Nursing diagnosis

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.

NANDA

The primary organization for defining, dissemination and integration of standardized nursing diagnoses worldwide is NANDA-International formerly known as the North American Nursing Diagnosis Association. 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. ^[1][2]

Global

The ICNP (International Classification for Nursing Practise) 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. ^{[3] [4] [5] [6] [7] [8]}

Structure of diagnoses

The NANDA-I system of nursing diagnosis provides for four categories.

1. 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.
2. 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.
3. 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.
4. 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.^[9]

Process of diagnoses

1. 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.
2. 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
3. Generate Hypotheses - possible alternatives that could represent the observed cues/patterns.
4. 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
5. Planning - Determining appropriate (realistic) patient outcomes and interventions most likely to support attainment of those outcomes through evidence-based practice
6. Implementation - Putting the plan of care (nursing diagnoses - outcomes - interventions) into place, preferably in collaboration with the care recipient(s)
7. 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.^[10]

Nursing Diagnoses Examples

The following are nursing diagnoses arising from the nursing literature with varying degrees of authentication by ICNP or NAND-i standards.

• Impaired Spirituality ^[11]
• Anxiety ^[12]
• Constipation ^{[13] [14]}
• Barriers to screening (formative or realized) ^[15]
• Pain ^[16]

See also

Nursing portal

• Clinical Care Classification System
• Nursing
• Nursing process
• Nursing care plan
• Nursing Interventions Classification (NIC)
• Nursing Outcomes Classification (NOC)

References

1. ^ Brokel, J & C Heath (2009). The value of nursing diagnoses in electronic health records. In Herdman, TH (Ed.), Nursing diagnoses: definitions and classification 2009-2011. Wiley-Blackwell: Singapore
2. ^ Weir-Hughes, D. (2009). Nursing diagnosis in administration. In Herdman, TH (Ed.), Nursing diagnoses: definitions and classification 2009-2011. Wiley-Blackwell: Singapore
3. ^ http://icnp.clinicaltemplates.org/info/v2/
4. ^ http://onlinelibrary.wiley.com/doi/10.1111/j.1466-7657.2004.00249.x/abstract
5. ^ http://www.carloshaya.net/biblioteca/enfer2008/need.pdf
6. ^ http://onlinelibrary.wiley.com/doi/10.1111/j.1744-618X.2007.00076.x/full
7. ^ http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.aspx?css=print
8. ^ http://findarticles.com/p/articles/mi_qa3836/is_199807/ai_n8804972/
9. ^ Herdman, TH (Ed.) (2009). Nursing diagnoses: definitions and classification 2009 - 2011. Wiley-Blackwell: Singapore.
10. ^ Lunney, M. (2009) Assessment, clinical judgment, and nursing diagnoses: how to determine accurate diagnoses. In Herdman, TH (Ed.), Nursing diagnoses: definitions and classification 2009-2011. Wiley-Blackwell: Singapore
11. ^ http://www.scielo.br/scielo.php?pid=S0103-21002010000200018&script=sci_arttext&tlng=en
12. ^ http://nursing-concept.blogspot.com/2009/02/nursing-care-plans-for-anxiety.html
13. ^ http://nursing-concept.blogspot.com/2009/02/nursing-care-plans-for-constipation.html
14. ^ http://www.ncbi.nlm.nih.gov/pubmed/8029726
15. ^ http://ana.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/ArticlePreviousTopics/tpc29_616065.aspx
16. ^ http://ana.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No3Sept04/ArticlePreviousTopic/PainAssessmentandManagementinAging.aspx

External links

• Müller-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