What it means
The second step of the nursing processNUR-sing PRAH-sesThe step-by-step method nurses use to plan and give care: assess, diagnose, plan, implement and evaluate.Full entry , after assessment. A nursing diagnosis names a client's actual or possible response, such as impaired gas exchange, acute pain or risk for falls, rather than the disease itself. Most use the NANDA-I list and include the problem, what it is related to, and the signs that show it. It guides the goals and interventions in the plan of care.
For the nurse
A medical diagnosis (such as pneumonia) names the disease; a nursing diagnosis (such as ineffective airway clearance) names what the nurse will treat. Put problems that threaten the airway, breathing and circulation first.
In a chart
"Acute pain related to surgical incision as evidenced by pain rating 7/10 and guarding."
At a glance
| Spanish | diagnóstico de enfermería |
|---|---|
| Also written | nursing diagnoses, nursing-diagnosis |
Related terms
assess
To gather information about a client by looking, listening, asking, measuring and examining.
intervention
An action taken to help a client, such as a treatment, a test, a teaching session or a nursing action.
nursing process
The step-by-step method nurses use to plan and give care: assess, diagnose, plan, implement and evaluate.
plan of care
A written plan that lists a client's problems, goals and the nursing actions to reach them.
expected outcome
A specific, measurable result the nurse and client aim for, used to judge whether care is working.