WordNet
- nourishing at the breast (同)breast_feeding
- the work of caring for the sick or injured or infirm
- the profession of a nurse
- identifying the nature or cause of some phenomenon (同)diagnosing
PrepTutorEJDIC
- (預かった子を)養育(保育)する / 授乳する / {名}〈U〉 / (職業としての)看護 / 保育
- 診断[書] / (問題の原因などの)判断,分析 / (問題の)解決;結論
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出典(authority):フリー百科事典『ウィキペディア(Wikipedia)』「2016/06/27 09:46:16」(JST)
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A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses are developed based on data obtained during the nursing assessment. An actual nursing diagnosis presents a problem response present at time of assessment. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis identifies problems that result from that disorder.[1] The North American Nursing Diagnosis Association (NANDA) is body of professionals that manage an official list of nursing diagnosis.[2]
All nurses must be familiar with the steps of the nursing process in order to gain the most efficiency from their positions.
Contents
- 1 NANDA International
- 2 Global
- 3 Structure
- 4 Process
- 5 Examples
- 6 See also
- 7 References
- 8 External links
NANDA International
NANDA-International formerly known as the North American Nursing Diagnosis Associationt is the primary organisation for defining, distribution and integration of standardised nursing diagnoses worldwide iNANDA-I has worked in this area for nearly 40 years to ensure that diagnoses are developed through a peer-reviewed process requiring standardised levels of evidence, definitions, defining characteristics, related factors and/or risk factors that enable nurses to identify potential diagnoses in the course of a nursing assessment. NANDA-I believes that it is critical that nurses are required to utilise standardised languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characteristics) and the related or etiologic factors upon which nurses intervene. NANDA-I terms are developed and refined for actual (current) health responses and for risk situations, as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities. The taxonomy is published in multiple countries and has been translated into 18 languages; it is in use worldwide.
Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the electronic health record and can be linked to nurse-sensitive patient outcomes.[3][4]
After a close 38-to-35 vote in 2016, the leaders of the American Nurses Association (ANA) voted to eliminate the nursing diagnosis from nursing notes and electronic health records. There will no longer be a need or requirement for nurses to complete a nursing diagnosis for their patients.
Global
The ICNP (International Classification for Nursing Practice) published by the International Council of Nurses has been accepted by the WHO (World Health Organisation) family of classifications. ICNP is a nursing language which can be used by nurses to diagnose.[5][6][7][8]
Structure
The NANDA-I system of nursing diagnosis provides for four categories.
- Actual diagnosis
- A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community. An example of an actual nursing diagnosis is: Sleep deprivation.
- Risk diagnosis
- Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability. An example of a risk diagnosis is: Risk for shock.
- Health promotion diagnosis
- A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualise human health potential as expressed in the readiness to enhance specific health behaviours, and can be used in any health state. An example of a health promotion diagnosis is: Readiness for enhanced nutrition'.'
- Syndrome diagnosis
- A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions. An example of a syndrome diagnosis is: relocation stress syndrome.[9]
Process
- Assessment
- The first step of the nursing process is assessment. During this phase, the nurse gathers information about a patients psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient's health history, obtaining a patient's family history, and general observation can also be used to gather assessment data. Patient interaction is generally the heaviest during this evaluative stage.
- Diagnosis
- The diagnosing phase involves a nurse making educated judgement about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These assessments not only include a description of the problem or illness (e.g. sleep deprivation) but also whether or not a patient is at risk of developing further problems. These diagnoses are also used to determine a patient's readiness for health improvement and whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment.
- Planning
- Once a patient and nurse agree of the diagnoses, a plan of action can be developed. If multiple diagnoses need to be addressed, the head nurse will prioritise each assessment and devote attention to severe symptoms and high risk patients. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. For this phase, nurses generally refer to the evidence-based Nursing Outcome Classification, which is a set of standardised terms and measurements for tracking patient wellness. The Nursing Interventions Classification may also be used as a resource for planning.
- Implementation
- The implementing phase is where the nurse follows through on the decided plan of action. This plan is specific to each patient and focuses on achievable outcomes. Actions involved in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for a follow-up. Implementation can take place over the course of hours, days, weeks, or even months.
- Evaluation
- Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine if the goals for patient wellness have been met. The possible patient outcomes are generally described under three terms: patient;s condition improved, patient's condition stabilised, and patient's condition deteriorated. In the event where the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step.[10]
Examples
The following are nursing diagnoses arising from the nursing literature with varying degrees of authentication by ICNP or NANDA-I standards.
- Anxiety
- Constipation[11]
- Pain[12]
See also
- Clinical Care Classification System
- Clinical formulation
- Nursing
- Nursing process
- Nursing care plan
- Nursing Interventions Classification (NIC)
- Nursing Outcomes Classification (NOC)
References
- ^ NANDA International (professional association of nurses), Glossary of Terms.
- ^ "Nursing Diagnosis List | Nanda Nursing Diagnosis List". www.nandanursingdiagnosislist.org. Retrieved 2016-05-17.
- ^ Brokel, J & C Heath (2009). The value of nursing diagnoses in electronic health records. In Herdman, TH (Ed.), Nursing diagnoses: definitions and classification 2009-2011. Wiley-Blackwell: Singapore
- ^ Weir-Hughes, Dickon (2010). "Nursing Diagnosis in Administration". Nursing Diagnoses 2009-2011, Custom: Definitions and Classification. John Wiley & Sons. pp. 37–40. ISBN 978-1-4443-2727-4.
- ^ Zarzycka, D; Górajek-Jóźwik, J (2004). "Nursing diagnosis with the ICNP in the teaching context". International Nursing Review 51 (4): 240–9. doi:10.1111/j.1466-7657.2004.00249.x. PMID 15530164.
- ^ Lunney, Margaret (2008). "The Need for International Nursing Diagnosis Research and a Theoretical Framework". International Journal of Nursing Terminologies and Classifications 19 (1): 28–34. doi:10.1111/j.1744-618X.2007.00076.x. PMID 18331482.
- ^ "Standardized Nursing Language: What Does It Mean for Nursing Practice?". www.nursingworld.org. Retrieved 2016-05-17.
- ^ "FindArticles.com | CBSi". findarticles.com. Retrieved 2016-05-17.
- ^ Herdman, TH (Ed.) (2009). Nursing diagnoses: definitions and classification 2009 - 2011. Wiley-Blackwell: Singapore.
- ^ "Nursing Process Steps". www.nursingprocess.org. Retrieved 2016-05-17.
- ^ Fima, Odile; Langlassé, Armelle (1994). "Proposition d'un diagnostic infirmier: constipation colique chronique chez la personne âgée" [Proposition for nursing diagnosis. Chronic colonic constipation in the elderly]. Soins (in French) (584): 30–4. PMID 8029726. INIST:4073742.
- ^ "American Nurses Association". www.nursingworld.org. Retrieved 2016-05-17.
External links
- Müller-Staub, M; Needham, I; Odenbreit, M; Lavin, M. A.; Van Achterberg, T (2007). "Improved quality of nursing documentation: Results of a nursing diagnoses, interventions, and outcomes implementation study". International journal of nursing terminologies and classifications 18 (1): 5–17. doi:10.1111/j.1744-618X.2007.00043.x (inactive 2015-01-12). PMID 17430533.
- The need for international nursing diagnosis research and a theoretical framework by Dr. Margaret Lunney
- NANDA International
- Nursing Interventions
- Nursing Diagnosis
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UpToDate Contents
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English Journal
- Setting research priorities to improve global newborn health and prevent stillbirths by 2025.
- Yoshida S1, Martines J2, Lawn JE3, Wall S4, Souza JP5, Rudan I6, Cousens S7; neonatal health research priority setting group, Aaby P8, Adam I9, Adhikari RK10, Ambalavanan N11, Arifeen SE12, Aryal DR13, Asiruddin S14, Baqui A15, Barros AJ16, Benn CS17, Bhandari V18, Bhatnagar S19, Bhattacharya S20, Bhutta ZA21, Black RE22, Blencowe H23, Bose C24, Brown J25, Bührer C26, Carlo W27, Cecatti JG28, Cheung PY29, Clark R30, Colbourn T31, Conde-Agudelo A32, Corbett E33, Czeizel AE34, Das A35, Day LT36, Deal C37, Deorari A38, Dilmen U39, English M40, Engmann C41, Esamai F42, Fall C43, Ferriero DM44, Gisore P45, Hazir T46, Higgins RD47, Homer CS48, Hoque DE12, Irgens L49, Islam MT50, de Graft-Johnson J51, Joshua MA52, Keenan W53, Khatoon S54, Kieler H55, Kramer MS56, Lackritz EM57, Lavender T58, Lawintono L59, Luhanga R60, Marsh D51, McMillan D61, McNamara PJ62, Mol BW63, Molyneux E64, Mukasa GK65, Mutabazi M66, Nacul LC67, Nakakeeto M68, Narayanan I69, Olusanya B70, Osrin D71, Paul V38, Poets C72, Reddy UM73, Santosham M74, Sayed R75, Schlabritz-Loutsevitch NE76, Singhal N77, Smith MA78, Smith PG79, Soofi S80, Spong CY81, Sultana S82, Tshefu A83, van Bel F84, Gray LV85, Waiswa P86, Wang W87, Williams SL88, Wright L73, Zaidi A89, Zhang Y90, Zhong N91, Zuniga I92, Bahl R1.
- Journal of global health.J Glob Health.2016 Jun;6(1):010508. doi: 10.7189/jogh.06.010508.
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- PMID 26401272
- Nursing Interactions With Intensive Care Unit Patients Affected by Sleep Deprivation: An Observational Study.
- Giusti GD1, Tuteri D, Giontella M.
- Dimensions of critical care nursing : DCCN.Dimens Crit Care Nurs.2016 May-Jun;35(3):154-9. doi: 10.1097/DCC.0000000000000177.
- BACKGROUND: Patients in intensive care units (ICUs) often experience sleep deprivation due to different factors. Its consequences are damaging both physiologically and psychologically. This study focuses particularly on nursing interactions as the main factor involved in sleep deprivation issues.OBJ
- PMID 27043401
- Experiences of Newly Diagnosed Breast Cancer Patients in Turkey.
- Inan FŞ1, Günüşen NP2, Üstün B3.
- Journal of transcultural nursing : official journal of the Transcultural Nursing Society / Transcultural Nursing Society.J Transcult Nurs.2016 May;27(3):262-9. doi: 10.1177/1043659614550488. Epub 2014 Sep 15.
- PURPOSE: The purpose of this qualitative study is to describe the experiences of women in Turkey during the diagnostic phase of breast cancer.DESIGN: In the research, the phenomenological approach was used. The data were collected through semistructured in-depth interviews. The sample comprised nine
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Japanese Journal
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- 脳神経外科ジャーナル 20(5), 322-329, 2011-05-20
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- NAID 110008608115
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- 音声言語医学 52(2), 158-164, 2011-04-20
- 2006年4月〜2008年4月の間に3歳児健診で耳鼻咽喉科精密検査を勧められ, 福島県総合療育センターを受診した65例に対し, 聴覚障害, 構音障害, 発達障害, 知的障害の有無を精査した. この精査により, 新たに診断がついた症例は聴覚障害5例, 機能性構音障害11例, 自閉症5例, HFPDD 2例, MR 4例であった. さらにこれらの症例の経過を調査した. 中等度伝音難聴の1例は補聴器装用 …
- NAID 10028169979
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- Now in its 14th edition, this respected resource offers definitive guidance on key elements of nursing diagnosis, its role in the nursing process, and its application to clinical practice. Section 1 thoroughly explains the role of nursing diagnosis in the nursing process and in care planning. Section 2 offers a ...
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