How to write a diagnostic statement for a care plan.

When writing a diagnostic statement using the Problem-etiology-symptom (PES) method, we are conveying a lot of information to our colleagues. We start with the diagnosis itself, followed by the etiologic factors (related factors in an actual diagnosis). Finally, we identify the major signs/symptoms (Defining characteristics) that are appearing in the patient, in the case of actual diagnoses. In the case of risk and health promotion diagnoses, no etiologic factors apply, so we identify risk factors that predispose a patient to a potential problem for risk diagnoses, or evidence that suggests a potential for health promotion (Defining characteristics) for a health promotion diagnosis.

 

PROBLEM-FOCUSED DIAGNOSIS
Problem-Focused Diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics).

Problem-Focused Diagnosis Example: Anxiety related to situational crises and stress (related factors) as evidenced by restlessness, insomnia, anguish and anorexia (defining characteristics).

RISK DIAGNOSIS
For risk diagnoses, there are no related factors (etiological factors), since we are identifying a vulnerability in a patient for a potential problem; the problem is not yet present. Therefore we identify the risk factors that predispose the individual to a potential problem.

The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced by __________________________ (Risk Factors).

Risk Diagnosis Example: Risk for infection as evidenced by inadequate vaccination and immunosuppression (risk factors).

HEALTH PROMOTION DIAGNOSIS
Because health promotion diagnoses do not require a related factor, there is no “related to” in the writing of this diagnosis. Instead, the defining characteristic(s) are provided as evidence of the desire on the part of the patient to improve his/her current health state.

Health Promotion Diagnosis Example: Readiness for enhanced self-care as evidenced by expressed desire to enhance self-care.