A nursing diagnosis can be a clinical diagnosis regarding human, family, and community relationships to current or potential medical conditions/care transitions/life-style changes. The clinical documentation of nursing diagnosis defines the specifics of the nursing assignments, patient characteristics, and pertinent nursing management perspectives. It includes a description of care plans, case management planning, and discharge planning.
The nursing diagnosis definition has four major steps: manual clinical evaluation, patient/family history, descriptive evaluation, and nursing research. In manual clinical evaluation, nursing specialist perform a comprehensive examination to obtain information on the nursing assignments, patients’ medical histories, and other aspects as deemed relevant by the nursing team. The nursing history includes detailed information regarding the patient’s medical condition and treatment history. The next step in the nursing diagnosis definition is the descriptive evaluation, which is an investigation of what would be expected from the patient with regard to his or her nursing and rehabilitation services. The final step in the nursing diagnosis definition process is nursing research, which involves a systematic review of the data regarding the nursing assignments, patient’s medical history, and other factors considered relevant. The aforementioned steps are performed in conjunction with other areas such as implementation, supervision, evaluation, and evaluation.
Nursing diagnosis refers to various terms used by people who supervise nursing staff in different disciplines. In nursing, the term patient care is usually used in reference to care provided by nursing staff to patients. This diagnosis is also used to specify various nursing actions. For example, the nursing diagnosis definition might specify that a patient has been discharged home after a seven-day hospital stay, when in reality, the patient spent one night in the hospital and two nights in the home. In this latter example, the seven-day hospital stay was considered a complete nursing diagnosis, while the two-night stay at home was categorized as an error of administration.
A number of problems can occur when nursing diagnosis is misused. One major problem is the tendency for nurses to consider their own actions during the course of nursing care as nursing research. Nurses might use their findings to justify unnecessary actions by other means. Also, some my review here nurses research findings so extensively that they come to the wrong conclusions about a particular clinical trial, a financial proposal, or marketing plan.
A number of reviews have found that nursing diagnosis definition is generally accurate. However, the tendency for nursing researchers to search for only those facts that support their own nursing opinions can lead to the invalidation of nursing research findings. For example, the results of a meta-analysis involving placebo effects showed only a very small effect size (0.10) for the effects of medical treatment for depression. While the reviewer thought that the results were statistically significant, the journal that published the study did not take into account the placebo effects factor, thus invalidating the entire conclusion based on this small data set.
Another problem occurs when the definition of nursing diagnosis is too narrow. The guideline book of the American Board of Nursing recommends that a nurse should diagnose a condition based on the standard criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Narrowing the scope of nursing diagnosis greatly increases the risk of issuing false positive results. This can be especially problematic for conditions that, if left untreated, may become life-threatening.
The guideline also recommends that a nurse use the International Statistical Classification of Diseases and Disorders (ISD) version IV as the source for any demographic data. The current ICD-IV classifications are based on the North American Association of Health Services (AHDS) classification system. Although these classifications are recommended for use in nursing diagnosis, they are limited in accuracy and often lead to the identification of nonexistent conditions.
Many other reviews have found that the vast majority of classifications used in research studies conform to the official nursing diagnosis definition. One major difficulty occurs when researchers examine the large amount of variability within the guideline manual. Variability exists both between countries and within agencies within countries. For example, in most countries, agencies outside of clinical practice do not typically use the same definitions for diagnosing various medical conditions.