Nursing diagnosis
Diagnosing is the second phase of the
nursing process. In this phase, nurses use critical thinking skills to
interpret assessment data and identify client strengths and problems.
The
term diagnosing refers to the reasoning process, whereas the term diagnosis is
a statement or conclusion regarding the nature of a phenomenon.
NANDA
nursing diagnosis
North
American nursing diagnosis association
The
purpose of NANDA is to define, refine and promote a taxonomy of nursing
diagnostic terminology of general use to professional nurses.
A
taxonomy is a classification system or set of categories arranged based on a
single principle or set of principles.
The
members of NANDA include staff nurses, clinical specialists, faculty, directors
of nursing, deans , theorists and researchers.
Types
of nursing diagnoses:
1. Actual Diagnosis: client problem that is present at
the time of the nursing assessment. Eg: ineffective breathing pattern, anxiety.
2. 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. Eg: risk for infection,
fall, injury
3. Wellness diagnosis: describes human responses to levels
of wellness in an individual, family or community that have a readiness for
enhancement. Eg: readiness for enhanced family coping.
4. Possible nursing diagnosis: is one in which evidence about a
health problem is incomplete or unclear.
Eg:
for an elderly widow who lives alone- possible social isolation related to
unknown etiology
5. Syndrome diagnosis: that is associate with cluster of
other diagnoses. Eg: risk for disuse syndrome for a long term bedridden
patients.
Clusters
of diagnoses associated with this syndrome include
Impaired
physical mobility
Risk
for impaired tissue integrity
Risk
for activity intolerance
Risk
for constipation, Risk for infection
Risk
for injury, Risk for powerlessness
Components
of a NANDA diagnosis
A
nursing diagnosis has three components
1. The problem and its definition
2. The etiology
3. Defining characteristics
1. Problem (diagnostic label) and definition
The problem statement or diagnostic label,
describes the clients health problem or response for which
nursing therapy is given.
The purpose of the diagnostic label is
to direct the formation of client goals and described outcomes.
Eg: deficient knowledge (medications,
dietary adjustments)
Qualifiers are words that have been added to
some NANDA labels to give additional meaning. Eg:
Deficient (inadequate in amount, quality, or
degree; not sufficient; incomplete)
Impaired (made worse, weakened, damaged,
reduced, deteriorated)
Decreased (lesser in size, amount or degree)
2. Etiology (related factors and risk
factors)
Identifies one or more probable
causes of the health problem, gives direction to the
required nursing therapy, and enables the nurse to individualize the client's
care. Eg:
Causes of activity intolerance include
sedentary lifestyle, generalized weakness and so on
3. Defining characteristics
Are
the cluster of signs and symptoms that indicate the presence
of a particular diagnostic label.
For actual nursing
diagnoses, the defining characteristics are the client signs and symptoms
For risk nursing
diagnoses no subjective signs are present.
Identification of client problems
Identifying
client problems helps to individualize nursing diagnoses, by focusing on the
more relevant data.
Formulation
of nursing diagnosis involves recognizing the specific health problem. Eg.
General
health problem - Problem
with elimination.
Specific
problem – Constipation
Nursing
diagnosis statement
Most
diagnosis are written as two part or three part statements, but there are
variations of these.
1. One part statements
2. Basic two part statements
3. Basic three part statements
One part statements
Some diagnostic statements, such as
wellness diagnoses and syndrome nursing diagnoses, consist of a NANDA
label only.
As the diagnostic labels are refined, they
tend to become more specific, so that nursing interventions can be described
from the label itself.
There fore, an etiology may not be needed.
eg
Readiness for enhanced parenting
Rape trauma syndrome
Basic
two part statements
It includes the following
1. Problems (P): statement of the clients response
(NANDA label)
2. Etiology (E): factors contributing to or probable
causes of the responses.
The two parts are joined by the
words related to rather than due to.
Basic three part statements
The
basic 3 part nursing diagnosis statement is called the PES format includes
the following:
1. Problems (P): statement of the clients response
(NANDA label)
2. Etiology (E): factors contributing to or probable
causes of the responses.
3. Signs and symptoms (S): defining characteristics manifested
by the client
Difference between medical and nursing
diagnosis
A nursing diagnosis is a statement of
nursing judgment and refers to a condition that nurse, by virtue of her
education, experience and expertise are licensed to treat
A medical diagnosis is made by a physician
and refers to a condition that only physician can treat.
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Nursing Diagnosis
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Medical Diagnosis
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Example
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Activity
intolerance related to decreased cardiac output.
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Myocardial
infarction
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Description
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Describe
human responses to disease process of health problem, consist of
one, two or three part statement, usually including problem and etiology.
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Describe
disease and pathology; physician responsible for diagnosing, diagnosis not
within the scope of nursing practice.
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Orientation
and responsibility for diagnosing.
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Oriented
to the individual; nurses responsible for diagnosing.
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Oriented
to pathology; physician responsible for diagnosing; Diagnosing not with the
scope of nursing practice.
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Nursing
focus
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Treat and
prevent
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Implement
medical orders for treatment and monitor status of condition.
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Nursing
action
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Independent
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Dependent
(primarily)
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Duration
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Can change
frequently
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Remains
the same while disease is present
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Classification
system
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Classification
system is developed and being used but is not universally
accepted
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Well
developed classification system accepted by the medical profession.
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COMMENTS