Nursing diagnoses

Medical diagnoses are but one basis upon which health professionals may be guided to intervene in response to a health care need. Since 1973 work has been undertaken by the National Group for the Classification of Nursing Diagnosis in the USA to develop a system of nursing diagnoses. They refer to actual or potential health problems which nurses by virtue of their education and experience are capable and licensed to treat (Gordon, 1976). The benefit of this system is that it provides a method of framing patients’ needs for nursing in ways other than by medical diagnosis alone, giving a partial indication of the implications for nursing intervention to aid the process of care planning. It is also a reminder that nursing care of the skin is a fundamental consideration and transcends the scope of dermatological disease, by highlighting the range of causes of impaired skin integrity and skin at risk of impairment. The classification system has progressively developed taxonomy of nursing diagnoses since 1973. The development of nursing diagnoses is directed towards standardising nursing terminology; this process is now led by the North American Nursing Diagnosis Association (NANDA). This process aims to achieve the following outcomes (NANDAInternational, 2007):

• name client responses to actual or potential health problems, life processes and wellness;
• documentation of nursing care;
• contribute to the development of informatics and information standards, ensuring the inclusion of nursing terminology in electronic health care records; and
• facilitates the study of the phenomena of concern to nurses to improve patient care.

Related developments have been led by the International Council of Nurses (ICN) to develop the International Classification for Nursing Practice (ICNP^®).

The system used within the NANDA-I taxonomy utilises what are termed axes, which are defined as a dimension of the human response that is considered in the diagnostic process (NANDA-International, 2007). These include: (1) the diagnostic concept (fundamental root of the diagnostic statement), for example skin integrity, mucous membrane, bathing hygiene self-care; (2) the subject of diagnosis (individual, family and community); (3) judgement (impaired, ineffective); (4) location (e.g. skin); (5) age (infant, child, adult); (6) time (chronic, acute, intermittent); and (7) status of diagnosis (actual, risk, wellness, health promotion). Those nursing diagnoses directly related to skin care (NANDA-International, 2007) are summarised in Table 3.6.

Table 3.6 Nursing diagnoses directed related to skin health (NANDA-International, 2007).   Nursing diagnosis   Definition   Defining characteristics   Related or risk factors   Impaired skin integrity   Altered epidermis and/or dermis   Destruction of skin layers Disruption of skin surface Invasion of body structures   Related external factors: chemical substance, extremes of age, humidity, hyperthermia, hypothermia, mechanical factors (e.g. shearing forces, pressure, restraint), medications, moisture, physical immobilisation, radiation. Related internal factors: Change in fluid status, changes in pigmentation, changes in turgor, developmental factors, imbalanced nutritional status, immunological deficit, impaired circulation, impaired metabolic state, impaired sensation, skeletal prominence.   Risk for impaired skin integrity   At risk for skin being adversely altered       Related risk external factors: chemical substance, extremes of age, humidity, hyperthermia, hypothermia, mechanical factors, medications, moisture, physical immobilisation, radiation, secretions. Related risk internal factors: Change in fluid status, changes in pigmentation, changes in turgor, developmental factors, imbalanced nutritional status, immunological factors, impaired circulation, impaired metabolic state, impaired sensation, skeletal prominence, medication, psychogenic factors.

Of course, given the range of nursing diagnoses, generic needs for nursing may be manifested in a person with a skin health problem. For example, in supporting a child with severe atopic eczema, there may also be considerations regarding the following nursing diagnostic areas: for example, parenting, parental–child attachment, parental role conflict, caregiver role strain, infant feeding pattern, self-esteem, social isolation, anxiety and sleep deprivation – to name only some possible dimensions. Consideration of nursing diagnoses within a skin/dermatological nursing context may highlight a broader range of needs for nursing that may arise from a pathological problem (dermatological disease or other condition impacting on the skin) for which there may be a wide range of human responses and scope for nursing intervention through care planning.