DIAGNOSING

BY
TIYAS K
MATERNITY-CHILD NURSNG DEPARTMENT
AIRLANGGA UNIVERSITY
WHAT IS DIAGNOSIS???
 Carpenito:

“Diagnosis is the careful, critical study of something to

determine its nature.”

The question is not: can nurse diagnose? But what

nurse can diagnose?
WHAT IS NURSING DIAGNOSIS???
 North American Nursing Diagnosis Association
(NANDA), 1990:

“Nursing diagnosis is a clinical judgment about individual,

family, or community responses to actual or potential
health problems/life process. Nursing diagnosis provides
the basis for selection of nursing interventions to achieve
outcomes for which the nurse is accountable”

National Conference of NANDA-I in Miami, 2008:

Revised: “the nurse accountable” to “the nurse has

accountability”
COMPONENTS OF NURSING LANGUAGE

NANDA: Nursing Diagnosis: Definitions and

Classification
NIC: Nursing Interventions Classification
NOC: Nursing Outcomes Classification
DOMAIN OF EXPERTISE

Nursing Medicine

Discipline Expertise Shared Expertise Discipline Expertise

SHARED LANGUAGE

Hypokalemia
hypovolemic shock
Hyperglycemia
increased intracranial pressure
etc
 TYPES OF NURSING DIAGNOSIS

1. Actual diagnosis
2. Risk diagnosis
3. Wellness diagnosis
4. Syndrome diagnosis

(NANDA, 2009) and (Denehy & Poulton, 1999)

ACTUAL DIAGNOSIS
Describes health conditions that exist and supported
by defining characteristics

Ex: Anxiety related to cardiac surgery as evidence by

rapid speech, pacing

An actual nursing diagnosis use Three Part Statement:

•Label: Anxiety
•Related factor: cardiac surgery
•Sign & symptoms of diagnosis: rapid speech, pacing
RISK & HIGH RISK DIAGNOSIS
Risk diagnosis:
“a clinical judgment that an individual, family, or
community is more vulnerable to develop the
problem than others in the same or similar situation”

High risk diagnosis:

Have additional risk factors that make patient more
vulnerable for the problem to occur
 EXAMPLES OF DIAGNOSIS
Risk diagnosis:
Ex: Risk for infection related to incision and loss of
protective skin barrier

High Risk diagnosis:

Ex: High risk for infection related to incision, loss of
protective skin barrier and high blood glucose level
secondary to diabetes mellitus

An risk nursing diagnosis use Two Part Statement:

•Label: Risk for infection
•Related factor: cardiac surgery
WELLNESS DIAGNOSIS
“a clinical judgment about an individual, group, or
community in transition from specific level of wellness
to higher level of wellness”

To have wellness nursing diagnosis should be:

1. Desire for increase wellness
2. Effective present status or function

Ex: Readiness for enhanced family process

Note: “In wellness nursing diagnosis only use One-part
statement”
SYNDROME DIAGNOSIS
In medicine:
Syndromes cluster signs and symptoms, not diagnosis

In nursing:
syndrome nursing diagnosis comprise a cluster of
predicted actual or high-risk nursing diagnosis related
to a certain event or situation.

Ex: Rape trauma syndrome

WHAT DO YOU NEED TO MAKE NURSING
DIAGNOSIS?

Enough assessment: patient history, physical

examination, diet, activity, perception, etc

Diagnostic data: laboratory data, X-ray, etc

Knowledge and experience

SAMPLE OF MAKING DIAGNOSIS
 SAMPLE OF NURSING DIAGNOSIS
Activity Intolerance
Definition: Insufficient physiological or psychological energy to endure
or desired daily activities
RELATED FACTORS
•Generalized weakness
•Immobility
•Imbalance between oxygen supply and demand, [anemia]
•[Cognitive deficits/emotional status; secondary to underlying disease process/
•[Pain, vertigo, dysrhythmias, extreme stress]
DEFINING CHARACTERISTICS
Subjective
•Verbal report of fatigue/weakness
•Exertional discomfort/dyspnea
•[Verbalizes no desire and/or lack of interest in activity]
Objective
•Abnormal heart rate/blood pressure response to activity
•Electrocardiographic changes reflecting arrhythmias/or ischemia
•[Pallor, cyanosis]
 SAMPLE OF NURSING DIAGNOSIS
Ineffective Airway Clearance
Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a
clear airway
RELATED FACTORS
Environmental
Smoking; secondhand smoke; smoke inhalation
Obstructed airway
Retained secretions; secretions in the bronchi; exudate in the alveoli; excessive mucus; airway
spasm; foreign body in airway; presence of artificial airway
Physiological
Chronic obstructive pulmonary disease (COPD); asthma; allergic airways; hyperplasia of the
bronchial walls; Neuromuscular dysfunction; Infection
DEFINING CHARACTERISTICS
Subjective
Dyspnea
Objective
Diminished/adventitious breath sounds [rales, crackles, rhonchi, wheezes]
Cough, ineffective/absent; excessive sputum
Changes in respiratory rate and rhythm
Difficulty vocalizing, Wide-eyed; restlessness, Orthopnea, Cyanosis
 SAMPLE OF NURSING DIAGNOSIS
Anxiety [specify level: mild, moderate, severe, panic]
Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic
response (the source often nonspecific or unknown to the individual); a feeling of
apprehension caused by anticipation of danger. It is an alerting signal that warns of impending
danger and enables the individual to take measures to deal with threat.
RELATED FACTORS
•Unconscious conflict about essential [beliefs]/goals and values of life
•Situational/maturational crises
•Stress
•Familial association/heredity
•Interpersonal transmission/contagion
•Threat to self-concept [perceived or actual]; [unconscious conflict]
•Threat of death [perceived or actual]
•Threat to or change in health status [progressive/debilitating disease, terminal illness],
•interaction patterns, role function/status, environment [safety], economic status
•Unmet needs
•Exposure to toxins
•Substance abuse
•[Positive or negative self-talk]
•[Physiological factors, such as hyperthyroidism, pulmonary embolism, dysrhythmias,
pheochromocytoma, drug therapy including steroids]
 SAMPLE OF NURSING DIAGNOSIS
DEFINING CHARACTERISTICS
Subjective
Behavioral
Expressed concerns due to change in life events; insomnia
Affective
Regretful; scared; rattled; distressed; apprehensive; uncertainty; fearful; feelings of inadequacy; jittery; worried;
painful/persistent increased helplessness; [sense of impending doom]; [hopelessness]
Cognitive
Fear of unspecific consequences; awareness of physiological symptoms
Physiological
Shakiness
Sympathetic
Dry mouth, heart pounding; weakness; respiratory difficulties; anorexia; diarrhea
Parasympathetic
Tingling in extremeties; nausea; abdominal pain; diarrhea; urinary frequency/hesitancy; faintness; fatigue; sleep disturbance;
[chest, back, neck pain]
Objective
Behavioral
Poor eye contact, glancing about, scanning and vigilance, extraneous movement [e.g., foot shuffling, hand/arm movements,
rocking motion]; fidgeting; restlessness; diminished productivity; [crying/tearfulness]; [pacing/purposeless activity],
[immobility]
Affective
Increased wariness; focus on self; irritability; overexcited; anguish
Cognitive
Preoccupation; impaired attention; difficulty concentrating; forgetfulness; diminished ability to problem-solve; diminished
learning ability; rumination; tendency to blame others; blocking of thought; confusion; decreased perceptual field
Physiological
Voice quivering; trembling/hand tremors; increased tension, facial tension, increased perspiration
NURSING DIAGNOSIS
 NURSING DIAGNOSIS BOOKS
 Nursing Care Plans & Documentation: Nursing Diagnoses
and Collaborative Problems by Lynda Juall Carpenito
Organized by medical diagnosis

 Nursing Diagnosis Handbook: A Guide to Planning Care, 7th

Edition, by Betty J. Ackley and Gail B
Alphabetic listing of medical diagnoses, diagnostic procedures,
symptoms and patient problems that gives you suggestions for
nursing diagnoses

NANDA, NOC, and NIC Linkages: Nursing Diagnoses,

Outcomes, and Interventions , Johnson. M, et all
ASSESSMENT
COMMUNICATING DIAGNOSIS
 EXERCISE
CASE STUDY
The patient is 28 years old, 36 week pregnant. She is
complaining about swelling foot, and mild headache.
From the examination nurse found:
BP: 160/110 mmHg
P: 90 bpm
Pitting edema at the ankle

1. Make nursing diagnosis from the case above!

2. Make conversation about assessment and how
you communicate the diagnosis!
 REFERENCES
Nursing diagnosis: application to clinical practice
By Lynda Juall Carpenito-Moyet

•Nursing diagnosis manual: planning, individualizing, and

documenting client care
By Marilynn E. Doenges, Mary Frances Moorhouse, Alice C.
Murr. – 2nd ed.

•Assess Notes: Nursing Assessment & Diagnostic Reasoning

By Marjory Gordon