1. THE NURSING PROCESS Chapter 3 The Diagnosis Step: Analyzing the Data
Fundamentals:
Diagnosing
Chapter 3
The Nursing Process:
The diagnosis or Need Identification Step:
Analyzing the data
Chapter 13
Fundamentals:
Diagnosing

2. Reference
Doenges, M. E., & Moorhouse, M. F. (2008). Application of nursing process and nursing diagnosis: An interactive text for diagnostic reasoning (5th ed.). Philadelphia: F. A. Davis.

3. 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

4. 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
To diagnose means to determine the cause and nature of a pathological condition, to recognize a disease.
Diagnosis means the use of scientific and skillful methods to establish the cause and nature of a sick person’s disease.
The purpose of Diagnosing is 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

5. 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
Nursing Process-2nd Step: Diagnosing
Interpret and analyze client data. Analysis is the process of examining and categorizing information to reach a conclusion about a client’s needs.
Identify client strengths and health problems
Formulate and validate nursing diagnoses
Develop a prioritized list of nursing diagnoses

6. 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?
Interpret and analyze client data
You want to know:
Is there a health problem?
a condition that necessitates intervening to prevent or resolve disease or illness or to promote coping and wellness
Which healthcare professional can best treat the problem?
Nursing diagnosis – actual or potential health problems that can be prevented or resolved by independent nursing interventions

7. 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
Medical Diagnosis – identify diseases, describes problems for which physician directs the primary treatment. A medical diagnosis remain the same for as long as the disease is present.
Nursing Diagnosis – focus on unhealthy responses to health and illness, problems treated by nurses within the scope of independent nursing practice. A nursing diagnosis may change from day to day as the patient’s responses change. What it is about the patient that gives rise to the need for nursing as opposed to the need for medicine or for physical therapy. Nursing diagnoses are written to describe patient problems that nurses can treat independently.
Example:
Myocardial Infarction or Heart attack is a medical diagnosis.
Fear, altered health maintenance, knowledge deficit, an pain are nursing diagnoses
Collaborative problems – certain physiologic complications that nurses monitor to detect onset or changes in status or “when the nurse writes patient outcomes that require delegated medical orders for goal achievement, this situation is not a nursing diagnosis but a collaborative problem” (Carpenito, 1995) These problems require nursing and medical intervention. Collaborative problems are the primary responsibility of nurses but the prescription for treatment comes from both nursing and medicine.
See table 13-1 Page 258 Fundamentals for comparisons

8. 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
Interpret and analyze client data
Interpretation begins at assessments -you are interpreting and analyzing the data while you are still collecting it
Look for cues (significant data or data that influence this analysis) A piece of data that raises a red flag so you begin to look for patterns that indicate an actual or potential problem.
Look for:
clusters(Data Cluster – grouping of patient data or cues that points to the existence of a patient health problem ),
strengths (Determining strengths – healthy physiologic functioning, emotional health, cognitive abilities, coping skills, interpersonal strengths, and spiritual strengths),
Problems (Determining problem areas – limitation in this aspect of health status and may benefit from professional care),
potential problems (Potential problems – important for nurses to identify potential health problems)
Compare to standards-changes, deviation, behavior. For example, need to know normal ranges for blood pressure and the client’s normal range to know if blood pressure is a deviation.
Know that sorting out healthy data and not healthy data is not as clear cut as it appears.
Draw conclusions
Reaching conclusions
No problem-no nursing response is indicated, reinforce health habits, initiate health promotion activities to prevent disease or illness or to promote a higher level of wellness
Possible problem-collect more data to confirm or disconfirm suspected problem
Actual or potential nursing diagnosis-begin planning, implementing and evaluating care designed to prevent, reduce or resolve the problem.
Clinical problem other than nursing diagnosis-Consult with appropriate healthcare professional and work collaboratively on problem or refer to medicine.

9. Formulate/Validate Nursing Diagnoses
Types of Nursing Diagnosis
Actual Diagnoses
Wellness Diagnoses
Risk Diagnoses
Resolved Diagnoses
Formulate and validate nursing diagnoses
Types of Nursing Diagnosis
Actual Diagnoses
human response to health conditions that currently exist
Wellness Diagnoses
actual diagnosis that has a wellness focus –opportunity to improve an aspect of health more than a need
Risk Diagnoses
potential responses in a vulnerable individual-risk factors
Resolved Diagnoses
no intervention needed-problem resolved-no diagnostic statement needed

10. 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
P = Problem-to describe the health state or problem of a client as clearly as concisely as possible
E = Etiology/Cause -identifies the physiologic, psychological, sociologic, and spiritual and environmental factors
S = Signs/symptoms-Defining Characteristics – subjective and objective data that signal the existence of the actual or potential health problem.
Sign – objective. Symptom – Subjective changes in the body
Nursing Diagnosis – Noun – NANDA – identifying specific client needs
Nursing Diagnosis – Verb
3 Part
-Identifying the client’s need
-Cause of the need
-Associated signs/ symptoms

11. 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)
Writing a nursing diagnosis
Consult NANDA for lists of health problems that may be identified and treated by nurses
Write a nursing diagnosis if a health problem is identified that is treatable by independent nursing intervention
Nursing diagnosis statements are written as two-part statements (problem/cause) or three-part statements (problem/cause/problem’s defining characteristics)

12. 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)
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)
Remember:
Indicates health problem or what patient wants to change
Use non-judgmental language and legally advisable terms
Avoid using defining characteristics or medical diagnosis in problem statement

13. 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
Hypothesis
Step 5 - List client needs
Step 6 - Re-evaluate the Problem List
Nursing Process-2nd Step: Diagnosing
Step 1 – Problem Sensing-review and analyze data to identify cues (signs and symptoms) suggesting client needs that can be described by a nursing diagnosis
Step 2 – Rule out Process-alternative explanations are considered for the identified cues to determine which nursing diagnosis is most appropriate.
What are my concerns about this client?
Can I do something about it?
Can the overall risk be reduced by nursing intervention?
Step 3 - Synthesizing the Data-view the data as a whole-include information collected by other members of the healthcare team to provide a comprehensive picture of the client
Step 4 – Evaluating or Confirming the Hypothesis-compare NANDA nursing diagnosis with the assessed possible etiology
Step 5 – List client needs-combine accurate nursing diagnosis label with the assessed etiology and signs/symptoms
Step 6-Re-evaluate the Problem List-make sure all nursing diagnoses are identified and list them according to priority and classify them according to status, actual need, risk need or resolved need.

14. Remember: 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
Remember:
Nursing Diagnosis – NOT – medical diagnosis
Medical Diagnosis – identify diseases, describes problems for which physician directs the primary treatment
Nursing Diagnosis – focus on unhealthy responses to health and illness, problems treated by nurses within the scope of independent nursing practice
Collaborative problems – certain physiologic complications that nurses monitor to detect onset or changes in status
Nursing Diagnosis change with the client’s progress through various stages of illness. Medical Diagnosis remains the same for as long as the disease is present.
Validating – patients who are able to participate in their care should be encouraged to validate the diagnosis.
Use of Nursing Diagnosis – common language – improved communication among nurses, and other healthcare providers

15. 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

16. Avoiding Errors Identify client response, not medical diagnosis
Correct: Anxiety related to fear of illness
Incorrect: Anxiety related to myocardial infarction

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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
See page 194 Nursing Process book for info on NANDA Constipation diagnosis

23. Summary 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

24. 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

25. 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