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Chapter 13
Diagnosing
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Purposes of the Diagnosing Step
• Identify how an individual, group, or community
responds to actual or potential health and life processes
• Identify factors that contribute to, or cause, health
problems (etiologies)
• Identify resources or strengths upon which the individual,
group, or community can draw to prevent or resolve
problems
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Diagnosing
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Nursing Concerns and Responsibilities
(Alfaro, 2004)
• Monitoring for changes in health status
• Promoting safety and preventing harm
• Identifying and meeting learning needs
• Promoting comfort and managing pain
• Promoting health and well-being
• Addressing problems that limit independence
• Determining human responses
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Types of Diagnoses
• Nursing diagnosis
– Describes patient problems nurses can treat
independently
• Medical diagnosis
– Describes problems for which the physician directs
the primary treatment
• Collaborative problems
– Managed by using physician-prescribed and nursingprescribed interventions
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Collaborative Problems
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Four Steps of Data Interpretation
and Analysis
• Recognizing significant data
– Comparing data to standards
• Recognizing patterns or clusters
• Identifying strengths and problems
• Reaching conclusions
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Reaching Conclusions
• No problem
• Possible problem
• Actual or potential nursing diagnosis
• Clinical problem other than nursing diagnosis
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Formulation of Nursing Diagnoses
• Problem—identifies what is unhealthy about patient
• Etiology—identifies factors maintaining the unhealthy
state
• Defining characteristics—identifies the subjective and
objective data that signal the existence of a problem
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Types of Nursing Diagnoses
• Actual
• Risk
• Possible
• Wellness
• Syndrome
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Four Components of a Diagnosis
• Label
• Definition
• Defining characteristics
• Related factor
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Benefits of Nursing Diagnoses
• Individualizing patient care
• Defining domain of nursing to healthcare administrators,
legislators, and providers
• Seeking funding for nursing and reimbursement for
nursing services
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Limitations of Nursing Diagnosis
• If used incorrectly, patient might be “misdiagnosed”
• Nursing practice might be restricted
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Sources of Error When Writing
Nursing Diagnoses
• Making legally inadvisable statements
• Reversing the clauses
• Identifying environmental factors rather than patient
factors as the problem
• Identifying as a patient response what is not necessarily
unhealthful
• Having both clauses say the same thing
• Identifying as a patient problem what cannot be changed
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Common Sources of Error in
Nursing Diagnoses
• Premature diagnoses based on incomplete database
• Erroneous diagnoses resulting from inaccurate or faulty
database
• Routine diagnoses resulting from failure to tailor data to
patient
• Errors of omission
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Question
A patient who admits to smoking two packs of cigarettes
a day is diagnosed with lung cancer based on his
symptoms and a series of test results. Which of the
following is the etiology in this scenario?
A. Lung cancer
B. Test results
C. Smoking cigarettes
D. The subjective and objective data
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
Answer: C. Smoking cigarettes
Rationale:
The etiology is the factor that maintains the unhealthy
condition (smoking cigarettes). Lung cancer is the
problem, and the remaining factors are the distinguishing
characteristics.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
A nurse decides that a patient has a possible problem
with high blood pressure. During which step of data
interpretation would this most like be determined?
A. Recognizing significant data
B. Recognizing patterns or clusters
C. Identifying strengths and problems
D. Reaching conclusions
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
Answer: D. Reaching conclusions
Rationale:
A possible problem, such as high blood pressure, is diagnosed
as a conclusion of data interpretation.
Recognizing significant data refers to the comparison of data to
a standard or norm (e.g., normal blood pressure values).
A data cluster is a grouping of patient data or cues that points
to the existence of a problem (e.g., a series of readings).
The nurse must then identify strengths and problems and
determine if the patient is motivated to address them.
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Question
Tell whether the following statement is true or false.
The nursing diagnosis: “Risk for Imbalanced Nutrition:
Less Than Body Requirements” is an example of a risk
diagnosis.
A. True
B. False
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Answer
Answer: B. False
The nursing diagnosis: “Risk for Imbalanced Nutrition:
Less Than Body Requirements” is an example of a
potential diagnosis.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Tell whether the following statement is true or false.
A nursing diagnosis may be used to seek reimbursement
for nursing services.
A. True
B. False
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Answer
Answer: A. True
A nursing diagnosis may be used to seek reimbursement
for nursing services.
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Question
Which of the following nursing diagnoses is written
correctly?
A. Child Abuse related to maternal hostility
B. Breast Cancer related to family history
C. Deficient Knowledge related to alteration in diet
D. Imbalanced Nutrition related to insufficient funds in
meal budget
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Answer
Answer: D. Imbalanced Nutrition related to insufficient
funds in meal budget
Rationale:
Answer A makes legally inadvisable statements, answer
B is a medical diagnosis, and answer C reverses the
clauses in the statement.
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