Perform a nursing assessment to identify pertinent patient issues. Your assessment may include an interview with the patient and/or significant others, a physical examination, a review of the patient’s medical record, and/or consultation with other health care providers. You may also include findings from patient monitors, vital signs, laboratory tests, and other diagnostic studies.
A nursing diagnosis refers to standardized nursing language developed by the North American Nursing Diagnosis Association (NANDA) to allow registered nurses to identify patient issues in a way that can be consistently communicated across clinical settings. Nursing diagnoses identify issues that can be appropriately addressed by nurses, as opposed to medical diagnoses that reflect physician-related issues. According to A Texas Resource for Advocates of Nursing Education, an online resource for nurses, most well-written nursing diagnoses have three parts.
Things You'll Need
- Intranet access
- Current RN license
Briefly scan the NANDA list of approved nursing diagnoses to see if any match the findings from your assessment. While there are entire books on the subject, you can also choose quick access online at sites such as Scribd.com. (Find a link in References.) Some hospitals provide pocket cards with relevant nursing diagnoses, and there are commercial products available as well.
Select an appropriate nursing diagnosis and determine whether it has two or three parts. Most nursing diagnoses are comprised of the NANDA diagnostic label, a related factor, and the evidence to support the diagnosis. “Risk for” nursing diagnoses will have only two components: the diagnostic label and the related factor(s).
Write out the nursing diagnosis in a standardized way. For most nursing diagnoses, the format would look something like: “Confusion, acute, related to anesthesia, as evidenced by inability to identify person or place." A “risk for” nursing diagnosis might read “bleeding, risk for, related to clotting disorder," with only two parts.
As you and your colleagues deliver nursing care and the patient’s status changes, your nursing assessment may identify the need to alter some of his nursing diagnoses. Once the patient recovers from his anesthesia, for example, the nursing diagnosis related to confusion may no longer be appropriate. The nurse will note that change on the patient’s nursing care plan.
Tips & Warnings
- When you use NANDA terminology and write nursing diagnoses in a standardized way, you're better able to convey recommendations to colleagues in a way that promotes consistency in patient care and improves outcomes.
- A nursing diagnosis is not the same as a medical diagnosis, and there are laws prohibiting nurses from making a medical diagnosis. Stick with NANDA terminology and focus on nursing-related issues.
What Are the Four Types of Nursing Diagnosis Statements?
Based on the nursing diagnosis, ... which is associated with a cluster of predicted high-risk or actual nursing diagnosis, related to a...
Priority Nursing Diagnosis
How to Write a Risk for Nursing Diagnosis. Registered nurses are considered practitioners, and their job is to take care of their...
Wellness Nursing Diagnosis
How to Write a Nursing Diagnosis; Print this article; Emotional Readiness. The first requirement for a wellness diagnosis is a desire to...
Nursing Diagnosis & Rationales
Nursing Diagnosis & Rationales. Nursing diagnoses are not medical diagnoses. ... A two part diagnosis would read "risk for disuse syndrome RT...
How to Formulate Nursing Care Plans
How to Write a Nanda Nursing Diagnosis. NANDA is an acronym for North American Nursing Diagnosis Association. NANDA was founded in 1982...
What Is Community Nursing Diagnosis?
How to Write a Nursing Assessment & Diagnosis; You May Also Like. Nursing Diagnosis for Thrombocytopenia. ... The North American Nursing Diagnosis...
Developing a Nursing Diagnosis Goals & Interventions
Nursing diagnosis, goals and interventions are important parts of the nursing care plan. A nursing care plan summarizes the care a patient...
How to Write a Diagnostic Report
How to Write a Diagnostic Report. ... A pathology report contains four different sections: diagnosis, gross description, microscopic description and comments.
List of Nursing Diagnoses & Interventions
List of Nursing Diagnoses & Interventions. ... The dimpled nipple occurs when only part of the nipple protrudes. You can pull the...
Nursing Diagnosis of Imbalanced Nutrition
Proper nutrition is a vital part of the healing process. Imbalanced nutrition can lead to poor wound healing, heart disease, bone loss...