Cấu trúc của một chẩn đoán điều dưỡng Chẩn đoán điều dưỡng

Theo tổ chức quốc tế NANDA, hệ thống chẩn đoán điều dưỡng gồm có 4 phần:

  1. Chẩn đoán các nhu cầu thực tại - "A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community". An example of an actual nursing diagnosis is: Sleep deprivation.
  2. Xác định các nguy cơ - "Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability." An example of a risk diagnosis is: Risk for shock.
  3. Đề nghị người bệnh thay đổi các hành vi sức khỏe có lợi - "A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state." An example of a health promotion diagnosis is: Readiness for enhanced nutrition.
  4. Chẩn đoán các hội chứng - "A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions." An example of a syndrome diagnosis is: Relocation stress syndrome.[1]