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).
 
Nursing Responsibilities Related to Diagnosis
• Recognizing safety and infection-transmission riss and addressing these immediately.
• Identifying human responses!how problems, signs and symptoms, and treatment regimens impact on patients’ lives!and promoting optimum function, independence, and "uality of life.
• #nticipating possible complications and taing steps to prevent them.
 
Predict, Prevent, Manage, and Promote (PPMP
• In the presence of nown problems, predict the most common and most dangerous complications and tae immediate action to (a) prevent them, and (b) manage them in case they cannot be prevented.
• %hether problems are present or not, loo for evidence of ris factors (things that evidence suggests contribute to health problems). If you identify ris factors, aim to reduce or control them, thereby preventing the problems themselves.
 
!"pes of Diagnoses
• &ursing diagnosis' escribes patient problems nurses can treat independently
#ddresses the client*s response to healthcare and illness
• +edical diagnosis' escribes problems for which the physician directs the primary treatment
• ollaborative problems' +anaged by using physician- prescribed and nursing-prescribed interventions
rimarily managed by nurses
Diagnostic Reasoning and Clinical Reasoning
• e familiar with nursing diagnoses and other health problems/ read professional literature and eep reference guides handy.
• 0rust clinical e1perience and 2udgment, but be willing to as for help when the situation demands more than your "ualifications and e1perience can provide.
• Respect your clinical intuition, but before writing a diagnosis without evidence, increase the fre"uency of your observations and continue to search for cues to verify your intuition.
• Recognize personal biases and eep an open mind.
 
#our Steps of Data $nterpretation and %nal"sis
• Recognizing significant data
&ote any changes
• Identifying strengths, problems, and potential issues
• Identifying potential complications
 
!"pes of Nursing Diagnoses
• ossible
• %ellness
• 6yndrome
 
#ormulation of Nursing Diagnoses
• 7tiology
• efining characteristics
 
#our Components of a Diagnosis
• 8abel
• Related factors
&alidating Nursing Diagnoses
• Is my patient database (assessment data) sufficient, accurate, and supported by nursing research9
• oes my synthesis of data (significant cues) demonstrate the e1istence of a pattern9
• #re the sub2ective and ob2ective data I used to determine the e1istence of a pattern characteristic of the health problem I defined9
• Is my tentative nursing diagnosis based on scientific nursing nowledge and clinical e1pertise9
• Is my tentative nursing diagnosis able to be prevented, reduced, or resolved by independent nursing action9
 
Documentation of Diagnoses on 'R 
• =iew the patient*s ongoing riss and problems that others have identified and documented.
• ecide on and document new nursing diagnoses based on the patient assessment findings.
• >acilitate communication of the patient*s actual problems with nurses and others on the health care team.
• 3se nursing diagnosis to mae decisions about what mutual goals the patient desires and what can be done.
• etermine and document when the nursing diagnoses are resolved.
 
)enefits of Nursing Diagnoses
• Individualizing patient care
• #llows the patient to be nowledgeable and involved with their plan of care
• Improves interaction between health care worers
 
*imitations of Nursing Diagnosis
• &ursing practice might be restricted.
 
Common 'rrors in +riting Nursing Diagnoses
• %riting diagnosis in terms of needs and response
• +aing legally inadvisable statements
• Identifying as a problem a patient response that is not necessarily unhealthy
• Identifying as a problem signs and symptoms of illness
• Identifying as a patient problem or etiology what cannot be changed
• Identifying environmental factors rather than patient factors as a problem
• Reversing clauses
• Including the medical diagnosis in the diagnostic statement
 
Sources of 'rror +hen +riting Nursing Diagnoses
• remature diagnoses based on an incomplete database
• 7rroneous diagnoses resulting from an inaccurate database or a faulty data analysis
• Routine diagnoses resulting from the nurse*s failure to tailor data collection and analysis to the uni"ue needs of the patient
• 7rrors of omission