For the future of evidence-based professional nursing care and how to more effectively meet patient needs, nursing diagnoses are essential.
Today, electronic health records are on the rise, and it is standardized nursing terminologies such as Nanda, Nic, and Noc that provide us with a way to collect data that can be systematically analyzed.
A nursing diagnosis is defined as a clinical judgment about the experiences/responses of a person, family or community to real or potential health problems/life processes. The nursing diagnosis provides the basis for the selection of nursing interventions aimed at achieving 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.
- Validation.
- Diagnosis.
Each nursing diagnosis consists of a label or name of the diagnosis, a definition, defining characteristics, risk factors and/or 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 that favor the appearance of the health problem are reflected.
S = Symptoms, consisting of the signs and symptoms that appear as a consequence of the problem.
Each of these parts is linked to the others by means of links to constitute the complete diagnostic statement:
Health problem related to (r/c) Etiology and manifested by (m/p) Symptoms.
Depending on the type of diagnosis being treated, they are stated in one, two or three parts:
- Real nursing diagnoses, their statement consists of three parts:
Health problem + Etiology + Symptoms. Example:
Acute pain r/c physical harmful agents m/p expressive behavior (agitation, moaning…) - Risk nursing diagnoses, 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 behaviors. - Well-being nursing diagnoses, its statement consists only of the first part:
Health problem Example:
Willingness to increase spiritual well-being. - Nursing diagnoses of syndrome, its statement consists only of the first part:
Health problem Example:
Post-rape trauma syndrome.
NIC:
The Classification of Nursing Interventions includes nursing interventions in line with the nursing diagnosis, appropriate to the result we hope to obtain in the patient, and which include the actions that must be carried out to achieve this goal.
The NIC uses a standardized and global language to describe the treatments carried out by nursing professionals on the basis that the use of standardized language does not inhibit practice; but rather 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 that is carried out directly with the patient and/or family through nursing actions. These nursing actions can be physiological, psychosocial or supportive.
- Indirect intervention: Treatment carried out without the patient but for their benefit.
An example of NIC interventions is the following:
- MONITORING OF VITAL SIGNS (6680)
– Periodically monitor blood pressure, pulse, temperature and respiratory status if applicable.
– Observe and record if there are signs and symptoms of hypothermia and hyperthermia.
– Periodically monitor pulse oximetry.
– Periodically observe the color, temperature and humidity of the skin.
– Identify possible causes of changes in vital signs.
NOC:
The Nursing Outcomes Classification (NOC) incorporates standardized terminology and criteria to describe and obtain results as a consequence of carrying out nursing interventions. These results represent the objectives that were set before carrying out these interventions. It also uses standardized language in order to universalize nursing knowledge. It facilitates the 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 patient outcomes that directly depend on nursing actions and that are clinically useful.
For example, for the diagnosis Acute Pain, the Nursing result (NOC) would be: Pain intensity (Magnitude of pain observed or reported).
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