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The first nursing diagnosis was introduced in 1950 by Dr. Marjory Gordon. He developed a functional health system that is still in use. The first company to use nursing diagnosis was Johnson & Johnson. Dorthy Johnson is known for her “Behavioral System Model of Nursing.” She proposed it in 1968, stating that “each individual has patterned, purposeful, repetitive ways of acting that comprises a behavioral system specific to that individual.”
However, in 1973, the development of nursing diagnosis formally began when two faculty members of Saint Louis University, Kristine Gebbie and Mary Ann Lavin, perceived a need to identify the nurses' roles in ambulatory care settings. Now this formula is more or less used as a care plan.
What Is the Modern Form of Nursing Diagnosis?
Nursing diagnosis is an integral part of the medical process. It is a clinical judgment about the individual, family, or community responses to actual or potential health problems/life processes. It provides the basis for the selection of nursing interventions to achieve positive outcomes.
Based on the Nursing Outcomes Classification (NOC) system, nursing diagnoses are classified into different categories. They are:
- Actual Nursing Diagnosis (Problem-Focused)
- Risk Nursing Diagnosis (Risk-Focused)
- Potential Nursing Diagnosis (Wellness-Focused)
- Syndrome Nursing Diagnosis (Etiology-Focused)
Let us see what these diagnoses are and their goals with examples!
1. Actual Nursing Diagnosis (Problem-Focused)
Actual nursing diagnosis is related to a specific health problem present during the nursing assessment. Care provided by the nurse is directed at resolving the identified problem. For example, nursing diagnosis and care for diabetes.
2. Risk Nursing Diagnosis (Risk-Focused)
The risk nursing diagnosis is based on the assessment data and is related to a health problem that may develop if interventions are not implemented. The goal of risk-focused care is to prevent the identified problem from occurring. For example, if you have muscle weakness then there will be risk-focused nursing interventions for falls or injury.
3. Potential Nursing Diagnosis (Wellness-Focused)
The potential nursing diagnosis is related to the promotion of a health condition that is not currently present but has the potential to develop. It focuses on the transition of health conditions from a specific level to a higher level. For example, readiness for enhanced parenting, where parents want a healthy growing environment for their children under medical guidance.
4. Syndrome Nursing Diagnosis (Etiology-Focused)
The syndrome nursing diagnosis is a clinical judgment related to a group of signs and symptoms that are present together and represent a specific health condition. The goal of care is to resolve the underlying problem that is causing the symptoms. For example, post-trauma syndrome includes conditions of shock, fear, shivering, difficulty in understanding and expressing things, and more.
How to Develop a Nursing Diagnosis?
Now you have learned what the four major domains of nursing diagnosis are. Let us understand the process. Here we are including the basic and defined steps by NADA-I, which will remain the same for all kinds of nursing diagnoses. The only variation in these steps can occur with the change in type, cause, and objectives of diagnosis. These steps are:
- Assessment: Nursing assessment includes patient/family/community observations. These observations have physiological and psychosocial attributes. This information can be gathered through examinations, interviews, and general observations
- Diagnosis: This includes defining the condition(s) in an educated and comprehensive manner. For a single patient, there can be multiple diagnoses. The types of diagnosis and their uses depend on the patient's conditions and the required outcome. This is the most important and defining step in the process.
- Planning: A roadmap is formed for handling the patient’s conditions and their family/community is informed about the diagnosis, its results, and further treatment procedures. If multiple diagnoses are required, those are prioritized by the head nurse and respective health goals are defined. In this phase, NOC plays a significant role as it includes standardized rules for diagnosis and its results.
- Implementation: In this phase, a plan of action is followed. It includes performing the medical task, monitoring the patient, advising about further health care, follow-ups, and referring for required therapies, medicines, or checkups. The period of this phase varies from hours to months.
- Evaluation: This can be defined as the assessment (first step) of post-nursing interventions. In this step, the patient’s vitals are observed and defined in one of the 3 terminologies — patient's condition improved, patient's condition stabilized, and patient's condition deteriorated. If the wellness goals are not met, the diagnosis process is repeated till the desired results are achieved.
Therefore, nursing diagnosis needs critical thinking and keen observations. For this, you can use our ready-made templates and save your time and energy for more critical and life-saving tasks. So grab these templates now!
Template 1: Quarterly Nursing Diagnosis PowerPoint Template
This template can help you make a treatment plan and distribute it for a chronic illness in four quarters. You can mention the problem statement and diagnosis in the first-quarter analysis. Planning and setting goals can be done, and implement the planning and actions in Q3. Note down the observations and evaluate results in Q4. Download it now!
Template 2: Nursing Diagnosis and Interventions PPT Template
You can use this template to mention the brief about the nursing diagnosis. Collate the critical aspects of the diagnosis program and present them concisely with the help of this template. Utilize this template to share the different types of diagnosis and their uses. Get it now!
Template 3: Five Year Nursing Diagnosis Roadmap PowerPoint Template
Use this template to make a five-year-long nursing diagnosis plan. You can take the help of this PPT slide to explain what medical procedures you are going to follow in the upcoming years. Also, you can easily track the progress and plan the next step with this template. Grab this PowerPoint layout now!
Template 4: Psychiatric Nursing Diagnosis PowerPoint Presentation Slide
Deploy this template to share the nursing diagnosis for psychiatric conditions. You can use it to share the steps in the procedure. Besides, this template is entirely customizable. You can change the color, icons, and text to match your requirements. So download this PPT design now!
Template 5: Half Yearly Nursing Diagnosis Roadmap PPT Template
Employ this template to draft a half-yearly plan that you can share the plan of the diagnosis in two phases, H1 and H2. H1 phase consists of analysis and planning, and H2 of implementation and results with scientific principles. Get this template now!
Template 6: Critical Care Nursing Diagnosis PowerPoint Slide
Incorporate this template in your classroom lecture to enhance the learning experience of students. With the help of this template, brief the students on how the nursing diagnosis is a part of critical care procedures. You can use this template to share the importance and other factors that affect diagnosis. So get this now!
Template 7: Six Months Nursing Diagnosis and Action Criteria Roadmap PPT Template
This template can be used to draft a monthly brief plan. It will help you prepare a six-step medical procedure to help your patients. Besides, you can change the color scheme, edit the pre-written text, and do more with this template. Download this now!
Template 8: Nursing Diagnosis and Intervention PowerPoint Slide
Use this template to brief the patients about procedures and results. Also share other related medical advice with this PPT slide. You can use it to describe a step-by-step process for diagnosis and other phases. Besides, the subtle color theme of this PPT layout is eye-catching. So try this now!
Template 9: Three Months Nursing Diagnosis Roadmap PPT Template
This template can help you share the short three months plan for nursing diagnosis. Share the steps for problem analysis and conduct it smoothly with the help of this template. For the next month, plan activities, interact with the patient, set fitness goals, and measure to achieve those goals. In the last month, implement the actions and evaluate results using this template. Download this now!
Template 10: One-pager Nursing Diagnosis PPT Template
If you are looking for something to share the nursing diagnosis plan in a clear and concise manner, this one-pager template is perfect for you. Besides, this is easy to customize. Download it once, edit when required and present it afresh!
Nursing diagnosis is vital for a person seeking medical aid. However, you need to plan and conduct it mindfully to utilize its full potential. You can do this easily with the help of our predesigned templates. So grab them now and give yourself a smooth head start!
P.S: If you are a healthcare professional looking for something to aid your presentations, don't miss this medical and healthcare guide, which includes the best templates. So read it now!
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