NURSING

PROCESS
PREPARED AND PRESENTED BY

MRS.S.ANUKRISHNAN,

VICE PRINCIPAL CUM HOD OBG NURSING,

P.D.BHARATESH COLLEGE OF NURSING,

HALAGA, BELGAUM.
INTRODUCTION
 Second phase of the Nursing Process.
 Nurses use critical thinking skills to interpret assessment data and
identify client strengths & problems.
 Diagnosing is the pivotal step in the nursing process.
 All activities preceding this phase are directed toward formulating the
nursing diagnosis.
 All the care planning activities following this phase are based on the
nursing Diagnoses.
 The identification & development of nursing Diagnosing began formally
in 1973.
NORTH AMERICAN NURSING DIAGNOSING
ASSOCIATION
 NANDA: - is to define, refine & promote taxonomy of
Nursing Diagnostic terminology of general use to professional
nurses.
 Taxonomy - is the classification system
 Currently NANDA approved more than 150 Nursing
Diagnosis labels for clinical use & testing. In 2000 taxonomy
I revised & now referred to as Taxonomy II.
DEFINITION

 “It is a clinical judgment about individual, family or

community responses to actual and potential health
problems/life processes. Nursing diagnoses provide the
basis for selection of nursing interventions to achieve
outcomes for which the nurses are accountable”.
TYPES OF NURSING DIAGNOSES

1. Actual Nursing Diagnosis

2. Risk Nursing Diagnosis

3. Wellness Diagnosis

4. Possible Nursing Diagnosis

5. Syndrome Diagnosis
ACTUAL NURSING DIAGNOSIS
 Actual Nursing Diagnosis is a client problem that is present
at the time of the Nursing assessment.
 The actual Nursing Diagnosis is based on the

presence of associated signs & symptoms.

EXAMPLES OF ACTUAL NURSING DIAGNOSIS
 Ineffective breathing pattern related to bacterial / viral
inflammatory Process.
 Ineffective breathing pattern related to Tracheo-bronchial
obstruction
 Anxiety related to changes in the environment and routines,
threat to socio economic status.
 Anxiety related to change in health status and situational crisis.
 Body image disturbance related to temporary presence of a
visible drain/ tube.
RISK NURSING DIAGNOSIS
 It is a clinical judgment that a problem doesn’t exist, but the
presence of risk factors indicates that a problem is likely to
develop unless nurses intervene.
 Eg. A client with Diabetes Mellitus or a compromised immune
system is at high risk than others.
 Therefore the nurse would appropriately use the label risk for
infection to describe the client’s health status.
WELLNESS DIAGNOSIS

 Describes human responses to levels of wellness in an

individual, family or community that have a readiness for
enhancement.

Eg.

i) Readiness for enhanced spiritual well being

ii) Readiness for enhanced family coping.

POSSIBLE NURSING DIAGNOSIS
 is one in which evidence about a health problem is
incomplete or unclear.
 For Eg. Elderly widow who lives alone admitted in hospital
have no visitors & is pleased with attention and conversation
from the nursing staff. Until more data are collected, the
nurse may write a Nursing Diagnosis of :

i) Possible social Isolation Related to unknown etiology.

A SYNDROME DIAGNOSIS

 is a diagnosis associated with a Cluster of other diagnoses.

 Eg. Risk for disuse syndrome – experienced by bed ridden
patient.
 1. Impaired physical mobility 2. Impaired gas exchange 3. Risk
for impaired tissue integrity 4. Risk for Activity intolerance 5.
Risk for constipation 6. Risk for infection 7. Risk for injury 8.
Risk for powerlessness
 COMPONENTS OF NANDA NURSING
DIAGNOSIS
 A nursing Diagnosis has 3 components.

1. The problem and its definition

2. The etiology

3. The defining characteristics.

 Each component serves a specific purpose.
 1] THE PROBLEM (DIAGNOSTIC LABEL)
AND ITS DEFINITION
 Describes the clients health problem or response for which
nursing therapy is given.
 It describes the client’s health status clearly & concisely in few
words.
 Purpose is to direct the formation of client goals and desired
outcomes.
 It may also suggest some nursing interventions.
 To be clinically useful,
 diagnostic labels need to be specific;
 when the words specify follows a NANDA Label, the nurse states the
area in which the problem occurs.
 For eg.
Deficient knowledge (specify) Medication
Deficient knowledge (Dietary adjustments).
 Qualifiers are words that have been added to some NANDA
Labels to give additional meaning to the diagnostic statement; for eg.

 Deficient (inadequate in amount quality or degree not sufficient,

incomplete)

 Impaired (Made worse, weakened, damaged, reduced, deteriorated)

 Decreased (lesser in size amount or degree)

 Ineffective (not producing the desired coping)

 Compromised (to make Vulnerable to threat)

 Each Diagnostic label approved by NANDA carries a definition that

clarifies its meaning.
 2] ETIOLOGY

 The etiology component of a nursing diagnosis

 identifies one or more probable cause of the health problem,
 gives direction to the required nursing therapy and
 enables the nurse to individualize the client’s care.

 Eg. of problems having different etiologies and different

interventions
 Problem Client Etiology Nursing Intervention

A Long term Gradual withdraw of laxatives

laxative use - teach components of high fiber diet.

Constipati B Inactivity & - exercise information about daily schedule

on insufficient - types of fluid he likes
- Plan to include sufficient amount of fluid
fluid intake in his diet.

Ineffective A Breast -massage of breast before feeding

Breast engorgement - use hot packs
- hot shower before nursing infant
Feeding
B Inexperience - Advice to feed infant on demand
and lack of - Show her how infant is sucking &
swallowing
knowledge - demonstrate different holding positions for
feedings.
 3] DEFINING CHARACTERISTICS
 Defining Characteristics are the client’s signs & symptoms. That
indicates the presence of a particular diagnostic label.
 For Actual Nursing Diagnosis the defining characteristics are
the client’s signs & symptoms.
 For Risk Nursing Diagnosis no subjective & objective signs
are present.
 Thus the factors that cause the client to be more than “normally”
vulnerable to the problem form the etiology of a risk nursing
diagnosis.
 Characteristics are listed separately according to whether they
are subjective or objective in nature.
 DIFFERENCE BETWEEN MEDICAL & NURSING
DIAGNOSES
Sl No. Nursing Diagnoses Medical Diagnoses

1 It is a statement of Nursing judgment Medical Diagnoses is made by

physician
2 Refers to a condition that Nurses are Refers to a condition that only a
licensed to treat physician can treat.

3 Nursing Diagnoses describe a client’s Medical Diagnoses refers to

physical, socio-cultural, psychologic, disease processes
and spiritual responses to an illness or
health problem.
4 It changes depend upon the response of Fairly uniform from one client to
the client to an illness & health another
problem.
5 Nursing Diagnoses change as the client Medical Diagnose remains same
responses change. for as long as the disease process
is present.
 THE DIAGNOSTIC PROCESS

 The Diagnostic Process uses critical thinking skills of analysis

and synthesis.
 Critical thinking is a cognitive process during which a person
reviews data and considers explanations before forming an
opinion.
 Analysis – is the separation into components that is breaking down
of the whole into its parts.
 Synthesis – is the opposite that is the putting together of parts into
the whole.
 The diagnostic process is used continuously by most nurses.
 An experienced nurse may enter a client’s room and
immediately observe significant data and draw conclusions
about the client.
 As a result of attaining knowledge skill and expertise in the
practice setting, the expert nurse may seem to perform these
mental processes automatically.
 Novice nurses, however, need guidelines to understand and
formulate nursing diagnoses.
 THE DIAGNOSTIC PROCESS

The diagnostic process has 3 steps:-

1] Analyzing data

2]Identifying health problems, risks and strengths.

3] Formulating Diagnostic statements.

Assessing
a. Collect data
b. Organize data
c. Validate data
d. Document data

Diagnosing
a. Analyze data
b. Identify health
problems, risks and
strength,
c. Formulating
nursing diagnosis
 1] ANALYZING DATA

 In analyzing data following steps are involved.

A. Compare data against standards (identify significant cues)

B. Cluster cues (generate tentative hypotheses)

C. Identify gaps & inconsistencies.

 For experienced nurses, these activities occur

continuously rather than sequentially.
 A. COMPARING DATA AGAINST STANDARDS

 A Standard or Norm is generally accepted measure, model

rule, or pattern.
 Eg. of Standards
 Growth and Development patterns
 Normal vital signs
 Laboratory values.
 B. CLUSTER CUES

 It is a process of determining the relatedness of facts and

determining whether data are significant.
 C. IDENTIFY GAPS & INCONSISTENCIES
 Skillful assessment minimizes the gaps & inconsistencies,
conflicting data's.
 Possible sources are measurement error, expectation and
unreliable report.
 It helps to have final check to ensure the data are complete and
correct.
 Eg. Patient reports not having seen a Doctor in 15 years, yet during
Physical Examination he states “My doctor takes my BP every year”.
 All inconsistencies must be clarified before valid pattern “Validating
data”.
2] IDENTIFYING HEALTH PROBLEMS, RISKS
& STRENGTHS

 After data are analyzed, the nurse and client can together
identify strengths & problems.
 That is after gaping and clustering the data, the nurse and
client together identify problems that support tentative actual,
risk, and possible diagnoses.
 EG. OF A CLIENT WITH PNEUMONIA
Sl
No. Client cue clusters

1 a) No appetite since Imbalanced Nutrition: Less that

having “Cold” Body Requirements related to
b) Has not eaten decreased appetite & Nausea, &
today, Last fluids increased metabolism
at noon today (Strength: - Normal Weight for
c) Nauseated x 2 Height.)
days
 EG. OF A CLIENT WITH PNEUMONIA
Sl
No. Client cue clusters
2 a) Last fluids at noon
today Deficient fluid volume related to
b) Oral temperature intake insufficient to replace
39.40c (1030 F) fluid loss secondary to fever,
c) Skin lot & pale, diaphoresis, anorexia
checks flushed
d) Dry mucous
membrane
e) Poor skin turgor
f) Decreased Urinary
frequency x 2 days
 EG. OF A CLIENT WITH PNEUMONIA
Sl
Client cue clusters
No.
3 Difficulty in Disturbed sleep pattern related to
sleeping because cough, pain, orthopnea, fever,
of cough, and diaphoresis.
“Can’t breathe
while lying down”
 EG. OF A CLIENT WITH PNEUMONIA
Sl
No. Client cue clusters

4 a) States “I feel Weak”

b) Short of breath on Activity Intolerance related to
exertion general weakness imbalance between
c) Radial pulses weak, O2 supply / demand
regular Strength: - No musculoskeletal
d) Pulse rate – 92 bt/mt impairment, normal energy level is
e) States “I can think Satisfactory, exercises regularly.
ok, just weak”
 EG. OF A CLIENT WITH PNEUMONIA
Sl
No. Client cue clusters

5 Reports pain in Acute pain related to cough

chest especially secondary to inflammation of
when coughing lung parenchyma.
Strength:-No cognitive or
sensory deficits.
 EG. OF A CLIENT WITH PNEUMONIA
Sl
No. Client cue clusters

6 a) Husband out of Interrupted family processes

town; will be back related to mother’s illness &
tomorrow temporary unavailability of
afternoon father to provide child care.
b) Child with Strength :- Neighbors available
neighbor until & willing to help.
husband returns.
 EG. OF A CLIENT WITH PNEUMONIA
Sl
No. Client cue clusters
7 a) Anxious :- “I can’t
breathe” Anxiety related to difficulty breathing,
b) Facial muscles tense, inability to work, and child care.
c) Trembling
d) States “I’ll never get
caught up”
e) Husband out of town;
will be back tomorrow
afternoon.
f) Child with neighbor
house
g) Express “concern” &
“Worry”
 EG. OF A CLIENT WITH PNEUMONIA
Sl
No. Client cue clusters
8 a) Radial pulse weak, regular
pulse rate 92 Ineffective Airway clearance related to
b) Skin hot, pale, and moist viscous secretions & shallow chest
c) Respirations shallow, chest expansion secondary to pain, fluid
expansion, 3cm volume deficit & fatigue.
d) Productive cough
e) Thick pale pink sputum
f) Inspiratory crackles
auscultated through out. Right
upper & lower lungs.
g) Diminished breath sounds
an ® side
h) Mucous membranes pale,
dry
 DETERMINING STRENGTHS

 Eg. of strengths
 Weight is with in normal as per age & Height – Enables client
to cope with surgery.
 Absence of allergies & Non smoker.
 It can be found in the nursing assessment record (health, home
life, Education, recreation, exercise, work, family & friends
religious beliefs, sense of humour)
 3] FORMULATING DIAGNOSTIC
STATEMENTS
 Most Nursing Diagnoses are written as two part or three part
statements, but there are variations of these.

1. Basic two part statements

2. Basic three part statements

3. One part statements

4. Variations of Basic formats.

5. Collaborative problems.
 BASIC TWO PART STATEMENTS
 The basic two part statement includes the following.

1] Problem (P) :- Statement of the client’s response (NANDA Label)

2] Etiology (E) :- Factors contributing to or probable cause of

responses.
 The two parts are joined by the words related to rather than due to.
 The phrase due to implies that one part causes or is responsible
for the other part.
 By contrast, the phrase related to merely implies a relationship.
 EG. OF TWO PART STATEMENTS

Problem Related to Etiology

Constipation Related to Prolonged

Laxative use

Ineffective Related to Breast

Breast Feeding engorgement
 Some NANDA Labels contain the word specify. For these the
nurse must add words to indicate the problem more specifically.
 Eg. Noncompliance (specify)
 Noncompliance (Diabetic Diet) related to denial of having
disease.
 For ease in alphabetizing, many NANDA lists are arranged with
qualifying words after the main word (Eg. Infection, Risk For).
 Avoid writing Diagnostic statements in that manner instead,
write them as they would be stated in normal conversation (Eg.
Risk for infection)
 BASIC THREE PART STATEMENTS

 The three part Diagnostic Statements called the PES format

and includes the following:

1] Problem (P) :- Statement of the client’s response (NANDA

Label)

2] Etiology (E) :- Factors contributing to or probable cause of

the response.

3] S/S (S) :- Defining characteristics manifested by the client.

 Actual nursing diagnoses can be documented by using the
three part statement
 because the signs & symptoms have been identified.

 This format cannot be used for risk diagnoses

 because the client doesn’t have signs & symptoms of the
diagnosis.
 EG. OF 3 PART STATEMENT
Problem Related Etiology As manifested Signs & symptoms
To by
Situational Related to Rejection by As manifested by States that “I don’t know if I can
Low Self husband
Esteem
manage by myself”
Rejects positive feed back.

Hyperthermia Related to Bacterial infection As manifested by Elevated body temperature. 1000F

Increased pulse rate 92bt/mt
Increased R.R 30br/mt
Dry lips . States Fatigue, tired.
Feels so Hot
Reduced Skin turgor.

Ineffective Related to Viscious secretions As manifested by Viscious secretions, shallow chest

breathing
pattern
expansion.
 ONE PART STATEMENTS

 Wellness diagnoses and Syndrome nursing diagnoses.

 As the diagnostic labels are refined they tend to become more
specific, so that nursing interventions can be derived from the
label itself.
 Therefore an etiology may not be needed.
 The wellness diagnoses statement begins with words
Readiness for Enhanced (Parenting, Spiritual well being,
Effective breast feeding, Health seeking behaviors,
Anticipatory Grieving Low fat Diet.)
 GUIDELINES FOR WRITING A NURSING
DIAGNOSTIC STATEMENT
Sl Correct statement Incorrect
No.
1 State in terms of Deficient fluid volume Fluid replacement
problem, not a related to fever (need) related to fever.
need.
2 Word the statement Impaired skin integrity Impaired skin integrity
so that it is legally related to immobility related to improper
advisable (legally acceptable) positioning (implies
legal liability)

3 Use nonjudgmental Spiritual distress related Spiritual distress related

statements to inability to attend to strict rules
church services necessitating church
secondary to immobility attendance
(Nonjudgmental)
 GUIDELINES FOR WRITING A NURSING
DIAGNOSTIC STATEMENT
Sl Correct statement Incorrect
No.
4 Make sure that both elements Impaired skin Impaired skin
of the statement don’t say the integrity (ulcer in integrity related
samething. sacral area) to ulceration of
related to sacral area.
immobility.

5 Be sure that cause and effect Pain severe head Pain related to
are correctly stated (that is the ache related to severe head ache.
etiology causes the problem) fear of addiction
to narcotics
 GUIDELINES FOR WRITING A NURSING
DIAGNOSTIC STATEMENT
Sl Correct statement Incorrect
No.
6 Word the diagnosis Impaired oral mucus Impaired oral
specifically and precisely membrane related to mucus membrane
to provide direction for decreased salivation related to noxious
planning nursing secondary to radiation agent (vague)
intervention of neck. (specific)

7 Use nursing terminology Risk for ineffective Risk for

rather than medical airway clearance pneumonia
terminology to describe related to (Medical
the client response & its accumulation of Terminology)
cause. secretions in lungs
(nursing terminology)
 CONCLUSION
 Definition
 Types of Nursing Diagnoses –Actual, Risk, Wellness, Possible and Syndrome
 Components of NANDA nursing diagnosis- Problem, Etiology, Defining
characteristics
 Difference between medical and nursing diagnoses
 Diagnostic process-
 Analyzing data - Compare data against standards (identify significant cues), Cluster
cues (generate tentative hypotheses) , Identify gaps & inconsistencies.
 Identifying health problems risk and its strengths

 Formulating diagnostic statements - Basic two part, Basic three part, One part,
Variations of Basic formats, Collaborative problems.
 Guidelines for writing a nursing diagnostic statement