Lesson 1, Topic 1
In Progress

Diagnosis

May 1, 2021

Diagnosis

To diagnose is to identify the type and cause of a health condition. The ANA defines diagnosis as “a clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis provides the basis for determination of a plan of care to achieve expected outcomes” (ANA, 2010). The LPN/LVN and the registered nurse (RN) observe and collect data. Once the initial assessment has been completed, the data require analysis. In most situations, the RN is responsible for analyzing and interpreting data to identify health problems (Table 5-2). The RN often collaborates with the LPN/LVN when determining the nursing diagnosis.

Nursing Diagnosis

A nursing diagnosis is a type of health problem that can be identified. In 1990, the North American Nursing Diagnosis Association (NANDA) was created; in 2002, NANDA became NANDA International (NANDA-I) to reflect nursing diagnosis terminology that is used across the world. NANDA-I approves the official definition for a nursing diagnosis. A nursing diagnosis is a “clinical judgment about actual or potential individual, family, or community responses to health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability” (NANDA-I, 2012). Nurses are legally permitted to identify and prescribe the primary interventions to treat or prevent problems that are nursing diagnoses. The nurse must be aware of this important point. By definition, if the nurse is not able to prescribe the primary treatment, the problem is not a nursing diagnosis.

Components of a Nursing Diagnosis

Nursing research is ongoing in its identification of nursing diagnoses. When nurses submit nursing diagnoses, the following four components are addressed: (1) nursing diagnosis title or label; (2) definition of the title or label; (3) contributing, etiologic, or related factors; and (4) defining characteristics. The diagnosis should also be research based. The selection of an accurate nursing diagnosis depends on closely matching the elements in the patient situation with all four components of the nursing diagnosis. These four components are found in numerous nursing diagnosis handbooks, and each component is explained in the following discussion.

Title or label.

The problem that is identified based on a pattern of related cues and this analysis is given a title or label. Frequently, the name given to the problem is simply called the nursing diagnosis. In this chapter, the terms nursing diagnosis and nursing diagnostic label are used to describe this component. The nursing diagnosis provides a concise name for the identified health problem. Lists of nursing diagnoses are often presented in alphabetical order. Constipation, fatigue, hopelessness, powerlessness, and pain are examples of nursing diagnostic labels.

Adjectives add meaning to the nursing diagnosis label by describing or modifying the label. Examples of adjectives are imbalanced, ineffective, perceived, impaired, and excess. The nursing diagnoses listed in the nursing care plans and nursing process sections of this book follow the format used by NANDA-I in the original list (i.e., placing the noun first for easier location and identification in a list). When writing the nursing diagnosis, however, the adjective is placed before the noun modified. This provides a more natural word order and is less awkward. For example, impaired physical mobility is easier to say and understand than mobility, impaired physical.

Both international nursing groups and American nurses have challenged NANDA-I to simplify the language of nursing diagnoses. Although this is ongoing work, many labels have already undergone modification. Altered comfort: pain has been shortened to acute pain or chronic pain. Similarly, alteration in bowel elimination: constipation has been changed to constipation.

NANDA-I currently uses an organization structure for the diagnostic labels that is called Taxonomy II. New modifiers have been suggested as part of the organizational system. (See Table 5-3 for terms and their definitions.) The work of NANDA-I was never intended to be stagnant, so the nurse must monitor language changes and label additions every 2 years following the NANDA-I meetings. The nurse may also visit the NANDA-I website at www.nanda.org to keep current with the changes. A new feature at NANDA-I is the periodic opportunity to vote on new diagnoses.

Definition.

The definition presents a clear, precise description of the problem. This description helps identify the difference between similar nursing diagnoses. For example, if the nurse is deciding whether to select constipation or perceived constipation, the definitions are helpful. Constipation is defined as “Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool” (Johnson et al., 2012, p. 75). Perceived constipation is defined as “Self-diagnosis of constipation and abuse of laxatives, enemas, and/or suppositories to ensure a daily bowel movement” (Johnson et al., 2012, p. 76). For the most appropriate diagnosis, the nurse should refer to the definitions for nursing diagnoses in nursing diagnosis handbooks.

Contributing, etiologic, and related factors and risk factors.

Contributing, etiologic, and related factors are conditions that are often involved in the development of a problem. These topics are covered in nursing diagnosis handbooks. The factors may become the focus for nursing interventions. Most authors also refer to a contributing factor as a “related to.” Contributing, etiologic, and related factors are written as the “related to” in actual nursing diagnoses statements. A contributing, etiologic, or related factor for the nursing diagnosis of anxiety is a change in some area of the person’s life, such as health, economics, or role function (Ackley, 2011).

Risk factors are circumstances that increase the susceptibility of a patient to a problem. Prolonged immobility increases the risk for skin impairment and is a risk factor for the nursing diagnosis of impaired skin integrity. Risk factors are written as the “related to” in risk nursing diagnostic statements.

Defining characteristics.

Defining characteristics are the clinical cues, signs, and symptoms that furnish evidence that the problem exists. The cues, signs, and symptoms that were identified in the patient’s assessment are prefaced with “as evidenced by” in the nursing diagnosis statement. Examples are presented in the following discussion of the writing of nursing diagnostic statements. Look for defining characteristics for each nursing diagnosis title or label in nursing diagnosis handbooks.

Writing Nursing Diagnosis Statements

The four main types of nursing diagnoses are: actual, risk, syndrome, and health promotion. The following discussion provides descriptions of each type and furnishes guidelines for writing each type of nursing diagnosis statement.

Actual nursing diagnosis.

NANDA-I’s description of an actual nursing diagnosis is “a clinical judgment about human experience/responses to health conditions/life processes that exist in an indi­vidual, family, or community” (NANDA-I, 2012). Cues obtained from a nursing assessment indicate that a problem exists. In an educational setting, the actual nursing diagnosis statement is usually represented by a three-part statement. In a clinical setting, only the first two parts of the statement are typically used. The three parts are written in the following order: (1) the nursing diagnosis label from the NANDA-I list; (2) the contributing, etiologic, or related factor; and (3) the specific cues, signs, and symptoms from the patient’s assessment. Connecting phrases are used to join the three parts of the statement. “Related to” (r/t) links the first and second parts of the statement. “As evidenced by” (AEB) joins the second and third parts of the diagnostic statement. Note the italicized connecting words of an actual nursing diagnostic statement in the following example.

•Constipation, related to insufficient fluid intake as evidenced by increased abdominal pressure, no bowel movement for 5 days, and straining with defecation.

Risk nursing diagnosis.

NANDA-I defines a risk nursing diagnosis as a clinical judgment that “describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability” (NANDA-I, 2012). The assessment indicates that risk factors are present that are known to contribute to the development of the problem. Risk nursing diagnoses are written as two-part statements: (1) the nursing diagnosis label from the NANDA-I list; and (2) the risk factor(s). As in an actual nursing diagnosis, the two parts are connected by the words “related to.” An example of a risk nursing diagnosis statement is as follows:

•Risk for impaired skin integrity, related to physical immobilization

Note that no third part (as evidenced by) is seen in this statement. If signs or symptoms were found, an actual problem would exist.

Syndrome nursing diagnosis.

A syndrome nursing diagnosis is “a clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions” (NANDA-I, 2012). Posttrauma syndrome, risk for disuse syndrome, impaired environmental interpretation syndrome, and relocation stress syndrome are the current syndrome diagnoses. Because these diagnoses are so specific, the syndrome diagnoses are usually written as one-part statements.

Health promotion nursing diagnosis.

NANDA-I describes a wellness nursing diagnosis as “a clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state” (NANDA-I, 2012). A wellness nursing diagnosis is written as a one-part statement. The words “readiness for enhanced” are used in a wellness nursing diagnosis. An example of a wellness nursing diagnosis is readiness for enhanced self-health management (Ackley, 2011).

Other Types of Health Problems

Collaborative problems and medical diagnoses must be distinguished from nursing diagnoses. These two types of problems are defined and discussed separately.

Collaborative Problems

Collaborative problems are health-related problems that the nurse anticipates based on the condition or diagnosis of a patient. Both health care provider–prescribed and nursing-prescribed interventions (discussed subsequently in this chapter) are used in the management of collaborative problems (Carpenito, 2013). An example of a collaborative problem is the care of a patient with hypertension who is taking a new medication for the condition. The potential for hypotension is considered a collaborative problem because prevention uses both physician-prescribed interventions (i.e., adjustment of the hypertensive medications as needed) and nursing-prescribed interventions (i.e., monitoring of the patient’s blood pressure, assistance when the patient goes from a sitting to standing position). If the prevention or treatment of the problem is primarily the nurse’s responsibility, the problem is identified as a nursing diagnosis. Risk for infection for the new postoperative surgical case is a potential complication that is a nursing responsibility.

Medical Diagnosis

A medical diagnosis is the identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, laboratory tests, diagnostic procedures, review of medical records, and patient history. The health care provider is licensed to make and treat medical diagnoses. Examples of medical diagnoses are congestive heart failure, pneumonia, diabetes mellitus, and hepatitis B.

Differentiation of Medical and Nursing Diagnoses

Students often have difficulty with the distinction between a medical and a nursing diagnosis. Health care providers, including physicians and advanced practice nurses, diagnose diseases or disorders such as those listed previously. These diseases or disorders are the result of changes in the structure or the function of an organ or body system. Diagnostic studies such as x-ray examinations and laboratory studies help with identification of medical diagnoses. Although the patient is often able to recover from a medically diagnosed condition, the diagnosis itself does not change. The patient who recovers from a heart attack (myocardial infarction) has a history of a myocardial infarction. The patient who was diagnosed with diabetes is likely to still have diabetes.
In the case of nursing diagnoses, the situation is different. Nursing diagnoses address human responses to health problems and life processes. The nurse addresses the patient’s concerns about the medical problem. If a patient is diagnosed with cancer, the nurse has the opportunity to address the patient’s responses to the diagnosis; responses to the disease may include anxiety, fear, anticipatory grieving, activity intolerance, and nausea. These problems often change as the LPN/LVN carries out interventions. The nurse may assist the patient who is concerned about dying with grief resolution or perhaps teach the patient coping strategies. A nursing diagnosis may change or resolve as care is provided or the condition changes. The medical diagnosis of cancer may not go away; however, the goal for the patient may be the ability to resolve feelings of fear regarding the diagnosis, prognosis, and treatment through nursing interventions addressed in the care plan.