Key Concepts, Chapter 12, Diagnosing

Diagnosing, the second step in the nursing process, begins after the nurse has collected

and recorded the patient data. The purposes of diagnosing are to (1) identify how a

person, group, or community responds to actual or potential health and life processes; (2)

identify factors that contribute to or cause health problems (etiologies); and (3) identify

resources or strengths the person, group, or community can draw on to prevent or resolve

problems.
A health problem is a condition that necessitates intervention to prevent or resolve

disease or illness, or to promote coping and wellness. Actual or potential health problems

that can be prevented or resolved by independent nursing intervention are called nursing

diagnoses.
As nurses interpret and analyze patient data, they may identify health problems that are

better treated by physicians (medical diagnoses) or by nurses working with other health

care professionals (collaborative problems).

Successful implementation of each step of the nursing process requires high-level skills

in clinical reasoning. Nursing diagnoses are best used by nurses who have strong

interpersonal and communication skills that allow them to gain patients trust.
The term cue is often used to denote significant data or data that influence data

interpretation and analysis. Significant data should raise a red flag for the nurse, who

then looks for patterns or clusters of data that signal an actual or possible nursing

diagnosis.

When analyzing data, determine the patients strengths and problems. Determine also

whether the patient agrees with the nurses identification of strengths and problems and is

motivated to work toward problem resolution.

 The NANDA-I list is a beginning list of suggested terms for health problems that might

be identified and treated by nurses. Each of the diagnoses in NANDA International

Nursing Diagnoses: Definitions and Classification, 20122014 is presented in taxonomic

order and includes the basic components of a nursing diagnosis: definition, defining

characteristics, and related factors or risk factors.

NANDA-I describes five types of nursing diagnoses: actual, risk, possible, wellness, and

syndrome.

Most nursing diagnoses are written either as two-part statements listing the patients

problem and its cause or as three-part statements that also include the problems defining

characteristics.
After a tentative nursing diagnosis is formulated, it should be validated.
The nurse documents validated nursing diagnoses in the patient record. In the past, nurses

were urged to only use NANDA-I accepted terms to state nursing diagnoses. Today,

accepted terms vary. Nurses should use the terms recommended by their school,

employer, or specialty organization.

The primary benefit of nursing diagnosis for the patient is the individualization of patient

care. The use of nursing diagnoses also allows patients to be informed and willing

participants in their care, as they validate their diagnoses and assist in prioritizing them.

The process of prioritizing nursing diagnoses is the first step in planning care.
Improved communication among nurses and other health care professionals is probably

the most important benefit of accurate, up-to-date diagnosesexpressed in well-defined

and standardized terminologyfor nurses and their patients.