NANDA International standardizes nursing terminology, specifically nursing diagnoses. Nurses use collected patient data to formulate nursing diagnoses or determine health problems better managed by physicians (medical diagnoses) or collectively with other health care professionals (collaborative problems).
Nursing diagnoses are made up of three components: problem statement, the etiology/related factors, and defining characteristics/risk factors. The problem statement pertains to the patient’s current health problem and needed nursing interventions.
Nursing diagnoses are made up of three components: problem statement, the etiology/related factors, risk factors, and defining characteristics. The etiology, or related factors, identifies probable causes of the health problem, and/or the conditions involved in the development of the problem.
Defining characteristics are the groups of signs and symptoms that indicate the presence of a particular diagnostic label. An example of a written nursing diagnosis using all three components is as follows: “Ineffective airway clearance (problem statement) related to bronchial airway inflammation (etiology/related factor) as evidenced by coarse rhonchi to bilateral apices heard on auscultation (defining characteristics).” Risk factors can be used in place of defining characteristics and encompass the patient’s vulnerability toward their health problem. An example would be something such as, “Risk for infection as evidenced impaired skin integrity.”
A problem-focused diagnosis is the patient's problem that is present at the time of the nursing assessment. This nursing diagnosis is based on the signs and symptoms present in this assessment. Examples are decreased cardiac output and impaired gas exchange. Problem-focused nursing diagnoses include three components: (1) nursing diagnosis, (2) related factors, and (3) defining characteristics.
This nursing diagnosis identifies interventions needed to decrease the risk related to a patient’s problem. There are no etiological factors (related factors) for risk diagnoses. The components of a risk nursing diagnosis include (1) risk diagnostic label and (2) risk factors. An example of a risk diagnosis would be “Risk for infection as evidenced by a suppressed inflammatory response.”
The purpose of this kind of nursing diagnosis is to improve individual patient, family, or community health and well-being. Examples include readiness for enhanced family coping. Components of a health promotion diagnosis generally include only the diagnostic label or a one-part statement. An example would be something such as Readiness for Enhanced Family Coping.
These diagnoses are used when the patient is experiencing multiple health problems forming a pattern that are responsive to similar nursing interventions. Syndrome Diagnoses are written as a one-part statement requiring only the diagnostic label. Examples include decreased cardiac output or decreased tissue perfusion.
To write a problem-focused diagnostic statement, use the problem-etiology-symptom (PES) method. Start with the diagnosis itself, followed by the etiologic factors (related factors in an actual diagnosis), then identify the major signs/symptoms (defining characteristics) that are appearing in the patient. This is for an actual diagnosis, not a risk diagnosis. An example would be: (Impaired physical mobility) related to (decreased muscle control) as evidenced by (the inability to control lower extremities).
For risk diagnoses, there are no related factors (etiological factors) as you are identifying a vulnerability in a patient for a potential problem; the problem is not yet present. Therefore, you identify the risk factors that predispose the individual to a potential problem. An example would be “Risk for (infection) as evidenced by (suppressed inflammatory response).”
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