Nursing diagnosis is a reflection of the patient's condition
The middle and junior medical staff, along with the doctors involved in the treatment of the patient. This category of employees is responsible for the life and health of the patient, since it depends on them how quickly the person will recover. Therefore, nurses in the process of care for the patient write a kind of medical history, where they display their diagnoses.
Definition and history of
Nursing diagnosis is a characteristic of a patient's health collected in the course of a nursing survey and requires active intervention from nurses. It represents a syndrome or symptom diagnosis, which is based on the patient's complaints.
This concept first appeared in the United States of America in the middle of the last century. Officially it was accepted and introduced at the legislative level only in 1973.For nurses there are directories in which all possible diagnoses are listed. The sister must justify her point of view in relation to each particular patient.
Stages of the nursing process
The definition of nursing diagnosis is part of a large process. Carrying out all of its stages helps patients recover more quickly and relieves the doctor of some burdensome duties.
- The first stage is a survey. The nurse collects and documents the patient's data. For this, confidential contact must be established between the medical staff and the patient.
- The second stage is the diagnosis. The sister determines the patient's existing problems in order to solve them due to their competence. In addition, there are still potential problems that may arise in the near future.
- The third stage is planning. This is the preparation of an action plan to facilitate the patient's condition.
- The fourth stage is the implementation of a plan for the care of a specific patient. There are three categories of nursing intervention( independent, interdependent and dependent), and in each individual case, the nurse must decide what to choose to help the person recover. The fifth stage is the evaluation of the work. It includes the patient's response to the work done, the achievement of the objectives of paragraph 3 and the quality of care provided.
The patient's problem and the sister problem
A nurse must be able to formulate a sister diagnosis. This is an indicator of her solvency as a health worker. But besides this, according to the plan given above, it should highlight the patient's problems and solve them.
The patient's problems are the subjective reaction of a sick person to their illness. It may not be related to the amount of damage done to health. It all depends on the patient's priorities.
The sister problem is a "dry residue", a conclusion from the information that the sister received from the patient. The more clearly and simply the problem is formulated, the clearer the path to its solution.
Determining the needs of the patient
The nurse must remember that at the heart of any problem is the dissatisfaction of one or more needs. The sisters' problem appears at a time when the patient is unable to cope with the amount of daily work, and this affects his health.
A natural reaction to this state of affairs is anger, resentment and despair. The patient thinks that he has now become a cripple, once for some time and not through his own fault is not capable of taking care of himself. In this case, the nurse must arrange care for the patient so that he does not feel weak. Here the psychological side of the issue is important, as it has long been known that the emotional state strongly affects the speed of recovery and the effectiveness of treatment.
Nursing and Medical Diagnosis
These concepts should be shared. Nursing diagnosis is a description of the patient's external reaction to the pathological process that develops in his body. It is based on disharmony in meeting their needs due to illness. This diagnosis often varies depending on the physical and mental state of the patient. In addition, his wording should be within the competence of the nurse.
A medical diagnosis is the name of a pathological process that reflects its localization, severity and cause of occurrence. It is based on a violation of the function of the organ or system due to pathophysiological or pathologoanatomical reasons. As a rule, after the final diagnosis is made, it does not change, and its formulation always corresponds to the international classification of diseases.
Classification of nursing diagnoses
These groups are not too extensive, but are basic. Nursing diagnosis determines the patient's reaction to their disease. On this basis, the following categories of nursing problems are distinguished:
- psychological( social).
Physical problems include eating disorders, reducing immunity, feeling pain, swelling, or, conversely, dehydration, shortness of breath, attacks of suffocation, hemoptysis. And this is only a small part of what can happen to the patient. Physical problems also include disorders of the digestive tract and urinary system, scabies, impaired hygiene and lack of self-control. But all of the above issues, one way or another, can be solved with the use of care or medication.
Psychological and spiritual problems, unfortunately, are not so easy to eliminate. They include a low level of knowledge about their illness, fear and anxiety for their lives, lack of communication and support, distrust of medical workers, refusal of treatment and others. Sometimes, in order to solve these problems, the nurse has to get used to the role of a psychologist, nurse or girlfriend for the patient. It is necessary that he relax and feel comfortable.
Priorities and criteria for their selection
It is necessary to highlight the main priorities before exposing a nursing diagnosis. These are the primary and most important problems for the patient. Such a ranking is necessary in order to establish the order of nursing manipulations and draw up a plan for their implementation, as well as the appropriateness and degree of intervention.
Criteria for selecting priorities are:
1. Any emergency conditions( risk of bleeding, myocardial infarction, cardiac arrest).
2. Manifestations, which at the moment are the most painful for the patient.
3. Presence of problems which in the near future can lead to complications.
4. Problems, the solution of which will help solve some other difficulties.
Examples of nursing diagnoses
A nursing diagnosis usually does not take much time. An experienced nurse can, after several minutes of communication with the patient, place emphasis on his problems and plan an action plan. It does not need to formulate and record a diagnosis for this. But young nurses should make records about the condition of each patient in a special magazine, note that the plan has already been realized, and what points need to be adjusted in view of the changed state of the patient. In the "Diagnosis" column, the nurse can write down the following:
- high blood pressure;
- general weakness;
- decreased emotional background, stress;
- urinary incontinence;
- need for moral support, etc.
Thus, the sister diagnosis is of considerable importance in a favorable prognosis for recovery.