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The use of nursing diagnoses in perioperative documentation

Kristiina Junttila1, Maija Hupli, Sanna Salanterä

  • 1Hospital District of Helsinki and Uusimaa, Finland. kristiina.junttila@hus.fi

International Journal of Nursing Terminologies and Classifications : the Official Journal of NANDA International
|May 27, 2010
PubMed
Abstract

Related Concept Videos

Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
Nursing Diagnosis01:22

Nursing Diagnosis

Following assessment, a nursing diagnosis is the next step in the nursing process. It begins after the nurse has collected and recorded the patient data. The purpose of diagnosing is to identify how the client responds to actual or potential health processes, identify factors that bestow or that cause health problems, the etiologies, and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.
The nursing diagnosis focuses on evidence-based...
Formulating and Validating Nursing Diagnosis I01:26

Formulating and Validating Nursing Diagnosis I

A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing interventions. The standardized terminologies of a nursing diagnosis help nurses identify and treat patients' problems. Every electronic health record that uses nursing diagnosis must employ standard diagnostic terminology. Developing an efficient, individualized care plan begins with accurate nursing diagnoses.
There are thirteen domains for...
Formulating and Validating Nursing Diagnosis II01:25

Formulating and Validating Nursing Diagnosis II

Nursing diagnoses represent a problem validated by major defining characteristics. There are four categories of nursing diagnoses: problem-focused, risk, health promotion or wellness, and syndrome. The anatomy of a nursing diagnosis includes three components: problem statement or diagnostic label, defining characteristics, and related factors.
Risk nursing diagnoses represent clinical judgments of an individual, family, or community more vulnerable to developing the health problem than others...
Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Role of Communication in the Nursing Process I: Assessment and Diagnosis01:25

Role of Communication in the Nursing Process I: Assessment and Diagnosis

The nursing process uses scientific reasoning, problem-solving, and critical thinking to guide nurses in providing patients with appropriate care. This process is a systematic approach to recognize, avoid, and treat current or potential health issues while promoting the patient's well-being.
The nursing process considers the patient's emotional and physical well-being. The process can be repeated or stopped at any point if judged essential. Assessment is the first step in the nursing process.