What's your diagnosis?

Nursing, Jan 2000 by Christensen, Robert A, Taylor, Cynthia M

HELPING OUR PATIENTS

Let's look at what nursing diagnoses help us achieve for our patients. A careful analysis of our assessment data leads us to clusters of specific signs and symptoms that help us rule a particular nursing diagnosis in or out. We can then set clear expectations and establish interventions for the patient.

So why use the language that NANDA employs to identify a particular nursing diagnosis? Why not have each nurse express the problem in terms that seem correct to the individual practitioner? Let's suppose that you're working in a critical care unit. Your patient has suffered major head trauma. Your assessment leads you to identify three nursing diagnoses:

1. self-care deficit: dressing, grooming, feeding related to perceptual or cognitive impairment

2. verbal impairment: barrier because patient is intubated

3. mobility impairment related to perceptual or cognitive impairment.

You develop outcomes that the patient can achieve in the time that he's under your care. The diagnoses and the outcomes form the basis for your nursing interventions.

The patient moves on to step-down care and then to rehabilitation. The previously identified nursing diagnoses most likely won't change, but the goals and interventions will as the patient progresses through the stages of his recovery or illness. Even if the patient needs home care, the nurse coming into the home can build the plan with the patient and family using the diagnoses, outcomes, and interventions that other nurses have specified.

As the patient moves through the health care system, his nursing care remains continuous and consistent. In addition, nursing diagnoses give the nurse the chance to exercise independent clinical judgment.

Many of the technical tasks we do require clinical judgment, but these are based largely on a physician's orders or standard protocols. Although an important function of nursing, orders represent only one facet of the care we give. If we accept monitoring critical functions and doing tasks ordered by other health care professionals as our only role, then we agree to function simply as high-level technicians.

A UNIQUE CONTRIBUTION

Nursing diagnosis defines the nature of nursing practice and brings us into a place among the health care professions where we contribute uniquely to the holistic well-being of individuals, families, and communities. We have a chance to make a difference in our patients' care, but we need to work together to analyze, use, and test the nursing diagnoses that have been approved for our practice.

Robert A. Christensen is clinical nurse III in the critical care unit at El Camino Hospital in Mountain View, Calif. Cynthia M.Taylor is an independent nurse-consultant and president of GCT, Inc., of Rockville, Md. She is the author of the Nursing Diagnosis Reference Manual, 4th edition, published by Springhouse Corporation in 1998.