Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the electronic health record and can be linked to nurse-sensitive patient outcomes.
is the primary organisation for defining, distribution and integration of standardised nursing diagnoses worldwide iNANDA-I has worked in this area for nearly 40 years to ensure that diagnoses are developed through a process requiring standardised levels of evidence, definitions, defining characteristics, related factors and/or risk factors that enable to identify potential diagnoses in the course of a nursing assessment. NANDA-I believes that it is critical that nurses are required to utilise standardised languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characteristics) and the related or etiologic factors upon which nurses intervene. NANDA-I terms are developed and refined for actual (current) health responses and for risk situations, as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities. The taxonomy is published in multiple countries and has been translated into 18 languages; it is in use worldwide.
What is the primary nursing diagnosis? Did you think of impaired gas exchange? Seems obvious, doesn’t it, considering the data and medical diagnosis? However, the question the nurse should ask is this: “What is causing the low SpO2?”
After completing a thorough assessment, the nurse discusses her findings with the patient, including the very shallow breathing. She learns the patient is breathing shallowly because he’s in pain. He’s suffering from posthepatic neuralgia as a result of a very painful course of shingles. In this example, the assessment-based, primary nursing diagnosis is chronic pain.
Consider these two scenarios:
Nursing Diagnosis Linked to the Medical Diagnosis
A care plan is developed to address the nursing diagnosis of impaired gas exchange, based on the medical diagnosis of Viral Pneumonia. The posthepatic neuralgia as a cause for shallow breathing is not identified and overlooked in treatment.
Nursing Diagnosis Linked to Nursing Assessment and Critical Thinking
A care plan is developed to address the nursing diagnosis of chronic pain, with treatment designed to resolve this as the primary cause of the shallow breathing, and to prevent recurrence.
Which scenario provides the best patient care and outcome? What do you think the relationship is – or is not – between medical diagnosis and nursing diagnosis?