Describe the term nursing diagnosis, distinguishing it from a collaborative problem and a medical diagnosis.
Diagnosing—the second step in the nursing process—begins after the nurse has collected and recorded the patient data. The purpose of diagnosing is to (1) identify how an individual,group, or community responds to actual or potential health and life processes; (2) identify factors that contribute to or cause health problems (etiologies); and (3) identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.When a health problem is identified, the nurse must decide which healthcare professional can best address the problem.Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses. The nurse formulates, validates, and lists nursing diagnoses for each patient. Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued patient outcomes for which the nurse is responsible. Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness.Medical diagnoses describe problems for which the physician directs the primary treatment, whereas nursing diagnoses describe problems treated by nurses within the scope of independent nursing practice. A medical diagnosis remains the same for as long as the disease is present, whereas a nursing diagnosis may change from day to day as the patient’s responses change. These distinctions reflect key differences in medical and nursing practices. Myocardial infarction (heart attack) is a medical diagnosis.Examples of nursing diagnoses for a person with myocardial infarction include Fear, Altered Health Maintenance, Deficient Knowledge, Pain, and Altered Tissue Perfusion. Nursing diagnoses are also different from collaborative problems.Together, nursing diagnoses and collaborative problems constitute the range of responses that nurses treat, and as such, they define the unique nature of nursing. Collaborative problems are “certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse interventions to minimize the complications of the event” Unlike medical diagnoses, collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses,with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines. When the nurse writes patient outcomes that require delegated medical orders for goal achievement, the situation is not nursing diagnosis, but a collaborative problem. Because collaborative problems involve potential complications, they must be identified early so that preventive nursing care canbe instituted early.To write a diagnostic statement for a collaborative problem,focus on the potential complications of the problem. Use “PC”(for potential complication), followed by a colon, and list the complications that might occur. For clarity, link the potential complications and the collaborative problem by using “related to.” Example: PC: Paralytic ileus related to anesthesia.