Nursing Diagnosis Lab Work

WRITING NURSING DIAGNOSIS
Nursing Diagnosis Medical Diagnosis

 Made by the nurse  Made by a physician
 Oriented to individual  Oriented to pathology
 Care focused  Etiology focused
 Describes clients response  Refers to the disease process
 Responses vary between individuals  Somewhat uniform between clients
 Changes as client responses change  Remains same during disease process
 Nurse orders interventions  Physician orders interventions
 Refers to a condition that a  Refers to a condition that only a physician
registered nurse can treat can treat
Domain 1: Health Promotion
Class 1: Health Awareness
Class 2: Health Management
Diagnosis: Risk for frail elderly syndrome
Domain 2: Nutrition
Class 1: Ingestion
Class 2: Digestion
Class 3: Absorption
Class 4: Metabolism
Class 5: Hydration
Diagnosis: Risk for unstable blood glucose level
• Domain 3: Elimination and exchange
• Class 1: Urinary function
• Class 2: Gastrointestinal function
• Class 3: Integumentary function
• Class 4: Respiratory function
• Diagnosis: Urinary retention
• Domain 4: Activity/rest
• Class 1: Sleep/Rest
• Class 2: Activity/Exercise
• Class 3: Energy balance
• Class 4: Cardiovascular/pulmonary responses
• Class 5: Self-care
• Diagnosis: Bathing self-care deficit
Domain 5: Perception/cognition
Class 1: Attention
Class 2: Orientation
Class 3: Sensation/perception
Class 4: Cognition
Class 5: Communication
Diagnosis: Impaired memory
Domain 6: Self-perception
Class 1: Self-concept
Class 2: Self-esteem
Class 3: Body image
Diagnosis: Chronic low self-esteem

Domain 7: Role relationship
Class 1: Caregiving roles
Class 2: Family relationships
Class 3: Role performance
Diagnosis: Impaired social interaction
Domain 8: Sexuality
Class 1: Sexual identity
Class 2: Sexual function
Class 3: Reproduction
Diagnosis: Risk for disturbed maternal-fetal dyad
Domain 9: Coping/stress tolerance

Class 1: Post-trauma responses
Class 2: Coping responses
Class 3: Neurobehavioral stress
Diagnosis: Risk for post-trauma syndrome

Domain 10: Life principles
Class 1: Values
Class 2: Beliefs
Class 3: Value/belief/action congruence
Diagnosis: Moral distress
Domain 11: Safety/protection

Class 1: Infection
Class 2: Physical injury
Class 3: Violence
Class 4: Environmental hazards
Class 5: Defensive processes
Class 6: Thermoregulation
Diagnosis: Risk of surgical site infection

Domain 12: Comfort
Class 1: Physical comfort
Class 2: Environmental comfort
Class 3: Social comfort
Diagnosis: Impaired comfort
Domain 13: Growth/development

Class 1: Growth
Class 2: Development
Diagnosis: Delayed infant motor development

How to Write a Nursing Diagnosis
• Standardized methods of writing nursing diagnoses allow for clear

communication of their purpose and driving factors.
• Writing a complete nursing diagnosis helps the nurse clarify their
reasoning for potential interventions and care goals.
Writing a Problem-Focused Nursing
Diagnosis
• Problem-focused nursing diagnoses are three-part statements that include the problem, etiology, and
symptoms
• Problem (Diagnostic Label) + Etiology (Cause or Related Factors) + Signs/Symptoms (Defining
Characteristics)
• [Diagnostic Label] + “related to” + [Etiology] + “as evidenced by” + [Defining Characteristics]
• Examples of Problem-Focused Diagnosis:
• Deficient Fluid Volume related to prolonged vomiting as evidenced by increased pulse rate and poor
skin turgor.
• Acute Confusion related to alcohol abuse as evidenced by hallucinations and increased agitation.
Writing a Health Promotion-Based Diagnosis
• A health promotion diagnosis is also described using a two-part statement.
• Health Promotion (Diagnostic Label) + Signs & Symptoms (Defining Characteristics)
• [Diagnostic Label] + “as evidenced by” + [Defining Characteristics]
• Health Promotion-Based Diagnosis Examples:
• Readiness for Enhanced Breastfeeding as evidenced by the patient stating their desire to
exclusively breastfeed and requesting information on how to achieve this.
• Readiness for Enhanced Coping as evidenced by the patient expressing a desire to enhance social
support and spiritual resources.
Writing a Syndrome Diagnosis
• The syndrome diagnosis is a group of related nursing diagnoses and should be written
as a two-part statement.
• Syndrome (Diagnostic Label) + 2 or more supporting Nursing Diagnoses
• [Diagnostic Label] + “as evidenced by” + [Nursing Diagnosis] + [Nursing Diagnosis]
• Syndrome Diagnosis Examples:
• Post-Trauma Syndrome as evidenced by Disturbed Sleep Pattern and Hopelessness.
• Frail elderly syndrome as evidenced by Social Isolation and Chronic Confusion
Writing a Risk-Focused Diagnosis
• The risk-focused diagnosis is a two-part statement that includes statements of the
problem and risk factors.
• Risk (Diagnostic Label) + Risk Factors
• [Diagnostic Label] + “as evidenced by” + [Risk Factors]
• Examples of Risk Diagnosis:
• Risk for Infection as evidenced by a history of cancer and recent surgery.
• Risk for Falls as evidenced by a history of falls, use of an assistive device, and
visual difficulties.
COMMONLY USED NURSING DIAGNOSIS
• Activity Intolerance Impaired Gas Exchange Risk for Electrolyte
Impaired Physical Mobility Imbalance
• Acute Confusion
Impaired Skin Integrity Risk for Falls
• Acute Pain
Risk for Infection
Impaired Urinary Elimination
• Anxiety Risk for Injury
Impaired Verbal Communication
• Chronic Pain Ineffective Airway Clearance Risk For Unstable Blood
• Constipation Ineffective Breathing Pattern Glucose
• Decreased Cardiac Output Ineffective Coping Self-Care Deficit
Ineffective Health Maintenance Social Isolation
• Diarrhea
Ineffective Tissue Perfusion Stress Overload
• Disturbed Body Image
Insomnia Urinary Retention
• Excess Fluid Volume
Knowledge Deficit
• Fatigue Noncompliance (Ineffective
• Fluid Volume Deficit (Dehydration)Adherence)
• Hopelessness Risk For Aspiration
• Hyperthermia Risk for Bleeding
• Imbalanced Nutrition Hypothermia
Hyperthermia
• Impaired Comfort
Ineffective thermoregulation

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WRITING NURSING DIAGNOSIS

Nursing Diagnosis Medical Diagnosis

Diagnosis: Impaired memory

Diagnosis: Chronic low self-esteem

Diagnosis: Impaired social interaction

Diagnosis: Risk for disturbed maternal-fetal dyad

Domain 9: Coping/stress tolerance

Diagnosis: Risk for post-trauma syndrome

Diagnosis: Moral distress

Domain 11: Safety/protection

Diagnosis: Risk of surgical site infection

Diagnosis: Impaired comfort

Domain 13: Growth/development

Diagnosis: Delayed infant motor development

• Standardized methods of writing nursing diagnoses allow for clear

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