Nursing Diagnosis and Care Plan
Nursing diagnosis is crucial since it determines the quality of care plan to be offered to a patient to enhance the quality of their health. The nursing diagnosis is used to show the potential problems a patient is likely to face while the care plan contains information about diagnosis treatment goals, nursing observations plus evaluation (Wang, Ping and Hailey 562). The diagnosis should be carried out accurately to determine the care plan. It is the responsibility of a nurse to observe a patient closely or refer them to any specialist for purposes of identifying the cause of their ill health (Wang, Ping and Hailey 564). The reason is that poor diagnosis will also lead to poor care plans. The purpose of nursing diagnosis and care plan is to promote quality healthcare thus they should be accurate.
Nursing diagnosis is grouped into actual, risk, and wellness statements. The actual statements involve the problems currently identified by a nurse. Risk statements include the problems that a patient is likely to face (Caldeira 46). Wellness statements involve the health activities that may be used to improve quality of health. Therefore, the nursing diagnosis should involve data analysis and problem identification. The information collected during the diagnosis will be shared among healthcare professionals using the care plans. The other healthcare plans will use the care plans to make decisions about the treatment procedures of a patient (Caldeira 48). The care plan will be updated as the patients’ condition continues to change positively or negatively. Therefore, the information received from nursing diagnosis is used to develop a care plan which is important in evaluating the progress of a patient.
Nursing diagnosis should focus on various aspects of health including physical, psychological, social and spiritual health. The reason is that care plans will require information from the nursing diagnosis on various aspects of health (Lake, Germack and Molly Viscardi 536). For example, psychological health may be an indicator of health problems that are likely to develop. Therefore, care plans focus on holistic health management and the prevention of diseases. Additionally, once the nursing diagnosis has identified the health problems, the care plans are used to identify the expected patient outcomes (Lake, Germack and Molly Viscardi 538). Therefore, nurses can evaluate if they are achieving the projected patient outcomes. Changes in the projected goals will be used to adjust the medication or other health procedures, but promote continuity of care, to ensure the patient is making positive progress towards total recovery.
Caldeira, Sílvia. “Clinical validation of the nursing diagnosis spiritual distress in cancer patients undergoing chemotherapy.” International Journal of Nursing Knowledge 28.1 (2017): 44-52.
Lake, Eileen T., Hayley D. Germack, and Molly Kreider Viscardi. “Missed nursing care is linked to patient satisfaction: a cross-sectional study of US hospitals.” BMJ Qual Saf 25.7 (2016): 535-543.
Wang, Ning, Ping Yu, and David Hailey. “The quality of paper-based versus electronic nursing care plan in Australian aged care homes: A documentation audit study.” International Journal of Medical Informatics 84.8 (2015): 561-569.