Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Nursing Care Processes
Lecture:Nursing process including clinical judgment and patient assessment; legal and societal expectations; and roles in improving patient care
Slide content:Diagnosing The diagnosis considers Current health problems Current non-health problems Risk of future health problems Possible link to a larger syndrome Unlike a medical diagnosis of disease, a nursing diagnosis can change as the patients response changes 13
Slide notes:The nurse then develops a nursing diagnosis. She or he considers the health problems that need to be addressed and any non-health issues that could affect treatment. The nurse also needs to think about, and plan for, the patients risk of other health problems and whether the patients current health problem is part of a larger syndrome. Nursing diagnoses usually differ from medical diagnoses. A medical diagnosis, which refers to a disease, is made only by a physician, advanced practice nurse, or physician assistant. In contrast, a nursing diagnosis describes a patients physical, sociocultural, psychological, and spiritual response to an illness or potential health problem. For as long as a disease is present, the medical diagnosis never changes, but a nursing diagnosis evolves as the patients responses change. Some examples of nursing diagnoses are anxiety, confusion, diarrhea, fatigue, hopelessness, impaired parenting, and risk of violence. 13