Systematic Nursing Diagnosis

e process of A.P.I. E was later modified to A.S.P.I.R.E resulting in the systematic nursing diagnosis stage being brought in; By completing the initial assessment stage, it will help to establish the nursing diagnosis which involves making a decisive statement concerning the client’s needs (George 1995). This is often referred to as a Systematic Nursing Diagnosis; which involves identifying the patient needs from a nursing perspective. This nursing diagnosis differs greatly from that of a medical as it emphasises the holistic needs of the patient (Barrett et al 2009) and recognises individuality. Therefore this takes into consideration the entire needs of a patient. However, problems have been associated with the addition of this stage; one
being the degree to which the Nurse had contributed to the whole Nursing Process (Mason and Attree 1997), for example this would mean that if they had had little involvement in the patients assessment then they would not be able to make accurate judgements by only reading the assessment. After the Nursing diagnosis, a need statement should be produced which is a clear sentence that exactly describes the patients problem or need. Alongside this, should be a set of baseline information.
A baseline offers a description of where the patient is now in relation to the need. Finally, the needs of the patient are prioritised and should be patient-led (Barrett et al 2009). The fact that the patient is fully in charge of this stage means that the care is entirely based and planned around themselves as individuals. RLT (2000) prefer to use the word “assessing” as opposed to “assessment” as it suggests that it is implies a more cyclical activity rather a “once only” one (Holland et al 2003). The main aims of assessment when using RLT (2000) as the nursing model are to; collect information, review and order the information, identify the problems, prioritise the problems and consider the 12 activities of living in order to identify the patients previous and present routines Barrett et al (2009). In the first stage of assessment, it is here where all the information is collected about the patient in order to create a baseline Barrett et al (2009). Roper et al (2000) state that biographical information and health data are vital to ensuring effective assessment of nursing needs (Holland et al
2003). When documenting information regarding the patient, it is seen as essential that any data recorded is kept confidential and accordance with the Data Protection Act (1998). The Data Protection Act (1998) states that “any information you get from someone has to be used in accordance with the reason that they gave it to you to begin with” meaning that in no circumstances, should this information be passed on to anyone without consent from the individual.
The second stage of assessment, the nurse aims at establishing what they patient can and cannot do in terms of each of the activities of daily living (Pearson et al 1986). Here it involves finding out the patient’s usual and present routines as to how they carry out the activities of living, where they are on the dependence/independence continuum, considering their coping strategies, identifying the influencing factors and identifying the nursing care (Barrett et al 2009). The dependence/independence continuum is influenced by an individual’s stage of lifespan; it is how dependant or independent that they are in regards to the activities of living “each person is said to have a dependence/independence continuum for each activity of living” (Healey and Timmins 2003). By conducting the full assessment stage, it will help to provide both qualitative and quantitative
data. Quantitative data is most reliable for such things that need to be measured for example blood pressure readings and helps to provide objective data. Whereas qualitative data gives insight into thoughts, feelings and experiences (Siviter 2008) so is seen as more subjective information. Broom and Willis (2007) state that quantitative data in the past has dominated health care but it has been stated that qualitative data is seen as “unscientific” and “subjective” (Abusabha & Woelfel, 2003).