7.7: Nursing Diagnosis
Following assessment, a nursing diagnosis is the next step in the nursing process. It begins after the nurse has collected and recorded the patient data. The purpose of diagnosing is to identify how the client responds to actual or potential health processes, identify factors that bestow or that cause health problems, the etiologies, and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.
The nursing diagnosis focuses on evidence-based interventions by anticipating illness complications, controlling or reducing risk, and promoting optimum function. A health problem is a state that necessitates intervention in preventing or resolving disease or illness to promote coping and wellness.
Following the diagnosis, the nurse monitors the health response and promotes optimum health through time-lapsed assessment, appropriate treatment, and evaluation. The nursing diagnosis focuses on evidence-based intervention and applies three steps. Step one is to anticipate complications of the illness and take immediate action to avoid or resolve the issue. Step two is to control or reduce any risks identified. Step three is to promote optimum function.
The difference between medical diagnosis, nursing diagnosis, and collaborative problems are distinctive. Medical diagnoses are formulated based on an individual's need to seek medical treatment and remain the same until resolved. For clarity, the medical diagnosis of epigastric or stomach ulcer remains the same until healed. The nursing diagnosis describes physical, sociocultural, psychological, and spiritual responses resolved with autonomous nursing action.
The nursing diagnosis keeps changing until all problems or symptoms are resolved. The nursing diagnosis of stress-induced epigastric ulcer management is "ineffective coping," the measures are relaxation techniques, intake of a soft, bland diet, and avoiding stomach irritants like caffeine.
The collaborative problem is that the nurse identifies, monitors, and prevents potential problems using independent nursing intervention and medical management. For example, collaborative problem handling for heartburn includes taking medications and utilizing nursing measures to avoid epigastric mucus erosion.
