This document discusses nursing diagnosis, including its definition, steps for formulating a nursing diagnosis, categories and types. It defines nursing diagnosis as a statement of a health problem or potential problem that a nurse can treat. The steps for formulation include establishing a database through various assessments, analyzing client responses, organizing the data, and confirming the diagnosis. Nursing diagnoses can be actual, risk, or potential complications. They should not merely restate a medical diagnosis but provide a basis for nursing interventions.

1. Prepared by :-
Taghreed hamza hawsawi
RN- BSN
Nursing Educator

2.  Introduction
 Definition
 Steps of formulating nursing diagnosis
 Category of nursing diagnosis
 Type of nursing diagnosis
 summary
 Reference

3. diagnosis :-
1. determination of the nature of a cause of a
disease.
2. a concise technical description of the cause,
nature, or manifestations of a condition,
situation, or problem.

4. physical diagnosisdifferential
diagnosis
medical diagnosisclinical diagnosis
diagnosis based on
information
obtained by
inspection,
palpation,
percussion, and
auscultation
the determination
of which one of
several diseases
may be producing
the symptoms
diagnosis based on
information from
sources such as
findings from a
physical
examination,
interview with the
patient or family or
both, medical
history of the
patient and family,
and clinical findings
as reported by
laboratory tests and
radiologic studies
diagnosis based on
signs, symptoms,
and laboratory
findings during life

5.  a statement of a health problem or of a potential
problem in the client's health status that a nurse
is licensed and competent to treat.
 The process of assessing potential or actual
health problems, including those pertaining to
an individual patient, a family or community,
that fall within the scope of nursing practice; a
judgment or conclusion reached as a result of
such assessment or derived from assessment
data.

7. 1. A database is established by collecting
information from all available sources:-
a. including interviews with the client and the
client's family
b. a review of any existing records of the client's
health
c. observation of the client's response to any
alterations in health status, a physical
assessment, and a consultation with others
concerned in the client's care.The database is
continually updated.

8. 2.The second step includes analysis of the
client's responses to the problems, healthy or
unhealthy, and classification of those
responses as psychologic, physiologic,
spiritual, or sociologic.
3.The third step is the organization of the data
so that a tentative diagnostic statement can
be made that summarizes the pattern of
problems discovered.

9. 4.confirmation of the sufficiency and accuracy
of the database by evaluation of the
appropriateness of the diagnosis to nursing
intervention and by the assurance that, given
the same information, most other qualified
practitioners would arrive at the same
nursing diagnosis.

10.  Part 1 the term that concisely describes
 Part 3 the problem, the probable cause of the
problem
 Part 3 the defining characteristics of the
problem.

11. 1- ACTUAL:
This diagnosis has 3 parts and follows the PES format. It
will actually paint a picture of the existing health
problem. The evidence in this diagnostic statement
must be specific.
Example: Impaired gas exchange r/t status of
secretions associated with difficulty coughing up
secretions from fatigue .
1. Large amounts thick green-yellow sputum
2. Frequent coughing with expectoration of sputum
3. Crackles throughout both lung fields
4. O2 sat of 90% without oxygen

12. RISK:
This diagnosis indicates from the data, a strong
likelihood that it will occur if actions are not
taken.
The Risk diagnosis only has 2 parts. It can be
used with any NANDA diagnosis.
Example: Risk for falls r/t to unsteady gait

13. POTENTIAL COMPLICATION:
This is also known as a collaborative diagnosis. This is a
problem the nurse cannot treat independently.
Nursing care will focus on monitoring and preventing
the problem. A collaborative diagnosis can be written
as a one or two part statement.
Example:
P.C of surgery: Hemorrhage or P.C. of chronic
obstructive pulmonary disease: respiratory failure

14.  Merely a nursing diagnosis label that you make up that
“sounds like” it explains what you are seeing in your
patient.
 Another way of explaining the medical diagnosis, or of
renaming a medical condition.
 Something that “goes with a particular medical diagnosis”.
 A nursing diagnosis provides the basis for selection of
nursing interventions to achieve outcomes for which the
nurse has accountability.” (Herdman, 2012, p. 515).
 The medical diagnosis provides one important piece of
data, but it does not provide anywhere near the depth of
information necessary for making an accurate nursing care