Nursing Diagnosis

Nursing diagnosis – a statement that describes the client’s actual or potential response to a health problem that the nurse is competent and licensed to treat Nursing Diagnosis is the basis for planning nursing interventions that help prevent, minimize or alleviate specific health issues. A Medical Diagnosis is much different than nursing diagnosis; it is used to define etiology of the disease. It only focuses is on the function and malfunction of a specific organ system. The two are very different. A Nursing Diagnosis is written in a format called "PES ", developed by NANDA(1). • • •

"P" stands for PROBLEM "E "stands for ETIOLOGY or cause of problem "S "stands SIGNS and SYMPTOMS of problem

By using all of the components of the nursing diagnosis, the problem is clearly communicated to everyone involved in the clients care. Nursing Diagnostic Process Data Validatio

Data Clusterin

Interpretation of Data

Identification of Client’s Needs

Formulation of Nursing Diagnosis

Analysis/ Interpretation of Data -

Data are initially collected from a variety of sources and validated

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Data are sorted into clusters or categories

Clusters - a set of signs and symptoms that are grouped together in a logical order - contains Defining Characteristics which are clinical criteria or assessment findings that support the presence of a diagnostic category -

the identified pattern is then compared with normal, healthful patterns Defining Characteristics that are not within the healthy norms are isolated and form the basis for problem identification

Identification of Client’s Needs - The nurse first determines what the client’s health problems are and whether they are actual or potential health problem Actual health problem – perceived or experienced by the patient At risk health problem – identified when the nurse makes a clinical judgment that an individual, family, or community is more vulnerable to development of a problem than others in the same or similar situation

Formulation of Nursing Diagnosis There are five types of nursing diagnoses in the NANDA system. An actual diagnosis is a statement about a health problem that the client has, and could benefit from nursing care. Example: Ineffective airway clearance related to decreased energy and manifested by an ineffective cough. A risk diagnosis is a statement about a health problem that the client doesn't have yet, but is at a higher than normal risk of developing in the near future. Example: Risk for injury related to altered mobility and disorientation. A possible diagnosis is a statement about a health problem that the client might have now, but the nurse doesn't yet have enough information to make an actual diagnosis. Example: Possible fluid volume deficit related to frequent vomiting for three days and manifested by increased pulse rate. A syndrome diagnosis is used when a cluster of nursing diagnoses are often seen together.

Example: Rape-trauma syndrome related to anxiety about potential health problems and as manifested by anger, genitourinary discomfort, and sleep pattern disturbance. A wellness diagnosis is used to describe an aspect of the client which is at a high level of wellness. Example: Potential for enhanced organized infant behavior, related to prematurity and manifested by response to visual and auditory stimuli.