In your first semester of nursing school, the nursing diagnosis can seem like a really, really bizarre concept. I mean, why not just say “patient can’t breathe” instead of “impaired breathing pattern as evidenced by blah blah blah.” It can drive you bonkers if you don’t understand how to decipher them, so let’s get to it! Show
Nursing diagnoses vs. medical diagnosesThe first thing to understand about nursing school is that nurses don’t diagnose medical problems…that’s up to the MD. What nurses diagnose is the patient’s RESPONSE to that medical problem. So, for example…the MD might diagnose your patient with pneumonia. As the nurse, you think about how the patient responds to this pneumonia (or even how they respond to the treatment for pneumonia). What are some things that can go wrong with pneumonia and it’s treatment? Here are a few:
 Two kinds of nursing diagnosesThe first thing to understand is that there are two types of nursing diagnoses. As you can see above, the first two state a problem, and the last two say “risk for.” The first two are an example of a nursing diagnoses that states a problem the patient is ACTUALLY having right now; and the bottom two state a problem the patient could POTENTIALLY have. Let’s talk about type 1 first. Type 1: the “ACTUAL” nursing diagnosisThe easiest way to decode nursing diagnoses is to look at them like a template. They’re always written the same way, which actually makes your life easier! For ACTUAL or DEFINITIVE diagnoses, we’re going to write them out like this…the CAPITAL PINK words are the ones that change based on each situation: NANDA DIAGNOSIS related to PATIENT’S MEDICAL PROBLEM as evidenced by DATA OBTAINED FROM ASSESSMENT OR CHART. So let’s look at this piece by piece. You start with the “NANDA diagnosis”…NANDA is simply the governing body that develops the terminology to be used for nursing diagnoses. Note above in our bulleted list how we say something simple like “Low oxygen saturation levels?” Do you think nursing is going to keep things simple? Nope! Enter your good pals at NANDA. NANDA takes simple language and “nursifies” it. So, “low oxygen saturation levels” becomes “ineffective gas exchange.” There are books which list all the NANDA-developed nursing diagnoses and how they correlate to different medical diagnoses (I loved this one) #ad. Using a care plan book such as this is critical as your professors aren’t going to let you make up your own terminology…they’ll want you to use NANDA. Learn to love it. The next part is to talk about what your NANDA diagnosis is related to….and it’s always going to be related to a medical problem the patient is actually having RIGHT NOW. In this case, it’s related to the patient’s pneumonia. But, of course, you need some evidence for this right? Nursing is, after all, an “evidence-based practice!” So, what’s your evidence for this problem? It is either going to be DATA you obtain from the chart or DATA you obtain from your assessment (and yes, it can be something the patient says). So let’s put this all together and write a definitive/actual nursing diagnosis for your patient with pneumonia. Again, here’s our template: NANDA DIAGNOSIS related to PATIENT’S MEDICAL PROBLEM as evidenced by DATA OBTAINED FROM ASSESSMENT OR CHART. And here’s how we customize it for our pneumonia patient: Ineffective gas exchange related to pneumonia as evidenced by O2 saturation level of 88% on 2L nasal cannula. Want to do another one? Let’s say we’re talking about a patient who had a whopper of a surgery and it hurts! Well, PAIN is always an acceptable nursing diagnosis….if you think about it, it’s the patient’s RESPONSE to their medical problem. Is it getting clearer yet? Pain related to hysterectomy as evidenced by patient rating pain 7 out of 10. See how this one includes data from the actual patient? Yes, you can use what your patient tells you as bona-fide data in your nursing diagnoses. Now, what if your patient isn’t in pain now, but you expect they will be soon? That’s when you’re going to write the second type of nursing diagnosis…the one that applies to POTENTIAL problems. Let’s go! Type 2: the “POTENTIAL” nursing diagnosisThe good nurse will try to catch problems before they become doozies, so that’s why we also think about problems the patient could POTENTIALLY have. If they don’t have it right now, they certainly could…and this type of diagnosis is written like so: Risk for NANDA DIAGNOSIS related to PATIENT’S MEDICAL PROBLEM. Notice how this template is shorter? It doesn’t have the data component, as there is no data for a problem the patient doesn’t have yet…if there were data, it would be an ACTUAL nursing diagnosis (which we discussed in Type 1). For your surgical patient, maybe they’re not in pain now because they got a hefty load of Fentanyl in PACU…but you know it’s coming! Risk for PAIN related to HYSTERECTOMY. Another one that’s common for surgical patients is a risk for infection. So you’d write it out like so: Risk for INFECTION related to HYSTERECTOMY. Note that these all use the phrase “related to.” You might also see the phrase “secondary to.” They are more or less interchangeable, so just didn’t want you to think there was yet another type of diagnosis to write! Using nursing diagnoses in your care plansNow that you understand the logistics of a NANDA nursing diagnosis, what are you going to do with them? Well, develop care plans, of course! I go into much more detail about care plans in my book, but let’s just do a few practice nursing diagnoses so you can get the hang of it! Your patient is a 22 year old male who broke both arms and a few ribs in a freak accident…attempting to take a selfie while standing on the edge of a cliff! He is now s/p surgical repair of bilateral humerus two days ago and his ribs are taped. You check his chart and find the following information: HR: 124 (too high) If you don’t know anything about pathophysiology yet…no worries…I’ll walk you through it! As you approach your care plans and writing out your nursing diagnoses, I like to start by writing them in plain ol’ English…no need to get fancy yet. You’re just going to look at his chart and gather information for your ACTUAL diagnoses and basically brainstorm some POTENTIAL diagnoses. Your list might look like this:
Now, look through your NANDA book and find the proper terminology for each of these! They are:
Ok, there are likely more…but this is a hefty start. Now, you go back through and add in all the “related to” and “as evidenced by” mumbo jumbo. I’ll do a few with you!
See how it works? Is it clear as mud now? Don’t worry…you’ll get it and the NANDA language will become more clear. I promise! Some doozies are:
A note about medical diagnosesRemember earlier when I said nurses don’t make medical diagnoses, and that we leave that up to our physician colleagues? Well, guess what? You still should have a pretty good idea of what the medical diagnosis will be, because guess why? Your nursing diagnoses and interventions will play off that. Super frustrating, I know! As a student I found myself saying many times, “But I’m not the doctor…why do I need to differentiate between Addison’s and Cushings if I’m not diagnosing?” You just do…so don’t think you’re getting off easy, nurslings! Was this tutorial helpful to you? What else are you having trouble with? Join our Facebook group, Thriving Nursing Students and join the conversation! What is the difference between nursing diagnosis and medical diagnosis?What is the difference between a medical diagnosis and a nursing diagnosis? A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes.
Which differentiates a nursing diagnosis from a medical diagnosis quizlet?A nursing diagnosis is a clinical judgment; whereas, a medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, and the patients medical history.
What is the difference between a clinical diagnosis and a medical diagnosis?Clinical diagnosis. A diagnosis made on the basis of medical signs and reported symptoms, rather than diagnostic tests. Laboratory diagnosis. A diagnosis based significantly on laboratory reports or test results, rather than the physical examination of the patient.
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Which of the following comparison between a nursing diagnosis and medical diagnosis is incorrect?
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