Advanced Health Assessment & Clinical Diagnosis In Primary Care – In this final nursing diagnosis tutorial and checklist, we’ll introduce you to the concepts behind writing a nursing diagnosis. Learn what a nursing diagnosis is, its history and evolution, the nursing process, the different types and classifications, and how to write nursing diagnoses correctly. Also included in this guide are tips on how to make better nursing diagnoses, plus guidelines on how to use them in creating nursing care plans.
A nursing diagnosis is a clinical judgment regarding a human response to health conditions/life processes, or a vulnerability to that response, by an individual, family, group or community. A nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is responsible. Nursing diagnoses are developed based on the data obtained during the nursing assessment and allow the nurse to develop the care plan.
Advanced Health Assessment & Clinical Diagnosis In Primary Care
The term nursing diagnosis is associated with different concepts. It may refer to the second distinct stage in the nursing process, diagnosis (the “D” in “ADPIE”). Nursing diagnosis also applies to the label when nurses assign meaning to collected data appropriately labeled as a nursing diagnosis. For example, during the assessment, the nurse may recognize that the client is feeling anxious, fearful, and having difficulty sleeping. These problems are labeled with nursing diagnoses: anxiety, fear, and sleep disturbance, respectively. In this context, a medical diagnosis is based on the patient’s response to the medical condition. It is called a “nurse diagnosis” because these are matters that hold a distinct and precise action associated with what nurses are empowered to do with a particular illness or condition. This includes anything that is a physical, mental and spiritual type of response. Therefore, a nursing diagnosis focuses on care.
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On the other hand, a medical diagnosis is made by a physician or an advanced practitioner who deals more with the disease, medical condition, or pathological condition that only a physician can treat. Moreover, through experience and know-how, the specific and precise clinical entity that could be the possible cause of the disease will then be undertaken by the doctor, thereby providing the appropriate medication that would cure the disease. Examples of medical diagnoses are
The medical diagnosis does not normally change. Nurses must follow physician orders and perform prescribed treatments and therapies.
Collaboration problems are potential problems that nurses manage using both independent and physician-prescribed interventions. These are problems or conditions that require both medical and nursing interventions, the aspect of nursing focused on monitoring the client’s condition and preventing the potential complication from developing.
As explained above, it is now easier to distinguish a medical diagnosis from a medical diagnosis. Nursing diagnosis is directed at the patient and their physiological and psychological response. On the other hand, a medical diagnosis is specific to the disease or medical condition. Its center is on disease.
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How are nursing diagnoses listed, arranged, or classified? In 2002, Taxonomy II was adopted, which was based on Dr. Mary Joy Gordon’s framework for evaluating functional models of health. Taxonomy II has three levels: domains (13), classes (47), and nursing diagnoses. Nursing diagnoses are no longer grouped according to Gordon’s patterns, but coded according to seven axes: diagnostic concept, time, care unit, age, state of health, descriptor and topology. Additionally, diagnoses are now listed alphabetically by their concept, not by their first word.
The five stages of the nursing process are assessment, diagnosis, planning, implementation, and evaluation. All stages of the nursing process require critical thinking on the part of the nurse. In addition to understanding nursing diagnoses and their definitions, the nurse promotes awareness of the defining characteristics and behaviors of the diagnoses, factors related to selected nursing diagnoses, and appropriate interventions to treat the diagnoses.
The steps, importance, goals, and characteristics of the nursing process are discussed in more detail here: “The Nursing Process: A Comprehensive Guide”
The four types of nursing diagnosis are Current (problem-focused), Risk, Health Promotion and Syndrome. Here are the four categories of nursing diagnoses:
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TYPES OF NURSING DIAGNOSES. The four types of nursing diagnosis are Current (problem-focused), Risk, Health Promotion and Syndrome.
A problem-focused diagnosis (also known as an actual diagnosis) is a client problem present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms. The actual nursing diagnosis should not be seen as more important than the risk diagnosis. There are many cases where a risk diagnosis may be the highest priority diagnosis for a patient.
Problem-oriented nursing diagnoses have three components: (1) the nursing diagnosis, (2) correlated factors, and (3) defining characteristics. Examples of real nursing diagnoses are:
The second type of nursing diagnosis is called risk nursing diagnosis. These are clinical judgments that a problem does not exist, but the presence of risk factors indicates that a problem may develop if the nurses do not intervene. A risk diagnosis is based on the patient’s current health status, past health history, and other risk factors that may increase the patient’s likelihood of experiencing a health problem. They are an integral part of nursing because they help identify potential problems early and allow the nurse to take steps to prevent or mitigate risk.
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There are no etiological factors (related factors) for risk diagnoses. The individual (or group) is more likely to develop the problem than others in the same or a similar situation because of risk factors. For example, an elderly client with diabetes and vertigo who has difficulty walking, refuses to ask for help while ambulating may be appropriately diagnosed with
The components of a medical risk diagnosis include (1) the risk diagnosis label and (2) risk factors. Examples of medical risk diagnosis are:
The health promotion diagnosis (also known as the well-being diagnosis) is a clinical judgment about the motivation and desire to increase well-being. It is a statement that identifies the patient’s readiness to engage in activities that promote health and well-being. For example, if a first-time mother shows interest in how to properly breastfeed her baby, a nurse will make a health promotion diagnosis of “Preparing for Improved Breastfeeding.” This nursing diagnosis will then be used to guide nursing interventions aimed at supporting the patient in learning about appropriate breastfeeding.
In addition, the diagnosis of health promotion refers to the transition of the individual, family or community from a specific level of well-being to a higher level of well-being. The components of a health promotion diagnosis generally include only the diagnosis label or a one-part statement. Examples of health promotion diagnosis:
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A syndrome diagnosis is a clinical judgment about a group of problem or risk care diagnoses that are expected to occur because of a particular situation or event. They also are written as a single-part statement that only requires the diagnostic tag. Examples of nursing syndrome diagnoses are:
A possible nursing diagnosis is not a type of diagnosis, as are current, risks, health promotion, and syndrome. Possible nursing diagnoses are statements that describe a suspected problem for which additional data are needed to confirm or rule out the suspected problem. It gives the nurse the ability to communicate with other nurses that a diagnosis may be present, but further data collection is indicated to rule out or confirm the diagnosis.
A nursing diagnosis typically has three components: (1) the problem and its definition, (2) etiology, and (3) defining characteristics or risk factors (for the risk diagnosis).
The problem statement, or diagnostic label, concisely describes the client’s health problem or response to which care therapy is given. A diagnostic tag usually has two parts: the qualifier and the focus of the diagnosis. Qualifiers (also called modifiers) are words that have been added to some diagnostic labels to provide additional meaning, limit, or specify the diagnostic statement. Exceptions to this rule are single-word nursing diagnoses (eg, anxiety, constipation, diarrhea, nausea, etc.) where their qualifier and focus are inherent to a single term.
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The etiology, or related factors, component of a nurse diagnosis label identifies one or more likely causes of the health problem, is the conditions involved in the development of the problem, directs the necessary medical therapy, and allows the nurse to individualize the care of the client. Nursing interventions should target etiological factors to eliminate the underlying cause of the nursing diagnosis. The etiology is related to the statement of the problem with the phrase “
Risk factors are used instead of etiologic factors for risk diagnosis. Risk factors are forces that place an individual (or group) at increased vulnerability to an unhealthy condition. Risk factors are written after the phrase “as evidenced by” in the diagnostic statement.
Defining features are groups of signs and symptoms that indicate the presence of a particular diagnostic label. In effective nursing diagnosis, the defining characteristics are the client’s identified signs and symptoms. For the nursing diagnosis of risk, no signs and symptoms are present, so the factors that make the client more susceptible to the problem form the etiology of a nursing diagnosis of risk. The defining characteristics are written after the phrase “as demonstrated by” or “as manifested by” in the diagnostic statement.
There are three phases during the diagnostic process: (1) data analysis, (2) identification of the client’s health problems, health risks,
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