Nursing diagnosis
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A nursing diagnosis is a standardized statement about the health of a client (individual, family, or community) for the purpose of providing nursing care. One organization for defining standard diagnoses is the North American Nursing Diagnosis Association now known as NANDA-International. Nursing diagnoses are developed by doing an health assessment.
Nursing diagnoses are part of a movement in nursing to standardize terminology which includes standard descriptions of diagnoses, interventions, and outcomes. Those in support of standardized terminology believe that it will help nursing become more scientific and evidence based. Many nurses feel, however, that nursing diagnoses are an ivory tower mentality and are not relevant to clinical practice.
Structure of diagnoses
There are five types of nursing diagnoses in the NANDA system.
- An actual diagnosis is a statement about a health problem that the client has, and could benefit from nursing care. An example of an actual nursing diagnosis is: Ineffective airway clearance related to decreased energy as manifested by an ineffective cough.
- A risk diagnosis is a statement about a health problem that the client doesn't have yet, but is at a higher than normal risk of developing in the near future. An example of a risk diagnosis is: Risk for injury related to altered mobility and disorientation.
- A possible diagnosis is a statement about a health problem that the client might have now, but the nurse doesn't yet have enough information to make an actual diagnosis. An example of a possible diagnosis is: Possible fluid volume deficit related to frequent vomiting for three days as manifested by increased pulse rate.
- A syndrome diagnosis is used when a cluster of nursing diagnoses are often seen together. An example of a syndrome diagnosis is: Rape-trauma syndrome related to anxiety about potential health problems as manifested by anger, genitourinary discomfort, and sleep pattern disturbance.
- A wellness diagnosis is used to describe an aspect of the client which is at a high level of wellness. An example of a wellness diagnosis is: Potential for enhanced organized infant behaviour, related to prematurity and as manifested by response to visual and auditory stimuli.
See Also
- Nursing
- List of nursing diagnoses
- Nursing Interventions Classification
- Nursing Outcomes Classification
References
- K. N. Anderson (Ed.): Appendix 19: Nursing Diagnoses. In: Mosby's Medical, Nursing, & Allied Health Dictionary. 5th ed. Mosby, St. Louis, MO, 1998, pp. 1975-2035, ISBN 0-8151-4800-3
- A. G. Perry, P. A. Potter: Canadian Fundamentals of Nursing. 2nd ed. Mosby, Toronto, ON, 2001, ISBN 0-9205-1340-9de:Pflegerische Diagnostik