Nursing diagnosis: an overview and application to emergency nursing.

Abstract

N ursing diagnosis has been discussed for more than two decades, but its impact on clinical practice has actually been felt only during the past few years. Nursing diagnosis is the identification of the human response to acute episodes of illness and injury. Once the patient is assessed and a diagnosis has been made, treatment of the human response to the diagnosis may begin. Not only is the impact of nursing diagnosis felt in the actual delivery of nursing care, but nursing diagnosis presents a foundation on which to build standards of care and the whole definition and scope of nursing practice. Nursing has historically focused on the immediate needs of the patient without fully understanding, many times, the pathophysiology behind the actions. Emergency nurses, in particular, take pride in our rapid response to patients in distress. What nursing diagnosis requires is that we slow our assessment enough to gather clinical objective and subjective data about the patient. We then use those data to place a nursing diagnostic label. Once the label is placed, specific patient care may be planned and executed. A recent master’s degree thesis, by Abel,’ demonstrates that in multiple trauma situations, nurses quickly assess patients in a logical manner, and whether or not they are aware of the process, they do make nursing diagnoses that are appropriate for each patient. Nursing diagnosis focuses on the underlying defining characteristics that cluster together to force the diagnosis labeling. Diagnostic labeling without underlying patient assessment is inappropriate. As nursing develops as a clinical science, increasing evidence is being placed on professionalism, accountability, and nursing research. Nursing is focusing more on its own domain of practice. ‘The challenge has been to operationally define nursing and to determine the uniqueness of nursing as a clinical science. Nursing diagnosis has been an important concept and an important part of the development of professional nursing.