Understanding the Nursing Diagnosis
A nursing diagnosis is a crucial step in the nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, and Evaluation). Unlike a medical diagnosis, which identifies a specific disease, a nursing diagnosis describes a patient's human response to an actual or potential health problem. This patient-centered approach allows nurses to select interventions for which they are accountable and provides a basis for evaluating the effectiveness of nursing care. Effective communication and continuity of care are enhanced when the entire healthcare team understands the nursing diagnosis. For problem-focused diagnoses, the structure is standardized into the three-part PES format: Problem, Etiology, and Signs/Symptoms (or Defining Characteristics).
Component 1: The Problem (P)
The first component is the Problem, or diagnostic label. This is a concise statement describing the patient's health problem or response. The diagnostic label comes from a standardized list, most notably from NANDA-International (NANDA-I), which provides a common language for nurses. Choosing the correct diagnostic label requires careful analysis of the assessment data collected from the patient.
Selecting the Correct Diagnostic Label
- Analyze Assessment Data: Review both subjective data (what the patient says) and objective data (what the nurse observes or measures). Look for patterns that align with a specific NANDA-I diagnosis.
- Consider Patient Needs: The diagnostic label should reflect the most pressing issue affecting the patient's well-being. For instance, a patient with pneumonia might have a problem statement of "Impaired Gas Exchange," which focuses on their physical response to the illness.
- Use Precise Terminology: NANDA-I labels are carefully worded to provide specific meaning. Qualifiers like "impaired," "ineffective," or "deficient" specify the nature of the problem, ensuring clarity in documentation.
Component 2: The Etiology (E)
The Etiology, or related factors, is the second component and identifies the probable cause or contributing factors of the identified health problem. This part of the statement provides the rationale for the nursing interventions that will be selected to help resolve the problem. The etiology is linked to the problem statement with the phrase "related to".
Identifying Related Factors
- Determine the Underlying Cause: Ask yourself, "Why is the patient experiencing this problem?" For example, the etiology for "Impaired Physical Mobility" might be "decreased muscle control" in a patient who has had a stroke.
- Avoid Medical Diagnoses as Etiology: The etiology should focus on the cause from a nursing perspective, not a medical one. While a medical diagnosis can be part of the related factors, the etiology itself should describe a factor that nurses can influence. For example, instead of related to pneumonia, a better etiology would be related to chronic bronchitis if that is the underlying cause of the patient's impaired gas exchange.
- Ensure it's Actionable: The etiology should directly inform the nurse's plan of care. If the nurse can address the cause, the intervention is more likely to be effective. For a diagnosis of "Activity Intolerance related to generalized weakness," interventions would focus on increasing strength and mobility.
Component 3: The Signs and Symptoms (S)
The third component, Signs and Symptoms, also known as Defining Characteristics, provides the objective and subjective evidence that supports the nursing diagnosis. For a problem-focused diagnosis, this is crucial for proving that the problem actually exists. In a risk diagnosis, this component is replaced by the risk factors that make the patient vulnerable to the problem. The phrase "as evidenced by" or "as manifested by" connects the defining characteristics to the diagnosis statement.
Documenting Defining Characteristics
- Objective Data: Include observable and measurable evidence such as vital signs, lab results, weight loss, or skin turgor.
- Subjective Data: Incorporate patient statements or reported feelings, such as a patient stating, "I feel exhausted after just a few steps" for an activity intolerance diagnosis.
- Risk Factors: When writing a risk diagnosis, list the factors that increase the patient's vulnerability. For example, a diagnosis of "Risk for Infection as evidenced by impaired skin integrity".
The PES Format in Practice: Problem-Focused vs. Risk Diagnoses
Problem-focused diagnoses, the most common type, use all three components in the PES format. Risk diagnoses, however, are two-part statements because the problem has not yet occurred and therefore has no signs and symptoms. They link the risk diagnosis label with the risk factors. Health promotion and syndrome diagnoses are often one-part statements.
Comparison of Nursing vs. Medical Diagnoses
| Aspect | Nursing Diagnosis | Medical Diagnosis |
|---|---|---|
| Focus | Patient's response to a health condition or life process. | The specific disease or pathology. |
| Initiator | A nurse based on clinical judgment. | A physician or advanced healthcare practitioner. |
| Scope | Addresses holistic patient needs (physical, emotional, social). | Addresses the biological illness or injury. |
| Duration | Can change and evolve as the patient's condition changes. | Remains a permanent part of the patient's medical history. |
| Example | Ineffective Breathing Pattern related to muscle fatigue as evidenced by shortness of breath. | Chronic Obstructive Pulmonary Disease (COPD). |
| Outcome | Leads to a nursing care plan to manage the patient's response. | Leads to a medical treatment plan to cure or manage the disease. |
Conclusion: The Importance of the Three Components
Mastering the three components of a nursing diagnosis—Problem, Etiology, and Signs/Symptoms—is essential for providing targeted and effective patient care. This structured PES format allows nurses to clearly communicate a patient's needs, define appropriate interventions, and create measurable outcomes for which they are accountable. By focusing on the patient's holistic response rather than just the medical condition, the nursing diagnosis provides a comprehensive foundation for the nursing care plan.
For further reading and official guidance on nursing diagnoses, refer to the NANDA International, Inc. website.
Developing Your Diagnostic Skills
To become proficient in formulating nursing diagnoses, practice is key. Start by thoroughly assessing your patient, then analyze the collected data to identify patterns and select the most appropriate NANDA-I label. Next, determine the contributing factors for the etiology. Finally, link the supporting evidence to the diagnosis statement using the correct format. Regular practice and collaboration with experienced nurses can significantly improve your critical thinking and diagnostic accuracy.
