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m  


m  
p Is a process which results to a
diagnostic statement or nursing
diagnosis. It is the clinical act of
identifying problems. To diagnose in
nursing, it means to analyze
assessment information and derive
meaning from this analysis..
p is the 2nd step of the nursing process.

p the process of reasoning or the clinical


act of identifying problems
 

p to identify the client¶s health


care needs and to prepare
diagnostic statements.

p a statement of client¶s potential or actual
alteration of health status. It uses the
critical thinking skills of analysis and
synthesis.
p is a statement of a client¶s potential or
actual health problem resulting from
analysis of data.
p is a statement of client¶s potential or actual
alterations/changes in his health status.
p 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.
p Is the problem statement that the nurse
makes regarding a client¶s condition
which she uses to communicate
professionally.
p 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.
p Analysis ± separation into components
or the breaking down f the whole into its
parts.
p Synthesis ± the putting together of parts
into whole
Activities During Diagnosing
ż Organize or cluster group data. E.g. pallor,
dyspnea, weakness, fatigue, RBC of 4Mcu
mm, Hgb= 10g/dl, pertain to problems with
oxygenation.
ż Compare data against standards. Standards
are accepted norms, measures or patternsfor
purposes of comparison. E.g. the standard
color of sclera is white, the standard color of
urine is amber
ż Analyze data after comparing with standards
DIAGNOSING = Data
Analysis + Problem
Identification +
Formulation of Nsg
Diagnosis
  m  
  
p Should include the problem and its
etiology
 

p Defines the cause of the problem


p Represented in the nursing diagnostic
statement by the phrase: related to

  

ż P ± Problem statement/diagnostic
label/definition
ż R ± related factors
ż S ± Defining characteristics/signs
and symptoms
ż P ± ± Problem
statement/diagnostic
label/definition
ż E ± Etiology
ż S ± Defining characteristics/signs
and symptoms
 m
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.
!"

p Imbalanced Nutrition: Less than body


requirements r/t decreased appetite
nausea.
p Disturbed Sleep Pattern r/t cough, fever
and pain.
p Constipation r/t long term use of laxative.
p Ineffective airway clearance r/t to viscous
secretions
p Noncompliance (Medication) r/t unknown
etiology
p Noncompliance (Diabetic diet) r/t
unresolved anger about Diagnosis
p Acute Pain (Chest) r/t cough 2nrdary to
pneumonia
p Activity Intolerance r/t general
weakness.
p 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.
#$$
m
p It states a clear and concise health
problem.
p It is derived from existing evidences
about the client.
p It is potentially amenable to nursing
therapy.
p It is the basis for planning and carrying
out nursing care.
p
ż Identify inconsistencies and gaps in data
ż Determine the client¶s health problems, health
risks and strengths.
ż Formulate Nursing Diagnosis statements
!"m

p Anxiety related to insufficient knowledge


regarding surgical experience.
p Risk for injury related to sensory and
integrative dysfunction as manifested by
altered mobility and family function.
p Ineffective airway clearance related to
tracheobronchial infectionas manifested
by weak cough, adventitious breath
sounds and copious green sputum
production.
$$
$$m

Correct ± High risk for ineffective airway


clearance related to thick, copious mucus
secretions.

Incorrect ± High risk for ineffective


airway clearance related to
pneumonia.
p Correct ± High risk for injury related to
disorientation.

p Incorrect ± High risk for injury related to


absence of side rails.
p Correct - High risk for self concept
disturbance related to the effects of
mastectomy (surgical removal of the
breast)
p Incorrect ± Mastectomy related to
cancer.
m%

1973 ± nursing diagnosis was developed,


by Kristie Gebbie and Mary Ann Lavin.

1982 ± NANDA (North American Nursing


Diagnosis Association) was recognized

Purpose: to promote taxonomy of nursing


diagnostic terminologies of general use
to professional nurses.
p Members: staff nurses, clinical
specialist, faculty, directorsof nursing,
deans, theorists and researchers.

p At present ± these labels are considered


the standard for use in US and Canada.
It represents a professional focus for
independent nursing practice.