DIFFERENCE BETWEEN MEDICAL AND NURSING DIAGNOSIS

MEDICAL DIAGNOSIS

It is the procedure by which a disease, nosological entity, syndrome, or

any health-disease condition, that is, it is a clinical judgment about the psychophysical state
of a person.

Diagnostic process

Clinical diagnosis requires taking into account both aspects of logic, namely, analysis and the
synthesis, using various tools such as anamnesis, medical history, physical examination and
complementary explorations.

The medical diagnosis is established based on symptoms, signs, and findings from examinations.
complementary, what disease does a person have. Generally, a disease is not
related in a one-to-one manner to a symptom, that is to say, a symptom is not exclusive to a
disease. Each symptom or finding in an examination presents a probability of occurrence.
in each disease.

Bayes' theorem helps in diagnosing a disease based on symptoms and other factors.
findings presented by the patient if the diseases are mutually exclusive, it is known
its prevalences and the frequency of occurrence of each symptom in each disease. According to the
prevalence of each disease in each population, the same set of symptoms or syndrome
it can produce a different diagnosis in each population, that is, each syndrome can be
produced by a different disease in each population.

Diagnostic tools

Symptoms: They are the negative physical subjective experiences reported by the patient.
collected by the doctor during the clinical interview in the medical history, using a language
doctor, that is to say understandable for all doctors. For example, patients at the
sensation of shortness of breath or uncomfortable and unpleasant perception in breathing
(dyspnea), they call it suffocation, anxiety, fatigue, easy tiredness...
Signs: They are the objective findings that the doctor detects by observing the patient.
For example, tachypnea at more than 30 breaths per minute. Medical semiotics or
Clinical semiology is the part of medicine that deals with the signs of diseases.
from the point of view of diagnosis and prognosis.
Physical examination or Semiotechnics: It consists of various maneuvers performed by the doctor.
about the patient, with the main ones being inspection, palpation, percussion, smelling and
auscultation, which obtain more specific clinical signs.

All the symptoms reported in the anamnesis and the signs observed in the physical examination are
noted in the patient's medical history.
Generally, the signs and symptoms define a syndrome that may be caused by several
diseases. The doctor must formulate a hypothesis about the diseases that may be
causing the syndrome and to verify the certainty of the hypothesis, it requests explorations.
complementary.

Types of diagnosis

Clinical or individual diagnosis: It is the total issued from the contrast of all the
mentioned and the personal conditions of the patient. All these factors
determine qualitatively and quantitatively the clinical picture, so that it can
be different even when the morbid entity is the same. This is what the maxim refers to.
There are no diseases, only sick people.
Certain diagnosis: It is the diagnosis confirmed through interpretation and
analysis of complementary methods.
Differential diagnosis: Knowledge that is reached after critical evaluation
comparative analysis of its most common manifestations with those of other diseases.
Etiological diagnosis: Determines the causes of the disease; it is essential for the
certain diagnosis of many diseases.
Generic diagnosis: Determine whether the subject is sick or not. Questions may arise
problems of prosecution, as it is necessary to consider a possible simulation and with the
neurosis and hysteria, which constitute true illnesses.
Heroic diagnosis: When the diagnosis becomes an obsession, an absurdity,
in a kind of mental and professional imposition, that is to say, it is an extreme diagnosis in
the meaning of "by itself", and unnecessary.
Lesional, anatomical or topographical diagnosis: It is the location and identification of the
lesions in the different organs and tissues.
Nosological diagnosis: It is the specific determination of the disease.
Pathogenetic diagnosis: It states the mechanisms that produce the disease.
action of the causes and the organic reaction.
Presumptive diagnosis: It is one that the professional considers possible based on the
data obtained from the anamnesis and physical examination.
Syndromic and functional diagnosis: Syndromes are sets of signs and symptoms.
with a common development; e.g., jaundice syndrome (yellow skin, dark urine,
discolored feces, etc.). Although in some cases it cannot be further advanced, it allows
a partial pathogenic one, but that enables a functional treatment.
Symptomatic diagnosis: Its purpose is to identify the disease through the
symptoms. Generally, an isolated symptom does not provide a precise indication of the
disease, since it can be characteristic of many of them.

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 Nursing Diagnosis

A nursing diagnosis deals with the human response to real or potential problems.
of health and the processes of life. Complementary nursing diagnoses aim to
alterations in verbal communication, risk of falls, the interruption of family processes and the
impotence, provide a more holistic understanding of the effects of the accident
cerebrovascular in this patient and their family in particular – also directs the
nursing interventions to achieve specific outcomes for each patient.

Nurse Diagnosis According to Authors:

1. Marjory Gordon (1982): Nursing diagnosis is defined as the problem of

real or potential health of nursing professionals by virtue of their training and
experience has the capacity and legal right to handle.
2. Alfaro (1986): The nursing diagnosis is a real or potential problem (of a
individual, family or group) that nurses can treat legally or
independent in initiating the nursing activities necessary to prevent it,
solve it or reduce it.
3. L. Carpenito (1995): The nursing diagnosis is a statement that describes a.
human response of an individual or group to the vital processes that the nurse can
legally identify and prescribe activities to maintain health status
reduce, eliminate or prevent its alterations.
4. NANDA (1999): The nursing diagnosis is a clinical judgment about the response of a
individual, family or community to their health problems whether real or potential, and to
vital processes. The nursing diagnosis provides the basis for selection of
interventions and for the achievement of objectives, for which the nurse is responsible.
5. NANDA (2008): The nursing diagnosis is the clinical judgment that nurses formulate.
nurses about the responses of individuals, families, or the community to conditions
or vital processes. In light of this judgment, the nurse will be responsible for the
motorization of customer responses, of decision-making that will culminate
in a care plan and the execution of interventions.

Nursing diagnosis development

It is the ability to establish a clinical judgment about the response of an individual, family or
community to stages of life/real or potential health problems, that the professional of
nursing identifies, validates, and independently addresses for decision-making the
time to design a care plan.

There are different types of diagnosis

 1. Reality: Describe the current response to a health problem. It is advised for its
formulation using the PES format (problem, etiology, signs and symptoms).
2. Risk: They describe problems that may arise in the near future and always
they begin with the term Risk. It is recommended to use the PE format for its formulation.
3. Health Promotion: It is a clinical judgment about a person's motivation and desire.
family or community to enhance their well-being, update their human potential and
improving specific health behaviors. Its formulation always begins with the
term Disposition for…. Or Manifested by….

Diagnosis Formulation

A simple proposal for the development of diagnoses is that of Dr. Marjory Gordon and it
done using the PES format.

The formulation of a diagnosis will not only include the problem, but also 2 markers that
they will define the objectives of nursing interventions, that is, the cause of the problem and its
symptomatology.

Problem (is the condition, alteration, deficit, difficulty we have in gathering all the data
obtained during the assessment

Etiology (these are the causes or determinants of the problem we are referring to)

Signs and symptoms (are the manifestations of the problem, remembering that signs are objective
and the symptoms are subjective)

NANDA Taxonomy

NANDA proposes the standardization of the management of interventions, goals or objectives that are
they expect from the care plan through:

1. NURSING ASSESSMENT ACCORDING TO VIRGINIA HENDERSON'S 14 NEEDS AND

THE 11 FUNCTIONAL PATTERNS OF MARJORY GORDON.

TYPology OF THE 11 FUNCTIONAL PATTERNS

The assessment system designed by Marjory Gordon in the 1970s meets all the requirements.
necessary for the realization of an effective nursing assessment, as it constitutes a
useful tool for evaluation with any nursing disciplinary model. Define 11
relevant patterns of behavior for the health of individuals, families and
communities. These are configurations of behaviors, more or less common to all the
people who contribute to their health, quality of life, and to the achievement of their human potential.

PERCEPTION OF HEALTH

It aims to understand the person's own perception of their health and well-being situation.
Includes:

Lifestyles, health promotion practices, and risk prevention. Prescriptions

medical and nursing.

PATTERN 2: NUTRITIONAL - METABOLIC

It aims to know the food and liquid consumption of the person in relation to their
metabolic needs.

Includes:

Individual pattern of food and liquid consumption (eating habits).

Anthropometric measurements.
Psychological aspects of eating.
Feeding pattern of the infant.
Skin lesions. Condition of the skin, mucous membranes, and teeth.

PATTERN 3: ELIMINATION

It aims to understand the patterns of a person's excretory function.

Includes:

Intestinal elimination pattern.

Bladder elimination pattern.
Pattern of elimination through the skin.

PATTERN 4: ACTIVITY - EXERCISE

Describe the patterns of activity, exercise, leisure, and entertainment.

Includes:

Daily life activities.

Amount and type of exercise and sport.
Recreational activities.
Factors that interfere with the completion of desired activities.

PATTERN 5: SLEEP–REST
Sleep patterns refer to the cycles and stages of sleep that individuals experience throughout the night. This includes the phases of light sleep, deep sleep, and REM sleep, which are essential for physical and mental recovery.

Includes:

Quantity and perceived quality of sleep and rest.

 Sleep and rest aids.

PATTERN 6: COGNITIVE - PERCEPTUAL

Describe the sensory, perceptual, and cognitive patterns of the person.

Includes:

Situation of the sensory senses.

Use of compensation systems or prosthetics.

PATTERN 7: SELF-PERCEPTION - SELF-CONCEPT

Describe the patterns of self-concept and mood perception.

Includes:

Attitude of the person towards herself and towards her worth.

Body image and emotional pattern
Non-verbal communication pattern: posture and body movement, eye contact
Communication verbal pattern: voice and speech pattern.

PATTERN 8: ROLE - RELATIONSHIPS

Describe the patterns of engagement with the role and relationships.

Includes:

Perception of the responsibilities of your role.

Satisfaction with family, work, and social relationships.

PATTERN 9: SEXUALITY - REPRODUCTION

Describe the sexual and reproductive patterns of the person.

Includes:

Satisfaction with sexuality.

Sexual disorders.
Problems in the reproductive stage of women.
Problems in menopause.

PATTERN 10: STRESS TOLERANCE

Describe the pattern of adaptation and coping of the person to vital processes, and their
effectiveness, expressed in terms of stress tolerance.
Includes:

The person's resistance capacity to attacks on integrity.

Stress management.
Support and assistance systems.
Perceived ability to handle stressful situations.

PATTERN

Describe the pattern of spiritual and/or religious values and beliefs that influence the
decision making.

Includes:

Things perceived as important in life.

The perception of quality of life.
Conflict with important values or beliefs.
Expectations related to health

2. 14 NEEDS OF VIRGINIA HENDERSON

Breathe normally.
Need 2: Eat and drink appropriately.
Need 3: Eliminate bodily waste.
Need 4: Move and maintain proper posture.
Need 5: Sleep and rest.
Need 6: Choose the right clothing.
Need 7: Maintain body temperature.
Need 8: Maintain personal hygiene.
Need 9: Avoid the dangers of the environment.
Need 10: Communicate with others.
Need 11: Act according to one's own faith.
Need 12: Work to feel fulfilled.
Need 13: To participate in various forms of entertainment.
Need 14: To learn, discover, or satisfy curiosity

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3. NOC nursing outcomes.

The Nursing Outcomes Classification (NOC) includes a terminology and a

standardized criteria to describe and obtain results as a consequence of the
implementation of nursing interventions. These results represent the objectives that
were raised before carrying out these interventions. It also makes use of a language
standardized in order to universalize nursing knowledge. It facilitates understanding
of results and the inclusion of specific indicators to evaluate and score the
results obtained with the patient.

Its content promotes the optimization of information for assessment of the

effectiveness of nursing care complemented by the information provided to
through other classifications

4. Nursing interventions NIC.

The Classification of Nursing Interventions includes nursing interventions in

consonance with the nursing diagnosis, appropriate to the result we expect to achieve in the
patient, and includes the actions that must be taken to achieve this goal. The NIC uses a
normalized and global language to describe the treatments performed by professionals
nursing from the premise that the use of standardized language does not inhibit practice; rather it
it rather serves to communicate the essence of nursing care to others and helps to improve
practice through research.

5. Complete Classification of NANDA Nursing Diagnoses 2012-2014

DOMAIN 1: HEALTH PROMOTION

Recreational activities deficit (00097)

Sedentary lifestyle (00168)
Tendency to adopt health risk behaviors (00188)
Willingness to improve the immunization status (00186) – This diagnosis will be
withdrawn in the next edition.
Ineffective management of one's own health (00078)
Willingness to improve one's own health management (00162)
Ineffective management of the family therapeutic regimen (00080)
Ineffective health maintenance (00099)
Ineffective protection (00043)
Poor community health (00215)

DOMAIN 2: NUTRITION

Deterioration of swallowing (00103)

Insufficient breast milk (00216)
Nutritional imbalance: intake lower than needs (00002)
Nutritional imbalance: intake exceeding needs (00001)
Disposition to Improve Nutrition (00163)
Risk of nutritional imbalance: intake exceeding needs (00003)
Ineffective feeding pattern of the infant (00107)
neonatal jaundice (00194)
Risk of neonatal jaundice (00230)
Risk of liver function deterioration (00178)
Risk of unstable blood glucose level (00179)
Risk of electrolyte imbalance (00195)
Disposition to improve fluid balance (00160)
Fluid volume deficit (00027)
Excess fluid volume (00026)
Risk of fluid volume deficit (00028)
Risk of fluid volume imbalance (00025)

DOMAIN 3: REMOVAL AND EXCHANGE

Deterioration of urinary elimination (00016)

Willingness to improve urinary elimination (00166)
Stress urinary incontinence (00017)
Urgency urinary incontinence (00019)
Functional urinary incontinence (00020)
Urinary incontinence due to overflow (00176)
Reflex urinary incontinence (00018)
Risk of urgency urinary incontinence (00022)
Urinary retention (00023)
Diarrhea (00013)
Constipation (00011)
Subjective constipation (00012)
Risk of constipation (00015)
Fecal incontinence (00014)
Dysfunctional gastrointestinal motility (00196)
Risk of dysfunctional gastrointestinal motility (00197)
Deterioration of gas exchange (00030)

DOMAIN 4: ACTIVITY/REST

Insomnia (00095)
Sleep pattern disorder (00198)
Sleep deprivation (00096)
Willingness to improve sleep (00165)
Deterioration of ambulation (00088)
The deterioration of translation ability (00090)
Deterioration of mobility in bed (00091)
Deterioration of mobility in wheelchair (00089)
Deterioration of physical mobility (00085)
Risk of disuse syndrome (00040)
Perturbation of the energy field (00050)
Fatigue (00093)
Wandering
Decreased cardiac output (00029)
Intolerance to activity (00092)
Risk of activity intolerance (00094)
Ineffective respiratory pattern (00032)
Risk of ineffective gastrointestinal perfusion (00202)
Risk of ineffective renal perfusion (00203)
Ineffective peripheral tissue perfusion (00204)
Ineffective cerebral tissue perfusion risk (00201)
Risk of ineffective peripheral tissue perfusion (00228)
Risk of decreased cardiac tissue perfusion (00200)
Dysfunctional ventilatory response to weaning (00034)
Deterioration of spontaneous ventilation (00033)
Self-care deficit: nutrition (00102)
Self-care deficit: bathing (00108)
Self-care deficit: use of the toilet (00110)
Self-care deficit: dress (00109)
Willingness to improve self-care (00182)
Personal negligence (00193)
Deterioration of home maintenance (00098)

DOMAIN 5: PERCEPTION/COGNITION
Unilateral neglect (00123)
The syndrome of deterioration in the interpretation of the environment (00127)
Acute confusion (00128)
Chronic Confusion (00129)
Risk of acute confusion (00173)
Deficient knowledge (00126)
Willingness to improve knowledge (00161)
ineffective impulse control (00222)
Memory deterioration (00131)
Willingness to improve communication (00157)
The deterioration of verbal communication (00051)
Disposition to improve self-concept (00167)

DOMAIN 6: SELF-PERCEPTION
Despair (00124)
Risk of compromising human dignity (00174)
Personal identity disorder (00121)
Risk of personal identity disorder (00225)
Risk of loneliness (00054)
Chronic low self-esteem (00119)
Situational low self-esteem (00120)
Risk of chronic low self-esteem (00224)
Risk of situational low self-esteem (00153)
Body image disorder (00118)

DOMAIN 7: ROLE/RELATIONSHIPS
The fatigue of the caregiver role (00061)
Risk of caregiver fatigue (00062)
Ineffective breastfeeding (00104)
Provision to improve breastfeeding (00106)
Interruption of breastfeeding (00105)
Parental deterioration (00056)
Willingness to improve parental role (00164)
Parental deterioration risk (00057)
Dysfunctional family processes (00063)
Willingness to improve family processes (00159)
Interruption of family processes (00060)
Risk of deterioration of the linkage (00058)
Parental role conflict (00064)
Ineffective performance of the role (00055)
The deterioration of social interaction (00052)
Ineffective relationship (00223)
Willingness to improve the relationship (00207)
Risk of ineffective relationship (00229)

DOMAIN 8: SEXUALITY
Sexual dysfunction (00059)
Ineffective sexual pattern (00065)
Ineffective maternity process (00221)
Willingness to improve the maternity process (00208)
Risk of ineffective maternity process (00227)
Risk of alteration of the mother/fetus dyad (00209)

DOMAIN 9: COPING/STRESS TOLERANCE

Relocation Stress Syndrome (00114)
Risk of relocation stress syndrome (00149)
Post-rape trauma syndrome (00142)
Post-Traumatic Syndrome (00141)
Risk of post-traumatic syndrome (00145)
Chronic affliction (00137)
Defensive coping (00071)
ineffective coping
Ineffective coping of the community (00077)
Committed family coping (00074)
Disabling family confrontation (00073)
Willingness to improve coping (00158)
Willingness to improve community coping (00076)
Willingness to improve family coping (00075)
oAnxiety (00146)
Anxiety before death (00147)
Generalized deterioration of the adult (00101)
The Duel (00136)
A complicated duel (00135)
Risk of complicated grief (00172)
Stress due to overload (00177)
Impotence (00125)
Risk of impotence (00152)
Ineffective denial (00072)
Ineffective planning of activities (0199)
Risk of ineffective planning of activities (0226)
Disposition to improve power (00187)
The deterioration of personal resilience (00210)
Disposition to improve resilience (00212)
Risk of resilience compromise (00211)
Fear
Decreased intracranial adaptive capacity (00049)
Disorganized behavior of the infant (00116)
Risk of disorganized behavior in infants (00115)
Willingness to improve the organized behavior of the infant (00117)
Autonomic dysreflexia (00009)
Risk of Autonomic Dysreflexia (00010)

DOMAIN 10: VITAL PRINCIPLES

Disposition to improve hope (00185)
Disposition to improve spiritual well-being (00068)
Conflict of decisions (00083)
Non-compliance (00079)
The Deterioration of Religiousness (00169)
Disposition to improve religiosity (00171)
Risk of deterioration of religiosity (00170)
Spiritual suffering (00066)
Risk of spiritual suffering (00067)
Moral suffering (00175)
Willingness to improve decision-making (00184)

DOMAIN 11: SECURITY/PROTECTION

Infection risk (00004)
Risk of suffocation (00036)
Aspiration risk (00039)
Fall risk (00155)
Deterioration of dentition (00048)
Risk of peripheral neurovascular dysfunction (00086)
Deterioration of skin integrity (00046)
Risk of deterioration of skin integrity (00047)
Tissue integrity deterioration (00044)
Risk of injury (00035)
Risk of perioperative postural injury (00087)
Risk of thermal injury (00220)
Ineffective airway clearance (00031)
Deterioration of the oral mucosa (00045)
Risk of dry eye (00219)
Delay in surgical recovery (00100)
bleeding risk (00206)
Shock risk (00205)
Risk of sudden infant death syndrome (00156)
Risk of trauma (00038)
Vascular trauma risk (00213)
Self-harm (00151)
Risk of self-harm (00139)
Suicide risk (00150)
Risk of self-directed violence (00140)
Risk of violence directed at others (00138)
Contamination
Risk of contamination (00180)
Risk of poisoning (00037)
Risk of adverse reaction to iodinated contrast media (00218)
Risk of allergic reaction (00217)
Latex allergy response (00041)
Risk of allergic reaction to latex (00042)
Hyperthermia (00007)
Hypothermia (00006)
 Risk of body temperature imbalance (00005)
Ineffective thermoregulation (00008)

DOMAIN 12: COMFORT

Discomfort (00214)
Disposition to improve comfort (00183)
Acute pain (00132)
Chronic pain (00133)
Nausea (00134)
social isolation (00053)

DOMAIN 13: GROWTH/DEVELOPMENT

Risk of disproportionate growth (00113)
Delay in growth and development (00111)
Risk of developmental delay (00112)

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