Nursing Diagnoses

Nursing diagnoses differ from medical diagnoses. Simply put by NANDA (North American Nursing Diagnosis Association); "A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes." (1)

Nursing diagnoses are statements explaining the problem with relation to the source and if patient interaction has taken place, the addition of evidence (signs/symptoms) to support is preferred. For example, a person medically diagnosed with asthma could have a nursing diagnosis of ineffective airway clearance related to bronchial constriction, as evidenced by increased mucus and wheezing. Many medical diagnoses are one word pathologies. Nursing diagnoses are statements which include more depth, making the problem individualized to each patient. 

1. Altered comfort; dyspepsia related to reflux of gastric content
2. Risk for GI bleed related to ulcerated esophagus
3. Risk for cancer related to cell transformation due to recurrent tissue trauma.
4. Risk for nutrition deficit related to pain when eating.
5. Ineffective health maintenance related to deficient knowledge regarding self-care with disease.

Altered comfort; dyspepsia related to reflux of gastric content: 

Actual or potential goals	Related to	Plan and outcome	Nursing intervention
·         Patient will verbalize a desire to quit smoking and limit alcohol intake ·        Patient will eliminate high fatty foods ·         Patient will adhere to medication regimen	·       Alcohol intake ·      Fatty foods ·       Smoking	·         Feelings of indigestion will become rare  ·        Lifestyle changes will reverse symptoms and lessen the need for medications	·         Keep HOB elevated 2-3 hours after meals ·         Provide small frequent meals rather than large ones ·         Administer antacid and PPI/H2 blockers as ordered

(2)

References:

1.     (2015, March 1). Retrieved February 26, 2015, from http://kb.nanda.org/article/AA-

              00266/0/What-is-the-difference-between-a-medical-diagnosis-and-a-nursing-diagnosis-.html

2.     Elsevier (2012). Retrieved May 22, 2015. from 

             http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=326