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What is a nursing diagnosis? Definition of Nursing Diagnosis A nursing diagnosis is the part of the nursing process, is clinical judgment about individual, family, or community responses to actual or potential health/life processes.  Nursing diagnosis are developed based on data obtained during nursing assessment. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

 Nursing Diagnosis Have two related meanings:

  • Nursing diagnosis is an action: the process of analyzing assessment data to arrive at a nursing diagnosis!
  • Nursing diagnosis is a label that describes the patient’s response to an actual or potential health problem

How do nurses make a Nursing Diagnosis?

  1. Analyze collected data
  2. Identify the client’s strengths
  3. Identify the client’s normal functional level and indicators of actual or potential dysfunction
  4. Formulate a diagnostic statement in relations to this synthesis

Benefits of Nursing Diagnosis

  • Gives nurses a common language
  • Promotes identification of appropriate expected outcomes
  • Provides acuity information
  • Can create a standard for nursing practice
  • Provide a quality improvement base
  • Promotes improved communication among nurses, other healthcare providers, and alternate care settings

Nursing Diagnosis VS Medical Diagnosis

Nursing Diagnosis

Medical Diagnosis

  1. Nursing Diagnosis
  2. Made by the nurse
  3. Describes clients response
  4. Describes a disease or pathology
  5. Responses vary between individual
  6. Changes as client responses change
  7. Nurse orders interventions
  1. Medical Diagnosis
  2. Made by a physician
  3. Refers to the disease process
  4. Describes patient response to a health problem
  5. Somewhat uniform between clients
  6. Remains same during disease process
  7. Physician orders interventions

Steps of Developing Nursing Diagnosis

Identify patterns

  • Review data and look for cues
  • Cluster cues (signs and symptoms)
  • Synthesizing the cue clusters
  • Three questions to ask self  (What are my concerns about this client, Can I or am I doing something about it, Can the overall risk be decreased by nursing interventions)

Synthesis the data

Look at all data as a whole to provide a comprehensive picture of the client in relation to past, present, and future health status

Validate the diagnosis

Test for a fit, Refer to the NANDA Diagnosis and defining characteristics. Then, compare the assessed possible ETIOLOGY with NANDA’s RELATED FACTORS or RISK FACTORS. Next, compare the assessed client cues with NANDA’s Defining Characteristics, which are used to support and provide an increased level of confidence in your selected nursing diagnosis.

Formulate the nursing diagnosis statement using nursing language

NANDA

 

Types of Nursing Diagnosis

  • Actual Nursing Diagnosis

A client problem that is present at the time of the nursing assessment. It is based on the presence of signs and symptoms. Can be documented from assessment

  • Risk Nursing Diagnosis

Risk Nursing diagnosis, a clinical judgment that the client is more vulnerable to develop this problem than others in the same or similar situation. A clinical judgment that a problem does not exist, therefore no S/S are present. This diagnosis indicates from the data, a strong likelihood that it will occur if actions are not taken by the nurses.  The Risk diagnosis only has 2 parts.  It can be used with any NANDA diagnosis

  • Potential Nursing Diagnosis

This is also known as a collaborative diagnosis. one in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it, or the causative factors are unknown but a problem is only considered possible to occur. This is a problem the nurse cannot treat independently. Nursing care will focus on monitoring and preventing the problem. A collaborative diagnosis can be written as a one or two part statement.

  • Wellness Nursing Diagnosis

Potential for enhancement of current well state, this diagnosis involves a judgment about an individual, family or community in transition from one level of wellness to a higher level of wellness.

  • Syndrome Nursing Diagnosis

Associated with a cluster of other diagnoses

Components of Nursing Diagnosis

Diagnostic Label

  • P  Problem, Name of the nursing diagnosis as listed in the taxonomy, describes the problem using as few words as possible. DO NOT use the medical diagnosis. Must be a problem the nurse and/or client can change to do something about. Relating the problem to an unchangeable situation
  • Qualifier, Used to give additional meaning to the Nursing Diagnosis. words added to the diagnostic label/problem statement to gain additional meaning
  • E Etiology. This is the “related to, R/T” portion of the diagnosis. What caused the client to have the problem listed? Do Not use the medical diagnosis, Must be a problem the nurse and/or client can change to do something about
  • S Symptom. These are the major and minor clinical cues that validate the presents of an actual nursing diagnosis. Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the Nursing Diagnosis

 Problems to avoid in writing Nursing Diagnosis

  • Don’t confuse the etiology with the problem
  • Do not use the medical diagnosis.
  • Must be a problem the nurse and/or client can change to do something about. Relating the problem to an unchangeable situation
  • Focus on the human responses to the problem
  • Avoid the use of one piece of assessment data as a Nursing Diagnosis(EDEMA)
  • Be specific
  • Don’t combine NDX
  • Don’t relate one Nursing Diagnosis to another.  There is a different related to factor if this is a valid Nursing Diagnosis
  • Nursing interventions should not be included in the Nursing Diagnosis
  • Keep your language non-judgmental
  • Don’t make assumptions or statements you can’t prove with assessment data
  • Be sure your statement is legally advisable

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