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nursing process documentation system

A medical diagnosis, on the other hand, is made by the physician or advance health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat. Moreover, through experience and know-how, the specific and precise clinical entity that might be the possible cause of the illness will then be undertaken by the doctor, therefore, providing the proper medication that would cure the illness. Examples of medical diagnoses are Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. The medical diagnosis normally does not change. Nurses are required to follow the physician’s orders and carry out prescribed treatments and therapies.

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As explained above, now it is easier to distinguish nursing diagnosis from that of a medical diagnosis. Nursing diagnosis is directed towards the patient and his physiological and psychological response. A medical diagnosis, on the other hand, is particular with the disease or medical condition. Its center is on the illness.

NANDA International (NANDA-I)
NANDA–International earlier known as the North American Nursing Diagnosis Association (NANDA) is the principal organization for defining, distribution and integration of standardized nursing diagnoses worldwide.

The term nursing diagnosis was first mentioned in the nursing literature in the 1950s. Two faculty members of Saint Louis University, Kristine Gebbie and Mary Ann Lavin, recognized the need to identify nurses’ role in an ambulatory care setting. In 1973, NANDA’s first national conference was held to formally identify, develop, and classify nursing diagnoses. Subsequent national conferences occurred in 1975, in 1980, and every two years thereafter. In recognition of the participation of nurses in the United States and Canada, in 1982 the group accepted the name North American Nursing Diagnosis Association (NANDA).

The first taxonomy of nursing diagnoses was alphabetical which was considered unscientific by some. In 1982, NANDA adopted the “nine patterns of unitary man” based on the nursing models of Sr. Calista Roy and Martha Rogers as an organizing principle. In 2002, Taxonomy II was adopted, which was adapted from the Functional Health Patterns assessment framework of Dr. Maryjoy Gordon. Taxonomy II has three levels: domain, classes, and nursing diagnoses. Nursing diagnoses are no longer grouped by Gordon’s patterns but coded according to seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology. In addition, diagnoses are now listed alphabetically by its concept, not by the first word.

The American Nurses Association (ANA) incorporated nursing diagnosis into its Standards of Practice in 1973, Nursing: A Social Policy Statement in 1995, and Standards of Clinical Practice in 1998.

In 2002, NANDA became NANDA International (NANDA-I) in response to its significant growth in membership outside of North America. The acronym NANDA was retained in the name because of its recognition.

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Review, refinement, and research of diagnostic labels continue as new and modified labels are discussed at each biannual conference. Nurses can submit diagnoses to the Diagnostic Review Committee for review. The NANDA-I board of directors give the final approval for incorporation of the diagnosis into the official list of labels. As of 2019, NANDA-I has approved 244 diagnoses for clinical use, testing, and refinement.