nursing diagnosis

nursing diagnosis,

a statement of a health problem or of a potential problem in the client's health status that a nurse is licensed and competent to treat. Four steps are required in the formulation of a nursing diagnosis. A database is established by collecting information from all available sources, including interviews with the client and the client's family, a review of any existing records of the client's health, observation of the client's response to any alterations in health status, a physical assessment, and a conference or consultation with others concerned in the client's care. The database is continually updated. The second step includes analysis of the client's responses to the problems, healthy or unhealthy, and classification of those responses as psychologic, physiologic, spiritual, or sociologic. The third step is the organization of the data so that a tentative diagnostic statement can be made that summarizes the pattern of problems discovered. The last step is confirmation of the sufficiency and accuracy of the database by evaluation of the appropriateness of the diagnosis to nursing intervention and by the assurance that, given the same information, most other qualified practitioners would arrive at the same nursing diagnosis. In use, each diagnostic category has three parts: the term that concisely describes the problem, the probable cause of the problem, and the defining characteristics of the problem. A number of nursing diagnoses have been identified and are listed as accepted by the North American Nursing Diagnosis Association, and they are updated and refined at periodic meetings of the group.

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diagnosis [di″ag-no´sis]

1. determination of the nature of a cause of a disease.

2. a concise technical description of the cause, nature, or manifestations of a condition, situation, or problem. adj., adj diagnos´tic.

clinical diagnosis diagnosis based on signs, symptoms, and laboratory findings during life.

differential diagnosis the determination of which one of several diseases may be producing the symptoms.

medical diagnosis diagnosis based on information from sources such as findings from a physical examination, interview with the patient or family or both, medical history of the patient and family, and clinical findings as reported by laboratory tests and radiologic studies.

nursing diagnosis see nursing diagnosis.

physical diagnosis diagnosis based on information obtained by inspection, palpation, percussion, and auscultation.

diagnosis-Related Groups (DRG) a system of classification or grouping of patients according to medical diagnosis for purposes of paying hospitalization costs. In 1983, amendments to Social Security contained a prospective payment plan for most Medicare inpatient services in the United States. The payment plan was intended to control rising health care costs by paying a fixed amount per patient. The program of DRG reimbursement was based on the premise that similar medical diagnoses would generate similar costs for hospitalization. Therefore, all patients admitted for a surgical procedure such as hernia repair would be charged the same amount regardless of actual cost to the hospital. If a patient's hospital bill should total less than the amount paid by Medicare, the hospital is allowed to keep the difference. If, however, a patient's bill is more than that reimbursed by Medicare for a specific diagnosis, the hospital must absorb the difference in cost. See also appendix of Diagnosis-Related Groups.