Master the concepts behind formulating nursing diagnosis in this ultimate guide! Learn about the different types of nursing diagnosis, how to write them correctly, and the difference of medical and nursing diagnoses. Lastly, we’ll give some tips on how you can formulate better nursing diagnosis!
- 1 What is a nursing diagnosis?
- 2 Nursing Processes
- 3 Types of Nursing Diagnoses
- 4 Difference of Medical and Nursing Diagnoses
- 5 How to Write Nursing Diagnosis?
What is a nursing diagnosis?
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses are developed based on data obtained during the nursing assessment.
NANDA-International earlier known as the North American Nursing Diagnosis Association is the principal organization for defining, distribution and integration of standardized nursing diagnoses worldwide.
In the diagnostic process, the nurse is required to have critical thinking. Apart from the understanding of nursing diagnoses and their definitions, the nurse promotes awareness of defining characteristics and behaviors of the diagnoses, related factors to the diagnoses, and the interventions suited for treating the diagnoses
What data is collected? The first step of the nursing process is assessment. When the nurse first encounters a patient, the former is expected to perform an assessment to identify the patient’s health problems as well as the physiological, psychological, and emotional state. The most common approach to gathering important information is through an interview. Physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to collect assessment data.
What is the problem? Once the assessment is completed, the nurse will take all the gathered information into consideration and diagnose the patient’s condition and medical needs. This involves a nurse making an educated judgment about a potential or actual health problem with a patient. More than one diagnoses are sometimes made for a single patient.
How to manage the problem. When the nurse, any supervising medical staff, and the patient agree on the diagnosis, the nurse will plan a course of treatment that takes into account short- and long-term goals. Each problem is committed to a clear, measurable goal for the expected beneficial outcome.
Putting plan into action. The implementing phase is when the nurse put the treatment plan into effect. This typically begins with the medical staff conducting any needed medical interventions. Interventions should be specific to each patient and focus on achievable outcomes. Actions associated in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or conducting important medical tasks, educating and guiding the patient about further health management, and referring or contacting the patient for a follow-up.
Did the plan work? Once all nursing intervention actions have taken place, the team now learns what works and what doesn’t by evaluating what was done beforehand. The possible patient outcomes are generally explained under three terms: patient’s condition improved, patient’s condition stabilized, and patient’s condition worsened. Accordingly, evaluation is the last, but if goals were not sufficed, the nursing process begins again from the first step.
Types of Nursing Diagnoses
Here are the five categories/structures of nursing diagnosis provided by NANDA-I system:
A problem diagnosis (or also called actual diagnosis) is a client problem that is present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms. Examples: Ineffective Breathing Pattern and Anxiety, Acute Pain, and Impaired Skin Integrity.
Risk Nursing Diagnosis
A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client’s health status.
Wellness Diagnoses (or also called health promotion diagnosis) describe human responses to levels of wellness in an individual, family or community that have a readiness for enhancement. Examples of wellness diagnosis would be Readiness for Enhanced Spiritual Well Being or Readiness for Enhanced Family Coping.
A syndrome diagnosis is associated with a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event. Example is Rape Trauma Syndrome.
Possible Nursing Diagnosis
Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem. A possible nursign diagnosis also provides the nurse the ability to communicate to other nurses that a diagnosis may be present but additional data collection is indicated to rule out or confirm the diagnosis. Examples include Possible Chronic Low Self-Esteem, Possible Social Isolation.
Difference of Medical and Nursing Diagnoses
What is Nursing Diagnosis?
The term nursing diagnosis is associated with three different concepts. It may refer to the distinct second step in the nursing process, diagnosis. Also, nursing diagnosis applies to the label when nurses assign meaning to collected data appropriately labeled with a NANDA-approved nursing diagnosis. During the assessment, the nurse may recognize that the client is feeling anxious, fearful, and finds it difficult to sleep. It is those problems which are labeled with nursing diagnoses: respectively, Anxiety, fear, and Disturbed Sleep Pattern. Lastly, a nursing diagnosis refers to one of many diagnoses in the classification system established and approved by NANDA. In this context, a nursing diagnosis is based upon the response of the patient to the medical condition. It is called a ‘nursing diagnosis’ because these are matters that hold a distinct and precise action that is associated with what nurses have autonomy to take action about with a specific disease or condition. This includes anything that is a physical, mental, and spiritual type of response. Hence, a nursing diagnosis is focused on care.
What is a medical diagnosis?
A medical diagnosis, on the other hand, is made by the physician or advance health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat. Moreover, through experience and know-how, the specific and precise clinical entity that might be the possible cause of the illness will then be undertaken by the doctor, therefore, providing the proper medication that would cure the illness. Examples of medical diagnoses are Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. The medical diagnosis normally does not change. Nurses are required to follow the physician’s orders and carry out prescribed treatments and therapies.
As explained above, now it is easier to distinguish nursing diagnosis from that of a medical diagnosis. Nursing diagnosis is directed towards the patient and his physiological and psychological response. A medical diagnosis, on the other hand, is particular with the disease or medical condition. Its center is on the illness.
How to Write Nursing Diagnosis?
Diagnostic statement describes the health status of an individual and the factors that have contributed to the status. Diagnostic statements can be one-part, two-part, or three-part statements.
Wellness nursing diagnoses are written as one-part statements because related factors are always the same: motivated to achieve a higher level of wellness. Syndrome diagnoses also have no related factors. Examples include:
Risk and possible nursing diagnoses have two-part statements: the first part is the diagnostic label and the second is the validation for a risk nursing diagnosis or the presence of risk factors. It’s not possible to have a third part for risk or possible diagnoses because signs and symptoms do not exist. Examples include:
- Risk for Infection related to compromised host defenses
- Risk for Injury related to abnormal blood profile
- Possible Social Isolation related to unknown etiology
An actual or problem nursing diagnosis have three-part statements: diagnostic label, contributing factor (“related to”), and signs and symptoms (“as evidenced by”). Three-part nursing diagnosis statement is also called the PES format which includes the Problem, Etiology, and Signs and Symptoms. Examples include:
- Impaired Physical Mobility related to decreased muscle control as evidenced by inability to control lower extremities.
- Acute Pain related to tissue ischemia as evidenced by statement of “I feel severe pain on my chest!”
Variations on Basic Statement Formats
Variations in writing statement formats include the following:
- Using “secondary to” to divide the etiology into two parts to make the diagnostic statement more descriptive and useful. Following the “secondary to” is often a pathophysiologic or diseases process or a medical diagnosis. For example: Risk for Decreased Cardiac Output related to reduced preload secondary to myocardial infarction.
- Using “complex factors” when there are too many etiologic factors or when they are too complex to state in a brief phrase. For example: Chronic Low Self-Esteem related to complex factors.
- Using “unknown etiology” when the defining characteristics are present but the nurse does not know the cause or contributing factors. For example: Ineffective Coping related to unknown etiology.
- Specifying a second part to the general response or NANDA label to make it more precise. For example: Impaired Skin Integrity (Right Anterior Chest) related to disruption of skin surface secondary to burn injury.