hi, jules6616, and welcome to allnurses!
a nursing diagnosis is merely a label you place on a patient's "problem".
this is how you choose nursing diagnoses. . . it involves the nursing process and really has nothing to do with what the patient's medical diagnoses are
. nursing diagnoses are based upon symptoms the patient has that you discover through the process of assessing the patient.
(from page 4 of nursing diagnosis handbook: a guide to planning care
, 7th edition, by betty j. ackley and gail b. ladwig)
"when the assessment is complete, identify common patterns/symptoms of response to actual or potential health problems and select an appropriate nursing diagnosis label using critical thinking skills.
- highlight or underline the relevant symptoms.
- make a short list of the symptoms.
- cluster similar symptoms.
- analyze/interpret the symptoms.
- select a nursing diagnosis label that fits with the appropriate related factors and defining characteristics.
the process of identifying significant symptoms, clustering or grouping them into logical patterns, and then choosing an appropriate nursing diagnosis involves diagnostic reasoning (critical thinking) skills that must be learned in the process of becoming a nurse."
(from page 10 of nursing care plans: guidelines for individualizing client care across the life span
, 7th edition, by marilynn e. doenges, mary frances moorhouse and alice c. murr)
"nursing diagnosis labels provide a format for expressing the problem identification portion of the nursing process. in 1989, nanda developed a taxonomy or classification scheme to categorize and classify nursing diagnostic labels. the nanda definition of nursing diagnosis approved in 1990 further clarified the second step of the nursing process (i.e., problem identification/diagnosis). [nanda definition of nursing diagnosis: nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problem/life processes. nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.]
there are several steps involved in the process of problem/need identification. integrating these steps provides a systematic approach to accurately identifying nursing diagnoses using the process of critical thinking.
- collecting a client database (nursing interview, physical assessment, and diagnostic studies) combined with information collected by other healthcare providers.
- reviewing and analyzing the client data.
- synthesizing the gathered client data as a whole and then labeling your clinical judgment about the client's responses to these actual or high-risk problems/life processes
- comparing and contrasting the relationships of your clinical judgments against related factors and defining characteristics for the selected nursing diagnosis. this step is crucial to choosing and validating the appropriate nursing diagnosis label that will be used to create a specific client diagnostic statement.
- combining the nursing diagnosis with the related factors and defining characteristics to create the client diagnostic statement. for example, the diagnostic statement for a paraplegic client with a decubitus ulcer could read: impaired skin integrity related to pressure, circulatory impairment, and decreased sensation evidenced by draining wound, sacral area.
the nursing diagnosis is as correct as the present information allows because it is supported by the immediate data collected. it documents the client's situation at the present time and should reflect changes as they occur in the client's condition. accurate need identification and diagnostic labeling provide the basis for selecting nursing interventions.
the nursing diagnosis may be a physical or a psychosocial response. physical nursing diagnoses include those that pertain to physical processes, such as circulation (ineffective renal tissue perfusion), ventilation (impaired gas exchange), and elimination (constipation). psychosocial nursing diagnoses include those that pertain to the mind (acute confusion), emotions (fear), or lifestyle /relationships (ineffective role performance). unlike medical diagnoses, nursing diagnoses change as the client progresses through various stages of illness/maladaptation to resolution of the problem or to the conclusion of the condition. each decision the nurse makes is time dependent, and, with additional information gathered at a later point in time, decisions may change. for example, the initial problems/needs for a client undergoing cardiac surgery may be acute pain, decreased cardiac output, ineffective airway clearance, and risk for infection. as the client progresses, problems/needs are likely to shift to activity intolerance, deficient knowledge, and ineffective role performance.
diagnostic reasoning is used to ensure the accuracy of the client diagnostic statement. the defining characteristics and related factors associated with the chosen nursing diagnosis are reviewed and compared with the client data. if the diagnosis is not consistent with a majority of the cues or is not supported by relevant cues, additional data may be required or another nursing diagnosis needs to be considered."
what all this is saying is that you must follow the steps of the nursing process to determine your patient's nursing diagnoses. those steps are:
- assessment (collect data from medical record and by doing a physical assessment of the patient)
- nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
with assessment being the most important one. finish your assessment of the patient and follow the advice and instructions of the authors above to find the nursing diagnoses for your patient. if you are still having difficulties, then post a question along with your patient data
. however, medical diagnoses tell us nothing about your patient's nursing problems.
there is also help for writing care plans and determining nursing diagnsoes on these two sticky threads of the nursing forums: