A nursing diagnosis and a medical diagnosis are different in terms of characteristics and features. The main difference between the nursing diagnosis and medical diagnosis is that the medical diagnosis is specific to the disease or illness pathology while the nursing diagnosis focuses on the patient and his or her physiological and psychological response.
A nursing diagnosis is created by a nursing professional, while a medical diagnosis is made by a physician. Let us further explore their differences in this article.
What is a Nursing Diagnosis?
A nursing diagnosis is a kind of diagnosis that focuses on the response of the patient to his or her medical condition. It is called nursing diagnosis because of the specific action which is related to what the nurses need to prioritize.
A nursing diagnosis is a part of the nursing process in which the nurse needs to focus on his or her clinical judgment to determine the appropriate plan of care for the patients. A nursing diagnosis is developed with consideration of the patient’s physical assessment which will also help in measuring the possible outcomes for the nursing care plan.
A nursing diagnosis includes the clinical judgment about the individual, family, or the response of the community to the actual or possible health problems. The nursing diagnosis contains possible interventions for the patient, family, and community.
The role of the nurse in this kind of diagnosis is to treat the patient with any kind of instant reaction to a specific disease. The patient’s reaction may be related to his or her condition and can be related to mental trauma, or physical and spiritual actions.
Every nurse in any kind of hospital should be knowledgeable about the terms of the nursing diagnosis. The nurse should provide quick and accurate treatment to the patient’s reaction to a certain condition.
A nursing diagnosis is a statement that describes a suspected problem that requires additional data to confirm or rule out the suspected problem. A nursing diagnosis provides the nurse the ability to communicate with the other nurses through the diagnosis.
The purposes of a nursing diagnosis include:
- To communicate the health care needs of the patients and aggregate among the members of the whole healthcare team.
- To facilitate individualized care for the patient, family, and the community.
- To empower the nursing profession.
The nursing diagnosis includes three (3) components:
- Problem and its definition. This describes the patients’ health problems or responses to which the nurse should focus. The problem and its definition include the qualifiers that add words to some diagnostics to give meaning or to specify the diagnostic statement. Qualifiers include: deficient, imbalanced, impaired, ineffective, and risk for
- Etiology. This is the part of nursing diagnosis which identifies one or more possible causes of the patient’s health conditions. This will give the nurse directions to the needed nursing therapy that will enable the nurse to individualize the patient’s care. Etiology is linked with the problem statement “related to”.
- Defining characteristics or the risk factors. The risk factor is used for risk nursing diagnosis which forces an individual or group at increased vulnerability to an unhealthy condition. A risk factor is written after the phrase “as evidenced by”. The defining characteristics are the signs and symptoms that indicate the presence of a particular diagnostic label. Defining characteristics are written after the phrase “as evidenced by” or “as manifested by” in the patient’s diagnostic statement.
A Nursing Diagnosis has four (4) types:
- Problem-focused. A problem-focused diagnosis also known as the actual diagnosis focuses on the present problem during a nursing assessment. It is generally the problem that is seen throughout the shifts or the patient’s entire hospitalization. In problem-focused diagnosis, the nurse will observe associated concerns, stressors, or the potential complications related to the concerns, stressors, or potential complications related to the patient’s condition and develop a care plan.
- Risk-focused. A risk-focused diagnosis is applied when the risk factors of the patient require intervention from the nurse and the healthcare team before the real problem is developed. The risk-focused diagnosis includes the nurse’s clinical judgment when the risk factors are present and indicates that the problem is likely to develop unless the nurses intervene.
- Health promotion. A health promotion nursing diagnosis helps in improving the overall wellbeing of the patient, family, and the community. A health promotion diagnosis is a clinical judgment about the motivation of the patient.
- Syndrome-focused. A syndrome-focused diagnosis refers to the cluster of nursing diagnoses that occurs in a pattern that can be addressed by similar nursing interventions. A syndrome-focused diagnosis is written as a one-part statement that requires only the diagnostic label.
What is a Medical Diagnosis?
A medical diagnosis deals with and prioritizes the medical condition of a person. The medical diagnosis of findings made by a physician focuses on the physiologic state of the patient or the patient’s medical condition The diagnosis of a physician focuses on the illness which looks for the exact clinical entity that is possible to be the cause of the illness. A medical diagnosis helps in giving the proper medication that would cure the patient’s illness.
A doctor that uses the medical diagnosis will come up with a diagnosis that will treat the medical problem. A medical diagnosis identifies the illness of a patient through his or her symptoms and signs that are seen through observation. This diagnosis also includes performing a lot of procedures that involve tests, scans, and a patient’s medical history which is performed to know the brief history of the patient’s illness. A medical diagnosis is a complex medical step that involves patient history, personal exams, and testing.
Medical history does not change even if the condition of the patient is resolved, and it remains a part of the patient’s history forever. A diagnosis can be challenging for physicians because many signs and symptoms are nonspecific. In some cases, multiple diagnoses can be completed by varying doctors. This will allow the physician to be more comprehensive in understanding the patient’s ailments.
The process of an effective and complete medical diagnosis of a patient includes:
- Gathering the information. This process of a medical diagnosis involves reviewing the patient’s medical history, population health, notating the primary complaint of the patient, physical examination, and the observation period.
- Integrating the information. This process involves combining the information that is learned from the patient’s medical history with the data obtained from technological diagnostic testing.
- Determining a working diagnosis. This final step in making a medical diagnosis applies the integrated medical knowledge about the actual symptoms and potential threats.
Types of medical diagnosis include:
- Provisional. A medical diagnosis that is based on a physical exam and patient’s clinical; findings.
- Histopathological. A medical diagnosis that is done by a pathologist after examining sample tissue under a microscope
- Final. A medical diagnosis is done based on the provisional diagnosis and investigations.
The following information should be gathered as a part of the medical diagnosis:
- Clinical History. The clinical history includes the information from the patient, relatives, and the charted medical history of the patient. Health care providers use an electronic medical record system that provides an in-depth history of the patient’s illness and response to the previous treatment.
- Results of Physical Examinations. The results of the physical examinations allow the medical professional or the physician to visually note the signs and symptoms and confirm patient claims.
- Results of Diagnostic Testing. The result of the diagnostic testing involves studying data through technologically advanced medical diagnosis equipment. Diagnostic testing includes physical, laboratory, and clinical information. This will allow a comprehensive review and analysis of the patient’s condition and corresponding treatments.
- Laboratory results. The patient’s laboratory results are needed for the overall medical diagnosis. Laboratory results need a complete understanding of the patient’s physical health and limitations. Laboratory results can also be used as conclusive data in many cases and can also be used to rule out conditions.
- Medical Imaging. Medical imaging also known as radiology is used to diagnose a variety of symptoms and conditions including tumors, bone density, and brain diseases.
What are the differences between a nursing diagnosis and a medical diagnosis?
1. Focus. A nursing diagnosis focuses more on patient care while a medical diagnosis focuses more on the etiology of the patient’s condition.
2. Meaning. In a nursing diagnosis, the process of identification of the possibilities of the risk and the medical problem assessment is done by the nurse, while in a medical diagnosis there is a process of identification of a clear medical entity that causes the patient’s illness.
3. Identification. A nursing diagnosis identifies the patient’s present signs and symptoms, while the medical diagnosis identifies the pathology which causes the patient’s illness.
4. Main feature. A nursing diagnosis helps to focus on the patient’s physical and psychological reactions, while the medical diagnosis helps to focus on the patient’s actual illness.
A diagnosis of a patient related to a heart attack, such as Decreased Cardiac Output, is an example of a nursing diagnosis, while a diagnosis related to infarction, such as Myocardial Infarction is an example of a medical diagnosis.
The nursing diagnosis applies an appropriate meaning to the collected data that will provide evidence to it. For instance, during a nursing assessment, the nurse recognizes that the patient is feeling anxious, fearful, and has difficulty sleeping.
Those present problems can be turned into nursing diagnoses, such as: Anxiety, Fear, and Disturbed Sleep Pattern.
On the other hand, the medical diagnosis that is made by a physician or advanced health care practitioner deals more with the disease, medical condition, and pathological state that only the practitioner can treat.
Examples of medical diagnoses are diabetes mellitus, tuberculosis, amputation, hepatitis, and chronic kidney disease. The nurse should follow the physician’s order based on these medical diagnoses, and carry out the physician’s prescribed treatment and therapies.
Both nursing and medical diagnosis are two terms in medical science that appear from the same subject and roots.
Even though this diagnosis comes from the same root, they have vast differences. The difference between nursing and medical diagnosis lies in their features and characters.
A medical practitioner, whether a nurse or a doctor, should be well-fledged and should have adequate knowledge of different terms. The nurse and the doctor should be efficient in the treatment and the identification of the health of a patient.
The patient makes the medical diagnosis that will come up with a diagnosis that focuses on the patient’s medical problem, while the diagnosis made by the nurses focuses on the care of the patient behind his or her illness.
A nursing diagnosis includes the patient’s mental, spiritual, psychosocial, and physical condition. It focuses on the patient’s overall care of the patient while the medical diagnosis involves the patient’s medical aspects to the condition.
Collaborative problems can be resolved or determined through both nursing and medical interventions. The patient’s conditions and problems medical and nursing interventions, with the nurse aspect, focused on the monitoring of the patient’s condition and help in the prevention of potential complications.
Examples of a Nursing Diagnosis
- Dysfunctional Ventilator Weaning Response
- Impaired Transferability
- Activity Intolerance
- Risk For Disturbed Sleeping Pattern
- Impaired Emancipated Decision-Making
- Risk For Impaired Skin Integrity
- Risk For Metabolic Imbalance Syndrome
- Urge Urinary Incontinence
- Risk For Unstable Blood Pressure
- Risk Of Bleeding
- Risk For Autonomic Dysreflexia
- Impaired Skin Integrity
- Impaired Verbal Communication
- Acute Confusion
- Acute Pain
- Disturbed Body Image
- Relocation Stress Syndrome
- Ineffective Role Performance
- Ineffective Breathing Pattern
- Readiness For Enhanced Sleep
- Excessive Fluid Volume
- Risk For Infection
- Risk For Injury
- Deficient Knowledge
- Ineffective Airway Clearance
- Risk For Impaired Body Temperature
- Hypothermia
- Hyperthermia
- Risk For Nutritional Excess
- Ineffective Thermoregulation
- Altered Urinary Elimination
- Decreased Tissue Perfusion
- Fluid Volume Deficit
- Decreased Cardiac Output
- Risk Of Choking
- Risk Of Trauma
- Sexual Dysfunction
- Anxiety
- Fatigue
- Disturbance Of Growth And Development
- Disturbance Of Body Image
- Chronic Pain
- Fear
- Syndrome Of Misinterpretation Of The Environment
- Acute Confusion
- Feelings Of Powerlessness
- Loss Of Hope
- Altered Sensory Perception
- Disturbance Of Personality Identity
- Disruption Of Situational Self-Esteem
- Disturbance Of Chronic Self-Esteem
- Risk Of Injury In Perioperative
- Risk For Neuromuscular Dysfunction
- Non-Observance
- Ineffective Coping Strategies Of A Community
- Denial
- Inability To Adapt To A Change
- Spiritual Distress
- Failure In The Performance Of The Caregiver Role
- Risk Of Loneliness
- Disturbance In The Exercise Of Parenting
- Decreased Intracranial Adaptive Capacity
- Alteration Of Protective Mechanisms
- Risk For Impaired Liver Function
- Urinary Retention
- Self-Care Deficit
Examples of a Medical Diagnosis
The following are the 5 most common medical diagnoses:
- Alzheimer’s disease. Alzheimer’s disease is the most common form of dementia which severely impair the patient’s day-to-day function.
- Arrhythmia. Arrhythmia or irregular heartbeat is a condition when a person’s heart is unable to pump blood efficiently.
- Arthritis. Arthritis is the inflammation of the person’s muscles and joints.
- Chronic Kidney Disease. Chronic kidney disease is the condition in which the person’s kidneys do not filter waste from the blood which leads to the accumulation of waste in the body.
- Diabetes. Diabetes is a situation in which the person’s body cannot utilize insulin efficiently and fails to regulate the blood sugar levels of a person.
Conclusion
It is important to understand where a diagnosis is more focused to help the patient and the family, whether it is a nursing diagnosis or a medical diagnosis.
Understanding each type of diagnosis will help to fully comprehend how a medical diagnosis will be able to complement the nursing diagnosis, and vice versa.
A nursing diagnosis recognizes the important risk and the needs of the patient. The nurse may be in different types of settings where a nursing diagnosis is warranted, such as the clinical setting, which will be within the hospital, or the home / community setting, where the patient is discharged.
In writing a nursing diagnosis, the nurse will describe the individual’s health status and the factors that will contribute to the status.
A medical diagnosis is specific to the pathology of the patient’s illness. The physician will come up with a medical diagnosis to treat the patient’s medical problem, while the nursing diagnosis made by the nurse will focus on the care for the patient behind his or her illness. A complete and effective diagnosis must be accurate and timely.
Both nursing diagnosis and medical diagnosis have strengths and weaknesses that will help to improve the effectiveness and success of treatment to avoid long-term complications.
Each process involves identifying a condition, seeking causes, and making a prognosis and treatment that will be helpful for the patient’s condition.
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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The medical information on this site is provided as an information resource only and should not be used or relied on for diagnostic or treatment purposes.
This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.
