What is a nursing diagnosis?

A nursing diagnosis is a tool used by nurses to identify specific patient needs that fall within the scope of nursing practice. Diagnosis is one of the first steps in developing a plan of care and is based on physician recommendations, review of patient records, and examination of patients in person. The nurses look at all the information and determine the areas that may cause problems or complications for the patients.

To understand what a nursing diagnosis is, it is important to understand what it is not. Nurses do not make medical diagnoses as this is outside their scope of practice. Determining the underlying cause of a condition falls to physicians and surgeons, while nurses look at how that disease affects other areas of a patient's life that can be improved through nursing care. For example, a doctor diagnoses a patient with heart disease and recommends a low-salt diet, while a nurse diagnoses the patient with a learning deficit related to following a therapeutic diet and develops a plan to educate the patient.

There are several different types of nursing diagnoses, four of which identify a problem or potential problem, and a wellness nursing diagnosis that identifies a patient's strengths. A true diagnosis is based on a problem that is currently present, such as diarrhea. A possible diagnosis identifies a problem that is probably present, but has not yet been confirmed. A problem that has the potential to become a problem based on current health status is written as a risk diagnosis. When a patient has a real risk or cluster of related problems, such as post-traumatic stress, those problems are grouped together under a syndrome diagnosis.

In general, a nursing diagnosis consists of at least two parts: the diagnosis itself and the rationale for the diagnosis. For example, if a patient is on complete bed rest and unable to move frequently, a nurse may diagnose a risk of disuse syndrome related to decreased mobility. Actual and potential diagnoses go a step further and add evidence of the condition after the "related to" part. A three-part nursing diagnosis for pain can be read as "surgery-related pain as manifested by verbalizing to the patient that they are in pain." It may sound redundant to mention pain twice, but it is important because it identifies how a nurse determined the diagnosis.

Once a nursing diagnosis is made, the nurse must follow up by determining a goal to solve the problem as well as a plan to achieve that outcome. When more than one diagnosis is present, the nurse should prioritize them based on those with the greatest immediate need. Patients' conditions can change frequently during their stay in a facility, and nurses must be prepared to adapt their diagnoses accordingly.

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