Nursing process: Nursing diagnosis

Focus topic: Nursing process

In 1990, NANDA International (NANDA-I) defined the nursing diagnosis as “a clinical

judgment about individual, family, or community responses to actual or potential health
problems or life processes. Nursing diagnoses provide the basis for the selection of nursing
interventions to achieve outcomes for which the nurse is accountable.”

Identify, diagnose, and validate

In forming a nursing diagnosis, you’ll identify the patient’s problem, write a diagnostic
statement, and validate the diagnosis. You’ll establish several nursing diagnoses for each patient.
Arrange the diagnoses according to priority so that you address the patient’s most crucial
problems first.

Identifying the problem

The first step in developing a nursing diagnosis is to identify the problem. To do this, you must
assess the patient and obtain clinical information. Then organize the data obtained during the
assessment and determine how the patient’s basic needs can be met. The problem identified can
be either actual or potential. The diagnosis must be one that can be resolved by a nurse working
within her scope of practice.

Writing the diagnostic statement

The diagnostic statement consists of a nursing diagnosis and the etiology (cause) related to it. For
example, a diagnostic statement for a patient who’s too weak to bathe himself properly might be
Bathing or hygiene self-care deficit related to weakness. A diagnostic statement related to an
actual problem might be Impaired gas exchange related to pulmonary edema. A statement
related to a potential problem might be Risk for injury related to unsteady gait.

Stress present, balance absent

The etiology is a stress or or something that brings about a response, effect, or change. A stress
or results from the presence of a stress agent or the absence of an equilibrium factor. Causative
agents may include birth defects, inherited factors, diseases, injuries,signs or symptoms, psycho
social factors, iatrogenic factors, developmental phases, lifestyle, or situational or environmental
factors.

Validating each diagnosis

Next, validate the diagnosis. Review clustered data. Are they consistent? Does the patient verify
the diagnosis? If not, you may need to re look at the data and modify the diagnosis.

Prioritizing the diagnoses

After you’ve established several nursing diagnoses, categorize them in order of priority.
Obviously, life-threatening problems must be addressed first, followed by health-threatening
concerns. Also, consider how the patient perceives his health problem; his priority problem may
differ from yours.

Maslow’s hierarchy
One system of categorizing diagnoses uses Maslow’s hierarchy of needs, which classifies human
needs based on the idea that lower level, physiologic needs must be met before higher-level,
abstract needs. For example, if a patient has shortness of breath, he probably isn’t interested in
discussing his relationships.