Nursing Diagnosis

GROUP 2
Member Of Group 2
Ade Suryo Mangampe
Salmia Upi
Resky Amelinda
Harpiana Syahrayni
St. Iin Hardianti
Juliana
St. Johar Manikam
Definition of Nursing Diagnsis
A nursing diagnosis is a clinical judgment
about individual, family, or community
responses to actual or potential health
problems or life processes. Nursing diagnosis
provide the basis for selection of nursing
intervention to achieve outcomes for which
the nurse is accountable (NANDA, 2003)
Next...
A nursing diagnosis is a statement of the
high risk or actual problems in the
clients health status that the nurse is
licensed and competent to treat
Components of Analysis
Phase
3 major components of analysis phase:
Analysis and interpretation of data
Validation of data
Clustering of data
Identification of problems/health care
needs
Formulation of nursing diagnosis statement
 Next...
A working of nursing diagnosis may have two or three parts.
The three-part system consists of the nursing diagnosis, the
related to statement, and the defining characteristics.
PES system:
P (problem) - The nursing diagnosis, the label; a concise
term or phrase that represent a pattern of related
cues
E (etiology) Related to phrase or etiology; related
cause or contributor to the problem
S (symptoms) Defining characteristics phrase;
symptoms that the nurse identifted in the assessment
 Part 1 (Problem)
Interpretation of information:
difficulty breathing when walking short

distances= dyspnea
heart feels like it is racing= dysrythmia

tired all the time= fatigue

In Section II we can find the nursing diagnosis

Activity intolerance listed with these symptoms.
 Part 2 (Etiology)
Reated to Phrase
This phrase states what may be causing or contributing to
the nursing diagnosis, commonly referred to as the
etiology.
Ideally the etiologe, or cause, of the nursing diagnosis is
something that can be treated by a nurse. When this is
the case, the diagnosis is identified as an independent
nursing diagnosis. If medical Intervention is also
necessary, it might be identified as a collabarative
diagnosis.
For each suggested nursing diagnosis, the nurse should
refer to the statements listed under the heading Related
Factors
Part 3 (Symptoms)
Defining Characteristic phrase
It consist of the signs and symptoms that
have been gathered during the assessment
phase. Signs and symptoms are labeled as
defining characteristics in Section III.
The use of identifying defining characteristics is
similar to the process the physician uses
when making a medical diagnosis.
Nursing Diagnostic Statement
Derived from actual or potential
problems
Derived from physiological,
sociocultural, developmental, and
spiritual dimensions of client
Focus: Helping client to achieve a
maximal level of wellness and highest
level of independence
Nursing Diagnosis vs Medical
Diagnosis
Medical diagnosis deals with disease or
medical condition or pathology (treating
or curing)
Nursing diagnosis deals with human
response to bio-psycho-social stressors
and/or health problems that a nurse is
licensed and competent to treat
Advantages of Nursing
Diagnosis
For client- individualization of care,
appropriate selection of interventions,
establishment of goals
For nursing- facilitates communication,
documentation, and continuity of care
among health care providers
Sources of error
Errors in data collection
Errors in data analysis
Clustering errors
Incorrect diagnostic statement
Common error, however, if correct steps
are followed this will not occur
Nursing Diagnostic Statement
Diagram

#___ ___________ r/t __________ e/b _____________

Priority Patients this is the cause these are signs/ symptoms

needs/problem (etiology) that come from the assess-
ment (what you see that
supports the problem)

r/t= related to
e/b or m/b= evidenced by or manifested by
Patients needs/problem= NANDA approved statement found in book
Example Statements
#1 Pain r/t tissue damage e/b patient complains of
pain at level of 7 out of 10

#2 Constipation r/t poor fiber intake e/b no bowel

movement for 3 days and abdominal distention

#3 Risk for injury r/t generalized weakness

Parts of Nursing Diagnostic
Statement
Problem
Actual- firm diagnosis supported by
nurses findings (validated)
High risk- has risk factors but does not
have signs and symptoms, more
vulnerable to develop problems
Possible- tenative- additional data needed
to confirm or rule out problem
Parts of Nursing Diagnostic
Statement
Qualifiers/ Modifiers
Impaired
Altered
Decreased
Possible
Ineffective
High risk
Parts of Nursing Diagnostic
Statement
Related to (r/t)
Educated guess as to what factors are contributing
to or causing the problem
Placed between problem and etiology to indicate
relationship between them
Can not be a medical diagnosis
Must be modifiable by nursing interventions
Must be able to do something about it
Will be in one of five categories:
Environmental, situational, psychological, pathophysical,
and maturational
Parts of Nursing Diagnostic
Statement
Evidenced by (e/b) or Manifested by (m/b):
Signs and symptoms (assessment data) that led
to your nursing diagnosis.
Examples:
SOB while walking
Client stating food intake is poor
Client states they are in pain
Client hasnt had bowel movement in 3 days
Client has open wound on buttocks
Case Study
Mrs. Angela Garcia is a 46-year-ol Hispanic woman who works as an x-ray
technician at a busy local hospital. She is being seen in the orthopedic clinic for
complaints of steadily worsening pain in her right knee. The pain began 4
months ago when she fell and hyperextended the knee. Mrs. Garcia reports that
the pain is more intense with weight-bearing activities, including running,
standing, and playing tennis. Because of this, she has been limiting her physical
activities. She also reports the recent onset of painful muscle spasms in the
right leg, both with activity and at rest. The pain and muscle spasms are
disrupting her sleep and making it difficult for her to work. At home she has
terated the discomfort with acetaminophen and stretching exercises but has
experienced no relief.
On physical examination you notice a marked limp with walking, decreased
extension in the right knee, and a reluctance to allow her knee to be touched or
manipulated. The knee is slightly swollen and warm to the touch. During the x-
ray examination of the knee, she grimaces in pain when placed in a kneeling
position.
Mrs. Garcias medical diagnosis is patellar tenonitis, and she is started on a
regimen of non-steroidal anti-inflammatory drug (NSAID). As her nurse, you
want to use the most accurate nursing diagnosis as a basis for her nursing care.
To begin the process of identifying a nursing diagnosis, you first cluster the
significant assessment data.
Source
1. http://www.google.com/url?
sa=t&rct=j&q=&esrc=s&source=web&cd=7&cad=rja&uact=8&v
ed=0ahUKEwjizrWK0KjUAhVBjpQKHW3-
AaQQFghVMAY&url=http%3A%2F%2Fiihsdgn.weebly.com
%2Fuploads
%2F8%2F0%2F2%2F4%2F8024844%2Fnursing_diagnosis.pp
tx&usg=AFQjCNH0d0slbcCnvCyRm8b0vXpbw4ka0Q
2. http://www.google.com/url?
sa=t&rct=j&q=&esrc=s&source=web&cd=4&cad=rja&uact=8&v
ed=0ahUKEwjizrWK0KjUAhVBjpQKHW3-
AaQQFgg9MAM&url=http%3A%2F%2Fintranet.tdmu.edu.ua
%2Fdata%2Fkafedra%2Ftheacher%2Fmeds
%2Fmeds_ysunska%2FEnglish%2FLectures%2FNursing
%2520proc.ppt&usg=AFQjCNFZcu2dsZ4z69uRJwdTs7LryhWl
pA