Mastering Problem-Focused Nursing Diagnosis: An In-Depth Guide for Nurses

Nursing diagnosis is a cornerstone of effective patient care. It’s the critical thinking process that allows nurses to identify patient problems, plan interventions, and evaluate outcomes. Among the different types of nursing diagnoses, problem-focused nursing diagnosis, also known as actual diagnosis, plays a pivotal role in addressing immediate health concerns. This comprehensive guide will delve deep into the concept of problem-focused nursing diagnosis, differentiating it from other types, exploring its components, and providing practical steps on how to formulate them accurately.

Understanding Nursing Diagnosis

A nursing diagnosis is a professional nurse’s clinical judgment about a patient’s response to actual or potential health conditions or life processes. It’s not simply identifying a disease; instead, it focuses on the patient’s unique experience of health and illness. This judgment forms the foundation for selecting nursing interventions and achieving patient-centered outcomes for which nurses are accountable. Nursing diagnoses are derived from a thorough nursing assessment, which is the first step in the nursing process, and they are essential for developing individualized nursing care plans.

The Purpose of Nursing Diagnosis in Healthcare

Nursing diagnoses serve several critical purposes in healthcare:

• Enhancing Critical Thinking: For nursing students and practicing nurses, formulating nursing diagnoses is an invaluable exercise in problem-solving and sharpening critical thinking skills. It requires analyzing patient data, identifying patterns, and making informed judgments.
• Prioritizing Nursing Care: Nursing diagnoses help nurses prioritize patient needs. By clearly defining patient problems, nurses can direct their interventions to address the most pressing issues first, ensuring efficient and effective care delivery.
• Guiding Nursing Interventions: Once a nursing diagnosis is established, it serves as a roadmap for planning and implementing appropriate nursing interventions. The diagnosis points directly to the areas where nursing actions are needed to achieve desired patient outcomes.
• Establishing Outcome Measures: Nursing diagnoses are crucial for defining expected outcomes and measuring the quality of nursing care. They provide a framework for evaluating the effectiveness of interventions and meeting the accountability standards required by healthcare organizations and third-party payers.
• Facilitating Interprofessional Communication: Nursing diagnoses provide a standardized and common language for communication among nurses and other healthcare professionals. This shared understanding enhances collaboration and ensures a cohesive approach to patient care.
• Evaluating Care Effectiveness: By providing a clear statement of patient problems and desired outcomes, nursing diagnoses become the basis for evaluating whether nursing care has been beneficial and cost-effective. They allow for objective assessment of patient progress and the impact of nursing interventions.

Nursing Diagnosis vs. Medical Diagnosis vs. Collaborative Problems

It’s crucial to distinguish nursing diagnoses from medical diagnoses and collaborative problems to understand the unique role of nursing in patient care.

Nursing Diagnosis: Focuses on the patient’s response to health conditions or life processes. It identifies problems that nurses can independently address within their scope of practice. For instance, a patient with pneumonia might have a nursing diagnosis of “Ineffective Airway Clearance related to increased mucus production.”

Medical Diagnosis: Identifies a disease, pathology, or medical condition. This is made by a physician or advanced practitioner and deals with what is medically wrong with the patient. Examples include Pneumonia, Diabetes Mellitus, or Congestive Heart Failure. Medical diagnoses describe illnesses that physicians treat with medications, surgery, or other medical treatments.

Collaborative Problems: These are potential or actual health complications that require both medical and nursing interventions. Nurses monitor for the onset of these problems and use physician-prescribed and nursing-initiated interventions to minimize the complications. For example, a patient with surgery is at risk for infection (a collaborative problem) requiring both medical interventions (antibiotics) and nursing interventions (wound care, monitoring).

The key difference lies in the focus: nursing diagnoses are patient-centered and response-oriented, while medical diagnoses are disease-centered. Nursing diagnoses guide independent nursing actions, whereas collaborative problems require interdependent actions with other healthcare team members.

Classifying Nursing Diagnoses: Taxonomy II

To standardize and organize nursing diagnoses, the NANDA-I (North American Nursing Diagnosis Association International) taxonomy is widely used. Taxonomy II organizes diagnoses into a hierarchical structure with three levels:

• Domains (13): Broad areas of human experience (e.g., Health Promotion, Nutrition, Elimination and Exchange, Activity/Rest, Perception/Cognition, Self-Perception, Role Relationship, Sexuality, Coping/Stress Tolerance, Life Principles, Safety/Protection, Comfort, Growth/Development).
• Classes (47): Subcategories within each domain (e.g., within the Domain “Nutrition,” classes include Ingestion, Digestion, Absorption, Metabolism, Hydration).
• Nursing Diagnoses: Specific diagnostic labels within each class, arranged alphabetically by concept.

This taxonomy provides a systematic way to categorize and retrieve nursing diagnoses, facilitating their use in practice, education, and research.

NURSING DIAGNOSIS TAXONOMY II. Taxonomy II for nursing diagnosis contains 13 domains and 47 classes. Image via: Wikipedia.com

Here is a brief overview of the 13 Domains:

• Domain 1: Health Promotion: Focuses on the awareness of well-being and health management.
• Domain 2: Nutrition: Addresses activities of taking in, assimilating, and using nutrients.
• Domain 3: Elimination and Exchange: Concerns secretion and excretion of waste products from the body.
• Domain 4: Activity/Rest: Focuses on activities of daily living, exercise, sleep, and energy.
• Domain 5: Perception/Cognition: Addresses sensory and cognitive processes.
• Domain 6: Self-Perception: Concerns awareness of self.
• Domain 7: Role Relationship: Focuses on connections and associations between persons or groups.
• Domain 8: Sexuality: Addresses sexual identity, function, and reproduction.
• Domain 9: Coping/Stress Tolerance: Focuses on coping capacity and stress tolerance.
• Domain 10: Life Principles: Concerns values, beliefs, and spiritual practices.
• Domain 11: Safety/Protection: Addresses being free from danger, physical injury, or immune system damage.
• Domain 12: Comfort: Focuses on sense of mental, physical, and social well-being.
• Domain 13: Growth/Development: Addresses age-appropriate increases in physical dimensions, organ systems, and achievement of developmental milestones.

The Nursing Process and Nursing Diagnosis

Nursing diagnosis is the second step in the five-step nursing process (ADPIE):

1. Assessment: Collecting subjective and objective data about the patient’s health status.
2. Diagnosis: Analyzing assessment data to identify patient problems and formulate nursing diagnoses.
3. Planning: Developing a nursing care plan with patient-centered goals and nursing interventions.
4. Implementation: Carrying out the nursing interventions outlined in the care plan.
5. Evaluation: Assessing the patient’s response to interventions and evaluating goal achievement.

Each step of the nursing process relies on critical thinking. Nursing diagnosis is the bridge between assessment and planning, requiring nurses to interpret data and make clinical judgments that guide subsequent care planning and interventions.

Types of Nursing Diagnoses: Focusing on Problem-Focused Diagnosis

There are four main types of nursing diagnoses:

• Problem-Focused Nursing Diagnosis (Actual Diagnosis): Describes a current problem that the patient is experiencing at the time of assessment.
• Risk Nursing Diagnosis: Describes a potential problem that the patient is at risk of developing.
• Health Promotion Nursing Diagnosis: Describes a patient’s desire to improve their well-being and health status.
• Syndrome Nursing Diagnosis: A cluster of nursing diagnoses that occur together and are best addressed as a group.

TYPES OF NURSING DIAGNOSES. The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.

In-Depth Look at Problem-Focused Nursing Diagnosis

Problem-focused nursing diagnoses are clinical judgments about undesirable human responses to health conditions or life processes that exist in an individual, family, group, or community. These diagnoses are supported by defining characteristics – observable signs and symptoms that cluster together to indicate the presence of a particular problem. It is crucial to understand that while problem-focused diagnoses address existing issues, they are not inherently more critical than risk diagnoses, which aim to prevent potential problems.

Key Components of a Problem-Focused Nursing Diagnosis:

1. Nursing Diagnosis Label: A concise term or phrase that represents a pattern of related, clustered data (defining characteristics). Examples include “Acute Pain,” “Impaired Physical Mobility,” or “Ineffective Coping.”
2. Related Factors: These are the etiological or contributing factors that have influenced or are likely to influence the patient’s health problem. They provide context and direction for nursing interventions. Related factors are linked to the diagnosis label using the phrase “related to.” Examples of related factors for “Acute Pain” might be “related to surgical incision” or “related to inflammation.”
3. Defining Characteristics: These are the observable signs and symptoms (subjective and objective data) that provide evidence for the nursing diagnosis. They are clustered manifestations that indicate the presence of the diagnostic label. Defining characteristics are linked to the diagnosis label and related factors using the phrase “as evidenced by” or “as manifested by.” For “Acute Pain,” defining characteristics could include “patient reports pain of 7/10,” “guarding behavior,” “increased heart rate,” and “diaphoresis.”

Example of a Complete Problem-Focused Nursing Diagnosis Statement (PES Format):

• Problem: Acute Pain
• Etiology (Related Factors): related to surgical incision
• Signs and Symptoms (Defining Characteristics): as evidenced by patient reports pain of 7/10, guarding behavior, increased heart rate, and diaphoresis.

Full Diagnostic Statement: Acute Pain related to surgical incision as evidenced by patient reports pain of 7/10, guarding behavior, increased heart rate, and diaphoresis.

Contrasting Problem-Focused with Other Types of Nursing Diagnoses

• Risk Nursing Diagnosis: Focuses on potential problems. It has two components: a risk diagnosis label and risk factors (circumstances or conditions that increase vulnerability). Example: Risk for Infection related to surgical incision and immunosuppression. Notice there are no defining characteristics because the problem hasn’t occurred yet.

• Health Promotion Nursing Diagnosis: Focuses on wellness and the patient’s readiness to enhance health behaviors. It typically has one part: the diagnosis label. Example: Readiness for Enhanced Nutrition. Sometimes, related factors can be added for clarity.

• Syndrome Nursing Diagnosis: A cluster of actual or risk nursing diagnoses predicted to occur together. Example: Rape-Trauma Syndrome. It is also a one-part statement.

• Possible Nursing Diagnosis: Describes a suspected problem requiring more data to confirm or rule out. It is not a recognized NANDA-I diagnosis type but is used in practice to communicate potential issues needing further assessment. Example: Possible Anxiety related to unknown outcome of diagnostic tests.

Components of a Nursing Diagnosis in Detail

A well-written nursing diagnosis statement typically has three key components, particularly for problem-focused diagnoses:

1. Problem (Diagnostic Label) and Definition

The problem statement or diagnostic label concisely describes the patient’s health problem or response. It is the “what” of the nursing diagnosis. A diagnostic label often includes two parts:

• Qualifier (Modifier): Words that add specific meaning, limit, or clarify the diagnosis. Examples: Deficient, Imbalanced, Impaired, Ineffective, Risk for.
• Focus of the Diagnosis: The area of health concern. Examples: Fluid Volume, Nutrition, Gas Exchange, Tissue Perfusion, Injury.

Examples of Diagnostic Labels:

Qualifier	Focus of the Diagnosis	Combined Diagnostic Label
Deficient	Fluid Volume	Deficient Fluid Volume
Imbalanced	Nutrition	Imbalanced Nutrition: Less Than Body Requirements
Impaired	Gas Exchange	Impaired Gas Exchange
Ineffective	Tissue Perfusion	Ineffective Tissue Perfusion
Risk for	Injury	Risk for Injury

Some nursing diagnoses are single words (e.g., Anxiety, Constipation, Diarrhea, Nausea, Sleep Deprivation) where the qualifier and focus are inherent.

2. Etiology (Related Factors)

The etiology or related factors identify the probable causes or contributing factors to the health problem. It is the “why” behind the nursing diagnosis. Identifying etiology is crucial because nursing interventions are often directed at addressing these factors. Etiology is linked to the problem statement using the phrase “related to.”

Examples of Etiology:

• Problem: Impaired Skin Integrity related to prolonged pressure and immobility.
• Problem: Deficient Knowledge related to lack of exposure to information and unfamiliarity with resources.
• Problem: Ineffective Coping related to situational crises and inadequate support systems.

3. Defining Characteristics (Signs and Symptoms)

Defining characteristics are the observable cues, signs, and symptoms that cluster together as evidence of the nursing diagnosis. They are the “how you know” aspect of the diagnosis. For problem-focused diagnoses, defining characteristics are always present. They are linked to the problem and etiology using the phrase “as evidenced by” or “as manifested by.”

Examples of Defining Characteristics:

• Problem: Anxiety related to threat to self-concept as evidenced by restlessness, irritability, difficulty concentrating, and verbalization of anxious feelings.
• Problem: Constipation related to decreased physical activity and inadequate fluid intake as evidenced by reported decrease in frequency of bowel movements, hard stools, and abdominal distention.
• Problem: Ineffective Airway Clearance related to increased mucus production as evidenced by adventitious breath sounds (rhonchi), ineffective cough, and changes in respiratory rate and depth.

The Diagnostic Process: A Step-by-Step Approach

The diagnostic process involves three key phases:

1. Analyzing Data

This phase involves critical examination of the data collected during the nursing assessment. It includes:

• Comparing data to standards: Identifying deviations from normal health patterns or expected norms.
• Clustering cues: Grouping related data to identify patterns and relationships.
• Identifying gaps and inconsistencies: Recognizing missing information or conflicting data that requires further investigation.

2. Identifying Health Problems, Risks, and Strengths

After data analysis, nurses:

• Identify actual and potential health problems: Determine which problems are nursing diagnoses, medical diagnoses, or collaborative problems.
• Identify patient strengths and resources: Recognize the patient’s assets, coping mechanisms, and available support systems that can be leveraged in the care plan.

3. Formulating Diagnostic Statements

This is the final step where nurses construct the nursing diagnosis statement. The format varies depending on the type of diagnosis (problem-focused, risk, health promotion, syndrome).

How to Write a Nursing Diagnosis Statement: The PES Format

The PES format is a widely used method for writing nursing diagnosis statements, particularly for problem-focused diagnoses. It stands for:

• Problem (Diagnostic Label)
• Etiology (Related Factors)
• Signs and Symptoms (Defining Characteristics)

WRITING DIAGNOSTIC STATEMENTS. Your guide on how to write different nursing diagnostic statements.

PES FORMAT. Writing nursing diagnoses using the PES format.

Variations in Diagnostic Statements

• One-Part Statements: Used for health promotion and syndrome diagnoses, typically only including the diagnostic label. Example: Readiness for Enhanced Parenting.

• Two-Part Statements: Used for risk and possible diagnoses. They include the diagnostic label and risk factors (for risk diagnoses) or “etiology” for possible diagnoses. Example: Risk for Falls related to muscle weakness.

• Three-Part Statements: Used for problem-focused (actual) diagnoses, following the full PES format. Example: Ineffective Breathing Pattern related to anxiety as evidenced by shortness of breath, rapid respirations, and patient report of feeling unable to get enough air.

Nursing Diagnosis for Effective Care Planning

Nursing diagnoses are the foundation for developing comprehensive nursing care plans. They directly inform:

• Goal Setting: Goals and expected outcomes are derived directly from the nursing diagnosis, aiming to resolve the problem, reduce risk, or promote health.
• Intervention Selection: Nursing interventions are chosen to address the etiology (related factors) of the nursing diagnosis and alleviate the defining characteristics.
• Evaluation Criteria: The effectiveness of nursing interventions is evaluated by assessing whether the defining characteristics have diminished and the patient has progressed towards the established goals.

By mastering the formulation and application of problem-focused nursing diagnoses, nurses can provide targeted, effective, and patient-centered care. This guide has provided a comprehensive overview of the concept, its components, and the process of writing accurate and clinically relevant diagnostic statements. Continuous practice and utilization of resources like nursing diagnosis handbooks are key to developing expertise in this essential nursing skill.

Recommended Resources:

• Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
• Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
• 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 offer extensive lists of nursing diagnoses, detailed care plan templates, and evidence-based guidelines to further enhance your understanding and application of nursing diagnosis in practice.

References:

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• Fry, V. (1953). The Creative approach to nursing. AJN, 53(3), 301-302.
• Gordon, M. (1982). Nursing diagnosis: Process and application. New York: McGraw-Hill.
• Gordon, M. (2014). Manual of nursing diagnosis. Jones & Bartlett Publishers.
• Gebbie, K., & Lavin, M. (1975.) Classification of nursing diagnoses: Proceedings of the First National Conference. St. Louis, MO: Mosby.
• McManus, R. L. (1951). Assumption of functions in nursing. In Teachers College, Columbia University, Regional planning for nurses and nursing education. New York: Columbia University Press.
• Powers, P. (2002). A discourse analysis of nursing diagnosis. Qualitative health research, 12(7), 945-965.