagnosis that is associated
with a cluster of other diagnosis.

Ex. Impaired physical mobility

Risk for impaired tissue integrity

Components:
- Problem and definition
- Etiology
- Defining characteristic

Problem and definition- is client’s health problem

or response in a few words.
- Specific

Qualifiers:
-Words added to some NANDA labels.
- Deficient- inadequate amount
- Impaired- made worse/ weakened
- Decrease- lessen in size
- Ineffective- not producing desired effect
- Compromised- made vulnerable

Etiology- is the probable cause of a health

problem.
- Related factors/ risk factors.

Defining characteristics- cluster of signs and

symptoms that indicate the presence of a specific
diagnostic label.
Differentiating Nursing Diagnosis from Medical
Diagnosis:

A. Nursing Diagnosis- a statement of nursing

judgement and refers to a condition that a
nurse is licensed to treat.
- Describe client’s holistic response to an
illness.
- Change as a client response change

B. Medical Diagnosis- made by physician and

refers to a condition that only a physician can
treat.
- Disease process
- Remains the same for as long as the
disease process

The Diagnostic Process

- Analyzing data
- Indentifying health problems
- Formulating diagnostic statement

Analyzing Data
- Compare the data against standards
- Cluster cues
- Identify gaps and inconsistencies

a.Compare standards
- Points to positive/ negative in a client’s
health status or pattern
- Varies from norms of the client
population
- Developmental delay
 b.Cluster cues
- According to systems affected
c. Identify gaps and inconsistencies
- Conflicting data
a.Measurements error
b.Expectations
c. Inconsistent/ unreliable reports

Identify Health Problems

- Determine Problems/ risks
- Determining strengths

Formulating Diagnostic Statement

- PES Format
a.Problem
b.Etiology
c. Signs and symptoms

Variations in Basic Format

- Writing the unknown etiology
(uncompliance)
- Using the phrase “complex factors”
(chronic low self-esteem)
- Using the word possible ( possible low
self-esteem)
- Using secondary to
a.Divides etiology into parts, thereby
making statement more descriptive
and useful.
- Adding a second part to general phrase

Collaborative Problems
- Start with complication
 - Followed by groups of complications
Ex. Potential complication of Pregnancy-Induced
Hypertension: seizure, fetal distress,
pulmonary edema, hepatic/ renal failure,
premature labor, CNS hemorrhage

Evaluating Diagnostic Statement

- Accurate
- Concise
- Descriptive
- Specific
- Based on NANDA signs and symptoms
and risk factors.

Avoiding Errors in Diagnostic Reasoning

- Verify
- Build a good knowledge base and
acquire clinical experience
- Have a working knowledge of what is
normal
- Consult resources
- Base diagnosis on patterns
- Improve critical-thinking skills