WHAT IS NURSING DIAGNOSIS?
As a nurse, you will agree that nursing diagnosis is a major foundation of the nursing practice. It is one of the four components of the nursing process. Nursing diagnosis provides a framework for the selection of nursing interventions to achieve outcomes for which the nurse is accountable to (Vera, 2019). NANDA International (2013) defines nursing diagnosis as a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community. It may also be described as a statement indicating several different potential or perceived problems a patient might face (Roseman University of Health Sciences, 2014).
IS NURSING DIAGNOSIS DIFFERENT FROM MEDICAL DIAGNOSIS?
Dr. T. Heather Herdman, CEO and Executive Director of NANDA simply states “A medical diagnosis is a concept that defines a disease process or injury” and “nursing diagnoses describe human response to potential or actual health problems”. So, for example, a person may have a medical diagnosis of Myocardial Infarction and one of the corresponding nursing diagnoses may be “imbalanced nutrition more than body requirement” which indicates obesity.
TYPES OF NURSING DIAGNOSIS
There are four types of nursing diagnosis according to NANDA.
Problem-focused or Actual Nursing diagnosis: an actual or problem-focused nursing diagnosis refers to clinical judgement about patient’s current health problem that is evident at the time of nursing assessment, verified by presence of the major defining symptoms, signs and characteristics, and would benefit from nursing care.
Problem-focused nursing diagnosis has three main components; nursing diagnosis, related factors and defining characteristics. Example: Impaired physical mobility related to decreased muscle control as evidenced by inability to control lower extremities.
Risk Nursing Diagnosis: Risk nursing diagnosis is a clinical judgement about a client’s health problem that does not exist but there are risk factors that may cause the problem to develop except when nurses intervene. Example of Risk nursing diagnosis is: ‘risk for infection related to compromised immune system or diabetes’.
Syndrome Nursing Diagnosis: A syndrome nursing diagnosis statement is a clinical judgment, which is associated with a collection of predicted high-risk or actual nursing diagnosis, related to a certain situation or event. The five types are: post-trauma syndrome, rape trauma syndrome, relocation stress syndrome, impaired environmental interpretation syndrome and disuse syndrome. Example: Rape trauma syndrome manifested by sleep pattern disturbance, anger and genitourinary discomfort and related to feeling anxious about possible resulting health problems.
Wellness Nursing Diagnosis or Health Promotion Nursing Diagnosis: Health promotion nursing diagnosis is a clinical judgment about motivation and desire to increase well-being of an individual, family or community. The individual, family or community must possess effective present function or status and demonstrate a desire to increase their wellness. Example: “Readiness for Enhanced Family Coping”.
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COMPONENTS OF NURSING DIAGNOSIS
A nursing diagnosis has basically three components; the Problem statement or diagnostic label, the Etiology and the Signs and symptoms.
PROBLEM STATEMENT: The problem statement or diagnostic label indicates the client’s problem or response for which requires nursing intervention. This also has two parts that is, the focus of diagnosis and the modifiers or qualifiers. For example, in the following nursing diagnosis “Risk for injury related to impaired sensory function of vision as evidence by patient is blind in both eyes”, the focus of diagnosis is the “injury” and the qualifier is the “Risk for”.
Qualifier/Modifier Focus of the Diagnosis
Deficient Fluid volume
Imbalanced Nutrition: Less Than Body Requirements
Impaired Gas Exchange
Risk for Injury
ETIOLOGY/RELATED FACTORS/RISK FACTORS: This is the “related to” portion of the nursing diagnosis. This indicates the possible cause of the problem listed. Nursing interventions should be directed at the etiological factors in order to remove the underlying cause of the nursing diagnosis.
SIGNS AND SYMPTOMS/DEFINING CHARACTERISTICS: These are the major and minor clinical cues that validate the presents of an actual nursing diagnosis. These are the actual signs and symptoms the client present. Defining characteristics are written “as evidenced by” or “as manifested by” in the diagnostic statement.
WRITING THE NURSING DIAGNOSTIC STATEMENTS
There are three ways of writing nursing diagnosis or the nursing diagnostic statement. These are: The One-Part, Two-Part and Three-Part Nursing Diagnosis.
ONE-PART NURSING DIAGNOSIS: Wellness or Health promotion nursing diagnosis are mostly written in the one-part format. This is made up of only the diagnostic label. Example include:
Readiness for Enhance Breastfeeding
Readiness for Enhanced Coping
TWO-PART NURSING DIAGNOSIS: Risk Nursing Diagnosis are written in the two-part format. The first part indicates the diagnostic label and the second part indicates the presence of risk factors or confirmation for a risk nursing diagnosis. Example: ‘Risk for infection related to compromised immune system’’.
THREE-PART NURSING DIAGNOSIS: Also known as the PES (Problem, Etiology and Signs and symptoms) format. These are used when writing Actual or Problem-focused nursing diagnosis. This consist of; the diagnostic label, the contributing factors or etiology (“related to”) and the signs and symptoms (“as evidenced by”).
Roseman University of Health Sciences. (2014, July 9). What is a three-part nursing diagnosis? Retrieved from Roseman University of Health Sciences: https://acceleratednursing.roseman.edu/blog/three-part-nursing-diagnosis/
Vera, M. (2019, February 3). Nursing Diagnosis (NDx): Complete Guide and List for 2019. Retrieved from NURSESLABS: https://nurseslabs.com/nursing-diagnosis/
NANDA; Potential Use of Syndrome Diagnoses in a BSN Curriculum; Sally Decker, et al.