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 â€‹â€‹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 â€‹â€‹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.
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 must be included. for example:
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 â€‹â€‹in one part: label diagnosed (problem) prefixing Example:
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:
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.
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/