Evaluation of Admission Nursing Diagnoses

Despite the interest and research in nursing diagnosis, few studies have examined the incidence and quality of the diagnoses. Specifically, a lack of knowledge exists regarding what nursing diagnoses are formulated on a patient's admission to the hospital. Data from the charts of 33 adult orthopedic patients were evaluated for the type, frequency, and quality of admission nursing diagnoses. Of the 106 nursing diagnoses written, approximately two-thirds were on the accepted list of the North American Nursing Diagnosis Association (NANDA) at the time of the study (1988). Alteration in comfort was the most prevalent diagnostic label. The quality of the diagnoses was evaluated using Ziegler's (1984) tool. Only one diagnosis, potential alteration in skin integrity related to bedrest, met all 12 criteria. Nurses showed more difficulty in correctly identifying the etiology component than the response component of the diagnostic statement. Factors that affect the quality of nursing diagnoses and the need for tool refinement are discussed, and research recommendations are made.