1. Chapter 17 Nursing Diagnosis
After you assess a patient, the next step in the process is to form a diagnostic conclusion. Some conclusions can be used to select a nursing diagnosis.
The diagnostic process includes critical analysis and interpretation of assessment data that reveal a patient’s response to health problems with the goal of identifying patient needs and formulating nursing diagnoses.

2. Nursing Diagnosis 1. Medical diagnosis
Identification of a disease condition based on specific evaluation of signs and symptoms
2. Nursing diagnosis
Clinical judgment about the patient in response to an actual or potential health problem
3. Collaborative problem
Actual or potential physiological complication that nurses monitor to detect a change in patient status
A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs and symptoms, the patient’s medical history, and the results of diagnostic tests and procedures.
A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. What makes the nursing diagnostic process unique from medical diagnoses is having patients involved, when possible, in the process.
Selection of a nursing diagnosis provides the basis for choosing nursing interventions. Accurate diagnosis of patient problems ensures the selection of more effective and efficient nursing interventions.
Nursing diagnoses are listed according to the North American Nursing Diagnosis Association (NANDA). Selecting the correct nursing diagnosis on the basis of an assessment involves diagnostic expertise.

3. History of Nursing Diagnosis
First introduced in 1950
In 1953, Fry proposed the formulation of a nursing diagnosis.
In 1973, the first national conference was held.
In 1980 and 1995, the American Nurses Association (ANA) included diagnosis as a separate activity in its publication Nursing: a Social Policy Statement.
In 1982, NANDA was founded.
Nursing diagnoses have been around for more than 60 years! Nursing diagnoses allow nurses to practice independently, especially in the areas of patient education and symptom relief.
NANDA, the North American Nursing Diagnosis Association, was established in The purpose of this organization was to develop, refine, and promote a taxonomy of nursing diagnostic terminology for use by all professional nurses.
NANDA has changed its name to NANDA International (NANDA-I).
Research in diagnosis continues to grow. [See Box 17-1 on text p. 224 Evidence-Based Practice Nursing Diagnosis: Impact on Nursing Practice.]
One purpose of nursing diagnosis to provide a precise definition of a patient’s problem that gives nurses and other members of the health care team a common language for understanding the patient’s needs.

4. Case Study
John is a first semester nursing student who is particularly interested in the cardiac system and specifically heart disease since his father died of a heart attack at age 48. John decided to go into nursing because of his father’s death, which prompted him to select a career that improves people’s lives.
John is studying nursing diagnoses in his nursing fundamentals course and is learning the steps of the nursing diagnostic process. He knows this information will help him care for cardiac patients in the future.
[Ask the class: Do you have a situation in your life that caused you to consider nursing? How will it affect your ability to provide nursing care?]

5. Nursing Diagnostic Process
Assessment of patient’s health status:
• Patient, family, and health care resources constitute database.
• Nurse clarifies inconsistent or unclear information.
• Critical thinking guides and directs line of questioning and examination to reveal detailed and relevant database.
Validate data with other sources.
Are additional data needed? If so, reassess.
If not, continue…
NANDA-I continually develops and adds new diagnostic labels to the NANDA International listing through the process outlined in Fig (on text p. 224, the beginning of which is shown here).

6. Nursing Diagnostic Process (cont’d)
If no additional data are needed, proceed:
Interpret and analyze meaning of data
Data clustering
• Group signs and symptoms.
• Classify and organize.
Look for defining characteristics
and related factors.
Identify patient needs.
Formulate nursing diagnoses
and collaborative problems.
[This is the remainder of Fig from text p. 224.]
Most state Nurse Practice Acts include nursing diagnosis as part of the domain of nursing practice.
[See text pp for a list of Nanda International Nursing Diagnoses as provided in Box 17-2.]

7. Nursing Diagnostic Statements
Provides a precise definition of a patient’s problem that gives nurses and other members of the health care team a common language for understanding patients’ needs
Allows nurses to communicate what they do among themselves and with other health care professionals and the public
Distinguishes the nurse’s role from that of the physician or other health care provider
Helps nurses focus on the scope of nursing practice
Two additional purposes of nursing diagnosis are that they
Foster the development of nursing knowledge
Promote creation of practice guidelines that reflect the essence of nursing

8. Case Study (cont’d) John reviews the phases of the nursing process.
Rank in correct order the phases of the nursing process:
Evaluation
Planning
Assessment
Diagnosis
Implementation
Answer: The correct order of the phases of the nursing process is: Assessment, diagnosis, planning, implementation, and evaluation.

9. Critical Thinking and the Nursing Diagnostic Process
The diagnostic reasoning process involves using the assessment data you gather about a patient to logically explain a clinical judgment or a nursing diagnosis.
Nursing diagnoses and definitions
Defining characteristics = Clinical criteria or assessment findings
Related factors pertinent to the diagnoses
Interventions suited for treating the diagnoses
The diagnostic process flows from the assessment process and includes decision-making steps: Data clustering, identifying patient health problems, and formulating the diagnosis or collaborative problem.
Think back to the critical thinking chapter. You will use your critical thinking abilities to identify an appropriate nursing diagnosis to individualize patient care.
In the practice of nursing, it is important for you to know nursing diagnoses, their definitions and defining characteristics for making diagnoses, related factors pertinent to the diagnoses, and interventions suited for treating the diagnoses.
Sources of information about nursing diagnoses include faculty, advanced practice nurses, documentation systems, and, in some settings, practice guidelines or protocols.
The application of critical thinking attitudes and standards helps you to be thorough, comprehensive, and accurate when identifying nursing diagnoses that apply to your patients.
See Figure 17-1 (on text p. 223), which shows how critical thinking interacts with the nursing process.
Each nursing diagnosis contains a specific set of defining characteristics to support it. When you focus on the defining characteristics, you also need to compare the patient’s pattern of data with normal or expected data. Data you will look at include laboratory and diagnostic values, professional standards, and normal anatomy and physiology.

10. Data Clustering
A data cluster is a set of signs or symptoms gathered during assessment that you group together in a logical way.
Data clusters are patterns of data that contain defining characteristics—clinical criteria that are observable and verifiable.
Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion.
Each NANDA-I–approved nursing diagnosis has an identified set of defining characteristics that support identification of a nursing diagnosis. You learn to recognize patterns of defining characteristics from your patient assessments and then readily select the corresponding diagnosis.
Working with similar patients over a period of time helps you recognize clusters of defining characteristics, but remember that each patient is unique and requires an individualized diagnostic approach.
Defining characteristics are subjective and objective clinical criteria that form clusters, leading to a diagnostic conclusion.
Box 17-3 (Examples of NANDA International–Approved Nursing Diagnoses with Defining Characteristics) (on text p. 227) shows two examples of approved nursing diagnoses and their associated defining characteristics.
When an assessment reveals defining characteristics that apply to more than one nursing diagnosis, gather more information to clarify your interpretation.

11. Case Study (cont’d)
Because of John’s interest in cardiac nursing, he is familiar with the clinical criteria for heart disease.
Which of the following is an example of a clinical criterion?
(Select all that apply.)
Hypertension
Fatigue
Food preference
High cholesterol
Answers: Hypertension, fatigue, and high cholesterol
Rationale: Clinical criteria consist of objective or subjective signs and symptoms or risk factors that lead to a diagnostic conclusion. Hypertension, fatigue, and high cholesterol are all clinical criteria for heart disease, whereas food preference is not.

12. Interpretation— Identifying Health Problems
It is critical to select the correct diagnostic label for a patient’s need.
From assessment to diagnosis, move from general information to specific.
Think of the problem identification phase in assessment as the general health care problem and the formulation of the nursing diagnosis as the specific health problem.
The absence of certain defining characteristics suggests that you reject a diagnosis under consideration.
While analyzing clusters of data, you begin to consider the patient’s health problems. Your interpretation of the information allows you to select among various diagnoses the ones that apply to your patient.
Often a patient has defining characteristics that apply to more than one diagnosis.
Knowing that there are similar diagnoses directs you to gather more information to clarify your interpretation.
Always examine carefully the defining characteristics in your database to support or eliminate a nursing diagnosis. To be more accurate, review all characteristics, eliminate irrelevant ones, and confirm relevant ones.

13. Formulating a Nursing Diagnosis
A related factor is a condition, historical factor, or causative event that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis.
A related factor allows you to individualize a nursing diagnosis for a specific patient.
When you are ready to form a plan of care and select nursing interventions, a concise nursing diagnosis allows you to select suitable therapies.
To individualize a nursing diagnosis further, you identify the associated related factor.
Placing a diagnosis into the context of the patient’s situation clarifies the nature of the patient’s health problem.
While focusing on patterns of defining characteristics, you compare a patient’s pattern of data with data that are consistent with normal, healthful patterns. Use accepted norms as the basis for comparison and judgment. This includes using laboratory and diagnostic test values, professional standards, and normal anatomical or physiological limits.
When comparing patterns, judge whether the grouped signs and symptoms are expected for the patient, and whether they are within the range of healthful responses.
Isolate any defining characteristics not within healthy norms to allow you to identify a specific problem.
A nursing diagnosis focuses on a patient’s actual or potential response to a health problem rather than on the physiological event, complication, or disease.
A nurse cannot independently treat a medical diagnosis.
Critical thinking is necessary in identifying nursing diagnoses and collaborative problems, so you can appropriately individualize care for your patients.
[See also Figure 17-3 on text p. 228 Differentiating nursing diagnoses from collaborative problems.]

14. Types of Nursing Diagnoses
Actual Nursing Diagnosis
Describes human responses to health conditions or life processes
Risk Nursing Diagnosis
Describes human responses to health conditions/life processes that may develop
Health Promotion Nursing Diagnosis
A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human health potential
NANDA-I (2012) identifies three types of nursing diagnoses: actual diagnoses, risk diagnoses, and health promotion diagnoses.
An actual nursing diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community.
The selection of an actual diagnosis indicates that assessment data are sufficient to establish the nursing diagnosis.
Risk factors serve as cues to indicate that a risk nursing diagnosis applies to a patient’s condition.
A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. These diagnoses do not have defining characteristics because they have not occurred yet. Instead a risk diagnosis has risk factors: environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.
Risk factors are diagnostic-related factors that help in planning preventive health care measures.
A health promotion nursing diagnosis is a clinical judgment of a person’s, family’s, or community’s motivation, desire, and readiness to enhance well-being and actualize human health potential as expressed in their readiness to focus on specific health behaviors such as nutrition and exercise.
Health promotion diagnoses can be used in any health state and do not require current levels of wellness. A person’s readiness is supported by defining characteristics.

15. Components of a Nursing Diagnosis
Diagnostic Label (NANDA-I)
Definition
Related Factors/Etiology:
Treatment-related
Pathophysiological (biological or psychological)
Maturational
Situational (environmental or personal)
PES Format:
Problem
Etiology
Symptoms (or defining characteristics)
A common method of developing a nursing diagnosis is to assign a diagnostic label and then note the related or causative factor. Table 17-1 (on text p. 229), NANDA International Two-Part Nursing Diagnosis Format, presents examples.
[You will want to individualize this format to the format used at your college/university/agency.]
The diagnostic label is the name of the nursing diagnosis as approved by NANDA International.
All NANDA-I approved diagnoses also have a definition, which describes the characteristics of the human response identified.
The related factor is identified from the patient’s assessment data and is the reason the patient is displaying the nursing diagnosis. The related factor is associated with a patient’s actual or potential response to the health problem and can change by using specific nursing interventions.
Inclusion of the “related to” phrase requires you to use critical thinking to individualize the nursing diagnosis and then select nursing interventions. [See Table 17-2 (on text p. 229) Comparison of Interventions for Nursing Diagnoses with Different Related Factors.]
[See also Fig Relationship between a diagnostic label and related factor (etiology) on text p. 229.]
In the case of a risk nursing diagnosis, a risk factor is the related factor.
Table 17-3 (on text p. 230), Developing a Two-part Nursing Diagnosis Label, demonstrates the association between a nurse’s assessment of a patient, the clustering of defining characteristics, and the formulation of nursing diagnoses.
The diagnostic process results in the formation of a total diagnostic label that allows you to develop an appropriate, patient-centered plan of care.
Some agencies prefer a three-part nursing diagnostic label: the NANDA-I label, the related factor, and the defining characteristics.
A three-part nursing diagnosis, using a PES format, includes a diagnostic label, etiological statement, and symptoms or defining characteristics.

16. Case Study (cont’d) John learns the four types of nursing diagnoses.
Which of the following are the four types of nursing diagnoses?
(Select all that apply.)
Actual diagnoses
Risk diagnoses
Wellness diagnoses
Health promotion diagnoses
Disease prevention diagnoses
Answer: The four types of nursing diagnoses are actual diagnoses, risk diagnoses, wellness diagnoses, and health promotion diagnoses.

17. Cultural Relevance of Nursing Diagnoses
Consider patients’ cultural diversity when selecting a nursing diagnosis. Ask questions such as:
How has this health problem affected you and your family?
What do you believe will help or fix the problem?
What worries you most about the problem?
Which practices within your culture are important to you?
Cultural awareness and sensitivity improve your accuracy in making nursing diagnoses.
It is important to consider your own cultural competence so you are more sensitive to a patient’s health care problems and the implications.
Additional examples of questions that contribute to making culturally competent nursing diagnoses are:
• What do you expect from us, your nurses, to help maintain some of your cultural practices?
• What cultural practices do you do to keep yourself and your family well?
When you ask questions such as these, you use a patient-centered care approach that allows you to see the patient’s health situation through his or her eyes.
When making a diagnosis, be sure to also consider how culture influences the related factor for your diagnostic statement.
Your own culture potentially influences the cues and defining characteristics that you select from your assessment.

18. Case Study (cont’d)
John knows that a ______________ diagnosis is applied to vulnerable populations.
Answer: risk nursing
Rationale: A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community.

19. Concept Mapping Nursing Diagnosis
A visual representation of a patient’s nursing diagnoses and their relationships with one another
Concept maps promote problem solving and critical thinking skills by
organizing complex patient data,
analyzing concept relationships, and identifying interventions.
A concept map places the central focus on the patient rather than on the patient’s disease or health alteration. This encourages nursing students to concentrate on patients’ specific health problems and nursing diagnoses. The focus also promotes patient participation with the eventual plan of care.
A concept map diagrams the critical thinking associated with making accurate diagnoses. A concept map promotes critical thinking because you identify, graphically display, and link key concepts by organizing and analyzing information
Patients seldom have only one health problem. Your holistic view of a patient heightens the challenge of thinking about all patient needs and problems.
Therefore a picture of each patient usually consists of several interconnections between sets of data, all associated with identified patient problems. Data sources include physical, psychological, and sociocultural domains. Concept mapping helps students to display knowledge in a visual format. [See Figure 17-5 on text p. 231.]
For each diagnosis, you list defining characteristics and begin to see the connections or associations among different diagnostic statements.

20. Sources of Diagnostic Error
Data collection
Data clustering
Interpretation and analysis of data
Labeling the diagnosis/
the diagnostic statement
Documentation and informatics
Nursing diagnostic errors occur during data collection, clustering, interpretation, and labeling of the diagnosis.
Box 17-4 (on text p. 232) lists Sources of Diagnostic Error.
You should strive to avoid inaccurate or missing data and to collect data in an organized way.
It is important to validate the measurable, objective physical findings that support subjective data.
Errors in data collection occur when data are clustered prematurely, incorrectly, or not at all.
Begin interpretation by identifying and organizing relevant assessment patterns to support the presence of patient problems. Be careful to consider conflicting cues, or decide whether cues are insufficient to form a diagnosis.
To reduce errors, you will need to word the diagnostic statement in appropriate, concise, and precise language using NANDA-I terminology.
Documentation is of paramount importance. Always date the diagnosis accurately. Refer to your clinical facility for the way to list nursing diagnoses.

21. Quick Quiz!
1. Concept mapping is one way to A. Connect concepts to a central subject. B. Relate ideas to patient health problems. C. Challenge a nurse’s thinking about patient needs and problems. D. Graphically display ideas by organizing data. E. All of the above
Answer: E

22. Diagnostic Statement Guidelines
1. Identify the patient’s response, not the medical diagnosis.
2. Identify a NANDA-I diagnostic statement rather than the symptom.
3. Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention.
4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself.
5. Identify the patient response to the equipment rather than the equipment itself.
Be sure that the etiology portion of the diagnostic statement is within the scope of nursing to diagnose and treat.
[Discuss each guideline.]
Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis.
Identify nursing diagnoses from a cluster of defining characteristics, not just from a single symptom.
An accurate etiology allows you to select nursing interventions directed toward correcting the cause of the problem or minimizing the patient’s risk.
Patients experience many responses to diagnostic tests and medical treatments.
Patients often are unfamiliar with medical technology.

23. Diagnostic Statement Guidelines (cont’d)
6. Identify the patient’s problems rather than your problems with nursing care.
7. Identify the patient problem rather than the nursing intervention.
8. Identify the patient problem rather than the goal of care.
9. Make professional rather than prejudicial judgments.
10. Avoid legally inadvisable statements.
11. Identify the problem and its cause to avoid a circular statement.
12. Identify only one patient problem in the diagnostic statement.
[Discuss each.]
Nursing diagnoses are always patient centered and form the basis for goal-directed care.
You plan nursing interventions after identifying a nursing diagnosis.
Goals based on accurate identification of a patient’s problems serve as a basis for determining problem resolution.
Base nursing diagnoses on subjective and objective patient data, and do not include your personal beliefs and values.
Statements that imply blame, negligence, or malpractice have the potential to result in a lawsuit.
Circular statements are vague and give no direction to nursing care.
It is permissible to include multiple causes that may be contributing to one patient problem.

24. Quick Quiz!
2. For a student to avoid a data collection error, the student should A. Assess the patient and, if unsure of the finding, ask a faculty member to assess the patient. B. Review his or her own comfort level and competency with assessment skills. C. Ask another student to perform the assessment. D. Consider whether the diagnosis should be actual, potential, or risk.
Answer: A

25. Nursing Diagnosis: Application to Care Planning
By learning to make accurate nursing diagnoses, your care plan will help communicate the patient’s health care problems to other professionals.
A nursing diagnosis will ensure that you select relevant and appropriate nursing interventions.
Nursing diagnosis is a mechanism for identifying the domain of nursing.
Diagnoses direct the planning process and the selection of nursing interventions to achieve desired outcomes for patients.
Just as the medical diagnosis of diabetes leads a physician to prescribe a low-carbohydrate diet and medication for blood glucose control, the nursing diagnosis of Impaired skin integrity directs a nurse to apply certain support surfaces to a patient’s bed and to initiate a turning schedule. In Chapter 18, you will learn how unifying the languages of NANDA-I with the Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) facilitates the process of matching nursing diagnoses with accurate and appropriate interventions and outcomes (Dochterman and Jones, 2003). The care plan (see Chapter 18) is a map for nursing care, and it demonstrates your accountability for patient care. When you make accurate nursing diagnoses, your subsequent care plan communicates to other professionals the patient’s health care problems and ensures that you select relevant and appropriate nursing interventions.