3 Part Nursing Diagnosis Examples

Waren Burn

2 min read

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28-11-2024

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Nursing diagnoses are concise descriptions of a patient's health problems that nurses can treat independently. They form the foundation of a comprehensive care plan, guiding interventions and evaluating outcomes. A correctly formulated nursing diagnosis follows a three-part structure: Problem, Etiology (cause), and Symptoms (defining characteristics). Understanding this structure is crucial for effective nursing practice. This guide provides examples to illustrate the three-part format.

Understanding the Three-Part Structure

The three-part structure ensures clarity and precision in identifying patient needs. Each component plays a vital role:

• Problem: This describes the patient's health issue using standardized NANDA-I (North American Nursing Diagnosis Association International) terminology. It's the concise summary of the patient's condition.

• Etiology: This identifies the factors contributing to the problem. It explains why the patient is experiencing the health issue. It's typically connected to the problem using the phrase "related to" (r/t).

• Symptoms (Defining Characteristics): These are the subjective and objective data that support the diagnosis. This is the evidence observed and/or reported by the patient indicating the presence of the problem. It's connected to the etiology using the phrase "as evidenced by" (AEB).

Example 1: Impaired Skin Integrity

Problem: Impaired Skin Integrity

Etiology: Related to prolonged pressure on bony prominences

Symptoms (Defining Characteristics): As evidenced by a 2cm x 3cm stage II pressure ulcer over the sacrum with redness, partial thickness skin loss, and serous drainage.

This example clearly shows the problem (pressure ulcer), its cause (prolonged pressure), and the observable evidence supporting the diagnosis (size, location, appearance of the wound).

Example 2: Risk for Infection

Problem: Risk for Infection

Etiology: Related to surgical incision and immunosuppression

Symptoms (Defining Characteristics): As evidenced by recent abdominal surgery and a history of chemotherapy.

This example illustrates a risk diagnosis. There is no current infection, but the patient's circumstances increase the likelihood of one. The defining characteristics support the risk.

Example 3: Ineffective Breathing Pattern

Problem: Ineffective Breathing Pattern

Etiology: Related to postoperative pain and decreased lung expansion

Symptoms (Defining Characteristics): As evidenced by shallow respirations, respiratory rate of 28 breaths per minute, and use of accessory muscles during breathing.

This diagnosis highlights a problem with breathing, its cause (pain and decreased lung expansion), and the observable symptoms (respiratory rate, use of accessory muscles).

Conclusion

Mastering the three-part nursing diagnosis is essential for providing safe and effective patient care. This framework provides a structured and systematic approach to identifying, documenting, and treating patient problems. Consistent use of standardized terminology and precise documentation are key to accurate nursing diagnoses. These examples illustrate the process, aiding in better understanding and application within clinical settings.