Diagnosis - Second Step in the Nursing Process

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Diagnosing

• is the 2^nd step of the nursing process.
• the process of reasoning or the clinical act of identifying problems

Purpose: To identify health care needs and prepare a Nursing Diagnosis.

To diagnose in nursing: it means to analyze assessment information and derive meaning from this analysis.

Nursing Diagnosis

• is a statement of a client’s potential or actual health problem resulting from analysis of data.
• is a statement of client’s potential or actual alterations/changes in his health status.
• 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.
• Is the problem statement that the nurse makes regarding a client’s condition which she uses to communicate professionally.
• 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.

Analysis – separation into components or the breaking down f the whole into its parts.

Synthesis – the putting together of parts into whole

3 activities in Diagnosing:

DIAGNOSING = Data Analysis + Problem Identification + Formulation of Nsg Diagnosis

Characteristics of Nursing Diagnosis:

1. It states a clear and concise health problem.
2. It is derived from existing evidences about the client.
3. It is potentially amenable to nursing therapy.
4. It is the basis for planning and carrying out nursing care.

Components of a nursing diagnosis: PES or PE

1. Problem statement/diagnostic label/definition = P
2. Etiology/related factors/causes = E
3. Defining characteristics/signs and symptoms = S

Therefore may be written as 2-Part or a 3-Part statement.

Types of Nursing Diagnosis:

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.

Examples:

• Imbalanced Nutrition: Less than body requirements r/t decreased appetite nausea.
• Disturbed Sleep Pattern r/t cough, fever and pain.
• Constipation r/t long term use of laxative.
• Ineffective airway clearance r/t to viscous secretions
• Noncompliance (Medication) r/t unknown etiology
• Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis
• Acute Pain (Chest) r/t cough 2nrdary to pneumonia
• Activity Intolerance r/t general weakness.
• Anxiety r/t difficulty of breathing & concerns over work

1. 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.

Examples:

• Possible nutritional deficit
• Possible low self-esteem r/t loss job
• Possible altered thought processes r/t unfamiliar surroundings

3. Risk Nursing diagnosis – is a clinical judgment that a problem does not exist, therefore no S/S are present, but the presence of RISK FACTORS is indicates that a problem is only is likely to develop unless nurse intervene or do something about it.

No subjective or objective cues are present therefore the factors that cause the client to be more vulnerable to the problem is the etiology of a risk nursing diagnosis.

Examples:

• Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in diabetes.
• Risk for interrupted family processes r/t mother’s illness & unavailability to provide child care.
• Risk for Constipation r/t inactivity and insufficient fluid intake
• Risk for infection r/t compromised immune system.
• Risk for injury r/t decreased vision after cataract surgery.

Formula in writing nursing diagnosis: PES or PE

1. Actual nursing diagnosis = Patient problem + Etiology – replace the (+) symbol with the words “RELATED TO” abbreviated as r/t.

= Problem + Etiology + S/S

2. Risk Nursing diagnosis = Problem + Risk Factors

3. Possible nursing diagnosis = Problem + Etiology

Qualifiers – words added to the diagnostic label/problem statement to gain additional meaning.

• “deficient” - inadequate in amount, quality, degree, insufficient, incomplete
• “impaired” – made worse, weakened, damaged, reduced, deteriorated
• “decreased” – lesser in size, amount, degree
• “ineffective” – not producing the desired effect

Activities during diagnosis:

1. Compare data against standards
2. Cluster or group data
3. Data analysis after comparing with standards
4. Identify gaps and inconsistencies in data
5. Determine the client’s health problems, health risks, strengths
6. Formulate Nursing Diagnosis – prioritize nursing diagnosis based on what problem endangers the client’s life

Situation: Functional Health Pattern – Activity/Exercise

Aling Sylvia,35 years of laundry woman seeks consultation at the Ospital ng Sampaloc due to fever 2 days PTA. She verbalizes: “Bigla na lang ako giniginaw, masakit ang ulo at mainit ang pakiramdam pagkatapos kong maglaba sa kabilang kanto. “She has 3 children she walks off to school everyday before she goes to work

VS: T=39.2C RR = 35 P = 96; With flush skin and warm to touch, teary eyed and with dry lips and mucous membrane.

Nsg Dx: Hyperthermia r/t environmental condition AMB T = 39C, flush skin, warm to touch, teary eyed and dry lip and mucous membrane.

Situation: Functional Health Pattern = Nutritional/Metabolic

States, “No appetite since having cough”

Has not eaten today; last fluids at noon today

Has lost 8 lbs in past 2 weeks

Nauseated x 2 days

Nsg. Dx: Imbalanced Nutrition: Less than body Requirements r/t decreased appetite and nausea 2ndary to disease process/cough

Situation: Functional Health Pattern = Activity/Exercise

Difficulty sleeping because of cough

States, “Can’t breath lying down”

Report pain on chest when coughing

Nsg Dx: Disturbed Sleep Pattern r/t a disease process, orthopnea and pain.

Acute Pain (chest) r/t pathologic condition 2ndary to pneumonia

Situation: Functional Health Pattern = Coping/Stress

Anxious

State, “I can’t breath”

Facial muscles tense, trembling

Expresses concern and worry over leaving daughter with neighbors

Husband out of town, will be back next week.

Nsg. Dx: Anxiety r/t difficulty of breathing and concerns over parenting roles.

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• NURSING PROCESS by: one of our best professor in NCM (Mrs. Cubon, RN, MAN) The term NURSING PROCESS was first used/mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced 3 STEPs: observation, administration of care and validation. Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-step process (APIE),
• Assessment - First Step in the Nursing Process it is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm. it includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles. Purpose: To establish a
• Planning involves determining before and the strategies or course of actions to be taken before implementation of nursing care. To be effective, the client and his family should be involve in planning. Purpose: To determine the goals of care and the course of actions to be undertaken during
• EVALUATION is assessment the client’s response to nursing interventions and then comparing that response to predetermined standards or outcome criteria. Purpose: To appraise the extent to which goals and outcome criteria of nursing care have been achieved. Activities: Collect data about the client’s response. Compare the client’s response to goals
• Family Nursing Care Plan Part 2 by: Luvi Jane Cruz Scholar Nursing Student, FEU Graded 94% by C.I. HEALTH HISTORY A. BIOGRAPHIC DATA The client’s name is JCP, a 17 years old, single, female, and lives at 1037 J. B. Miguel St. Bambang, Pasig, City. She is a Roman Catholic although she was born on October 10, 1989 in the Kingdom of Saudi Arabia. The client