Understanding Nursing Diagnosis: Definitions, Classifications, and Care
Understanding Nursing Diagnosis
It’s crucial to understand the specific benefits of a diagnostic taxonomy in various professional fields such as research, teaching, and patient care. Nursing diagnostics, like those used in clinical trials, help assess an individual’s, family’s, or community’s response to potential health and life process problems.
Nursing Diagnosis Classifications
Nursing diagnosis classifications include definitions, risk factors, and self-care characteristics. For example, deficit evacuation is a state where a person cannot perform or complete basic elimination activities. Factors contributing to this may include impaired transfer ability, mobility disturbances, and activity intolerance.
CIPE and CIE: Standardizing Nursing Language
CIPE (International Classification for Nursing Practice) and CIE (International Council of Nurses) aim to establish a common language to improve communication. Key features include nursing diagnoses, nursing actions, and performance indicators. The goal is to:
- Describe nursing care for population immunity in various institutional and non-institutional contexts.
- Enable data comparison in clinical settings across populations, geographical areas, and time.
- Demonstrate or project trends in nursing care performance and resource allocation based on diagnoses.
Types of Nursing Diagnoses
Nursing diagnoses can be categorized as:
- Real: Refers to a situation that currently exists.
- Potential: Refers to a situation that may cause difficulties in the future.
Nursing functions are 3-dimensional: dependent, interdependent, and independent.
The Diagnostic Phase: Key Steps
The steps in the diagnostic phase include:
- Data Analysis: Analyzing significant data.
- Synthesis: Confirming or eliminating alternative hypotheses.
- Formulation: Defining nursing diagnosis problems and interrelated issues.
Real vs. Potential Diagnoses
A real diagnosis represents a clinically validated state with major defining characteristics. The statement includes etiology, signs, and symptoms. These elements validate the diagnosis according to NANDA (North American Nursing Diagnosis Association) standards, including the label, definition, defining characteristics, and related factors (causes).
Wellness and High-Risk Diagnoses
- Wellness Diagnosis: Concerns a person, group, or community transitioning from a specific level of wellness to a higher one, such as desiring community health education.
- High-Risk Diagnosis: Indicates that an individual, family, or community is more vulnerable to a problem than others in similar situations. It often includes potential problems preceded by etiology or risk factors.
- Suspected Diagnosis: Describes a problem needing additional data for confirmation or exclusion.
Nursing Theories: Guiding Principles
To develop a nursing diagnosis, consider theories such as:
- Florence Nightingale’s Environmental Theory
- Virginia Henderson’s Need Theory
Virginia Henderson’s 14 Basic Needs
Virginia Henderson identified 14 basic needs:
Physiological Needs:
- Breathe normally.
- Eat and drink adequately.
- Eliminate body waste.
- Move and maintain posture.
- Rest and sleep.
- Select suitable clothing.
- Maintain body temperature.
Safety and Security Needs:
- Maintain personal hygiene.
- Avoid environmental hazards.
Esteem Needs:
- Communicate emotions, needs, fears, and opinions.
Belonging Needs:
- Live according to beliefs.
Self-Actualization Needs:
- Work to feel accomplished.
- Participate in recreation and leisure.
- Explore, discover, and satisfy curiosity for health development.