Nursing Process: Nursing Diagnosis

George Ann Daniels, MS, RN

Definition of Nursing Diagnosis

A clinical judgment about individual, family, or community responses to actual or potential health/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

How do you make a NDX?

Analyze collected data Identify the clients strengths Identify the clients normal functional level and indicators of actual or potential dysfunction Formulate a diagnostic statement in relations to this synthesis

Benefits of Nursing Diagnosis

Gives nurses a common language Promotes identification of appropriate expected outcomes Provides acuity information Can create a standard for nursing practice Provide a quality improvement base

NDX VS Medical Diagnosis

Nursing Diagnosis Made by the nurse Describes clients response Responses vary between individuals Changes as client responses change Nurse orders interventions

Medical Diagnosis Made by a physician Refers to the disease process Somewhat uniform between clients Remains same during disease process Physician orders interventions

Steps

Identify patterns

Review data and look for cues Cluster cues (signs and symptoms) Synthesizing the cue clusters Three questions to ask self

What are my concerns about this client Can I or am I doing something obout it Can the overall risk be decreased by nursing interventions

Synthesis the data

Look at all data as a whole Test for a fit Refer to the NANDA DX and defining characteristics

Validate the diagnosis

Formulate the nursing diagnosis statement using nursing language

NANDA

Types of Nursing Diagnosis

Actual (3 parts)

Can be documented from assessment

Risk (2 parts)

A clinical judgment that the client is more vulnerable to develop this problem than others in the same or similar situation
Potential for enhancement of current well state

Wellness (2 parts)

Components of Nursing Diagnosis

Diagnostic Label

P Qualifier E

Etiology

Defining characteristics

Diagnostic Label

Problem

Name of the nursing diagnosis as listed in the taxonomy Describes the problem using as few words as possible Used to give additional meaning to the NDX

Qualifier

Problems to avoid in writing this part

DO NOT use the medical diagnosis Must be a problem the nurse and/or client can change to do something about Relating the problem to an unchangeable situation

Dont confuse the etiology with the problem Focus on the human responses to the problem Avoid the use of one piece of assessment data as a NDX (EDEMA)

Be specific Dont combine NDX Dont relate one NDX to another. There is a different related to factor if this is a valid NDX Nursing interventions should not be included in the NDX Keep your language non-judgmental Dont make assumptions or statements you cant prove with assessment data Be sure your statement is legally advisable

Etiology

This is the related to, R/T portion of the diagnosis. What caused the client to have the problem listed? Problems to avoid in writing this part

DO NOT use the medical diagnosis Must be a problem the nurse and/or client can change to do something about

Defining Characteristics

These are the major and minor clinical cues that validate the presents of an actual nursing diagnosis Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the NDX

Measurement criteria for ANA

Standard II: Diagnosis: The nurse analyzes the assessment data in determining diagnosis.

Diagnoses are derived from assessment data Diagnoses are validated with the patient, family, and HCP when possible and appropriate Diagnoses are documented in a manner that facilitates the determination of expected outcomes and plan of care