Components of Nursing Diagnosis

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Components of Nursing Diagnosis

1. Diagnostic Label

a. Problem: 

  • Name of the nursing diagnosis as listed in the taxonomy 
  • Describes the problem using as few words as possible
Problems to avoid in writing this part
  • DO NOT use the medical diagnosis
  • Must be a problem the nurse and/or client can change to do something about
  • Relating the problem to an unchangeable situation
  • Don’t confuse the etiology with the problem
  • Focus on the human responses to the problem
  • Avoid the use of one piece of assessment data as a NDX (EDEMA)
  • Be specific
  • Don’t combine NDX
  • Don’t relate one NDX to another. There is a different related to factor if this is a valid NDX
  • Nursing interventions should not be included in the NDX
  • Keep your language non-judgmental
  • Don’t make assumptions or statements you can’t prove with assessment data
  • Be sure your statement is legally advisable

b. Qualifier:

  • Used to give additional meaning to the nursing diagnosis

2. Etiology

  • This is the “related to, R/T” portion of the diagnosis.
  • What caused the client to have the problem listed?
Problems to avoid in writing this part
  • DO NOT use the medical diagnosis
  • Must be a problem the nurse and/or client can change to do something about

3. Defining characteristics

  • These are the major and minor clinical cues that validate the presents of an actual nursing diagnosis
  • Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the nursing diagnosis
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