A nursing diagnosis is a tool used by nurses to identify the specific needs of the patient that fall under the nursing scope of practice. Diagnosing is one of the first steps in developing a care plan, and is based on doctor recommendations, evaluation of patient records, and examining the patients in person. Nurses look at all the information and determine areas that may cause problems or complications for the patients.
In order to understand what a nursing diagnosis is, it is important to understand what it is not. Nurses do not make medical diagnoses, as this falls outside their scope of practice. Determining the underlying cause of a condition falls on doctors and surgeons, while nurses look at how that disease affects other areas of the patient’s lives that can be improved through nursing care. For example, a doctor diagnosis 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 an issue or potential issue — and a wellness nursing diagnosis that identifies patient strengths. An actual diagnosis is based on an issue that is currently present, such as diarrhea. A possible diagnosis identifies a problem that is likely present, but has not yet been confirmed. An issue that can potentially become a problem based on current health status are written as a risk diagnosis. When a patient has actual or risk for a cluster of related problems, such as with post-traumatic stress, those issues are grouped together in 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 around frequently, a nurse may diagnose a risk for disuse syndrome related to impaired 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 may read as “pain related to surgery as manifested by patient verbalizing that he is 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 on it by determining a goal to resolve the issue as well as a plan for reaching that outcome. When more than one diagnosis is present, the nurse must prioritize them based on those that present the greatest immediate need. Patients’ conditions can change frequently during their stay at a facility, and nurses must be prepared to adapt their diagnoses accordingly.