Nursing Diagnosis Flashcards
WHAT IS THIS?
- Interpret assessment data (Subjective and Objective).
- Identify client strengths and problems.
Diagnosing
What are the 3 important steps in making a Diagnosis?
DATA ANALYSIS + PROBLEM IDENTIFICATION + FORMULATION OF NURSING DIAGNOSIS
In creating a Nursing Diagnosis, the _______ health problem is the existing problem that independent nursing intervention can prevent or resolve.
Actual
In creating a Nursing Diagnosis, the _______ health problem is a not-yet-existing problem that independent nursing intervention can prevent or resolve.
Potential
In creating a Nursing Diagnosis, the client’s problem statement consists of the ________________ that comes from NANDA book.
Diagnostic label & Etiology
Note:
- These describes a continuum of health status; deviations from health, presence of risk factors and areas of enhanced personal growth.
What are the 5 Types of Nursing Diagnosis?
- Actual Nursing Diagnosis
- RISK Nursing Diagnosis
- Wellness Diagnosis
- Possible Nursing Diagnosis
- Syndrome Nursing Diagnosis
WHAT IS THIS?
It refers to a client problem that is present at the time of the nursing assessment and has been validated by the presence of major defining characteristics.
Example:
Ineffective Airway Clearance r/t excessive and tenacious secretions
- Definition: The patient has difficulty clearing secretions from the airway, leading to ineffective breathing.
- Related to (r/t): The cause of the problem is excessive and thick (tenacious) secretions, which may block the airway and make it hard for the patient to breathe properly.
- Signs and Symptoms (Defining Characteristics): Coughing, abnormal breath sounds, shortness of breath, cyanosis (bluish skin), and decreased oxygen saturation.
ACTUAL NURSING DIAGNOSIS
Note:
- This means that the patient is experiencing the issue at the time of the assessment, and there is enough evidence to support the diagnosis.
WHAT IS THIS?
It refers to a clinical judgment that a problem does not yet exist, but there are risk factors that make the patient vulnerable to developing the problem.
Example:
Risk for Impaired Skin Integrity r/t Immobility Secondary to Fractured Hip
- Risk for Impaired Skin Integrity → This means that the patient does not yet have skin breakdown (such as pressure ulcers or bedsores), but they are at high risk of developing it.
- Related to (r/t): Immobility → The patient is unable to move properly due to a fractured hip, which limits repositioning and increases pressure on certain areas of the skin.
- Risk Factors:
→ Pressure on the skin from prolonged lying or sitting in one position.
→ Reduced circulation to certain body areas.
→ Moisture buildup from sweat or urine (if incontinent), increasing the chance of skin breakdown.
RISK NURSING DIAGNOSIS
Note:
- This means that if no nursing intervention is done, the condition is likely to occur.
WHAT IS THIS?
It describes a person, family, or community’s readiness to improve their health and well-being.
Example:
- Readiness for Enhanced Spiritual Well-Being
- Meaning: The individual is in a state of spiritual health but is open and ready to deepen their spiritual beliefs, values, or practices.
- Readiness for Enhanced Family Coping
- Meaning: The family is managing stress or challenges well but wants to further improve its ability to handle situations and support each other.
WELLNESS DIAGNOSIS also called as Health Promotion Diagnosis
Note:
- Unlike Actual or Risk Diagnoses, which focus on problems, a Wellness Diagnosis focuses on positive health behaviors and the potential for growth.
WHAT IS THIS?
This is used when a nurse suspects a problem but does not yet have enough data to confirm it. It indicates the need for further assessment and data collection to determine if an actual nursing diagnosis should be made.
Example:
Possible Self-Care Deficit r/t Impaired Ability to Use Left Hand Secondary to Presence of Intravenous (IV) Therapy
- Possible Self-Care Deficit → The nurse suspects that the patient might have difficulty performing self-care activities (e.g., eating, dressing, or hygiene), but more assessment is needed.
- Related to (r/t): Impaired Ability to Use Left Hand → The patient has limited use of the left hand, which could affect self-care tasks.
- Secondary to: Presence of Intravenous Therapy → The IV line in the left hand may be restricting movement, making tasks harder.
POSSIBLE NURSING DIAGNOSIS
WHAT IS THIS?
This is a cluster of related actual or risk nursing diagnoses that are expected to occur due to a specific situation or event. These diagnoses often arise from complex conditions such as trauma, illness, or long-term stress.
Example:
1. Rape Trauma Syndrome
- Definition: A group of physical, emotional, and psychological responses that occur after sexual assault or rape.
- Related Actual or Risk Diagnoses:
→ Risk for Post-Traumatic Stress Disorder (PTSD)
→ Fear and Anxiety
→ Ineffective Coping
→ Social Isolation
- Defining Characteristics:
→ Nightmares or flashbacks.
→ Avoidance of places or people related to the event.
→ Emotional numbness or outbursts.
→ Physical symptoms like headaches or digestive issues.
- Nursing Interventions:
→ Provide emotional support and crisis counseling.
→ Encourage the patient to talk about their feelings in a safe environment.
→Offer referrals to therapy or support groups.
2. Post-Trauma Syndrome
- Definition: A group of symptoms that develop after experiencing or witnessing a traumatic event, leading to psychological distress.
- Related Actual or Risk Diagnoses:
→ Risk for Anxiety Disorders
→ Sleep Pattern Disturbance
→Ineffective Coping
→ Chronic Low Self-Esteem
- Defining Characteristics:
→ Difficulty sleeping or frequent nightmares.
→ Irritability, aggression, or withdrawal.
→ Hypervigilance (constantly feeling on edge).
- Nursing Interventions:
→ Teach relaxation techniques and coping strategies.
→ Monitor for signs of severe emotional distress or self-harm.
→ Encourage seeking professional mental health support.
SYNDROME NURSING DIAGNOSIS
Note:
- Since Syndrome Diagnoses involve multiple interconnected issues, nursing care should focus on comprehensive, holistic support rather than treating just one symptom.
What are the 3 Components of Nursing Diagnosis?
- Problem (diagnostic label)
- Etiology (related factors & risk factors)
- Defining Characteristics (signs and symptoms)
WHAT IS THIS?
Describes the client’s health problem/status or response.
Problem Statement
WHAT IS THIS?
Specific; when the word SPECIFY follows a NANDA label, the nurse states the area in which the problem occurs.
Diagnostic labels
What is the difference between Problem Statement and Diagnostic Labels?
The difference between a Problem Statement and Diagnostic Labels lies in their scope and specificity within nursing diagnosis.
- PROBLEM STATEMENT
- Definition: A broad description of the client’s health problem, status, or response to a condition.
- Focus: General issue affecting the patient.
- Example: Impaired physical mobility due to weakness
- DIAGNOSTIC LABELS
- Definition: The specific term used to identify a nursing diagnosis based on NANDA International (NANDA-I) terminology.
- Focus: A standardized name for a condition, often requiring further specification if instructed.
- Example:
+ Impaired Physical Mobility → A diagnostic label from NANDA-I
+ If the label includes “SPECIFY,” the nurse must identify the affected area, e.g., Impaired Physical Mobility: Lower Extremities
WHAT IS THIS?
- It refers to the cause or contributing factors of a health problem. It helps the nurse identify what is leading to the issue, guiding the appropriate nursing interventions.
Etiology (related factors & risk factors)
Note:
- Related Factors → Causes of an actual nursing diagnosis.
- Risk Factors → Conditions that increase the likelihood of a problem occurring in a risk nursing diagnosis.
WHAT IS THIS?
These are observable signs, symptoms, or cues that confirm the presence of a specific nursing diagnosis. These characteristics help the nurse validate that a patient truly has the identified problem.
Defining Characteristics
Note:
- Defining characteristics are the evidence that supports an actual nursing diagnosis. They help nurses identify what symptoms are present and tailor interventions accordingly.
WHAT IS THIS?
These are multidisciplinary health concerns that require both nursing interventions and medical management to prevent or treat potential complications. These problems often have a diagnostic label of “Potential for Complication” and involve working with physicians and other healthcare professionals to address them.
Collaborative problems
Note:
- Collaborative problems require nurses to monitor and intervene while working with other healthcare providers to prevent complications.
What are the 3 Steps of Diagnostic Process?
- Analyzing data
- Identifying Health Problems, Risks, & Strengths
- Formulating Diagnostic Statements
What are the 3 Subtopics under Analyzing Data?
- Comparing data with standards
- Clustering of cues
- Identifying gaps and inconsistencies of data
UNDER ANALYZING DATA, WHAT IS THIS?
- Identify significant cues.
- Nurses draw on knowledge and experiences to compare client data to standards and norms and identify significant & relevant cues.
Comparing data with Standards
Note: This is about Comparing all the objective data’s to normal standards
UNDER ANALYZING DATA, WHAT IS THIS?
- Process of determining the relatedness of facts and determining whether any patterns are present, whether the data represents isolated incidents and whether the data are significant.
- Grouping of data/cues that point to the existence of a health problem.
Clustering cues
UNDER ANALYZING DATA, WHAT IS THIS?
- Include the final check to ensure that data are complete and correct.
- Skillful assessment minimizes gaps and inconsistencies in data.
- Possible sources of inconsistencies: measurement error, expectations, and inconsistent or unreliable reports.
Identifying gaps and inconsistencies of data
Under STEPS OF DIAGNOSTIC PROCESS, WHAT IS THIS?
- Identify problems that support tentative actual, risk, and possible diagnosis.
- Establish the client’s strengths resources and abilities to cope.
- Must determine whether the client’s problem is a nursing diagnosis or a collaborative problem.
Identifying Health Problems, Risks, & Strengths
What are the 3 Formulating Diagnostic Statements?
- One-part statement
- Basic two-part statement
- Basic three-part statement
What is the formula for one-part statement?
Problem
What is the formula for basic two-part statement?
Problem + Etiology
What is the formula for basic three-part statement?
Problem + Etiology + Signs and Symptoms
Determine what formulating diagnostic statement this is.
Constipation r/t prolonged laxative use.
A. One-part statement
B. Basic two-part statement
C. Basic three-part statement
B. Basic two-part statement
Determine what formulating diagnostic statement this is.
Situational low self-esteem r/t feelings of rejection by husband as manifested by hypersensitivity to criticism.
A. One-part statement
B. Basic two-part statement
C. Basic three-part statement
C. Basic three-part statement
Determine what formulating diagnostic statement this is.
Severe anxiety r/t threat to physiologic integrity: possible CA diagnosis.
A. One-part statement
B. Basic two-part statement
C. Basic three-part statement
B. Basic two-part statement
Determine what formulating diagnostic statement this is.
Rape-trauma syndrome.
A. One-part statement
B. Basic two-part statement
C. Basic three-part statement
A. One-part statement
Determine what formulating diagnostic statement this is.
Altered dentition related to chronic use of tobacco as manifested by tooth enamel discoloration.
A. One-part statement
B. Basic two-part statement
C. Basic three-part statement
C. Basic three-part statement
Determine what formulating diagnostic statement this is.
Readiness for enhanced parenting.
A. One-part statement
B. Basic two-part statement
C. Basic three-part statement
A. One-part statement
What are the 5 Variations of Basic Formats in Nursing Diagnosis?
- Writing “Unknown Etiology”
- Using “Complex Factors”
- Using “Possible”
- Using “Secondary To”
- Adding Specificity to the NANDA Label
WHAT IS THIS?
Used when: The cause of the problem is unclear, but defining characteristics (signs/symptoms) are present.
Example: Noncompliance (medication regimen) r/t unknown etiology
- Why? The patient is not following the medication regimen, but the exact reason is not yet identified.
Writing “Unknown Etiology”
WHAT IS THIS?
Used when: There are too many contributing causes that make it hard to pinpoint one.
Example: Chronic low self-esteem r/t complex factors
- Why? The patient has multiple possible causes of low self-esteem (e.g., childhood trauma, social issues, medical conditions), so a broad term is used.
Using “Complex Factors”
WHAT IS THIS?
Used when: The nurse suspects a problem but needs more data to confirm it.
Example: Possible low self-esteem r/t loss of job and rejection by family
- Why? The patient may have low self-esteem due to life events, but further assessment is needed before confirming the diagnosis.
Using “Possible”
WHAT IS THIS?
Used when: The etiology (cause) has two levels, with a medical condition as a contributing factor.
Example: Risk for impaired skin integrity r/t decreased peripheral circulation secondary to diabetes
Why?
- Primary cause: Decreased circulation (nursing-related)
- Underlying condition: Diabetes (medical condition)
Using “Secondary To”
WHAT IS THIS?
Used when: The diagnosis needs to be more precise by specifying the affected area.
Example: Impaired Skin Integrity (left lateral ankle) r/t decreased peripheral circulation
- Why? Instead of just saying Impaired Skin Integrity, the affected location is included for clarity.
Adding Specificity to the NANDA Label
FAMILIARIZE ONLY!
KEY TAKEAWAY:
These variations help refine nursing diagnoses when:
✔ The cause is unknown → Use “unknown etiology”
✔ There are too many causes → Use “complex factors”
✔ More data is needed → Use “possible”
✔ A medical condition is involved → Use “secondary to”
✔ Affected area needs specification → Add location to the NANDA label
FAMILIARIZE ONLY!
“NURSING DIAGNOSIS VS MEDICAL DIAGNOSIS”
NURSING DIAGNOSIS (NANDA)
- Definition: A statement of nursing judgment.
- Focus: Describes the human response to illness or health problems.
- Who Makes It?: Nurses (based on assessment, education, and expertise)
- Scope: Covers physical, psychological, socio-cultural, and spiritual responses to illness.
- Treatment Approach: Nurses provide independent interventions (e.g., repositioning, health education, wound care)
- Nursing Actions: Independent—nurses can intervene without a doctor’s order (e.g., assisting in breathing exercises, wound dressing)
Examples:
✔ Ineffective Airway Clearance r/t excessive mucus production
✔ Risk for Infection r/t compromised immune system
MEDICAL DIAGNOSIS
- Definition: A diagnosis made by a physician.
- Focus: Identifies a disease or condition.
- Who Makes It?: Physicians (based on medical tests and evaluation)
- Scope: Focuses on pathophysiology and disease processes.
- Treatment Approach: Requires medical treatment (e,g., medications, surgery, procedures)
- Nursing Actions: Primarily dependent—requires a physician’s order (e.g., prescribing antibiotics, ordering diagnostic tests)
Examples:
✔ Pneumonia
✔ Diabetes Mellitus
FAMILIARIZE ONLY!
“Guidelines for Writing a Nursing Diagnosis”
- State in Terms of a Problem, Not a Need:
- ❌ Need for fluid replacement r/t fever
- ✅ Deficient fluid volume r/t fever
- Ensure the Statement is Legally Advisable:
Avoid language that could imply negligence or blame.
- ❌ Impaired skin integrity r/t improper positioning
- ✅ Impaired skin integrity r/t immobility
- Use Nonjudgmental Statements:
- ❌ Spiritual distress r/t strict rules necessitating church attendance
- ✅ Spiritual distress r/t inability to attend church services secondary to immobility
- Avoid Repetition (Both Elements Should Not Say the Same Thing):
- ❌ Impaired skin integrity r/t ulceration of sacral area (ulceration is a result, not a cause)
- ✅ Impaired skin integrity r/t immobility
- Ensure Correct Cause-and-Effect Relationship:
- ❌ Pain r/t severe headache (headache is the pain itself, not the cause)
- ✅ Pain: severe headache r/t fear of demands of student life
- Be Specific and Precise to Guide Nursing Interventions:
- ❌ Impaired oral mucous membrane r/t noxious agent (vague)
- ✅ Impaired oral mucous membrane r/t decreased salivation secondary to radiation of neck
- Use Nursing Terminology Instead of Medical Terminology:
- ❌ Risk for pneumonia (pneumonia is a medical diagnosis)
- ✅ Risk for ineffective airway clearance r/t accumulation of secretions in lungs
- ❌ Risk for ineffective airway clearance r/t emphysema (emphysema is a medical condition)
- ✅ Risk for ineffective airway clearance r/t accumulation of secretions in lungs
