As a nurse it is important to understand the difference between a medical diagnosis, a
nursing diagnosis and a collaborative problem.
Nurses have the ability to independently make decisions about nursing diagnoses and collaborative
problems.
Medical diagnoses, on the other hand, are made by physicians.
A medical diagnosis identifies a specific disease or condition.
In the hospital it is commonly simply referred to as the patient’s diagnosis.
This diagnosis is made by a physician after they assess the patient’s history, signs
and symptoms as well as conduct diagnostic tests as needed.
The medical diagnosis will then be treated by the physician.
You can check out the link below for more examples and information about specific medical
diagnoses including signs, symptoms and diagnostic tests.
A nursing diagnosis identifies a client’s response to their health that the nurse can
manage.
These diagnoses serve as the basis for the next steps in the nursing process which include
planning, intervention and evaluation.
Nursing diagnoses need to fall within the scope of what nurses are licensed to treat
because nurses are accountable for outcomes related to these diagnoses.
When the nurse assesses the patient, they use their clinical judgement to identify specific
client problems and responses that are identified using standardised language from NANDA International.
Using this standardised language is important for communication among nurses.
It also has helped to promote research into client issues that were previously underexplored.
A nursing diagnosis handbook will come in handy as you work through the process of turning
your assessment data into a nursing diagnosis.
For a current list of nursing diagnostic labels please see the link below this video.
There are quite a few so we will talk more about how to formulate your nursing diagnoses
in the next video.
In short - A medical diagnosis identifies a disease that the physician treats.
A nursing diagnosis identifies an actual or potential response to a disease or situation
that the nurse focuses on.
For example, a patient admitted with a medical diagnosis of breast cancer may have a nursing
diagnosis of disturbed body image among others.
The physician would be concerned with treating the medical diagnosis by ordering surgery,
chemotherapy or radiation.
The nurse would develop a plan with the patient to help them deal with any shame, embarrassment
or guilt they are experiencing.
The term “collaborative problem” is sometimes used in multiple ways so be sure to clarify
what your teacher means if they ask you to identify or discuss a collaborative problem.
A nursing diagnosis may have an intervention that requires collaboration.
For example, to manage acute pain with medication it first needs to be prescribed.
The diagnosis of acute pain is still a nursing diagnosis.
Some textbooks define a collaborative problem as an issue that another discipline has identified
that requires a nursing intervention.
This issue would then be placed on the interdisciplinary care plan.
Chances are that if you are asked to write a collaborative problem statement your teacher
is referring to an RC diagnosis.
Carpenito’s nursing diagnosis handbook shows how to place a diagnostic label on complications
that nurses cannot treat independently.
Carpenito defines Collaborative problems as potential complications of a client’s condition
that a nurse cannot treat independently.
They will probably occur with a specific disease, injury or treatment.
Just like the name suggests, collaborative problems are treated collaboratively by both
physicians and nurses working together, often in collaboration with other health care team
members.
In your nursing diagnosis handbook they may be listed under associated nursing diagnoses
or in a separate section.
Nurses work to prevent collaborative problems from developing.
When collaborative problems exist nurses have the responsibility to monitor the patient’s
status, intervene or get the physician to intervene when necessary and evaluate how
effective interventions are.
In short - Nurses cannot treat collaborative problems independently.
They do however monitor for and attempt to prevent these potential complications.
If the nurse can provide the primary treatment for a complication it is a nursing diagnosis.
For example, a patient with a medical diagnosis of AIDS may have a collaborative problem of
being at risk for complications of opportunistic infections.
The nurse can manage and minimize complications related to the patient’s immunodeficiency
but they cannot treat it alone.
This same patient may have a nursing diagnosis of imbalanced nutrition: less than body requirements
that the nurse can intervene to manage more independently.
I am interested in your thoughts about collaborative problems.
Does your teacher ask you to write Risk for Complication diagnoses?
When you create a care plan do you use collaborative problems?
Do you distinguish them from nursing diagnoses?
Do you find collaborative problems confusing?
Please tell me what you think.
This video is part of a series where I walk you through how to apply the nursing process.
In a subsequent video I will talk about how to formulate nursing diagnoses.
If you haven’t seen the nursing process overview video yet I recommend that you watch
it now.
If you aren’t already subscribed you can subscribe to be notified when the next video
in this series comes out.
Normally I aim to get videos out weekly but right now my baby is keeping me busy so I
am aiming for every second week.
Please let me know if you have any questions or if there is anything else you would like
explained.