Today our topic of discussion is Nursing Diagnosis.

Table of Contents

Nursing Diagnosis

Nursing Diagnosis:

Since 1973, a group of nurse researchers and educators formulated plans to standardize communication and categories of nursing care. Before this standardization, descriptions of nursing care differed both between hospitals and also within one hospital because nurses literally invented their own descriptions of nursing-related concerns for clients.

In 1982, with members from Canada and the United States, the group became known as the organization North American Nursing Diagnosis Association (NANDA). The nursing diagnosis serves the following purposes: In 2002, the organization was revised and became NANDA-I International (NANDA-1) using an updated model of health called Taxonomy II.

Nursing diagnosis is actual or potential problems that are amenable to resolution by nursing actions are identified as nursing diagnosis.
The five national conferences on the classification of nursing diagnosis held in 1970’s and the early 1980’s have provided an impetus for the identification and classification of nursing diagnosis according to symptomatology.
When developing the nursing diagnosis for a particular Is of help when making staff assignments. patient, the nurse must first identify the commonalities among the assessment data-collected. These common features lead to the categorization of related data that reveal the existence of a problem and the need for nursing intervention. The patient’s nursing problem is then defined as the nursing diagnosis.
It must be remembered that nursing diagnosis are not medical diagnosis, they are not medical treatments prescribed by the physician; they are not diagnostic.
They are not the equipment utilized to implement medical therapy.They are not the patient’s actual or potential health problems that are amenable to resolution by nursing actions. Nursing diagnoses that are succinctly stated in terms of the specific problems of the patient will guide the nurse in the development of the nursing care plan.

Purpose of Nursing Diagnosis:

Identifies nursing priorities
Directs nursing interventions to meet the client’s high-priority needs
Provides a common language and forms a basis for communication and understanding between nursing professionals and the healthcare team.
Guides the formulation of expected outcomes for quality assurance requirements of third-party payers.
Provides a basis of evaluation to determine if nursing care was beneficial to the client and cost effective.

Diagnostic Reasoning

Classification:

The initial step of data analysis is classification of the data. Data need to be organized in order to be clearly analyzed and the most logical means to organize data is to classify them. The body systems approach functional health pattern approaches are two convenient methods of classification. When these methods are used for taking a history and performing a physical examination, the data are already classified.

Validation:

The next step of data analysis is validation. In this step the nurse verifies the diagnosis by speaking to the client. The nurse can validate finding with the family. especially if the client is unable to communicate. For example, the nurse could ask about scars or wounds and therefore, expand the data base on the client. The nurse can also validate the diagnosis by comparing it to textbook Problems can be managed material or by talking to other nurses.

Inductive versus deductive reasoning:

The nurse may use inductive or deductive reasoning to interpret data. Inductive reasoning begins with a set of facts from which a conclusion is drawn. Inductive reasoning is the use of cues to draw a conclusion.

Deductive reasoning begins with the facts that the client is on bed rest and taking narcotics and concludes (deduces) that the client is at an increased risk

Errors in Diagnosis

Incomplete data: Common cause of incomplete data occurs during the interview phase of assessment. Some clients withhold information intentionally because some they feel embarrassed or are unsure how the nurse would react to the information.

Inaccurate interpretation: Data from the client can be misinterpreted in several ways. The problem can be diagnosed in several ways. The problem can be diagnosed before the data are completely collected. Sometimes the nurse can have a personal prejudice about the client

Lack of knowledge or experience: The clinical experience and knowledge may result in inaccurate data processing. Failure to recognize a problem is a common experience for most nurses. The inexperienced nurse may overlook important data or fail to realize the significance of the data.

Using a Nursing Diagnosis

The diagnosis is anything abnormal or that concerns the client, or strengthens of the client. Diagnoses within the realm of nursing are the response of the client to a state of health or illness and include physical, psychological, same thing
spiritual and educational areas These nursing diagnosis and their treatment are within the legal scope of nursing practice. The actual conditions that nurses are educated to handle and licensed to treat are called nursing diagnosis
The role of the nurses can vary greatly between settings; there has always been difficulty in describing the work in nursing, NANDA has provided national leadership in the development of standardized statements or nursing diagnosis, to describe human response to actual or potential health problems which nurses treat.

Writing a Nursing Diagnosis

A nursing diagnosis should be written in three parts indicating the human response, related factors and defining characteristics.

Human response:

The human response is the client’s problem attached as a nursing diagnosis. Most nurses use NANDA nursing diagnosis as the human response statement, but other form of problem statements are possible.

The human response should always be stated as a response to care rather than as a need for care. Needs for care such as needs to be fed or needs to be turned every 2 hours, describe a nursing intervention rather than a client problem.

The related factors:

The related factors are the possible causes or etiology of the problem. This section of the statement describes the factors associated with the problem. These factors may be environmental, psychological, physiological, sociocultural or spiritual.

Because these factors direct nursing actions aimed at resolving, preventing or reducing the problem, the related factor should be directed at an aspect of the client response on which the nurse have an impact.

The defining characteristics are the data indicating the problem is present. When the client is at risk of developing a problem, the risk factors are identified rather than defining characteristics.

Ten Rules for Writing a Nursing Diagnosis

Write the diagnosis in terms of the client’s response rather than nursing need.
Use “related to” rather than “due to” or “caused by” to connect the first two parts of the statement.

Write the diagnosis in legally advisable terms.
Write the diagnosis without value judgments.
Avoid reversing the parts of the statement.
Avoid using single cues as the first part of the statement.
The two parts of the statement should not mean the
Express the related factor in terms that can be changed.
Do not include the medical diagnosis in the nursing diagnosis.

State the diagnosis clearly and concisely.

Collaborative Problems

As nurses have continued to work with nursing diagnosis shortcomings of the system have been identified
Carpenito defines collaborative problems as the psychological complications that have resulted or may result from the pathophysiologic and treatment related conditions, and from other situations.
Nurses monitor to detect the onset and status of complications and collaborate with physicians in treatment.