NURSING PROCESS - DIAGNOSIS

• Diagnosing is the 2^nd phase of nursing process
• Nurse uses critical thinking skills to interpret assessment data
• All the activities preceding this phase are directed toward formulating nursing diagnosis.
• The use of the nursing process and nursing diagnoses is rapidly becoming an integral part of an effective system of nursing practice.
• Identification & Development of Nursing Diagnosis began in year 1973.
• It is derived from actual or potential problems.
• Derived from physiological, social, cultural, developmental and spiritual dimensions of client.

NANDA INTERNATIONAL

• NANDA -North American Nursing Diagnosis Association
• a professional organization of nurses interested in standardized nursing terminology.
• Officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses.
• In 2002 Taxonomy II, which was a revised version of Gordon's functional health patterns, was released.
• The current structure of NANDA's nursing diagnoses is referred to as Taxonomy II and has three levels: Domains (13), Classes (47) and (206)Diagnosis labels.

Taxonomy II

Domain

Health promotion

Nutrition

Elimination/ Exchange

Activity/ Rest

Perception/ Cognition

Self- perception

Role relationship

Sexuality

Coping/Stress tolerance

Life principles

Safety/ Protection

Comfort

Growth/ Development

Class 1

Health awareness

Ingestion

Urinary function

Sleep/Rest

Attention

Self-concept

Caregiving roles

Sexual identity

Post-trauma responses

Values

Infection

Physical comfort

Growth

Class 2

Health management

Digestion

Gastrointestinal function

Activity/ Exercise

Orientation

Self-esteem

Family relationships

Sexual function

Coping responses

Beliefs

Physical injury

Environmental comfort

Development

Class 3

Absorption

Integumentary function

Energy balance

Sensation/ Perception

Body image

Role performance

Reproduction

Neuro-behavioral stress

Value/Belief/ Action congruence

Violence

Social comfort

Class 4

Metabolism

Respiratory function

Cardio-vascular/ Pulmonary responses

Cognition

Environmental hazards

Class 5

Hydration

Self-care

Communi- cation

Defensive processes

Class 6

Thermo- regulation

MEANING

• The word “diagnosis” is singular and “diagnoses” is plural.
• The nursing diagnoses are involved with human responses to stressors or other factors that adversely effect achievement of optimum health.
• Treatment is directed towards causes of the responses or factors influencing it.
• Nursing diagnoses are different from medical diagnoses.

Differences between nursing and medical diagnosis

S. No.	Nursing	Medical
1.	Diagnose and treat human responses	Diagnose and treat disease
2.	Care for client	Cure disease
3.	Holistic-effects on whole individual	Biological, physical effects
4.	Teach clients to do selfcare and become more independent in daily activities	Teach clients about treatments for their disease

DEFINITION

• Nursing diagnosis is a statement or conclusion of a client’s potential or actual health problem resulting from analysis of data.
• Nursing diagnosis 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.
• Nursing diagnosis is the problem statement that the nurse makes regarding a client’s condition which she uses to communicate professionally.
• A Nursing diagnosis is a statement of a patient problem that is arrived at by making inferences from the collected data (Mundiger and Jauron, 1975),
• American Nurses’ Association has implied nursing diagnosis in the definition of nursing: Nursing is the diagnosis and treatment of human responses to actual or potential health problems (ANA, 1980).
• “A clinical judgement about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.” (NANDA, March 1990).

USE/PURPOSE OF NURSING DIAGNOSES
General

• Gives Nurses a Common Language
• Promotes Identification of Appropriate Goals
• Provides Acuity Information
• Can Create a Standard for Nursing Practice
• Provides a Quality Improvement Base

Specific

• For client:
• Individualization of care
• Appropriate selection of interventions
• Establishment of goal
• For Nursing:
• Facilitates communication, documentation
• Continuity of care among health care provider

CHARACTERISTICS OF NURSING DIAGNOSIS

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

TYPES OF NURSING DIAGNOSES
Actual Nursing Diagnoses

• A client problem that is present at the time of the nursing assessment.
• It is based on the presence of signs and symptoms.
• Actual Nursing Diagnoses defined as “a clinical judgment that the nurse has validated because of the presence of major defining characteristics.”
• EXAMPLES
• Ineffective breathing pattern related to bacterial / viral inflammatory Process.
• Anxiety related to changes in the environment and routines, threat to socio economic status.
• Body image disturbance related to temporary presence of a visible drain/ tube.

Risk Nursing Diagnoses

• 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.
• A clinical judgment that an individual/group is more vulnerable to develop the problem than others in the same or a similar situation because of risk factors.
• Describes human responses to health conditions / life processes that may develop in a vulnerable individual / family / community.
• EXAMPLES
• Risk for impaired skin integrity related to immobility.
• Risk for impaired skin integrity related to edema and neuropathy
• Risk for injury related to generalized weakness
• Risk for Impaired skin integrity (left ankle) related to decrease peripheral circulation in diabetes.
• Risk for Impaired skin integrity related to loss of pain perception

Wellness Nursing Diagnoses

• Also known as Health-promotion Nursing Diagnosis
• A clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness (NANDA-I, 2012).
• Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement.
• A clinical judgment about a person's, family’s or community's motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviours, and can be used in any health state.
• Health-promotion nursing diagnosis are one part statement includes diagnostic label.
• EXAMPLES
• Readiness for Enhanced Self-Esteem.
• Readiness for enhanced spiritual well being
• Readiness for enhanced family coping.

Syndrome Nursing Diagnoses

• A syndrome diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to present because of a certain situation or event.
• A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.
• Example –
• Rape-trauma syndrome as manifested by anger, genitourinary discomfort, and sleep pattern disturbance.

Potential/ Possible Nursing diagnosis

• Possible nursing diagnosis is not a type of diagnosis as are actual, risk, and syndrome.
• A possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. It requires more data either to support or to refuse it.
• Possible nursing diagnoses are a diagnostician’s option to indicate that some data are present to confirm a diagnosis but are insufficient at this time.
• 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.
• For Eg.
• Possible social isolation R/t unknown etiology
• Potential risk of constipation as a result of enforced bed rest.
• Potential risk of pressure sore development from enforced bed rest.

COMPONENTS OF A NURSING DIAGNOSIS STATEMENT
A nursing diagnostic statement consists of four parts:

1. Label
2. Problem
3. The Related Factor
4. Defining characteristics

LABEL

• It is a concise term or phrase that represents a pattern of related clues.
• It may include Qualifiers and modifiers.
• Describes the client's health problem or response for which nursing therapy is given.
• It describes the client's health status clearly and concisely in few words.
• Each diagnostic label approved by NANDA carries a definition that clarifies its meaning.

Purpose:

• Is to direct the formation of client goals and desired outcomes.
• It may also suggest some Nursing interventions.

Qualifiers and Modifiers - these are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement.

• Qualifiers for e.g.
• “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
• “Compromised” – to make vulnerable to threat
• Modifiers for e.g. –
• “Acute” – sever, serious, intense, critical
• “Chronic” - constant, persisting, ever present
• “Depleted” - exhausted, tired, useless
• “Disturbed” - troubled, uneasy, unbalanced, bothered
• “Dysfunctional” - inability to function, organ or part of body unable to function
• “Enhanced” - improved, better
• “Excessive” - extreme, too much, unnecessary, disproportionate
• “Increased” - greater than before, improved
• “Intermittent” - irregular, alternating, discontinuous
• “Potential for” - likely to occur, may or might

PROBLEM

• The problem in the statement is as identified by the nurse during the assessment phase. The nurse needs to consider two areas while identifying the problem.
• Provides a clear, precise description; delineates its meaning and helps differentiate it from similar diagnoses.
• Based on data collected
• Must be approved NANDA format begin with qualifier or modifiers
• Use the exact NANDA wording to state the problem
• Examples
• Poor sleep pattern/ Sleep Pattern, disturbed
• Poor circulation / Tissue perfusion, ineffective (cardiopulmonary)

Problem Identification

• What is the problem that is inferred by assessment data?
• For example:
• Client worried about surgery planned for the next day.
• High glucose level due to lack of knowledge about right selection of food items.
• Pupil dilated with medicine for eye testing.
• Not able to sleep in changed setting of hospital.
• Feeling of loneliness.
• To what degree is the problem present ?
• A degree of problem can be explained as:
• Post-operative patient on first day require assistance to brush his teeth.
• A malnourished child is at risk for acquiring infection, hypothermia.
• A nurse observes indifferent behaviour of mother towards the child.

THE RELATED FACTOR/ ETIOLOGY

• The related factors are “conditions or circumstances that can cause or contribute to the development of a diagnosis.”
• The factors contributing to or causing the problem
• It can't be a medical diagnosis
• Must be modifiable by nursing intervention
• Nurse must be able and license to do something about it.
• The etiology component of a nursing diagnosis identifies one or more probable cause of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care.
• Examples of related factors are given below:
• Environmental – Excessive noise, light, fumes, pollutants.
• Psychological – Fear of death, feeling of loneliness, impaired parent-child bonding.
• Socio-cultural – Inability to procure food, lack of support system, lack of finances, literacy level.
• Physiological – Abnormal fluid loss, sensory deficit, loss of skin integrity, breathing difficulty.
• Spiritual – Inability to practice religious rituals, conflict between religious beliefs and prescribed health regimen.

DEFINING CHARACTERISTICS

• Defining Characteristics are the cluster of signs an symptoms that indicate the presence of a particular diagnostic label
• For Actual Nursing Diagnosis- The Defining Characteristics are the client's signs and symptoms
• For Risk Nursing Diagnosis- No subjective and objective signs are present Thus the factors that cause the client to be more than ''Normally'' vulnerable

WRITING THE DIAGNOSTIC STATEMENT
Most Nursing Diagnoses are written as two part or three part statements, but there are variations of these.

1. One part statements
2. Two part statements
3. Three part statements

One-Part Statements

• Wellness nursing diagnoses will be written as one-part statements.
• e.g., Readiness for Enhanced Parenting
• Related factors are not present for wellness nursing diagnoses because they would all be the same: motivated to achieve a higher level of wellness.
• Syndrome diagnoses, such as Rape-Trauma Syndrome, have no “related to” designations.

Two-Part Statements

• The basic two part statement includes the following.
• Problem (P) :- Statement of the client's response (NANDA Label)
• Etiology (E) :- Factors contributing to or probable cause of responses.
• The two parts are joined by the words related to rather than due to.
• The phrase due to implies that one part causes or is responsible for the other part.
• By contrast, the phrase related to merely implies a relationship.
• Risk and possible nursing diagnoses have two parts. The validation for a risk nursing diagnosis is the presence of risk factors. The
• Risk factors are the second part, as in:
• Risk Nursing Diagnosis Related to Risk Factors
• Possible nursing diagnoses are suspected because of the presence of certain factors.
• For Examples -
• Risk for Impaired Skin Integrity related to immobility secondary to fractured hip
• Possible Self-Care Deficit related to impaired ability to use left hand secondary to IV

Three-Part Statements

• The three part Diagnostic Statements called the PES format and includes the following:
• Problem (P) :- Statement of the client's response (NANDA Label)
• Etiology (E) :- Factors contributing to or probable cause of the response.
• Signs and Symptoms (S) :- Defining characteristics manifested by the client.
• Diagnostic label(Problem) related to contributing factors (Etiology) as evident by signs and symptoms
• The presence of major signs and symptoms (defining characteristics) validates that an actual diagnosis is present. This is the third part.
• Actual nursing diagnoses can be documented by using the three part statement because the signs & symptoms have been identified.
• It is not possible to have a third part for risk or possible diagnoses because signs and symptoms do not exist.
• Examples
• Anxiety related to unpredictable nature of asthmatic episodes as evident by statements of “I’m afraid I won’t be able to breathe”
• Urge Incontinence related to diminished bladder capacity secondary to habitual frequent voiding as evident by inability to hold off urination after desire to void and report of voiding out of habit, not need.

GUIDELINES TO FORMULATE NURSING DIAGNOSTIC

• First write an actual or high-risk health problem and not an environmental problem. State environmental factors in the second part.
• For e.g.:
• Wrong: Excessive environmental stimuli related to monitoring equipment
• Right: Sensory perceptual alterations (auditory and visual) related to excessive environmental stimuli
• Do not write several unrelated problems in the first part even though the related factor of the problem may be the same.
• Judge the problems as unrelated when the nursing plan requires separate interventions for each problem.
• For e.g.:
• Wrong: Anxiety and activity intolerance related to frequent episodes of chest pain
• Right: Activity intolerance related to frequent episodes of chest pain
• Right: Anxiety related to frequent episodes of chest pain
• Write the diagnostic statement in a manner that both the problem and related factors refer to different findings.
• For e.g.:
• Wrong: Self-feeding deficit related to inability to feed self.
• Right: Self-feeding deficit related to muscle weakness.
• Write the diagnosis in legally advisable terms.
• For e.g.:
• Wrong: Ineffective airway clearance related to inadequate suction.
• Right: Ineffective airway clearance related to effects of sedation.
• Write the nursing diagnosis in terms of response rather than the need.
• For e.g.:
• Wrong: Need for maintenance of nutritional intake.
• Right: Altered nutrition (less than body requirements) related to nausea and vomiting.
• The purpose of nursing diagnosis is to keep the planning care focused on problems that are amenable to nursing interventions.

VERIFICATION OF THE DIAGNOSIS
The accuracy of nursing diagnosis is verified by the nurse asking the following questions.

1. Is the data base sufficient and accurate?
2. Does a pattern exist?
3. Is the nursing diagnosis based on nursing knowledge?
4. Can the nursing diagnosis be altered by independent nursing actions?

DOCUMENTATION

• After developing and verifying nursing diagnosis the nurse documents the statements on the chart and care plan.
• The statement must also be included on nurses notes or progress notes, discharge summary and referral forms.
• Diagnostic statements are reviewed and revised when it is necessary.

BIBLIOGRAPHY

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