What is a nursing diagnosis?
Nursing diagnosis means identifying and categorizing patient problems. This diagnosis is based on the patient’s symptoms, clinical findings, and patient history. In this blog, we will discuss the nursing diagnosis process.
The purpose of nursing diagnosis is to form a distinct nursing language that will help the nurses assess, plan, and evaluate patient care.
What is NANDA-I?
NANDA-I, known as North American Nursing Diagnosis Association International, is a standardized nursing language that helps nurses to select the appropriate nursing diagnosis. In 1973, the first national conference was held on classification, and then, in 1982, NANDA was formed. In 2002, it became NANDA-I, which means North American Nursing Diagnosis Association International. It develops and updates standardized nursing diagnoses for nurses to perform worldwide.
Types of nursing diagnosis:
There are diverse types mentioned below
- Actual diagnosis
- Risk Diagnosis
- Health promotion diagnosis
- Syndrome diagnosis
Actual diagnosis:
Actual diagnosis is diagnosing a patient with an existing health problem. It consists of the patient’s existing signs and symptoms.
Example:
- Acute pain
- Ineffective breathing pattern
- Impaired gas exchange
Risk diagnosis
Risk nursing diagnosis is the type of diagnosis where patients are at risk of developing potential problems. This means that the problem has not occurred yet, but it might develop later. Risk diagnosis means that the patient is at risk of potential problems if preventive measures are not taken. An example of a risk diagnosis is given below.
Examples:
- Risk of fall due to weakness.
- Risk of infection
Health promotion diagnosis
Health promotion diagnosis focuses on how to improve a patient’s health. An example of health promotion is given below.
Examples:
- Enhanced self-care
- Enhanced nutrition
Syndrome Diagnosis
A complex clinical scenario is one in which a group of symptoms and a diagnosis cause certain illnesses. In syndrome diagnosis, multiple issues should be managed simultaneously.
Examples:
- Post-trauma syndrome
- Frailty Syndrome
- Impaired Environmental Interpretation Syndrome
Components
Nursing diagnosis consists of the PES format.
- Problem
- Etiology
- Symptoms
Example: Acute pain
Problem: What is the problem? The problem is acute pain.
Etiology: What is causing the problem? The cause of acute pain is surgical incision.
Symptoms: What are the symptoms or evidence that support the diagnosis? Pain around the incision and frowning.
Steps of nursing diagnosis
5 key steps include:
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Assessment:
Collecting both subjective and objective information about the patient. This includes the physical, vital signs, psychological, social, and spiritual health of the patient. Make sure that the data you collect is accurate by cross-checking it with patients and family members.
Diagnosis:
Use the data that is collected during the assessment to identify the health issues. Diagnosis is a bridge between assessment and planning. Nurses analyze the data that is collected through assessment so that they can form effective care plans for the patients.
Planning:
Develop a nursing care plan based. Follow the smart goals while forming the care plan. Smart goals stand for specific, measurable, achievable, relevant, and time-bound. The comprehensive care plan should be made by collaborating with patients, their family members, and other healthcare workers.
Implementations:
Implementation means putting it into action. Once you produce a comprehensive care plan for the patient, put the plan into action. Record patient response to the patient care plan.
Evaluation:
The last step is evaluation. See how the patient responds to the care plan and make changes if necessary. You can modify the care plan until you achieve the patient’s health goal.
Nursing diagnosis vs medical diagnosis
- Nursing diagnosis: focuses on patient’s response to health conditions and how it affects their daily life. The role is to make a care plan that is according to the patient’s needs and improves their quality of life.
- Medical diagnosis: Focuses on identifying the diseases or problems that are causing the symptoms.
Who is able to make a nursing diagnosis?
Registered nurses (RNs) and advanced practice nurses (APNs) both can do it.
Conclusion:
Nursing diagnosis is an important part of personalized patient care. It is important to understand the distinct types and it should follow the NANDA-I standards. The goal should be to focus on the patient’s problems and form a care plan that meets the patient’s needs to achieve health goals.
Nursing Diagnoses: Definitions and classification | NANDA International, Inc
