Chapter 29 – Nursing Diagnosis

A nursing diagnosis can be a part of the nursing process. Nursing diagnosis is a clinical judgment about an individual’s or a community’s experience in relation to potential health problems or life processes. A nursing diagnosis can help determine the proper course of action for an individual’s care.

History

The first Canadian Conference on Nursing Diagnosis was held in Toronto in 1977. It was followed by an International Nursing Conference in Alberta, Canada, in 1987. In 1982, the North American Nursing Diagnosis Association was formed. This group recognized the contributions of nurses in the United States and used Sr. Callista Roy’s “nine patterns of unitary man” as an organizing principle. The group also made an early taxonomy, listing nursing diagnoses alphabetically. Although deemed unscientific, the original taxonomy was revised by NANDA in 1984, and renamed it “human response patterns”. Gordon’s functional health pattern is the basis of this process and will be discussed in future chapters.

After the Second World War, the United States saw a surge of nurses returning from military service. These nurses were highly skilled in diagnosing and treating medical conditions with physicians, and faced renewed domination by medical professionals and social pressures to return to traditionally defined female roles. They felt increased pressure to redefine their uniqueness, and began to see nursing diagnosis as an essential part of clinical practice. They began to use problem-focused diagnosis as a frame of reference to evaluate a patient’s health.

Problem-focused diagnosis

Nurses can make a problem-focused diagnosis of a patient based on a physical examination. This approach is helpful in promoting patient safety. The actual diagnosis refers to the presence of signs and symptoms that indicate the patient is suffering from an illness. It is important to remember that problem-focused diagnosis is not necessarily more important than risk-diagnosis, as risk-diagnosis is often the most important for the patient.

The four components of a problem-focused nursing diagnosis include the label, definition, defining characteristics, and related factors. The defining characteristics refer to the signs and symptoms that collectively comprise the diagnosis. They may also be subdivided into major and minor components. If there is a significant difference between the defining characteristics and the diagnosis, the latter should be chosen. The label should be the more specific, because the more detailed the information, the more accurate the diagnosis will be.

Traditionally, medical diagnoses are made by a medical professional. They deal with disease, medical problems, and life processes. RNs may make a problem-focused diagnosis if they are examining a patient. But the RN must follow the physician’s order and carry out the prescribed treatment. If a physician has given a problem-focused diagnosis, the nurse must refer to the patient’s diagnosis when making a clinical decision.

Risk diagnosis

In the field of nursing, risk diagnosis refers to a potential problem that has certain characteristics or factors. Risk factors increase the probability of a person developing the condition in question. For example, an older patient with diabetes and vertigo could be classified as a Risk for Injury, or he could be suffering from impaired gas exchange. Similarly, a health promotion diagnosis, or wellness diagnosis, may be appropriate for a patient who does not want to seek medical care. A risk diagnosis is a type of nursing practice that seeks to promote wellness and prevent illness.

A nurse should identify risk factors in addition to symptoms to determine what interventions are needed to treat the condition. They must take into account Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation. Then, they must prioritize the interventions based on the priority of the condition. The importance of risk factors is most evident when the patient is suffering from an uncompensated illness. When a patient is suffering from chronic low self-esteem, a risk factor that can reduce his/her self-esteem is a potential underlying problem.

A risk diagnosis in nursing includes the development of a clinical statement based on a client’s symptoms and signs. The diagnosis is usually made using clinical reasoning and nursing judgment. Then there are health promotion nursing diagnoses, which focus on the overall well-being of the patient. A syndrome diagnosis, on the other hand, is a group of diagnoses relating to a specific condition, often a common cause. For example, a patient may have a history of depression, but not necessarily be suffering from it.

Health promotion diagnosis

A health promotion diagnosis is a clinical judgment of a client’s readiness to change their behavior to promote their own wellbeing. The diagnosis takes into account factors that can affect a person’s risk of developing a specific health condition, as well as the client’s own motivation to change those behaviors. Health promotion diagnosis may exist at the individual, family, group, or community level. These factors may include the age of the client and his or her family.

Related factors show a pattern of relationship between a health-promotion diagnosis and the variables that can contribute to that diagnosis. For example, an impaired gas exchange nursing diagnosis may have several defining characteristics, including a person’s age, skin color, and the presence of a headache upon awakening. Related factors may include environmental, physiological, psychological, chemical, or social elements. These factors may not be directly measurable. Health promotion diagnosis is useful in determining the most effective course of treatment, but may not be applicable to every patient.

Nursing diagnosis plays a role in health promotion by helping nurses to organize their knowledge and clinical judgment in community practice. Diagnosing a client’s symptoms and responding to life events are key elements of nursing care. Nursing diagnoses include problem-focused, health promotion-focused, and syndrome-focused approaches. The latter is the most common, but may not be appropriate for every patient. There are several differences between these types of nursing diagnoses, but they all have the same purpose: to promote a person’s well-being.

Enhanced Readiness for Health Promotion and Risk for Falls are the two most important categories of health promotion diagnosis in nursing. These two diagnoses are closely linked by the risk of falling. These factors are critical for the patient’s safety and can lead to injury. Whether or not a client is ready to fall depends on the situation, but the diagnosis must be made in a systematic manner. A nurse may use a single diagnosis or a combined set of diagnoses.

Errors in data collection and interpretation are significant factors in the production of an accurate nursing diagnosis. The data may be incomplete, inaccurate, or not valid enough. The clinician may also use an inappropriate diagnosis based on bias and other factors. These errors may also result in an inability to identify the most appropriate interventions. Incorrect diagnosis can lead to errors in data analysis and interpretation. The best way to address these problems is to adopt an objective attitude and validate the data in multiple ways.

Syndrome

A nursing diagnosis statement, also called a syndrome, refers to a group of related diagnoses. These diagnoses are usually associated with similar clinical behaviors, i.e., similar signs and symptoms, but with different causes. For example, rape trauma syndrome is characterized by disturbed sleep patterns, anger, and genital discomfort, while relocation stress syndrome is characterized by an impaired ability to interpret environmental cues. All of these syndromes involve heightened nursing care needs and are often the result of stressful circumstances.

Nursing diagnoses are classified by NANDA based on their defining characteristics. The first category is problem focused diagnoses, which are based on specific signs or symptoms. The second category is a risk diagnosis, which is based on certain factors or defining characteristics. A nursing diagnosis can have many defining characteristics, which means that it is important to distinguish between these two groups. In order to determine the most appropriate nursing care, a nurse must be trained in multiple categories.

A nursing diagnosis is a clinical judgment developed by a nurse based on their physical assessment of the patient. This diagnosis is likely to change as nursing care is provided. However, evidence-based research has helped nurse diagnose the most effective nursing care plans. A nursing diagnosis is a critical component of nursing care. It enables the nurse to develop a nursing care plan based on measurable outcomes. In addition, a nursing diagnosis can help to guide the development of the best care plan for a patient.

Developing a nursing diagnosis

The process of developing a nursing diagnosis requires an understanding of the various parts of the statement. The problem statement describes the current health problem of the patient and its etiology communicates the causes or conditions that lead to the condition. Developing a nursing diagnosis is also crucial for identifying the risk factors of the patient, which increase his or her vulnerability to health problems. The following steps can help you develop a nursing diagnosis.

First, the nurse must conduct an assessment. The assessment will provide cues to help her or him decide on the best course of action. The cues are applied in a decision-making process to establish a specific nursing diagnosis. The nurse then consults the NANDA list of nursing diagnoses to determine the etiology of the condition. A nursing diagnosis will have a problem statement, defining characteristics, and possible interventions.

Developing a nursing diagnosis can be both simple and difficult. A nursing diagnosis can be problem-focused or risk-focused. A problem-focused diagnosis is based on the signs and symptoms of the patient, and is the simplest to develop. A risk-focused diagnosis, on the other hand, takes clinical judgment and reasoning to determine which patient risks have to be managed. In either case, it’s imperative to consider the patient’s risk factors.

A nursing diagnosis defines a medical condition or disease and is an important part of the nursing process. It defines the nursing response to that diagnosis. As a nurse, you are responsible for choosing the most appropriate diagnosis, as well as the outcome of care. There are several types of nursing diagnosis statements, including clinical and functional. Once you’ve determined which type is right for the patient, you can move on to the next step. And remember: the more accurate your diagnosis, the better the care plan can be!