It is important when writing a nursing diagnosis that standardized nursing terminology is used. Since 1982 NANDA { North American Nursing Diagnosis Association} has refined nomenclature necessary to communicate in an organized and uniform way with all health care providers.. A paperback handbook by Linda Juall Carpenetto Moyet, published by Lippincott Williams& Wilkins- {Handbook of Nursing Diagnosis. } is a quick reference book of 2007/2008. NANDA approved with all nursing diagnoses and associated interventions and outcomes, this is a small pocket-size book that can fit into a lab coat pocket.
http://search.barnesandnoble.com/Handbook-of-Nursing-Diagnosis/Lynda-Juall-Carpenito-Moyet/e/9780781769860
Writing a nursing diagnosis is part of the ongoing nursing process. It is the responsibility of the registered nurse who is caring for the patient. It is determined by a physical examination and a psychosocial assessment. This includes a pertinent collection of data related to the patient’s clinical history, such as any information on any chronic illness the patient may have, or bowel or bladder problems. Included in this data is the patient’s mental status and medication regime if any, allergies, physical mobility problems or compromised nutritional maintenance. This is also the time for the nurse to assess for any special needs the patient may have..
The nurse while doing a clinical assessment is using his or her observational skills; the nurse determines the patient’s acuity, especially observing for any pain the patient may or may not have. The nursing assessment would include the patient’s weight, temperature, apical heart rate, and respiratory rate. A nurse will also palpate and use auscultation on the the abdomen and lungs. The blood pressure is also checked for any signs of hyper or hypo tension. The time it takes to make this thorough assessment is very necessary to determine an accurate nursing diagnosis and then to write the nursing diagnosis in her plan of care for this patient.
The physician will have most likely determined the medical diagnosis in order to admit the patient to the hospital. The nursing diagnosis includes the clinical findings related to the medical diagnosis.
The Registered Nurse uses her nursing diagnosis as it is incorporated into the patient’s care plan. It is prioritized according to the acuity of the patient. Physicians’ orders may be needed and are requested if not available by the Registered Nurse who then can initiate the care needed for the patient. There are in some health care institutions standardized care plans in place.
The importance of the care plan picks up after a nursing diagnosis has been made. It offers insight on the patient, his or her health problem, the symptoms , and the interventions needed to return the patient to their optimum health. It will then be evaluated daily to assess for any needed updates. Nursing diagnosis is part of the nursing process that is always on going during the patient’s hospitalization.
As time and practice makes all nurses more experienced, the process of nursing diagnosis gets easier and more refined. An experienced nurse can make a nursing diagnosis is less time than a new graduate might. However, it is the on going process of making a nursing diagnosis that makes the nurse more proficient in nursing.
