This document discusses nursing diagnosis, including its evolution, purpose, definition, components, types, prioritization, case studies, errors to avoid, limitations, and overcoming barriers. Specifically, it outlines how nursing diagnosis evolved from Fry's identification in 1953 as a tool for individualized care to NANDA developing new diagnoses in 1998. The purpose is to identify areas nurses can resolve, demonstrate professional judgment, and promote accountability. A nursing diagnosis is a clinical judgment about an individual's response to health problems.
2. Evolution of nursing process
Fry (1953) identified that nursing diagnosis is a
tool for individualizing patient care.
First National Conference for the Classification
of Nursing Diagnoses, (1973).
American Nurses Association (ANA)
published Standards of Nursing Practice (1973).
North American Nursing Diagnosis
Association (NANDA), 1982.
NANDA developed 21 new nursing diagnoses
and revised 37 existing diagnoses (1998).
3. Purpose of nursing process
Identifies areas that nurses can resolve or enhance.
Demonstrates professional judgment.
Organizes decision making as part of the nursing
process.
Promotes accountability.
Provides communication among nurses and other
health care personnel.
Promotes use of standardized language and process.
A means to individualize care.
Provides a mechanism for conducting nursing research.
4. Definition of a Nursing Diagnosis
(NANDA, 1996)
A nursing diagnosis is defined as a clinical
judgment about an individual, family or
community responses to actual and potential
health problems/life processes. Nursing
diagnosis provide the basis for selection of
nursing interventions to achieve outcomes
for which the nurse is accountable.
(NANDA, 2009)
5. Comparison of Medical and Nursing
Diagnoses
Medical diagnosis is the terminology
used for a clinical judgment by the
physician that identifies or
determines a specific
disease, condition, or pathologic
state.
6. Nursing Diagnosis
Terminology used for a clinical
judgment by the professional nurse that
identifies the clients
actual, risk, wellness, or syndrome
responses to a health state, problem, or
condition.
7. Components of a Nursing Diagnosis
The two-part statement
Problem statement or diagnostic label
Etiology
The diagnostic label and etiology are
linked by the term related to (RT).
8. Components of a Nursing Diagnosis
The three-part statement
Diagnostic Label
Etiology
Defining Characteristics
Defining characteristics are the signs and
symptoms, subjective and objective data, or clinical
manifestations.
The phrase, as evidenced by (AEB), is joined
to the first two components.
14. Avoiding Errors in Developing
a Nursing Diagnosis
Accurate and complete collection of data.
Use of an organizational framework for
clustering data cues.
Thorough analysis and validation of data.
Correct writing of the nursing diagnosis.
15. Limitations of Nursing Diagnosis
Lack of consensus among nurses regarding
the NANDA-approved nursing diagnosis
list.
Nurses are overworked and have less time
with clients.
Care is still organized around the medical
diagnosis.
16. Limitations of Nursing Diagnosis
Nurses are afraid they may be ridiculed for
using nursing diagnoses.
The nursing diagnosis list does not always fit
the client situation.
Nurses may be unable or unwilling to use
nursing diagnoses because of incomplete
knowledge.
If a nursing diagnosis is inappropriate, and as a
result, the interventions are inappropriate or
lacking, the nurse is liable for these errors in
judgment.
17. Overcoming Barriers to Nursing Diagnosis
Familiarity of nursing diagnosis language
empowers the nurse to communicate more
effectively.
Health care agency administrators and
medical staffs need to be more supportive of
the use of nursing diagnoses.
18. Overcoming Barriers to Nursing Diagnosis
Enhanced communication between clinical
nurses and leaders will increase the
development of nursing diagnoses.
Most nursing education programs offer
standardized content related to nursing
diagnoses.
Experienced nurses need opportunities to
review nursing diagnoses.
19. Overcoming Barriers to Nursing Diagnosis
Every attempt should be made to
describe phenomena that do not fit
into existing nursing diagnosis
language.
The nurse may be on the threshold
of documenting a new nursing
diagnosis.
20. At the end of the day
I can truly says I made a difference
in someones life today.
And that is why I am
NURSE