Nursing Diagnosis - Second Component

           Nursing Diagnosis is the second component in the nursing process involves advance analysis and modified data together in a new way. A list of nursing diagnoses is the result of this process. According to NANDA-International, a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Patients have both medical and nursing diagnoses. The first conference on nursing diagnosis was held in 1973 to identify nursing knowledge and establish a classification system.

Types of Nursing Diagnoses

Analysis of the collected data leads the nurse to make a diagnosis in one of four types:

1 - Actual Nursing Diagnosis: 

           Indicates that a problem exists; it is composed of the diagnostic label, related factors, and signs and symptoms.

2 - Risk Nursing Diagnosis (potential problem):

           Indicates that a problem does not yet exist but that specific risk factors are present. Risk for followed by the diagnostic label and a list of the risk factors.

3 - Wellness Nursing Diagnosis:

           Denotes the client’s statement of a desire to attain a higher level of wellness in some area of function. It begins with the phrase Readiness for Enhanced followed by the diagnostic label.

Syndrome nursing diagnosis: associated with a cluster of predicted high-risk or actual nursing diagnosis, related to a certain situation or event.

4 - Syndrome Nursing Diagnosis

           It is further categories in five types: post-trauma syndrome, rape trauma syndrome, relocation stress syndrome, impaired environmental interpretation syndrome and disuse syndrome. An example of a syndrome nursing diagnosis statement is rape trauma syndrome manifested by sleep pattern disturbance, anger and genitourinary discomfort and related to feeling anxious about possible resulting health problems.

Examples of the four types of nursing diagnoses

Actual Nursing Diagnosis Perceived Constipation R/T faulty appraisal AEB expectation of passage of stool at same time every day.

Risk Nursing Diagnosis Risk for Aspiration R/T decreased cough and gag reflexes.

Wellness Nursing Diagnosis Readiness for Enhanced Spiritual Well-Being.

Syndrome Nursing Diagnosis statement is rape trauma syndrome manifested by sleep pattern disturbance, anger and genitourinary discomfort and related to feeling anxious about possible resulting health problems.

Component of nursing diagnosis

The components are the same for each client situation, but the correlation and results will be different. The nursing process is used with clients of all ages and in any care setting.

1 - Problem statement (Diagnostic label)

2 - Etiology (related factors)

3 - Defining characteristics

1 - Problem statement (diagnostic label)

This describes the client’s health problem for which nursing therapy is given and describes health status clearly and consciously in few words. Qualifiers (words added to the label to give additional specific meaning are altered (change), impaired (worse, weak, damage, reduce, decreased in degree or size, ineffective, acute, chronic. Each label is approved by NANDA. For example altered thought process, altered nutrition less than body requirement, impaired physical mobility, Ineffective air ways clearance and other in relation.

2 - Etiology (related factor)

This identifies one or more cause or risk factor of health problem. For example fluid volume deficit related to dehydration secondary to cholera as evidence by loss of skin turgor.

3 - Defining characteristics

This is cluster of sign and symptoms that indicate the presence of a particular diagnostics label for actual nursing diagnosis. For example Anxiety related disease process as evidence by restlessness. Restlessness is the defining of diagnostics label.

Formatting of Nursing Diagnosis statement

1 - One part statement

This consist of one statement such as in wellness or syndrome diagnosis, for example post stress trauma syndrome, rape trauma syndrome, and other in relation.

2 - Two part statement

This is used for risk, high risk, potential and possible nursing diagnosis. It includes the P (Problem), E (Etiology), its format is called P.E format. For example Risk for infection related to diabetic foot.

3 - Three part statement

 This is used for actual nursing diagnosis. This format is called PES. P (problem), E (Etiology), S (sign and Symptoms/ Defining characteristics). For example altered breathing pattern related bronchospasm secondary to bronchial asthma as evidence by use of accessory muscles.

Difference between Nursing Diagnosis and Medical diagnosis

Nursing diagnosis	Medical diagnosis
Nursing diagnosis is based on health problems.	Medical diagnosis is based on the physiologic conditions.
Nursing diagnosis can be changed at any time.	It remains same throughout course of disease
Nursing diagnoses focus on human response to stimuli	Medical diagnosis focus on the disease process
Names on undesirable human response to a health condition or life process	Names on disease, illness or injury
Nursing Diagnoses change as the client response change	Medical diagnose remains same as long as the disease process is present.

"The Nursing Diagnosis" - Second Component of Nursing Process | POST RN BSN Nursing Resources