A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and/or potential health problems or life processes. A medical diagnosis, on the other hand, is the identification of a disease based on its signs and symptoms.
The professional practice of nursing is the diagnosing and treatment of these basic human responses. Nurses need a common language to describe the human responses of individuals, families, and communities to health threats. NANDA strives to classify in a scientific manner these basic human responses.
Nursing diagnoses are based on assessment data and are classified under the concepts of ingestion, digestion, absorption, metabolism, urinary/gastrointestinal elimination, sleep/rest, activity/exercises, energy balance, sexuality, post trauma responses, comfort, and growth and development.
Identification of human responses to health problems and life processes is the basis for the nurses' decisions on how to best intervene to help people heal or improve their quality of life. With nursing diagnoses, emphasis is placed upon achievement of the client's maximum health potential. The nurse gathers the assessment data and from this data, identifies high-priority nursing diagnoses. The nursing diagnoses then provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
The patient (not the nurse) is central to the nursing process. The nursing process involves looking at the whole patient at all times. It personalizes the patient. Nursing care needs to be directed at all times for improving outcomes for the patient.
In order to tailor the nursing process to the patient, you need to identify the patient's problems related to the objective and subjective assessment data. Then you need to formulate a nursing diagnosis for each of these problems. You will also prioritize the problems in formulating your plan and goals (according to the ABC's and Maslow's Hierarchy of Needs).
Nursing diagnoses are written in "PES" format
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"P" stands for problem
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"E" stands for etiology or cause of problem
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"S" stands signs and symptoms of problem
However, if you identify a high-priority "risk for" nursing diagnosis, then you do not put the signs and symptoms (in other words, no "aeb"). How can you have evidence (signs and symptoms) for something that is only a risk and not a manifested problem?
Nursing goals are simply the antithesis of the nursing diagnostic statement with a reasonable time frame. In other words, diagnostic statements are "problems" (negative). goals are "positive" (turn the nursing diagnostic statement around). If the nursing diagnosis is "Risk for Infection R/T..." for instance, then the goal statement might be "Client will not experience infection throughout hospital stay AEB clear lung sounds, afebrile, WBC count between 5,000 and 11,000, wound site well approximated with no purulent drainage." Goal statements always begin with "The patient/ client will..." and have a specified time element.
Nursing interventions are the "meat and gravy" of the nursing process and flow from the "etiology" part of the nursing diagnostic statement. Nursing interventions are either independent (such as teaching/learning or safety) or collaborative/ dependent (require a physician's order, such as administration of medications). The nurse must use his or her critical thinking skills to plan, coordinate, and implement nursing interventions, and then evaluate the effect of these interventions in achieving the desired patient goal. Nursing interventions always begin with "Student nurse will..." or "Nurse will..." and are very specific, as well as being realistic to the client situation (not just "cookie-cutter" interventions copied from a nursing care plan book).
Nursing interventions must be backed up with a scientific rationale - otherwise, this action is just your opinion and has no merit. Remember, everything in nursing must be evidenced-based. Provide a citation for your scientific rationale, in APA 6th Edition Format, from a peer-reviewed source: professional journal, textbook, lecture.
When evaluating your goals, you need to state specifically: goal met, goal not met, goal partially met, or unable to evaluate goal due to time constraints. If the latter is the case (unable to evaluate goal due to time constraints), then you need to state what outcome criteria would be needed in order to state goal met. In other words, if I were present (at specified time element), I would look for the following outcome criteria in order to state, "goal met." Then you list the desired outcome criteria. Remember, you are evaluating the goals, not the interventions.
So you see, it is an orderly, evidenced-based process and not that difficult with practice. Nurses cannot know what interventions to select or which outcomes to project unless they have accurate representations of what patients are experiencing (using a common reference language, NANDA).
References
NANDA Nursing Diagnoses
Nursing Diagnoses 2012 - 2014.pdf
