behind writing nursing diagnosis. Learn what a nursing diagnosis is, its history and
evolution, the nursing process, the different types and classifications, and how to write
nursing diagnoses correctly. Included also in this guide are tips on how you can formulate
better nursing diagnoses, plus guides on how you can use them in creating your nursing care
plans.
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.
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. Taxonomy II for nursing diagnosis contains 13 domains
and 47 classes. Image via: Wikipedia.com
• Domain 1. Health Promotion
• Class 1. Health Awareness