A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing interventions. The standardized terminologies of a nursing diagnosis help nurses identify and treat patients' problems. Every electronic health record that uses nursing diagnosis must employ standard diagnostic terminology. Developing an efficient, individualized care plan begins with accurate nursing diagnoses.
There are thirteen domains for health problems in taxonomy order. They are health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationships, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development. A nursing diagnosis starts with a problem statement and provides the foundation for the complete diagnosis.
When creating a diagnosis, the nurse must have clarity about the patient's problem. The format varies depending on the type of diagnosis. A problem-focused nursing diagnostic statement includes three parts such as a diagnosis label, related factors, and significant defining characteristics.
A diagnostic label indicates the name of a nursing diagnosis. It is a standardized term describing the characteristics of the identified human response. Related factors may be the etiology or circumstance that influenced or caused the patient's response. It may be the etiology or circumstances. Significant defining characteristics include a major assessment finding or defining characteristics.
In addition, the risk nursing diagnosis contains two elements: a diagnosis and the associated risk factors. Further, the diagnostic label and the defining features or assessment findings are the only elements that make up a health promotion nursing diagnosis.
