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A nursing diagnosis is an essential tool to upgrade the skills of nursing students as well as to provide a common ground for effective communication between nurses and doctors. It allows identifying the healthcare priorities and contributes to cost-effective treatment. However, the benefits and objectives of NANDA nursing diagnosis do not come down to the aforementioned terms.
It is pretty obvious that every professional nurse has to be able to make a diagnosis and properly organize it. Today, the NANDA-I taxonomy encompasses 234 diagnoses divided into 13 categories. Plus, there are several types of nursing diagnoses and different formats. So, you may ask, – how to break them down by categories and coverage?
The first nursing diagnosis may catch you off-balance. But the best thing you can do to master it is to ease up. In the end, it is just a part of your nursing journey. So, let’s figure out in more detail how to write a nursing diagnosis!
What Should You Know About NANDA Nursing Diagnosis?
The first thing you should know about the nursing diagnosis is what it implies and why you should actually write it. The NANDA nursing diagnosis refers to the type of medical report that discusses a patient’s reaction to certain conditions or processes, potential risks, and vulnerabilities. This document helps to define the set of measures a nurse should undertake to improve the effectiveness of treatment. Based on the nursing diagnosis, you, as a nurse, can elaborate the best possible care plan. However, before writing it you need to complete the nursing assessment and analyze the data received.
The main objectives of the nursing diagnosis include the following:
- To determine nursing treatment methods and practices;
- To define the potential outcomes and treatment results;
- To identify patient’s reaction to certain conditions and processes after the treatment and ways to resolve the related health problems in the future;
- To provide the bridge between medical professionals and nurses for smoother communication;
- To open a prospect for the nursing care quality evaluation;
- To enhance the analytical and problem-solving abilities of nursing students.
The nursing diagnosis is always about care. Nurses are the type of healthcare professionals that deal with patients all day and all night long. Thus, they can notice things that escape the attention of doctors. At the same time, the medication and treatment can impact patients differently, causing a certain response. This response usually occurs in the form of anxiety, sleep problems, etc. All these types of reactions are highlighted in the nursing diagnosis and come from the NANDA classification system.
NANDA-International stands for the North American Nursing Diagnosis Association that has been transformed into an international entity. This organization is designed to define, revise, distribute, and integrate standardized nursing diagnoses all over the world. This association has also developed the Classification of Nursing Diagnoses (Taxonomy II).
According to it, Nursing diagnoses fall into 13 Domains and 47 Classes. Plus, there are 234 diagnoses in total. The NANDA-I has a large database of nursing diagnosis examples and best practices. So, before starting writing your own paper, check out how it should look.
Take into account that there are differences between the nursing diagnosis and the medical diagnosis. While the first one is focused on the daily care performed by nursing professionals, the second refers to the report made by advanced healthcare practitioners. The latter touches upon the disease, its medication, medical condition, etc.
NANDA Nursing Diagnosis: Types and Components
The NANDA nursing diagnosis has four main types that include Problem-Focused, Health Promotion, Syndrome, and Risk. Let’s look into them in more detail:
- The problem-focused nursing diagnosis aims at identifying the symptoms and problems detected during the nursing assessment.
- Health promotion diagnosis focuses on the ways and measures to increase the patient’s general physical and mental state. This type of diagnosis evaluates the level of wellness and allows creating an individual healthcare plan.
- Syndrome diagnosis implies a clinical report that identifies certain health problems that may occur due to particular conditions or risky situations.
- Risk nursing diagnosis speaks for itself. It states that the problem is not identified yet but will probably be present in the future due to specific risk factors.
Each of the aforementioned types includes three integral components:
- Problem statement: it is also known as the diagnostic label. This part aims at identifying and revealing the patient’s health problem as well as the response to the medical condition and medication. The diagnostic label, therefore, includes two main components – a qualifier and the focus of the diagnosis. The qualifier specifies the diagnosis, providing additional details.
- Etiology: this part determines the possible causes of the existing health problem, conditions, or events that could provoke the problem. And it also provides ideas for nursing therapy. Plus, the etiology allows personalizing the patient’s care and should stem from the problem statement.
- Characteristics and risk factors: one of these parts can be replaced by the other. Risk factors refer to the description of things that make a patient more vulnerable to certain conditions. On the other hand, characteristics usually include the symptoms and other indicators, allowing you to determine a particular problem. Which one you should use depends on the nursing diagnosis format that you follow.
Writing A Nursing Diagnosis: Essential Guidelines
Nursing diagnosis writing takes two main stages; each of them falls down into several steps. The first stage implies diagnosis making, whereas the second refers to the writing process itself. We will look into the diagnostic process first which includes three steps.
- Step 1: Data analysis
Before analyzing data, make sure you have all the necessary information about the patient’s state of health. This data is usually collected during the nursing assessment, based on the current medical observations and labs. To analyze this data correctly, you should evaluate it according to standards, highlighting any deviations and inconsistencies.
- Step 2: Identification of health issues, risks, and strengths
This step requires the collaboration between a nurse and a patient to determine the problems, risks, and strengths. The strengths imply the inner health resources that will help the patient to overcome the health issues and minimize the risks. You should also identify whether the existing problem stems from a medical diagnosis, nursing diagnosis, or both.
- Step 3: Formulation of diagnostic claims
As soon as the data has been analyzed and problems have been identified, you need to elaborate on the key statements of your nursing diagnosis. At this stage, you need to underline all of the important conclusions you have drawn in the previous steps.
- Step 4: Nursing diagnosis writing
Then, you have to pass on the writing process itself. In your nursing diagnosis, you should explicate the health status of a patient and highlight the factors that have impacted it. Take into account that there are several nursing diagnosis formats. So, the diagnostic statements will depend on the type of paper. Let’s figure out what is what.
The nursing diagnosis PES format abbreviation refers to P for Problem, E for Etiology, and S for Symptoms. This format has three variations as follows:
1. One-part nursing diagnosis
This is quite a concise format that is used while writing the health promotion and syndrome nursing diagnoses. In the first case, the related factors come down to the motivation to improve the overall health state. As for the syndrome diagnosis, it does not usually have related factors at all.
2. Two-part nursing diagnosis
This format is usually attributed to the risk nursing diagnoses and possible nursing diagnoses. While the first piece refers to the diagnostic label, the second describes the risk factors. Risk and possible diagnoses do not include the third part due to the symptoms are typically absent.
3. Three-part nursing diagnosis
This format encompasses the three pillars of problem-focused nursing diagnoses – the Problem, Etiology, and Symptoms. Every part is dedicated to one of these aspects. So, you should first describe the existing problem, then highlight the risk factors, and finish with the summary of symptoms.
In Wrapping Up
Writing a NANDA nursing diagnosis is an important part of your nursing training. You will deal with this kind of task all the time during your nursing career. So, it is essential to learn how to do it correctly from the very start. Nursing diagnosis writing allows improving your critical thinking and problem-solving skills that may also be really useful for research paper writing. But if this task leads you up a blind alley, do not hesitate to ask for professional help.
On a final note, let’s summarize all of the essential steps you have to take while writing a nursing diagnosis:
- Decide what type of document you should write – Problem-Focused, Health Promotion, Syndrome, or Risk diagnosis.
- Depending on the type of nursing diagnosis, choose the right format – one-part, two-part, or three-part document.
- Analyze the data gained from nursing assessment.
- Identify problems, risks, symptoms, and strengths.
- Come up with the diagnostic statements.
- Put that all in writing.