Nursing diagnosis is significantly different from medical diagnosis as it does not identify the disease or seek to influence the treatment process. It is flexible and changes as the patient moves through the intervention phase. NANDA International defines nursing diagnosis as a clinical judgment about an individual, family, or community’s response to health conditions or life processes. Based on this definition, the process entails an assessment of the patient’s concerns or problems, the characteristics of the issue, and the label assigned by the nurse. This information is used in the planning phase, where the nurse selects the appropriate intervention based on the desired outcome for the presenting problem.
Components of a nursing diagnosis
NANDA-I’s definition highlights various aspects of the diagnosis or diagnostic criteria. Since the assessment does not involve an advanced nurse practitioner or physician, it does not culminate into a medical diagnosis or treatment. However, the nursing diagnosis is a critical component of the intervention process as it identifies the problem and sets the stage for interaction between health professionals. It also forms the basis for medical diagnosis and subsequent steps in the treatment process. Thus, a nursing diagnosis contains several components.
Diagnosis label
A nursing diagnosis contains a problem statement comprising the patient’s concerns or issue at hand. The nurse may also include the necessary intervention for tackling the problem or mitigating the enabling factors. This statement also contains a diagnosis label with generally accepted nursing terms. For instance, the nurse may use the word acute pain to denote a sudden sharp pain. This label will determine the follow-up questions, and further investigation needed.
Defining characteristic
A nursing diagnosis also contains definitions and defining characteristics. First, the nurse must describe and differentiate the problem from similar issues. They must then note the observable characteristics that determine the patient’s concern. These factors are derived from various data collection methods, including observation. The nurse can also question the patient, family, or community member to gather more information about the problem and develop a comprehensive and detailed description. Thus, the defining characteristics are the observable signs and symptoms necessitating the assessment and diagnosis process.
Etiology: Risk and Related factors
The description will provide the basis for further assessment of the causative factors. At this point, the nurse analyzes the issue’s environmental, genetic, psychological, and physiological aspects. They seek to understand the factors necessitating vulnerability. These are the possible reasons and explanations for susceptibility or probability of occurrence of the specific issue. For instance, a rugby player may present with signs of a concussion or head trauma. In such a case, playing rugby is an environmental and occupational risk factor for the said diagnosis. The etiology of the presenting problem implies the conditions in which the issue arises.
What is the purpose of writing a community nursing diagnosis? A brief description
A community nursing diagnosis is a detailed report outlining the focus on nursing care for an individual, family, or community. It contains a clinically identified label of specific concern with defining characteristics and probable interventions. A community nursing diagnosis synthesizes the assessment data, allocates a clinical label, and outlines the etiological components of the problem. Its primary purpose is to establish a community health need with proper descriptions to necessitate the development of a nursing care plan. At this level, the labels refer to the epidemiological terms for the identified issues.
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Tips for writing a nursing diagnosis for college students
Writing a nursing diagnosis essay at school may require sufficient knowledge of NANDA-I’s taxonomy II. The list of labels has three levels classified in 13 domains, 47 classes, and numerous nursing diagnoses. The classification also adheres to seven coding axes: age, concept, descriptor, health status, time, and topology. Here are some tips on how to write a nursing diagnosis.
Analyze the available data
One of the three components of the nursing diagnosis is the problem statement or definition. This aspect describes the presenting issue and allocates a clinically acceptable label. The nurse also notes the possible response or immediate intervention for the health problem. Although a nursing diagnosis may contain only the label, providing a detailed diagnosis is sometimes necessary. This process involves specificity descriptors and modifiers that would help a third party to understand the conclusion.
Outline the risks factors and patient’s strengths
Another component of the nursing diagnosis is the risk and related factors. Identify various aspects in the patient’s life that necessitate the health problem. You can achieve this by seeking details about the patient’s health and family history of the issue. You may also gather more information from other sources, such as close relatives.
Review NANDA-I’s taxonomy II
Making a nursing diagnosis also involves assigning clinical labels that identify the issue. Classifying the problem with known and generally acceptable terms can help with accuracy and eliminate confusion. Hence, reviewing NANDA-I’s taxonomy II will equip you with the relevant information for making an accurate nursing diagnosis. You may also review sample applications of the taxonomy from only examples and essays to familiarize yourself with nursing diagnosis.
Notable nursing diagnosis example(s)
Nursing diagnoses are categorized into descriptive categories: problem-focused, risk, health promotion, and syndromes.
Problem-focused diagnosis
This type of nursing diagnosis addresses the observable issues based on the signs and symptoms. It is the most basic style of diagnosis and entails the diagnostic label, defining factors, and related factors.
- Example: Acute pain resulting from a recent surgical procedure characterized by sharp pains at the incision.
Risk diagnosis
A risk nursing diagnosis has no specific signs and symptoms. The clinical judgment is based on specific risk factors signaling a possible health problem if necessary intervention is not implemented.
- Example: Risk tuberculosis infection to a HIV-positive patient living in an area where TB is prevalent.
Health promotion diagnosis
The nurse may also make a clinical judgment about a patient’s willingness to improve their well-being by adjusting their behaviors. It entails the desire to improve health status from a given state to a specific level.
- Example: Readiness for weight loss for an obese patient.
Syndrome diagnosis
A syndrome diagnosis is a cluster of diagnoses with similar characteristics and interventions. The nurse makes a clinical judgment based on the availability of information on several health problems with overall similarities.
- Example: Post-trauma syndrome
Conclusion
A detailed nursing diagnosis is also essential when learning how to write a nursing care plan. A nursing care plan is usually the fourth step in a six-step nursing process. This follows the first three stages, the first being assessment, which entails gathering information from the client or relatives. The second stage is the nursing diagnosis, which utilizes the data collected to assign a clinical label. The third stage involves setting smart goals to be incorporated into the plan based on the patient’s conditions and information about critical factors of their health states.