Therapeutic diagnosis is a description of a disease and a group of symptoms and signs, with a name to explain the cause and pathophysiological changes of the disease, so as to guide the treatment measures; Nursing diagnosis describes the existing or potential nursing problems that affect patients' health due to pathological and psychological changes, and is the basis for formulating nursing measures. Nursing diagnosis is made by nurses. Nursing diagnosis should refer to medical diagnosis, understand patients' pain and physiological needs, take measures to cooperate with medical treatment or doctors to treat diseases, and promote and restore patients' health. It is also necessary to establish different nursing diagnoses according to the individual differences of patients, different psychological and social factors, and different characteristics of their reactions and needs to diseases. The same disease can have different nursing diagnosis, and different diseases can also have similar nursing diagnosis. It is generally believed that nursing diagnosis involves three aspects.
1. cooperative nursing diagnosis
If the doctor's advice is carried out, in this category, the nurse's duty is to make the treatment plan in the doctor's advice accurately implemented. Generally, it is not necessary for nurses to diagnose the problems within the scope of doctor's advice, but it is necessary for nurses to make nursing diagnosis in the process of monitoring the changes of illness and treatment response and preventing complications. For example, if diabetic patients are found to have premonitory symptoms of hypoglycemia, nurses should diagnose "hypoglycemia may be related to the use of insulin", accurately detect urine sugar, adjust diet according to standards, strictly record food intake, observe clinical symptoms, and provide doctors with the basis for adjusting insulin dosage.
2. Cooperative nursing diagnosis
The goal of treating patients is often achieved through the cooperation between nurses and doctors. For example, patients with cerebrospinal fluid leakage "have the possibility of intracranial infection", the medical field is to choose antibiotics, and the nursing work is to cut off the source of infection. For example, put the patient in a clean ward, keep a proper lying position, put a sterile treatment towel on his head, and clean the nasal cavity and external auditory canal regularly to prevent retrograde infection or scab. Prevent colds and prevent coughing from affecting crack healing. This is a process in which doctors and nurses cooperate for the same goal-preventing intracranial infection.
3. Independent nursing diagnosis
According to the patients' existing or potential physical and mental pains or adverse reactions, nurses have the responsibility to diagnose patients' health problems within the scope of nursing functions and choose suitable nursing measures to promote health or alleviate diseases. Limit and prevent all kinds of negative factors that are not conducive to health, including life care, functional exercise, nutritional metabolism, excretory function, rest and sleep, cognitive perception, emotional behavior, family and social support, etc. For example, when patients are afraid of coughing or unable to cough up secretions due to pain, the nursing diagnosis is that "respiratory secretions cannot be effectively removed, which is related to sticky sputum and inability to cough up". Nursing measures are turning over regularly, knocking on the back, atomizing inhalation and blowing bubbles to exercise patients, helping to maintain correct posture, effectively guiding abdominal breathing and coughing to promote sputum discharge and preventing pulmonary complications.
Independent nursing diagnosis is the work done by nurses independently, which is essentially different from medical diagnosis. Cooperation and cooperative nursing diagnosis are related to medical diagnosis. After the patient's medical diagnosis is established, corresponding cooperation and collaborative nursing diagnosis are often adopted, but this is not absolute. Due to the differences of patients' physiological, psychological, family and social factors, the nursing diagnosis of the same medical diagnosis may be different.
The establishment of nursing diagnosis is the embodiment of nurses' independent responsibilities, which is helpful for nurses to decide nursing goals and measures for patients. The role of nursing diagnosis is that nurses can put forward preventive measures, such as health education, function, bedsore prevention and complications prevention. Corrective measures can also be put forward, such as squeezing chest tube regularly to help patients cough, so as to solve the possibility of reducing the efficiency of closed thoracic drainage tube.
In a word, nursing diagnosis reflects the patient's physiological, psychological and social conditions, and suggests the care that patients should receive, which is essentially different from medical diagnosis and closely related.