The Core of Nursing Care: Understanding Diagnosis
A nursing diagnosis is a critical, independent clinical judgment made by a nurse after a thorough assessment of a patient's condition. It is fundamentally different from a medical diagnosis, which identifies a disease or medical condition. Instead, a nursing diagnosis describes a patient's human response to that condition, focusing on their specific needs and concerns. Mastering this skill is paramount for any nursing student or professional looking to develop effective, patient-centered care plans.
The Foundational PES Format: A Detailed Breakdown
Writing an effective nursing diagnosis often relies on the Problem-Etiology-Symptoms (PES) format, a structured framework that ensures clarity and completeness.
The 'P' for Problem
This is the diagnostic label from a standardized nursing terminology list, such as NANDA-I. It is a concise, clear statement of the patient's health issue or response. For example: Ineffective Breathing Pattern or Acute Pain. It is crucial to choose the most specific label that accurately reflects the patient's condition.
The 'E' for Etiology
This component identifies the probable cause or contributing factors related to the patient's health problem. The etiology is linked to the problem statement with the phrase "related to" (r/t). Understanding the etiology is key to developing targeted nursing interventions. Examples include: related to bronchial airway inflammation or related to surgical incision.
The 'S' for Signs and Symptoms
Also known as defining characteristics, these are the objective and subjective data points collected during the patient assessment that provide evidence for the nursing diagnosis. They are linked to the etiology with the phrase "as evidenced by" (aeb). Examples include: as evidenced by coarse rhonchi on auscultation or as evidenced by patient pain score of 8/10.
A Step-by-Step Guide to Formulating Diagnoses
- Assess the Patient: The first step is to perform a comprehensive assessment, gathering both subjective and objective data. This includes patient interviews, physical examinations, and reviewing medical records.
- Analyze and Cluster Data: Look for patterns in the collected data. Grouping related signs and symptoms can help point toward a specific diagnostic label.
- Identify the Diagnostic Label: Based on your clustered data, select the most appropriate NANDA-I approved nursing diagnosis label. Avoid making a medical diagnosis.
- Determine the Etiology: Identify the related factors or probable causes of the patient's problem. This often ties into the patient's medical condition or specific life process.
- Write the Complete Statement: Assemble the three parts into a cohesive PES statement using the correct linking phrases. For example: Acute Pain related to surgical incision as evidenced by patient's report of pain at 8/10 on a pain scale and facial grimacing.
- Validate and Revise: Consult a reliable nursing diagnosis handbook, like those available from authoritative sources, to ensure accuracy. The diagnoses should be reassessed and revised as the patient's condition changes. A reliable resource for validation is NANDA International's website: https://www.nanda.org.
Comparison of Nursing Diagnosis Types
| Type | Description | PES Format | Example |
|---|---|---|---|
| Problem-Focused | Identifies an existing problem based on current assessment data. | Problem (r/t) Etiology (aeb) Signs/Symptoms | Ineffective Gas Exchange r/t bacterial pneumonia aeb O2 saturation 85% on room air. |
| Risk | Identifies potential problems the patient is vulnerable to. | Risk Diagnosis Label (aeb) Risk Factors | Risk for Infection aeb impaired skin integrity and compromised inflammatory response. |
| Health Promotion | Reflects a patient's motivation and readiness to enhance their well-being. | Only the diagnostic label or one-part statement. | Readiness for Enhanced Nutrition. |
| Syndrome | A cluster of multiple diagnoses that often occur together. | Only the diagnostic label. | Post-trauma Syndrome. |
Example Scenarios for Practice
Here are some concrete examples to illustrate how to make nursing diagnosis examples using the PES format.
Example 1: Post-Surgical Patient
- Assessment: A 55-year-old male post-op total hip replacement reports a pain score of 8/10, grimaces when repositioning, and is hesitant to ambulate.
- Diagnosis: Acute Pain related to total hip replacement as evidenced by patient pain score of 8/10 and grimacing upon movement.
Example 2: Congestive Heart Failure Patient
- Assessment: A 70-year-old female with CHF presents with shortness of breath, crackles in her lungs, and a 5-pound weight gain over three days.
- Diagnosis: Excess Fluid Volume related to compromised regulatory mechanisms as evidenced by bilateral crackles in lungs and weight gain of 5 lbs in 3 days.
Example 3: Diabetic Foot Ulcer
- Assessment: A 60-year-old male with diabetes has a non-healing foot ulcer with redness, swelling, and purulent drainage.
- Diagnosis: Risk for Infection as evidenced by impaired skin integrity and delayed wound healing.
Example 4: New Mother
- Assessment: A new mother expresses feelings of being overwhelmed with infant care but is motivated to learn and improve her parenting skills.
- Diagnosis: Readiness for Enhanced Parenting as evidenced by expressing desire to improve skills and engaging in educational materials.
Conclusion
Crafting accurate and specific nursing diagnoses is a cornerstone of effective clinical practice. By following the PES format, utilizing NANDA-I terminology, and continuously refining your assessment skills, you can ensure that patient care is always targeted, individualized, and evidence-based. These examples provide a solid foundation for understanding the process, enabling you to build comprehensive and compassionate care plans for your patients.
