Nursing diagnosis
Nursing diagnosis is a vital component of the nursing process, which encompasses patient assessment, intervention planning, and outcome evaluation. It involves the nurse's clinical judgment regarding a patient's health status and responses to actual or potential health problems, taking into account physical, psychological, sociocultural, and spiritual factors. This contrasts with medical diagnoses, which are provided by physicians and focus on specific illnesses. Nursing diagnoses guide nurses in directing their interventions to address not just physical symptoms, but also emotional aspects like anxiety and lifestyle factors such as poor nutrition.
Standardized taxonomies like NANDA International (NANDA-I) help categorize nursing diagnoses and interventions, enhancing the quality of patient care and safety. NANDA-I organizes nursing diagnoses into twelve domains and four categories, including problem-focused and risk diagnoses. Additionally, the Nursing Interventions Classification (NIC) offers a comprehensive framework for nursing actions across various healthcare settings. The implementation of these standardized classifications facilitates clear communication among healthcare providers, supports effective patient care, and contributes to better health outcomes.
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Nursing diagnosis
The nursing process encompasses patient assessment, nursing diagnosis, planning of patient outcome criteria, implementation of nursing interventions, and evaluation of whether the desired patient outcomes have been achieved. Nursing diagnosis is a critical part of the nursing process wherein a nurse provides a clinical judgment in response to a patient’s tangible or possible health issues and communicates it to the patient, family members, and caregivers. Nursing diagnoses can then be used to direct nursing interventions, the actions nurses perform, based on the patient’s specific health condition to achieve outcomes for which nurses are responsible.
Nursing diagnoses differ from medical diagnoses, which are completed by attending physicians and include notes on a patient’s illness or condition that the doctor can use for research and treatment. Conversely, the nursing diagnosis incorporates the nurse’s clinical judgement regarding the individual’s response to actual or potential health concerns and defines the patient’s physical, sociocultural, psychological, and spiritual response to the health condition. Apart from the pain experienced by the patient, nursing diagnoses also consider other sources of poor health such as anxiety and poor eating habits.
Background
There are several organizations that provide standardized taxonomies for nursing diagnoses, interventions, and outcomes that are accepted by the American Nurses Association (ANA). One of the most well-known is NANDA International (NANDA-I), formerly the North American Nursing Diagnosis Association. NANDA-I is an organization of nurses focused on continuously improving nursing diagnosis to increase in the quality of patient care in coordination with the promotion and improvement of patient safety. The group receives and assesses recommendations from nurses outside of the organization. Research is funded by the NANDA International Foundation to create a community-implemented model for executing nursing practices.
NANDA-I has categorized nursing diagnoses into twelve domains: health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationships, sexuality, coping/stress tolerance, life principles, safety/protection, and comfort. These domains encompass 235 NANDA-I nursing diagnoses in the organization’s Nursing Diagnoses: Definitions and Classification 2015–2017, the tenth edition of its nursing diagnosis guide book.
NANDA-I also divides the nursing diagnosis into four categories: problem-focused diagnosis, health promotion diagnosis, risk diagnosis, and syndrome diagnosis. Problem-focused diagnosis refers to responses to health conditions or life processes. Health promotion diagnosis has to do with the motivation to improve well-being and health potential. Risk diagnosis is concerned with vulnerabilities for developing adverse responses to health conditions or life processes. Syndrome diagnosis involves to a defined grouping of concurrent nursing diagnoses that can be addressed as a group and via similar nursing interventions.
Healthcare facilities that use the NANDA-I classification maintain preprinted forms of the standardized NANDA-I nursing diagnosis list in each of their patient care units to allow nursing and clinical staff to have easy access to these forms for implementation and review. Changes in the patient’s health conditions are noted in the diagnosis forms and are added to the patient’s permanent health record or electronic medical record (EMR). Correct collection and completion of the EMR enables clear communication among the clinical staff and permits continuous recovery in patient care.
The Nursing Interventions Classification (NIC) is another empirical, comprehensive classification for the nursing process, similar to that published by NANDA-I. NIC interventions are applicable in all health and wellness settings, although interventions can be approached both directly and indirectly. The 554 interventions listed in the sixth edition of the NIC are categorized into thirty classes and seven physiological domains (basic, complex, behavioral, safety, family, health system, and community). The NIC is accepted by the ANA and is an addition to the National Library of Medicine’s Unified Medical Language System Metathesaurus and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). The NIC has been recognized by the Joint Commission (TJC) as meeting the TJC standard for uniform data, and is also listed in the Health Level Seven International (HL7) and used in the Systemized Nomenclature of Medicine (SNOMED).
The International Council of Nurses is the publisher of the International Classification for Nursing Practice (ICNP), which serves as the standardized global nursing language and is accepted by the World Health Organization (WHO). The ICNP was developed in conjunction with ANA-recognized nursing taxonomies, including NANDA-I, NIC, Omaha System, Home Health Care Classification, and Nursing Outcomes Classifications.
Impact
Healthcare agencies around the world have adopted the NIC, ICNP, and NANDA-I nursing diagnosis methods for standardized and competent nursing evaluation. The NIC and ICNP have been translated into several other languages such as French, Spanish, Japanese, Korean, and German. Standardized, regulated nursing language allows uniform and comprehensive understanding of the patient’s conditions to efficiently address the patient’s needs, continue the developed course of care, and produce predictable health outcomes.
Bibliography
Amer. Nurses Assn. "What Is Nursing? The Nursing Process." Nursing World. ANA,2016. Web. 22 June 2016.
Bulechek, G., et al., eds. Nursing Interventions Classification (NIC). 6th ed. St. Louis: Elsevier, 2013. Print.
Herdman, T. Heater, and Shigemi Kamitsuru, eds.; NANDA International. Nursing Diagnoses: Definitions and Classification: 2015–2017. 10th ed. Hoboken: Wiley, 2014. Print.
"Nursing Diagnoses: Definitions and Classifications." NANDA International. NANDA-I, 2016. Web. 30 Aug. 2016.
"Nursing Diagnosis List." Nanda Nursing Diagnosis List. Nanda Nursing Diagnosis List, 2016. Web. 22 June. 2016.
Warren, Judith J., and Amy Coenen. "International Classification for Nursing Practice (ICNP): Most-Frequently Asked Questions." Journ. Amer. Med. Information Assn. 5.4 (1998): 335–36. NCBI. Web. 30 Aug. 2016.
"What Is a Nursing Care Plan and Why Is It Needed?" RNCentral. RNCentral, 2003–2016. Web. 22 June 2016.