Summary

Nursing diagnosis is a defining characteristic of the nursing profession. The breadth and depth of patient problems that fall under the umbrella of this concept are the basis of nursing practice. The ANA Standards of Practice and the ANA Competencies for Nursing Diagnosis both support the autonomy of the profession. The decision was founded on the nursing profession exhibiting strong clinical judgment. The nursing profession deemed a problem-solving approach the best way to achieve patient care outcomes.

NANDA-I supports nursing diagnosis through taxonomy and classification. Taxonomy for clinicians is used to communicate in a clear, efficient, and standardized manner. NANDA-I and Tanner’s Clinical Judgment Model (CJM) both provide a framework for clinical decision-making using a problem-solving approach.

As patient needs become more complex, the need for nurses to think critically evolves as well. The most current evolution of clinical decision-making is the Clinical Judgment and Measurement Model (CJMM). The CJMM uses six cognitive skills to develop critical thinking that can be aligned with both the nursing process and Tanner’s CJM.

While all the processes look very similar, each requires a slightly different way of thinking and incorporating progressive levels of knowledge to provide patient care. Ultimately, the goal is to provide all patients with the best possible care and help them achieve the best possible outcomes.

The foundational steps for clinical decision-making are to predict, prevent, manage, and promote. Using this as a framework for thought processes helps beginning and experienced nurses alike form appropriate nursing diagnoses and understand the steps they took to reach those diagnoses. It is important to differentiate between nursing and medical diagnoses.

As mentioned previously, medical diagnosis focuses on the actual disease or condition, while nursing diagnosis focuses on the patient’s response to that disease or condition. Once a decision has been made, the planning process gets underway. The nurse must keep the focus on the patient’s expected versus actual outcomes, which includes using the nursing diagnosis to promote the best possible outcomes for the patient. Using SMART goals is one proven tool for the nurse to keep sight of patient outcomes. The evidence-based tool can ensure the outcomes remain attainable and reasonable for the patient to achieve and allow the nurse to adjust the nursing diagnosis as necessary.

Understanding how nursing diagnoses are categorized is the first step in determining how to select one for a patient. The four NANDA-I approved categories are problem-focused, risk for, health promotion, and syndrome-based. Once a category is chosen, the nurse can identify which diagnosis best suits an individual patient’s needs. After assigning, the nurse must then validate the selected diagnosis. Validating the nursing diagnosis is based on evidence. Re-examining the signs and symptoms discovered during data collection and comparing them to current evidence-based practice standards are two ways the nurse will validate the selected diagnosis. The nurse needs a plan in case the identified nursing diagnosis does not produce the desired outcomes or the patient’s condition changes. In this situation, redefining the diagnosis may be warranted. Redefining the diagnosis is narrowing it down or creating a new one based on current needs. Sometimes, associated interventions are unsuccessful, and the addition or revision of a nursing diagnosis allows for new interventions to be applied to the plan of care.

The planning phase utilizes research and resources to organize and prioritize a patient’s needs. Using evidence-based resources such as clinical pathways and core measures ensures that best practice standards are incorporated into the patient’s plan of care. Prioritizing patient care is also initiated during the planning phase when the nurse systematically determines which of a patient’s needs should be addressed first. This process is called prioritizing care. The decision process can utilize frameworks such as ABCs, Maslow’s hierarchy, acute versus chronic problems, expected versus unexpected problems, and actual versus potential problems. The importance of outcome identification cannot be overstated; nurses must ensure that patient outcomes or goals are realistic, attainable, and time-specific. Goals can be short- or long-term goals. Nurses have a crucial role in the planning phase where they serve as care coordinator and team player, provide education, and communicate efficiently.