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Nursing diagnosis is a clinical judgment about actual or potential individual, family, or community responses to health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.
Actual Nursing Diagnosis
A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community.
Health-Promotion Nursing Diagnosis
A clinical judgment about a person’s, family’s or community’s motivation and desire to increase well being and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state.
Risk Nursing 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.
A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.
COMPONENTS OF A DIAGNOSIS
Provides a name for a diagnosis. It is a concise term or phrase that represents a pattern of related cues. It may include modifiers.
Provides a clear, precise description; delineates its meaning and helps differentiate it from similar diagnoses.
Observable cues / inferences that cluster as manifestations of an actual or wellness nursing diagnosis.
Environmental factors and physiological, psychological, genetic or chemical elements that increase the vulnerability of an individual, family or community to an unhealthful event.
Factors that appear to show some type of patterned relationship with the nursing diagnosis. Such factors may be described as antecedent to, associated with, related to, contributing to or abetting. Only actual nursing diagnoses have related factors.
DEFINITIONS FOR CLASSIFICATION OF NURSING DIAGNOSIS
Systematic arrangement of related phenomena in groups or classes based on characteristics that objects have in common.
Level of Abstraction
Describes the concreteness / abstractness of a concept:
(a) Very abstract concepts are theoretical, may not be directly measurable, defined by concrete concepts, inclusive of concrete concepts, disassociated from any specific instance, independent of time and space, have more general descriptors, may not be clinically useful for planning treatment.
(b) Concrete concepts are observable and measurable, limited by time and space, constitute a specific category, more exclusive, name a real thing or class of things, restricted by nature, may be clinically useful for planning treatment.
A system of designations (terms) elaborated according to pre-established rules (American Nurses Association, 1999).
Classification according to presumed natural relationships among types and their subtypes (American Nurses Association, 1999).
American Nurses Association. (1999). ANA CNP II recognition criteria and definitions. Washington DC: Author. McCourt, A. (1991). In R.M. Carroll-Johnson (Ed.), Classification of nursing diagnoses: Proceedings of the ninth conference (p. 79). Philadelphia: Lippincott.