| NURSING DIAGNOSIS VS. MEDICAL DIAGNOSIS Posted: 04 May 2011 06:22 PM PDT NURSING DIAGNOSIS VS. MEDICAL DIAGNOSISWhat is the difference between a medical diagnosis and a nursing diagnosis?
A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes. For example, a medical diagnosis of Cerebrovascular Attack (CVA or Stroke) provides information about the patient's pathology. The complimentary nursing diagnoses of Impaired verbal communication, risk for falls, interrupted family processes and powerlessness provide a more holistic understanding of the impact of that stroke on this particular patient and his family – they also direct nursing interventions to obtain patient-specific outcomes. What is the best nursing diagnosis to use for my patient with congestive heart failure (or any other) medical diagnosis?
Using a medical diagnosis alone does not provide enough information to accurately diagnosis a patient from a nursing perspective. A holistic nursing assessment is critical for you to identify the potential nursing diagnoses. A medical diagnosis may be a related (or etiologic) factor for a nursing diagnosis, but you must identify defining characteristics of a nursing diagnosis during your assessment; it is impossible to make an accurate nursing diagnosis strictly from a medical diagnosis. Does NANDA-I provide a list of nursing diagnoses that go along with the most common medical diagnoses?
There are several books that use this format. However, we believe the individual nursing assessment is critical to the accurate nursing diagnosis for a patient. It can be helpful to consider nursing diagnoses that tend to cluster with a particular medical diagnosis. However, if nurses only use a "list" of nursing diagnoses with a particular medical diagnosis, they are missing the uniqueness of the patient for whom they are providing care – that is the risk of this approach. A nursing diagnosis must always be related to each individual patient's nursing assessment, or we risk misdiagnosis and inappropriate interventions. Remember that patient safety demands accurate nursing diagnosis!
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| NURSING DIAGNOSIS BASICS Posted: 04 May 2011 06:08 PM PDT NURSING DIAGNOSIS BASICSWhat is a nursing diagnosis?
A nursing diagnosis is a clinical judgment about individual, family, or community experiences and responses to actual or potential health problems and life processes. Why use nursing diagnosis?
A nursing diagnosis is used to determine the appropriate plan of care for the patient. The nursing diagnosis drives interventions and patient outcomes, enabling the nurse to develop the patient care plan. Nursing diagnoses also provide a standard nomenclature for use in the Electronic Health Record, enabling clear communication among care team members and the collection of data for continuous improvement in patient care. Why doesn't NANDA International provide a list of its diagnoses on its website?
There is no real use for simply providing a list of terms – to do so defeats the purpose of a standardized language. Unless the definition, defining characteristics, related and/or risk factors are known, the label itself is meaningless. Therefore, we do not believe it is in the interest of patient safety to produce simple lists of terms that could be misunderstood or used inappropriately in a clinical context.
Should all of nursing practice related to patient care be named with nursing diagnoses? Not all nursing interventions or actions are based on nursing diagnosis. Nurses intervene on conditions described by medical diagnoses as well as nursing diagnoses. We do not rename medical diagnoses or terms to create actual nursing diagnosis.
How specific should each nursing diagnosis be?
Specificity – or granularity – differs by concept. It is important to look at each diagnosis based on the level of evidence available in the literature and to stay clinically focused in decision-making.
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