Nursing staff along with doctors are involved in the treatment of the patient. This category of employees has a great responsibility 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 caring for the patient write a kind of medical history, where they put their diagnoses.
Definition and History
Nursing diagnosis is a characteristic of the patient’s health collected during the nursing examination and requires active intervention from the nursing staff. It presents a syndromic or symptomatic diagnosis that is based on patient complaints.
This concept first appeared in the United States in the middle of the last century. It was officially adopted and introduced at the legislative level only in 1973. There are directories for nurses that list all possible diagnoses. The sister must substantiate her point of view in relation to each specific patient.
Stages of the nursing process
Determining a nursing diagnosis is part of a large process. Performing all its stages helps patients recover faster and relieves the doctor of some burdensome duties.
- The first stage is an examination. A nurse collects and processes patient data. For this, trustful contact should be established between the medical staff and the patient.
- The second stage is the diagnosis. The sister determines the patient’s problems in order to solve them by virtue of her competence. In addition, there are still potential problems that may arise in the near future.
- The third stage is planning. This is a plan of action to alleviate the condition of the patient.
- The fourth stage is the implementation of a specific patient care plan. There are three categories of nursing intervention (independent, interdependent and dependent), and in each individual case, the nurse must decide which one to choose to help the person recover.
- The fifth stage is the assessment of work. It includes the patient’s reactions to the work done, achieving the goals of paragraph 3 and the quality of care provided.
Patient Problem and Nursing Problem
The nurse should be able to formulate a nursing diagnosis. This is an indicator of her solvency as a health worker. But besides this, according to the plan given above, she should highlight the problems of the patient and solve them.
Patient's problems are a subjective reaction of a sick person to his illness. It may not correlate with the amount of damage done to health. It all depends on the patient's priorities.
The nursing problem is a “dry residue”, a conclusion from the information that the sister received from the patient. The clearer and simpler the problem is formulated, the clearer the path to resolving it.
Determining Patient Needs
The nurse must remember that the foundation of any problem is the failure to meet one or more needs. The nursing problem appears at a time when the patient becomes unable to cope with the amount of daily work, and this affects his health.
The natural reaction to this state of affairs is anger, resentment and despair. The patient thinks that he has now become crippled, since for some time and through no fault of his own he is not able to take care of himself. In this case, the nurse should organize the care of the patient so that he does not feel weak. The psychological side of the issue is important here, since it has long been known that the emotional state greatly affects the speed of recovery and the effectiveness of treatment.
Nursing and medical diagnosis
These concepts should be separated. 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 one's needs due to illness. This diagnosis often changes depending on the physical and mental condition of the patient. In addition, its 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 an organ or system due to pathophysiological or pathoanatomical reasons. As a rule, after the final diagnosis is made, it no longer changes, and its wording 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 response to their disease. Based on this, the following categories of nursing problems are distinguished:
- physiological;
- psychological (social).
Physical problems include malnutrition, decreased immunity, a feeling of pain, swelling, or, conversely, dehydration, shortness of breath, asthma attacks, hemoptysis. And this is only a small fraction of what can happen to the patient. Physical problems also include disruption of the digestive tract and urinary system, scabies, hygiene and lack of self-care. But all of the above issues, one way or another, can be solved with the use of care or medicines.
Psychological and spiritual problems, unfortunately, are not so easily eliminated. These include a low level of knowledge about their disease, 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 relaxes and feels comfortable.
Priorities and criteria for their selection
It is necessary to highlight the main priorities before making a nursing diagnosis. These are the primary and most important problems for the patient. Such a ranking is necessary in order to establish the sequence of sisterly manipulations and draw up a plan for their implementation, as well as the appropriateness and degree of intervention.
Priority selection criteria are:
1. Any emergency conditions (risk of bleeding, myocardial infarction, cardiac arrest).
2. Manifestations that are currently the most painful for the patient.
3. The presence of problems that in the near future may lead to complications.
4. Problems whose solution will help to resolve some other difficulties.
Examples of nursing diagnoses
Making a nursing diagnosis usually does not take much time. An experienced nurse can, after several minutes of communication with the patient, put emphasis on his problems and think out an action plan. She does not need to formulate and write down a diagnosis for this. But young nurses should make notes about the condition of each patient in a special journal, note what has already been implemented from the plan, and what points need to be corrected due to the changed condition of the patient. In the column "Diagnosis" the nurse can write the following:
- high blood pressure;
- general weakness;
- decreased emotional background, stress;
- fear;
- vomiting
- urinary incontinence;
- the need for moral support, etc.
Thus, the nursing diagnosis is of considerable importance in a favorable prognosis for recovery.