制定和验证护理诊断 I

The 13 domains for health problems in taxonomy order are health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationships, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development. These standardized domains help nurses systematically identify and categorize patient health problems across all dimensions of human experience.

The PES format stands for Problem, Etiology, and Symptom. The problem statement comes first, followed by etiology connected with 'related to,' and then symptoms introduced by 'as manifested by' or 'as evidenced by.' For example: 'Hyperthermia related to urinary tract infection as evidenced by a body temperature of 39 degrees Celsius' demonstrates the complete PES structure.

Nursing diagnoses must use legally acceptable and non-judgmental language to maintain professional standards and avoid bias. For instance, 'chronic pain related to improper medication use' is more appropriate than 'recurrent pain related to insufficient medication' because it focuses objectively on the clinical situation rather than making subjective evaluations about patient behavior or care quality.

A problem-focused nursing diagnostic statement includes three parts: a diagnostic label (the standardized term describing the patient's health response), related factors (the etiology or circumstances that caused the response), and significant defining characteristics (major assessment findings). These elements work together to create a complete clinical picture of the patient's problem.

A risk nursing diagnosis contains only two elements: a diagnostic label and associated risk factors, rather than the three components of a problem-focused diagnosis. Risk diagnoses identify potential health problems that may develop if preventive nursing interventions are not implemented, whereas problem-focused diagnoses address existing health issues already present in the patient.

A health promotion nursing diagnosis consists of only two elements: the diagnostic label and defining features or assessment findings. Unlike problem-focused diagnoses that address existing health problems, health promotion diagnoses focus on enhancing patient wellness and supporting positive health behaviors and outcomes.

The problem statement is critical because it emphasizes the patient's actual health problem and provides the foundation for the entire diagnosis. A clear problem statement ensures the diagnosis focuses on what the patient is experiencing rather than their needs, enabling nurses to develop accurate, individualized care plans and select appropriate independent nursing interventions.