A nursing diagnosis based model: guiding nursing practice

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M Krenz1, B Karlik, S Kiniry

  • 1Robert Wood Johnson University Hospital, New Brunswick, New Jersey.

The Journal of Nursing Administration
|May 1, 1989
PubMed

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Nursing Process for Patient and Caregiver Teaching I: Assessment and Diagnosis

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Nursing Diagnosis

Following assessment, a nursing diagnosis is the next step in the nursing process. It begins after the nurse has collected and recorded the patient data. The purpose of diagnosing is to identify how the client responds to actual or potential health processes, identify factors that bestow or that cause health problems, the etiologies, and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.
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A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing interventions. The standardized terminologies of a nursing diagnosis help nurses identify and treat patients' problems. Every electronic health record that uses nursing diagnosis must employ standard diagnostic terminology. Developing an efficient, individualized care plan begins with accurate nursing diagnoses.
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