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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