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Writing a successful nursing diagnosis often demands the nurse to be observant, knowledgeable in the field of nursing and possess good writing skills. However, sometimes nursing students, nurses or researchers feel overwhelmed when writing a nursing diagnosis. You don’t have to worry anymore, by reading this article you have an edge and it will make writing your nursing diagnosis a breeze.
Let us start by knowing what nursing diagnosis is about.
What is a nursing diagnosis?
A nursing diagnosis is a clinical judgement about an individual, family, or community experiences/ responses to actual or potential health problems/life problems. It can also be referred to as a statement made by a registered nurse which addresses the target of nursing care to get provided to someone.
A nursing diagnosis may be part of a nursing process. It is developed based on data obtained during the nursing assessment.
Why nursing diagnoses are important?
Often, some nursing students wonder why their professors ask them to write nursing diagnosis assignments. Nursing students view nursing diagnosis assignments as tiring, boring and requiring proficiency in writing skills. However, mastering the art of writing professional nursing diagnoses is essential in the nursing process.
Here is a list of how nursing diagnoses helps to make the nursing process better:
- In nursing schools, a nursing diagnosis is an effective teaching tool used to sharpen the problem-solving skills and critical thinking skills of the nursing students.
- Nursing diagnosis is used as a basis for evaluation to determine whether the nursing care was beneficial and cost-effective to the patient.
- A nursing diagnosis helps to identify nursing priorities. It also helps to direct nursing interventions based on the identified priorities.
- It helps to recognise how a patient or a group respond to actual or possible health processes and to know the available resources of strengths to combat the emerging issues.
- Nursing diagnosis helps to formulate the expected outcomes for quality assurance requirements of third-party payers.
- A nursing diagnosis provides a common language while still forming a basis for communication and understanding between nursing professionals and the healthcare team.
Types of nursing diagnosis.
There are four main types of nursing diagnoses.
- Problem-focused/actual diagnosis.
- Risk diagnosis.
- Health promotion diagnosis.
- Syndrome diagnosis.
- Other possible nursing diagnoses*
A problem-focused nursing diagnosis refers to a diagnosis that involves clinical judgement about human experiences/responses to health conditions/life processes that are occurring in an individual, family or community.
Components of actual diagnosis
There are 3 components of actual diagnosis namely:
- Nursing diagnosis.
- Related factors.
- Defining characteristics.
This type of diagnosis describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is often reinforced by risk factors that lead to increased vulnerability.
Components of risk diagnosis.
- Risk diagnostic label.
- Risk factors.
Health promotion diagnosis.
Health promotion diagnosis refers to a clinical judgement about motivation and desire to increase well-being. This type of nursing diagnosis is concerned with the individual, family, or community transition from a specific level of wellness to a higher level of wellness.
A syndrome diagnosis is a clinical judgement concerning a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event.
Example of this is an Alzheimer’s disease nursing diagnosis.
Possible nursing diagnosis*
Possible nursing diagnosis is not a type of diagnosis as are actual, risk, health promotion, and syndrome.
Possible nursing diagnosis refers to statements describing a supposed problem for which additional data are needed to confirm or rule out the suspected problem. It helps the nurse to communicate with other nurses that a diagnosis may be present but additional data collection is indicated to rule out or confirm the diagnosis.
To conclude, when writing nursing diagnostic statements, describe the health status of the individual and the factors that have contributed to the status. It is optional to include all types of diagnostic indicators.