How to Write Nursing Diagnosis
Definition of a Nursing Diagnosis
Nursing diagnosis definition refers to the clinical judgment that concerns an individual response to a certain health condition or life process. It is an integral part of the nursing process. There are several key goals of a nursing diagnosis.
First, to identify the responses to a certain disease or a life process and understand what nursing interventions are needed. Second, to create a fundament for a further evaluation of the outcomes of nursing care. And the last one is to increase the quality of communication between nurses and advanced health care practitioners.
Sometimes, people mistakenly identify a nursing diagnosis with a medical diagnosis, but there is a big difference between these two terms. A nursing diagnosis is focused on identifying spiritual, physical, and mental responses to health problems, while a medical diagnosis is focused on identifying a medical condition/disease of an individual or group.
Why Is It Important to Write a Nursing Diagnosis?
While sometimes a nursing diagnosis is seen as unnecessary, it is an important tool for proper patient care. With an accurate nursing assessment, a nurse can find a better treatment for a patient and provide quality care.
Thus, it is essential to make a nursing assessment and write a proper nursing diagnosis to provide quality patient care.
Types of a Nursing Diagnosis
According to the NANDA-I, there are 4 main types of nursing diagnosis:
- Actual (Problem-focused)
- Health Promotion
All of these types are equally important but differ in the focus of the assessment and the situation of the use.
The first type, the actual nursing diagnosis, is about identifying a patient’s responses to a current health condition. The three main components of this type of diagnosis are nursing diagnosis, related factors, and defining characteristics.
The next type, the risk nursing diagnosis, is about assessing possible risks and problems that are likely to develop without appropriate nursing interventions. The main components are risk diagnostic labels and risk reasons.
The third type, the health promotion nursing diagnosis, is used to identify the patient’s level of readiness for improvement of their health.
The last type, the syndrome nursing diagnosis, concerns the cluster of risks that are predicted due to the current health condition of a patient.
How to Formulate a Nursing Diagnosis: Main Components
Accurate formulation of a nursing diagnosis is critical for the nursing process. So, let’s take a look at the main component of a well-written nursing diagnosis:
- The problem statement/diagnosis label
- Defining characteristics
What exactly does each of these components describe? Generally, here is what should be described in each part of the diagnosis:
- A patient’s current health problem, symptoms, or possible risks
- State the cause of the problem/condition to give direction to the nursing care
- Identified signs and responses that evidence a problem stated at the beginning
Depending on the type of written nursing diagnosis, it may consist of only one first part (health promotion and syndrome diagnosis), two parts (risk diagnosis), or all three parts (problem-focused diagnosis).