The three-part nursing diagnosis is one of the most important aspects of the nursing process. A nursing diagnosis is a statement indicating several different potential problems a patient may face. A nurse will diagnose and treat the symptoms or health problems, and a nursing diagnosis is the groundwork for establishing and carrying out a patient care plan.
So how does a nursing diagnosis differ from a medical diagnosis? A doctor diagnoses a disease or a disorder. A nurse offers a diagnosis for a problem present during the nursing assessment which is caused by the disease or disorder. For example, during the nursing assessment, the nurse could diagnose the patient with poor breathing and a cough. A doctor will diagnose a patient with chronic bronchitis and prescribe medication.
A nursing diagnosis is not simply assessing the patient, which is the first step in the nursing process. A nurse will develop a diagnostic statement based on data collected during the nursing assessment. The assessment process involves physically examining a patient. A nurse will monitor a patient’s symptoms, such as nausea, and measure vital signs such as heart rate, temperature, blood pressure and oxygen levels, among many other things. Nurses must often discuss with patients any non-obvious symptoms they may have, such as pain or vertigo, as well as patient history. This is an important part of collecting the data necessary to develop a diagnosis. It may be necessary to perform a psychological exam or a social exam, depending on what field a nurse works in.
Developing a three-part nursing diagnosis consists of data analysis, problem identification and the formulation of the nursing diagnosis. There are four different types of nursing diagnosis; actual nursing diagnosis, wellness (or health promotion) nursing diagnosis, risk nursing diagnosis and syndrome diagnosis.
An actual diagnosis identifies a current health problem, such as inadequate airway clearance as evidence by the inability to maintain adequate oxygenation on room air.
A wellness or health promotion diagnosis identifies a patient’s readiness to transition to a higher wellness level, such as readiness for enhanced self-care to increase cardiac output related to increased cardiac output due to pacemaker insertion.
A risk diagnosis identifies when a patient could be at risk for additional health problems, such as infection.
A syndrome diagnosis determines symptoms based on certain situations, such as post-trauma syndrome or relocation stress syndrome.
So what’s the point of a nursing diagnosis? Ultimately, a nursing diagnosis increases patient safety and means more effective care. You’ll identify every potential syndrome a patient may have and record all important vital signs. This attention to detail could be the difference between the correct treatment and continued illness or injury.
Once you’ve reached your nursing diagnosis, it’s important to write the diagnosis correctly, as established by the North American Nursing Diagnosis Association (NANDA.) Correctly writing the diagnosis helps ensure consistency across communication lines to other health care professionals. The diagnosis can be structured differently depending on the type of diagnosis it is.
An actual nursing diagnosis is written as the problem/diagnosis related to (r/t) x factor/cause as evidenced by data/observations.
A risk nursing diagnosis is written as problem/diagnosis related to (r/t) x factor/cause.
A syndrome nursing diagnosis is written as problem/diagnosis related to (r/t) x factor/cause.
A wellness nursing diagnosis is written as readiness to/for action.
Nursing is an evidence-based practice, and no aspect more so than the three-part nursing diagnosis. Your diagnosis as a nurse can save patients a lot of pain and trouble.
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