Nursing diagnosis

With nursing diagnoses are pflegebegründende aspects that can have both physical, mental and social relations, described or evaluated. Nursing diagnosis is an integral part of the care process, it differs from the medical diagnosis. With its own technical language internationally uniform typical nursing phenomena are to be defined that are nursing recognizable, nameable and treatable.

Definition

The various authors or nursing classification systems (which classify nursing diagnoses ) define nursing diagnoses differently. Here are some definitions are listed as examples.

One of the first definitions was McManus:

"Nursing diagnosis is the identification of the maintenance problem, and the detection of its associated aspects. "

" Nursing diagnoses are descriptions of specific nursing assessments of human, health-related behavior and response patterns in the life process."

According to NANDA International, a nursing diagnosis is defined as follows:

" A nursing diagnosis is the clinical assessment of the individual, family, or community experiences / responses to actual or potential Gesundheitsproblme / life processes. A nursing diagnosis provides the basis for selection of nursing interventions in terms of achieving outcomes for which nurses are responsible. (Adopted at the ninth NANDA - I conference in 2009, "

Abderhalden a nursing diagnosis defined as follows:

" [ ... ] A nursing diagnosis [ ... ] a possible short, concise formulated professionally sound, supported on systematically collected, subjective and objective data characterization and evaluation of care -related problems / resources of care recipients / inside, which is differentiated they from nursing professionals delivers essential clues about the nature and extent of care needed and possibly can serve as a rough action orientation. He also gives two perspectives of the term nursing diagnoses. In theoretical- conceptual meaning a nursing diagnosis is a knowledge unit, a building block nursing expertise and / or a designation for such a knowledge unit. In the practical clinical significance, it is the name for the second step of the care process. "

Fischer defines something more pragmatic.

"Care services are to be measured, in order to say what the care is doing '; Nursing diagnoses are to be used to say why they do this. '"

Mortensen defined nursing diagnoses as follows:

" Nursing diagnoses can be described as phenomena which health problems and health conditions include, to which the care each act. Preventive, affecting or promoting "

An ENP nursing diagnosis is part of the nursing classification European Nursing care Pathways (ENP ) and is defined as follows:

" An ENP nursing diagnosis is a linguistic expression, the nurses, if possible, together with the person concerned and / or their family / caregivers based on a systematic assessment / evaluation (assessment, nursing history, physical examination ) the state of health and its psychological, physiological and developmental effects, or response to health problems use to meet on this basis, the decisions about care goals and select appropriate nursing interventions. "

Intention

Make nursing diagnoses, analogous to the Diagnosis Related Groups (DRGs ), a theory-based, standardized naming of care needs dar. On this basis, initiated the next steps in the nursing process and are finally settled. The nursing diagnoses describe the nursing care needs from a technical perspective. By assigning nursing tasks to nursing diagnoses a billing system will allow the nursing work and not the medical diagnosis of the International Statistical Classification of Diseases and Related Health Problems (ICD -10) as an accounting system is based. Nursing diagnoses describe the reactions of people around the current health status and health-related events in the life process and their dealing with it. The nursing assessment aligns itself in the experience of health or illness situations of people. The medical diagnostics and therapy deal directly with the diseases of a human ( practice -oriented nursing diagnoses - POP, Springer Vienna / NewYork, 2013, S6)

Recent studies have shown that due to the introduction of nursing diagnoses care needs will be charged more accurate and more effective care measures carried out and thus the quality of care can be increased. Another reason for the increasing use of nursing diagnosis in the German-speaking countries is the use is spreading computer-based management systems within the care based on standardized inputs.

In order to improve the documentation of care needs and prepare for DRGs led many nursing facilities, a nursing diagnosis. The implementation of standardized nursing diagnoses, interventions and outcomes possible to increase the practicality and efficiency of the management of nursing data. Adding NANDA International nursing diagnoses to the DRG models increases their explanatory power with respect to length of stay, costs, mortality and transfer to the nursing home by 30 percent. They provide standardized descriptions of care needs and enable you to establish care services on the basis of DRGs targeted. Studies have shown that thanks to the implementation of NANDA International nursing diagnoses increases the quality of care assessments and care needs are covered more effectively.

Formation and development

Planning care goes back to the 1950s. In the United States, published since 1960, the first article on maintenance planning in professional journals. The launch took place from about 1970. The idea was taken up in the UK and adapted to local conditions. The introduction in the U.S. and the UK was because the care planning of the nurses was considered as a method for improving quality. In the U.S., care planning was also seen as a tool that could help the profession to more prestige.

The care planning has been driven by the publication of the book care planning Fiechter and Meier in 1981. Already in the 1950s, the model of nursing diagnoses by different authors was used, but the implementation was not until about 20 years later. 1967 by Helen Yura and Mary Walsh the first book on the care planning in 4 steps issued that divided the care planning in the steps of assessing, planning, implementation, evaluation.

In 1973, the first conference of the American Nurses Association ( ANA) took place. The Standards of Nursing Practice have been issued. Nursing diagnoses have been recognized as an autonomous part of nursing. After that nursing diagnoses are a regular topic in the corresponding literature and publications. In 1982, the North American Nursing Diagnosis Association ( NANDA ) was established and recommended a taxonomy for the classification of nursing diagnoses. Since then, the nursing process to assess (nursing assessment ), nursing diagnosis, planning, implementation and evaluation has been presented and is differentiated five levels shown include.

In the early 1990s, also world have tried Pflegediagnosentaxonomien created to develop, including the International Classification of Nursing Practice ( ICNP, dt International Classification for Nursing Practice ). At the same time ( ACENDIO ) was 1995, " Interventions and Outcomes Association for Common European Nursing Diagnoses, " founded (German Association for Common European Nursing Diagnoses, Interventions and Care Results ).

Types of nursing diagnoses

It is possible to distinguish the following types of nursing diagnoses:

• Current nursing diagnoses define a situation comparable to the medical diagnoses, is proven and verified by symptoms. They include the nursing diagnosis title, etiological factors and symptoms.

• High-risk or risk nursing diagnoses related to a not yet occurred, but possible situation. They give the care instructions, to recognize a hazard for the residents / patients and initiate early appropriate measures (such as prophylaxis).

• Syndrome nursing diagnoses summarize current and high-risk or risk nursing diagnoses together into a syndrome.

• Health care diagnosis or wellness nursing diagnoses are for general health promotion a person. They offer so advised people about the possibility of an improved dietary habits, improved parenting or an improved family life.

• Suspicion nursing diagnoses describe possible present problems of the patient, for their confirmation or exclusion of additional information is needed, however.

The diagnostic process ( Cox )

The essential elements that supposedly requires a caregiver for formulating their diagnoses, are perception, cognitive processing, description and communication of what is perceived. As such, it Cox following steps:

• Collection of data
• Identification of the general problems
• Repeated summary of the data ( clustering according to the identified problems )
• Possibly. Further data collection ( problem-based Assessment)
• Generate more diagnostic hypotheses
• Review of diagnostic hypotheses
• Selection of the most accurate nursing diagnosis
• Validation of the nursing diagnosis
• Formulation of the diagnostic significance

Classification systems

The development of nursing diagnoses is to be understood, particularly in the context of the development of classifications in nursing. These are used either

• As a parent, professional linguistic frame of reference

• Or concrete description of specific aspects of the nursing process

The highest awareness and penetration so far has reached here the classification of NANDA International ( NANDA -I). NANDA -I develops and promotes a nursing language, which is the clinical judgment of nurses exactly. This evidence-based presentation includes social, psychological and spiritual dimensions of care. In 2003, NANDA NIC and NOC Taxonomiy II became the NANDA - I- NIC -NOC taxonomy, also known as NNN Taxonomy, merged. This allows a total classification of nursing diagnoses, nursing interventions and nursing outcomes was developed. In Germany and Austria ENP has in software applications in various electronic patient records from different manufacturers the highest distribution. In training for health and medical care, and to care for the elderly ENP has a similarly high penetration rate in Germany as NANDA -I. Just practice guidelines provide for training a good basis for care planning.

Furthermore, there are still other international classifications, but could not really prevail, such as the Home Health Care Classification of V. K. Saba, which was developed specifically for the field of home care.

Examples of the elderly

The examples of nursing diagnoses in the elderly relate to an ATL / AEDL sub - area ( activities of daily living care model)

ATL Food and drink

• Malnutrition
• Dehydration
• Swallowing disorder
• Self- supply deficit in relation to the food
• Nausea
• Aspiration

ATL secure Social relationships and areas and make

• Interrupted family processes (see Family)
• Risk of role overload of family carers / laity
• Role overload of family carers / laity
• Because alcoholism dysfunctional family processes
• Vereinsamungsgefahr
• Social isolation

Can move ATL yourself

• Risk of Immobility
• Risk of interruption of the circulation, sensitivity or ability to move a limb

• Impaired bed mobility
• Impaired transfer ability ( bed - chair, etc.)
• Impaired Wheelchair Mobility
• Impaired ability to walk