For the first time the concept of "nursing diagnosis" was used by doctors in the United States of America in the mid-50s of the last century. Only in 1973 it was officially fixed at the legislative level. The reason was that the nursing staff is involved in treating patients along with doctors. In this case, the nurses are responsible for all medical procedures and procedures prescribed by the doctor.
Definition of a nursing diagnosis
An important part of the work of a nurse is the identification and classification of problems the patient has. Conventionally, they can be divided into existing in real life and those that are not yet, but they may arise in the near future. Existing problems bother the patient in the present tense, so they need to be addressed urgently. To prevent potential problems, preventive measures are required from the clinic staff.
Nursing diagnosis is an analysis of the patient’s real and possible problems and a conclusion about his state of health made by a nurse and formulated in accordance with accepted standards. According to the diagnosis made by the sister, a decision is made on the further intervention of the nursing staff in the treatment of the patient.
The relationship of the nursing process and the nursing diagnosis
The nursing process is a thoughtful action plan to identify the needs of the patient. It consists of several stages, the first of which is to determine the general condition of the patient. At this stage, the nurse conducts a physical examination, including measuring blood pressure, body temperature, weight and other procedures. A trust relationship is established with the patient to identify psychological problems.
The second stage is to identify existing real and potential problems that impede recovery, and establish a nursing diagnosis. For this, primary priorities are identified that require an emergency decision within the competence of the nurse. At the third stage, a work plan for the nursing team is drawn up, the order, methods and methods of conducting medical measures to alleviate the condition of the patient are determined. The fourth stage is the implementation of the plan and provides for the implementation of all the planned actions. At the fifth stage, the effectiveness of nursing intervention is determined taking into account the views of the patient and his family members, if necessary, an adjustment of the patient care plan is carried out.
Examining Patient Needs
There is a definite connection between the patient’s problems and the nursing diagnosis. Before delivering it, the nurse must identify all the needs of the patient and formulate a clinical judgment about the patient's response to the disease. The reaction can be associated not only with the disease, but also with the conditions of the clinic, physical condition (violation of the swallowing process, urinary incontinence, lack of independence), psychological or spiritual discomfort, personal circumstances.
Having studied the patient's needs and guided by the standards of nursing practice, the nurse draws up a plan for the care of a particular patient with an indication of the motivation for her actions.
Classification of Patient Problems
When establishing a nursing diagnosis, the patient simultaneously identifies a number of problems, consisting of two groups: existing in reality and potential that may arise if measures are not taken to treat the disease. Among the existing problems, first of all, priority ones are identified, in which emergency care is needed, intermediate ones that do not pose a danger to life, and secondary ones that have nothing to do with the disease.
Potential complications include the risks associated with the formation of pressure sores in bedridden patients, side effects caused by taking medications, hemorrhage due to rupture of aneurysm of the vessels, dehydration of the body with vomiting or loose stool, and others. After identifying priority problems, they begin to plan and implement nursing intervention.
Nursing Plan Implementation
The main goal of the nursing diagnosis is to alleviate the suffering of the patient and create the maximum comfort that the nurse can provide during the treatment. Nursing intervention in the treatment process is divided into three categories:
- independent activities include the implementation of activities related to professional skills and not requiring coordination with a doctor (training the patient in self-care rules, recommendations for relatives to care for the sick, etc.);
- dependent measures involve the implementation of procedures prescribed by a doctor (injections, preparation for a diagnostic examination);
- interdependent activities - this is the collaboration of a nurse with a doctor and relatives of the patient.
All completed actions are recorded in the relevant documentation, which subsequently assesses nursing activities.
Differences between medical and nursing diagnoses
The classification of diagnoses made by a nurse includes 114 items. There are significant differences between the medical and nursing diagnosis. If the first establishes the disease on the basis of the symptoms and the results of the diagnostic examination in accordance with the international classification of diseases, then in the second case, the physical and psycho-emotional state of the patient and his response to the disease are determined. After that, a care plan is compiled that is acceptable to both parties.
The doctor’s diagnosis remains unchanged throughout the treatment period, and the nursing one can change daily depending on the patient’s well-being. The treatment prescribed by the doctor is carried out within the framework of generally accepted medical practice, while nursing intervention is performed within the competence of the nurse.
The effectiveness of nursing care
At the final stage, an assessment is made of the effectiveness of nursing care provided to the patient during treatment. The work of a nurse is evaluated daily based on the dominant problem from the day the patient enters the hospital until his discharge or death. All information on conducting the nursing process is daily noted by the nurse in the observation map. The documentation notes the patient’s reaction to care and treatment procedures, identifies problems that need attention.
Upon reaching the goal of treatment, a corresponding mark is made in the map. If the goal is not achieved and the patient needs further care, the reasons for the deterioration of the condition are indicated, and the plan is adjusted accordingly. To do this, a search for new problems of the patient is carried out and the arising needs for care are determined.
Examples of Nursing Diagnosis
In an individual observation map, the patient's words describe the problems and complaints. This is the subjective opinion of the patient about the treatment, it helps to better formulate goals and determine the time frame during which improvements are possible. Along with this, the nurse notes an objective assessment of his condition, indicating a nursing diagnosis, an example of which is the record:
- nausea and vomiting due to intoxication of the body;
- chest pains that appear on the background of a satisfactory condition;
- repeated vomiting after taking medication;
- high blood pressure due to stress;
- increased anxiety, fear.
There can be many such records, their analysis allows you to adjust the prescribed treatment and contributes to the speedy recovery of the patient.