What is a nursing diagnosis?
Nursing diagnosis is a tool used by nurses to identify the specific needs of the patient that falls within the nursing range of practice. Diagnosis is one of the first steps in the development of care plan and is based on the recommendations of the doctor, the evaluation of patient records and personally examines patients. Nurses look at all information and determine areas that can cause problems or complications for patients.
To understand what nursing diagnosis is, it is important to understand what it is not. Nurses do not make medical diagnoses because it falls beyond their extent of practice. Determination of the basic cause of the condition falls to the doctor and surgeons, while nurses are engaged in how this disease affects other areas of the patient's life that can be improved by nursing care. For example, a physician diagnoses a patient with heart disease and develops a patient education plan.
there is a fewFor various types of nursing diagnoses - four of them identify a problem or potential problem - and wellness nursing diagnosis that identifies the patient's strengths. The real diagnosis is based on a problem that is currently present, such as diarrhea. Possible diagnosis identifies a problem that is probably present, but has not yet been confirmed. A problem that can potentially become a problem based on current health is written as a risk diagnostics. If the patient has a real or risk for clusters of related problems such as post -traumatic stress, these problems are grouped into the diagnosis of syndrome.
In general, nursing diagnosis consists of at least two parts: the diagnosis and justification of the diagnosis. For example, if the patient is at full rest in bed and is unable to Move around, the nurse can diagnose the risk of abuse syndrome related to disturbed mobility. Real and potential diagnoses go one step further and add a cutterAza about the state of the "related to" part. A three -part nursing diagnosis of pain can read as "surgery -related pain, as the patient verbalizes that he is in pain". This may sound redundant to mention the pain twice, but it is important because it identifies how the nurse has made a diagnosis.
As soon as the diagnosis of nursing is made, the nurse must monitor by setting the goal to solve the problem and also the plan to achieve this result. If more than one diagnosis is present, the nurse must prefer them on the basis of those who represent the greatest immediate need. Patients' conditions can often change during their stay in the facility and nurses must be ready to adapt their diagnoses appropriately.