As content creators for xentrydiagnosis.store and auto repair experts, we understand the complexities of vehicle diagnostics. Just like in automotive repair, nursing also relies on a systematic diagnostic process to address patient health. This guide will explore the concept of “Secondary Diagnosis Nursing Care Plans,” drawing parallels to the detailed diagnostic approaches we use in auto repair. While our expertise is in vehicles, understanding healthcare diagnostic frameworks can broaden our perspectives and highlight the universality of systematic problem-solving.
Understanding Nursing Diagnosis in Healthcare
In nursing, a nursing diagnosis is a critical judgment made by nurses. It focuses on a patient’s response to health issues or life situations, or their susceptibility to such responses. This judgment is not about identifying a disease (that’s a medical diagnosis), but about understanding how a patient is affected by their health condition. It guides nurses in choosing appropriate nursing interventions to achieve specific patient outcomes. These diagnoses are formed based on data gathered during a thorough nursing assessment, which is akin to our initial vehicle inspection to gather symptoms and signs. This assessment is fundamental to developing a comprehensive care plan, much like our diagnostic process leads to a repair plan for a vehicle.
The Importance of Nursing Diagnosis
Nursing diagnoses serve several crucial purposes:
- Educational Tool: For nursing students, these diagnoses are excellent for developing problem-solving and critical thinking skills, much like diagnostic training sharpens our automotive repair skills.
- Prioritization of Care: They help nurses prioritize patient needs and direct nursing interventions accordingly, similar to how we prioritize repairs based on diagnostic findings and vehicle safety.
- Outcome Measurement: Nursing diagnoses assist in setting measurable outcomes for quality assurance, essential for healthcare providers and insurance, just as clear diagnostic reports are vital for our customers and service transparency.
- Resource Identification: They help identify how patients respond to health challenges and their available strengths for problem-solving, mirroring our assessment of vehicle condition and available repair resources.
- Communication Framework: Nursing diagnoses provide a common language for healthcare professionals, fostering clear communication within the team, much like standardized automotive terminology ensures effective communication in our field.
- Evaluation of Care: They offer a basis for evaluation to determine the effectiveness and cost-efficiency of nursing care, similar to how we evaluate the success and cost-effectiveness of our repairs.
Nursing Diagnosis vs. Medical Diagnosis vs. Collaborative Problems
It’s essential to differentiate between a nursing diagnosis, a medical diagnosis, and collaborative problems. The term “nursing diagnosis” itself has two meanings within the nursing process. First, it’s the second step, “diagnosis,” in the ADPIE (Assess, Diagnose, Plan, Implement, Evaluate) framework. Second, it’s the label nurses assign to patient data. For example, a nurse might observe a patient experiencing anxiety, fear, and difficulty with sleep. These observations lead to nursing diagnoses like “Anxiety,” “Fear,” and “Disturbed Sleep Pattern.” These are based on the patient’s response to their medical condition.
COMPARISON: Nursing diagnoses, medical diagnoses, and collaborative problems.
A medical diagnosis, on the other hand, is made by a physician and focuses on the disease, condition, or pathology that only a doctor can treat. It identifies the specific clinical entity causing the illness, leading to medication or medical treatment to cure the disease. Examples include Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. Medical diagnoses usually remain constant, and nurses follow doctor’s orders for treatment.
Collaborative problems are potential issues nurses manage using both independent nursing actions and physician-prescribed treatments. These require both medical and nursing interventions. Nursing’s role here is to monitor the patient’s condition and prevent potential complications.
The key difference is focus: nursing diagnosis addresses the patient’s response to illness, while medical diagnosis addresses the illness itself. This distinction is akin to diagnosing a car’s engine problem (medical diagnosis) versus understanding how the engine problem is affecting the car’s overall performance and the driver’s experience (nursing diagnosis).
Taxonomy of Nursing Diagnoses (Taxonomy II)
Nursing diagnoses are organized using Taxonomy II, adopted in 2002 and based on Dr. Mary Joy Gordon’s Functional Health Patterns. Taxonomy II has three levels: 13 Domains, 47 Classes, and the nursing diagnoses themselves. Diagnoses are coded across seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology, and listed alphabetically by concept.
The 13 Domains are:
- Domain 1. Health Promotion
- Class 1. Health Awareness
- Class 2. Health Management
- Domain 2. Nutrition
- Class 1. Ingestion
- Class 2. Digestion
- Class 3. Absorption
- Class 4. Metabolism
- Class 5. Hydration
- Domain 3. Elimination and Exchange
- Class 1. Urinary function
- Class 2. Gastrointestinal function
- Class 3. Integumentary function
- Class 4. Respiratory function
- Domain 4. Activity/Rest
- Class 1. Sleep/Rest
- Class 2. Activity/Exercise
- Class 3. Energy balance
- Class 4. Cardiovascular/Pulmonary responses
- Class 5. Self-care
- Domain 5. Perception/Cognition
- Class 1. Attention
- Class 2. Orientation
- Class 3. Sensation/Perception
- Class 4. Cognition
- Class 5. Communication
- Domain 6. Self-Perception
- Class 1. Self-concept
- Class 2. Self-esteem
- Class 3. Body image
- Domain 7. Role relationship
- Class 1. Caregiving roles
- Class 2. Family relationships
- Class 3. Role performance
- Domain 8. Sexuality
- Class 1. Sexual identity
- Class 2. Sexual function
- Class 3. Reproduction
- Domain 9. Coping/stress tolerance
- Class 1. Post-trauma responses
- Class 2. Coping responses
- Class 3. Neurobehavioral stress
- Domain 10. Life principles
- Class 1. Values
- Class 2. Beliefs
- Class 3. Value/Belief/Action congruence
- Domain 11. Safety/Protection
- Class 1. Infection
- Class 2. Physical injury
- Class 3. Violence
- Class 4. Environmental hazards
- Class 5. Defensive processes
- Class 6. Thermoregulation
- Domain 12. Comfort
- Class 1. Physical comfort
- Class 2. Environmental comfort
- Class 3. Social comfort
- Domain 13. Growth/Development
- Class 1. Growth
- Class 2. Development
The Nursing Process: A Step-by-Step Approach
The nursing process consists of five stages: assessment, diagnosing, planning, implementation, and evaluation. Each step demands critical thinking from the nurse. Beyond understanding definitions, nurses must recognize the defining characteristics and behaviors of diagnoses, related factors, and suitable interventions.
For a deeper dive into each stage, refer to: “The Nursing Process: A Comprehensive Guide“
Types of Nursing Diagnoses: Primary and Secondary Considerations
There are four main types of nursing diagnoses: Actual (Problem-Focused), Risk, Health Promotion, and Syndrome. These categories help nurses classify patient problems and plan appropriate care.
While not formally categorized as “primary” or “secondary,” the concept of secondary diagnosis is crucial in comprehensive patient care planning. A secondary diagnosis typically arises as a consequence of a primary condition or treatment, or it may be a co-existing condition that affects the patient’s overall health and response to the primary issue.
Problem-Focused (Actual) Nursing Diagnosis
A problem-focused diagnosis, or actual diagnosis, identifies a current patient problem at the time of nursing assessment. It’s based on observable signs and symptoms. While actual diagnoses are important, risk diagnoses are equally vital as they address potential future problems.
These diagnoses have three parts: (1) nursing diagnosis label, (2) related factors, and (3) defining characteristics. Examples include:
Risk Nursing Diagnosis: Identifying Potential Secondary Issues
Risk nursing diagnoses are clinical judgments about potential problems that don’t currently exist but are likely to develop without intervention due to risk factors. These diagnoses are based on the patient’s current health, health history, and risk factors. They are crucial for proactive care, allowing nurses to prevent or lessen potential problems.
Risk diagnoses don’t have etiological (related) factors in the same way as actual diagnoses. Instead, they highlight susceptibility due to risk factors. For instance, an elderly patient with diabetes, vertigo, and difficulty walking who refuses assistance might be diagnosed with risk for injury or risk for falls. These risks are often secondary to their primary health conditions.
IMPORTANT: For risk diagnoses, “as evidenced by” connects the diagnosis label to risk factors, not defining characteristics. Components are:
- Risk diagnostic label, linked by “as evidenced by”
- Risk factors
Examples of risk diagnoses relevant to secondary concerns:
- Risk for Infection as evidenced by surgical wound, compromised immune system, and prolonged hospitalization (secondary to surgery or underlying conditions).
- Risk for Falls as evidenced by muscle weakness, history of previous falls, impaired mobility, and use of assistive devices (potentially secondary to age, illness, or treatment).
Health Promotion Diagnosis: Enhancing Wellness Beyond Primary Concerns
Health promotion diagnoses, also known as wellness diagnoses, are about a patient’s motivation and desire to improve their well-being. They identify a patient’s readiness to engage in health-promoting activities. For example, a new mother interested in breastfeeding might receive a diagnosis of “Readiness for Enhanced Breastfeeding.” This guides nursing interventions to support her learning.
These diagnoses focus on moving an individual, family, or community from one wellness level to a higher one. They usually include just the diagnostic label, a one-part statement, but can be clarified with related factors. Examples include:
Syndrome Diagnosis: Recognizing Clusters of Related Issues
A syndrome diagnosis is a clinical judgment about a group of actual or risk nursing diagnoses predicted to occur together due to a specific situation or event. They are also one-part statements, using only the diagnostic label. Examples include:
Possible Nursing Diagnosis: Investigating Suspected Secondary Problems
A possible nursing diagnosis is not a formal type like actual, risk, health promotion, or syndrome. Instead, it describes a suspected problem needing more data to confirm or rule out. It signals to other nurses that a diagnosis might be present, requiring further data collection. Examples include:
Components of a Nursing Diagnosis: Building a Detailed Picture
A nursing diagnosis typically has three parts: (1) the problem and its definition, (2) the etiology (cause), and (3) defining characteristics or risk factors (for risk diagnoses).
Problem and Definition: The Diagnostic Label
The problem statement, or diagnostic label, concisely describes the patient’s health problem or response requiring nursing care. It usually has two parts: a qualifier and the focus of the diagnosis. Qualifiers, or modifiers, add meaning, limit, or specify the diagnosis. One-word diagnoses (e.g., Anxiety, Constipation, Diarrhea, Nausea) inherently include qualifier and focus.
| Qualifier | Focus of the Diagnosis |
|---|---|
| Deficient | Fluid volume |
| Imbalanced | Nutrition: Less Than Body Requirements |
| Impaired | Gas Exchange |
| Ineffective | Tissue Perfusion |
| Risk for | Injury |
Etiology: Identifying Related Factors
Etiology, or related factors, identifies the likely causes of the health problem, conditions involved in its development. It directs nursing care and helps personalize treatment. Nursing interventions should target etiological factors to address the root cause. Etiology is linked to the problem statement with “related to,” for example:
Risk Factors: Assessing Vulnerability to Secondary Conditions
Risk factors replace etiological factors in risk diagnoses. They are factors increasing an individual’s vulnerability to an unhealthy condition. Risk factors are written after “as evidenced by” in the diagnostic statement.
- Risk for falls as evidenced by old age and use of walker (age and mobility aids are risk factors).
- Risk for infection as evidenced by break in skin integrity (broken skin is a risk factor).
Defining Characteristics: Recognizing Signs and Symptoms
Defining characteristics are clusters of signs and symptoms indicating a specific diagnostic label. In actual diagnoses, these are the client’s signs and symptoms. In risk diagnoses, no signs/symptoms are present; instead, risk factors causing susceptibility form the etiology. Defining characteristics are written after “as evidenced by” or “as manifested by.”
Diagnostic Process: A Systematic Approach
The diagnostic process has three phases: (1) data analysis, (2) identification of health problems, risks, and strengths, and (3) formulation of diagnostic statements.
Analyzing Data: Similar to Automotive Diagnostics
Data analysis involves comparing patient data to norms, grouping cues, and finding gaps or inconsistencies. This mirrors our process in auto repair where we compare readings to specifications, group symptoms to systems, and identify anomalies.
Identifying Health Problems, Risks, and Strengths: Pinpointing Primary and Secondary Issues
In this decision-making step, nurses and patients identify problems supporting potential actual, risk, and possible diagnoses. They determine if a problem is a nursing diagnosis, medical diagnosis, or collaborative problem. Strengths and coping abilities are also identified. This stage is crucial for differentiating primary concerns from potential secondary diagnoses that need to be addressed.
Formulating Diagnostic Statements: Clear and Concise Communication
Formulating diagnostic statements is the final step, where nurses create clear and concise statements, much like writing a precise diagnostic report in auto repair.
Writing a Nursing Diagnosis: Clear and Accurate Language
Writing nursing diagnostic statements involves describing a patient’s health status and contributing factors. Not all diagnostic indicators need inclusion. Statements vary by diagnosis type.
PES Format: Problem, Etiology, Signs/Symptoms
The PES format (Problem, Etiology, Signs/Symptoms) is another way to write diagnostic statements. Statements can be one-part, two-part, or three-part using PES.
One-Part Statements: Health Promotion and Syndrome Diagnoses
Health promotion diagnoses are usually one-part statements because related factors are constant: motivation to improve wellness. Syndrome diagnoses also lack related factors. Examples:
- Readiness for enhanced coping
- Rape Trauma Syndrome
Two-Part Statements: Risk and Possible Diagnoses
Risk and possible diagnoses are two-part: diagnostic label and validation (risk factors for risk diagnosis, suspected problem for possible diagnosis). Signs and symptoms are absent. Examples:
- Risk for Infection as evidenced by weakened immune system response
- Risk for Injury as evidenced by unstable hemodynamic profile
Three-part Statements: Actual/Problem-Focused Diagnoses
Actual or problem-focused diagnoses are three-part: diagnostic label, contributing factor (“related to”), and signs/symptoms (“as evidenced by” or “as manifested by”). This is the PES format (Problem, Etiology, Signs/Symptoms). Example:
Variations on Basic Statement Formats
Variations exist in writing nursing diagnosis statements to accommodate different situations and complexities.
Nursing Diagnosis for Care Plans: A Foundation for Action
This section provides a database of common nursing diagnosis examples for developing nursing care plans. These plans are designed to address both primary and secondary diagnoses, ensuring comprehensive patient care.
See also: Nursing Care Plans (NCP): Ultimate Guide and List
Recommended Resources for Further Learning
Recommended books and resources for nursing diagnosis and care planning:
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care This handbook is valued for its evidence-based approach to interventions. It offers a three-step system for client assessment, diagnosis, and care planning, with instructions for implementation and outcome evaluation, fostering diagnostic reasoning and critical thinking skills.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) This resource includes over 200 care plans reflecting current evidence-based guidelines. New additions cover ICNP diagnoses, LGBTQ health, and electrolyte/acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales A quick reference tool for identifying correct diagnoses for efficient care planning. The 16th edition features updated diagnoses and interventions, alphabetized and covering over 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care This manual helps identify interventions for planning, personalizing, and documenting care for over 800 conditions. It uniquely offers subjective/objective data, clinical applications, prioritized actions/rationales, documentation sections, and more for each diagnosis.
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health Features over 100 care plans across medical-surgical, maternity, pediatrics, and psychiatric-mental health. “Patient problems” sections promote patient-centered communication.
Further Resources
Additional recommended resources on our site related to nursing care planning.
References and Sources
References for this guide and resources for further study.
- Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s Fundamentals of Nursing: Concepts, process and practice. Boston, MA: Pearson.
- Edel, M. (1982). The nature of nursing diagnosis. In J. Carlson, C. Craft, & A. McGuire (Eds.), Nursing diagnosis (pp. 3-17). Philadelphia: Saunders.
- Fry, V. (1953). The Creative approach to nursing. AJN, 53(3), 301-302.
- Gordon, M. (1982). Nursing diagnosis: Process and application. New York: McGraw-Hill.
- Gordon, M. (2014). Manual of nursing diagnosis. Jones & Bartlett Publishers.
- Gebbie, K., & Lavin, M. (1975.) Classification of nursing diagnoses: Proceedings of the First National Conference. St. Louis, MO: Mosby.
- McManus, R. L. (1951). Assumption of functions in nursing. In Teachers College, Columbia University, Regional planning for nurses and nursing education. New York: Columbia University Press.
- Powers, P. (2002). A discourse analysis of nursing diagnosis. Qualitative health research, 12(7), 945-965.
