Nursing diagnosis
Encyclopedia
A nursing diagnosis may be part of the nursing process
and is a clinical judgement about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses are developed based on data obtained during the nursing assessment
.
. For nearly 40 years NANDA-I has worked in this area to ensure that diagnoses are developed through a peer-reviewed process requiring standardized levels of evidence, standardized definitions, defining characteristics, related factors and/or risk factors that enable nurses to identify potential diagnoses in the course of a nursing assessment. NANDA-I believes that it is critical that nurses are required to utilize standardized languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characterisitcs) and the related or etiologic factors upon which nurses intervene. NANDA-I terms are developed and refined for actual (current) health responses and for risk situations , as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities. Contributing diagnostic associations include AENTDE (Spain), AFEDI (French language), and JSND (Japan). NANDA-I also has SOME regional networks including Brasil, Peru, Honduras, Nigeria-Ghana and a German-language group. The taxonomy is published in multiple countries and has been translated into 18 languages; it is in use worldwide. The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, is HL7 registered, ISO-compatible and available within SNOMED CT
with appropriate licensure.
Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the electronic health record and can be linked to nurse-sensitive patient outcomes.
Nursing process
The nursing process is a modified scientific method. Nursing practise was first described as a four stage nursing process by Ida Jean Orlando in 1958,. It should not be confused with nursing theories or Health informatics...
and is a clinical judgement about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses are developed based on data obtained during the nursing assessment
Nursing assessment
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status.-Stage one of the nursing process:...
.
NANDA International
The primary organization for defining, dissemination and integration of standardized nursing diagnoses worldwide is NANDA-International formerly known as the North American Nursing Diagnosis AssociationNANDA
NANDA International is a professional organization of nurses standardized nursing terminology that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses...
. For nearly 40 years NANDA-I has worked in this area to ensure that diagnoses are developed through a peer-reviewed process requiring standardized levels of evidence, standardized definitions, defining characteristics, related factors and/or risk factors that enable nurses to identify potential diagnoses in the course of a nursing assessment. NANDA-I believes that it is critical that nurses are required to utilize standardized languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characterisitcs) and the related or etiologic factors upon which nurses intervene. NANDA-I terms are developed and refined for actual (current) health responses and for risk situations , as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities. Contributing diagnostic associations include AENTDE (Spain), AFEDI (French language), and JSND (Japan). NANDA-I also has SOME regional networks including Brasil, Peru, Honduras, Nigeria-Ghana and a German-language group. The taxonomy is published in multiple countries and has been translated into 18 languages; it is in use worldwide. The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, is HL7 registered, ISO-compatible and available within SNOMED CT
SNOMED CT
SNOMED CT , is a systematically organised computer processable collection of medical terminology covering most areas of clinical information such as diseases, findings, procedures, microorganisms, substances, etc...
with appropriate licensure.
Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the electronic health record and can be linked to nurse-sensitive patient outcomes.
Global
The ICNP (International Classification for Nursing Practice) published by the International Council of Nurses has been accepted by the WHO (World Health organization) family of classifications. ICNP is a nursing language which can be used by nurses to diagnose.Structure of diagnoses
The NANDA-I system of nursing diagnosis provides for four categories.- Actual diagnosis - "A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community". An example of an actual nursing diagnosis is: Sleep deprivation.
- Risk diagnosis - "Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability." An example of a risk diagnosis is: Risk for shock.
- Health promotion diagnosis - "A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state." An example of a health promotion diagnosis is: Readiness for enhanced nutrition.
- Syndrome diagnosis - "A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions." An example of a syndrome diagnosis is: Relocation stress syndrome.
Process of diagnoses
- Conduct a nursing assessment - collection of subjective and objective data relevant to the care recipient's (person, family, group, community) human responses to actual or potential health problems / life processes.
- Cluster and interpret cues/patterns - Assessment data must be clustered and interpreted before the nurse can plan, implement or evaluate a plan to support patient care
- Generate Hypotheses - possible alternatives that could represent the observed cues/patterns.
- Validation & Prioritization of Nursing Diagnoses - taking necessary steps to rule out other hypotheses, to confirm with the patient(s) the validity of the hypotheses, and to prioritize the list of diagnoses. A focused assessment may be needed to obtain data for one or more diagnoses
- Planning - Determining appropriate (realistic) patient outcomes and interventions most likely to support attainment of those outcomes through evidence-based practice
- Implementation - Putting the plan of care (nursing diagnoses - outcomes - interventions) into place, preferably in collaboration with the care recipient(s)
- Evaluation - Movement toward identified outcomes is continually evaluated, with changes made to interventions as necessary. When no positive movement is occurring, reassessment to reevaluate appropriateness of diagnoses and/or achievability of outcomes must occur.
Nursing diagnoses examples
The following are nursing diagnoses arising from the nursing literature with varying degrees of authentication by ICNP or NANDA-I standards.- AnxietyAnxietyAnxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
- ConstipationConstipationConstipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...
- PainPainPain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
See also
- Clinical Care Classification SystemClinical Care Classification SystemClinical Care Classification SystemThe Clinical Care Classification System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice...
- NursingNursingNursing is a healthcare profession focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life from conception to death....
- Nursing processNursing processThe nursing process is a modified scientific method. Nursing practise was first described as a four stage nursing process by Ida Jean Orlando in 1958,. It should not be confused with nursing theories or Health informatics...
- Nursing care planNursing care planA nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process...
- Nursing Interventions ClassificationNursing Interventions ClassificationThe Nursing Interventions Classification is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associate with the creation of a nursing care plan. The NIC consists of a standardized list which contains 433...
(NIC) - Nursing Outcomes ClassificationNursing Outcomes ClassificationThe Nursing Outcomes Classification is a classification system which describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate the effects of nursing care as a part of the nursing process...
(NOC)
External links
- http://onlinelibrary.wiley.com/doi/10.1111/j.1744-618X.2007.00043.x/abstractMüller-Staub, M., Needham, I., Odenbreit, M., Ann Lavin, M. and Van Achterberg, T. (2007), Improved Quality of Nursing Documentation: Results of a Nursing Diagnoses, Interventions, and Outcomes Implementation Study. International Journal of Nursing Terminologies and Classifications, 18: 5–17. doi: 10.1111/j.1744-618X.2007.00043.x]
- The need for international nursing diagnosis research and a theoretical framework by Dr. Margaret Lunney
- NANDA International
- Nursing Interventions