nursing diagnosis


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Related to nursing diagnosis: Nursing care plan, Nursing process

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 ?
Nursing diagnosis in the chronically ill: Methodology for clinical validation.
In the first stage of the study, of the 23 results contained in the link NOC-NANDA-I6 to the ND Risk for ineffective cerebral tissue perfusion (2), were selected the nine Suggested by NOC, because are results considered more approximate to the nursing diagnosis.
Nursing care plans; nursing diagnosis and intervention, 6th ed.
Many inexperienced RNs also attempt to use a nursing diagnosis for the problem focus.
The quality of nurses' independent role functioning can be assessed by collecting data on the timeliness, appropriateness, accuracy, and completeness of assessment, nursing diagnosis, nursing interventions, and followup care.
ADMISSION RECORD With the Neuman systems model, nursing diagnosis, defined as the client system's potential or actual response to identified potential or actual stressors, is aided by a taxonomy that gives direction to the prevention-as-intervention format and facilitates goal achievement (4,5,9).
Nursing diagnosis in the clinical setting is a judgment about individual, family, or community responses to actual and potential health problems/life processes (Kim, McFarland & McLane, 1991).
On the closed response form, nurses were asked to record up to 20 invasive procedures or operations common in their practice and identify nursing diagnoses that were used prior to, during, and after the procedure or operation; the subjects were asked to refer to the list of diagnoses formally approved by the North American Nursing Diagnosis Association (NANDA) in selecting the nursing diagnoses.

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