In our nursing program
, we were required to include 3 nursing diagnoses. Then each nursing diagnosis had a minimum of 6 nursing actions. If the nursing actions were good and appropriate, I included more.
It was suggested that we structure them in the following way:
1. R/t the patient's most acute physical condition, as in what has happened to cause this hospitalization? Many patients have a long laundry list of diagnoses, but think about what has changed or become unmanagable. We did list and research all the diagnoses in our care plans
, just not under the nursing diagnosis area, it was included in the pathophysiology area.
2. R/t patient safety - I always lumped/included skin integrity in this category, because it is so important and there are many patients that movement and skin has become an issue.
3. R/t patient psychological well being. I had a teen aged patient, and one of most important concerns she had was how to keep busy and connected to her friends. But with adults it may be family issues, body image, work stresses, issues with God/higher being - just depends on your patient.
Hope this helps, it made it easier for me to pick nursing diagnoses if I knew what I was looking for.