Second Step in the Nursing Process - Diagnosis

Question 1

ANALYSIS

Answer 1

Separation into components or the breaking down of the whole into its parts.

Question 2

SYNTHESIS

Answer 2

The putting together of parts into whole.

Question 3

WHAT ARE THE COMPONENTS OF A NURSING DIAGNOSIS? (PES OR PE)

Answer 3

~ Problem statement/ diagnostic label/definition = P
~ Etiology/related factors/causes = E
~ Defining characteristics/ Signs and symptoms

Question 4

ACTUAL NURSING DIAGNOSIS

Answer 4

A client problem that is present at the time of the nursing assessment. It is based on the presence of signs and symptoms.

EXAMPLES:
~ Imbalanced nutrition r/t decreased appetite
~ Disturbed sleep pattern r/t cough, fever, and pain
~ Constipation r/t long term use of laxative
~ Ineffective airway clearance r/t viscous secretions

Question 5

POTENTIAL NURSING DIAGNOSIS

Answer 5

One which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it; or the causative factors are unknown but a problem is only considered possible to occur.

EXAMPLES:
~ Possible nutritional deficit
~ Possible low self esteem r/t loss job

Question 6

RISK NURSING DIAGNOSIS

Answer 6

A clinical judgement that a problem does not exist, therefore no s/s are present but the presence of risk factors indicates that a problem is only likely to develop unless the nurse intervenes or does something about it. No subjective or objective cues are present therefore the factors that cause the client to be more vulnerable to the problem are the etiology of a risk nursing diagnosis.

EXAMPLES:
~ Risk for impaired skin integrity (left ankle) r/t decrease peripheral circulation in diabetes.
~ Risk for interrupted family processes r/t mothers illness and unavailability to provide child care.
~ Risk for constipation r/t inactivity and insufficient fluid intake.
~ Risk for infection r/t comprised immune system.