The concept of "nursing diagnosis" was first used by physicians in the United States of America in the mid-1950s. It was only in 1973 that it was officially enshrined at the legislative level. The reason was that the nursing staff is involved in the treatment of patients along with doctors. At the same time, nurses are responsible for carrying out all medical manipulations and procedures prescribed by the doctor.
Determining nursing diagnosis
An important part of a nurse's job is identifying and classifying a patient's problems. Conventionally, they can be divided into those that exist in real life and those that do not yet exist, but they may appear in the near future. Existing problems disturb the patient in the present, so they need to be addressed urgently. Preventive action by clinic staff is required to prevent potential problems.
Nursing diagnosis is an analysis of the patient's real and possible problems and a conclusion about the state of his he alth, made by a nurse and formulated in accordance with accepted standards. According to the diagnosis made by the nurse, a decision is made on the further intervention of the nursing staff in the process of treating the patient.
Relationship between nursing process and nursing diagnosis
The nursing process is a thoughtful plan of action to identify the needs of the patient. It consists of several stages, the first of which is the determination of the general condition of the patient. At this stage, the nurse performs a physical examination, including measurement of blood pressure, body temperature, weight, and other procedures. A trusting relationship is established with the patient to identify psychological problems.
The second step is to identify existing and potential problems preventing 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 patient's condition are determined. The fourth stage is the implementation of the drawn up plan and provides for the implementation of all planned actions. At the fifth stage, the effectiveness of nursing intervention is determined, taking into account the opinion of the patient and his family members, if necessary.patient care plan is being adjusted.
Research on patient needs
There is a definite relationship between patient problems and nursing diagnosis. Before placing 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 stay in the clinic, physical condition (impaired swallowing, urinary incontinence, lack of independence), psychological or spiritual discomfort, personal circumstances.
After studying the needs of the patient and guided by the standards of nursing practice, the nurse draws up a plan for caring for a specific patient, indicating the motivation for her actions.
Classification of patient problems
When establishing a nursing diagnosis in a patient, a number of problems are simultaneously revealed, consisting of two groups: existing in reality and potential ones that may arise if measures are not taken to treat the disease. Among the existing problems, first of all, priority ones are distinguished, 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 risks associated with pressure ulcers in bedridden patients, side effects caused by medication, hemorrhage due to ruptured aneurysmblood vessels, dehydration of the body with vomiting or loose stools, and others. Once priority issues have been identified, nursing intervention planning and implementation begins.
Implementation of the nursing plan
The main goal of nursing diagnosis is to alleviate the suffering of the patient and create the maximum comfort that a nurse can provide in the process of treatment. Nursing intervention in the treatment process is divided into three categories:
- independent activities imply the performance of actions related to professional skills and not requiring the consent of the doctor (teaching the patient the rules of self-care, recommendations to relatives on patient care, etc.);
- dependent activities involve the implementation of procedures prescribed by a doctor (injections, preparation for a diagnostic examination);
- interdependent activities are the cooperation of a nurse with a doctor and relatives of the patient.
All actions performed are recorded in the relevant documentation, according to which nursing activities are subsequently assessed.
Differences between medical and nursing diagnoses
The classification of diagnoses made by a nurse includes 114 items. There are significant differences between medical and nursing diagnosis. If the first establishes the disease on the basis of the existing symptoms and the results of a diagnostic examination in accordance with the international classification of diseases, then in the second casethe physical and psycho-emotional state of the patient and his reaction to the disease are determined. After that, an exit plan is drawn up that is acceptable to both parties.
The doctor's diagnosis remains unchanged during the entire period of treatment, and the nursing one can change daily depending on the patient's well-being. Treatment prescribed by a doctor is carried out within the framework of accepted medical practice, while nursing intervention is carried out within the competence of a nurse.
Effectiveness of nursing care
At the final stage, the effectiveness of nursing care provided to the patient in the course of treatment is evaluated. 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 about the conduct of the nursing process is noted daily by the nurse in the observation chart. The documentation notes the patient's reaction to care and treatment procedures, identifies problems that need to be addressed.
When the goal of treatment is achieved, a corresponding mark is made in the map. If the goal is not achieved and the patient needs further care, the reasons that caused the deterioration of the condition are indicated and the plan is adjusted accordingly. To do this, new patient problems are searched for and emerging care needs are identified.
Examples of Nursing Diagnosis
In an individual observation chart, the patient's words describe existing problems and complaints. This is the subjective opinion of the patient abouttreatment, 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 are entries:
- nausea and vomiting due to intoxication of the body;
- chest pain that appeared 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 for the adjustment of the prescribed treatment and contributes to the speedy recovery of the patient.
