Problem-Focused Nursing Diagnosis
Problem-Focused Nursing Diagnosis
A
problem-focused diagnosis (also known as
actual diagnosis) is a client problem present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms. Actual nursing diagnosis should not be viewed as more important than risk diagnoses. There are many instances where a risk diagnosis can be the diagnosis with the highest priority for a patient.
Problem-focused nursing diagnoses have three components: (1) nursing diagnosis, (2) related factors, and (3) defining characteristics. Examples of actual nursing diagnoses are:
- Anxiety related to stress as evidenced by increased tension, apprehension, and expression of concern regarding upcoming surgery
- Acute pain related to decreased myocardial flow as evidenced by grimacing, expression of pain, guarding behavior.
Risk Nursing Diagnosis
The second type of nursing diagnosis is called
risk nursing diagnosis. These are clinical judgments that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. A risk diagnosis is based on the patient’s current health status, past health history, and other risk factors that may increase the patient’s likelihood of experiencing a health problem. These are integral part of nursing care because they help to identify potential problems early on and allows the nurse to take steps to prevent or mitigate the risk.
There are no etiological factors (related factors) for risk diagnoses. The individual (or group) is more susceptible to developing the problem than others in the same or a similar situation because of risk factors. For example, an
elderly client with
diabetes and vertigo who has difficulty walking refuses to ask for assistance during
ambulation may be appropriately diagnosed with
risk for injury or risk for falls.
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