A nursing diagnosis may be part of the nursing process and is a clinical judgment 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. An actual nursing diagnosis presents a problem response present at time of assessment. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis identifies problems that result from that disorder. The North American Nursing Diagnosis Association (NANDA) is body of professionals that manage an official list of nursing diagnosis.
Contents
All nurses must be familiar with the steps of the nursing process in order to gain the most efficiency from their positions.
NANDA International
NANDA-International formerly known as the North American Nursing Diagnosis Association is the primary organization for defining, distribution and integration of standardized nursing diagnoses worldwide. NANDA-I has worked in this area for nearly 40 years to ensure that diagnoses are developed through a peer-reviewed process requiring standardised levels of evidence, 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 utilise standardised languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characteristics) 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. The taxonomy is published in multiple countries and has been translated into 18 languages; it is in use worldwide.
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 Organisation) family of classifications. ICNP is a nursing language which can be used by nurses to diagnose.
Structure
The NANDA-I system of nursing diagnosis provides for four categories.
- Actual diagnosis
- Risk diagnosis
- Health promotion diagnosis
- Syndrome diagnosis
Process
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Examples
The following are nursing diagnoses arising from the nursing literature with varying degrees of authentication by ICNP or NANDA-I standards.