Importance of a Complete Nursing Assessment
One of the most frequently asked questions that we field at NANDA-I is how to ensure that a diagnosis is correct for a particular patient. In other words, is there a “normal nursing diagnosis” for every individual medical diagnosis or condition?
It’s important to remember that the accuracy of a diagnosis is based on a good, solid nursing assessment. This assessment needs to be based in nursing theory and in nursing practice.
When you consider your documentation requirements in your organization or classroom, is assessment driving your diagnosis? If not, it’s time to reconsider how you diagnose it!
It’s just not acceptable to link a nursing diagnosis directly to a medical diagnosis or condition. There is no evidence that suggests that for every patient, one nursing diagnosis links to one medical diagnosis.
Therefore, NANDA-I asserts that it is critical that a complete nursing assessment should be conducted, considered, and used as a basis for diagnosis.
This is the same in nursing, as it is in any other discipline: Diagnosis comes from assessment.
Are you linking your nursing diagnosis to your patient’s assessments? Please reach out if you have questions on this topic.