NURSING DIAGNOSIS

 NURSING DIAGNOSIS 

What is a Nursing Diagnosis?

A nursing diagnosis is a clinical judgment concerning 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 has accountability. Nursing diagnoses are developed based on data obtained during the nursing assessment and enable the nurse to develop the care plan.

Purposes of Nursing Diagnosis

The purpose of the nursing diagnosis is as follows:

For nursing students, nursing diagnoses are an effective teaching tool to help sharpen their problem-solving and critical thinking skills.

Helps identify nursing priorities and helps direct nursing interventions based on identified priorities.

Helps the formulation of expected outcomes for quality assurance requirements of third-party payers.

Nursing diagnoses help identify how a client or group responds to actual or potential health and life processes and knowing their available resources of strengths that can be drawn upon to prevent or resolve problems.

Provides a common language and forms a basis for communication and understanding between nursing professionals and the healthcare team.

Provides a basis of evaluation to determine if nursing care was beneficial to the client and cost-effective.

Differentiating Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems

The term nursing diagnosis is associated with different concepts. It may refer to the distinct second step in the nursing process, diagnosis (“D” in “ADPIE“). Also, nursing diagnosis applies to the label when nurses assign meaning to collected data appropriately labeled a nursing diagnosis. For example, during the assessment, the nurse may recognize that the client feels anxious, fearful, and finds it difficult to sleep. Those problems are labeled with nursing diagnoses: respectively, Anxiety, Fear, and Disturbed Sleep Pattern. In this context, a nursing diagnosis is based upon the patient’s response to the medical condition. It is called a ‘nursing diagnosis’ because these are matters that hold a distinct and precise action associated with what nurses have the autonomy to take action about with a specific disease or condition. This includes anything that is a physical, mental, and spiritual type of response. Hence, a nursing diagnosis is focused on care.

Examples of different nursing diagnoses, medical diagnoses, and collaborative problems – to show comparison.

COMPARED. Nursing diagnoses vs medical diagnoses vs collaborative problems

On the other hand, a medical diagnosis is made by the physician or advanced health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat. Moreover, through experience and know-how, the specific and precise clinical entity that might be the possible cause of the illness will then be undertaken by the doctor, therefore, providing the proper medication that would cure the illness. Examples of medical diagnoses are Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. The medical diagnosis normally does not change. Nurses must follow the physician’s orders and carry out prescribed treatments and therapies.

Collaborative 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, with the nursing aspect focused on monitoring the client’s condition and preventing the development of the potential complication.

As explained above, now it is easier to distinguish a nursing diagnosis from a medical diagnosis. Nursing diagnosis is directed towards the patient and their physiological and psychological response. On the other hand, a medical diagnosis is particular to the disease or medical condition. Its center is on the illness.

Classification of Nursing Diagnoses (Taxonomy II)

How are nursing diagnoses listed, arranged, or classified? In 2002, Taxonomy II was adopted, which was based on the Functional Health Patterns assessment framework of Dr. Mary Joy Gordon. Taxonomy II has three levels: Domains (13), Classes (47), and nursing diagnoses. Nursing diagnoses are no longer grouped by Gordon’s patterns but coded according to seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology. In addition, diagnoses are now listed alphabetically by their concept, not by the first word.

Nursing Diagnosis Taxonomy II

NURSING DIAGNOSIS TAXONOMY II. Taxonomy II for nursing diagnosis contains 13 domains and 47 classes. Image via: Wikipedia.com

Domain 1. Health Promotion

Class 1. Health Awareness

Class 2. Health Management

Domain 2. Nutrition

Class 1. Ingestion

Class 2. Digestion

Class 3. Absorption

Class 4. Metabolism

Class 5. Hydration

Domain 3. Elimination and Exchange

Class 1. Urinary function

Class 2. Gastrointestinal function

Class 3. Integumentary function

Class 4. Respiratory function

Domain 4. Activity/Rest

Class 1. Sleep/Rest

Class 2. Activity/Exercise

Class 3. Energy balance

Class 4. Cardiovascular/Pulmonary responses

Class 5. Self-care

Domain 5. Perception/Cognition

Class 1. Attention

Class 2. Orientation

Class 3. Sensation/Perception

Class 4. Cognition

Class 5. Communication

Domain 6. Self-Perception

Class 1. Self-concept

Class 2. Self-esteem

Class 3. Body image

Domain 7. Role relationship

Class 1. Caregiving roles

Class 2. Family relationships

Class 3. Role performance

Domain 8. Sexuality

Class 1. Sexual identity

Class 2. Sexual function

Class 3. Reproduction

Domain 9. Coping/stress tolerance

Class 1. Post-trauma responses

Class 2. Coping responses

Class 3. Neurobehavioral stress

Domain 10. Life principles

Class 1. Values

Class 2. Beliefs

Class 3. Value/Belief/Action congruence

Domain 11. Safety/Protection

Class 1. Infection

Class 2. Physical injury

Class 3. Violence

Class 4. Environmental hazards

Class 5. Defensive processes

Class 6. Thermoregulation

Domain 12. Comfort

Class 1. Physical comfort

Class 2. Environmental comfort

Class 3. Social comfort

Domain 13. Growth/Development

Class 1. Growth

Class 2. Development