Nursing Diagnosis

Structure of diagnoses

1. An actual diagnosis is a statement about a health problem that the client has, and could benefit from nursing care. An example of an actual nursing diagnosis is: Ineffective airway clearance related to decreased energy as manifested by an ineffective cough.
2. A risk diagnosis is a statement about a health problem that the client doesn't have yet, but is at a higher than normal risk of developing in the near future. An example of a risk diagnosis is: Risk for injury related to altered mobility and disorientation.
3. A possible diagnosis is a statement about a health problem that the client might have now, but the nurse doesn't yet have enough information to make an actual diagnosis. An example of a possible diagnosis is: Possible fluid volume deficit related to frequent vomiting for three days as manifested by increased pulse rate.
4. A syndrome diagnosis is used when a cluster of nursing diagnoses are often seen together. An example of a syndrome diagnosis is: Rape-trauma syndrome related to anxiety about potential health problems as manifested by anger, genitourinary discomfort, and sleep pattern disturbance.
5. A wellness diagnosis is used to describe an aspect of the client which is at a high level of wellness. An example of a wellness diagnosis is: Potential for enhanced organized infant behaviour, related to prematurity and as manifested by response to visual and auditory stimuli.

See Also

• Nursing
• List of nursing diagnoses
• Nursing Interventions Classification
• Nursing Outcomes Classification

References

• K. N. Anderson (Ed.): Appendix 19: Nursing Diagnoses. In: Mosby's Medical, Nursing, & Allied Health Dictionary. 5th ed. Mosby, St. Louis, MO, 1998, pp. 1975-2035, ISBN 0-8151-4800-3
• A. G. Perry, P. A. Potter: Canadian Fundamentals of Nursing. 2nd ed. Mosby, Toronto, ON, 2001, ISBN 0-9205-1340-9

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