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Nursing Diagnosis

A nursing diagnosis is a clinical judgment about individual, family, or community experiences / responses to actual or potential health problems / life processes. Nursing diagnoses are developed based on data obtained during the nursing assessment.

The primary organization for defining, dissemination and integration of standardized nursing diagnoses worldwide is NANDA-International formerly known as the North American Nursing Diagnosis Association. For nearly 40 years NANDA-I has worked in this area to ensure that diagnoses are developed through a peer-reviewed process requiring standardized levels of evidence, standardized definitions, defining characteristics, related factors and/or risk factors that enable nurses to identify potential diagnoses in the course of a nursing assessment. NANDA-I believes that it is critical that nurses are required to utilize standardized languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characterisitcs) and the related or etiologic factors upon which nurses intervene. NANDA-I terms are developed and refined for actual (current) health responses and for risk situations , as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities. Contributing diagnostic associations include AENTDE (Spain), AFEDI (French language), and JSND (Japan). NANDA-I also has several regional networks including Brasil, Peru, Honduras, Nigeria-Ghana and a German-language group. The taxonomy is published in multiple countries and has been translated into 18 languages; it is in use worldwide. The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, is HL7 registered, ISO-compatible and available within SNOMED-CT with appropriate licensure.

Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the electronic health record and can be linked to nurse-sensitive patient outcomes.

Brokel, J & C Heath (2009). The value of nursing diagnoses in electronic health records. In Herdman, TH (Ed.), Nursing diagnoses: definitions and classification 2009-2011. Wiley-Blackwell: Singapore.

Weir-Hughes, D. (2009). Nursing diagnosis in administration. In Herdman, TH (Ed.), Nursing diagnoses: definitions and classification 2009-2011. Wiley-Blackwell: Singapore.

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