Nursing diagnoses are critical, forcing diagnoses essential to the future of evidence-based professional nursing care and how to meet patient needs more effectively.
Today, electronic health records are on the rise, and standardised nursing terminologies such as Nanda, Nic, and Noc provide a way to collect data that can be analysed systematically.
A nursing diagnosis is a clinical judgment about the experiences/responses of a person, family or community in the face of actual or potential health problems/life processes. The nursing diagnosis provides the basis for selecting nursing interventions to achieve the results for which the nurse is responsible.
The creation of a nursing diagnosis goes through a series of stages:
- Collection of relevant statistical data to develop a diagnosis.
- Detection of signs/patterns and changes in physical state.
- Establishment of possible alternative hypotheses that could have caused previous signals or patterns.
- Each nursing diagnosis includes a diagnostic label or name, definition, defining characteristics, risk factors, and related factors.
Nursing diagnoses are stated according to the PES format :
P = Health problem, which corresponds to the diagnostic label
E = Etiology, where the causes favour the appearance of the health problem are reflected.
S = Symptomatology, consisting of the signs and symptoms that appear as a result of the problem.
Each of these parts is linked to the others utilising links to constitute the complete diagnostic statement:
Health problem related to (r/c) Etiology and manifested by (m/p) Symptomatology.
Depending on the type of diagnosis in question, they are stated in one, two or three parts:
- A real nursing diagnosis statement consists of three parts:
Health problem + Etiology + Symptomatology. Example:
Acute pain r/c physical injurious agents m/p expressive behaviour (agitation, groan)
- Nursing diagnoses of risk, its statement consists of the first two parts:
Health problem + Etiology Example:
Risk of peripheral neurovascular dysfunction r / c fracture.
- Possible nursing diagnoses, their statement consists of the first two parts:
Health problem + Etiology Example:
Possible body image disorder r/c post-surgical isolation behaviour.
- Nursing diagnoses of well-being, its statement consists only of the first part:
Health problem Example: Willingness
to increase spiritual well-being.
- Nursing diagnoses of the syndrome, its statement consists only of the first part:
Health problem Example:
Post-rape trauma syndrome.
The Classification of Nursing Interventions includes the nursing interventions per the nursing diagnosis, appropriate to the result that we hope to obtain in the patient, and that consists of the actions that must be carried out to achieve the said end.
The NIC uses a standardised and global language to describe the treatments carried out by nursing professionals on the basis that the use of standardised language does not inhibit practice; Rather, it serves to communicate the essence of nursing care to others and helps improve practice through research.
Nursing Interventions can be direct or indirect.
Direct intervention: Treatment is carried out directly with the patient and family through nursing actions. These nursing actions can be physiological, psychosocial or supportive.
Indirect intervention: Treatment performed without the patient but for their benefit.
An example of NIC interventions is as follows:
VITAL SIGNS MONITORING
– Periodically check blood pressure, pulse, temperature and respiratory status, if applicable.
– Observe and record for signs and symptoms of hypothermia and hyperthermia.
– Periodically check pulse oximetry.
– Periodically observe the colour, temperature and humidity of the skin.
– Identify possible causes of changes in vital signs.
The Nursing Outcomes Classification
The Nursing Outcomes Classification (NOC) incorporates standardised terminology and criteria to describe and obtain outcomes from performing nursing interventions. These results represent the objectives that were set before carrying out these interventions. It also makes use of a standardised language to universalise nursing knowledge. Finally, it facilitates understanding of results and the inclusion of specific indicators to evaluate and score the results obtained with the patient.
One of the objectives of the NOC (CRE) is to identify and classify the results of patients that depend directly on nursing actions and are clinically useful.
For example, for the diagnosis of Acute Pain, the result in Nursing (NOC) would be Pain intensity (Magnitude of observed or reported pain).