12.

Diagnosing

LEARNING OUTCOMES

After completing this chapter, you will be able to:

1. Differentiate various types of nursing diagnoses.

2. Identify the components of a nursing diagnosis.
3. Compare nursing diagnoses, medical diagnoses, and collaborative problems.
4. Identify basic steps in the diagnostic process.
5. Describe various formats for writing nursing diagnoses.
6. Describe the characteristics of a nursing diagnosis.
7. List guidelines for writing a nursing diagnosis statement.
8. Describe the evolution of the nursing diagnosis movement, including work currently in
progress.
9. List advantages of a taxonomy of nursing diagnoses.

KEY TERMS

defining characteristics, 198

dependent functions, 198
diagnosis, 196
diagnostic label, 196
etiology, 196
independent functions, 198
norm, 199
nursing diagnosis, 196
PES format, 202
possible nursing diagnosis, 197
qualifiers, 197
risk factors, 197
risk nursing diagnosis, 197
standard, 199
syndrome diagnosis, 197
taxonomy, 196
wellness diagnosis, 197

INTRODUCTION

Diagnosing is the second phase of the nursing process. In this phase, nurses use critical-thinking skills
to interpret assessment data and identify client strengths and problems. Diagnosing is a pivotal step in
the nursing process. Activities preceding this phase are directed toward formulating the nursing
diagnoses; the care-planning activities following this phase are based on the nursing diagnoses (see
Figure 12-1).

The identification and development of nursing diagnoses began formally in 1973, when two faculty
members of Saint Louis University, Kristine Gebbie and Mary Ann Lavin, perceived a need to
identify nurses' roles in an ambulatory care setting. The First National Conference to identify nursing
diagnoses was sponsored by the Saint Louis University School of Nursing and Allied Health
Professions in 1973. Subsequent national conferences occurred in 1975, in 1980, and every 2 years
thereafter.

International recognition came with the First Canadian Conference in Toronto in 1977 and the
International Nursing Conference in May 1987 in Calgary, Alberta, Canada. In 1982, the conference
group accepted the name North American Nursing Diagnosis Association (NANDA), recognizing the
participation and contributions of nurses in the United States and Canada.

The purpose of NANDA is to define, refine, and promote a taxonomy of nursing diagnostic
terminology of general use to professional nurses. A taxonomy is a classification system or set of
categories arranged based on a single principle or set of principles. The members of NANDA include
staff nurses, clinical specialists, faculty, directors of nursing, deans, theorists, and researchers. The
group has currently approved more than 170 nursing diagnosis labels for clinical use and testing. In
2000, Taxonomy I was revised and is now referred to as Taxonomy II (see the list in Appendix C on

page 1530).

Figure 12-1. Diagnosing. The pivotal second phase of the nursing process.

NANDA NURSING DIAGNOSES

To use the concept of nursing diagnoses effectively in generating and completing a nursing care plan,
the nurse must be familiar with the definitions of terms used, the types, and the components of
nursing diagnoses.

Definitions

The term diagnosing refers to the reasoning process, whereas the term diagnosis is a statement or
conclusion regarding the nature of a phenomenon. The standardized NANDA names for the diagnoses
are called diagnostic labels; and the client's problem statement, consisting of the diagnostic label plus
etiology (causal relationship between a problem and its related or risk factors), is called a nursing
diagnosis.

In 1990, NANDA adopted an official working definition of nursing diagnosis: ". . . a clinical
judgment about individual, family, or community responses to actual and potential health
problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions
to achieve outcomes for which the nurse is accountable" (as cited in NANDA International, 2005, p.
277). This definition implies the following:

• Professional nurses (registered nurses) are responsible for making nursing diagnoses, even though
other nursing personnel may contribute data to the process of diagnosing and may implement
specified nursing care. The American Nurses Association Nursing: Scope and Standards of Practice
(2004) state that nurses are accountable for this phase of the nursing process. The Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) requires evidence of nursing diagnoses in
clients' medical records as well (JCAHO, 2005).

• The domain of nursing diagnosis includes only those health states that nurses are educated and
licensed to treat. For example, generalist nurses are not educated to diagnose or treat diseases such as
diabetes mellitus; this task is defined legally as within the practice of medicine. Yet nurses can
diagnose and treat Deficient Knowledge, Ineffective Coping, or Imbalanced Nutrition, all of which are
the human responses to the medical diagnosis of diabetes mellitus.

• A nursing diagnosis is a judgment made only after thorough, systematic data collection.

• Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk
factors, and areas of enhanced personal growth.

Types of Nursing Diagnoses

The five types of nursing diagnoses are actual, risk, wellness, possible, and syndrome.

1. An actual diagnosis is a client problem that is present at the time of the nursing assessment.
Examples are Ineffective Breathing Pattern and Anxiety. An actual nursing diagnosis is based on the
presence of associated signs and symptoms.

2. A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of
risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all
people admitted to a hospital have some possibility of acquiring an infection; however, a client with
diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would
appropriately use the label Risk for Infection to describe the client's health status.

3. A wellness diagnosis "Describes human responses to levels of wellness in an individual, family or

community that have a readiness for enhancement" (NANDA International, 2005, p. 277). Examples
of wellness diagnoses would be Readiness for Enhanced Spiritual Well-Being or Readiness for
Enhanced Family Coping.

4. A possible nursing diagnosis is one in which evidence about a health problem is incomplete or
unclear. A possible diagnosis requires more data either to support or to refute it. For example, an
elderly widow who lives alone is admitted to the hospital. The nurse notices that she has no visitors
and is pleased with attention and conversation from the nursing staff. Until more data are collected,
the nurse may write a nursing diagnosis of Possible Social Isolation related to unknown etiology.

5. A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses

(Carpenito-Moyet, 2006). Currently six syndrome diagnoses are on the NANDA International list.
Risk for Disuse Syndrome, for example, may be experienced by long-term bedridden clients. Clusters
of diagnoses associated with this syndrome include Impaired Physical Mobility, Risk for Impaired
Tissue Integrity, Risk for Activity Intolerance, Risk for Constipation, Risk for Infection, Risk for
Injury, Risk for Powerlessness, Impaired Gas Exchange, and so on.

Components of a NANDA Nursing Diagnosis

A nursing diagnosis has three components: (1) the problem and its definition, (2) the etiology, and (3)
the defining characteristics. Each component serves a specific purpose.

Problem (Diagnostic Label) and Definition

The problem statement, or diagnostic label, describes the client's health problem or response for
which nursing therapy is given. It describes the client's health status clearly and concisely in a few
words. The purpose of the diagnostic label is to direct the formation of client goals and desired
outcomes. It may also suggest some nursing interventions.

To be clinically useful, diagnostic labels need to be specific; when the word Specify follows a
NANDA label, the nurse states the area in which the problem occurs, for example, Deficient
Knowledge (Medications) or Deficient Knowledge (Dietary Adjustments).

Qualifiers are words that have been added to some NANDA labels to give additional meaning to the
diagnostic statement; for example:

• Deficient (inadequate in amount, quality, or degree; not sufficient; incomplete)

• Impaired (made worse, weakened, damaged, reduced, deteriorated)

• Decreased (lesser in size, amount, or degree)

• Ineffective (not producing the desired effect)

• Compromised (to make vulnerable to threat)

Each diagnostic label approved by NANDA carries a definition that clarifies its meaning. For
example, the definition of the diagnostic label Activity Intolerance is shown in Table 12-1.

Etiology (Related Factors and Risk Factors)

The etiology component of a nursing diagnosis identifies one or more probable causes of the health
problem, gives direction to the required nursing therapy, and enables the nurse to individualize the
client's care. As shown in Table 12-1, the probable causes of Activity Intolerance include sedentary
lifestyle, generalized weakness, and so on. Differentiating among possible causes in the nursing
diagnosis is essential because each may require different nursing interventions. Table 12-2 provides
examples of problems that have different etiologies and therefore require different interventions.

Defining Characteristics
Defining characteristics are the cluster of signs and symptoms that indicate the presence of a
particular diagnostic label. For actual nursing diagnoses, the defining characteristics are the client's
signs and symptoms. For risk nursing diagnoses, no subjective and objective signs are present. Thus,
the factors that cause the client to be more vulnerable to the problem form the etiology of a risk
nursing diagnosis.

The NANDA lists of defining characteristics are still being developed and refined. Characteristics are
listed separately according to whether they are subjective or objective in nature.

Differentiating Nursing Diagnoses from Medical Diagnoses

A nursing diagnosis is a statement of nursing judgment and refers to a condition that nurses, by virtue
of their education, experience, and expertise, are licensed to treat. A medical diagnosis is made by a
physician and refers to a condition that only a physician can treat. Medical diagnoses refer to disease
processesspecific pathophysiologic responses that are fairly uniform from one client to another. In
contrast, nursing diagnoses describe the human response, a client's physical, sociocultural,
psychologic, and spiritual responses to an illness or a health problem. See how these responses vary
among individuals:

Seventy-year-old Mary Cain and 20-year-old Kristi Vidan both have rheumatoid arthritis. Their
disease processes are much the same. X-ray studies show that in both clients, the extent of
inflammation and the number of joints involved are similar, and both clients experience almost
constant pain. Ms. Cain views her condition as part of the aging process and is responding with
acceptance. Ms. Vidan, however, is responding with anger and hostility because she views her disease
as a threat to her personal identity, role performance, and self-esteem.

A client's medical diagnosis remains the same for as long as the disease process is present, but nursing
diagnoses change as the client's responses change. Ms. Vidan's response to her illness may change
over time to become more similar to that of Ms. Cain.

Nurses have responsibilities related to both medical and nursing diagnoses. Nursing diagnoses relate
to the nurse's independent functions, that is, the areas of health care that are unique to nursing and
separate and distinct from medical management.

It is possible that the nurse cannot prescribe all the care for a nursing diagnosis, but the nurse can
prescribe most of the interventions needed for prevention or resolution. For example, most clients
with a nursing diagnosis of Pain have medical orders for analgesics, but many independent nursing
interventions can also alleviate pain (e.g., guided imagery or teaching a client to "splint" an incision).
With regard to medical diagnoses, nurses are obligated to carry out physician-prescribed therapies and

treatments, that is, dependent functions. See Chapter 13 for a discussion of independent and
dependent nursing interventions.
Differentiating Nursing Diagnoses from Collaborative Problems
A collaborative problem is a type of potential problem that nurses manage using both independent and
physician-prescribed interventions. Independent nursing interventions for a collaborative problem
focus mainly on monitoring the client's condition and preventing development of the potential
complication. Definitive treatment of the condition requires both medical and nursing interventions.

Collaborative problems are present when a particular disease or treatment is present; that is, each
disease or treatment has specific complications that are always associated with it. For example, a
statement of collaborative problems is "Potential complication of pneumonia: atelectasis, respiratory
failure, pleural effusion, pericarditis, and meningitis."

Nursing diagnoses, by contrast, involve human responses, which vary greatly from one person to the
next. Therefore, the same set of nursing diagnoses cannot be expected to occur with all persons who
have a particular disease or condition; moreover, a single nursing diagnosis may occur as a response
to any number of diseases. For example, all postpartum clients have similar collaborative problems,
such as "Potential complication of childbearing: postpartum hemorrhage," but not all new mothers
have the same nursing diagnoses. Some might experience Impaired Parenting(delayed bonding), but
most will not; some might have Deficient Knowledge whereas others will not. Thus, the nurse uses
nursing diagnoses rather than collaborative problems whenever possible, since nursing diagnoses are
more individualized to a specific client and emphasize human responses to which the nurse can
independently take action. Table 12-3 provides a comparison of nursing diagnoses, medical problems,
and collaborative problems.

THE DIAGNOSTIC PROCESS

The diagnostic process uses the critical-thinking skills of analysis and synthesis. Critical thinking is a
cognitive process during which a person reviews data and considers explanations before forming an
opinion. Analysis is the separation into components, that is, the breaking down of the whole into its
parts (deductive reasoning). Synthesis is the opposite, that is, the putting together of parts into the

whole (inductive reasoning). See Chapter 10 to review the concepts of deductive and inductive
reasoning.

The diagnostic process is used continuously by most nurses. An experienced nurse may enter a
client's room and immediately observe significant data and draw conclusions about the client. As a
result of attaining knowledge, skill, and expertise in the practice setting, the expert nurse may seem to
perform these mental processes automatically. Novice nurses, however, need guidelines to understand
and formulate nursing diagnoses. The diagnostic process has three steps:

• Analyzing data

• Identifying health problems, risks, and strengths

• Formulating diagnostic statements

Analyzing Data

In the diagnostic process, analyzing involves the following steps:

1. Compare data against standards (identify significant cues).

2. Cluster cues (generate tentative hypotheses).

3. Identify gaps and inconsistencies.

For experienced nurses, these activities occur continuously rather than sequentially.
Comparing Data with Standards
Nurses draw on knowledge and experience to compare client data to standards and norms and identify
significant and relevant cues. A standard or norm is a generally accepted measure, rule, model, or
pattern. The nurse uses a wide range of standards, such as growth and development patterns, normal
vital signs, and laboratory values. A cue is considered significant if it does any of the following:

• Points to negative or positive change in a client's health status or pattern. For example, the client
states: "I have recently experienced shortness of breath while climbing stairs" or "I have not smoked
for 3 months."

• Varies from norms of the client population. The client's pattern may fit within cultural norms but
vary from norms of the general society. The client may consider a patternfor example, eating very
small meals and having little appetiteto be normal. This pattern, however, may not be healthy and
may require further exploration.

• Indicates a developmental delay. To identify significant cues, the nurse must be aware of the normal
patterns and changes that occur as the person grows and develops. For example, by age 9 months an
infant is usually able to sit alone without support. The infant who has not accomplished this task
needs further assessment for possible developmental delays.

Table 12-4 lists specific examples of client cues and norms to which they may be compared.

Clustering Cues
Data clustering or grouping cues is a process of determining the relatedness of facts and determining
whether any patterns are present, whether the data represent isolated incidents, and whether the data
are significant. This is the beginning of synthesis.

The nurse may cluster data inductively (as in Table 12-5) by combining data from different
assessment areas to form a pattern. Or the nurse may begin with a framework, such as Gordon's
functional health patterns, and organize the subjective and objective data into the appropriate
categories (see Box 11-4, page 190). The latter is a deductive approach to data clustering (see Chapter

10).

Experienced nurses may cluster data as they collect and interpret it, as evidenced in remarks or
thoughts such as "I'm getting a sense of . . ." or "This cue doesn't fit the picture." The novice nurse
does not have the knowledge base or the clinical experience that aids in recognizing cues. Thus, the
novice must take careful assessment notes, search data for abnormal cues, and use textbook resources
for comparing the client's cues with the defining characteristics and etiologic factors of the accepted
nursing diagnoses.

Data clustering involves making inferences about the data. The nurse interprets the possible meaning
of the cues, and labels the cue clusters with tentative diagnostic hypotheses. Data clustering or
grouping for Amanda Aquilini is illustrated in Table 12-5, in which data are clustered according to
standardized diagnosis labels.

Identifying Gaps and Inconsistencies in Data

Skillful assessment minimizes gaps and inconsistencies in data. However, data analysis should
include a final check to ensure that data are complete and correct.

Inconsistencies are conflicting data. Possible sources of conflicting data include measurement error,
expectations, and inconsistent or unreliable reports. For example, a nurse may learn from the nursing
history that the client reports not having seen a doctor in 15 years, yet during the physical health
examination he states, "My doctor takes my blood pressure every year." All inconsistencies must be

clarified before a valid pattern can be established. See "Validating Data" in Chapter 11.

Identifying Health Problems, Risks, and Strengths

After data are analyzed, the nurse and client can together identify strengths and problems. This is

primarily a decision-making process (see Chapter 10 ).

Determining Problems and Risks

After grouping and clustering the data, the nurse and client together identify problems that support
tentative actual, risk, and possible diagnoses. In addition the nurse must determine whether the client's
problem is a nursing diagnosis, medical diagnosis, or collaborative problem. See Figure 12-2 and
Table 12-3.

Significant cues and data clusters for Amanda Aquilini that were extracted from Figure 11-4 on page
188 and Box 11-7 on page 191 are shown in Table 12-5. In this example, the nurse and client
identified eight tentative problems: Imbalanced Nutrition: Less than Body Requirements; Deficient
Fluid Volume; Disturbed Sleep Pattern; Activity Intolerance; Acute Pain (Chest); Interrupted Family
Processes; Anxiety; and Ineffective Airway Clearance.

Note that some data may indicate a possible problem but when clustered with other data, the possible
problem disappears. For example, the following data for Amanda Aquilini, "Decreased urinary
frequency and amount × 2 days," suggests a possible urinary elimination problem. However, when
these data are considered along with data associated with Deficient Fluid Volume, the nurse eliminates
urinary elimination as a problem.

Determining Strengths
At this stage, the nurse and client also establish the client's strengths, resources, and abilities to cope.
Most people have a clearer perception of their problems or weaknesses than of their strengths and
assets, which they often take for granted. By taking an inventory of strengths, the client can develop a
more well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and
regenerative processes.

A client's strength might be weight that is within the normal range for age and height, thus enabling
the client to cope better with surgery. In another instance, a client's strengths might be absence of
allergies and being a nonsmoker.

A client's strengths can be found in the nursing assessment record (health, home life, education,
recreation, exercise, work, family and friends, religious beliefs, and sense of humor, for example), the
health examination, and the client's records. See Table 12-5 for the strengths identified for Amanda
Aquilini.

Formulating Diagnostic Statements

Most nursing diagnoses are written as two-part or three-part statements, but there are variations of
these.

Basic Two-Part Statements

The basic two-part statement includes the following:

1. Problem (P): statement of the client's response (NANDA label)

2. Etiology (E): factors contributing to or probable causes of the responses

The two parts are joined by the words related to rather than due to. The phrase due to implies that one
part causes or is responsible for the other part. By contrast, the phrase related to merely implies a
relationship. Some examples of two-part nursing diagnoses are shown in Box 12-1.

For NANDA labels that contain the word Specify, the nurse must add words to indicate the problem
more specifically. The format is still a two-part statement. For example, Noncompliance (Specify)
would be Noncompliance (Diabetic Diet) related to denial of having disease. For ease in
alphabetizing, many NANDA lists are arranged with qualifying words after the main word (e.g.,
Infection, Risk for). Avoid writing diagnostic statements in that manner; instead, write them as they
would be stated in normal conversation (e.g., Risk for Infection).

Basic Three-Part Statements

The basic three-part nursing diagnosis statement is called the PES format and includes the following:

1. Problem (P): statement of the client's response (NANDA label)

2. Etiology (E): factors contributing to or probable causes of the response

3. Signs and symptoms (S): defining characteristics manifested by the client

Actual nursing diagnoses can be documented by using the three-part statement (see Box 12-2)
because the signs and symptoms have been identified. This format cannot be used for risk diagnoses
because the client does not have signs and symptoms of the diagnosis.

The PES format is especially recommended for beginning diagnosticians because the signs and
symptoms validate why the diagnosis was chosen and make the problem statement more descriptive.
The PES format can create very long problem statements, sometimes making the problem and
etiology unclear. To minimize long problem statements, the nurse can record the signs and symptoms
in the nursing notes instead of on the care plan. Another possibility, recommended for students, is to
list the signs and symptoms on the care plan below the nursing diagnosis, grouping the subjective (S)
and objective (O) data. The signs and symptoms are easily accessible, and the problem and etiology
stand out clearly. For example:

Noncompliance (Diabetic Diet) related to unresolved anger about diagnosis as manifested by

S "I forget to take my pills." "I can't live without sugar in my food." O Weight 98 kg (215 lb)
[gain of 4.5 kg (10 lb)] Blood pressure 190/100

BOX 12-1 Basic Two-Part Diagnostic Statement

Problem Related to Etiology Constipation related to prolonged laxative use Severe Anxiety related to
threat to physiologic integrity: possible cancer diagnosis

One-Part Statements
Some diagnostic statements, such as wellness diagnoses and syndrome nursing diagnoses, consist of a
NANDA label only. As the diagnostic labels are refined, they tend to become more specific, so that
nursing interventions can be derived from the label itself. Therefore, an etiology may not be needed.
For example, adding an etiology to the label Rape-Trauma Syndrome does not make the label any
more descriptive or useful.
NANDA has specified that any new wellness diagnoses will be developed as one-part statements
beginning with the words Readiness for Enhanced followed by the desired higher level wellness (for
example, Readiness for Enhanced Parenting).

BOX 12-2 Basic Three-Part Diagnostic Statement

Problem Related to Etiology As Manifested by Signs and Symptoms Situational related to feelings of
as manifested by hypersensitivity to criticism; states "I Low (r/t) rejection by (a.m.b.) don't know if I
can manage by myself" and husband rejects positive feedback Self-Esteem

Currently the NANDA list includes several wellness diagnoses. Some of these are Spiritual Well-
Being, Effective Breastfeeding, Health-Seeking Behaviors, and Anticipatory Grieving. These are
usually accepted as one-part statements but may be made more explicit by adding a descriptor, for
example, Health-Seeking Behaviors (Low-Fat Diet).

Variations of Basic Formats

Variations of the basic one-, two-, and three-part statements include the following:

1. Writing unknown etiology when the defining characteristics are present but the nurse does not
know the cause or contributing factors. One example is Noncompliance (Medication Regimen) related
to unknown etiology.

2. Using the phrase complex factors when there are too many etiologic factors or when they are too
complex to state in a brief phrase. The actual causes of chronic low self-esteem, for instance, may be
long term and complex, as in the following nursing diagnosis: Chronic Low Self-Esteem related to
complex factors.

3. Using the word possible to describe either the problem or the etiology. When the nurse believes
more data are needed about the client's problem or the etiology, the word possible is inserted.
Examples are Possible Low Self-Esteem related to loss of job and rejection by family; Altered
Thought Processes possibly related to unfamiliar surroundings.

4. Using secondary to to divide the etiology into two parts, thereby making the statement more
descriptive and useful. The part following secondary to is often a pathophysiologic or disease process
or a medical diagnosis, as in Risk for Impaired Skin Integrity related to decreased peripheral
circulation secondary to diabetes.

5. Adding a second part to the general response or NANDA label to make it more precise. For
example, the diagnosis Impaired Skin Integrity does not indicate the location of the problem. To make
this label more specific, the nurse can add a descriptor as follows: Impaired Skin Integrity (Left
Lateral Ankle) related to decreased peripheral circulation.

Collaborative Problems
Carpenito-Moyet (2006) has suggested that all collaborative (multidisciplinary) problems begin with
the diagnostic label Potential Complication (PC). Nurses should include in the diagnostic statement
both the possible complication they are monitoring and the disease or treatment that is present to
produce it. For example, if the client has a head injury and could develop increased intracranial
pressure, the nurse should write the following:

Potential Complication of Head Injury: Increased intracranial pressure

When monitoring for a group of complications associated with a disease or pathology, the nurse states
the disease and follows it with a list of the complications:

Potential Complication of Pregnancy-Induced Hypertension: seizures, fetal distress, pulmonary

edema, hepatic/ renal failure, premature labor, CNS hemorrhage

In some situations, an etiology might be helpful in suggesting interventions. Nurses should write the
etiology when (a) it clarifies the problem statement, (b) it can be concisely stated, and (c) it helps to
suggest nursing actions. See the examples in Box 12-3.

Evaluating the Quality of the Diagnostic Statement

In addition to using the correct format, nurses must consider the content of their diagnostic
statements. The statements should, for example, be accurate, concise, descriptive, and specific. The
nurse must always validate the diagnostic statements with the client and compare the client's signs and
symptoms to the NANDA defining characteristics. For risk problems, the nurse compares the client's
risk factors to NANDA risk factors. After writing nursing diagnoses, the nurse checks them against
the criteria in Table 12-6.

Avoiding Errors in Diagnostic Reasoning

Some error is inherent in any human undertaking, and diagnosis is no exception. However, it is
important that nurses make nursing diagnoses with a high level of accuracy. Nurses can avoid some
common errors of reasoning by recognizing them and applying the appropriate critical-thinking skills.
Error can occur at any point in the diagnostic process: data collection, data interpretation, and data
clustering.

The following suggestions help to minimize diagnostic error:

• Verify. Hypothesize possible explanations of the data, but realize that all diagnoses are only tentative
until they are verified. Begin and end the diagnostic process by talking with the client and family.
When collecting data, ask them what their health problems are and what they believe the causes to be.
At the end of the process, ask them to confirm the accuracy and relevance of your diagnoses.

• Build a good knowledge base and acquire clinical experience. Nurses must apply knowledge from
many different

areas to recognize significant cues and patterns and generate hypotheses about the data. To name only
a few, principles from chemistry, anatomy, and pharmacology each help the nurse understand client
data in a different way.

• Have a working knowledge of what is normal. Nurses need to know the population norms for vital
signs, laboratory tests, speech development, breath sounds, and so on. In addition, nurses must
determine what is usual for a particular person, taking into account age, physical makeup, lifestyle,
culture, and the person's own perception of what his or her normal status is. For example, normal
blood pressure for adults is in the range of 110/60 to 140/80. However, a nurse might obtain a reading
of 90/50 that is perfectly normal for a particular client. The nurse should compare actual findings to
the client's baseline when possible.

• Consult resources. Both novices and experienced nurses should consult appropriate resources
whenever in doubt about a diagnosis. Professional literature, nursing colleagues, and other
professionals are all appropriate resources. The nurse should use a nursing diagnosis handbook to
determine whether the client's signs and symptoms truly fit the NANDA label chosen.

• Base diagnoses on patternsthat is, on behavior over timerather than on an isolated incident. For
example, even though Amanda Aquilini is concerned today about needing to leave her child with a
neighbor, it is likely that this concern will be resolved without intervention by the next day.
Therefore, the admitting nurse should not diagnose Interrupted Family Processes.

• Improve critical-thinking skills. These skills help the nurse to be aware of and avoid errors in
thinking, such as overgeneralizing, stereotyping, and making unwarranted assumptions. See Chapter

10.

BOX 12-3 Collaborative Problems

Disease/Situation Complication Related to Etiology Potential complication of hemorrhage related to

uterine atony retained childbirth: placental fragments bladder distention Potential complication of
arrhythmia related to low serum potassium diuretic therapy:

Figure 11-3. Assessing. The assessment process involves four closely related activities.

Figure 12-2. Decision tree for differentiating among nursing diagnoses, collaborative problems,
and medical diagnoses.

ONGOING DEVELOPMENT OF NURSING DIAGNOSES

The first taxonomy of nursing diagnoses was alphabetical. This ordering was considered unscientific
by some, and a hierarchic structure was sought. In 1982, NANDA accepted the "nine patterns of
unitary man" (based on the nursing models of Sr. Callista Roy and Martha Rogerssee Chapter 3

) as an organizing principle. In 1984, NANDA renamed the "patterns of unitary man" as "human
response patterns" based more on the work of Marjorie Gordon (Kim, McFarland, & McLane, 1984),
as listed in Box 12-4.

Having undergone refinements, revisions, and acceptance of new diagnoses, the taxonomy is now
called Taxonomy II (NANDA International, 2005). Taxonomy II has three levels: domains, classes,
and nursing diagnoses (Figure 12-3). The diagnoses are no longer grouped by Gordon's patterns but
coded according to seven axes: diagnostic concept, time, unit of care, age, health status, descriptor,
and topology. In addition, diagnoses are now listed alphabetically by concept, not by first word.

BOX 12-4 Human Response Patterns

1. Exchanging: mutual giving and receiving

2. Communicating: sending messages

3. Relating: establishing bonds

4. Valuing: assigning relative worth

5. Choosing: selection of alternatives

6. Moving: activity
7. Perceiving: reception of information

8. Knowing: meaning associated with information

9. Feeling: subjective awareness of information

Review and refinement of diagnostic labels continue as new and modified labels are discussed at each
biannual conference. Nurses submit diagnoses to the Diagnostic Review Committee, which reviews
and "stages" the diagnosis according to how well developed and supported it is. The NANDA board
of directors gives final approval for incorporation of the diagnosis into the official list of labels.
Diagnoses on the NANDA list are not finished products but are approved for clinical use and further
study. Many on the list have been studied only minimally.

In 1997, NANDA changed the name of its official journal from Nursing Diagnosis to Nursing
Diagnosis: The International Journal of Nursing Language and Classification. The subtitle
emphasizes that nursing diagnosis is part of a larger, developing system of standardized nursing
language. This system includes classifications of nursing interventions (NIC) and nursing outcomes
(NOC) that are being developed by other research groups and linked to the NANDA diagnostic labels.

NIC and NOC are discussed in greater detail in Chapter 13.

Research groups are examining what nurses do from these three different perspectives (diagnoses,
interventions, and outcomes) to clarify and communicate the role nurses play in the health care
system. A standardized language will also enable nurses to implement a Nursing Minimum Data Set
needed for computerized client records.

RESEARCH NOTE What New Nursing Diagnoses Are Being Researched?

The International Journal of Nursing Terminologies and Classifications is a public forum for the
publication of work currently conducted worldwide on the development of nursing diagnoses,
outcomes, and interventions. In the paper by Lamont, the author reviewed published literature with
the goal of establishing discomfort as a separate nursing diagnosis from pain. However, his review
failed to provide clear evidence for this discrimination. He suggests that research be conducted to
attempt to determine if pain and discomfort can be usefully separated.

Lopes and Higa conducted interviews with 148 women who had complaints of urinary incontinence.
Over half the women (57%) described incontinence with characteristics of both urge and stress
incontinence. They suggest that this should lead to a new nursing diagnosis of mixed urinary
incontinence so that clients are not treated for urge or stress incontinence when they truly require a
plan related to both types.

IMPLICATIONS

Many nursing diagnoses are being studied in a variety of settings. This is important work to determine
the reliability and validity of existing diagnoses, identify gaps in the current list, and establish
usefulness of the diagnoses in everyday practice. Nurses should be familiar with the direction of this
work as it progresses.

Note: From "Discomfort as a Potential Nursing Diagnosis: A Concept Analysis and Literature
Review," by S. C. Lamont, 2003, International Journal of Nursing Terminologies and Classifications,
14(4 Suppl), p. 5, and "Mixed Incontinence in Women: A New Nursing Diagnosis," by M. H. B.
Lopes and R. Higa, 2003, International Journal of Nursing Terminologies and Classifications, 14(4
Suppl), p. 49.

LIFESPAN CONSIDERATIONS Diagnosing

CHILDREN

Many developmental issues in pediatrics are not considered problems or illnesses, yet can benefit
from nursing intervention. When applied to children and families, nursing diagnoses may reflect a
condition or state of health. For example, parents of a newborn infant may be excited to learn all they
can about infant care and child growth and development. Assessment of the family system might lead
the nurse to conclude that the family is ready and able, even eager, to take on the new roles and
responsibilities of being parents. An appropriate diagnosis for such a family could be Readiness for
Enhanced Family Processes, and nursing care could be directed to educating and providing
encouragement and support to the parents.

ELDERS

Elders tend to have multiple problems with complex physical and psychosocial needs when they are
ill. If the nurse has done a thorough, accurate assessment, nursing diagnoses can be selected to cover
all problems and, at the same time, prioritize the special needs. For example, if a client is admitted
with severe congestive heart failure, prompt attention will be focused on Decreased Cardiac Output
and Excess Fluid Volume, with interventions selected to improve these areas quickly. As these
conditions improve, then other nursing diagnoses, such as Activity Intolerance and Deficient
Knowledge related to a new medication regimen, might require more attention. They are all part of the
same medical problem of congestive heart failure, but each nursing diagnosis has specific expected
outcomes and nursing interventions. The client's strengths should be an essential consideration in all
phases of the nursing process.

Critical Thinking Checkpoint

Mr. H. has recently been diagnosed with lung cancer. Someone has written the nursing diagnosis of
Anxiety on his care plan.

1. What data/defining characteristics would support this nursing diagnosis? 2. Which related factors
might exist in his situation? 3. Which other nursing diagnoses might you expect to find in Mr. H.'s
case? 4. Another nursing diagnosis on the care plan reads "Lung cancer related to smoking." Is this
diagnosis written in an acceptable format? If not, why not?

See Critical Thinking Possibilities in Appendix A.

Figure 12-3. Taxonomy II. Source: From Definitions and Classifications, 2003-2004 by
NANDA International, 2003, Philadelphia, PA. Adapted with permission
CHAPTER 12 REVIEW

CHAPTER HIGHLIGHTS

• The purpose of the North American Nursing Diagnosis Association is to define, refine, and promote
a taxonomy of nursing diagnostic terminology.

• Diagnosis is a reasoning process that uses critical thinking.

• Professional standards of care hold that registered nurses are responsible for making nursing
diagnoses, even though others may contribute data or implement care.

• A nursing diagnosis is a clinical judgment about the client's responses to actual and potential health
problems or life processes.

• A nursing diagnosis provides the basis for selecting independent nursing interventions to achieve
outcomes for which the nurse is accountable.

• There are various types of nursing diagnoses: actual, risk, wellness, possible, and syndrome.

• A nursing diagnosis has three components: the problem (and its definition), the etiology, and the
defining characteristics. Each component serves a specific purpose.

• Nursing diagnoses differ from medical diagnoses and collaborative problems in orientation,
duration, and nursing focus.

• A collaborative problem is a type of potential problem that nurses manage using both independent
and physician-prescribed interventions.

• The three phases of the diagnostic process are data analysis; identification of the client's health
problems, health risks, and strengths; and formulation of diagnostic statements.

• In data analysis and processing, the nurse compares data against standards to identify significant
cues, clusters the data, and identifies gaps and inconsistencies.

• Significant cues are those that (a) point to change in a client's health status or pattern, (b) vary from
norms of the client population, or (c) indicate a developmental delay.

• It is important to identify client strengths as well as problems.

• The basic format for a nursing diagnostic statement is "Problem related to etiology." However, there
are several variations on this format.

• The development of a taxonomy of nursing diagnosis labels is an ongoing process.

• The organizing principles for the NANDA Taxonomy II are the seven axes: diagnostic concept,
time, unit of care, age, potentiality, descriptor, and topology.

• Work is progressing on a unified standardized nursing language that includes NANDA nursing
diagnoses, a nursing interventions classification, and a nursing outcomes classification.

TEST YOUR KNOWLEDGE

1. The nurse is conducting the diagnosing phase (nursing diagnosis) for a client with a seizure
disorder. Which of the following elements exists
between data analysis and formulating the diagnostic statement?

1. Assess the client's needs

2. Delineate the client's problems and strengths
3. Determine which interventions are most likely to succeed
4. Estimate the cost of several different approaches

2. In the diagnostic statement "Excess fluid volume related to decreased venous return as manifested
by lower extremity edema (swelling)," the etiology of
the problem is which of the following?

1. Excess fluid volume

2. Decreased venous return
3. Edema
4. Unknown

3. Which of the following nursing diagnoses contains the proper components?

1. Risk for caregiver role strain related to unpredictable illness course

2. Risk for falls related to tendency to collapse when having difficulty breathing
3. Decreased communication related to stroke
4. Sleep deprivation secondary to fatigue and a noisy environment

4. One of the primary advantages of using a three-part diagnostic statement such as the problem-
etiology-signs/symptoms (PES) format includes which of
the following?

1. Decreases the cost of health care

2. Improves communication between nurse and client
3. Helps the nurse focus on health and wellness elements
4. Standardizes organization of client data

5. A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis:

1. If both medical and nursing interventions are required to treat the problem
2. When independent nursing actions can be utilized to treat the problem
3. In cases where nursing interventions are the primary actions required to treat the problem
4. When no medical diagnosis (disease) can be determined

See Answers to Test Your Knowledge in Appendix A.

EXPLORE MEDIALINK WWW.PRENHALL.COM/BERMAN

COMPANION WEBSITE

• Additional NCLEX Review

• Case Study:

Selecting Nursing Diagnoses for Client with Pneumonia

• Application Activity:

Resources for a Chronically Ill Child

• Links to Resources

READINGS AND REFERENCES

SUGGESTED READINGS

Kelly, J. H., Weber, J., & Sprengel, A. (2005). Taxonomy of nursing practice: Adding an
administrative domain. International Journal of Nursing Terminologies and Classifications, 16(3/4),
74-80.

In this article, the authors propose the addition of a fifth domain, Administrative, to the Taxonomy of
Nursing Practice, and to introduce the related concept of organization nursing diagnoses. The
current taxonomy does not include diagnoses that relate to the management/leadership roles of
nurses.

RELATED RESEARCH

Junttila, K., Salantera, S., & Hupli, M. (2005). Perioperative nurses' attitudes toward the use of
nursing diagnoses in documentation. Journal of Advanced Nursing, 52, 271-280.

Keenan, G., Falan, S., Heath, C., & Treder, M. (2003). Establishing competency in the use of North
American Nursing Diagnosis Association, nursing outcomes classification, and nursing interventions
classification terminology. Journal of Nursing Measurement, 11, 183-198.

REFERENCES

American Nurses Association. (2004). Nursing: Scope and standards of practice. Kansas City, MO:
Author.

Carpenito-Moyet, L. J. (2006). Nursing diagnosis: Application to clinical practice (11th ed.).

Philadelphia: Lippincott Williams & Wilkins.

Joint Commission on Accreditation of Healthcare Organizations. (2005). Accreditation manual for

hospitals. Chicago: Author.

Kim, M. J., McFarland, G. K., & McLane, A. M. (Eds.). (1984). Classification of nursing diagnoses:
Proceedings of the fifth national conference. St. Louis, MO: Mosby.

Lamont, S. C. (2003). Discomfort as a potential nursing diagnosis: A concept analysis and literature
review. International Journal of Nursing Terminologies and Classifications, 14(4 Suppl), 5.

Lopes, M. H. B., & Higa, R. (2003). Mixed incontinence in women: A new nursing diagnosis.
International Journal of Nursing Terminologies and Classifications, 14(4 Suppl), 49.

NANDA International. (2005). NANDA nursing diagnoses: Definitions and classification 2005-2006.
Philadelphia: Author.

SELECTED BIBLIOGRAPHY
Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care (7th
ed.). St. Louis, MO: Elsevier Health Sciences.

Alfaro-LeFevre, R. A. (2005). Applying the nursing process: Promoting collaborative care (6th ed.).
Philadelphia: Lippincott Williams & Wilkins.

Alfaro-LeFevre, R. A. (2005). The nursing process made easy: Concept mapping and care planning
for students. Philadelphia: Lippincott Williams & Wilkins.

Doenges, M. E., & Moorhouse, M. F. (2003). Application of nursing process and nursing diagnosis:
An interactive text for diagnostic reasoning (4th ed.). Philadelphia: F.A. Davis.

Doenges, M. E., Moorhouse, M. F., & Geissler-Murr, A. C. (2005). Nursing diagnosis manual:
Planning, individualizing, and documenting client care. Philadelphia: F. A. Davis.

Gardner, P. (2003). Nursing process in action. Albany, NY: Delmar.

Gordon, M. (1982). Historical perspective: The National Group for Classification of Nursing
Diagnoses. In M. J. Kim & D. A. Moritz (Eds.), Classification of nursing diagnoses: Proceedings of
the fourth national conference. New York: McGraw-Hill.

Gordon, M. (2006). Manual of nursing diagnosis (11th ed.). St. Louis, MO: Mosby.

Johnson, M., Bulechek, G. B., Butcher, H., Dochterman, J., Moorhead, S., Maas, M., et al. (Eds.).
(2005). NANDA, NOC and NIC linkages: Nursing diagnoses, outcomes, and interventions (2nd ed.).
St. Louis, MO: Elsevier Health Sciences.

Ladwig, G. B., & Ackley, B. J. (2005). Mosby's guide to nursing diagnosis. St. Louis, MO: Elsevier
Health Sciences.

Seaback, W. (2005). Nursing process: Concept & application (2nd ed.). Albany, NY: Delmar.

Wilkinson, J. M. (2005). Nursing diagnosis handbook: With NIC interventions and NOC outcomes
(8th ed.). Upper Saddle River, NJ: Prentice Hall.

Wilkinson, J. M. (2007). Nursing process & critical thinking (4th ed.). Upper Saddle River, NJ:
Prentice Hall.