Nursing Diagnosis is originated from patient health status data collected. This include objective and subjective findings. It is done during the assessment phase when you are developing patient -nurse relationship.The nurse collects the data and express professional judgments based on the information collected. The nurse identify potential problems, recognize strength and should not create any story that doesn’t exist.Nursing diagnosis is a health problem and the human response to the problem. Nursing diagnosis is part of the nursing process (Assessment, Diagnosis, Planning, Implementation and Evaluation)and important clinical judgment about the clients (patients) the families and the community at large response to health problems/ health crisis. When planning your nursing diagnosis remember that they are based on data collected during assessment. Refer to NANDA – approved nursing diagnoses . The nursing diagnosis should be divided into three:
(1) Problem Identification.
(2) The etiology ( Origin of the problem)
(3) What is the risk factors associated with this?.Characteristics.
Nursing Diagnosis examples: Risk of infection.
Medical diagnosis : Diabetes mellitus type 11
Nursing diagnosis: Risk for unstable or control blood sugar.
Etiology: History of diabetes, noncompliance with plan of care.Poverty unable to afford medications. Lack of access to health care.
Risk factors: Complications from diabetes, neuropathy, blindness,amputation. Possible death.
Nursing diagnosis main purpose is to create alertness and communication of healthcare needs of the patient so that care can be initiated immediately and minimize risk for the patient (s).For example you admitted a patient with diabetes, high blood sugar and there is no order to check blood sugar, sliding scale or to give insulin. After your assessment and data collection, you formulate your Nursing diagnosis as “Risk for unstable blood sugar”. You check blood sugar 450,and in Emergency room it was 600,you will call the PCP or the doctor on call for orders. You are not going to wait and said since the doctor didn’t write the order, I will ignore high blood sugar of 450 because patient can go into coma and will need you to call RRT( Rapid Reponse Team) for a simple thing that you should have controlled. After patient is treated and blood sugar controlled. You the nurse will become temporary unstable because you have to write incident report of what happened send to your manager, risk management department and the nursing supervisor. As a nurse know what is right and what is wrong. What is call to duty.Function and do what any other competent nurse will do. You are in this to succeed.
NURSING DIAGNOSIS IN A NUTSHELL.
(A)Interpretation of information collected from the patient.
(B)What health issues about the patient are you worried about?.
(C )Develop a vivid nursing diagnosis.
(D )Identify the problems and analyze them.