Nursing diagnosis

With nursing diagnoses are pflegebegründende aspects that can have both physical, mental and social relations, described or evaluated. Nursing diagnostics is part of the nursing process ; it differs from the diagnosis made by a doctor . With its own specialist language , internationally standardized typical nursing phenomena are to be defined, which are recognizable, identifiable and treatable by nursing.

definition

The different authors or nursing classification systems (which classify nursing diagnoses) define nursing diagnoses differently. Some definitions are given below as examples.

One of the first definitions comes from McManus:

"Nursing diagnosis is the identification of the nursing problem and the recognition of its related aspects."

- McManus, 1951

In the Practice-Oriented Nursing Diagnostics - POP classification , nursing diagnoses are defined as follows:

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

- Stefan / Allmer / Schalk et al. 2013, p. 16).

The definition according to POP is based on the definition of care of the International Council of Nursing (ICN). As a result, the POP definition of nursing diagnoses not only includes problems and deficits, but also the positive, healthy parts of people (resources).

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

“A nursing diagnosis is the clinical assessment of individual, family or community experiences / reactions to current or potential health problems / life processes. A nursing diagnosis forms the basis for the selection of nursing interventions with regard to the achievement of outcomes for which the nursing staff is responsible. (accepted at the ninth NANDA-I conference in 2009 "

- NANDA International, 2013

Abderhalden defines a care diagnosis as follows:

"[...] a nursing diagnosis [...] a short, concisely formulated, technically sound characterization and assessment of the nursing-related problems / resources of nursing recipients based on systematically collected, subjective and objective data, which is so differentiated that it is a specialist provides essential clues from care about the type and extent of care needs and can possibly serve as a rough guide to action. He also gives two ways of looking at the term nursing diagnosis. In the theoretical-conceptual sense, a nursing diagnosis is a unit of knowledge, a component of specialist nursing knowledge and / or a name for such a unit of knowledge. In the clinical-practical meaning it is the name for the second step of the nursing process. "

- Abderhalden, 1995

Fischer defines something more pragmatic.

“Nursing performance should be measured to say 'what the care is doing'; Nursing diagnoses should be used to say 'why she does this'. "

Mortensen defines nursing diagnoses as follows:

"Nursing diagnoses can be described as phenomena that include health problems and health conditions on which nursing has an effect: preventive, influencing or promoting."

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

"An ENP nursing diagnosis is a linguistic expression that the caregiver, if possible, together with the person concerned and / or their relatives / caregivers based on a systematic assessment (assessment, nursing history, physical examination) of the state of health and its psychological, physiological and use development-related effects or the response to health problems in order to make decisions about care goals and select suitable care interventions on this basis. "

- Pia Wieteck

intention

Like the Diagnosis Related Groups (DRGs), nursing diagnoses represent a theory-based, standardized designation of the need for nursing care. On this basis, the next steps in the nursing process can be initiated and finally billed. The nursing diagnoses describe the nursing needs from a nursing perspective. The assignment of nursing activities to nursing diagnoses enables an accounting system that is based on the nursing work and not the medical diagnosis of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Nursing diagnoses describe the reactions of people to the current health status and health-related events in the life process or how they deal with them. The nursing assessment is based on the experience of people's health or illness situations. Medical diagnostics and therapy deal directly with a person's illnesses.

Recent studies have shown that, due to the introduction of nursing diagnoses, the need for nursing care is ascertained more precisely and more effective nursing measures can be carried out, thereby increasing the quality of care. Another reason for the increasing spread of nursing diagnostics in German-speaking countries is the widespread use of computer-aided administration systems within nursing that are based on standardized entries.

In order to improve the documentation of care needs and to prepare for DRGs, many care facilities introduced care diagnostics. The implementation of standardized nursing diagnoses, interventions and results enables the practicability and efficiency of the management of nursing data to be increased. The addition of NANDA-International nursing diagnoses to the DRG models increases their explanatory power with regard to length of stay, costs, probability of death and transfer to the nursing home by 30 percent. They represent standardized descriptions of the need for care and enable care services to be justified based on the DRGs. Studies have shown that, thanks to the implementation of NANDA-International nursing diagnoses, the quality of nursing assessments increases and the need for nursing is recorded in a more targeted manner.

Origin and development

The care plan dates back to the 1950s. In the USA, the first articles on nursing planning appeared in specialist journals from 1960. The introduction took place from around 1970. The idea was taken up in Great Britain and adapted to the local conditions. The introduction in the USA and Great Britain took place because nursing planning was viewed by the nursing staff as a method of increasing quality. In the USA, care planning was also understood as an instrument that could help the profession to gain more prestige.

Care planning was promoted by the publication of the book Care Planning by Fiechter and Meier in 1981. The nursing diagnosis model was used by various authors as early as the 1950s, but it was not implemented until about 20 years later. In 1967, Helen Yura and Mary Walsh published the first book on nursing planning in 4 steps , which divided nursing planning into the steps of assessing, planning, implementing, and evaluating.

In 1973 the first American Nurses Association (ANA) conference took place. The Standards of Nursing Practice have been issued. Nursing diagnoses were recognized as an autonomous part of nursing. Thereafter, nursing diagnoses are a regular topic in the relevant specialist literature and publications. In 1982 the North American Nursing Diagnosis Association (NANDA) was founded and a taxonomy was recommended for classifying nursing diagnoses. Since then, the nursing process has been presented in a more differentiated manner and is presented in five stages, which include assessment ( nursing assessment ), nursing diagnosis, planning, implementation and evaluation.

In the early 1990s, there were also worldwide efforts to develop nursing diagnosis taxonomies, including the International Classification of Nursing Practice (ICNP, German International Classification for Nursing Practice ). At the same time, the "Association for Common European Nursing Diagnoses, Interventions and Outcomes" (ACENDIO) was founded in 1995 (German association for common European nursing diagnoses, interventions and nursing outcomes ).

Types of nursing diagnoses

The following types of nursing diagnoses can be distinguished:

• Current nursing diagnoses define a situation which, comparable to medical diagnoses, can be demonstrated and checked through symptoms. They include the nursing diagnosis title, etiological factors, and symptoms.
• High-risk or hazardous care diagnoses relate to a situation that has not yet occurred but is possible. They give the nursing staff advice on recognizing a risk for the resident / patient and initiating appropriate measures at an early stage (e.g. prophylaxis).
• Syndrome nursing diagnoses combine current and high-risk or hazardous nursing diagnoses into one syndrome .
• Health care diagnoses or wellness care diagnoses serve the general health promotion of a person. They offer people advised in this way, for example, the possibility of improved nutritional behavior, improved parenthood or improved family life.
• Suspected nursing diagnoses describe possible problems the patient may have, but additional information is required to confirm or exclude them.

The diagnostic process (according to Cox)

The essential elements that a caregiver supposedly needs to formulate their diagnoses are perception, cognitive processing, description and communication of what is perceived. To do this, according to Cox, she takes the following steps:

• Collection of the data
• Identify common problems
• Another summary of the data (clustering according to the identified problems)
• Possibly. Collection of further data (problem-oriented assessment )
• Generation of several diagnostic hypotheses
• Review of the diagnostic hypotheses
• Selection of the most accurate nursing diagnosis
• Validation of the nursing diagnosis
• Formulation of the diagnostic statement

Classification systems

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

• as a higher-level, technical-language reference framework

e.g. International Classification of Nursing Practice

• or for a concrete description of sub-aspects of the maintenance process

such as NANDA-International , classifies nursing diagnoses and is accessible in German both as a database for integration in electronic patient files and as a book publication; POP - Practice-oriented nursing diagnostics , classifies nursing diagnoses and, outside the classification, offers exemplary nursing goals and measures for each nursing diagnosis (POP is also available as a book publication and as a database for use in EDP-supported documentation systems); Nursing Interventions Classification , classified nursing interventions (NIC); Nursing Outcomes Classification (NOC), classifies nursing outcomes; or ENP European Nursing Care Pathways , the classification combines nursing diagnoses, goals and measures in the form of ENP practice guidelines. The practice guidelines are scientifically developed, validation work is available and is continuously updated. They represent the current nursing knowledge, so the claim of the developers. ENP is available in various languages ​​(German, English, Italian, French), ENP is published in the form of a database for integration in electronic patient files or as a book. It should be noted at this point that this list is not complete and that other care classification systems exist.

The classification of NANDA International (NANDA-I) has so far achieved the highest level of awareness and distribution. NANDA-I develops and promotes nursing terminology that accurately represents the clinical judgments of nurses. This evidence-based presentation includes social, psychological and spiritual dimensions of care. In 2003 the NANDA Taxonomy II was merged with NIC and NOC to form the NANDA-I-NIC-NOC taxonomy, which is also known as the NNN taxonomy. An overall classification for nursing diagnoses, nursing interventions and nursing outcomes was thus developed. In Germany and Austria, ENP is most widespread in software applications in various electronic patient files from different manufacturers. In training in health care and nursing as well as care for the elderly, ENP is as widespread in Germany as NANDA-I. The practical guidelines in particular provide a good basis for care planning for training.

In addition, there are other international classifications that have not really caught on, such as the Home Health Care Classification by V. K. Saba, which was specially developed for the area of ​​home care.

Examples from elderly care

The examples of nursing diagnoses from elderly care relate to an ATL / AEDL sub-area (everyday activities care model)

Notes: The “nursing diagnoses” listed below are not complete and only become a nursing diagnostic statement if the characteristics and causes are also specified. Some of the formulations are linked to medically oriented pages, so that the descriptions sometimes describe symptoms and do not represent a nursing diagnostic statement. In some cases, the formulations are similar to NANDA nursing diagnoses, it should be checked whether references are useful here.

ATL can eat and drink

• Malnutrition
• Dehydration
• Swallowing disorder
• Self-sufficiency in terms of food
• nausea
• Aspiration hazard

ATL Secure and design social relationships and areas

• Interrupted family processes (see family )
• Danger of overloading the roles of caring relatives / lay people
• Role overload of caring relatives / lay people
• Family processes disturbed due to alcoholism
• Danger of isolation
• Social isolation

ATL Being able to move

• Danger of immobility
• Risk of interruption of circulation, sensitivity or mobility of an extremity

• Impaired bed mobility
• Impaired transfer ability (bed-chair etc.)
• Impaired wheelchair mobility
• Impaired walking ability

literature

• Harald Stefan, Franz Allmer, Kurt Schalk et al .: POP - practice-oriented nursing diagnostics . Springer Vienna / New York. 2013, ISBN 978-3-7091-1283-0
• Marylinn E. Doenges, Mary F. Moorhouse, Alice C. Geissler-Murr: Nursing diagnoses and measures. Maintenance process. 1. corr. Reprint of the 3rd complete revision. u. extended Edition, Verlag Hans Huber, Bern 2002, ISBN 3-456-82960-4
• Marjory Gordon : Handbook of Nursing Diagnoses. The book for practice. 4th edition. Urban & Fischer, Munich / Jena. 2003. ISBN 3-437-26442-7
• Marjory Gordon, Sabine Bartholomeyczik : Nursing diagnoses. Theoretical foundations. 1st edition. Urban & Fischer, Munich / Jena 2001, ISBN 3-437-26380-3
• Harald Stefan, Franz Allmer, Josef Eberl et al .: Practice of nursing diagnoses . Springer, Vienna / New York 2004, ISBN 978-3-211-00807-2 .
• Mary C. Townsend: Nursing Diagnoses and Actions for Psychiatric Nursing. 2nd Edition. Verlag Hans Huber, Bern 2006, ISBN 3-456-83944-8 .
• Wolfram Fischer: Diagnosis Related Groups (DRGs) and care. Basics, coding systems, integration options. Verlag Hans Huber, Bern 2002, ISBN 3-456-83576-0 .
• Wolfram Fischer: The importance of nursing diagnoses in health economics and health statistics 2nd edition Wolfertswil 1999, ISBN 3-9521232-4-2 .
• Michael Herrmann, Jürgen Georg: NANDA nursing diagnoses. Definitions and Classification 2005–2006. Verlag Hans Huber, Bern 2005, ISBN 3-456-83322-9 .
• Annette Heuwinkel-Otter et al .: Taking care of people . (Vol. 1 to 3, training guide), Springer MedizinVerlag, Heidelberg 2006/2007
• Annette Heuwinkel-Otter et al .: Taking care of people . The practical companion for nursing professionals, Springer MedizinVerlag, Heidelberg 2009. ISBN 978-3-540-79320-5
• Annette Heuwinkel-Otter et al .: Taking care of people. Nursing diagnoses for the smock pocket, Springer MedizinVerlag, Heidelberg 2011, ISBN 978-3-642-01318-8
• Jürgen Hollick, Andrea Kerres: Care in the DRG system. DRGs - Nursing - Nursing Diagnosis . Spitta Verlag, Balingen. 2005. ISBN 3-934211-00-3
• Ingrid Kollak, Margret Georg: Nursing diagnoses. 3rd edition. Mabuse-Verlag. 1999. ISBN 3-933050-18-9 (conference proceedings)
• Berta Schrems: The process of diagnosing in nursing. UTB, Heidelberg 2003, ISBN 3-8252-2468-6
• Cathrin Björvell, R. Wredling, I. Thorell-Ekstrand: Long-term increase in quality of nursing documentation: Effects of a comprehensive intervention . In: Scandinavian Journal of Caring Sciences , 16, 2002, pp. 34-42.
• A. Brune, A. Budde: Results from two empirical studies on the status of the introduction from the point of view of the patient and the nurse . In: S. Käppeli (Ed.): Care diagnostics under the microscope: Scientific evaluation of various aspects of the care diagnostics project at the University Hospital Zurich . Center for Development and Research Care, Zurich 2000, pp. 62–102.
• J. Florin, A. Ehrenberg, M. Ehnfors: Quality of nursing diagnoses: evaluation of an educational intervention . In: International Journal of Nursing Terminologies and Classifications , 16 (2), 2005, pp. 33-43.
• MH Hanson, FT Kennedy, LL Dougherty, LJ Bauman: Education in nursing diagnosis: Evaluating clinical outcomes . In: The Journal of Continuing Education in Nursing , 21 (2), 1990, pp. 79-85.
• CF Johnson, LW Hales: Nursing diagnosis anyone? Do staff nurses use nursing diagnosis effectively? In: The Journal of Continuing Education in Nursing , 20 (1), 1989, pp. 30-35.
• MA Lavin, K. Avant, M. Craft-Rosenberg, TH Herdman, K. Gebbie: Contexts for the study of the economic influence of nursing diagnoses on patient outcomes . In: International Journal of Nursing Terminology in Classification , 15 (2), 2004, pp. 39-37.
• M. Müller Staub: Quality of nursing diagnostics and patient satisfaction: a study on the question of the relationship . In: Pflege : The scientific journal for care professions, 15 (3), 2002, pp. 113–121.
• M. Müller-Staub: Promotion of nursing diagnostics and its contribution to patient-oriented cost models . In: W. Oggier, A. Walter, S. Reichlin, M. Egli (eds.): Handbook Health Care Switzerland in Change . Trend Care AG, eHealthCare.ch, Sursee 2008, pp. 1–8.
• M. Müller-Staub, I. Needham, M. Odenbreit, MA Lavin, T. van Achterberg: Improved quality of nursing documentation: Results of a nursing diagnoses, interventions and outcomes implementation study . In: International Journal of Nursing Terminology in Classification , 18 (1), 2007, pp. 5-17.
• M. Müller-Staub, I. Needham, M. Odenbreit, MA Lavin, T. van Achterberg: Nursing diagnoses, interventions and outcomes: Application and effects on nursing practice: A systematic review of the literature . In: Pflege: The scientific journal for care professions, 20 (6), 2007, pp. 352–371.
• JM Welton, EJ Halloran: Nursing diagnoses, diagnosis-related group, and hospital outcomes . In: Journal of Nursing Administration , 35 (12), 2005, pp. 541-549.

Web links

• German-speaking ICNP user group
• ICD-10 list for nursing (final draft, German professional association for nursing professions , of the discussion proposal by experts from the Höhenrieder district (HK) on behalf of the German Nursing Council (DPR), 2002)
• Scientific background to ENP nursing diagnoses

Individual evidence

1. ↑ Nanda International ( Memento of the original from March 17, 2013 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 
2. ↑ NANDA-International - Nursing Diagnoses Definitions and Classification 2012–2014 . German edition translated by Holger Mosebach. RECOM-Verlag, Kassel 2013, p. 505.
3. ↑ ENP nursing diagnosis . pflegewiki.de
4. ↑ Pia Wieteck (Ed.): Practical guidelines for care, planning and documentation based on care diagnoses of the ENP classification . RECOM Verlag, Kassel 2013, p. 40
5. ↑ Practice-Oriented Care Diagnostics - POP . Springer, Vienna / New York 2013, p. 6
6. ^ The Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACENDIO)
7. ↑ Technical information from the German Care Association e. V .: nursing diagnoses. (PDF; 99 kB) Accessed May 10, 2011 . 
8. ↑ Karin Eveslage: Nursing diagnoses: practical and efficient. P. 92f. Springer, Heidelberg 2006, ISBN 978-3-540-25578-9 . Online: limited preview in Google Book search
9. ↑ NANDA-International - Nursing Diagnoses Definitions and Classification 2012–2014 . German edition translated by Holger Mosebach. RECOM-Verlag, Kassel 2013
10. ↑ H. Stefan, F. et al .: Allmer POP Practical nursing diagnoses nursing diagnoses - Objectives - Measures , 2nd Edition. Springer Verlag, Vienna 2013
11. ↑ Nursing Interventions Classification (NIC) ( Memento of the original from November 29, 2006 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 
12. ↑ Nursing Outcomes Classification (NOC) ( Memento of the original from October 13, 2006 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 
13. ↑ P. Wieteck (Ed.): Practice guidelines care, planning and documentation based on care diagnoses of the ENP classification . RECOM Verlag, Kassel 2013