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
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.
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.