Nursing diagnosis
Stage II of the nursing process
At the second stage of the nursing process, the nursing diagnosis or identification of the patient's existing and potential problems is determined.
In contrast to the medical diagnosis, nursing diagnosis is most often not one due to several problems in the patient. Nursing diagnostics covers all spheres of the patient's life, in connection with which nursing diagnoses are combined as:
- physiological;
- psychological;
- spiritual;
- social.
Since 1982 there has been a definition:
Nursing diagnosis is a patient's present and potential health condition identified as a result of a nursing examination and requiring nursing interventions.
In diagnosing at her level, the nurse uses the knowledge gained as a result of training and experience.
A classification of nursing diagnoses has been adopted based on the violation of the following processes with examples:
- breathing - difficulty, suffocation, unproductive or productive cough;
- blood circulation - tachycardia, arrhythmia, cold extremities, edema;
- homeostasis - dehydration, fever, hypothermia;
- nutrition - high, low;
- digestion - violation of swallowing, heartburn, nausea, vomiting, diarrhea, constipation;
- urination - urinary retention or incontinence, pain when urinating;
- movement - impaired coordination, stiffness of the joints;
- Behavior – self-isolation, refusal to eat or take medication;
- attention - arbitrary, involuntary;
- memory - amnesia and other disorders;
- emotional and sensitive sphere - anxiety, fear, euphoria, negativity towards health workers, loneliness;
- hygiene needs - lack of skills, knowledge of hygiene, self-care;
- perceptions and sensations - sensory disturbances, pain;
- thinking - intelligence, spatial orientation.
Examples of nursing diagnoses:
- Elevated BP.
- Lack of knowledge about the disease.
- General weakness.
- Reduced emotional background due to stress.
- Fear of surgery.
- Urinary incontinence.
- Vomit.
- Sleep disorders.
- Feeling of false shame.
- The need for psychological support.
