Nursing diagnosis genitourinary discomfort, and sleep

pattern disturbance.
A nursing diagnosis is a standardized statement
about the health of a client (who can be an
individual, a family, or a community) for the
purpose of providing nursing care. Nursing
diagnoses are developed based on data obtained
during the nursing assessment.
The main organization for defining standard
diagnoses in North America is the North American
Nursing Diagnosis Association, now known as
NANDA-International. Other international
associations are AENTDE (Spanish), AFEDI (French
language) and ACENDIO (Europe).
Nursing diagnoses are part of a movement in
nursing to standardize the terminology involved.
This includes standard descriptions of diagnoses,
interventions and outcomes. Nurses who support
standardized terminology believe that it will help
nursing become more scientific and evidence-
based. Other nurses feel that nursing diagnoses
are an ivory tower mentality and neither help in
care planning nor in differentiating nursing from
medicine.[1]
Structure of diagnoses
5. Wellness diagnosis - describes an
aspect of the client that is at a low level of
wellness. An example of a wellness
diagnosis is: Readiness for enhanced
organized infant behaviour related to
prematurity as manifested by appropriate
response to visual and auditory stimuli.
Process of diagnoses
1. Collect data - statistical data relevant to
achieving a diagnosis.
2. Cues/patterns - changes in physical
status. (for example: lower urinary output)
3. Hypothesis - possible alternatives that
could have caused previous cues/patterns.
4. Validation - taking necessary steps to
rule out other hypothesis, to single out
one problem.
5. Diagnosis - making a decision on the
problem based on validation.
6. Strategies - taking necessary action to
solve the problem and/or to provide
adequate nursing care.

The NANDA-International system of nursing Abbrevia

Medical Term
diagnosis provides for five categories. tion
a.a. Amino Acids
1. Actual diagnosis - a statement about a
health problem that the client has and the AB Abortion
benefit from nursing care. An example of ab Abdomen or Abdominal
an actual nursing diagnosis is: Ineffective
airway clearance related to decreased AD Alzheimer's Disease
energy as manifested by adventitious lung
sound auscultation. ADD Attention Deficit Disorder
2. Risk diagnosis - a statement about ADHD Attention Deficit Hyperactivity Disorder
health problems that a client doesn't have
yet, but is at a higher than normal risk of AE Hyperkalemia
developing in the near future. An example
AED Automated External Defibrillator
of a risk diagnosis is: Risk for injury
related to altered mobility and AF Amniotic Fluid
disorientation.
AI Artificial Insemination
3. Possible diagnosis - a statement about
a health problem that the client might AIDS Acquired Immune Deficiency Syndrome
have now, but the nurse doesn't yet have
enough information to make an actual Alc Alcohol
diagnosis. An example of a possible
ALL Acute Lymphoblastic Leukemia
diagnosis is: Possible fluid volume deficit
related to frequent vomiting for three AMS Acute Mountain Sickness
days as manifested by increased pulse
rate. ARF Acute Renal Failure
4. Syndrome diagnosis - used when a ASD Autism Spectrum Disorder
cluster of nursing diagnoses are seen
together. An example of a syndrome BAC Blood Alcohol Content
diagnosis is: Rape-trauma syndrome
BCAA Brached Chain Amino Acid
related to anxiety about potential health
problems as manifested by anger,
BCP Birth Control Pill DUB Dysfunctional Uterine Bleeding
BD Bipolar Disorder DVT Deep Vein Thrombosis
BDD Body Dysmorphic Disorder dz Disease
BE Barium Enema EAA Essential Amino Acids
BM Bone Marrow ECT Electroconvulsive Therapy
BMI Body Mass Index ED Erectile Dysfunction
BMR Basal Metabolic Rate EFAD Essential Fatty Acid Deficiency
BMT Bone Marrow Transplant EI Emotional Intelligence
BP Blood Pressure EMR Electronic Medical Record
BPD Borderline Personality Disorder ESWL Extracorporeal Shock Wave Lithotripsy
BPH Benign Prostatic Hyperplasia ETOH Ethanol
BSL Blood Sugar Level FBS Fasting Blood Sugar
CA Cancer FFA Free Fatty Acids
Ca Calcium Flu Influenza
CAPD Central Auditory Processing Disorder Fx Fracture
CV Cardiovascular GAD Generalized Anxiety Disorder
CFS Chronic Fatigue Syndrome GB Gallbladder
CHF Congestive Heart Failure GC Gonorrhea
CHO Carbohydrate GERD Gastroesophageal Reflux Disease
Chol Cholesterol GH Growth Hormone
CKD Chronic Kidney Disease GI Glycemic Index
COPD Chronic Obstructive Pulmonary Disease GN Glomerulonephritis (Nephritis)
CPT Current Procedural Terminology GTT Glucose Tolerance Test
CPR Cardiopulmonary Resuscitation GU Gastric Ulcer
CRF Chronic Renal Failure HA, H/A Headache
CTS Carpal Tunnel Syndrome HACE High Altitude Cerebral Edema
DBT Dialectical Behavioral Therapy HAPE High Altitude Pulmonary Edema
Detox Detoxification HAV Hepatitis A Virus
DHEA Dehydroepiandrosterone HBP High Blood Pressure
DI Diabetes Insipidus HBV Hepatitis B Virus
DID Dissociative Identity Disorder HCC Hepatocellular Carcinoma
DJD Degenerative Joint Disease HCV Hepatitis C Virus
DKA Diabetic Ketoacidosis Hgb Hemoglobin
DM Diabetes Mellitus HGH Human Growth Hormone
DMD Duchenne Muscular Dystrophy HH Hiatus Hernia
DNA Deoxyribonucleic Acid HIV Human Immunodeficiency Virus
DSM Diagnostic and Statistical Manual HONK Hyperosmolar Nonketotic Coma
DU Duodenal Ulcer HR Heart Rate
HRT Hormone Replacement Therapy NLP Neuro-Linguistic Programming
HSV Herpes Simplex Virus Normal Spontaneous Delivery (Natural
NSD
Childbirth)
HTN Hypertension
O2 Oxygen
H&M Hematemesis and Melena
OA Osteoarthritis
IBC Inflammatory Breast Cancer
OCD Obsessive Compulsive Disorder
IBS Irritable Bowel Syndrome
OCP Oral Contraceptive Pill
ID Infectious Disease
Obsessive Compulsive Personality
IDA Iron Deficiency Anemia OCPD
Disorder
IDDM Insulin Dependent Diabetes Mellitus OPV Oral Polio Vaccine
IMN Infectious Mononucleosis OS Orthopedic Surgery
IMS Irritable Male Syndrome OSA Obstructive Sleep Apnea
IOL Induction Of Labor Osteo Osteomyelitis
IPPB Intermittent Positive Pressure Breathing OTC Over-the-counter Drug
IQ Intelligence Quotient PAD Peripheral Artery Disease
IUD Intrauterine Device Pap Papanicolaou Test (Pap Smear)
JIA Juvenile Idiopathic Arthritis PCa Prostate Cancer
L Leukocytes (White Blood Cells) PCO Polycystic Ovary
LASIK Laser-Assisted In-Situ Keratomileusis PCOS Polycystic Ovarian Syndrome
LBP Low Back Pain PCR Patient Care Report
L&D Labor and Delivery (Childbirth) PD Parkinson's Disease
LFT Liver Function Test PDD Pervasive Developmental Disorder
LN Lymph Node PKD Polycystic Kidney Disease
LP Lumbar Puncture (Spinal Tap) PMS Premenstrual Syndrome
Major Depressive Disorder (Clinical PP Postpartum
MDD
Depression)
Preme Premature Baby
Mg Magnesium
PTA Peritonsillar Abscess
MI Myocardial Infarction (Heart Attack)
PTSD Post-traumatic Stress Disorder
MMR Measles, Mumps, Rubella
PUD Peptic Ulcer Disease
Infectious Mononucleosis (Glandular
Mono
Fever) RA Rheumatoid Arthritis
Methicillin-resistant Staphylococcus RAD Reactive Attachment Disorder
MRSA
Aureus
RBC Red Blood Cells
MS Multiple Sclerosis
RD Retinal Detachment
MSM Methylsulfonylmethane
REM Rapid Eye Movement
MVC Motor Vehicle Crash
RF Rheumatic Fever
NBN Newborn Baby Nursery
RLS Restless Legs Syndrome
Non-Insulin Dependent Diabetes
NIDDM Rx Prescription Drug
Mellitus
NKA No Known Allergies SAB Spontaneous Abortion (Miscarriage)
SAH Subarachnoid Hemorrhage
SARS Severe Acute Respiratory Syndrome
Scope Microscope or Endoscope
SI Sacroiliacal (Sacroiliac Joints)
SIDS Sudden Infant Death Syndrome
SLE Systemic Lupus Erythematosus
SMA Spinal Muscular Atrophy
SOB Shortness of Breath (Dyspnea)
SS Sickle-cell disease (anemia)
STD Sexually Transmitted Disease
STI Sexually Transmitted Infection
Surgical Termination Of Pregnancy
STOP
(Abortion)
Strep Streptococcus
STS Serological Test for Syphilis
SVT Supraventricular Tachycardia
Sz Seizure
TB Tuberculosis
TBI Traumatic Brain Injury
TG Triglycerides
TKR Total Knee Replacement
TMJ Temporomandibular Joint
Tu Tumor
UC Umbilical Cord
UTI Urinary Tract Infection
VV Varicose Veins
WBC White Blood Cell, White Blood Cell Count
W/C Wheelchair
WS Williams Syndrome
wt Weight
XRT Radiation Therapy
YF Yellow Fever