Nursing diagnosis refers to a clinical judgement of a human being response to normal life process or the susceptibility of the response to another person, group and community. It provides a baseline for nurses to choose nursing interventions and drive specific outcomes that make the nurse liable at every step. Nursing diagnosis are dependent on data sourced out from nursing assessment that create a proper care plan for the patient.
The purpose of nursing diagnosis is guide nursing interventions as per the identified priorities. Nursing diagnosis plays a vital role in helping nurse’s determine how a given patient responds to an actual life process or a critical life threatening process. It provides a unifying language that offers a two-way communication between the nurses and health professionals.
Nursing diagnosis refers to the second step of any nursing process that aligns itself to how nurses give meaning to data collected during assessment of a patient. The meaning follows the NANDA-1 that has been approved by the nursing council. It refers to accurately determining the diagnosis bases on the classification that has been accepted by NANDA. It is focused on care and take account of the precision in taking action on a given condition or disease. A medical diagnosis focuses on the underlying disease or condition affecting the patient. Advanced medical professionals are charged with the responsibility of dealing with the specific disease by giving the correct treatment that leads to a cure.
North American Nursing Diagnosis Association is an organization charged with the responsibility of defining and incorporation of nursing diagnosis across the world. Mary Ann and Kristine Gebbie are some of the pioneers of NANDA. Conferences held between 1975 and 1980 lead to the development of NANDA that was inaugurated in 1982. In 2002 the group was recognized and expanded to other parts of the world. New nursing diagnosis are reviewed and refined every year and entered into the existing database for application and learning purposes by nurses.
The growth of the nursing professional and new technology led to the desire to have standard nursing language for diagnosis. World-war II came to an end leading to the demand for nurses to help physicians in diagnosis. Nurses were elevated to another status that had value apart from the traditional physicians. Nursing diagnosis had to be reshaped to direct nurses in the clinical practice and identify the differences with medical diagnosis that was left to advanced medical professionals. Louise MacManus and Virginia Fry introduced the nursing diagnosis terms that were to be used by nurses in 1953. Nursing was identified as an independent domain through a legislation act by New York State Nurse Practice Act. Mary Ann and Kristine Gebbie are some of the pioneers of NANDA. Conferences held between 1975 and 1980 lead to the development of NANDA that was inaugurated in 1982. In 2002 the group was recognized and expanded to other parts of the world. New nursing diagnosis are reviewed and refined every year and entered into the existing database for application and learning purposes by nurses. Today in 2020 the organization has approved more than 244 diagnosis for nurses to use in their clinical practice.
The classification of nursing diagnosis adheres to Taxonomy II that defines how the diagnosis are listed and classified. Taxonomy II was borrowed from the work of Dr. Mary Gordon who pioneered the functional health patterns assessment framework. The taxonomy has three main levels: domains made of thirteen phases, fourteen seven classes and nursing diagnosis. Nursing diagnosis deviate from the functional health patterns assessment framework and follow a code made of seven axes. The axes include: time, diagnosis tic concept, descriptor, topology, age and health status.
Nursing process is made up five main steps: assessment, diagnosis, planning, implementation and evaluation. The nursing diagnosis is the second step that involves the nurse in thinking and application of nursing diagnosis definitions. Nurses determine the behavior, characteristics, factors related to the diagnoses then assign the best interventions.
Assessment refers to the step taken by nurses when a patient arrives at their desk. Nurses are required to perform a detailed examination or assessment to determine the patient’s underlying health problems .One further analyzes the emotional , psychological and physiological state of the patient .Nurses use interviews ,observation and physical examination to source out information from the patient .
The nurses used the assessment data to determine the problem with the patient. Nurses use all the data collected and use it to diagnose the condition that needs medical attention. One has to make a judgement on the problem affecting the patient that can be one or more diagnosis.
Nurses and advanced medical professionals have to agree on the diagnosis and determine how best to deal with or manage the issue. The treatment uses short and long term goals that have to come out at the end of the treatment.
The fourth step of the nursing process requires the nurses to put the management plan to action. Medical professionals are involved in setting up the interventions that should be detailed and specific to the goals or outcomes. Other actions linked to nursing care plan include monitoring of changes and educating the patient.
The last step is to determine if the nursing intervention used to deal with the issue has been dealt with by checking if the patient exhibits the expected outcomes. Patient must show signs that he or she has improved, stable or worsened after the intervention. If the patient falls in the third category then the intervention failed.
There are four types of nursing diagnosis according to NANDA: problem focused, risk nursing diagnosis, health promotion diagnosis and syndrome diagnosis.
It is a diagnosis in which the problem presents itself during nursing assessment. The diagnosis is based on the patient presenting signs and symptoms associated with the condition. It is made up of three parts nursing diagnosis, associated factors and defined characteristics.
Risk diagnosis refers to making a clinical judgement where one has not identified the problem at hand but there are risk factors that can result in a problem .A patient is more likely to develop the problem compared to others in the group. It is made up of risk diagnostic label and risk factors. Example elderly patients are more likely to suffer from risk injury.
Health promotion or wellness diagnosis is focused on improving a person, family unit or community to a desired level of wellness. One makes a diagnosis to improve the health status of the patient or increase the level of wellness. It is made of one part statement. For example readiness for enhanced family coping.
Syndrome diagnosis refers to making a clinical judgement based on a cluster of a presenting problem. Are predictable due to occurring events and consist of one statement. For example post trauma syndrome.
Possible nursing diagnosis refer to statements that give a description of a potential problem that requires more data to confirm the presence of that problem. Nurses use possible nursing diagnosis to communicate with other medical professionals on the presence of a problem but more information is needed to confirm or rule out the problem. Example possible respiratory condition.
Nursing diagnosis are made up of three main components: problem and definition, etiology and defined characteristics.
The problem gives a description of the patient underlying issue or response that can be tackled using nursing therapy. The diagnostic label is made up of a qualifier and focus what is being diagnosed. Qualifier are attached to the diagnostic labels to derive more meaning.
Etiology refers to the risk factors thus can be defined as key components of nursing diagnosis that are label that identify probable cause of a health problem. It gives direction on how to apply the nursing therapy. The nursing interventions target the etiological factors so that it removes the cause the identified diagnosis.
The signs and symptoms that are associated with or linked to a specific diagnostic label. Actual diagnosis – characteristics of the identified signs and symptoms of the patient while risk diagnosis the signs and symptoms are not present thus the factors make the patient susceptible to the issue.
The diagnostic process has three main parts data analysis, identification of health problems and formulation of diagnostic statements.
This process involves comparing the client’s data with existing standards, clustering and identifying any discrepancies.
This process involves making key decisions after analyzing the data. Nurses engage the patient in identifying the problems, and support depending on the outcome of the diagnosis. One has to determine if the problem is a nursing diagnosis or a medical diagnosis.
This process involves the creation of the diagnostic statements marking the end of the diagnostic process. The statements can be used to yield a nursing intervention or shared with advanced medical professionals.
Nurses are required to give a description of the health status of a person and outline some of the factors that might have contributed to the condition. One describes the diagnosis in form of three statements one-part, two part and three part diagnosis using the PES format.
This type of statement is written according to the associated factors and link to the problem. One desires to achieve a desired point of wellness. Example rape trauma syndrome.
This statement have two parts to as a diagnosis. The diagnostic label and validation for the risk nursing diagnosis. It is used when there no signs and symptoms and a third part cannot exist. For example risk of injury associated with abnormal blood outline.
Detonated by an actual nursing diagnosis, made up of diagnostic label, signs and symptoms and contributing factors. It also known as PES format –problem, etiology and signs and symptoms. Acute pain in a case of hypertension is evidenced by a persistent throb in the head and sleepiness, patient reports not sleeping and changes appetite. Others can have nausea, vomiting, and blurred vision and nick stiffness. The basic formats can change to have vary using secondary factors that divided etiology.
Imbalanced body requirements -NANDA defines imbalanced body requirements as the intake of human nutrients that are in excess of metabolic needs.
Anckley, B. J. (2019). Nursing diagnosis handbook: an evidence-based guide to planning care Ed 11 (77).
Karaca, T. &. (2018). Effect of ‘nursing terminologies and classifications’ course on nursing students’ perception of nursing diagnosis. Nurse education today 67 , 114-117.
Kurucová, R. Ž. (2018). CLINICAL VALIDATION OF NURSING DIAGNOSIS OF ACUTE PAIN. Central European Journal of Nursing and Midwifery, 9(1), 781-790.
Shimomai, K. F. (2018). The difficulty of selecting the NANDA‐I nursing diagnosis (2015–2017) of “Death Anxiety” in Japan. International journal of nursing knowledge, 29(1), 4-10.
Guedes, N. G. (2013). Review of nursing diagnosis sedentary lifestyle in individuals with hypertension: conceptual analysis. Rev Esc Enferm USP, 47(3), 734-41.
Ioannidis, J. P. (2018). Diagnosis and treatment of hypertension in the 2017 ACC/AHA guidelines and in the real world. Jama, 319(2), 115-116.