Potential nursing diagnosis

[Roro]

Dear All,

we introduced in our hospital the PIE (Problem (which is our nursing diagnosis)/Intervention/Evaluation) charting for documenting our nurses' progress note. It is a multidiscplinary record where all nurses, physicians and other healthcare professionals write their notes.

I'd like to seek your advice in two things:1- when we write our Nursing progress note how do we identify the potential Nursing diagnoses?

2- Do we have a special format for documenting our PIE charting. if yes please can you provide me with this format.

Thank you in advance for your help and waiting for your kind reply as soon as possible.

Roro.

[VickyRN, MSN, DNP, RN]

At the facility in which I am employed part time as a staff nurse, there is a separate form for the "Nursing Care Plan." This form follows the pie-format: Problem, Intervention, and Evaluation. This is written out on a separate narrative form that accompanies the care plan.

The Care Plan itself is a simple page in table format with about 8 high-priority/ most common NANDA diagnoses provided (such as Impaired Gas Exchange, Decreased Cardiac Output, Risk for Injury, Acute Pain, etc.). There is a column for the initiation/ activation of the nursing diagnosis (with space for nurse's initials, date, and time); another column for the resolution of the problem (again with space for nurse's initials, date, and time). The third column provides the list of nursing diagnoses, out of which the nurse chooses the most pertinent/ high priority for the patient. The nurse provides the etiology for the chosen nursing diagnosis (For instance: Impaired Gas Exchange r/t... write in). Each chosen nursing diagnosis is labeled "Problem #1," "Problem #2," etc., according to priority. There is an area to write in another nursing diagnosis not in the list.

The narrative note refers back to the nursing diagnosis list on the patient: P#1, P#2, etc. It is actually much more simple than my description implies. Hope this helps.

[Beth's granddaughter]

Hi Roro

I was taught to use the "ADPIE" method for care planning, and this is how I teach my students this particular method. I set the separate categories into a table / outline format:

assessment	diagnosis	planning	implementation	evaluation
	2 NANDA	2A Pt will... by...	2Ai nurse will...	2Ai resolved

The website http://www.mtmercy.edu/nursour/nuproc.htm explains these ADPIE concepts very nicely. Assessment is the measurable, observable data that leads to the nursing diagnosis. The diagnosis area is where we put the nursing diagnosis (or problem), and the planning area is where we put patient-centered goals. Implementation is what the nurse will do (actions) to help the patient accomplish the goal, and the evaluation looks for resolution of the problem or ways to improve or change the nursing process.

There is a list of nursing diagnoses at http://www.efn.org/~nurses/nanda.html

VickyRN suggests numbering your problems (Nursing dx's) so when you refer to them in your nursing charting the reader knows where to look. That is an excellent way to get the ADPIE information into nursing documentation.

So first, gather your assessment data and write it in the assessment column.

Then, based on that data, choose one or more appropriate nursing diagnoses. Number them 1, 2, 3...

For Nursing dx #1, in the planning section, you will identify one or more patient-centered goals. Number these A, B, C... Continue this process with Nursing dx #2, etc.

Then identify nursing tasks in the implementation area which promote accomplishment of patient goal A. These can also be numbered i, ii, iii, iv...

For each nursing task, there should eventually be a correlating evaluation - Was the task accomplished? Has the patient moved toward reaching the goal? Does any goal need to be modified or resolved?

Continue until all Nursing dx's have been addressed with pt goals, and nursing tasks. Evaluate regularly.

The ADPIE care plan, of course, is part of the permanent medical record.

I like this method because it is so simple and logical. Many hospitals in the U.S. have moved away from this format and have integrated care planning into a computer-based documentation system.

I hope that helps.

[VickyRN, MSN, DNP, RN]

Excellent post and information, Beth's granddaughter :)

[Roro]

thank you all for your help