Fundamentals of Nursing Practice  © Rhodora Cruz

 


B- Nursing Diagnosis

 

Nursing Diagnosis

Nursing Diagnosis is the process in which you classify the problem in the assessment phase into an approved classification process called NANDA which stands for North American Nursing Diagnosis Association. A nursing diagnosis is a clinical diagnosis made by a registered nurse which, unlike physician's diagnosis, does not cover the patient's medical condition, but the patient's response to the medical condition.

Patients generally have multiple nursing diagnoses covering everything from their physical well-being through their psychosocial well-being to the well-being of their family and caregivers. These diagnoses must cover problems that the nurse can treat independently of the MD. A complete nursing diagnosis is written in the format problem related to cause of problem as evidenced by symptoms of problem ( www.everything2..com retrieved on 07/02/2008). An example of such a nursing diagnosis based on the nursing assessment above would be Impaired gas exchange related to productive cough as evidenced by shallow respiration of 32, oxygen saturation of 89 %, inspiratory crackles auscultated throughout right upper and lower chest, diminished breath sounds on right side and complaint of “can’t breathe lying down” and short of breath of exertion. You can formulate nursing diagnosis by looking up the NANDA list of nursing diagnosis while basing it on the assessment data acquired.

NANDA, the North American Nursing Diagnosis Association, has an approved list of nursing diagnoses which may be used in North America. There is also an international association attempting to create a list of nursing diagnoses which will hopefully become universal at some point in the future.

The current (2003-2004) North American List of Approved Nursing Diagnoses

Activity alteration

Activity intolerance

Activity intolerance risk

Activities of Daily Living (ADLs) alteration

Acute pain

Adjustment impairment

Adolescent behavior alteration

Adult behavior alteration

Airway clearance impairment

Alcohol abuse

Anticipatory grieving

Anxiety

Aspiration risk

Auditory alteration

Automic dysreflexia

Bathing/hygiene deficit

Blood pressure alteration

Body image disturbance

Body nutrition deficit

Body nutrition deficit risk

Body nutrition excess

Body nutrition excess risk

Bowel elimination alteration

Bowel incontinence

Breast feeding impairment

Breathing pattern impairment

Cardiac alteration

Cardiovascular alteration

Caregiver role strain

Cerebral alteration

Child behavior alteration

Chronic low self-esteem disturbance

Chronic pain

Colonic constipation

Comfort alteration

Communication impairment

Community coping impairment

Compromised family coping

Confusion

Contraceptive risk

Decisional conflict

Defensive coping

Denial

Diarrhea

Disabled family coping

Disuse syndrome

Diversional activity deficit

Dressing/grooming deficit

Drug abuse

Dying process

Dysfunctional grieving

Endocrine alteration

Failure to thrive

Family coping impairment

Family process alteration

Fatigue

Fear

Fecal impaction

Feeding deficit

Fertility risk

Fluid volume alteration

Fluid volume deficit

Fluid volume deficit risk

Fluid volume excess

Fluid volume excess risk

Functional urinary incontinence

Gas exchange impairment

Gastrointestinal alteration

Grieving

Growth and development alteration

Gustatory alteration

Health maintenance alteration

Health seeking behavior alteration

Home maintenance alteration

Hopelessness

Hyperthermia

Hypothermia

Immunologic alteration

Individual coping impairment

Infant behavior alteration

Infant feeding pattern impairment

Infection risk

Infection unspecified

Infertility risk

Injury risk

Instrumental Activities of Daily Living (IADLs) alteration

Intracranial adaptive capacity impairment

Kinesthetic alteration

Knowledge deficit

Knowledge deficit of diagnostic test

Knowledge deficit of dietary regimen

Knowledge deficit of disease process

Knowledge deficit of fluid volume

Knowledge deficit of medication regimen

Knowledge deficit of safety precautions

Knowledge deficit of therapeutic regimen

Labor risk

Latex allergy response

Meaningfulness alteration

Medication risk

Memory impairment

Musculoskeletal alteration

Nausea

Newborn behavior alteration

Noncompliance

Noncompliance of diagnostic test

Noncompliance of dietary regimen

Noncompliance of fluid volume

Noncompliance of medication regimen

Noncompliance of safety precautions

Noncompliance of therapeutic regimen

Nutrition alteration

Older adult behavior alteration

Olfactory alteration

Oral mucous membranes impairment

Parental role conflict

Parenting alteration

Perceived constipation

Perinatal risk

Perioperative injury risk

Perioperative positioning injury

Peripheral alteration

Personal identity disturbance

Physical mobility impairment

Physical regulation alteration

Poisoning risk

Polypharmacy

Postpartum risk

Post-trauma response

Powerlessness

Pregnancy risk

Protection alteration

Rape trauma syndrome

Reflex urinary incontinence

Relocation stress syndrome

Renal alteration

Reproductive risk

Respiration alteration

Role performance alteration

Self care deficit

Self concept alteration

Self mutilation risk

Sensory perceptual alteration

Sexual dysfunction

Sexuality patterns alteration

Situational self-esteem disturbance

Skin integrity impairment

Skin integrity impairment risk

Skin incision

Sleep deprivation

Sleep pattern disturbance

Social interaction alteration

Social isolation

Socialization alteration

Spiritual distress

Spiritual state alteration

Stress urinary incontinence

Substance abuse

Suffocation risk

Suicide risk

Surgical recovery delay

Swallowing impairment

Tactile alteration

Thermoregulation impairment

Tissue integrity alteration

Tissue perfusion alteration

Tobacco abuse

Tilting deficit

Total urinary incontinence

Thought processes alteration

Trauma risk

Unilateral neglect

Unspecified constipation

Unspecified pain

Urinary elimination alteration

Urinary retention

Urge urinary incontinence

Ventilatory weaning impairment

Verbal impairment

Violence risk

Visual alteration

Differentiating Nursing Diagnoses from Collaborative Problems

A collaborative problem is a type of potential problem that nurses manage using both independent and physician-prescribed interventions. Independent nursing interventions for a collaborative problem focus mainly on monitoring the client’s condition and preventing development of the potential complication. Definitive treatment of the condition requires both medical and nursing interventions. Collaborative problems tend to be present any time a particular disease of treatment is present; that is each disease or treatment has specific complications that are always associated with it. For example, a statement of collaborative problem is “Potential complication of pneumonia: atelectasis, respiratory failure, pleural effusion, pericarditis, and meningitis” (Kozier, Erb, Burman, and Burke, 2000). Whenever you write collaborative problems, you always write “Potential complication” then, followed by the medical diagnosis and other medical symptoms associated with it.

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