The three elements of nursing diagnosis are name, related factors (or reasons) and diagnostic basis.
The name is a concise description of the health status of the nursing object. There are four types: existing problems, high-risk problems, good health and medical cooperation problems. Related factors are some reasons that lead to the occurrence or influence the development of problems, which are described by "correlation", including pathophysiology, treatment, situational factors and growth and development factors.
The basis of diagnosis is the symptoms, signs and related examination results of the nursing object. Divided into primary foundation and secondary foundation. The main basis refers to the symptoms and signs that confirm the establishment of nursing diagnosis, and the secondary basis is the possible symptoms and signs.
The terms of nursing diagnosis are explained as follows:
Nursing diagnosis is a clinical judgment about the response of individuals, families or communities to existing or potential health problems and life processes, and it is the basis for nurses to choose nursing measures to achieve the expected results. These results should be the responsibility of nurses.
basic element
brief Introduction of the content
Nursing diagnosis includes four basic elements: diagnostic name, definition, diagnostic criteria and related factors.
diagnose
Describe the health status (existing or potential) of the nursing object in concise words. Specific words such as "change", "obstacle", "lack" and "ineffectiveness" are mainly used to describe the change of health status, but they cannot express the degree of change.
definition
This is a clear and correct name expression. In order to express the significance of diagnosis and its difference from other diagnoses simply and clearly.
standard
Making this diagnosis is the standard of clinical judgment. These standards are a sign, or a symptom, or a group of symptoms and signs, and may also be risk factors, and these standards are the reactions that individuals or groups actively express or observe.
This can be subjective or objective, and there are two kinds of subjective data and objective data: the main data must appear in the short-term diagnosis; Auxiliary data may appear during diagnosis.
factor
It refers to the change of health status or other problems caused by clinic or individuals. And these are usually "related" to nursing diagnosis.
Due to the natural differences and uniqueness of human individuals, the related factors vary from person to person due to different conditions. Relevant factors can be pathophysiology (biological or mental), psychology, treatment-related, situation (environment or individual) and maturity (i.e. age).