Nurse's Pocket Guide

healthcare delivery and reimbursement, the expansion of nursing’s
role, and the dawning of the computer age. The advent of
alternative healthcare settings (e.g., outpatient surgery centers,
home health, rehabilitation or sub-acute units, extended or longterm
care facilities) increases the need for a commonality of
communication to ensure continuity of care for the client, who
moves from one setting or level of care to another. The efficient
documentation of the client encounter, whether that is a single
office visit or a lengthy hospitalization, and the movement
toward a paperless (computerized or electronic) client record
have strengthened the need for standardizing nursing language
to better demonstrate what nursing is and what nursing does.
NANDA-I nursing diagnosis is one of the standardized nursing
languages recognized by the American Nurses Association
(ANA) as providing clinically useful terminology that supports
nursing practice. NANDA-I has also established a liaison with
the International Council of Nursing to support and contribute
to the global effort to standardize the language of healthcare
with the goal that NANDA-I NDs will be included in the International
Classification of Diseases. In the meantime, they are
included in the United States version of International Classification
of Diseases-Clinical Modifications (ICD-10CM). The
NANDA nursing diagnosis labels have also been combined with
Nursing Interventions Classification (NIC) and Nursing Outcomes
Classification (NOC) to create a complete nursing language
that has been coded into the Systematized Nomenclature
of Medicine (SNOMED). Inclusion in an international coded
terminology such as SNOMED is essential if nursing’s contribution
to healthcare is to be recognized in the computer database.
Indexing of the entire medical record supports disease
management activities, research, and analysis of outcomes for
quality improvement for all healthcare disciplines. Coding also
supports telehealth (the use of telecommunications technology
to provide healthcare information and services over distance)
and facilitates access to healthcare data across care settings and
various computer systems.
The key to accurate diagnosis is collection and analysis of
data. In Chapter 3, the NDs have been categorized into divisions
(Diagnostic Divisions: Nursing Diagnoses Organized According
to a Nursing Focus, Section 2), and a sample assessment tool
designed to assist the nurse to identify appropriate NDs as the
data are collected is provided. Nurses may feel at risk in committing
themselves to documenting an ND for fear they might
be wrong. However, unlike medical diagnoses, NDs can change
as the client progresses through various stages of illness/
maladaptation to resolution of the condition/situation.
Desired outcomes are then formulated to give direction to, as
well as to evaluate, the care provided. These outcomes emerge
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