Many books use the PES format to talk about the possible parts of a Nursing Diagnosis. PES stands for Problem, Etiology and Symptoms. In this video I define each of these components as well as show you how to add in other components that are used in three and four part nursing diagnoses.
The Problem should be identified using a NANDA label whenever possible. The “problem” is what the client needs, which with some types of nursing diagnoses may not be problem focused.
Sometimes the NANDA label will be general and ask you to add a more specific description of the problem to this section. Remember to include qualifiers to the general diagnostic concept as appropriate.
Be careful when writing your problem statement that judgmental language is not included. The problem statement should sound neutral to avoid offending clients or influencing treatment decisions.
The Problem and Etiology are connected by the phrase “Related to”, which is typically abbreviated as r/t. This phrase is always used because it does not imply a direct cause and effect relationship. Nursing diagnoses are worded this way to leave open the possibility that there may be factors contributing to the problem that have not yet been identified.
The Etiology identifies the factors that are causing the problem. For actual nursing diagnoses the etiology identifies the main contributing factors. With potential diagnoses risk factors are used as the etiology. This etiology should help to individualize care for your client.
The Etiology needs to be as specific and precise as possible. Do not write this section vaguely hoping that the symptoms section will explain what is going on with the patient. Write your Problem and Etiology as specific as possible before adding the signs and symptoms to the end.
“Secondary to” is used to make a statement more precise and clarify the etiology. Specify a pathophysiology or disease that is contributing to the problem. Keep in mind that it is not always necessary to use the “secondary to” phrase. You want to keep your diagnoses as clear and concise as possible.
If a client has the defining characteristics of a nursing diagnosis but you do not know the cause or contributing factors you can say there is an “unknown etiology.”
In very few cases the etiology may be so complex that you cannot include it in a nursing diagnosis concisely. This situation occurs when there are too many factors causing the problem to state. In these rare circumstances the phrase “complex etiology” may replace the etiology.
Symptoms are then listed at the end of your diagnosis following the clause “as manifested by” which is abbreviated.
References
Ackley, B., & Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care. St. Louis: Elsevier.
Carpenito, J. (2013). Nursing Diagnosis: Application to Clinical Practice. Philadelphia: Lippincott.
Doenges, M. E., & Moorhouse, M. F. (2008). Application of nursing process and nursing diagnosis. Philadelphia: Davis.
Potter, P. A., & Perry, A. G. (2014). Canadian fundamentals of nursing (5th ed.). Toronto: Elsevier.
Wilkinson, J. M. (2007). Nursing Process and Critical Thinking (4th ed.). New Jersey: Pearson.
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