Online Companion: Fundamentals of Nursing Standards and Practice 2E

Chapter Summary

Chapter 7 introduces the use of nursing diagnosis as a part of the nursing process. Nursing diagnosis is a clinical judgment about individual, family, or group responses to actual or risk health problems, wellness states, or syndromes. The purpose of using nursing diagnosis is to effectively communicate the health care needs of individuals or groups to other nurses and health team members. Nursing diagnosis is different from the medical diagnosis. Medical diagnosis is the use of terms to define a specific disease, condition or pathologic state that the physician treats within the scope of medical practice. Nursing diagnosis uses terminology for the clinical judgment made by the nurse within nursing scope of practice about the client's response to a health state, problem or condition. When an accurate nursing diagnosis is established, the goals and interventions required for the client can be specified. The nursing diagnosis is relatively new idea as compared to the long-established medical diagnosis. It has the endorsement of the American Nurses Association. The organization North American Nursing Diagnosis Association (NANDA) holds meetings every two years to identify, develop and classify nursing diagnoses. The list this group has developed is used as a standard for the naming of nursing diagnoses. The use of nursing diagnosis in clinical practice contributes to the professional accountability and autonomy of nursing, provides a means for effective communication, and enhances the quality and continuity of care.

The nursing diagnosis statement is typically composed of two parts: the problem statement and the etiology.There is a third part of the statement , the defining characteristics, that enhances the specific description of the problem statement. Four categories of nursing diagnoses have been identified: actual, risk, wellness, and syndrome. The list of nursing diagnoses is organized into a taxonomy of nine human response patterns; the taxonomy assists the nurse to review the entire list by pattern of response instead of the alphabetical list.

The steps involved in establishing a nursing diagnosis are systematic and require the nurse to use critical thinking skills. The nurse begins with the assessment data that has been gathered; cues are identified from the data and are reviewed and validated for accuracy and completeness. In the next step, the nurse assigns meaning to the cues and interprets their importance. The nurse then groups the data into clusters to observe relationships among the data and draws conclusions. The NANDA list is used to match the clustered data to a particular nursing diagnosis.

Errors in making nursing diagnoses are primarily related to use of the database: incomplete collection of assessment data, restricted data collection, failure to validate data, misinterpretation of data, and inappropriate data clustering. The incorrect writing of the nursing diagnosis statement is another type of error.

At this time, the use of nursing diagnosis has limitations and professional concerns. There is a lack of consensus among nurses about the NANDA list. There are legal considerations concerning the use of nursing diagnosis. There are barriers within the health care system to use of nursing diagnosis. The prevalence of medical diagnosis language is one of these. Nurses can use strategies to overcome these barriers to promote effective nursing care through the use of a shared language of nursing diagnosis.