A nursing diagnosis differs from a medical diagnosis. Nursing diagnoses describe problems that can be addressed by nursing measures. Because nurses can't diagnose a disease or prescribe medication, a nursing diagnosis doesn't describe a disease or prescribe medications or treatments beyond a nurse's scope of practice. In the case of a disease like cystic fibrosis, nursing diagnoses center on treating problems caused by the disease.
Description
According to the North American Nursing Diagnosis Association, or NANDA, there are five possible categories for a nursing diagnosis: an actual problem, possible problem, risk, syndrome or wellness. A syndrome is a cluster of symptoms that occur in a disease, and wellness diagnoses possible positive outcomes.
Cystic fibrosis causes lung damages from thickened secretions. A risk-related nursing diagnosis for cystic fibrosis would describe interventions that address complications from the disease. For example, recurrent lung infections are a symptom of cystic fibrosis, so "Risk for infection related to chronic pulmonary disease" would be a typical diagnosis, nursing instructor Gina Brandl, R.N., B.S.N., of Wisconsin's Mid-State Technical College states.
Purpose
The purpose of a nursing diagnosis is to establish actions that can be carried out by everyone caring for a patient so that certain goals can be achieved. NANDA emphasizes that nursing diagnoses should be modified as necessary and should always be related to an individual patient's needs, rather than being generalized for all patients with the same disease process.
Assessment
A nursing diagnosis includes assessments that are done to determine a problem. In the case of the diagnosis "Risk of infection related to chronic pulmonary disease," assessment might include checking lung sounds, taking oral temperatures or monitoring a patient's color for signs of decreased oxygenation.
Interventions
Every nursing diagnosis lists interventions that help achieve the goal. In the case of "Risk of infection related to chronic pulmonary disease," interventions to reduce the risk are spelled out. Examples of interventions might include oral antibiotics, adequate fluids and administering aerosol treatments as ordered by the physician, according to the Mayo Clinic. Interventions must be specifically geared to the patient's needs, listing a time frame and the exact action to be performed.
Expected Outcomes
Expected outcomes for a nursing diagnosis are the intended goals. In the case of a care plan for risk of infection, the expected outcome could be that the patient is free from infection as evidenced by clear lungs, no fever and no complaints of chest pain for the next 24 hours.
Evaluation
An evaluation is done after the intervention required by the nursing diagnosis to see whether the stated goals have been met. If the stated goals aren't met, the evaluation may describe new interventions to improve the chance of meeting the goals. In the case of infection risk, an evaluation might state that the patient's lungs are not clear after aerosol treatment and might mention the need to inform the physician.
