Editing Fundamentals of Nursing (section)

=== Diagnosis and analysis ===

The nursing diagnosis is a clinical judgment about a human response to an actual or potential health problem that nurses are licensed and competent to treat independently. It differs from a medical diagnosis, which names a disease. A patient may carry the medical diagnosis of stroke and the nursing diagnoses of impaired physical mobility, impaired swallowing, and risk for aspiration.

Standard structures include:
* '''Actual problem (three part, PES):''' problem, related to etiology, as evidenced by signs and symptoms. Example: impaired skin integrity related to prolonged pressure over the sacrum as evidenced by a 2 cm stage 2 sacral pressure injury.
* '''Risk problem (two part):''' the risk label plus risk factors. Risk diagnoses have no signs and symptoms yet, because the problem has not occurred. Example: risk for falls as evidenced by unsteady gait, sedating medication, and history of two falls in six months.
* '''Health promotion diagnosis:''' a readiness for enhanced response in a patient who wishes to improve.

The etiology must be something nursing can address. Writing "related to congestive heart failure" is not useful, because a nurse cannot independently treat heart failure. "Related to decreased cardiac output and activity intolerance" points toward nursing action.