Chapter 12

Diagnosing

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Purposes of the Diagnosing Step

Identify how an individual, group, or community

responds to actual or potential health and life processes.
Identify factors that contribute to, or cause, health
problems (etiologies).
Identify resources or strengths on which the individual,
group, or community can draw to prevent or resolve
problems.

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Nursing Responsibilities Related to

Diagnosis
Recognizing safety and infection-transmission risks and
addressing these immediately.
Identifying human responseshow problems, signs and
symptoms, and treatment regimens impact on patients
livesand promoting optimum function, independence,
and quality of life.
Anticipating possible complications and taking steps to
prevent them.
Initiating urgent interventions. You should not wait to
make a final diagnosis if there are signs and symptoms
indicating the need for immediate treatment.

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Predict, Prevent, Manage, and Promote

(PPMP)
In the presence of known problems, predict the most
common and most dangerous complications and take
immediate action to (a) prevent them, and (b) manage
them in case they cannot be prevented.
Whether problems are present or not, look for evidence
of risk factors (things that evidence suggests contribute
to health problems). If you identify risk factors, aim to
reduce or control them, thereby preventing the problems
themselves.
In all situations, ensure that safety and learning needs
are met and promote optimum function, and
independence, and a sense of well-being.

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Types of Diagnoses

Nursing diagnosis: Describes patient problems nurses can

treat independently
Addresses the clients response to healthcare and
illness
Medical diagnosis: Describes problems for which the
physician directs the primary treatment
Collaborative problems: Managed by using physicianprescribed and nursing-prescribed interventions
Primarily managed by nurses

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Diagnostic Reasoning and Clinical

Reasoning
Be familiar with nursing diagnoses and other health
problems; read professional literature and keep reference
guides handy.
Trust clinical experience and judgment, but be willing to
ask for help when the situation demands more than your
qualifications and experience can provide.
Respect your clinical intuition, but before writing a
diagnosis without evidence, increase the frequency of
your observations and continue to search for cues to
verify your intuition.
Recognize personal biases and keep an open mind.

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Four Steps of Data Interpretation

and Analysis
Recognizing significant data
Comparing data to standards or normal values
Note any changes
Recognizing patterns or clusters
Use multiple symptoms or results
Identifying strengths, problems, and potential issues
Identifying potential complications
Reaching conclusions
Actual problem, potential problem, no problem

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Types of Nursing Diagnoses

Actual
An identified problem
Risk
Client is susceptible to a problem
Possible
Rule in or rule out a problem
Wellness
To improve level of wellness Readiness diagnoses
Syndrome
A group of diagnoses associated with a problem
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Formulation of Nursing Diagnoses

Problem
Identifies what is unhealthy about patient
Etiology
Identifies factors maintaining the unhealthy state
Defining characteristics
Identify the subjective and objective data that signal
the existence of a problem

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Four Components of a Diagnosis

Label
Nursing diagnosis
Definition
Related to
Defining characteristics
Data collected by nurse that supports Dx
Related factors

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Validating Nursing Diagnoses

Is my patient database (assessment data) sufficient,
accurate, and supported by nursing research?
Does my synthesis of data (significant cues) demonstrate
the existence of a pattern?
Are the subjective and objective data I used to determine
the existence of a pattern characteristic of the health
problem I defined?
Is my tentative nursing diagnosis based on scientific
nursing knowledge and clinical expertise?
Is my tentative nursing diagnosis able to be prevented,
reduced, or resolved by independent nursing action?
Is my degree of confidence above 50% that other
qualified practitioners would formulate the same nursing
diagnosis based on my data?
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Documentation of Diagnoses on EHR

View the patients ongoing risks and problems that others

have identified and documented.
Decide on and document new nursing diagnoses based
on the patient assessment findings.
Facilitate communication of the patients actual problems
with nurses and others on the health care team.
Use nursing diagnosis to make decisions about what
mutual goals the patient desires and what can be done.
Determine and document when the nursing diagnoses
are resolved.

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Benefits of Nursing Diagnoses

Individualizing patient care

Allows the patient to be knowledgeable and involved with
their plan of care
Improves interaction between health care workers
Defining domain of nursing to health care administrators,
legislators, and providers
Seeking funding for nursing and reimbursement for
nursing services

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Limitations of Nursing Diagnosis

If used incorrectly, patient might be misdiagnosed.

Nursing practice might be restricted.

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Common Errors in Writing Nursing

Diagnoses
Writing diagnosis in terms of needs and response
Making legally inadvisable statements
Identifying as a problem a patient response that is not
necessarily unhealthy
Identifying as a problem signs and symptoms of illness
Identifying as a patient problem or etiology what cannot be
changed
Identifying environmental factors rather than patient factors as a
problem
Reversing clauses
Having both clauses say the same thing
Including value judgments in the nursing diagnosis
Including the medical diagnosis in the diagnostic statement
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Sources of Error When Writing

Nursing Diagnoses
Premature diagnoses based on an incomplete database
Erroneous diagnoses resulting from an inaccurate
database or a faulty data analysis
Routine diagnoses resulting from the nurses failure to
tailor data collection and analysis to the unique needs of
the patient
Errors of omission

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