The consultation of the dictionary definitions of these have emerged.
"Definition of a disease through medical history, signs and symptoms, laboratory tests and instrumental ones ..."
"Critical examination to detect symptoms of diseases ..."
Still other definitions:
"Evaluation of a phenomenon, having considered every aspect ..."
"Analysis of the functioning of a system with identification of any problems ..."
By definition, the diagnosis is accurate critical study of something in order to determine its nature.
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Emerge from the literature at least four definitions:
· A nursing function independent assessment of the individual responses of the human experience to its customers through the cycles of existence, whether accidental or developmental crises, illness, hardship or other stress (Bircher, 1975)
· Current or potential health problems that nurses, by virtue of their training and experience, are able to handle and able to do so (Gordon, 1982)
· A clinical judgment about a person, a family or a community in which you reach through a deliberate and systematic process of collecting and analyzing data. It forms the basis for prescribing treatments in solving the nurse is responsible.
· A statement that describes a human response of a person or group, that the nurse is enabled to recognize and which may require decisive interventions that aim to maintain the health or reduce, eliminate or prevent alterations (Carpenito , 1988).
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In March 1990, during the ninth Conference of the North American Nursing Diagnosis Association (NANDA), the General Assembly adopted an official definition of nursing diagnosis:
The Nursing Diagnosis is a clinical judgment regarding the responses of the individual, family or community health problems / life processes current or potential.
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The nursing diagnosis is the basis on which to choose nursing interventions designed to achieve results which the nurse is responsible.
The nursing diagnosis is a statement that describes a specific type of problem identified by the nurse or response. It should not be used to designate all the problems that nurses can recognize, because this would highlight the uniqueness of the nursing role: it is therefore necessary to distinguish it from the problem collaboratively.
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The nursing diagnosis expresses the professional judgment of the patient's condition, its responses to the treatments received and the need for nursing care.
E 'fundamental stage to proceed to the care plan ... moves, in essence, all the care process.
All that we have collected from observation, the interview, physical examination, the vision of the medical records, must be organized and interpreted to identify the patient's ability to meet health needs.
Identify the needs that the patient expressed in an attempt to adapt to the effects of the disease means "to consider" what kind of assistance is needed to build and develop his skills as possible to overcome the negative state of the disease.
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Making nursing diagnosis means to describe the responses, the signs, symptoms that indicate an actual or potential (risk) health problem and identify the most appropriate care to solve it.
The formulation of nursing diagnosis is a logical extension of data collection relating to the establishment. During the investigation have asked any question relating to history, played every technical examination on the physical conditions, taking into account any result of laboratory tests and performed a careful and insightful individual over the general conditions ...
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Through:
· Analysis of data
· Interpretation of data collected
· Identification of the problem
· Formulation of objectives
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You can diagnose the problem or problems, real or risk allowing professionals to schedule nurses nursing time to correct the problem itself.
Useful for this purpose shall be drawn up on a list of problems to be dialed one by one by following functional models of health proposed by Gordon. The problems must then be sorted in priority order to develop operating nursing diagnosis for care planning.
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Type, structure and systems of classification of nursing diagnoses.
There are various types of nursing diagnoses identified, the NANDA we propose three models of diagnosis.
· Actual or real
· Risk or high risk
· Welfare
Real
Represent a condition clinically validated.
Risk
Consist of clinical judgment according to which a person, a family or a community is vulnerable to a certain problem
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Welfare
They consist of a clinical judgment about a person, a family or a community in transition from a specific level of welfare to a higher level. Therefore relate to the diagnosis related to health promotion. In this case must be present two elements:
- The desire for a higher level of welfare
- the presence of a condition or function effectively, that is, personal and environmental potential to improve the situation.
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How to write a nursing diagnosis?
The structure of nursing diagnosis is composed of four elements useful primarily for the adoption of a nursing language shared. For this reason we will use a specific terminology for nursing diagnosis so. The components are:
1. Title
2. Definition
3. Defining characteristics
4. Factors related
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The title must "qualify" the nature of the problem and expresses so if our diagnosis examines an issue of "inefficiency", "alteration" or "deficit" is too subjective to replace terms such as "poor" or "inappropriate" ...
The definition allows us to express in a clear and precise meaning of the diagnosis, thus helping to differentiate them from those that look alike.
The defining characteristics are the equivalent of the signs and subjective symptoms and objective present in relation to a specific diagnosis.
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They are divided into
- Major or major, defined as critical indicators in 80% of cases-100
- Defined as minor or secondary indicators support (provide supporting evidence for the diagnosis, but may not be present) present in 50-70% of situations.
The factors are essentially related causes, the etiologic factors resulting in a certain situation, can be grouped into four categories:
- pathophysiological (biological or psychological)
- situational (environmental, social, personal)
- maturational stages (age related)
- treatments (treatments, interventions)
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These components to be used for the description of a diagnosis are the mental process by which we proceed to focus on the real needs of our users.
The use of terminology defining characteristics and related factors in place of signs and symptoms and etiology is due to the desire to find a specific language but different from that doctor.
Example 1
Title: Liberation ineffective airway
Related to:
- excessive or thick secretions
- immobility
- sedative effect of drugs
- pain
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That is manifested by:
- ineffective or absent cough
- inability to effectively expel the secretions
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Example 2
Title: Deficit of self-care (feeding)
Related to:
- lack of coordination
- external devices
- fatigue and pain
- decreased mobility and muscle weakness or visual
- comatose
That is manifested by:
- inability to cut food or open packages
- inability to bring food to mouth
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We go into more detail:
Example illustrating the components of a nursing diagnosis real, in this case, the diagnosis Impaired mobility:
Definition
Impaired mobility: the state in which a person has, or may have, a limitation of movement, but not be still.
Defining characteristics
More (80-100%)
Impairment of the ability to move with a purpose in the environment, such as bed mobility, transfers, ambulation
Limitations in the articular
Lower (50-70%)
Restriction imposed by the movement
Reluctance to move
Factors related
Pathophysiology, that is related to decreased strength and stamina for:
Ø neuromuscular disorders (paralysis, sensory deficits, diseases of the nervous system)
Ø musculoskeletal disorders (fractures)
Ø edema (increase of synovial fluid)
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Treatments, related to external equipment (chalk, intravenous infusion), prosthetics, crutches, walker
Situational
Related to:
Ø fatigue
Ø motivation
Ø pain
Maturational stages
Ø child
Ø senior
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For a description of the diagnosis of risk or high risk factors associated with the same risk factors, namely the situation that accentuates the vulnerability of the person or group.
In the title always appears the term "risk ..."
Example 1
Title: High risk for impaired skin integrity
Related to:
Immobility
Secondary to:
Pain
Example 2
Title: High risk of infection
Related to:
Surgical incision
Impaired healing
Secondary to:
Diabetes mellitus
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About the diagnosis of well-being, remember that these diagnoses are related to health promotion for which we will discuss the current conditions of a welfare state that aims to further growth.
There are situations where the individual in stable health attempts to change their habits in order to achieve a higher level of health.
Collaborative problems
The nurses do not work alone, often the management of health problems in users' calls to work under a multi-disciplinary, ie with other professional groups. Therefore, there are clinical situations, can not be described with nursing diagnoses, but who still require nursing care interventions in nature.
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The nurse, during its data collection, identifying clinical situations that must be addressed:
As an operator prescriber (independent)
And as a collaborator with other professions (in collaboration)
From the first situation, as autonomous, flow the nursing diagnosis, the second situation is rather highlight those that are called Collaborative Problem.
How to distinguish the collaborative nursing diagnosis of problems?
Both the diagnosis, both the problems collaborative require the implementation of the nursing process in all its phases, however, the approach required the nurse is different in the two cases.
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There is talk of collaborative problem about certain complications that nurses monitor to identify the occurrence or a modification. Nurses manage collaborative problems with prescription or nursing interventions aimed at minimizing the complications of certain interventions.
It should be pointed out that it is certain complications since not all of those that may occur are to be considered collaborative problems. If the nurse, in fact, is able to prevent the complication, or to establish the main treatment, then the problem is a nursing diagnosis.
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The nurse can prevent:
Ø Compression lesions
Ø Thrombophlebitis
Ø Risk of accidental fall
Ø Aspiration
The nurse can treat:
Ø Compression lesions
Ø Problems with swallowing
Ø Ineffective cough
The nurse can not prevent:
Ø Hemorrhage
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The problems are collaborative situations of which the nurse is responsible because it recognizes the presence and, to varying degrees working with their management. The management of collaborative problem relates to the monitoring of the creation or modification of the complications and the response to them with prescription drugs and nursing interventions.
The nurse takes on independent decisions in relation to the problems is that the collaborative nursing diagnosis. The difference is that with regard to the latter, the responsibility of the prescription of therapy to achieve the expected result, as regards the problem instead of the prescription is both collaborative nursing and medical.
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All problems are called collaborative potential complications and nursing goal is understood as a reduction in the severity of certain factors or events.
Finally, the nurse identifies a problem when there are some collaborative situations that increase the vulnerability of the patient to complications, or when it is already infected:
example, the patient smoker that manifests a persistent cough for some time.
Ø Potential complication: pulmonary edema
Ø Potential complication: gastrointestinal bleeding
Ø Potential complications: preterm labor
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In the phase of the nursing diagnosis, the nurse must also formulate what are the objectives to be pursued so that we can proceed to the next stage of planning.
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What are the objectives?
These are measures that are used to evaluate the user's progress (results) and / or nursing care.
Must be expressed in clear terms with observable, measurable, real, and temporal behavior. They are realistic when they are based on user data.
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They can be:
Ø Short-term
Ø Long-term
For short-term objectives are defined as those whose achievement is expected as a fundamental event in the path and straining to reach a long-term goal.
Long term refers to a goal whose achievement is expected within weeks or months.
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Example
Quit smoking: The resolution of cough in a smoker patient is short term, long-term prevention of diseases affecting the respiratory system.
Today it is more difficult to formulate long-term goals for patients hospitalized because hospitalization times are shrinking; ward nurses often present only short-term goals.
The objectives must also be agreed with the patient whenever this is possible, the membership user is required because the final objective involves him in person. The nurse can also make the family share and establish long-term or immediate goals. This is because often the family to continue the nursing program once the patient is discharged.
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The objectives are to:
1. The solution of the problem
2. Highlight a step towards the solution of the problem
3. Highlight a step towards an improved state of health
4. Maintaining good health and functionality
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