Nursing diagnosis is a cornerstone of effective patient care. It’s more than just identifying a health problem; it’s about understanding the patient’s response to illness and life processes. This guide will explore the concept of nursing diagnosis, its importance, and how to formulate them correctly, with a special focus on the crucial phrase “as evidenced by” and its role in creating accurate and impactful nursing diagnoses.
Understanding Nursing Diagnosis
A nursing diagnosis is a clinical judgment made by a registered nurse concerning a human response to health conditions, life processes, or vulnerabilities. This response can be experienced by an individual, family, group, or community. It’s the foundation for selecting nursing interventions and achieving specific patient outcomes for which nurses are accountable. Nursing diagnoses are derived from data gathered during a thorough nursing assessment and are essential for developing individualized nursing care plans.
The Significance of Nursing Diagnosis
Nursing diagnoses serve several vital purposes in healthcare:
- Enhancing Critical Thinking: For nursing students, learning to formulate nursing diagnoses is a powerful tool for developing problem-solving and critical thinking skills.
- Prioritizing Care: Nursing diagnoses help nurses identify and prioritize patient needs, guiding the direction of nursing interventions based on these priorities.
- Quality Assurance and Accountability: They contribute to the formulation of expected outcomes, which are essential for quality assurance and meeting the requirements of healthcare payers.
- Understanding Patient Responses: Nursing diagnoses facilitate the understanding of how patients and groups respond to actual or potential health issues, considering their strengths and resources to address these challenges.
- Facilitating Communication: They establish a common language among nursing professionals and the broader healthcare team, promoting clear and effective communication.
- Evaluating Care Effectiveness: Nursing diagnoses provide a basis for evaluating the benefits and cost-effectiveness of nursing care, ensuring positive patient outcomes.
Nursing Diagnosis vs. Medical Diagnosis vs. Collaborative Problems
It’s crucial to differentiate nursing diagnoses from medical diagnoses and collaborative problems.
Nursing diagnoses focus on the patient’s response to a health condition. For instance, a patient diagnosed with pneumonia (a medical diagnosis) might experience “Ineffective Airway Clearance” or “Fatigue” – these are nursing diagnoses addressing the patient’s response to pneumonia. They are within the nurse’s scope of practice to address independently.
Medical diagnoses, on the other hand, are made by physicians or advanced practitioners and identify diseases or pathological states that only medical professionals can treat. Examples include pneumonia, diabetes mellitus, or heart failure. Medical diagnoses focus on the disease process itself. Nurses follow medical orders related to these diagnoses but also address patient responses through nursing diagnoses.
Collaborative problems are potential health issues that nurses manage in collaboration with physicians and other healthcare team members. These situations require both physician-prescribed and nurse-initiated interventions. An example is managing potential complications of surgery. Nurses monitor for and prevent complications, while physicians may prescribe medical treatments.
The key distinction is that nursing diagnoses are patient-centered, focusing on responses to health conditions, while medical diagnoses are disease-centered.
Taxonomy of Nursing Diagnoses: Organizing the Concepts
To standardize and organize nursing diagnoses, the Nursing Diagnosis Taxonomy II was developed. This system, based on Dr. Mary Joy Gordon’s Functional Health Patterns, provides a hierarchical structure for classifying diagnoses.
NURSING DIAGNOSIS TAXONOMY II. Taxonomy II for nursing diagnosis contains 13 domains and 47 classes. Image via: Wikipedia.com
Taxonomy II is organized into 13 Domains, representing broad areas of health, and 47 Classes, which are more specific categories within each domain. Nursing diagnoses are then categorized within these classes. This system uses seven axes for coding diagnoses, including diagnostic concept, time, unit of care, age, health status, descriptor, and topology. Diagnoses are listed alphabetically by concept for easier navigation.
Examples of Domains and Classes:
- Domain 1: Health Promotion
- Class 1: Health Awareness
- Class 2: Health Management
- Domain 4: Activity/Rest
- Class 1: Sleep/Rest
- Class 2: Activity/Exercise
- Class 5: Self-care
- Domain 9: Coping/Stress Tolerance
- Class 1: Post-trauma responses
- Class 2: Coping responses
Understanding this taxonomy helps nurses to categorize and select appropriate nursing diagnoses.
The Nursing Process and Diagnosis
Nursing diagnosis is the second step in the nursing process, a systematic approach to patient care that includes:
- Assessment: Gathering patient data.
- Diagnosis: Analyzing data to identify nursing diagnoses.
- Planning: Developing a care plan with interventions.
- Implementation: Carrying out the care plan.
- Evaluation: Assessing the effectiveness of interventions.
Each step requires critical thinking. For diagnosis, nurses must understand definitions, defining characteristics, related factors, and appropriate interventions for various nursing diagnoses.
Types of Nursing Diagnoses
There are four main types of nursing diagnoses:
TYPES OF NURSING DIAGNOSES. The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.
1. Problem-Focused (Actual) Nursing Diagnosis
A problem-focused nursing diagnosis, also known as an actual diagnosis, describes a current problem the patient is experiencing at the time of assessment. It’s supported by defining characteristics – observable signs and symptoms.
Example:
- Problem: Acute Pain
- Defining Characteristics (as evidenced by): Patient reports pain level of 7/10, guarding behavior, facial grimacing, increased heart rate.
2. Risk Nursing Diagnosis
A risk nursing diagnosis identifies potential problems that a patient is vulnerable to developing. It’s based on risk factors that increase susceptibility. Crucially, a risk diagnosis describes a potential problem, not one that is currently present.
Key Point: “As Evidenced By” in Risk Diagnoses
For risk diagnoses, “as evidenced by” is used to link the diagnostic label to the risk factors, not defining characteristics (as defining characteristics are not yet present).
Example:
- Risk Diagnosis: Risk for Infection
- Risk Factors (as evidenced by): Surgical incision, compromised immune system (due to chemotherapy), prolonged hospitalization.
In this case, “as evidenced by” points to the factors that make the patient at risk for infection.
More Examples of Risk Diagnoses:
- Risk for Falls as evidenced by muscle weakness, history of falls, impaired mobility, and use of assistive devices.
- Risk for Injury as evidenced by reduced cognitive awareness and use of sedative medications.
3. Health Promotion Nursing Diagnosis
A health promotion nursing diagnosis focuses on a patient’s desire and motivation to improve their well-being and health. It identifies a patient’s readiness to enhance specific health behaviors.
Example:
- Health Promotion Diagnosis: Readiness for Enhanced Breastfeeding
- Related Factor (optional): Expresses interest in learning breastfeeding techniques (This is a related factor, not “as evidenced by,” as health promotion diagnoses are about readiness and motivation).
4. Syndrome Nursing Diagnosis
A syndrome nursing diagnosis represents a cluster of actual or risk nursing diagnoses that are likely to occur together in certain circumstances or events.
Example:
- Syndrome Diagnosis: Rape Trauma Syndrome
5. Possible Nursing Diagnosis (Important Note)
A possible nursing diagnosis is not a formal type of diagnosis like the four above. It indicates a suspected problem requiring more data to confirm or rule out. It’s a temporary label to signal a need for further assessment.
Example:
- Possible Deficient Fluid Volume (if the nurse suspects dehydration but needs more data like urine output and lab values).
Components of a Nursing Diagnosis Statement
A complete nursing diagnosis statement typically has three parts:
- Problem (Diagnostic Label) and Definition: A concise term describing the patient’s health problem.
- Etiology (Related Factors): The probable cause(s) or contributing factors to the problem (used in problem-focused diagnoses).
- Defining Characteristics (or Risk Factors): Signs and symptoms that indicate the presence of an actual diagnosis OR risk factors indicating vulnerability to a risk diagnosis. This is where “as evidenced by” becomes crucial.
1. Problem and Definition (Diagnostic Label)
The problem statement, or diagnostic label, is a standardized term that concisely describes the health issue. It often includes a qualifier (modifier) to add specificity.
Examples:
| Qualifier | Focus of Diagnosis |
|---|---|
| Deficient | Fluid Volume |
| Imbalanced | Nutrition: Less Than Body Requirements |
| Impaired | Gas Exchange |
| Ineffective | Tissue Perfusion |
| Risk for | Injury |
2. Etiology (Related Factors)
The etiology, or related factors, identifies the likely causes or contributing factors for a problem-focused diagnosis. It’s linked to the problem statement by “related to.” Interventions should aim to address these etiological factors.
Example:
- Problem: Impaired Physical Mobility
- Related to: Pain and stiffness in joints
3. Defining Characteristics and Risk Factors: The “As Evidenced By” Link
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Defining Characteristics (for Actual Diagnoses): These are the observable signs and symptoms that prove the problem is present. They follow the phrase “as evidenced by” or “as manifested by” in the diagnostic statement.
Example: Acute Pain related to surgical incision as evidenced by patient reporting pain of 8/10, guarding incision site, increased pulse.
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Risk Factors (for Risk Diagnoses): These are factors that increase vulnerability to a potential problem. They also follow the phrase “as evidenced by” in the diagnostic statement, but in this case, they are the reasons for the risk, not signs and symptoms.
Example: Risk for Infection as evidenced by presence of surgical wound, immunosuppression.
Understanding “As Evidenced By”:
“As evidenced by” is the critical link that provides the proof or justification for the nursing diagnosis. It connects the diagnostic label to the patient data that supports the nurse’s clinical judgment. For actual diagnoses, it’s the observable signs and symptoms; for risk diagnoses, it’s the identified risk factors.
The Diagnostic Process: Step-by-Step
Formulating a nursing diagnosis involves a three-phase process:
- Data Analysis: Compare patient data to norms, cluster cues, and identify gaps or inconsistencies.
- Problem, Risk, and Strength Identification: Identify health problems, risks, and patient strengths based on analyzed data. Differentiate between nursing diagnoses, medical diagnoses, and collaborative problems.
- Diagnostic Statement Formulation: Construct the nursing diagnosis statement using appropriate formats and components.
Writing Nursing Diagnosis Statements: Formats and Examples
There are different formats for writing nursing diagnoses, including the PES format.
PES Format: Problem, Etiology, Signs/Symptoms
The PES format is a common method for structuring nursing diagnosis statements, particularly for problem-focused diagnoses:
- P (Problem): Diagnostic Label
- E (Etiology): Related Factors (linked by “related to”)
- S (Signs/Symptoms): Defining Characteristics (linked by “as evidenced by”)
Example using PES:
- P: Deficient Fluid Volume
- E: related to excessive vomiting and diarrhea
- S: as evidenced by dry mucous membranes, decreased urine output, and weak pulse.
Variations in Diagnostic Statements
- One-Part Statements: Used for health promotion and syndrome diagnoses as related factors are often implied or inherent in the diagnosis itself.
- Example: Readiness for Enhanced Coping
- Example: Rape Trauma Syndrome
- Two-Part Statements: Used for risk and possible diagnoses. They include the diagnostic label and the risk factors (“as evidenced by” for risk) or the reason for suspicion (for possible).
- Example: Risk for Infection as evidenced by surgical incision and immunosuppression.
- Example: Possible Deficient Fluid Volume (further data needed).
- Three-Part Statements: Primarily for actual (problem-focused) diagnoses using the PES format, including Problem, Etiology, and Signs/Symptoms (“as evidenced by”).
- Example: Impaired Skin Integrity related to prolonged pressure as evidenced by stage II pressure ulcer on sacrum.
Nursing Diagnoses for Care Plans
Nursing diagnoses are the foundation for developing comprehensive nursing care plans. They guide the selection of nursing interventions and outcome identification. A well-formulated nursing diagnosis ensures that the care plan is individualized and addresses the patient’s specific needs and responses to health conditions.
Recommended Resources
To further enhance your understanding and skills in nursing diagnosis, consider these resources:
- Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
- Nursing Care Plans – Nursing Diagnosis & Intervention
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
- All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
These resources provide detailed information on various nursing diagnoses, their defining characteristics, related factors, and evidence-based interventions.
Conclusion
Mastering nursing diagnosis, particularly the effective use of “as evidenced by,” is crucial for providing patient-centered, high-quality nursing care. By understanding the types of diagnoses, their components, and the diagnostic process, nurses can formulate accurate and impactful diagnoses that drive effective care planning and improve patient outcomes. The phrase “as evidenced by” is not just a grammatical component; it’s the link that validates the nurse’s clinical judgment and ensures that diagnoses are based on concrete patient data, leading to more targeted and effective nursing interventions.
