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Standard 2. DiagnosisThe registered nurse analyzes the
assessment data to determine the diagnosis or the issues.
Definition and PurposeDiagnosis uses standard language to name health problems in order to:• Develop a plan of care and evaluate its outcomes • Communicate with healthcare providers• Differentiate among and educate healthcare
practitioners • Organize research to develop discipline’s body of
knowledge • Organize practice quality evaluation and
improvement• System for reimbursement for healthcare services
Types of Diagnoses Used in Nursing
• Statements of actual or potential response to a health problem experienced by a patient, family, or community.
• Terms used to identify the genetic and pathological conditions, illnesses, and syndromes that cause patient’s signs and symptoms.
• Terms used to identify health problems encountered within communities and system problems within healthcare organizations.
Diagnostic Processes• Use of clinical judgment • Analysis of assessment data• Knowledge of potential diagnoses• Use of pattern recognition and deductive
reasoning to match data to best diagnosis• Confirmation of diagnosis based on
collection of additional data and reassessment