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THE NURSING PROCESS. Chapter 3 The Diagnosis Step: Analyzing the Data Chapter 13 Fundamentals: Diagnosing. Reference.

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the nursing process

Chapter 3

The Diagnosis Step:

Analyzing the Data

Chapter 13



  • Doenges, M. E., & Moorhouse, M. F. (2008). Application of nursing process andnursing diagnosis: An interactive text for diagnostic reasoning (5th ed.). Philadelphia: F. A. Davis.
competencies for chapter 3 the diagnosis or need identification step
Competencies for Chapter 3: The Diagnosis or Need Identification Step
  • By the end of this unit the student will:
    • List 3 purposes of the nursing diagnosis
    • Differentiate between nursing and medical diagnoses
    • Define 4 types of nursing diagnoses
    • Define PES relating to parts of the nursing diagnosis statement
    • Identify the 6 steps involved in need identification
purpose of diagnosing
Purpose of Diagnosing

To identify:

  • Actual and potential problems in the way the client responds to health or illness
  • Factors that contribute to or cause the problems (etiologies)
  • Strengths the client can draw on to prevent or resolve problems
nursing process diagnosing
Nursing Process:Diagnosing
  • Interpret and analyze client data to identify client strengths and health problems
    • If data indicates a health problem treatable by independent nursing intervention
  • Formulate and validate nursing diagnoses
interpret analyze client data
Interpret/analyze client data
  • Is there a health problem?
  • Which healthcare professional can best treat the problem?
  • What problems can be managed by nursing intervention?
focus of nursing diagnosis
Focus of Nursing Diagnosis
  • Medical Diagnosis – identify diseases, describes problems, treated by a physician (narrow focus)
  • Nursing Diagnosis – focus on human response to disease process (holistic view)
  • The Nursing Diagnosis is a conclusion drawn from data with needs amenable to treatment by nurses
interpret analyze client data1
Interpret/Analyze Client Data
  • Interpretation begins at assessment
  • Diagnosis must be supported by data
  • Look for clusters, strengths, problems, potential problems
  • Draw conclusions
    • No problem
    • Possible problem
    • Actual or potential nursing diagnosis
formulate validate nursing diagnoses
Formulate/Validate Nursing Diagnoses

Types of Nursing Diagnosis

  • Actual Diagnoses
  • Wellness Diagnoses
  • Risk Diagnoses
  • Resolved Diagnoses
pes parts of the client diagnostic statement
PES: Parts of the Client Diagnostic Statement

P = Problem-describe the health state or problem of a client

E = Etiology-identifies the physiologic, psychological, sociologic, and spiritual and environmental factors

S = Signs/symptoms- defining characteristics – subjective and objective data that signal a problem and supports the diagnosis

writing a nursing diagnosis
Writing a Nursing Diagnosis
  • Consult NANDA
  • Nursing diagnosis statements are written in:
    • Two-part statements (problem/cause) or
    • Three-part statements (problem/cause/problem’s defining characteristics)
guideline for writing a nursing diagnosis
Guideline for Writing a Nursing Diagnosis

P: Phrase patient problem (need)

  • Link with phrase “related to”

E: Etiology (suspected cause for problem)

  • Link with phrase “as evidenced by”

S: List signs/symptoms (cues identified in the assessment that substantiate the nursing diagnosis)

nursing process 2 nd step diagnosing
Nursing Process-2nd Step: Diagnosing

Step 1 - Problem Sensing

Step 2 - Rule out Process

Step 3 - Synthesizing the Data

Step 4 - Evaluating or Confirming the


Step 5 - List client needs

Step 6 - Re-evaluate the Problem List

  • Nursing Diagnosis – NOT – medical diagnosis
  • Nursing Diagnosis change with the client’s progress through various stages of illness
  • Patients who are able to participate in their care should be encouraged to validate the diagnosis
  • Nursing Diagnosis provides a common language to improve communication among nurses, and other healthcare providers
examples of nursing diagnosis
Examples of Nursing Diagnosis
  • Potential altered oral mucus membrane related to NPO state
  • Grieving related to recent job loss as manifested by statement of anger
avoiding errors
Avoiding Errors
  • Identify client response, not medical diagnosis
    • Correct: Anxiety related to fear of illness
    • Incorrect: Anxiety related to myocardial infarction
avoiding errors1
Avoiding Errors
  • Identify problem created by condition rather than the condition itself
    • Correct: Ineffective individual coping related to noncompliance with treatment regimen
    • Incorrect: Ineffective individual coping related to chronic illness
avoiding errors2
Avoiding Errors
  • Identify problem brought about by diagnostic study rather than the diagnostic study itself
    • Correct: Anxiety related to lack of knowledge about cardiac catheterization as evidenced by hyperventilation and profuse sweating each time cardiac catheterization is discussed
    • Incorrect: Anxiety related to cardiac catheterization
avoiding errors3
Avoiding Errors
  • Identify the diagnostic category rather than the symptom
    • Correct: Altered breathing pattern related to excessive mucus production as evidenced by coughing and drooling
    • Incorrect: Cough related to excessive mucus production
avoiding errors4
Avoiding Errors
  • Identify the patient response to the equipment or treatment rather than the equipment itself
    • Correct: Impaired physical mobility related to weakness and fatigue
    • Incorrect: Impaired physical mobility related to cast
avoiding errors5
Avoiding Errors
  • Identify associated factors, avoid legally inadvisable and judgmental statements
    • Correct: Altered family processes related to social deviance by family member
    • Incorrect: Fear related to frequent beatings by husband
case scenario
Case Scenario

81 y.o. male S/P CVA admitted to ECF for custodial care. History includes:

  • Poor PO intake x 2 weeks
  • No bowel movement x 3 days
  • Unable to perform ADL’s independently
    • uses FWW in home or W/C on outing-last 2 weeks has had very limited ambulation related to viral illness
    • requires set-up for meals and encouragement with fluid intake
    • uses adult pads for bladder incontinence
    • requires assistance with showers

The Nursing Diagnosis:

  • Addresses human responses to actual and potential health concerns
  • Provides a common language for nurses and other healthcare professionals and promotes identification of appropriate patient goals
summary continued
Summary- (continued)
  • Is a conclusion drawn from data with patient needs amenable to treatment by nurses
  • Must be supported by data
  • The nursing diagnosis changes as patient progresses through various stages of illness
summary continued1
Summary- (continued)
  • There are six steps for diagnostic reasoning
  • Be specific when writing diagnosis and “related to” statement
  • Important to focus intervention on the roots of human response