COMPARISON OF NURSING AND MEDICAL

DIAGNOSES
Nursing diagnoses assist nurses in defining their scope of practice just as medical
diagnoses assist physicians in defining their scope of practice.

Medicine uses the term medical diagnosis and nursing uses

the term nursing diagnosis to identify problems relating to a clients health status:

Medical diagnosis is the terminology used for a clinical judgment by the physician that
identifies or determines a specific disease, condition, or pathologic state.
Ex. CHRONIC OBSTRUCTIVE PULMONARY DISEASE)

Nursing diagnosis is the terminology used for a clinical judgment by the professional nurse
that identifies the clients risk, wellness, or syndrome responses to a health state, problem,
or condition.
Ex. Ineffective Breathing Pattern
 Parts of a Nursing Diagnosis

Defining Characteristics: signs & symptoms that validate that an actual nursing diagnosis is present.

Major: at least one must be present to use the nursing diagnosis

Minor: may not be present, but if it is, helps to validate selecting the nursing diagnosis

Defining characteristics are not present in Risk diagnosis because signs & symptoms dont exist if
the problem hasnt happened Related Factors or Risk Factors:

Related Factors: factors that contributed to the development of patients problem (nursing dx)

Risk Factors: factors that increase the possibility of the patient developing a problem

Is a relationship rather than direct cause & effect (is related to rather than caused by)
 COMPONENTS OF A NURSING DIAGNOSIS and
Rules for Writing Diagnostic Statements
There are several formats that have been used to structure nursing diagnosis
statements.

1. Actual Diagnoses (three-part statement).

PES (Problem +Etiology+ Signs and Symptoms) or PRS (Problem+ Related (Risk) Factors+
Signs and Symptoms) format. Use related to link the problem and the etiology or related
factors. Add as evidenced by to state the evidence that supports that diagnosis is present.

Example:
Impaired Communication related to language barrier as evidenced by inability to speak or
understand English.

The three-part statement is preferred by those nurses desiring to strengthen the diagnostic
statement by including specific manifestations, an attribute that is not possible through the use
of the two-part format.
 COMPONENTS OF A NURSING DIAGNOSIS and
Writing Diagnostic Statements for Nursing Diagnosis

2. Risk Nursing Diagnoses (two part statement).

Use PE (Problem+ Etiology) or PR (Problem+ Related (Risk) Factors) format. Use related
to to link the potential problem with the related (risk) factors present.

Example:
Risk for impaired skin integrity related to obesity, excessive diaphoresis, and confinement to bed.

The two-part statement is NANDA approved and is used by most nurses, in large part because of
its brief and precise format. The three-part statement is preferred by those nurses desiring to
strengthen the diagnostic statement by including specific manifestations, an attribute that is not
possible through the use of the two-part format.
Writing Diagnostic Statements for Nursing Diagnosis

3. Possible Diagnoses (one-part statement). Simply name the possible problem.

Example: - Possible Altered Sexuality patterns.

4. For Wellness Diagnoses (one part statement). Use Potential for Enhanced before the words that
describe the area that is to be improved.

Example: Potential for enhanced parenting.

5.Syndrome Diagnoses (one-part statement). Simply name the syndrome.

Example: Rape Trauma Syndrome.

 Examples of Nursing Diagnosis Expressed in Two and
Three-Part Statements

Two-Part Statement Three- Part Statement

Feeding Self Care Deficit RT Feeding Self- Care Deficit RT

decreased strength and endurance decreased strength and endurance
AEB inability to maintain fork in hand
from plate to mouth.

Ineffective Airway Clearance RT

Ineffective Airway Clearance RT
fatigue
fatigue AEB dyspnea at rest

Anxiety RT change in role functioning

Anxiety RT change in Role AEB insomnia, poor eye contact and
Functioning quivering voice.
 Making Sure Diagnostic Statements Direct Interventions

Whenever possible, write nursing diagnoses in such a way that they direct nursing interventions.
When someone studies your diagnostic statement, it should answer the question, What can
nurses do about this problem?

For example, consider the boldface portions of each of the statements below, and note how the
first statement directs independent interventions.

Right: Risk for Ineffective Airway Clearance related to copious thick secretions and difficulty
positioning for coughing.

Wrong: Risk for Ineffective Airway Clearance related to pneumonia.

 QUALIFIERS FOR DIAGNOSTIC LABELS
Acute- Severe but of short duration. ( Acute Pain , Acute Confusion )

Altered- A change from baseline. ( Altered urinary elimination, Altered tissue perfusion)

Chronic- Lasting a long time, recurring, habitual, constant. ( Chronic pain , Chronic low
esteem)
Decreased- Lessened: lesser in size, amount, or degree. ( Decreased Cardiac output)

Deficient- Inadequate in amount, quality, or degree; defective; not sufficient; incomplete.

( Fluid volume Deficit , Diversional Activity Deficit )

Depleted- Emptied wholly or in part; exhausted of Disturbed- Agitated, interrupted,

interfered with. ( volume depletion )

Dysfunctional- Abnormal, incomplete functioning. (dysfunctional gastrointestinal motility)

 QUALIFIERS FOR DIAGNOSTIC LABELS

Excessive- Characterized by an amount or quantity that is greater than necessary, desirable,

or useful, Increased- Greater in size, amount, or degree. ( Excessive bleeding, excessive fluid
volume)
Impaired- Made worse, weakened, damaged, reduced, deteriorated. ( Impaired physical
mobility , Impaired Skin Integrity )

Ineffective- Not producing the desired effect ( Ineffective coping )

Intermittent- Stopping and starting again at intervals, periodic, cyclic. ( Intermittent fever )

Potential for Enhanced (for use with wellness diagnoses)- Made greater, to increase in
quality or more desire. ( Potential for enhanced organize infant behavior )
 CATEGORIES OF NURSING DIAGNOSES
Nursing diagnoses may be classified into three categories: actual, risk, and wellness.
The most common nursing diagnoses used are actual and risk diagnoses.

Actual diagnoses are those problems identified by the nurse that are already in
existence. Ex. Excess Fluid Volume related to (RT) intravenous infusion therapy
overload and Anxiety RT unknown results of breast biopsy.

Risk diagnoses are identified by the nurse in situations in which problems might
occur but are not currently in existence. Ex.Risk for Poisoning RT increased
mobility of infant and failure to have house childproofed and Risk for Deficient
Fluid Volume RT excessive number of stools.

Wellness diagnoses identify the individual or aggregate condition or state that

may be enhanced by healthpromoting activities. These consist of a one-part
statement (no related to phrase) that uses the label Potential for Enhanced
followed by the state the nurse desires to enhance. Examples of wellness
diagnoses may include Readiness for Enhanced Community Coping and Readiness
for Enhanced Spiritual Well-Being.
 AVOIDING ERRORS IN DEVELOPING A NURSING
DIAGNOSIS
PROBLEM WITH ASSESSMENT DATA -There is an underlying assumption that
nurses have adequate assessment skills and are knowledgeable about what data
need to be collected. However, this is not always the case.

INCOMPLETE COLLECTION OF ASSESSMENT DATA -Incomplete collection can occur

when the nurse has neither had nor taken the time to appropriately address all
subjective and objective data.

RESTRICTED DATA COLLECTION -Restricted data collection occurs when a client is

unable or unwilling to provide the necessary data.

FAILURE TO VALIDATE DATA-Failure to validate occurs when the nurse does not
confirm previously collected data.
 AVOIDING ERRORS IN DEVELOPING A NURSING
DIAGNOSIS
MISINTERPRETATION OF DATA -Misinterpretation can occur when the
meaning attached to the data is incorrect.

INAPPROPRIATE DATA CLUSTERING ASSOCIATED WITH LACK OF CLINICAL

KNOWLEDGE- Inappropriate data clustering may occur when the nurse lacks
sufficient theoretical and clinical expertise and knowledge to appropriately
cluster data cues.

INCORRECT WRITING OF THE NURSING DIAGNOSIS STATEMENT

Incorrect writing of the statement can occur when the nurse does not follow the
guidelines for formulating a two- or three-part statement. An example would be
in the two-part statement Imbalanced Nutrition: Less Than Body Requirements RT
renal disease. Renal disease is a medical diagnosis, and, according to the
guidelines, the etiologymust be a human response that the nurse is licensed and
competent to treat. This diagnosis would be better stated as Imbalanced
Nutrition: Less Than Body Requirements RT inadequate intake of an appropriate
renal diet.
 Values play an important role in interpretation
of data, clustering of data, and ultimately the
development of the diagnosis. Nurses must be
cognizant of personal biases, being careful not
to impose their value systems on clients.
Personal prejudices should be avoided in the
diagnostic statement.