A medical diagnosis is a health condition that has been confirmed by medical diagnostic tests. The focus is on improving or preventing the deterioration of specific organs or body systems. Physicians or advanced practice nurses manage the primary treatment. A medical diagnosis focuses on diseases and illness and remains the same for as long as the disease is present. A nursing diagnosis focuses on the harmful responses to health and illness, and changes as the patient's needs change.
Nursing diagnoses are actual or potential patient health problems that nurses can treat independently. Nurses develop nursing diagnoses by recognizing contributing factors in the health problem, confirming the perceived health problems with the patient, and then prioritizing the patient’s health problems with the patient. Nurses also use the collected data to find resources that can be utilized to prevent or resolve these issues.
Collaborative problems are health issues that require nurses to work with other health care professionals. Nurses approach collaborative problems using nursing and physician-prescribed interventions to reduce the complications of the event. Diagnostic statements for collaborative problems focus on the possible complications of the problem. They are written as “PC” (potential complication) followed by a colon, and a list of potential complications.
Significant data is determined by comparing standards or norms. A nurse must be aware of comparative standards of the collected data to be able to interpret, analyze, and sort it from healthy patient responses. It is essential to be aware of a patient's normal ranges, and how certain age groups, illness categories, and race can change the normative values.
Data clusters are a collection of relating patient data or cues that suggest the presence of a health problem. Nursing diagnoses should always be obtained from clusters of significant data rather than from a single occurrence.
The problem is what is unhealthy about the patient or what the patient would like to change in their health status.
The etiology are the physiologic, psychological, sociologic, spiritual and environmental factors that contribute to the unhealthy client response or problem.
The defining characteristics are subjective and objective data that signal the existence of a problem.
When determining which nursing intervention has priority when caring for a patient, it is important to remember Maslow’s Pyramid; basic needs such as food, water, warmth and rest take priority, followed by safety needs, belonging and love, esteem needs, and self actualization. Also keep in mind patient’s with health conditions, because they may affect priority.
Another important tip when choosing an appropriate nursing diagnosis on a test is to focus on a patient’s concern. Even if there are nursing diagnoses available that may seem like good options, if it is not related to the concerns expressed by the patient, then it could be incorrect.
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