Phase 2: Nursing Diagnosis
A nursing diagnosis is a term used to classify health problems within the domain of nursing (Potter & Perry, 2005). Do not confuse with a medical diagnosis which is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results, of diagnostic tests and procedures (Potter & Perry, 2005). A nursing diagnosis is derived from "a clinical judgement about individual, family, or community responses/experiences to health problems/life processes" (NANDA International, 2012). A diagnosis in nursing "provides the basis for the selection of interventions to achieve outcomes for which the nurse has accountability" (NANDA International, 2012). The nursing diagnosis becomes a statement describing a client's actual or potential response(s) to a health problem that the nurse is licensed and competent to treat (Potter & Perry, 2005). It is essential that the nurse use critical thinking and good clinical judgement upon selection of a nursing diagnosis.
There are three types of nursing diagnoses: actual diagnoses, at risk diagnoses, and wellness diagnoses.
There are three types of nursing diagnoses: actual diagnoses, at risk diagnoses, and wellness diagnoses.
- An actual nursing diagnosis describes human responses to health conditions/life processes that exist in an individual, family, or community (Potter & Perry, 2005). It is a judgment supported by defining characteristics such as manifestations, signs, and symptoms clustered in patterns of related cues or inferences.
- An at risk nursing diagnosis describes human responses to health conditions/life process that may develop in a vulnerable individual, family, or community. Prior to assigning this type of diagnosis the nurse must ensure the presence of data revealing risk factors that support the client's vulnerability (Potter & Perry, 2005).
- A wellness nursing diagnosis describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement (Potter & Perry, 2005). It is utilized as a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness. Used when a client wishes to or has achieved an optimal level of health.
Components of a Nursing Diagnosis
A nursing diagnosis is composed of two parts: a diagnostic label followed by a statement of a related factor.
What is a diagnostic label? It is the name of the nursing diagnosis as approved by NANDA (North American Nursing Diagnosis Association) International (Potter & Perry, 2005). In some cases three-part statements are recommended during the learning process. When written as a three-part statement, the problem-etiology-signs and symptoms (PEMS) format is used (Lewis, Heitkemper, & Dirksen, 2004).
(Lewis et al., 2004)
For more information on the components of nursing diagnoses, read pages 8-10 in Lewis et al. (2004) and pages 300-315 in Potter & Perry (2005).
What is a diagnostic label? It is the name of the nursing diagnosis as approved by NANDA (North American Nursing Diagnosis Association) International (Potter & Perry, 2005). In some cases three-part statements are recommended during the learning process. When written as a three-part statement, the problem-etiology-signs and symptoms (PEMS) format is used (Lewis, Heitkemper, & Dirksen, 2004).
- Problem (P): a brief statement of the patient's potential or actual health problem (i.e. pain)
- Etiology (E): a brief description of the probable cause of the problem; contributing or other related factors (i.e. related surgical incision, localized pressure, edema)
- Signs and Symptoms (S): a list of clustered objective and subjective data that helps the nurse find the problem; critical, major, or minor defining characteristics (i.e. as manifested by verbalization of pain, isolation, or withdrawal). Be aware that gathering the information in this section comes first in the diagnostic process.
(Lewis et al., 2004)
For more information on the components of nursing diagnoses, read pages 8-10 in Lewis et al. (2004) and pages 300-315 in Potter & Perry (2005).
NANDA International (NANDA-I)
NANDA International is a professional association established in 1982, to develop a standardized nursing language for identifying, defining, and classifying patient's actual or potential responses to health problems (Lewis, Heitkemper & Dirksen, 2004). It's purpose is to provide professional nurses with a taxonomy of nursing diagnostic terminology for general use.
To find out more about this organization, please proceed to this link: NANDA-I
To find out more about this organization, please proceed to this link: NANDA-I
NANDA Nursing Diagnoses
Below is a list of example nursing diagnoses from NANDA:
Activity Intolerance
Ineffective Airway Clearance Anxiety Risk for Aspiration Risk for latex allergy response Disturbed body image Risk for imbalanced body temperature Bowel incontinence Effective Breastfeeding Ineffective breastfeeding Decreased Cardiac output Risk for caregiver role strain Impaired verbal communication Constipation Confusion Obtained from Potter & Perry (2005) |
Ineffective Coping
Readiness for enhanced community coping Defensive Coping Compromised family coping Ineffective denial Impaired dentition Risk for delayed development Diarrhea Adult failure to thrive Risk for falls Fatigue Fear Fluid imbalance Risk for deficient fluid volume Risk for imbalanced fluid volume |
Assignment 2: Identify and formulate your own Nursing Diagnoses
Since the nursing process is not complete without a nursing diagnosis or two, your assignments will be to review a few examples and identify those that are stated correctly and incorrectly. Then you will need to create your own nursing diagnoses derived from the given case studies.
Due 9/3/12
Due 9/3/12
nursing_diagnosis_identification_activity_2a.docx | |
File Size: | 89 kb |
File Type: | docx |
formulating_nursing_diagnoses_assign_2b.docx | |
File Size: | 89 kb |
File Type: | docx |