Diagnosing Chapter 11

Second phase of nursing process. Use critical thinking skill to interpret assessment data and identify client strength and problems. Activities preceding this phase are directed toward formulating the nursing diagnoses; the care planning activities following this phase are based on the nursing diagnoses.

• Analyze data, identify health problems, risks, and strengths, and formulate diagnostic statements.

Definitions

• Diagnosis: statement for conclusion regarding nature of a phenomenon.

• Nursing diagnosis: Made after systemic data collection. Diagnostic phrase or label (client’s problem) followed by etiology. RNs responsible and use standardized classification systems when naming diagnoses. The domain of nursing diagnosis includes only those health states that nurses are educated and licensed to treat.

  • Nursing diagnosis highlights critical thinking and decision-making and provides consistent and universally understood terminology among nurses working in various settings, including hospitals, ambulatory care clinics, extended care facilities, occupational health facilities, and private practice

  • Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth.

  • Based on actual (known as a problem-based diagnosis, something that is present at time of nursing assessment) or potential (risks) health problems.

  • Health Promotion Diagnosis: Client’s preparedness to implement behaviors to improve condition. “Willingness to learn or change”

  • Syndrome Diagnosis: clinical nursing judgement when a client has several similar nursing diagnose