Nursing diagnosis

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A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician's orders (e.g., medication administration). [1] Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response present at time of assessment. Risk diagnoses represent vulnerabilities to potential problems, and health promotion diagnoses identify areas which can be enhanced to improve health. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis identifies the unique ways in which individuals respond to health or life processes or crises. [2] The nursing diagnostic process is unique among others. A nursing diagnosis integrates patient involvement, when possible, throughout the process. [3] NANDA International (NANDA-I) is body of professionals that develops, researches and refines an official taxonomy of nursing diagnosis. [4]

Contents

All nurses must be familiar with the steps of the nursing process in order to gain the most efficiency from their positions. In order to correctly diagnose, the nurse must make quick and accurate inferences from patient data during assessment, based on knowledge of the nursing discipline and concepts of concern to nurses. [3]

NANDA International

NANDA International, Inc., [4] formerly known as the North American Nursing Diagnosis Association, is the primary organization for defining, researching, revising, distributing and integrating standardized nursing diagnoses worldwide. NANDA-I has worked in this area for more than 45 years to ensure that diagnoses are developed through a peer-reviewed process requiring standardised levels of evidence, definitions, defining characteristics, related factors or risk factors that enable nurses to identify potential diagnoses in the course of a nursing assessment. NANDA-I believes that it is critical that nurses are required to utilise standardised languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characteristics) and the related or etiologic factors upon which nurses intervene. NANDA-I terms are developed and refined for actual (current) health responses and for risk situations, as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities. The taxonomy is published in multiple countries and has been translated into 18 languages; it is in use worldwide. As research in the field of nursing continues to grow, NANDA-I continually develops and adds new diagnostic labels.

Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the electronic health record and can be linked to nurse-sensitive patient outcomes. [5] [6]

Global

The ICNP (International Classification for Nursing Practice) published by the International Council of Nurses has been accepted by the World Health Organization family of classifications. ICNP is a nursing language which can be used by nurses to diagnose. [7] [8] [9] [10]

Structure

The NANDA-I system of nursing diagnosis provides for four categories and each has 3 parts: diagnostic label or the human response, related factors or the cause of the response, and defining characteristics found in the selected patient are the signs/symptoms present that are supporting the diagnosis.

  1. Problem-focused diagnosis
    A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community. An example of an actual nursing diagnosis is: Sleep deprivation.
  2. Risk diagnosis
    Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability. An example of a risk diagnosis is: Risk for shock.
  3. Health promotion diagnosis
    A clinical judgment about a person's, family's or community's motivation and desire to increase wellbeing and actualise human health potential as expressed in the readiness to enhance specific health behaviours, and can be used in any health state. An example of a health promotion diagnosis is: Readiness for enhanced nutrition.
  4. Syndrome diagnosis
    A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions. An example of a syndrome diagnosis is: Relocation stress syndrome. [11]

Process

The diagnostic process requires a nurse to use critical thinking. In addition to knowing the nursing diagnoses and their definitions, the nurse becomes aware of defining characteristics and behaviors of the diagnoses, related factors to the diagnoses, and the interventions suited for treating the diagnoses. [12]

  1. Assessment
    The first step of the nursing process is assessment. During this phase, the nurse gathers information about a patient's psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient's health history, obtaining a patient's family history, and general observation can also be used to gather assessment data. Patient interaction is generally the heaviest during this evaluative stage.
  2. Diagnosis
    The diagnosing phase involves a nurse making an educated judgement about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These assessments not only include a description of the problem or illness (e.g. sleep deprivation) but also whether or not a patient is at risk of developing further problems. These diagnoses are also used to determine a patient's readiness for health improvement and whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment.
  3. Planning
    Once a patient and nurse agree of the diagnoses, a plan of action can be developed. If multiple diagnoses need to be addressed, the head nurse will prioritise each assessment and devote attention to severe symptoms and high risk patients. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. For this phase, nurses generally refer to the evidence-based Nursing Outcome Classification, which is a set of standardised terms and measurements for tracking patient wellness. The Nursing Interventions Classification may also be used as a resource for planning.
  4. Implementation
    The implementing phase is where the nurse follows through on the decided plan of action. This plan is specific to each patient and focuses on achievable outcomes. Actions involved in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for a follow-up. Implementation can take place over the course of hours, days, weeks, or even months.
  5. Evaluation
    Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine if the goals for patient wellness have been met. The possible patient outcomes are generally described under three terms: patient's condition improved, patient's condition stabilised, and patient's condition deteriorated. In the event where the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step. [13]

Examples

The following are nursing diagnoses arising from the nursing literature with varying degrees of authentication by ICNP or NANDA-I standards.

See also

Related Research Articles

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A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including:

Readiness for enhanced therapeutic regimen management is a NANDA approved nursing diagnosis which is defined as "A pattern of regulating and integrating into daily living a program(s) for treatment of illness and its sequelae that is sufficient for meeting health-related goals and can be strengthened." It was introduced at the 15th NANDA conference in 2002. Purpose: This book is devoted to a discussion of nursing diagnoses, outcomes, and interventions for older persons. As such, the diagnoses selected for the volume are not exhaustive, but represent a severely underdeveloped knowledge base. We have chosen diagnoses that are most prevalent, most difficult to treat, and/or most in need of further development to inform practicing nurses and nursing students and to improve the quality of life of older persons.

NANDA International is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses. In 2002, NANDA became NANDA International in response to the broadening scope of its membership. NANDA International published Nursing Diagnosis quarterly, which became the International Journal of Nursing Terminologies and Classifications, and then later was reconceptualized as the International Journal of Nursing Knowledge, which remains in print today. The Membership Network Groups foster collaboration among NANDA-I members in countries and for languages: the German Language Group and the Dutch Language Group.

<span class="mw-page-title-main">Nursing process</span>

The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. It should not be confused with nursing theories or health informatics. The diagnosis phase was added later.

Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. It differs from a medical diagnosis. In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or mental health. Nursing assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions. An assessment format may already be in place to be used at specific facilities and in specific circumstances.

A nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the veterinary profession. A care plan includes the following components: assessment, diagnosis, expected outcomes, interventions, rationale and evaluation.

In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. In medical classification, diagnosis codes are used as part of the clinical coding process alongside intervention codes. Both diagnosis and intervention codes are assigned by a health professional trained in medical classification such as a clinical coder or Health Information Manager.

<span class="mw-page-title-main">Nodule (medicine)</span> Solid, non-blisterform elevated areas in or under the skin

In medicine, nodules are small firm lumps, usually greater than 1 cm in diameter. If filled with fluid they are referred to as cysts. Smaller raised soft tissue bumps may be termed papules.

In medicine, a biomarker is a measurable indicator of the severity or presence of some disease state. It may be defined as a "cellular, biochemical or molecular alteration in cells, tissues or fluids that can be measured and evaluated to indicate normal biological processes, pathogenic processes, or pharmacological responses to a therapeutic intervention." More generally a biomarker is anything that can be used as an indicator of a particular disease state or some other physiological state of an organism. According to the WHO, the indicator may be chemical, physical, or biological in nature - and the measurement may be functional, physiological, biochemical, cellular, or molecular.

A clinical nurse specialist (CNS) is an advanced practice nurse who can provide advice related to specific conditions or treatment pathways. According to the International Council of Nurses (ICN), an Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice.

The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associated with the creation of a nursing care plan.

The Nursing Outcomes Classification (NOC) is a classification system which describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, and is HL7 registered.

Evidence-based nursing (EBN) is an approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic. This approach is using evidence-based practice (EBP) as a foundation. EBN implements the most up to date methods of providing care, which have been proven through appraisal of high quality studies and statistically significant research findings. The goal of EBN is to improve the health and safety of patients while also providing care in a cost-effective manner to improve the outcomes for both the patient and the healthcare system. EBN is a process founded on the collection, interpretation, appraisal, and integration of valid, clinically significant, and applicable research. The evidence used to change practice or make a clinical decision can be separated into seven levels of evidence that differ in type of study and level of quality. To properly implement EBN, the knowledge of the nurse, the patient's preferences, and multiple studies of evidence must all be collaborated and utilized in order to produce an appropriate solution to the task at hand. These skills are taught in modern nursing education and also as a part of professional training.

A psychiatric assessment, or psychological screening, is the process of gathering information about a person within a psychiatric service, with the purpose of making a diagnosis. The assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for various legal purposes. The assessment includes social and biographical information, direct observations, and data from specific psychological tests. It is typically carried out by a psychiatrist, but it can be a multi-disciplinary process involving nurses, psychologists, occupational therapist, social workers, and licensed professional counselors.

Ambulatory care nursing is the nursing care of patients who receive treatment on an outpatient basis, ie they do not require admission to a hospital for an overnight stay. Ambulatory care includes those clinical, organizational and professional activities engaged in by registered nurses with and for individuals, groups, and populations who seek assistance with improving health and/or seek care for health-related problems. The American Academy of Ambulatory Care Nursing (AAACN) describes ambulatory care nursing as a comprehensive practice which is built on a broad knowledge base of nursing and health sciences, and applies clinical expertise rooted in the nursing process.

<span class="mw-page-title-main">Medical diagnosis</span> Process to identify a disease or disorder

Medical diagnosis is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as a diagnosis with the medical context being implicit. The information required for a diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures, such as medical tests, are also done during the process. Sometimes the posthumous diagnosis is considered a kind of medical diagnosis.

The Omaha System is a standardized health care terminology consisting of an assessment component, a care plan/services component, and an evaluation component. Approximately 22,000 health care practitioners, educators, and researchers use Omaha System to improve clinical practice, structure documentation, and analyze secondary data. Omaha System users from Canada, China, The Czech Republic, Estonia, Hong Kong, Japan, Mexico, New Zealand, The Netherlands, Turkey, the United States, and Wales, have presented at Omaha System International Conferences.

The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings.

Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients.

References

  1. ↑ Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy M. (2013). Fundamentals of Nursing (8 ed.). St. Louis: Mosby. p. 223. ISBN   978-0-323-07933-4.
  2. ↑ NANDA International (professional association of nurses), Glossary of Terms.
  3. 1 2 3 4 5 6 7 Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy M. (2013). Fundamentals of Nursing (8 ed.). St. Louis: Mosby. p. 222. ISBN   978-0-323-07933-4.
  4. 1 2 "NANDA International" . Retrieved 2023-12-09.
  5. ↑ Brokel, J & C Heath (2009). The value of nursing diagnoses in electronic health records. In Herdman, TH (Ed.), Nursing diagnoses: definitions and classification 2009–2011. Wiley-Blackwell: Singapore
  6. ↑ Weir-Hughes, Dickon (2010). "Nursing Diagnosis in Administration". Nursing Diagnoses 2009–2011, Custom: Definitions and Classification. John Wiley & Sons. pp. 37–40. ISBN   978-1-4443-2727-4.
  7. ↑ Zarzycka, D; Górajek-Jóźwik, J (2004). "Nursing diagnosis with the ICNP in the teaching context". International Nursing Review. 51 (4): 240–49. doi:10.1111/j.1466-7657.2004.00249.x. PMID   15530164.
  8. ↑ Lunney, Margaret (2008). "The Need for International Nursing Diagnosis Research and a Theoretical Framework". International Journal of Nursing Terminologies and Classifications. 19 (1): 28–34. doi:10.1111/j.1744-618X.2007.00076.x. PMID   18331482.
  9. ↑ "Standardized Nursing Language: What Does It Mean for Nursing Practice?". www.nursingworld.org. Retrieved 2016-05-17.
  10. ↑ "FindArticles.com | CBSi". findarticles.com. Retrieved 2016-05-17.
  11. ↑ Herdman, TH (Ed.) (2009). Nursing diagnoses: definitions and classification 2009–2011. Wiley-Blackwell: Singapore.
  12. ↑ Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy M. (2013). Fundamentals of Nursing (8 ed.). St. Louis: Mosby. p. 224. ISBN   978-0-323-07933-4.
  13. ↑ "Nursing Process Steps". www.nursingprocess.org. Retrieved 2016-05-17.
  14. ↑ Fima, Odile; Langlassé, Armelle (1994). "Proposition d'un diagnostic infirmier: constipation colique chronique chez la personne âgée" [Proposition for nursing diagnosis. Chronic colonic constipation in the elderly]. Soins (in French) (584): 30–4. PMID   8029726. INIST   4073742.
  15. ↑ "American Nurses Association". www.nursingworld.org. Retrieved 2016-05-17.
  16. ↑ Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy M. (2013). Fundamentals of Nursing. St. Louis: Mosby. p. 2225edition=8. ISBN   978-0-323-07933-4.
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