Analysis- Nursing Diagnosis
Definition of Nursing Diagnsis
A nursing diagnosis is a statement of
the high risk or actual problems in the
client’s health status that the nurse is
licensed and competent to treat
Components of Analysis
Phase
3 major components of analysis phase:
Analysis and interpretation of data
Validation of data
Clustering of data
Identification of problems/health care
needs
Formulation of nursing diagnosis statement
Nursing Diagnostic Statement
Derived from actual or potential
problems
Derived from physiological,
sociocultural, developmental, and
spiritual dimensions of client
Focus: Helping client to achieve a
maximal level of wellness and highest
level of independence
Nursing Diagnosis vs Medical
Diagnosis
Medical diagnosis deals with disease or
medical condition or pathology (treating
or curing)
Nursing diagnosis deals with human
response to bio-psycho-social stressors
and/or health problems that a nurse is
licensed and competent to treat
Advantages of Nursing
Diagnosis
For client- individualization of care,
appropriate selection of interventions,
establishment of goals
For nursing- facilitates communication,
documentation, and continuity of care
among health care providers
Sources of error
Errors in data collection
Errors in data analysis
Clustering errors
Incorrect diagnostic statement
Common error, however, if correct steps
are followed this will not occur
Nursing Diagnostic Statement
Diagram
#___ ___________ r/t __________ e/b _____________
Priority Patient’s this is the cause these are signs/ symptoms
needs/problem (etiology) that come from the assess-
ment (what you see that
supports the problem)
r/t= related to
e/b or m/b= evidenced by or manifested by
Patient’s needs/problem= NANDA approved statement found in book
Example Statements
#1 Pain r/t tissue damage e/b patient complains of
pain at level of 7 out of 10
#2 Constipation r/t poor fiber intake e/b no bowel
movement for 3 days and abdominal distention
#3 Risk for injury r/t generalized weakness
Parts of Nursing Diagnostic
Statement
Problem
Actual- firm diagnosis supported by
nurse’s findings (validated)
High risk- has risk factors but does not
have signs and symptoms, more
vulnerable to develop problems
Possible- tenative- additional data needed
to confirm or rule out problem
Parts of Nursing Diagnostic
Statement
Qualifiers/ Modifiers
Impaired
Altered
Decreased
Possible
Ineffective
High risk
Parts of Nursing Diagnostic
Statement
Related to (r/t)
Educated guess as to what factors are
contributing to or causing the problem
Placed between problem and etiology to indicate
relationship between them
Can not be a medical diagnosis
Must be modifiable by nursing interventions
Must be able to do something about it
Will be in one of five categories:
Environmental, situational, psychological, pathophysical,
and maturational
Parts of Nursing Diagnostic
Statement
Evidenced by (e/b) or Manifested by (m/b):
Signs and symptoms (assessment data) that led to
your nursing diagnosis.
Examples:
SOB while walking
Client stating food intake is poor
Client states they are in pain
Client hasn’t had bowel movement in 3 days
Client has open wound on buttocks
Case Study
Mrs. Angela Garcia is a 46-year-ol Hispanic woman who works as an x-
ray technician at a busy local hospital. She is being seen in the orthopedic clinic
for complaints of steadily worsening pain in her right knee. The pain began 4
months ago when she fell and hyperextended the knee. Mrs. Garcia reports
that the pain is more intense with weight-bearing activities, including running,
standing, and playing tennis. Because of this, she has been limiting her physical
activities. She also reports the recent onset of painful muscle spasms in the
right leg, both with activity and at rest. The pain and muscle spasms are
disrupting her sleep and making it difficult for her to work. At home she has
terated the discomfort with acetaminophen and stretching exercises but has
experienced no relief.
On physical examination you notice a marked limp with walking,
decreased extension in the right knee, and a reluctance to allow her knee to be
touched or manipulated. The knee is slightly swollen and warm to the touch.
During the x-ray examination of the knee, she grimaces in pain when placed in a
kneeling position.
Mrs. Garcia’s medical diagnosis is patellar tenonitis, and she is started on
a regimen of non-steroidal anti-inflammatory drug (NSAID). As her nurse, you
want to use the most accurate nursing diagnosis as a basis for her nursing care.
To begin the process of identifying a nursing diagnosis, you first cluster the
significant assessment data.