The formulation of a diagnosis is the second
phase of nursing care (PAE). The nursing diagnosis refers to the
identification of the problem and to achieve this we must interpret the data
collected in the assessment.
"A nursing diagnosis is a" real
health problem or potential nurses, by virtue of their training and experience,
they have ability and legal right to try. "Nursing diagnoses are,
therefore, problems that can be prevented, resolved or reduced through
independent nursing activities. " Marjory
Gordon (1990)
There are many definitions that can be
found in various texts, trying to give a concrete answer on that is a nursing
diagnosis, but all are based on the identification of human responses to health
problems responses that nurses in the exercise of their profession, based on
their knowledge, experience and legal responsibility are trained to deal
independently.
"The nursing diagnosis is a clinical
judgment about individual, family or community that derives from a deliberate
process of systematic data collection and analysis. It provides the basis of the requirements for
definitive therapy, which the nurse is responsible. " (NANDA
1990)
Diagnoses are problems
that fall within the competence of nursing; are human responses that the
nurse can treat completely independently.
Evolution of Nursing Diagnoses
Although all authors agree that the meeting
was held in 1973 at the School of Nursing at the University of St Louis, as the
most important for the acceptance and use of Nursing Diagnoses milestone, the
two decades that preceded this meeting were marked by continued discussions and
attempts to approximate the profession of nursing diagnosis term.
It was in 1950 when Louise R. Mcnaus first
use of the term (nursing diagnosis) to discuss professional roles referring to
the identification of problems. Vera Fry in 1953 indicates the possibility
of formulating a nursing diagnosis after observing the patient five areas: 1.
Treatment and medication. 2. Personal hygiene. 3. Environmental
Needs. 4. 5. Guide and teaching human and personal needs. In 1,955
Lesnick and Anderson defined the area of ​​responsibility of the nurse can
be called in 1,960 Faye Abdellah proposed a management system to identify
clinical problems, this system was applied in some schools to provide students
identifying problems patients.
Many were professionals during the 60s
worked and researched on the use of being in the 70s when using the diagnostics
as a result of the First National Conference CLASSIFICATION Nursing Diagnoses
(1,973 consolidates - School of Nursing University of St. Louis, Missouri,
USA), held after the approval of the use of the term by the American Nurses
Association (ANA). The group of experts who met in 1973 later became know
today as the North American Association of DE (NANDA), result of work done by
NANDA have been published listings different diagnoses accepted in his
lectures.
At
present the main organization for the standardized definition of diagnoses
remains the N orth A merican N ursing D iagnosis A ssociation,
also known as NANDA-International. For nurses, the use of
NANDA taxonomy is essential in the practice of their profession.
Among the advantages of using Taxonomy, they
are:
- The use of a common language
- The implementation of PAE (Process Nursing Care) as a working method
- The dynamic participation within the various health teams
The structuring of our activity following a
scientific method, must represent for the Nursing Profession defining our own
area of ​​responsibility with increasing motivation and prestige of the
professionals themselves.
Steps to Issue a Nurse Diagnosis
- Ask the user what their main problem or
concern.
- Make a complete assessment or focused on
functional health patterns. Detected signals, patterns or changes in the
physical state (eg decreased urine output).
- Write a list with actual problems or risk
detected in the valuation. prioritized according to their importance in
health and patient opinion.
- Look for other signs and symptoms or
delve into the valuation to find more clues.
- Once found the main problem, I relate it
to one of those approved by the NANDA diagnoses. To do this, check that at
least one of the defining characteristics is met. Link the problem found
in a particular pattern, with the diagnosis NANDA also grouped into the same
patterns. So it will be easier.
- Determine the cause or etiology of the
problem (its related factor).
- Identify risk factors.
- Formulate the diagnosis.
PES format
Nursing diagnoses are set according to the PES format:
P = health
problem, which corresponds to the diagnostic
label
E = Etiology, which reflects the
causes that favor the development of the health problem.
S = Symptomatology, consisting of signs
and symptoms that appear as a result of the problem.
On this basis they generate different types
of diagnoses discussed below
Types of diagnosis and
formulation:
Nursing diagnoses are classified as real
risk, potential, and health diagnoses.
- Real
Diagnosis:
Describe the current response of a person,
a family or a community to a situation health / life process. It should be
formulated in three parts: problem + because + objective and subjective data. The
problem is attached to the cause by the formula (r / c) and
it joins the defining characteristics (objective and subjective data) by the
formula (m / w) , for example:
Health
problem + causes + symptoms:
Alteration of nutrition excess r / c
excessive consumption of carbohydrates fats and lack of exercise m / p 15kg
overweight.
- Risk Diagnosis: Describes
human responses to situations of health / life processes that can develop in
the near future in a person, a family or a vulnerable community responses. The
formulation is this case only consists of two parts: problem and cause. In
making the diagnosis the word
Cause problem +
Risk
of injury r / c unsteady gait and loss of visual acuity.
- Diagnosis of health or welfare: It
is a real diagnosis that is formulated when a person, family or community
already enjoys an acceptable level of health or welfare, but can and will reach
a higher level. They are made ​​in one part: label diagnosed (problem)
prefixing
Problem
Potential
for improving self - care, bath / hygiene.
Potential for increased recreational activities.
Potential for increased recreational activities.
- Diagnostics syndrome: It is that which brings together a set of diagnoses
(eg disuse syndrome) phrased consists only of the first part: health problem. Example:
Problem
Transfer stress syndrome.
Although we believe that the NANDA taxonomy
are the most widely accepted, there are other taxonomies:
OMAHA: quite useful for community nurses.
CAMPBELL: contains nursing diagnoses,
medical diagnostics and dual diagnoses.
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Sources:
MT Luis. Nursing diagnosis: A tool for
clinical practice. Second edition.
Definition, formulation and types of
diagnoses NANDA-I. Http://prescripcionenfermera.com/
List of NANDA Diagnosis: Current Nursing
NANDA NOC-NIC Nursing Methodology http://enfermeriaactual.com/listado-de-diagnosticos-nanda/
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