Nursing Diagnosis: The Right Way To Do It

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A major stumbling block for most nurses and nursing students is the “diagnosis” part of the nursing process. Because this step has not been emphasized in clinical practice, some have the impression that it’s really not essential to formulate a nursing diagnosis, and that you can directly perform your actions based on what you observe. As nurses get so busy assisting clients in different settings, some believe that it’s impractical, hence they skip determining the client’s nursing problem and move along with their interventions.

However, bypassing the nursing diagnosis step has 2 serious consequences: (1) the nurse’s interventions may not be effective in alleviating the problem because they fail to address the cause of the problem; and (2) the nurse’s interventions may actually be harmful to the client and should be contraindicated. These are the only reasons that you need in order to understand why it’s very important to pay particular attention in making the correct diagnosis.

Some nurses do realize its importance and do their best to follow the nursing process, but oftentimes they approach it incorrectly in 2 ways:

1.       They formulate the nursing problem based on the medical diagnosis. “If the patient has rheumatoid arthritis, then the problem must be Pain.”

2.       They ask the wrong question. Example: “What are the nursing diagnoses for a patient with congestive heart failure?”

Nurses should bear in mind that the nursing diagnosis cannot be based hastily on the medical diagnosis, because each patient may experience a disease uniquely and differently. The nursing problem is the nurse’s clinical judgment of the patient’s response towards illness, and it sets the basis for instituting an appropriate plan of care.

The nurse should develop keen, critical thinking skills in analyzing and interpreting each and every piece of data, and although it may seem that formulating a nursing diagnosis is far from simple, the nurse can train herself to do it in the right way by a systematic step-by-step process.

Let’s demonstrate this by using the nursing assessment example of a client with rheumatoid arthritis in our previous post (you can read it here). Let’s assume that you obtained the following data from the parameters that you’ve explored:

Biographical Data: Age: 61 Past History: · Has already been diagnosed with rheumatoid arthritis

Subjective Data: · Chief Complaint 1: Difficulty moving both upper and lower extremities. Symptoms started when he was about 40, and it has progressed over time. Nothing seems to aggravate the symptoms, and movement improves when he takes his pain killers. He says that he experiences this symptom along with pain, with no exact timing and frequency. It affects his ability to perform usual activities, and he needs assistance in these episodes. · Chief Complaint 2: Intense pain on both upper and lower extremities. Symptoms started when he was about 40. The duration, severity and frequency of pain vary, and triggering factors are unknown. Based on a 10-point scale, pain is 8 on the average. Pain is usually relieved by his pain killers.

Objective Data: · (+) redness, warmth and swelling on joints of fingers and toes · (+) bilateral ulnar deviation · (+) bilateral tibial deviation · Client guards joints of fingers and toes when slight pressure is applied · Observable unequal and limited ROM of fingers, toes, elbows and knees · (+) crepitus on joints of fingers and toes when they are moved · Client displays slight facial grimace when moving both upper and lower extremities Diagnostics and Labs: · X-ray: bilateral deviation of fingers and toes · Rheumatoid factor: 27 IU/ml · C-reactive protein: 26 mg/L · ESR: 17 mm/hr · WBC: 13,000/mcL

Step 1: Determine which functional health patterns are affected by categorizing and clustering your subjective data according to these patterns.

Have you noticed why most nursing diagnosis books incorporate a list of Marjory Gordon’s 11 functional health patterns? It’s because these functional health patterns classify the diagnoses and help us narrow down the possible nursing problems experienced by clients. Let’s try to fit our subjective data to them:

Subjective Data/Cues	Functional Health Pattern	Remarks/Interpretation
Difficulty moving both upper and lower extremities. Symptoms started when he was about 40, and it has progressed over time. It affects his ability to perform usual activities, and he needs assistance in these episodes.	Activity/Exercise	Mobility is included in this pattern, and the client has clearly mentioned having difficulty moving. His problems with mobility also affect the way he performs ADLs independently. Interpretation: There’s an actual problem here.
Nothing seems to aggravate the symptoms, and movement improves when he takes his pain killers.	Health Perception/Health Management	The client seems to exert some effort in trying to alleviate the problem, and sees the need to seek medical attention to his problem. There seems to be no potential health risk with regard to his practices. Interpretation: No problem here. A wellness diagnosis may be identified.
Intense pain on both upper and lower extremities. Symptoms started when he was about 40. The duration, severity and frequency of pain vary, and triggering factors are unknown. Based on a 10-point scale, pain is 8 on the average.	Cognitive/Perceptual	Pain is an unpleasant sensation that is perceived by the client due to inflammation of his joints by an autoimmune disorder. The stimulus is transmitted from the affected joints to the central nervous system, where it is interpreted as pain. Interpretation: There’s an actual problem here.

Based on the given data, the functional health patterns that seem to be affected are the Activity/Exercise and the Cognitive/Perceptual pattern. The data is actually limited, because a focused assessment was done in this case. If the nurse wants to determine if there are other problems with the other functional health patterns, the only thing to do is this: expand the assessment into a comprehensive one, and explore everything about the patient. This should also be done if the nurse can’t seem to find any problem with the client. Remember: if you think you can’t see a possible nursing diagnosis, go back to the first step of the nursing process – assess.

Step 2: List the nursing diagnoses that fall within the affected functional health patterns. Look up each nursing diagnosis’s definition, and see if the given data provides cues to it.

Functional Health Pattern	Nursing Diagnoses Within This Pattern	Possible Nursing Diagnosis
Activity/Exercise	· Activity Intolerance · Autonomic Dysreflexia · Decreased Cardiac Output · Decreased Intracranial Adaptive Capacity · Deficient Diversional Activity · Delayed Growth and Development · Delayed Surgical Recovery · Disorganized Infant Behavior · Dysfunctional Ventilatory Weaning Response · Fatigue · Impaired Spontaneous Ventilation · Impaired Bed Mobility · Impaired Gas Exchange · Impaired Home Maintenance · Impaired Physical Mobility · Impaired Transfer Ability · Impaired Walking · Impaired Wheelchair Mobility · Ineffective Airway Clearance · Ineffective Breathing Pattern · Ineffective Tissue Perfusion · Readiness for Enhanced Organized Infant Behavior · Readiness for Enhanced Self Care · Risk for Delayed Development · Risk for Disorganized Infant Behavior · Risk for Disproportionate Growth · Risk for Activity Intolerance · Risk for Autonomic Dysreflexia · Risk for Disuse Syndrome · Sedentary Lifestyle · Self-care Deficit (bathing/hygiene, dressing/grooming, feeding, toileting) · Wandering	Going through the definitions of these problems, the ones that fit the client’s condition are: 1. Impaired Physical Mobility Definition: Limitation in independent, purposeful physical movement of the body or of one or more extremities Related Factors: · Joint stiffness · Pain and discomfort · Musculoskeletal impairment Remarks: Impaired Bed Mobility, Impaired Transfer Ability, Impaired Walking, Impaired Wheelchair Mobility may be potential diagnoses, but data is lacking. Further assessment is needed. 2. Self-care Deficit Definition: Impaired ability to perform or complete feeding, bathing/hygiene, dressing and grooming, or toileting activities for oneself [on a temporary, permanent, or progressing basis] Related Factors: · Joint stiffness · Pain and discomfort · Musculoskeletal impairment Remarks: Ideally, the nurse should specify which ADL the patient is having difficulty with. Further assessment is needed.
Cognitive/Perceptual	· Acute Confusion · Acute Pain · Chronic Confusion · Chronic Pain · Decisional Conflict · Deficient Knowledge · Disturbed Sensory Perception · Disturbed Thought Processes · Impaired Environmental Interpretation Syndrome · Impaired Memory · Readiness for Enhanced Comfort · Readiness for Enhanced Decision Making · Readiness for Enhanced Knowledge · Risk for Acute Confusion · Unilateral Neglect	Going through the definitions of these problems, the ones that fit the client’s condition are: 1. Chronic Pain Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a duration of greater than 6 months Related Factors: · Chronic joint inflammation secondary to autoimmune disorder
Health Perception/Health Management	· Contamination · Disturbed Energy Field · Effective Therapeutic Regimen Management · Health-seeking Behaviors · Ineffective Community Therapeutic Regimen Management · Ineffective Family Therapeutic Regimen Management · Ineffective Health Maintenance · Ineffective Protection · Ineffective Therapeutic Regimen Management · Noncompliance · Readiness for Enhanced Immunization Status · Readiness for Enhanced Therapeutic Regimen Management · Risk for Contamination · Risk for Falls · Risk for Infection · Risk for Injury · Risk for Perioperative Positioning Injury · Risk for Poisoning · Risk for Sudden Infant Death Syndrome · Risk for Suffocation · Risk for Trauma · Risk-prone Health Behavior	The client is taking medications to alleviate his symptoms, and the nurse needs to assist him in improving this practice. The possible wellness nursing diagnosis in this case is: 1. Readiness for Enhanced Therapeutic Regimen Management

Seems like we’re already done, but identifying the possible nursing diagnosis is just half the story. We need to justify them.

Step 3: Justify the nursing diagnoses with objective data.

Possible Nursing Diagnosis	Related Factor	Objective Data/Cues	Justified?
Impaired Physical Mobility	· Joint stiffness · Pain and discomfort ·Musculoskeletal impairment	· (+) redness, warmth and swelling on joints of fingers and toes · (+) bilateral ulnar deviation · (+) bilateral tibial deviation · Client guards joints of fingers and toes when slight pressure is applied · Observable unequal and limited ROM of fingers, toes, elbows and knees · (+) crepitus on joints of fingers and toes when they are moved · Client displays slight facial grimace when moving both upper and lower extremities Diagnostics and Labs: · X-ray: bilateral deviation of fingers and toes · Rheumatoid factor: 27 IU/ml · C-reactive protein: 26 mg/L · ESR: 17 mm/hr · WBC: 13,000/mcL	YES
Self-care Deficit	· Joint stiffness · Pain and discomfort ·Musculoskeletal impairment	· While there is evidence of limited ROM, the nurse must observe how the client performs ADLs to justify this diagnosis.	NO
Chronic Pain	· Chronic joint inflammation secondary to autoimmune disorder	· (+) redness, warmth and swelling on joints of fingers and toes · (+) bilateral ulnar deviation · (+) bilateral tibial deviation · Client guards joints of fingers and toes when slight pressure is applied · Observable unequal and limited ROM of fingers, toes, elbows and knees · (+) crepitus on joints of fingers and toes when they are moved · Client displays slight facial grimace when moving both upper and lower extremities Diagnostics and Labs: · X-ray: bilateral deviation of fingers and toes · Rheumatoid factor: 27 IU/ml · C-reactive protein: 26 mg/L · ESR: 17 mm/hr · WBC: 13,000/mcL	YES
Readiness for Enhanced Therapeutic Regimen Management	· Effective adherence to pain medication regimen	· While the client verbalized this, the nurse has yet to observe how the client takes his medications. Further observation is needed.	NO

Step 4: Finalize the statement of the justified nursing diagnosis.

We know that the standard format for stating nursing problems is:

[Problem] related to [Etiology] *as evidenced by [Signs and Symptoms]

Hence, we would state our justified nursing diagnoses as:

1. Impaired Physical Mobility related to joint stiffness, pain and discomfort and musculoskeletal impairment

2. Chronic Pain related to chronic joint inflammation secondary to autoimmune disorder

Step 5: Prioritize your nursing diagnoses.

Listing the justified nursing problems is not enough – the nurse should properly arrange and prioritize them to clearly see which problems are needed to be addressed first. (1) Actual problems always receive top priority, followed be (2) risk problems, then by (3) wellness diagnoses. In our example, both diagnoses are actual problems that results from chronic inflammation, therefore each are equally prioritized.

And there you have it – 5 steps to systematically identify and validate a nursing diagnosis. Keep in mind that a good working assessment is essential to properly diagnose nursing problems, and always make sure that you have both subjective and objective data to support your diagnosis.