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The Nursing
Process:
Diagnosis
2/21/2019 Compiled by C Settley 1
Objectives
• Define and identify the purposes of a nursing
diagnosis.
• Differentiate a nursing diagnosis from a
medical diagnosis.
• Identify the three segments of a diagnostic
statement and give examples of a
comprehensive diagnostic statement.
• Know what NANDA is and where to find
more information.
2/21/2019 Compiled by C Settley 2
2/21/2019 Compiled by C Settley 3
What is NANDA?
• NANDA International, originally known as
the North American Nursing Diagnosis
Association, was founded in 1982.
• The purpose of NANDA is to develop
standardized terminology so nurses can
have a common language to communicate
the needs of their patients and more easily
understand what needs to be done for
patients.
2/21/2019 Compiled by C Settley 4
Diagnosis
• The second step of the nursing process is identifying
the nursing care problem—
• otherwise called the nursing diagnosis.
• Based on your analysis of the data.
• A nursing diagnosis is a statement about the actual or
potential health concerns of the client that can be
managed through independent nursing interventions.
• Nursing diagnoses are (criteria)
• concise,
• clear,
• client-centered, and
• client-specific statements.
21/Feb/19 Compiled by C Settley 5
Types of Nursing Diagnoses
There are 3 types of nursing diagnoses.
• 1. Problem-focused
– which reflects 'a clinical judgment
concerning an undesirable human
response to health conditions or life
processes that exists in a patient.
– To make this diagnosis, certain elements
must be present, including: defining
characteristics (signs and/or symptoms)
that can be grouped to form recognizable
patterns and related factors that are
somehow related to, contribute to, or led
up to the identified problem.
2/21/2019 Compiled by C Settley
6
Types of Nursing Diagnoses
There are 4 types of nursing diagnoses.
• 1. Problem-focused
– Examples of problem-focused nursing
diagnoses include:
• Sleep deprivation related to pain
• Impaired bed mobility related to left-
sided paralysis
• Decreased cardiac output due to
myocardial infarction
2/21/2019 Compiled by C Settley 7
Types of Nursing Diagnoses
There are 4 types of nursing diagnoses.
• 2. Health promotion
– Concerns the motivation and desire to
increase well-being and to move closer to
a person's own optimum health potential.
– These diagnoses use terms related to a
patient's readiness for specific health
behaviors.
– To make a health-promotion diagnosis,
there must be defining characteristics that
begin with the phrase, 'Expresses desire
to enhance. . .‘
2/21/2019 Compiled by C Settley 8
Types of Nursing Diagnoses
There are 4 types of nursing diagnoses.
• 2. Health promotion
– Examples of health promotion nursing
diagnoses include:
• Sedentary lifestyle
• Risk-prone behavior
• Readiness for enhanced immunization
status
2/21/2019 Compiled by C Settley 9
Types of Nursing Diagnoses
There are 4 types of nursing diagnoses.
• 3. Risk
– Examines the patient's vulnerability for
developing an undesirable response to a
health condition or life process.
– It requires identification of specific,
personalized risk factors, such as
smoking, advanced age, and obesity.
2/21/2019 Compiled by C Settley 10
Types of Nursing Diagnoses
There are 4 types of nursing diagnoses.
• 3. Risk
– Examples of risk nursing diagnosis
include:
• Risk for infection
• Risk for falls
2/21/2019 Compiled by C Settley 11
Types of Nursing Diagnoses
There are 4 types of nursing diagnoses.
• 4. The final nursing diagnosis is
the syndrome.
– This diagnosis identifies specific
groups of diagnoses that occur
together in a pattern and are best
addressed together through similar
nursing interventions.
2/21/2019 Compiled by C Settley 12
Types of Nursing Diagnoses
There are 4 types of nursing diagnoses.
– Making a syndrome diagnosis
requires two or more nursing
diagnoses that serve as defining
characteristics and related factors, if
they add clarity.
– However, related factors are not
required.
2/21/2019 Compiled by C Settley 13
Types of Nursing Diagnoses
There are 4 types of nursing diagnoses.
– An example of a syndrome diagnosis
is a risk for decreased cardiac tissue
perfusion, ineffective cerebral tissue
perfusion,
– and ineffective peripheral tissue
perfusion related to dysfunctional
response
2/21/2019 Compiled by C Settley 14
Diagnosis
• It identifies the disease a person has or is believed to
have.
• Physicians arrive at a medical diagnosis by studying
the physiologic manifestations of the illness and
establishing its cause and nature.
• A medical diagnosis provides a basis for prognosis
(projected client outcome) and medical treatment
decisions.
• Hypertension, pneumonia, diabetes mellitus, and renal
failure are examples of medical diagnoses.
21/Feb/19 Compiled by C Settley 15
Diagnosis
21/Feb/19 Compiled by C Settley 16
• Nursing diagnosis, however, focuses on the
person—the individual’s response to his or her
health.
• Nursing asks how a disease or illness influences
an individual’s functioning and how his or her
needs can be met.
• It is something the nursing staff and the client can
treat without orders from the physician.
• Such actions are called independent nursing
actions.
EXAMPLE!!!
• Medical diagnosis: Pneumonia.
• Infection that inflames air sacs in one or both lungs,
which may fill with fluid
• Symptoms - abnormal breath sounds, a cough
with thick yellow sputum, increased respirations,
difficulty breathing, fever, and fatigue.
• Nursing diagnosis: Altered gas exchange,
ineffective airway clearance, activity intolerance,
risk for imbalanced nutrition, risk for infection
transmission, discomfort.
21/Feb/19 Compiled by C Settley 17
NURSING CARE PLAN FOR
PNEUMONIA
2/21/2019 Compiled by C Settley 18
Nursing diagnosis Interventions Rational Expected/
Desired outcomes
Evaluation
1. Altered gas
exchange
2. Ineffective
airway clearance
3. Activity
intolerance
4. Risk for
imbalanced
nutrition
5. Risk for infection
transmission
6. Discomfort.
EXERCISE:
COMPLETE THE FOLLOWING:
MEDICAL DIAGNOSIS:
 Chronic obstructive
pulmonary disease (lung
diseases that block airflow and
make it difficult to breathe)
SYMPTOMS:
Inflammation and constriction of
bronchial smooth muscle, hyper
secretion of mucus, and edema.
Precipitating factors include
allergens, emotional upheaval, cold
weather, and marked cyanosis,
inflammation, collapsed bronchioles
on expiration (air-trapping).
NURSING DIAGNOSIS
 Ineffective breathing
patterns, Impaired gas
exchange, Ineffective
Airway Clearance,
Imbalanced Nutrition:
Risk for Infection,
Deficient Knowledge
21/Feb/19 Compiled by C Settley 19
EXERCISE:
COMPLETE THE FOLLOWING:
MEDICAL DIAGNOSIS:
 Cerebrovascular accident
(when blood flow to a part of
the brain is stopped either by a
blockage or the rupture of a
blood vessel)
SYMPTOMS:
Difficulty walking, dizziness loss of balance
and coordination, difficulty speaking or
understanding others who are speaking,
numbness or paralysis in the face, leg, or
arm, most likely on just one side of the body,
blurred or darkened vision, a sudden
headache, especially when accompanied by
nausea, vomiting, or dizziness
NURSING DIAGNOSIS
 Risk for decreased
cardiac output, Activity
intolerance, Acute
headache, pain,
Imbalanced nutrition,
Ineffective coping,
Deficient knowledge
(Learning Need)
regarding condition,
treatment plan, self-
care, and discharge
needs
21/Feb/19 Compiled by C Settley 20
EXERCISE:
COMPLETE THE FOLLOWING:
MEDICAL DIAGNOSIS:
 Appendicitis (the
appendix becomes
inflamed and filled with
pus, causing pain)
SYMPTOMS:
Dull pain near the navel or the
upper abdomen that becomes
sharp as it moves to the lower
right abdomen, loss of
appetite, nausea and/or
vomiting soon after abdominal
pain begins, abdominal
swelling, fever.
NURSING DIAGNOSIS
 Acute pain, risk for
deficient fluid volume,
risk for Infection,
deficient knowledge,
impaired skin integrity,
anxiety
21/Feb/19 Compiled by C Settley 21
EXERCISE:
COMPLETE THE FOLLOWING:
MEDICAL DIAGNOSIS:
 Amputation
SYMPTOMS:
warm, red and tender skin.
discharge of fluid or pus.
increasing swelling.
NURSING DIAGNOSIS
 Disturbed body image,
related to amputation of a
left lower leg, grieving
related to anger and loss of
left lower leg, situational
low self-esteem related to
appearance, risk for injury
from infection and
contractures related to
refusal of care, pain related
to surgery
21/Feb/19 Compiled by C Settley 22
EXERCISE:
COMPLETE THE FOLLOWING:
MEDICAL DIAGNOSIS:
 Rheumatoid arthritis
SYMPTOMS:
Joint pain and progressive
stiffness that develops gradually,
swelling, inflammation, and
stiffness in the fingers, arms,
legs, and wrists occurring in the
same joints on both sides of the
body, especially upon
awakening.
NURSING DIAGNOSIS
 Chronic pain, activity
intolerance related to
the effects of
inflammation, self care
deficit.
21/Feb/19
Compiled by C Settley
23
• REMEMBER THAT THE
EXAMPLES OF NURSING
DIAGNOSIS GIVEN MAY
NOT ALWAYS APPLY TO
EACH PATIENT. NURSING
DIAGNOSIS IS CLIENT
CENTERED.
2/21/2019 Compiled by C Settley 24
Exercise 1 (Background data)
2/21/2019 Compiled by C Settley 25
Student activity 1
NURSING CARE PLAN FOR Bronchitis:
Nursing diagnosis
Nursing diagnosis Interventions Rational Expected/desired
outcomes
Evaluation
21/Feb/19 Compiled by C Settley 26
Exercise 2 (Background data)
2/21/2019 Compiled by C Settley 27
Student activity 2
NURSING CARE PLAN FOR Hypertension:
Nursing diagnosis
Nursing diagnosis Interventions Rational Expected/desired
outcomes
Evaluation
21/Feb/19 Compiled by C Settley 28
Reference list
• https://nurseslabs.com/8-pneumonia-nursing-
care-plans/2/
• http://www.nanda.org/
• https://study.com/academy/lesson/the-nursing-
diagnosis-statement-according-to-nanda.html
• https://www.epainassist.com/chest-
pain/lungs/bronchitis-how-do-you-get-bronchial-
infection-and-what-is-its-treatment
• https://depositphotos.com/69340565/stock-
illustration-symptoms-of-hypertension-high-
blood.html
2/21/2019 Compiled by C Settley 29

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3 the nursing process diagnosis

  • 2. Objectives • Define and identify the purposes of a nursing diagnosis. • Differentiate a nursing diagnosis from a medical diagnosis. • Identify the three segments of a diagnostic statement and give examples of a comprehensive diagnostic statement. • Know what NANDA is and where to find more information. 2/21/2019 Compiled by C Settley 2
  • 3. 2/21/2019 Compiled by C Settley 3
  • 4. What is NANDA? • NANDA International, originally known as the North American Nursing Diagnosis Association, was founded in 1982. • The purpose of NANDA is to develop standardized terminology so nurses can have a common language to communicate the needs of their patients and more easily understand what needs to be done for patients. 2/21/2019 Compiled by C Settley 4
  • 5. Diagnosis • The second step of the nursing process is identifying the nursing care problem— • otherwise called the nursing diagnosis. • Based on your analysis of the data. • A nursing diagnosis is a statement about the actual or potential health concerns of the client that can be managed through independent nursing interventions. • Nursing diagnoses are (criteria) • concise, • clear, • client-centered, and • client-specific statements. 21/Feb/19 Compiled by C Settley 5
  • 6. Types of Nursing Diagnoses There are 3 types of nursing diagnoses. • 1. Problem-focused – which reflects 'a clinical judgment concerning an undesirable human response to health conditions or life processes that exists in a patient. – To make this diagnosis, certain elements must be present, including: defining characteristics (signs and/or symptoms) that can be grouped to form recognizable patterns and related factors that are somehow related to, contribute to, or led up to the identified problem. 2/21/2019 Compiled by C Settley 6
  • 7. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. • 1. Problem-focused – Examples of problem-focused nursing diagnoses include: • Sleep deprivation related to pain • Impaired bed mobility related to left- sided paralysis • Decreased cardiac output due to myocardial infarction 2/21/2019 Compiled by C Settley 7
  • 8. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. • 2. Health promotion – Concerns the motivation and desire to increase well-being and to move closer to a person's own optimum health potential. – These diagnoses use terms related to a patient's readiness for specific health behaviors. – To make a health-promotion diagnosis, there must be defining characteristics that begin with the phrase, 'Expresses desire to enhance. . .‘ 2/21/2019 Compiled by C Settley 8
  • 9. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. • 2. Health promotion – Examples of health promotion nursing diagnoses include: • Sedentary lifestyle • Risk-prone behavior • Readiness for enhanced immunization status 2/21/2019 Compiled by C Settley 9
  • 10. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. • 3. Risk – Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. – It requires identification of specific, personalized risk factors, such as smoking, advanced age, and obesity. 2/21/2019 Compiled by C Settley 10
  • 11. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. • 3. Risk – Examples of risk nursing diagnosis include: • Risk for infection • Risk for falls 2/21/2019 Compiled by C Settley 11
  • 12. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. • 4. The final nursing diagnosis is the syndrome. – This diagnosis identifies specific groups of diagnoses that occur together in a pattern and are best addressed together through similar nursing interventions. 2/21/2019 Compiled by C Settley 12
  • 13. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. – Making a syndrome diagnosis requires two or more nursing diagnoses that serve as defining characteristics and related factors, if they add clarity. – However, related factors are not required. 2/21/2019 Compiled by C Settley 13
  • 14. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. – An example of a syndrome diagnosis is a risk for decreased cardiac tissue perfusion, ineffective cerebral tissue perfusion, – and ineffective peripheral tissue perfusion related to dysfunctional response 2/21/2019 Compiled by C Settley 14
  • 15. Diagnosis • It identifies the disease a person has or is believed to have. • Physicians arrive at a medical diagnosis by studying the physiologic manifestations of the illness and establishing its cause and nature. • A medical diagnosis provides a basis for prognosis (projected client outcome) and medical treatment decisions. • Hypertension, pneumonia, diabetes mellitus, and renal failure are examples of medical diagnoses. 21/Feb/19 Compiled by C Settley 15
  • 16. Diagnosis 21/Feb/19 Compiled by C Settley 16 • Nursing diagnosis, however, focuses on the person—the individual’s response to his or her health. • Nursing asks how a disease or illness influences an individual’s functioning and how his or her needs can be met. • It is something the nursing staff and the client can treat without orders from the physician. • Such actions are called independent nursing actions.
  • 17. EXAMPLE!!! • Medical diagnosis: Pneumonia. • Infection that inflames air sacs in one or both lungs, which may fill with fluid • Symptoms - abnormal breath sounds, a cough with thick yellow sputum, increased respirations, difficulty breathing, fever, and fatigue. • Nursing diagnosis: Altered gas exchange, ineffective airway clearance, activity intolerance, risk for imbalanced nutrition, risk for infection transmission, discomfort. 21/Feb/19 Compiled by C Settley 17
  • 18. NURSING CARE PLAN FOR PNEUMONIA 2/21/2019 Compiled by C Settley 18 Nursing diagnosis Interventions Rational Expected/ Desired outcomes Evaluation 1. Altered gas exchange 2. Ineffective airway clearance 3. Activity intolerance 4. Risk for imbalanced nutrition 5. Risk for infection transmission 6. Discomfort.
  • 19. EXERCISE: COMPLETE THE FOLLOWING: MEDICAL DIAGNOSIS:  Chronic obstructive pulmonary disease (lung diseases that block airflow and make it difficult to breathe) SYMPTOMS: Inflammation and constriction of bronchial smooth muscle, hyper secretion of mucus, and edema. Precipitating factors include allergens, emotional upheaval, cold weather, and marked cyanosis, inflammation, collapsed bronchioles on expiration (air-trapping). NURSING DIAGNOSIS  Ineffective breathing patterns, Impaired gas exchange, Ineffective Airway Clearance, Imbalanced Nutrition: Risk for Infection, Deficient Knowledge 21/Feb/19 Compiled by C Settley 19
  • 20. EXERCISE: COMPLETE THE FOLLOWING: MEDICAL DIAGNOSIS:  Cerebrovascular accident (when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel) SYMPTOMS: Difficulty walking, dizziness loss of balance and coordination, difficulty speaking or understanding others who are speaking, numbness or paralysis in the face, leg, or arm, most likely on just one side of the body, blurred or darkened vision, a sudden headache, especially when accompanied by nausea, vomiting, or dizziness NURSING DIAGNOSIS  Risk for decreased cardiac output, Activity intolerance, Acute headache, pain, Imbalanced nutrition, Ineffective coping, Deficient knowledge (Learning Need) regarding condition, treatment plan, self- care, and discharge needs 21/Feb/19 Compiled by C Settley 20
  • 21. EXERCISE: COMPLETE THE FOLLOWING: MEDICAL DIAGNOSIS:  Appendicitis (the appendix becomes inflamed and filled with pus, causing pain) SYMPTOMS: Dull pain near the navel or the upper abdomen that becomes sharp as it moves to the lower right abdomen, loss of appetite, nausea and/or vomiting soon after abdominal pain begins, abdominal swelling, fever. NURSING DIAGNOSIS  Acute pain, risk for deficient fluid volume, risk for Infection, deficient knowledge, impaired skin integrity, anxiety 21/Feb/19 Compiled by C Settley 21
  • 22. EXERCISE: COMPLETE THE FOLLOWING: MEDICAL DIAGNOSIS:  Amputation SYMPTOMS: warm, red and tender skin. discharge of fluid or pus. increasing swelling. NURSING DIAGNOSIS  Disturbed body image, related to amputation of a left lower leg, grieving related to anger and loss of left lower leg, situational low self-esteem related to appearance, risk for injury from infection and contractures related to refusal of care, pain related to surgery 21/Feb/19 Compiled by C Settley 22
  • 23. EXERCISE: COMPLETE THE FOLLOWING: MEDICAL DIAGNOSIS:  Rheumatoid arthritis SYMPTOMS: Joint pain and progressive stiffness that develops gradually, swelling, inflammation, and stiffness in the fingers, arms, legs, and wrists occurring in the same joints on both sides of the body, especially upon awakening. NURSING DIAGNOSIS  Chronic pain, activity intolerance related to the effects of inflammation, self care deficit. 21/Feb/19 Compiled by C Settley 23
  • 24. • REMEMBER THAT THE EXAMPLES OF NURSING DIAGNOSIS GIVEN MAY NOT ALWAYS APPLY TO EACH PATIENT. NURSING DIAGNOSIS IS CLIENT CENTERED. 2/21/2019 Compiled by C Settley 24
  • 25. Exercise 1 (Background data) 2/21/2019 Compiled by C Settley 25
  • 26. Student activity 1 NURSING CARE PLAN FOR Bronchitis: Nursing diagnosis Nursing diagnosis Interventions Rational Expected/desired outcomes Evaluation 21/Feb/19 Compiled by C Settley 26
  • 27. Exercise 2 (Background data) 2/21/2019 Compiled by C Settley 27
  • 28. Student activity 2 NURSING CARE PLAN FOR Hypertension: Nursing diagnosis Nursing diagnosis Interventions Rational Expected/desired outcomes Evaluation 21/Feb/19 Compiled by C Settley 28
  • 29. Reference list • https://nurseslabs.com/8-pneumonia-nursing- care-plans/2/ • http://www.nanda.org/ • https://study.com/academy/lesson/the-nursing- diagnosis-statement-according-to-nanda.html • https://www.epainassist.com/chest- pain/lungs/bronchitis-how-do-you-get-bronchial- infection-and-what-is-its-treatment • https://depositphotos.com/69340565/stock- illustration-symptoms-of-hypertension-high- blood.html 2/21/2019 Compiled by C Settley 29