Diagnostic classification
The diagnoses included in ATIC allow the representation of problems or situations that require nursing intervention to optimize the state of health and prevent deterioration:
- In health, for its preservation
- In the states of relative health, to prevent disease and promote the reestablishment of the previous state.
- In disease, to prevent disabilities, complications – or their progression or recurrence – and promote the restoration or achievement of the best possible state of health.
- In the end-of-life situation, to prevent and alleviate suffering.
Diagnoses in ATIC can be classified according to their:
- Potentiality
- Level
- Formulation (Type of judgment)
- Orientation (Class)
Classification of diagnoses in ATIC according to their Potentiality
| Category | Definition |
|---|---|
|
Real diagnostics |
Clinical judgment about the presence of a problem, situation or response evidenced by various manifestations, signs, symptoms or other observable, measurable or perceptible clues. Example in ATIC: Complicated duel |
|
Risk diagnosis |
Clinical judgment derived from the presence of risk and / or vulnerability factors. Risk factors refer to the existence of objective variables that establish the presence or magnitude of a threat. Vulnerability refers to the susceptibility of being affected by a condition, element, situation, relationship, interaction or influence, despite the absence of objective risk factors. Example in ATIC: Risk of hypothermia |
|
Diagnostic suspicion |
Clinical judgment on the intuition or orientation of the presence of a problem, situation or response, in the absence of more information for its verification. Example in ATIC : Suspicion of sexual abuse |
The categories in this classification are mutually exclusive.
Classification of ATIC diagnoses according to their Level
| Category | Definition |
|---|---|
|
Principal diagnostic |
Clinical judgment (or the conclusion of several judgments) about the problem or situation of the person (family, group or community) that, due to its dimensional affectation, severity, severity and / or potential to produce complications or act as an etiological factor, of high risk or trigger of other problems, generates the greatest need for nursing care in terms of immediacy of its approach, intensity and / or complexity Interventions aimed at addressing the main diagnosis may also be useful in the provision of care for some of the secondary diagnoses , but they should not be repeated in the record of the care plan. The main nursing diagnosis can be used as an indicator of severity and / or risk of mortality (See ATIC Patient Classification System ). |
|
Secondary diagnosis |
Clinical judgment (or the conclusion of several judgments) about the problem / s situation of the person (family, group or community) that coexist with the main diagnosis , from its detection or later, that generate the need for additional care. |
*The categories in this group are mutually exclusive.
Classification of ATIC diagnoses according to their Formulation
| Guy | Definition |
|---|---|
|
Descriptive diagnostics |
Explanatory clinical judgment of a real problem or situation. On multiple occasions they identify injuries, ailments or symptoms that require control. Examples in ATIC : Chronic pain |
|
Causal diagnoses |
Clinical judgment that includes the problem or situation and its etiological factors in its formulation.
Examples in ATIC: Suffering from near death experience |
|
Predictive diagnostics |
Predictive clinical judgment of probable evolution. Examples in ATIC: Risk of stroke |
|
Evaluative diagnoses |
Clinical judgment that contemplates the actual or potential changes in the person's state, from one point in time to the next. Examples in ATIC: Risk of recurrence / progression of peripheral ischemia |
|
Other diagnoses |
Not classifiable in any of the previous categories. |
*The categories of this classification can be combinatorial.
Classification of diagnoses in ATIC according to their Orientation
| Class | Definition |
|---|---|
|
Diagnostics oriented to surveillance and prevention |
Clinical judgment (or the conclusion of several judgments) about the course of an individual (family, group or community) at risk of evolving towards a worsening or worsening of their state of health, from less to more serious, to situations that put at risk imminent his life or his integrity. This type of diagn it or stico focuses on screening, monitoring and prevention of health status and its deterioration, including progression to states of aggravation or exacerbation , and production or recurrence of complications and events adver sos. Diagnoses oriented towards surveillance and prevention are sub-classified into 5 categories:
|
|
Diagnoses or directed to surveillance and primary prevention |
Clinical judgment aimed at the detection and control of risk factors for health or social determinants of health Example in ATIC: Sedentarism |
|
Diagnoses oriented towards surveillance and secondary prevention |
Clinical trial of screening and early detection in vulnerable, premorbid or disease situations. Example in ATIC: Risk of child neglect |
|
Diagnostics oriented to surveillance and tertiary prevention |
Juicio clinical oriented monitoring situations or problems that require follow - up ( in the presence of disease or situation chronic or fragility) and stabilization in situations ( illness or situation acute and subagud a). Examples in ATIC: Risk of infection recurrence / progression |
|
Diagnostics oriented to surveillance and quaternary prevention |
Clinical judgment aimed at the prevention of avoidable problems derived from health care. Examples in ATIC: Risk of extravasation |
|
Diagnostics oriented to surveillance and critical prevention |
Clinical judgment aimed at preventing acute deterioration and the risk of imminent mortality. Example in ATIC: Risk of cardiogenic shock |
|
Autonomy-oriented diagnostics |
Clinical judgment about the state and the ability of the person to choose their own options according to their convictions, reasoning and objectives, in the context of the relationship and interaction with others , so the person who is capable of identifying and cooperating is also autonomous with the people (or elements) on whom it depends, in terms of activities of daily living, personal development, will and decision-making Example in ATIC: Risk of family claudication |
|
Well-being-oriented diagnostics and symptom control |
Clinical judgment on the need of the person to improve their integral balance, their comfort level and alleviate physical , emotional, social and / or spiritual suffering . Example in ATIC: Fatigue |
|
Diagnosis of injuries and ailments |
Clinical judgment on localized damage to tissue integrity , without systemic involvement , or the presence of indispositions, physical conditions or minor illnesses that are self-limited and have a time-limited impact on daily life. Example in ATIC: Common cold |
|
Urgent action diagnoses |
Clinical trial aimed at addressing hyperacute health problems or situations that imply an imminent threat to the life or integrity of the person . Example in ATIC: Cardiorespiratory arrest |
|
Rehabilitation Oriented Diagnoses |
Clinical judgment oriented to physical, behavioral or psycho-emotional or interactional functional recovery . Example in ATIC : Post ICU syndrome |
|
Diagnoses oriented to adaptation to the environment or circumstances |
Clinical judgment on adaptive capacity, coping mechanisms and responses, stress management and relationships and interactions with oneself and with the environment. Example in ATIC: Risk of deterioration of adaptation to the new state of health |
|
Adverse outcomes |
Clinical judgment of problems avoidable or negative consequences , derivad to s health care. Examples in ATIC: Ex- travasation |
|
Cluster diagnostics |
Trial clinical about the status of the person to which adds a set of problems that share an etiology common . Examples in ATIC: Physiological immaturity of the newborn |