What is nursing diagnosis?
Nursing Diagnosis is the second phase of the nursing process.
It is an interpretation and analysis of the data collected by the nurse about the patient during the assessment phase.
What is the standard definition of the nursing diagnosis?
NANDA-International defines nursing diagnosis as follows:
“A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”.
What are the components of a nursing diagnosis?
These are the three main components of a nursing diagnosis:
- Defining Characteristics
It describes the essence of the client’s problem for which nursing therapy is given.
It contains the diagnostic label such as:
- Feeding Self-Care Deficit
- Stress Urinary Incontinence
The Problem is also expounded by qualifiers that give more details to the diagnostic label.
It describes the characteristics of the diagnostic label. For every diagnostic label approved by NANDA, there is a definition. For example, Hypothermia is a body temperature below normal range.
3. Defining Characteristics
These are set of clinical cues forming a cluster that is present if the diagnosis is accurate. For actual nursing diagnosis, the defining characteristics are the client’s signs and symptoms.
What are the types of diagnostic statements?
- Actual nursing diagnosis
Acute Pain related to surgical trauma and inflammation as evidenced by facial grimacing and verbal reports of pain
It includes diagnostic label, related factors and defining characteristics. It defines a human response to a health problem that is actually experienced.
- Risk nursing diagnosis
Risk for Infection related to immunosuppression
It includes diagnostic label and risk factors. Risk nursing diagnosis describes health conditions or life processes that may develop in a vulnerable client.
- Possible nursing diagnosis
Possible Self-Esteem Disturbance related to unknown cause
It includes diagnostic label and related factors. A possible nursing diagnosis is made when not enough information supports a highly probable problem that the nurse wants to explore in-depth.
- Wellness diagnosis
Readiness for Enhanced Spiritual Well-being
It includes diagnostic label.It describes human responses to levels of wellness.
How to formulate a nursing diagnosis?
These are the processes involved in creating a nursing diagnosis:
- Analyzing Data
Analyzing data involves comparing data against standards, clustering the cues and identifying inconsistencies.
The nurse may take note of changes in client’s health pattern (body temperature abnormalities); variations from the general norm (eating very small meals and having little appetite); and evidences of developmental delays.
- Identifying Health Problems, Risks and Strengths
After clustering the client data according to specific models and frameworks of health, the nurse determines whether the possible problem disappears when clustered with other data.
For example, Decreased Urinary Frequency and Amount x 2 days is a problem alone but when clustered with Deficient Fluid Volume, it can be eliminated.
You also have to identify strengths that can aid in recovery.
- Formulating Diagnostic Statements
Most nursing diagnosis are written in the following formats:
Problem – Etiology (PE) Format
Constipation related to prolonged laxative use
Anxiety related to threat to physiological integrity: possible cancer diagnosis
Problem – Etiology – Signs and Symptoms (PES) Format
Situational Low Self-Esteem related to feelings of rejection by husband as evidenced by hypersensitivity to criticism; states “I don’t know if I can manage by myself” and rejects positive feedback
One Part Statement
Readiness for Enhanced Parenting
Risk for Disuse Syndrome
These usually begin with the diagnostic label Potential Complication.
Potential Complication of Head Injury: increased intracranial pressure
Potential Complication of Pregnancy-Induced Hypertension: seizures, fetal distress, pulmonary edema, hepatic/renal failure, premature labor, CNS hemorrhage
- Nursing diagnosis is a collection of assessment data.
- The processes involved in creating a nursing diagnosis are analyzing data, identifying health problems, risks and strengths and formulating diagnostic statements.
- A nursing diagnosis consists of the problem (and its definition), the etiology, and the defining characteristics.