nursing diagnosis

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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.

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 data base 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 data base 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 psychological, physiological, spiritual, or sociological. 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 data base 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.

nurs·ing di·ag·no·sis

(nŭrs'ing dī-ăg-nō'sis)
The process of assessing potential or actual health problems, including those pertaining to an individual patient, a family or community, that fall within the scope of nursing practice; a judgment or conclusion reached as a result of such assessment or derived from assessment data.
See also: diagnosis

nursing diagnosis

The patient problem identified by the nurse for nursing intervention by analysis of assessment findings in comparison with what is considered to be normal. Nurses, esp. those involved in patient care, are in virtually constant need to make decisions and diagnoses based on their clinical experience and judgment. In many instances, that process dictates a course of action for the nurse that is of vital importance to the patient. As the nursing profession evolves and develops, nursing diagnosis will be defined and specified in accordance with the specialized training and experience of nurses, particularly for nurse practitioners and clinical nurse specialists.
See: nursing process; planning
References in periodicals archive ?
For Nursing Diagnosis: The North American Nursing Diagnosis Association's (NANDA) approved list of nursing diagnoses.
Problems or nursing diagnoses can reflect clinical symptoms, such as chest pain, or risk assessment, such as "potential complication: cardiac" (Carpenito 1995: 218).
Nursing diagnoses and treatments might include (but would not be limited to) the following:
Pertinent nursing diagnoses or problems based on the data included: (a) hopelessness, (b) impaired social interaction and (c) diversional activity deficit.
Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales, 8th Edition--Specifically designed for nursing students, this guide helps students identify interventions most commonly associated with nursing diagnoses when caring for patients.
Doenges (adult psychiatric/mental health nursing, retired, Beth-El College), Moorhouse, and Murr supply nurses and nursing students with a pocket guide to interventions associated with specific nursing diagnoses as proposed by NANDA International for settings from acute to community/home care, with a focus on adults.
In addition, the language used in nursing diagnoses is not accepted by physicians, which presents difficulties for students in clinical settings.
A range of fundamental skirls were taught, eg communication skills, risk assessment, working with suicidal patients, common medical and nursing diagnoses, assessment and formulation, and basic nursing care planning.
The nursing minimum data set (NMDS) is part of the continuity of care document that is a standard for exchanging patient information: assessments captured in electronic forms/screen displays; patient problems (NANDA-I nursing diagnoses, 2009) in problem lists; planned and performed interventions and education (NIC nursing interventions, 2008) within nursing plans for care/orders and electronic forms; and patient outcomes (NOC nursing-sensitive outcomes and indicators, 2008) scored, calculated or trended groups of assessments.
A study reported in 2000 by Welton and Halloran found that adding nursing diagnoses to DRGs provided a better explanation for length of stay, hospital charges, and mortality.
The SNOMED CT mappings of these leading nursing classifications will broaden nurses' access to the terminologies necessary to consistently and uniformly document nursing diagnoses, treatment and outcomes within electronic health records (EHRs).

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