A nurse is reviewing the diagnostic statements of a client who has multiple health problems. Which of the following statements is an example of an actual diagnosis?

Choice A reason:.

This is not an example of an actual diagnosis because it describes a potential problem that has not yet occurred. An actual diagnosis identifies a problem that is present at the time of the assessment and is based on signs and symptoms.

Choice B reason:.

This is an example of an actual diagnosis because it describes a problem that is present at the time of the assessment and is based on signs and symptoms. An actual diagnosis consists of three components: the problem, the etiology, and the defining characteristics. In this case, the problem is impaired skin integrity, the etiology is related to pressure ulcer, and the defining characteristics are evidenced by 4 cm x 3 cm wound on sacrum.

Choice C reason:.

This is not an example of an actual diagnosis because it does not include any defining characteristics that support the problem. An actual diagnosis requires evidence of signs and symptoms to validate the problem.

Choice D reason:.

This is not an example of an actual diagnosis because it describes a readiness to enhance a specific health behavior rather than a problem that is present at the time of the assessment. A readiness for enhanced diagnosis identifies a strength or potential for improvement in a client's health status.

Choice A reason:.

Problem is not the correct term to describe these findings because it is too vague and does not specify the human response to the health condition. A problem is a general label that can apply to many situations, but a nursing diagnosis should be more precise and descriptive.

Choice B reason:.

Etiology is not the correct term to describe these findings because it refers to the cause or contributing factors of the problem, not the problem itself. Etiology is usually preceded by the phrase "related to”. in a nursing diagnostic statement. For example, "Impaired skin integrity related to pressure ulcer”. is a nursing diagnosis where "pressure ulcer”. is the etiology.

Choice C reason:.

Defining characteristics is the correct term to describe these findings because it refers to the observable and verifiable signs and symptoms that indicate the presence of a problem or risk. Defining characteristics are usually preceded by the phrase "as evidenced by”. in a nursing diagnostic statement. For example, "Acute pain as evidenced by grimacing, guarding, and increased heart rate”. is a nursing diagnosis where "grimacing, guarding, and increased heart rate”. are the defining characteristics.

Choice D reason:.

Related factors is not the correct term to describe these findings because it refers to the conditions or circumstances that are associated with the problem or risk, but are not necessarily the cause. Related factors are usually preceded by the phrase "related to”. in a risk nursing diagnostic statement. For example, "Risk for falls related to impaired balance”. is a nursing diagnosis where "impaired balance”. is a related factor.