Nursing diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
A nursing diagnosis is a standardized statement about the health of a client (who can be an individual, a family, or a community) for the purpose of providing nursing care. Nursing diagnoses are developed based on data obtained during the nursing assessment.
The main organization for defining standard diagnoses in North America is the North American Nursing Diagnosis Association, now known as NANDA-International. Other international associations are AENTDE (Spanish), AFEDI (French language) and ACENDIO (Europe).
Nursing diagnoses are part of a movement in nursing to standardize the terminology involved. This includes standard descriptions of diagnoses, interventions and outcomes. Nurses who support of standardized terminology believe that it will help nursing become more scientific and evidence-based. Other nurses feel that nursing diagnoses are an ivory tower mentality and neither help in care planning nor in differentiating nursing from medicine.[1]
Structure of diagnoses
The NANDA-International system of nursing diagnosis provides for five categories.
- Actual diagnosis - a statement about a health problem that the client has and the benefit from nursing care. An example of an actual nursing diagnosis is: Ineffective airway clearance related to decreased energy as manifested by an ineffective cough.
- Risk diagnosis - a statement about health problems that a client doesn't have yet, but is at a higher than normal risk of developing in the near future. An example of a risk diagnosis is: Risk for injury related to altered mobility and disorientation.
- Possible diagnosis - a statement about a health problem that the client might have now, but the nurse doesn't yet have enough information to make an actual diagnosis. An example of a possible diagnosis is: Possible fluid volume deficit related to frequent vomiting for three days as manifested by increased pulse rate.
- Syndrome diagnosis - used when a cluster of nursing diagnoses are seen together. An example of a syndrome diagnosis is: Rape-trauma syndrome related to anxiety about potential health problems as manifested by anger, genitourinary discomfort, and sleep pattern disturbance.
- Wellness diagnosis - describes an aspect of the client that is at a low level of wellness. An example of a wellness diagnosis is: Potential for enhanced organized infant behaviour, related to prematurity and as manifested by response to visual and auditory stimuli.
Process of diagnoses
- Collect data - statistical data relevant to achieving a diagnosis.
- Cues/patterns - changes in physical status. (for example: lower urinary output)
- Hypothesis - possible alternatives that could have caused previous cues/patterns.
- Validation - taking necessary steps to rule out other hypothesis, to single out one problem.
- Diagnosis - making a decision on the problem based on validation.
- Strategies - taking necessary action to solve the problem and/or to provide adequate nursing care.[2]
See also
References
- ↑ Anderson, K. N. (1998). Mosby's Medical, Nursing & Allied Health Dictionary. pp. 1975–2035. ISBN 0-8151-4800-3.
- ↑ Watson and Royle (1987). Watson's Medical-Surgical Nursing and Related Physiology. Baillère Tindall. ISBN 0-7020-1190-8.
- A. G. Perry, P. A. Potter: Canadian Fundamentals of Nursing. 2nd ed. Mosby, Toronto, ON, 2001, ISBN 0-920513-40-9