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Related Concept Videos

Formulating and Validating Nursing Diagnosis I01:26

Formulating and Validating Nursing Diagnosis I

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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...
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Nursing Diagnosis01:22

Nursing Diagnosis

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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...
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Nursing Process for Patient and Caregiver Teaching I: Assessment and Diagnosis01:24

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The nursing process provides a clinical decision-making framework for patients and families to establish and implement a personalized care plan. Since part of the nurse's duties is to teach patients, the steps of the nursing process are the most effective way to approach instruction. The nursing process and the teaching-learning process are inextricably linked.
It is critical to determine the patient's learning needs during the assessment. Determination of learning needs compounds data...
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Formulating and Validating Nursing Diagnosis II01:25

Formulating and Validating Nursing Diagnosis II

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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...
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Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

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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...
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Role of Communication in the Nursing Process I: Assessment and Diagnosis01:25

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

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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...
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Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit
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Nursing diagnoses focused on universal self-care requisites.

Carmen Queirós1,2,3,4, Maria Antónia Taveira Cruz Paiva Silva2,5, Inês Cruz1,2,5

  • 1Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal.

International Nursing Review
|February 4, 2021
PubMed
Summary

Portuguese nurses identified nursing diagnoses related to universal self-care, highlighting a lack of consensus in terminology. Standardized language in electronic health records requires a nursing ontology for improved care and interoperability.

Keywords:
Activities of Daily LivingElectronic Health RecordsFocus GroupsModelsNursingNursing DiagnosesStandardized Nursing Terminology

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Area of Science:

  • Nursing
  • Health Informatics
  • Gerontology

Background:

  • Aging populations and rising chronic diseases increase dependence on self-care.
  • International Classification for Nursing Practice (ICNP) is utilized by Portuguese nurses for electronic health record documentation.

Purpose of the Study:

  • To identify and analyze nursing diagnoses documented by Portuguese nurses concerning universal self-care requisites.
  • To pinpoint syntax issues in nursing diagnoses affecting semantic interoperability.
  • To propose unified nursing diagnosis syntaxes for universal self-care requisites.

Main Methods:

  • Qualitative study employing inductive content analysis of nursing e-documentation.
  • Focus group discussions to explore implicit criteria and refine content analysis findings.

Main Results:

  • Content analysis of 1793 nursing diagnoses yielded 432 related to universal self-care requisites.
  • An additional 110 nursing diagnoses were identified after applying new encoding criteria from a focus group.

Conclusions:

  • Nursing diagnoses for universal self-care can indicate individual impairments or potentialities.
  • A lack of consensus exists in nominating nursing diagnoses for deficits in universal self-care, leading to varied terminology for similar needs.
  • Achieving semantic interoperability and improved care quality requires more than standardized language; electronic health records need integrated nursing ontologies.