Diagnostic classification

Diagnostic classification

Diagnoses are only included in ATIC if there exist nursing scientific production (evidence) on their identification, management or prevention. The allow the representation of problems or situations that require nursing intervention to optimize health status and prevent deterioration:

      • In health, for its preservation
      • In relative health, to prevent disease and promote the reestablishment of the previous status.
      • In disease, to prevent disabilities, complications – or their progression or recurrence – and promote the restoration or achievement of the best possible health status.
      • At the end-of-life, 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

Actual diagnosis

Clinical judgment on the presence of a problem, situation or response evidenced by various manifestations, signs, symptoms or other observable, measurable and perceptible clues.

Example in ATIC: Complicated grief

Risk diagnosis
  • Clinical judgment resulting from the identification of risk factors and/or vulnerability factors.
  • Risk factors refer to the existence of objective variables that establish the presence or magnitude of a threat or danger.
  • 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

Suspected diagnosis

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 : Suspected sexual abuse

The categories in this classification are mutually exclusive.

 

Classification of ATIC diagnoses according to their Level

Level Definition

Main diagnosis
  • 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 effect, seriousness, severity and/or potential to produce complications, or their rol as etiological factor, high risk factor or trigger for other problems, generates the greatest need for nursing care in terms of immediacy of its management, intensity and/or complexity.
  • Interventions aimed at addressing the main diagnosis may also be useful in the provision of care for secondary diagnoses however, they should not be repeated in the patient care plan.
  • The main nursing diagnosis is a useful, validated an indicator of required nursing hours per patient day (rNHPPD). (ATIC Patient Classification System ).

Secondary diagnosis

Clinical judgment (or the conclusion of several judgments) about the problem/s or situation of the person (family, group or community) that coexist with the main diagnosis, from its identification or further on, that generates the need for additional care.

*The categories in this group are mutually exclusive.

 

Classification of ATIC diagnoses according to their Formulation

Category Definition

Descriptive diagnosis
  • Explanatory clinical judgment of an actual problem or situation.
  • Commonly identify injuries, illnesses or symptoms that require control.

 

Examples in ATIC : Chronic pain

Causal diagnosis

Clinical judgment that includes the problem or situation and its etiological factors in its formulation.

 

Examples in ATIC: Suffering from near-death experience

Predictive diagnosis

Clinical judgment on a probable progression.

Examples in ATIC: Risk of stroke 

Evaluative diagnoses

Clinical judgment on the actual and potential changes in the person's status, 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

Surveillance and prevention oriented diagnoses
  • Clinical judgment (or the conclusion of several judgments) about the course of an individual (family, group or community) at risk of evolving towards deterioration or worsening health status, from minor to major seriousness, or placing them on the path to impending life-threatening risk or integrity hazard.
  • This class of diagnosis focuses on health status screening, monitoring and prevention of health and its deterioration, including progression to aggravation or exacerbation states, and progression or recurrence of complications and adverse events.
  • Surveillance and prevention oriented diagnoses (SPoD) are sub-classified into five categories:
    • Primary SPoD
    • Secondary SPoD
    • Tertiary SPoD
    • Quaternary SPoD
    • Critical SPoD

Primary surveillance and prevention oriented diagnoses

Clinical judgment aimed at identifying and controlling risk factors for health and social determinants of health.

Example in ATIC: Sedentary behavior

Secondary surveillance and prevention oriented diagnoses

Clinical judgment aimed at screening and early detection of vulnerable, premorbid or disease conditions.

Example in ATIC: Risk of child neglect

Tertiary surveillance and prevention oriented diagnoses

Clinical judgment oriented to monitoring situations or problems that require follow-up care in the presence of chronic conditions or fragility, or stabilization to avoid acute deterioration in the context of acute conditions .

Examples in ATIC: Risk of infection recurrence / progression

Quaternary surveillance and prevention oriented diagnoses

Clinical judgment aimed at the prevention of avoidable problems and adverse events resulting from healthcare services.

Examples in ATIC: Risk of extravasation

Critical surveillance and prevention oriented diagnoses

Clinical judgment aimed at preventing further acute deterioration and the risk of impending death.

Example in ATIC: Risk of cardiogenic shock

Autonomy oriented diagnoses

Clinical judgment about the status and the ability of the person to choose their own options according to their convictions, reasoning and goals, in the context of the relationship and interaction with others , so the person who is able of identifying and cooperate with their caregiver is also autonomous, in terms of activities of daily living, personal development, will and decision-making.

Example in ATIC: Risk of caregiver compassion fatigue

Well-being and symptom control oriented diagnoses

Clinical judgment on the need of the person to improve their integral balance, their comfort level and relieve physical , emotional, social and / or spiritual suffering .

Example in ATIC: Fatigue

Injuries and minor illnesses diagnoses

Clinical judgment on localized damage to tissue integrity  without systemic involvement, or the presence of indispositions, physical conditions or minor illnesses that usually self-limit and have a time-bound impact on daily life.

Example in ATIC: Common cold

Emergency diagnoses

Clinical judgment aimed at addressing hyperacute health conditions, complications or situations that imply an impending threat to the person's life or integrity. 

Example in ATIC: Cardiorespiratory arrest

Rehabilitation oriented diagnoses

Clinical judgment oriented to physical, behavioral or psycho-emotional, interactional, or functional recovery .

Example in ATIC : Post ICU syndrome

Environmental adaption diagnoses

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 deteriorating adaption to the new health status

Adverse outcomes

Clinical judgment of avoidable events or actual negative consequences resulting form healthcare services.

Examples in ATIC: Extravasation

Cluster diagnoses

Clinical judgment that cluster a set of problems that share a common etiology.

Examples in ATIC: Newborn physiological immaturity
*Some categories in this classification may not be mutually exclusive.