Nursing vs. Medical Diagnoses & Diagnostic Reasoning

Medical vs. Nursing Diagnosis

• Nursing Diagnosis: Made by a nurse, represents the client's actual or potential response to a health state. It uses nursing terminology, clinical judgment, and identifies potential problems or conditions.
  • Examples: Ineffective airway clearance (due to pneumonia), disturbed body image (due to amputation), impaired urinary elimination (due to post-op prostatectomy).
• Medical Diagnosis: Made by a doctor, determines the specific disease or medical condition.
  • Examples: Pneumonia, amputation, post-op prostatectomy.

Nursing Diagnostic Reasoning

• Process: A decision-making process involving several steps:
  • Gather all patient information/data.
  • Analyze the collected data.
  • Identify the client's needs.
  • Interpret all findings.
  • Formulate the nursing diagnosis.
  • Act upon the diagnosis with nursing interventions.

Developing a Nursing Diagnosis

• Requires asking specific questions:
  • What is the specific problem?
  • What might be the cause of the problem?
  • Are preventative measures needed?
  • What client education is necessary (e.g., how to prevent recurrence)?