nursing diagnosis, a statement of a health problem or of a potential problem in the client’s health status that a nurse is licensed and competent to treat. Four steps are required in the formulation of a nursing diagnosis. A database is established by collecting information from all available sources, including interviews with the client and the client’s family, a review of any existing records of the client’s health, observation of the client’s response to any alterations in health status, a physical assessment, and a conference or consultation with others concerned in the client’s care. The database is continually updated. The second step includes analysis of the client’s responses to the problems, healthy or unhealthy, and classification of those responses as psychological, physiological, spiritual, or sociological. The third step is the organization of the data so that a tentative diagnostic statement can be made that summarizes the pattern of problems discovered. The last step is confirmation of the sufficiency and accuracy of the database by evaluation of the appropriateness of the diagnosis to nursing intervention and by the assurance that, given the same information, most other qualified practitioners would arrive at the same nursing diagnosis. In use, each diagnostic category has three parts: the term that concisely describes the problem, the probable cause of the problem, and the defining characteristics of the problem. A number of nursing diagnoses have been identified and are listed as accepted by the North American Nursing Diagnosis Association, and they are updated and refined at periodic meetings of the group.
