Diagnosis: 2nd Phase of the Nursing Process

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What is nursing diagnosis?

Nursing Diagnosis is the second phase of the nursing process.

It is an interpretation and analysis of the data collected by the nurse about the patient during the assessment phase.

What is the standard definition of the nursing diagnosis?

NANDA-International defines nursing diagnosis as follows:

“A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”.

What are the components of a nursing diagnosis?

These are the three main components of a nursing diagnosis:

    • Problem
    • Definition
    • Defining Characteristics

1. Problem

It describes the essence of the client’s problem for which nursing therapy is given.

It contains the diagnostic label such as:

  • Anxiety
  • Feeding Self-Care Deficit
  • Stress Urinary Incontinence

The Problem is also expounded by qualifiers that give more details to the diagnostic label.

  • Compromised
  • Decreased
  • Increased
  • Anticipatory
  • Deficient
  • Disturbed
  • Disorganized
  • Excessive

2. Definition

It describes the characteristics of the diagnostic label. For every diagnostic label approved by NANDA, there is a definition. For example, Hypothermia is a body temperature below normal range.

3. Defining Characteristics

These are set of clinical cues forming a cluster that is present if the diagnosis is accurate. For actual nursing diagnosis, the defining characteristics are the client’s signs and symptoms.

What are the types of diagnostic statements?

      • Actual nursing diagnosis

Acute Pain related to surgical trauma and inflammation as evidenced by facial grimacing and verbal reports of pain

It includes diagnostic label, related factors and defining characteristics. It defines a human response to a health problem that is actually experienced.

      • Risk nursing diagnosis

Risk for Infection related to immunosuppression

It includes diagnostic label and risk factors. Risk nursing diagnosis describes health conditions or life processes that may develop in a vulnerable client.

      • Possible nursing diagnosis

Possible Self-Esteem Disturbance related to unknown cause

It includes diagnostic label and related factors. A possible nursing diagnosis is made when not enough information supports a highly probable problem that the nurse wants to explore in-depth.

      • Wellness diagnosis

Readiness for Enhanced Spiritual Well-being

It includes diagnostic label.It describes human responses to levels of wellness.

How to formulate a nursing diagnosis?

Nursing Process - Diagnosis
Nursing Process – Diagnosis

These are the processes involved in creating a nursing diagnosis:

      • Analyzing Data

Analyzing data involves comparing data against standards, clustering the cues and identifying inconsistencies.

The nurse may take note of changes in client’s health pattern (body temperature abnormalities); variations from the general norm (eating very small meals and having little appetite);  and evidences of developmental delays.

      • Identifying Health Problems, Risks and Strengths

After clustering the client data according to specific models and frameworks of health, the nurse determines whether the possible problem disappears when clustered with other data.

For example, Decreased Urinary Frequency and Amount x 2 days is a problem alone but when clustered with Deficient Fluid Volume, it can be eliminated.

You also have to identify strengths that can aid in recovery.

      • Formulating Diagnostic Statements

Most nursing diagnosis are written in the following formats:

Problem – Etiology (PE) Format

Constipation related to prolonged laxative use

Anxiety related to threat to physiological integrity: possible cancer diagnosis

Problem – Etiology – Signs and Symptoms (PES) Format

Situational Low Self-Esteem related to feelings of rejection by husband as evidenced by hypersensitivity to criticism; states “I don’t know if I can manage by myself” and rejects positive feedback

One Part Statement

Readiness for Enhanced Parenting

Risk for Disuse Syndrome

Collaborative Problems

These usually begin with the diagnostic label Potential Complication.

Potential Complication of Head Injury: increased intracranial pressure

Potential Complication of Pregnancy-Induced Hypertension: seizures, fetal distress, pulmonary edema, hepatic/renal failure, premature labor, CNS hemorrhage

Key Points:

      • Nursing diagnosis is a collection of assessment data.
      • The processes involved in creating a nursing diagnosis are analyzing data, identifying health problems, risks and strengths and formulating diagnostic statements.
      • A nursing diagnosis consists of the problem (and its definition), the etiology, and the defining characteristics.

Assessment: 1st Phase of the Nursing Process

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What is Assessment?

Assessment is the first phase of the nursing process.

During assessment, the nurse collects data, organizes it, validates the same and then documents the information gathered.

The information gathered during assessment serves as database about the client’s response to his or her illness.

What is the focus of nursing assessment?

The focus of a nursing assessment is the client’s responses to perceived health problem.

Upon assessment, the nurse is expected to gather information with regards to the client’s needs, health problems, health practices, lifestyle, values and related experiences. It is very crucial for assessment to be comprehensive for nursing care to be effective.

What are the Different Types of Assessment?

These are the various types of nursing assessment:

  • Initial Assessment. This is usually performed right after admission of the client to the health care agency. It establishes a database for identification of client’s health needs. It also serves as baseline data for later comparison.
  • Problem-Focused Assessment. This is usually performed anytime while nursing care is ongoing. It helps nurses identify the current status of the previously identified problem(e.g. hourly TPR monitoring).
  • Emergency Assessment. This type of assessment is usually done when the client is in crisis to identify any life-threatening problems (e.g. assessment of client’s airway, breathing and circulation during cardiopulmonary resuscitation).
  • Time-Lapsed Reassessment. This is done after a specific period has lapsed (e.g. reassessment of client’s status a month after discharge).

Data Gathered During Assessment

Types Of Data

  • Subjective Data. These data are symptoms experienced by the client. It involves client’s feelings, sensations, values, beliefs and perception about his or her health.
  • Objective Data. Also known as the signs, objective data are those directly detected by the observer. It can be seen, smelled, felt or touched and are obtained during physical examination.

Sources Of Data

  • Primary. The primary data source is the client. He or she is the best source of data unless the client suffers severe illness that affects communication.
  • Secondary. All data sources other than the client are secondary.  Secondary sources of data include: family members, health professionals, laboratory and diagnostic records or reports, and literature.

What Must Be Done During Assessment?

Nursing Process - Assessment
Nursing Process – Assessment

1) Data Collection.

Data collection is a systematic and continuous process of gathering data regarding the client’s health status to create a database.

The database is a sum of all the information about the client including but not limited to: nursing health history, physical assessment, primary care provider’s history and physical examination, laboratory and diagnostic test results and other pertinent health data.

There are 3 methods involved in collecting data:

  • Observation. It uses the different senses in gathering data. Here, the nurse takes note of the client’s overall appearance, body odors, sounds of the heart, lungs, bowel, skin temperature, pulse rate, etc.
  • Interview. An interview is a planned conversation with a purpose – in the case of nursing assessment – to gather health data and identify health needs and concerns. Before starting an interview with the client, it is important to first establish rapport, creating a relationship of mutual trust and understanding.
  • Examination. The examination referred to during data collection is physical examination. Here, the nurse uses observation to detect any health problems experienced by the client. It involves four techniques namely: 1) inspection, 2) auscultation, 3) palpation and 4) percussion.

Inspection is the visual examination of the client’s body. The nurse may look for rashes, breaks in the skin, and normal appearance of eyes, ears, nose, mouth, limbs, and genitals.

Palpation means touching or feeling the body and limbs for pulses, abnormal lumps, temperature, moisture, and vibrations.

Auscultation is listening for abnormal sounds in the lungs, heart, or bowels.

Percussion is the use of tapping movements to detect abnormalities of the internal organs.

2) Data Organization.

Data gathered and organized in written or electronic form is called the nursing health history.

Standard and systematic formats are being followed by different nursing schools and health agencies when organizing data. The two most common data organization framework are:

  • Gordon’s functional health pattern. This provides a framework of 11 functional health patterns namely: health perception and management, nutritional, metabolic, elimination, activity, sleep, cognitive, self perception and concept, role relationship, sexuality, coping and stress, and value belief systems. The nurse has to collect both abnormal and normal data for each of these patterns.
  • Roy’s Adaptation Model. Under this model, data are classified according to the four main adaptive modes. The nurse has to gather both normal and abnormal data on the following adaptive modes: 1) Physiologic Needs, 2) Self-Concept, 3) Role-Function and 4) Interdependence.

3) Data Validation.

The assessment data must meet the following criteria in order to be reliable:

  • Complete
  • Factual
  • Accurate

To ensure that the information gathered meets the criteria, the nurse must validate data. The nurse must ensure that his or her biases, values and belief are set aside. Assumptions are unacceptable. Rather than sticking to your assumptions, better ask the client for clarification.

Not all data must be validated. Only data with discrepancies will need validation.

For instance, if the client is not consistent with his or her response during interview or when there is a difference between the subjective and objective data, validation must be done.

4) Data Documentation.

Unrecorded assessment information is useless. It cannot serve as a baseline for planning and implementing nursing care.

Documentation must be complete and based on facts rather than assumptions.

For objective data, specific measurements rather than vague conclusions must be used as descriptions (e.g. 1 slice of bread, coffee 200 ml, 1 egg must be recorded rather than good appetite).

For subjective data, use client’s own words to prevent changing the actual meaning.

Key Points:

  • Assessment is the first phase of the nursing process wherein the nurse gathers information which serves as database about the client’s response to his or her illness.
  • During assessment, the nurse is expected to do four activities which are: 1) data collection, 2) data organization, 3) data validation and 4) documentation.
  • The primary data source is the client. He or she is the best source of data unless the client suffers severe illness that affects communication.

Overview of the Nursing Process

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What is the Nursing Process?

The Nursing Process is a standard process nurses and student nurses adhere to in order to provide a systematic, holistic, collaborative and individualized care for clients.

The client who is the main focus of the Nursing Process can be an individual, family, community or a group.

What is the goal of the nursing process?

The goal of the nursing process is to identify the client’s health status and needs, establish a health care plan and provide quality nursing care to meet the identified health care problems.

What are the phases of the Nursing Process?

There are five essential phases involved in the nursing process:

  1. Assessment
  2. Diagnosis
  3. Planning
  4. Implementation
  5. Evaluation

These five phases allow the nurse to:

  • identify the needs of the client;
  • formulate objectives to promote healing;
  • plan specific actions to meet desired objectives;
  • properly implement the action plan; and
  • thoroughly evaluate whether or not the goals and objectives for the client has been met.
Diagram of the Nursing Process
Diagram of the Nursing Process

These five phases are closely intertwined that an inadequacy in one area can affect all the other areas. Hence, if the data obtained during assessment is not accurate, inaccuracy may be seen in all the other four phases.

Overview of the Different Phases of the Nursing Process

1) Assessment

The nurse collects, organizes, validates and documents client data. The data collected serve as database to the client’s response to his or her illness.

Information gathered during assessment includes signs and symptoms of the client’s condition, patient history, physical examination, interview results, a review of the client’s laboratory and diagnostic tests.

2) Diagnosis

The nurse analyzes and makes a synthesis of the data previously collected. 

The purpose of a diagnosis is to develop a list of client problems that can be prevented or solved through appropriate nursing interventions.

3) Planning

The nurse develops an individualized plan of care that shows different client goals and objectives and related interventions which is known as the nursing care plan.

The nurse also determines expected outcomes to be met by the client for the nursing diagnosis to be resolved. 

4) Implementation

It is during this phase when the plan of nursing interventions will be carried out.

The goal of this phase is to assist the client to meet the stated objectives and goals, promote wellness, prevent illness, and restore health and aid in coping.

5) Evaluation

The nurse reviews the degree to which the client goals and objectives have been met. The nurse also pinpoints what are the possible factors (negative or positive) that affected the achievement of these objectives.

If goals are not achieved, the nurse must modify the interventions and create new goals to better fit the needs of the client.

What are the characteristics of the Nursing Process?

These are the distinctive nature of the Nursing Process:

  • Cyclic and Dynamic. Data gathered during the assessment phase serves as basis for the next phase. Also, any finding during the evaluation phase may alter or modify the data primarily gathered during assessment.
  • Client-centered. The plan of intervention is solely based on the needs of the client rather than the goals of the nurse.
  • Focused on Problem Solving. The nursing process is similar to the process doctors follow when treating a disease. Both start with data collection, followed by intervention and end with an evaluation.
  • Interpersonal. The nursing process demands the nurse to constantly communicate with the client and his or her family and also collaborate with other members of the health care team to provide quality care to the client.
  • Universal. The framework used in the nursing process is applicable to all health care settings, regardless of the client’s age.
  • Uses Critical Thinking. Nurses are expected to use critical thinking skills in all phases of the nursing process to ensure the delivery of quality and appropriate nursing care.

Key Points:

  • The nursing process is a systematic method of planning and providing nursing care to clients.
  • Its purposes are to identify client’s health care needs, establish goals and plans to meet those needs, deliver appropriate nursing interventions that address those needs and evaluate the whether or not the established goals have been met.
  • The nursing process is a dynamic process wherein more than one phase may be involved at the same time.