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 foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician's orders (e.g., medication administration). Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response present at time of assessment. Risk diagnoses represent vulnerabilities to potential problems, and health promotion diagnoses identify areas which can be enhanced to improve health. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis identifies the unique ways in which individuals respond to health or life processes or crises. The nursing diagnostic process is unique among others. A nursing diagnosis integrates patient involvement, when possible, throughout the process. NANDA International (NANDA-I) is a body of professionals that develops, researches and refines an official taxonomy of nursing diagnosis. All nurses must be familiar with the steps of the nursing process in order to gain the most efficiency from their positions. In order to correctly diagnose, the nurse must make quick and accurate inferences from patient data during assessment, based on knowledge of the nursing discipline and concepts of concern to nurses.
NANDA International NANDA International, Inc., formerly known as the North American Nursing Diagnosis Association, is the primary organization for defining, researching, revising, distributing and integrating standardized nursing diagnoses worldwide. NANDA-I has worked in this area for more than 45 years to ensure that diagnoses are developed through a peer-reviewed process requiring standardised levels of evidence, definitions, defining characteristics, related factors 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. As research in the field of nursing continues to grow, NANDA-I continually develops and adds new diagnostic labels. 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 World Health Organization family of classifications. ICNP is a nursing language which can be used by nurses to diagnose.
Evolution of Nursing Diagnosis Nursing diagnoses have become more structured as nursing education has improved. Diagnoses became more organized as critical thinking and problem-solving skills became more important in nursing. Standardized nursing diagnoses allow nurses to communicate clearly and provide better care.
Development and Standardization of Nursing Diagnoses Experts constantly update nursing diagnoses to make them better. One way they do this is through the Delphi method, where groups of nursing experts discuss and refine diagnoses over several rounds until they reach an agreement. The Delphi method helps ensure that nursing diagnoses are clear, useful, and based on research. This method allows experts to improve nursing diagnoses so that nurses can apply them correctly in different healthcare settings. This process keeps nursing diagnoses up to date and relevant for patient care. It also helps promote consistency in how nurses assess and describe patient needs, which is important for communication and care planning.
Structure The NANDA-I system of nursing diagnosis provides for four categories and each has 3 parts: diagnostic label or the human response, related factors or the cause of the response, and defining characteristics found in the selected patient are the signs/symptoms present that are supporting the diagnosis.
Problem-focused 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. 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. Health promotion diagnosis A clinical judgment about a person's, family's or community's motivation and desire to increase wellbeing and actualise human health potential as expressed in the readiness to enhance specific health behaviours, and can be used in any health state. An example of a health promotion diagnosis is: Readiness for enhanced nutrition. 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.
Process The diagnostic process requires a nurse to use critical thinking. In addition to knowing the nursing diagnoses and their definitions, the nurse becomes aware of defining characteristics and behaviors of the diagnoses, related factors to the diagnoses, and the interventions suited for treating the diagnoses.
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