Nursing diagnosis is a clinical decision about the response of individuals, families and communities to actual or potential health problems, where based on their education and experience, nurses can responsibly identify and provide definite interventions to maintain, reduce, limit, prevent and change the client's health status (Yeni, 2008). To be able to formulate nursing diagnoses requires high analytical skills in determining and understanding the appropriate actions or decisions of each nurse.
In the patient status that has been studied, it can be seen that the nurse only chooses the nursing diagnoses that have been provided on the side of the assessment format. This makes it easier for nurses but can also cause nurses to be lazy and lack the initiative to analyze data and then formulate their own nursing diagnoses if different data are found. Such conditions also cause the quality of documentation of nursing diagnoses to be monotonous (Hartati, Handoyo, Anis, 2010)
Nurses as health workers who are tasked with meeting the basic needs of clients holistically have a responsibility to help fulfill the client's inadequate oxygen needs. Nursing care must carry out nursing methods in the form of assessment, nursing diagnosis, intervention, and evaluation.
Nursing diagnoses can be divided into 5 categories: Actual nursing diagnosis, Risk nursing diagnosis, Possible nursing diagnosis, Wellness nursing diagnosis and Syndrome nursing diagnosis.
1. Actual nursing diagnosis
Describes the current real problem in accordance with the clinical data found. The condition for establishing an actual nursing diagnosis must include an element of PES. Symptoms (S) must meet the major criteria and some minor criteria from the NANDA diagnostic guidelines.
2. Risk nursing diagnosis
Explain the real health problems that will occur if no intervention is carried out. Conditions for enforcing the risk of nursing diagnoses include elements of PE (problem and etiology). The use of the term “high risk and risk” depends on the severity / susceptibility to the problem.
Diagnosis: “Risk for impaired skin integrity related to persistent diarrhea continuously".
3. Possible nursing diagnosis
Explained that additional data were needed to confirm possible nursing problems. In this situation, the problems and supporting factors do not yet exist, but there are factors that can help
cause problems. Requirements for enforcing possible nursing diagnoses include elements of a response (problem) and factors that might cause problems but do not yet exist.
4. Wellness nursing diagnosis
Wellness nursing diagnosis is a clinical decision about the state of an individual, family, and/or society in transition from a certain level of well-being to a higher level of well-being. There are 2 keys that must be present: 1) Something pleasant at a higher level of well-being 2) The existence of an effective status and function.
5. Syndrome nursing diagnosis
A syndrome nursing diagnosis is a nursing diagnosis consisting of a group of actual or risk nursing diagnoses, which are suspected to arise due to a particular event or situation.