What is a nursing diagnosis? Definition of Nursing Diagnosis A nursing diagnosis is the part of the nursing process, is clinical judgment about individual, family, or community responses to actual or potential health/life processes.  Nursing diagnosis are developed based on data obtained during nursing assessment. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

 Nursing Diagnosis Have two related meanings:

• Nursing diagnosis is an action: the process of analyzing assessment data to arrive at a nursing diagnosis!
• Nursing diagnosis is a label that describes the patient’s response to an actual or potential health problem

How do nurses make a Nursing Diagnosis?

1. Analyze collected data
2. Identify the client’s strengths
3. Identify the client’s normal functional level and indicators of actual or potential dysfunction
4. Formulate a diagnostic statement in relations to this synthesis

Benefits of Nursing Diagnosis

• Gives nurses a common language
• Promotes identification of appropriate expected outcomes
• Provides acuity information
• Can create a standard for nursing practice
• Provide a quality improvement base
• Promotes improved communication among nurses, other healthcare providers, and alternate care settings

Nursing Diagnosis VS Medical Diagnosis

Steps of Developing Nursing Diagnosis

Identify patterns

• Review data and look for cues
• Cluster cues (signs and symptoms)
• Synthesizing the cue clusters
• Three questions to ask self  (What are my concerns about this client, Can I or am I doing something about it, Can the overall risk be decreased by nursing interventions)

Synthesis the data

Look at all data as a whole to provide a comprehensive picture of the client in relation to past, present, and future health status

Validate the diagnosis

Test for a fit, Refer to the NANDA Diagnosis and defining characteristics. Then, compare the assessed possible ETIOLOGY with NANDA’s RELATED FACTORS or RISK FACTORS. Next, compare the assessed client cues with NANDA’s Defining Characteristics, which are used to support and provide an increased level of confidence in your selected nursing diagnosis.

Formulate the nursing diagnosis statement using nursing language

NANDA

Types of Nursing Diagnosis

• 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. Can be documented from assessment

• Risk Nursing Diagnosis

Risk Nursing diagnosis, a clinical judgment that the client is more vulnerable to develop this problem than others in the same or similar situation. A clinical judgment that a problem does not exist, therefore no S/S are present. This diagnosis indicates from the data, a strong likelihood that it will occur if actions are not taken by the nurses.  The Risk diagnosis only has 2 parts.  It can be used with any NANDA diagnosis

• Potential Nursing Diagnosis

This is also known as a collaborative 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. This is a problem the nurse cannot treat independently. Nursing care will focus on monitoring and preventing the problem. A collaborative diagnosis can be written as a one or two part statement.

• Wellness Nursing Diagnosis

Potential for enhancement of current well state, this diagnosis involves a judgment about an individual, family or community in transition from one level of wellness to a higher level of wellness.

• Syndrome Nursing Diagnosis

Associated with a cluster of other diagnoses

Components of Nursing Diagnosis

Diagnostic Label

• P  Problem, Name of the nursing diagnosis as listed in the taxonomy, describes the problem using as few words as possible. DO NOT use the medical diagnosis. Must be a problem the nurse and/or client can change to do something about. Relating the problem to an unchangeable situation

• Qualifier, Used to give additional meaning to the Nursing Diagnosis. words added to the diagnostic label/problem statement to gain additional meaning

• E Etiology. This is the “related to, R/T” portion of the diagnosis. What caused the client to have the problem listed? Do Not use the medical diagnosis, Must be a problem the nurse and/or client can change to do something about
• S Symptom. These are the major and minor clinical cues that validate the presents of an actual nursing diagnosis. Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the Nursing Diagnosis

 Problems to avoid in writing Nursing Diagnosis

• Don’t confuse the etiology with the problem
• Do not use the medical diagnosis.
• Must be a problem the nurse and/or client can change to do something about. Relating the problem to an unchangeable situation
• Focus on the human responses to the problem
• Avoid the use of one piece of assessment data as a Nursing Diagnosis(EDEMA)
• Be specific
• Don’t combine NDX
• Don’t relate one Nursing Diagnosis to another.  There is a different related to factor if this is a valid Nursing Diagnosis
• Nursing interventions should not be included in the Nursing Diagnosis
• Keep your language non-judgmental
• Don’t make assumptions or statements you can’t prove with assessment data
• Be sure your statement is legally advisable

Gordon’s Functional Health Patterns is a method develops By Marjorie Gordon in 1987 proposed functional health patterns as a guide for establishing a comprehensive nursing data base. By using these categories it’s possible to create a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function:

11 Gordon’s Functional Health Patterns

1. Health Perception Health Management Pattern
2. Nutritional Metabolic Pattern
3. Elimination Pattern
4. Activity Exercise Pattern
5. Sleep Rest Pattern
6. Cognitive-Perceptual Pattern
7. Self-Perception-Self-Concept Pattern
8. Role-Relationship Pattern
9. Sexuality-Reproductive
10. Coping-Stress Tolerance Pattern
11. Value-Belief Pattern

Health Perception and Health Management. It’s focused on the person’s perceived level of health and well-being, and on practices for maintaining health. Also evaluated Habits including smoking and alcohol or drug use.

• Contamination
• Disturbed energy field
• Effective therapeutic regimen management
• Health-seeking behaviors (specify)
• Ineffective community therapeutic regimen management
• Ineffective family therapeutic regimen management
• Ineffective health maintenance
• Ineffective protection
• Ineffective therapeutic regimen management
• Noncompliance (ineffective Adherence)
• Readiness for enhanced immunization status
• Readiness for enhanced therapeutic regimen management
• Risk for contamination
• Risk for infection
• Risk for injury
• Risk for perioperative positioning injury
• Risk for poisoning
• Risk for sudden infant death syndrome
• Risk for suffocation
• Risk for trauma
• Risk-prone health behavior

Nutritional Metabolic Pattern it’s focused on the pattern of food and fluid consumption relative to metabolic need. Is evaluated the adequacy of local nutrient supplies.  Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.

• Adult failure to thrive
• Deficient fluid volume: [isotonic]
• [Deficient fluid volume: hyper/hypotonic]
• Effective breastfeeding [Learning Need]
• Excess fluid volume
• Hyperthermia
• Hypothermia
• Imbalanced nutrition: more than body requirements
• Imbalanced nutrition: less than body requirements
• Imbalanced nutrition: risk for more than body requirements
• Impaired dentition
• Impaired oral mucous membrane
• Impaired skin integrity
• Impaired swallowing
• Impaired tissue integrity
• Ineffective breastfeeding
• Ineffective infant feeding pattern
• Ineffective thermoregulation
• Interrupted breastfeeding
• Latex allergy response
• Nausea
• Readiness for enhanced fluid balance
• Readiness for enhanced nutrition
• Risk for aspiration
• Risk for deficient fluid volume
• Risk for imbalanced fluid volume
• Risk for imbalanced body temperature
• Risk for impaired liver function
• Risk for impaired skin integrity
• Risk for latex allergy response
• Risk for unstable blood glucose

Elimination Pattern. It’s focused on excretory patterns (bowel, bladder, skin).

• Bowel incontinence
• Constipation
• Diarrhea
• Functional urinary incontinence
• Impaired urinary elimination
• Overflow urinary incontinence
• Perceived constipation
• Readiness for enhanced urinary elimination,
• Reflex urinary incontinence
• Risk for constipation
• Risk for urge urinary incontinence
• Stress urinary incontinence
• Total urinary incontinence
• Urge urinary incontinence
• [acute/chronic] Urinary retention

Activity and Exercise Pattern. It’s focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities.

• Activity intolerance
• Autonomic dysreflexia
• Decreased cardiac output
• Decreased intracranial adaptive capacity
• Deficient diversonal activity
• Delayed growth and development
• Delayed surgical recovery
• Disorganized infant behavior
• Dysfunctional ventilatory weaning response
• Fatigue
• Impaired spontaneous ventilation
• Impaired bed mobility
• Impaired gas exchange
• Impaired home maintenance
• Impaired physical mobility
• Impaired transfer ability
• Impaired walking
• Impaired wheelchair mobility
• Ineffective airway clearance
• Ineffective breathing pattern
• Ineffective tissue perfusion
• Readiness for enhanced organized infant behavior
• Readiness for enhanced self care
• Risk for delayed development
• Risk for disorganized infant behavior
• Risk for disproportionate growth
• Risk for activity intolerance
• Risk for autonomic dysreflexia
• Risk for disuse syndrome
• Sedentary lifestyle
• Self-care deficit
• Wandering

Cognitive-Perceptual Pattern. It’s focused on the ability to comprehend and use information and on the sensory functions. Neurologic functions, Sensory experiences such as pain and altered sensory input.

• Acute confusion
• Acute pain
• Chronic confusion
• Chronic pain
• Decisional conflict
• Deficient knowledge
• Disturbed sensory perception
• Disturbed thought processes
• Impaired environmental interpretation syndrome
• Impaired memory
• Readiness for enhanced comfort
• Readiness for enhanced decision making
• Readiness for enhanced knowledge
• Risk for acute confusion
• Unilateral neglect

Sleep Rest Pattern. It’s focused on the person’s sleep, rest, and relaxation practices. To identified dysfunctional sleep patterns, fatigue, and responses to sleep deprivation.

• Insomnia
• Readiness for enhanced sleep
• Sleep deprivation

Self-Perception-Self-Concept Pattern its focused on the person’s attitudes toward self, including identity, body image, and sense of self-worth.

• Anxiety
• disturbed Body image
• Chronic low self-esteem
• Death anxiety
• Disturbed personal identity
• Fear
• Hopelessness
• Powerlessness
• Readiness for enhanced hope
• Readiness for enhanced power
• Readiness for enhanced self-concept
• Risk for compromised human dignity
• Risk for loneliness
• Risk for powerlessness
• Risk for situational low self-esteem
• Risk for [/actual] other-directed violence
• Risk for [actual/] self-directed violence
• Situational low self-esteem

Role-Relationship Pattern. It’s focused on the person’s roles in the world and relationships with others. Evaluated Satisfaction with roles, role strain, or dysfunctional relationships.

• Caregiver role strain
• Chronic sorrow
• Complicated grieving
• Dysfunctional family processes: alcoholism (substance abuse)
• Grieving
• Impaired social interaction
• Impaired verbal communication
• Ineffective role performance
• Interrupted family processes
• Parental role conflict
• Readiness for enhanced communication
• Readiness for enhanced family processes
• Readiness for enhanced parenting
• Relocation stress syndrome
• Risk for caregiver role strain
• Risk for complicated grieving
• Risk for impaired parent/infant/child attachment
• Risk for relocation stress syndrome
• Social isolation

Sexuality and Reproduction. It’s focused on the person’s satisfaction or dissatisfaction with sexuality patterns and reproductive functions.

• Ineffective sexuality patterns
• Rape-trauma syndrome
• Sexual dysfunction

Coping-Stress Tolerance Pattern. its focused on the person’s perception of stress and coping strategies Support systems, evaluated symptoms of stress, effectiveness of a person’s coping strategies.

• Compromised family coping
• Defensive coping
• Disabled family coping
• Impaired adjustment
• Ineffective community coping
• Ineffective coping
• Ineffective denial
• Post-trauma syndrome
• Readiness for enhanced community coping
• Readiness for enhanced coping
• Readiness for enhanced family coping
• Risk for self-mutilation
• Risk for suicide
• Risk for post-trauma syndrome
• Self-mutilation
• Stress overload

Value-Belief Pattern it’s focused on the person’s values and beliefs.

• Impaired religiosity
• Moral distress
• Readiness for enhanced religiosity
• Readiness for enhanced spiritual well-being
• Risk for impaired religiosity
• Risk for spiritual distress
• Spiritual distress

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