NURSING DIAGNOSIS Presented by P. Arul valan Lecturer, SXCCON
Evolution of nursing process• Fry (1953) identified that nursing diagnosis is a tool for individualizing patient care.• First National Conference for the Classification of Nursing Diagnoses, (1973).• American Nurses Association (ANA) published Standards of Nursing Practice (1973).• North American Nursing Diagnosis Association (NANDA), 1982.• NANDA developed 21 new nursing diagnoses and revised 37 existing diagnoses (1998).
Purpose of nursing process• Identifies areas that nurses can resolve or enhance.• Demonstrates professional judgment.• Organizes decision making as part of the nursing process.• Promotes accountability.• Provides communication among nurses and other health care personnel.• Promotes use of standardized language and process.• A means to individualize care.• Provides a mechanism for conducting nursing research.
Definition of a Nursing Diagnosis (NANDA, 1996)A nursing diagnosis is defined as “ a clinicaljudgment about an individual, family orcommunity responses to actual and potentialhealth problems/life processes. Nursingdiagnosis provide the basis for selection ofnursing interventions to achieve outcomesfor which the nurse is accountable.”(NANDA, 2009)
Comparison of Medical and Nursing Diagnoses• Medical diagnosis is the terminology used for a clinical judgment by the physician that identifies or determines a specific disease, condition, or pathologic state.
Nursing Diagnosis• Terminology used for a clinical judgment by the professional nurse that identifies the client’s actual, risk, wellness, or syndrome responses to a health state, problem, or condition.
Components of a Nursing Diagnosis• The two-part statement – Problem statement or diagnostic label – Etiology• The diagnostic label and etiology are linked by the term related to (RT).
Components of a Nursing Diagnosis• The three-part statement – Diagnostic Label – Etiology – Defining Characteristics• Defining characteristics are the signs and symptoms, subjective and objective data, or clinical manifestations.• The phrase, “as evidenced by …” (AEB), is joined to the first two components.
Avoiding Errors in Developing a Nursing Diagnosis• Accurate and complete collection of data.• Use of an organizational framework for clustering data cues.• Thorough analysis and validation of data.• Correct writing of the nursing diagnosis.
Limitations of Nursing Diagnosis• Lack of consensus among nurses regarding the NANDA-approved nursing diagnosis list.• Nurses are overworked and have less time with clients.• Care is still organized around the medical diagnosis.
Limitations of Nursing Diagnosis• Nurses are afraid they may be ridiculed for using nursing diagnoses.• The nursing diagnosis list does not always fit the client situation.• Nurses may be unable or unwilling to use nursing diagnoses because of incomplete knowledge.• If a nursing diagnosis is inappropriate, and as a result, the interventions are inappropriate or lacking, the nurse is liable for these errors in judgment.
Overcoming Barriers to Nursing Diagnosis• Familiarity of nursing diagnosis language empowers the nurse to communicate more effectively.• Health care agency administrators and medical staffs need to be more supportive of the use of nursing diagnoses.
Overcoming Barriers to Nursing Diagnosis• Enhanced communication between clinical nurses and leaders will increase the development of nursing diagnoses.• Most nursing education programs offer standardized content related to nursing diagnoses.• Experienced nurses need opportunities to review nursing diagnoses.
Overcoming Barriers to Nursing Diagnosis• Every attempt should be made to describe phenomena that do not fit into existing nursing diagnosis language.• The nurse may be on the threshold of documenting a new nursing diagnosis.
“At the end of the dayI can truly says I made a difference in someone’s life today…. And that is why I am NURSE”