Nursing Diagnosis – Care Plan for Patients

?Nursing Diagnosis – Care Plan for Patients

Nursing diagnosis is developed during the course of performing health assessments. A nursing diagnosis is a standardized statement about the health of a client (who can be an individual, a family, or a community) for the purpose of providing nursing care.

Defined, Nursing Diagnosis is a diagnosis of a patient’s state of being, symptom, or reaction to a circumstance such as a disease process. Nursing diagnosis is part of a movement in nursing to standardize the terminology involved. This includes standard descriptions of diagnoses, interventions and outcomes. Nurses who support the standardized terminology believe that it will help nursing become more scientific and evidence-based. Other nurses feel that nursing diagnosis is an ivory-tower mentality and neither help in care planning nor in differentiating nursing from medicine. Nursing diagnosis may be the way to bridge care gaps and communicate nursing care along the healthcare continuum.

NANDA (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses to standardize nursing terminology that was founded in 1982 and develops and refines the nomenclature, criteria, and taxonomy of nursing diagnosis. In 2002, NANDA re-launched as NANDA-International in response to the broadening scope of their membership. NANDA International published Nursing Diagnosis quarterly, which became the International Journal of Nursing Terminologies and Classifications in 2002. NANDA-International is committed to increasing the visibility of nursing’s contribution to patient care by continuing to develop, refine and classify phenomena of concern to nurses. Essentially, they develop refine and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses.  This taxonomy is a conceptual framework for the development of nursing diagnoses. 

NANDA’s revolves along -categories:
* Actual diagnosis – statement about a health problem that the client has and the benefit from nursing care;
* Risk diagnosis – statement about health problems that a client doesn’t have yet, but is at a higher than normal risk of developing in the near future;
* Possible diagnosis – statement about a health problem that the client might have now, but the nurse doesn’t yet have enough information to make an actual diagnosis;
* Syndrome diagnosis – used when a cluster of nursing diagnoses are seen together; and
* Wellness diagnosis – describing an aspect of the client that is at a high-level of wellness.

An example of a common Nursing Diagnosis is as follows: Alteration in comfort: Pain (acute) related to surgical incision and inflammatory process as evidenced by guarding, grimacing, muscle rigidity, moaning, and patient complaint of pain as 5 on a 0-10 scale.

The concept of nursing diagnosis is a successful clinical initiative and nursing diagnosis is internationally accepted as a crucial step in a systematic and individualized care plan.

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