Nursing Diagnosis

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NURSING DIAGNOSIS

A Nursing Diagnosis (Nr.Dx) may be part of the nursing process and is a clinical judgment concerning human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community. A nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse has accountability. Nursing diagnosis are developed based on data obtained during the nursing assessment and enable the nurse to develop the care plan.

PURPOSES :

Helps identify nursing priorities and help direct nursing interventions based on identified priorities.Helps the formulation of expected outcomes for quality assurance requirements of third-party payers.Nursing diagnoses help identify how a client or group responds to actual or potential health and life processes and knowing their available resources of strengths that can be drawn upon to prevent or resolve problems.Provides a common language and forms a basis for communication and understanding between nursing professionals and the healthcare team.Provides a basis of evaluation to determine if nursing care was beneficial to the client and cost-effective.For nursing students, nursing diagnoses are an effective teaching tool to help sharpen their problem-solving and critical thinking skills.

NURSING DIAGNOSIS VERSUS MEDICAL DIAGNOSIS:

The term NURSING DIAGNOSIS is associated with three different concepts. It may refer to the distinct second step in the nursing process, Diagnosis and Also, Nursing Diagnosis applies to the label when nurses assign meaning to collected data appropriately labeled with NANDA-I-approved nursing diagnosis. For example, during the assessment, the nurse may recognize that the client is feeling anxious, fearful, and finds it difficult to sleep. It is those problems which are labeled with nursing diagnoses: respectively, FEAR , ANXIETY and DISTRUBED SLEEP PATTERN Lastly, a nursing diagnosis refers to one of many diagnoses in the classification system established and approved by NANDA. In this context, a nursing diagnosis is based upon the response of the patient to the medical condition. It is called a ‘nursing diagnosis’ because these are matters that hold a distinct and precise action that is associated with what nurses have autonomy to take action about with a specific disease or condition. This includes anything that is a physical, mental, and spiritual type of response. Hence, a nursing diagnosis is focused on care.

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_NR⚠SIS.                || DR⚠

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-Ineffective            ||  Pneumonia
Breathing Pattern.
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Disturbed               ||  Amputation.
Body Image.
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Risk For                  ||    Diabetic Mellitus
Unstable Glucose.     
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Impaired                ||    Post-Operative
Urinary                   ||    Prostatectomy.
Elimination.
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Self-Care                 ||   Cerebrovascular
Deficit: Dressing    ||           Accident.
& Grooming.
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COMPONENTS OF DIAGNOSIS

Etiology 

The etiology, or related factors and risk factors, component of a nursing diagnosis label identifies one or more probable causes of the health problem, are the conditions involved in the development of the problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care. Nursing interventions should be aimed at etiological factors in order to remove the underlying cause of the nursing diagnosis. Etiology is linked with the problem statement with the phrase “as related to”.

Defining Characteristics

Defining characteristics are the clusters of signs and symptoms that indicate the presence of a particular diagnostic label. In actual nursing diagnoses, the defining characteristics are the identified signs and symptoms of the client. For risk nursing diagnosis, no signs and symptoms are present therefore the factors that cause the client to be more susceptible to the problem form the etiology of a risk nursing diagnosis. Defining characteristics are written “as evidenced by” or “as manifested by” in the diagnostic statement.

Problem and Definition

The problem statement, or the diagnostic label, describes the client’s health problem or response for which nursing therapy is given as concisely as possible. A diagnostic label usually has two parts: qualifier and focus of the diagnosis. Qualifiers (also called modifiers) are words that have been added to some diagnostic labels to give additional meaning, limit or specify the diagnostic statement. Exempted in this rule are one-word nursing diagnoses (e.g., Anxiety, Vomitting where their qualifier and focus are inherent in the one term.

Nursing Diagnosis List

In this section is the list or database of NANDA nursing diagnoses examples with their definitions that you can read to learn more about them or use them in developing your nursing care plans. Click on the links to visit the complete guide.

• Activity Intolerance: Insufficient physiologic or psychological energy to endure or complete required or desired daily activities.
• Acute Confusion: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or the sleep/wake cycle.
• Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.
• Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.
• Bowel Incontinence: Change in normal bowel habits characterized by involuntary passage of stool
• Caregiver Role Strain: Difficulty in performing family caregiver role.
• Chronic Confusion: An irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli, decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation, and behavior.
• Chronic Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage…a duration of greater than 6 months.
  
• Constipation: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.
• Decreased Cardiac Output: Inadequate blood pumped by the heart to meet the metabolic demands of the body.
• Deficient Fluid Volume: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.
• Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
• Diarrhea: This nursing diagnosis is defined as passage of loose, unformed stools.
• Disturbed Body Image: Confusion in mental picture of one’s physical self.
• Disturbed Thought Processes: The state in which an individual experiences a disruption in such mental activities as conscious thought, reality orientation, problem solving, judgment, and comprehension related to coping, personality, and/or mental disorder.
• Excess Fluid Volume: Increased isotonic fluid retention.
• Fatigue: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.
• Fear: Response to perceived threat that is consciously recognized as danger.
• Grieving: A normal complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives.
• Hopelessness: Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf.
• Hyperthermia: Body temperature elevated above normal range.
• Hypothermia: Body temperature below normal range.
• Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.
• Imbalanced Nutrition: More Than Body Requirements: Intake of nutrients that exceeds metabolic needs.
• Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
• Impaired Oral Mucous Membrane: Disruption of the lips and/or soft tissue of the oral cavity.
• Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.
• Impaired Swallowing: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function.
• Impaired Tissue (Skin) Integrity: Damage to mucous membrane, corneal, or subcutaneous tissues.
• Impaired Urinary Elimination: Dysfunction in urinary elimination.
• Insomnia: A disruption in amount and quality of sleep that impairs functioning.
• Impaired Verbal Communication: Decreased, reduced, delayed, or absent ability to receive, process, transmit, and use a system of symbols.
• Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
• Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation.
• Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.
• Ineffective Therapeutic Regimen Management: Pattern of regulating and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals.
• Ineffective Tissue Perfusion: Decrease in oxygen, resulting in failure to nourish tissues at capillary level.
• Insomnia: A disruption in amount and quality of sleep that impairs functioning.
• Latex Allergy Response: A hypertensive reaction to natural latex rubber products.
• Nausea: An unpleasant, wavelike sensation in the back of the throat, epigastrium, or throughout the abdomen that may or may not lead to vomiting.
• Powerlessness: Perception that one’s own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening.
• Rape Trauma Syndrome: Sustained maladaptive response, violent sexual penetration against the victim’s will and consent.
• Risk for Aspiration: At risk for entry of gastrointestinal secretions, oropharyngeal secretion, solids, or fluids into tracheobronchial passages.
• Risk for Bleeding: At risk for a decrease in blood volume that may compromise health.
• Risk for Electrolyte Imbalance: At risk for change in serum electrolyte levels that may compromise health.
• Risk for Falls: Increased susceptibility to falling that may cause physical harm.
• Risk for Impaired Skin Integrity: At risk for skin being adversely altered.
• Risk for Infection: At increased risk for being invaded by pathogen organisms.
• Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
• Risk for Suicide: At risk for self-inflicted, life-threatening injury.
• Risk for Unstable Blood Glucose Level: Risk for variation of blood sugar levels from the normal range.
• Self-Care Deficit: Impaired ability to perform or complete activities of daily living for oneself, such as feeding, dressing, bathing, toileting.
• Situational Low Self Esteem: Development of a negative perception of self-worth in response to current situation.
• Urinary Incontinence, Functional: Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine.
• Urinary Incontinence, Reflex: Involuntary loss of urine at somewhat predictable intervals when a specific urine volume is reached.
• Urinary Incontinence, Stress: Sudden leakage of urine with activities that increase intraabdominal pressure.
• Urinary Incontinence, Urge: Involuntary passage of urine occurring soon after a strong sense of urgency to void.
• Urinary Retention: Incomplete emptying of the bladder.