A guide to nursing diagnosis.

What is a nursing diagnosis?

A nursing diagnosis may be part of the nursing process. It is defined as a clinical judgment about an individual, family, or community experiences to actual or potential health problems. It provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse has accountability. A Nursing diagnosis is designed from information collected by the nurse during nursing assessment. Therefore, it enables a nurse to develop a nursing care plan.

This is a guide to nursing diagnosis which focuses on teaching you everything you need to know to become a master in nursing diagnosis.

Objectives of a nursing diagnosis.

  1. To help identify nursing priorities and help direct nursing interventions based on priorities.
  2. It aids in the formulation of expected outcomes for quality assurance requirements for third party payers.
  3. It helps to identify how a group reacts to actual or potential health and life processes and knowing the resources that can be used to prevent or resolve problems.
  4. Provides a common language and forms a basis for communication and understanding between nursing professionals and the healthcare team.
  5. Provides a basis of assessment to determine if nursing care was beneficial to the client and cost-effective.
  6. It serves as a teaching tool to aid sharpen problem-solving and critical thinking skills of nursing students.

 

The difference between nursing diagnosis, medical diagnosis, and collaborative problems.

Nursing diagnosis can refer to three different concepts. Firstly, it can refer to the second step in the nursing process. Secondly, it may refer to the label when nurses assign meaning to collected data appropriately labeled with NANDA nursing diagnosis. Lastly, a nursing diagnosis can refer to one of the many diagnoses in the classification system established and approved by NANDA. On the other hand, a medical diagnosis is made by a medical practitioner who deals more with the medical condition or pathological state only a practitioner can treat. The precise clinical entity can be taken with experience. This is used to administer proper medication that would cure the illness. Medical diagnosis normally does not change. Thus, nurses are required to follow physician’s orders and carry out the prescribed treatments.

Collaborative problems are physiological complications for which a client may be at risk based on their medical diagnosis, medical treatment, or diagnostic studies. These problems require both medical and nursing interventions. Moreover, the nursing aspect is focused on monitoring the patient’s condition and preventing the development of potential complications.

nursing diagnosis

 

Types of nursing diagnoses.

There are four types of nursing diagnoses and include:

  • Actual (problem-focused).
  • Risk.
  • Syndrome.
  • Health promotion.

         i.            Actual or problem-focused diagnosis.

It refers to a patient problem that is present at the time of nursing assessment. These diagnoses are based on the presence of associated signs and symptoms.

Components of problem-focused nursing diagnosis.

  1. Anxiety: Related to stress as evidenced by increased tension, apprehension, and expression of concern regarding the upcoming surgery
  2. Ineffective Breathing: Pattern related to pain as evidenced by pursed-lip breathing, reports of pain during inhalation, and use of accessory muscles to breathe
  3. Acute Pain: Related to decreased myocardial flow as evidenced by grimacing, expression of pain, and guarding behavior.
  4. Impaired Skin Integrity: Related to pressure over a bony prominence as evidenced by pain, bleeding, redness, and wound drainage.

       ii.            Risk Nursing Diagnosis.

These are clinical arguments that a problem does not exist. However, the presence of risk factors indicates that a problem is likely to occur unless we intervene.

     iii.            Syndrome diagnosis.

It is a clinical judgment concerning a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain event.

     iv.            Health promotion diagnosis.

It is a clinical judgment about motivation and desire to increase well-being. Therefore, it is also known as wellness diagnosis.

Possible nursing diagnosis.

This is not a type of diagnosis. These are statements that describe a suspected problem for which additional data is needed to confirm or rule out the suspected problem.

Components of a nursing diagnosis.

A nursing diagnosis consists of three components namely:

  1. Problem and definition.
  2. Risk factors.
  3. Defining characteristics.

How to diagnose.

The diagnostic process consists of three stages:

1.      Analyze data.

Data analysis involves comparing patient standards, clustering cues, and identifying inconsistencies.

2.      Identifying health problems, risks, and strengths.

This is a decision-making step. During this step, the nurse focuses on determining whether a problem is a nursing diagnosis, medical diagnosis, or a collaborative problem.

3.      Formulating diagnostic statements.

This is the last step of the diagnostic process. During this step, the nurse designs diagnostic statements.

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