Clarifying Terms
Before we discuss the process of formulating Nursiing Diagnoses, we must clarify about some terms which are often used Interchangeably and thus causing confusion.
i)Health Problem vs Health Need ‘Health problem’ means that there is a difference between client’s health condition and the expected ‘normal’ standard of health. For example body temperature more than 98.4°F (normal standard).
‘Health needs’ are those physiologic, environmental and socio- psychologic aspects of life which are essential for feeling well and human survival. Important basic client needs are:
Before we discuss the process of formulating Nursiing Diagnoses, we must clarify about some terms which are often used Interchangeably and thus causing confusion.
i)Health Problem vs Health Need ‘Health problem’ means that there is a difference between client’s health condition and the expected ‘normal’ standard of health. For example body temperature more than 98.4°F (normal standard).
‘Health needs’ are those physiologic, environmental and socio- psychologic aspects of life which are essential for feeling well and human survival. Important basic client needs are:
- Air
- Rest
- Sleep
- Food
- Fluid
- Clean body
- Elimination
- Maintenance of body heat
- Clean environment
- Love and peace etc.
Health problem arises when the client’s health needs are not satisfied.
ii)Health Problem vs Diagnosis
The statement of ‘diagnosis’ has two parts, ‘the health problem’ and its ‘cause’. For example,swelling (problem) related to injury (cause).
iii)Data vs Health Problem vs Diagnosis
‘Data’ are only facts or information, e.g., ‘Pain’.
‘
Health problem’ is an interpretation of the ‘Data’, e.g., ‘discomfort’. ‘Diagnosis’ links the effect(Discomfort) with the evidence (pain) and cause (injury).
Making the Nursing Diagnosis
There are three major steps in making nursing diagnosis. These are:
ii)Health Problem vs Diagnosis
The statement of ‘diagnosis’ has two parts, ‘the health problem’ and its ‘cause’. For example,swelling (problem) related to injury (cause).
iii)Data vs Health Problem vs Diagnosis
‘Data’ are only facts or information, e.g., ‘Pain’.
‘
Health problem’ is an interpretation of the ‘Data’, e.g., ‘discomfort’. ‘Diagnosis’ links the effect(Discomfort) with the evidence (pain) and cause (injury).
Making the Nursing Diagnosis
There are three major steps in making nursing diagnosis. These are:
- Analysis of the data
- Stating the health problem
- Stating the cause or contributing factors of the health problem.
Now let us discuss each step in detail.
a)Analysis of the Data
After collecting data from different sources using various methods, the data are:
i) Classified into several groups, as information related to physical signs and symptoms,emotional balance etc.
ii) Any gap in the relationship among data is filled up. For example the client has breathing difficulty. Ask yourself “Is he having a heart problem?”
iii) Compare the client’s data with a standard measure. For example rate of his breathing is 30 per minute. The normal standard is 16-18 per minute.
iv) Compare the client’s present health related data with his past health condition, e.g., since how long he is having breathing difficulty and increased rate of breathing?
v) Find out client’s areas of abilities and disabilities. For example., he can walk slowly about half a kilometer, without having breathing difficulty. But he can not climb more than eight steps at a time without stopping for breath.
vi) Synthesise the data by relating the information with some life events, seeking some pattern in the symptoms and making your own conclusion and interpretation. For example,“Breathing difficulty increases by stress”.
vii) Check your conclusions about the client’s symptoms with various reliable sources such as doctors, records, text books etc.
b) State the Health Problem Write clearly the difficulties experienced by the client at a given point of time. For example, the
client feels shortness of breath when he climbs more than eight steps.
c) State the Cause of the Problem (If Possible) or Contributing Factors of the Health Problem Physical causes are easier to state than psychological causes. First make a list of all possible and remote causes. Delete the causes as you check them with the symptoms and at the end arrive at a tentative conclusion.
So far we have discussed a procedure for making one Nursing Diagnosis. In actual situation a client may have five to ten Nursing Diagnoses. Because the client’s situation may change from day to day and moment to moment, Nursing Diagnoses also change accordingly. The reason is that Nursing Diagnoses are the cause and effect relationship.Consult theory block for statement of necessary diagnosis.
Examples of a few Nursing Diagnoses are given below:
i) Airway clearance, ineffective (effect) related to: thick respiratory secretion (cause).
ii) Communication impaired, verbal (effect), related to: ulcers in the mouth (cause).
iii) Fluid volume deficit, actual (effect), related to: severe vomiting (cause).
a)Analysis of the Data
After collecting data from different sources using various methods, the data are:
i) Classified into several groups, as information related to physical signs and symptoms,emotional balance etc.
ii) Any gap in the relationship among data is filled up. For example the client has breathing difficulty. Ask yourself “Is he having a heart problem?”
iii) Compare the client’s data with a standard measure. For example rate of his breathing is 30 per minute. The normal standard is 16-18 per minute.
iv) Compare the client’s present health related data with his past health condition, e.g., since how long he is having breathing difficulty and increased rate of breathing?
v) Find out client’s areas of abilities and disabilities. For example., he can walk slowly about half a kilometer, without having breathing difficulty. But he can not climb more than eight steps at a time without stopping for breath.
vi) Synthesise the data by relating the information with some life events, seeking some pattern in the symptoms and making your own conclusion and interpretation. For example,“Breathing difficulty increases by stress”.
vii) Check your conclusions about the client’s symptoms with various reliable sources such as doctors, records, text books etc.
b) State the Health Problem Write clearly the difficulties experienced by the client at a given point of time. For example, the
client feels shortness of breath when he climbs more than eight steps.
c) State the Cause of the Problem (If Possible) or Contributing Factors of the Health Problem Physical causes are easier to state than psychological causes. First make a list of all possible and remote causes. Delete the causes as you check them with the symptoms and at the end arrive at a tentative conclusion.
So far we have discussed a procedure for making one Nursing Diagnosis. In actual situation a client may have five to ten Nursing Diagnoses. Because the client’s situation may change from day to day and moment to moment, Nursing Diagnoses also change accordingly. The reason is that Nursing Diagnoses are the cause and effect relationship.Consult theory block for statement of necessary diagnosis.
Examples of a few Nursing Diagnoses are given below:
i) Airway clearance, ineffective (effect) related to: thick respiratory secretion (cause).
ii) Communication impaired, verbal (effect), related to: ulcers in the mouth (cause).
iii) Fluid volume deficit, actual (effect), related to: severe vomiting (cause).
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