What is a three-part nursing diagnosis?

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What is a three-part nursing diagnosis?

What is a three-part nursing diagnosis?

NANDA nursing diagnosis essay/ care plan


So how does a nursing diagnosis differ from a medical diagnosis? A doctor diagnoses a disease or a disorder. A nurse offers a diagnosis for a problem present during the nursing assessment which is caused by the disease or disorder. For example, during the nursing assessment, the nurse could diagnose the patient with poor breathing and a cough. A doctor will diagnose a patient with chronic bronchitis and prescribe medication.

A nursing diagnosis is not simply assessing the patient, which is the first step in the nursing process. A nurse will develop a diagnostic statement based on data collected during the nursing assessment. The assessment process involves physically examining a patient. A nurse will monitor a patient’s symptoms, such as nausea, and measure vital signs such as heart rate, temperature, blood pressure and oxygen levels, among many other things. Nurses must often discuss with patients any non-obvious symptoms they may have, such as pain or vertigo, as well as patient history. This is an important part of collecting the data necessary to develop a diagnosis. It may be necessary to perform a psychological exam or a social exam, depending on what field a nurse works in. NANDA nursing diagnosis essay/ care plan.

Developing a three-part nursing diagnosis consists of data analysis, problem identification and the formulation of the nursing diagnosis. There are four different types of nursing diagnosis; actual nursing diagnosis, wellness (or health promotion) nursing diagnosis, risk nursing diagnosis and syndrome diagnosis.

An actual diagnosis identifies a current health problem, such as inadequate airway clearance as evidence by the inability to maintain adequate oxygenation on room air. NANDA nursing diagnosis essay/ care plan.

wellness or health promotion diagnosis identifies a patient’s readiness to transition to a higher wellness level, such as readiness for enhanced self-care to increase cardiac output related to increased cardiac output due to pacemaker insertion.

risk diagnosis identifies when a patient could be at risk for additional health problems, such as infection.

syndrome diagnosis determines symptoms based on certain situations, such as post-trauma syndrome or relocation stress syndrome. NANDA nursing diagnosis essay/ care plan.

So what’s the point of a nursing diagnosis? Ultimately, a nursing diagnosis increases patient safety and means more effective care. You’ll identify every potential syndrome a patient may have and record all important vital signs. This attention to detail could be the difference between the correct treatment and continued illness or injury.

Once you’ve reached your nursing diagnosis, it’s important to write the diagnosis correctly, as established by the North American Nursing Diagnosis Association (NANDA.) Correctly writing the diagnosis helps ensure consistency across communication lines to other health care professionals. The diagnosis can be structured differently depending on the type of diagnosis it is.

An actual nursing diagnosis is written as the problem/diagnosis related to (r/t) x factor/cause as evidenced by data/observations.

A risk nursing diagnosis is written as problem/diagnosis related to (r/t) x factor/cause.

A syndrome nursing diagnosis is written as problem/diagnosis related to (r/t) x factor/cause.

A wellness nursing diagnosis is written as readiness to/for action.

Nursing is an evidence-based practice, and no aspect more so than the three-part nursing diagnosis. Your diagnosis as a nurse can save patients a lot of pain and trouble. NANDA nursing diagnosis essay/ care plan.

The NANDA-I system of nursing diagnosis provides for four categories.

  1. Actual diagnosis
    A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community. An example of an actual nursing diagnosis is: Sleep deprivation.
  2. Risk diagnosis
    Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability. An example of a risk diagnosis is: Risk for shock.
  3. Health promotion diagnosis
    A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualise human health potential as expressed in the readiness to enhance specific health behaviours, and can be used in any health state. An example of a health promotion diagnosis is: Readiness for enhanced nutrition. NANDA nursing diagnosis essay/ care plan.
  4. Syndrome diagnosis
    A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions. An example of a syndrome diagnosis is: Relocation stress syndrome. NANDA nursing diagnosis essay/ care plan.

NANDA nursing diagnosis essay/ care plan Process

The diagnositic process requires a nurse to use critical thinking. In addition to knowing the nursing diagnoses and their definitions, the nurse becomes aware of defining characteristics and behaviors of the diagnoses, related factors to the diagnoses, and the interventions suited for treating the diagnoses. 

  1. Assessment
    The first step of the nursing process is assessment. During this phase, the nurse gathers information about a patients psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to gather assessment data. Patient interaction is generally the heaviest during this evaluative stage. NANDA nursing diagnosis essay/ care plan.
  2. Diagnosis
    The diagnosing phase involves a nurse making an educated judgement about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These assessments not only include a description of the problem or illness (e.g. sleep deprivation) but also whether or not a patient is at risk of developing further problems. These diagnoses are also used to determine a patient’s readiness for health improvement and whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment.
  3. Planning
    Once a patient and nurse agree of the diagnoses, a plan of action can be developed. If multiple diagnoses need to be addressed, the head nurse will prioritise each assessment and devote attention to severe symptoms and high risk patients. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. For this phase, nurses generally refer to the evidence-based Nursing Outcome Classification, which is a set of standardised terms and measurements for tracking patient wellness. The Nursing Interventions Classification may also be used as a resource for planning. NANDA nursing diagnosis essay/ care plan.
  4. Implementation
    The implementing phase is where the nurse follows through on the decided plan of action. This plan is specific to each patient and focuses on achievable outcomes. Actions involved in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for a follow-up. Implementation can take place over the course of hours, days, weeks, or even months.
  5. Evaluation
    Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine if the goals for patient wellness have been met. The possible patient outcomes are generally described under three terms: patient;s condition improved, patient’s condition stabilised, and patient’s condition deteriorated. In the event where the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step. NANDA nursing diagnosis essay/ care plan.