How to word this nursing diagnosis

HouTx, BSN, MSN, EdD · Feb 12, 2015

The overall scope of nursing practice is to manage (diagnose & treat) human reactions or responses to illness/disease.... rather than the disease itself. So, is 'readiness for extrauterine life' a good fit? Instead, you would have to re-word in terms of the reactions/problems that the nurse would be managing ... ex: risk for hypothermia d/t immature thermoregulatory capacity as evidenced by ____ (list defining characteristics). Clear as mud, right?

The key is to make sure that you are always focused on the scope of nursing practice. The whole N DX thing is so conceptual/theoretical that a lot of nurses see it as completely irrelevant to nursing practice. We don't do a good job of explaining the utility of NDx taxonomy and how it is used.

Over the years, it has gotten completely out of hand - LOL. Some schools require such elaborate NDx (multi-part) statements that the entire meaning is completely lost, even to us "Nurds". To me, there are only 3 essential parts: 1. The Dx, 2. Due To (what is causing the reaction/problem) 3. As evidenced by (defining criteria for the Dx). If you can link those three, ya got it!

nurseprnRN, BSN, RN · Feb 12, 2015

There is no such nursing diagnosis as "readiness for extrauterine life." None. Stop right there. You can't make these things up.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Now, as to your normal baby, think beyond the obvious. If that were your baby just born, what would you be concerned with? Is she warm enough? Is she taking enough by mouth? Is her cord still moist-- why would we care about that? HINT: Go to your NANDA-I 2015-2017 (yes, you really have to have this book) and look on page 374-6 for some hints. There are at least five nursing diagnoses I can see there that you might make based on your assessment of this baby and what you know to be normal in newborns.

la_chica_suerte85, BSN, RN · Feb 13, 2015

I'm assuming you mean your baby is a neonate, right? What data are in the newborn assessment that you would gather? What did you actually gather on this baby other than nothing was really wrong? But, this baby already has a couple good stories to tell about being born -- like, the umbilical cord was cut, it came into a world where it is immediately being assaulted by infectious organisms, and this kid was born to someone who may have no clue how to care for them! If you assessed this infant to be normal, there are several very pertinent diagnoses that are available based on this. Like, is the mom breastfeeding? Then Breastfeeding r/t normal oral structure and gestational age greater than 34 weeks is appropriate and there are assessment data you would gather for this. All babies, even "normal" newborns, have this as one: Ineffective Protection r/t immature immune system. This is a good one for teaching interventions: Risk for Sudden Infant Death Syndrome: Risk factors: lack of knowledge regarding infant sleeping in prone or side-lying position, prenatal or postnatal infant smoke exposure, infant overheating or overwrapping, loose articles in the sleep environment. Also, Risk for infection: Risk factor: open umbilical stump is essential. There are several others, too. Look at each individual essential aspect of the baby and it should lead you to better, actual NANDA diagnoses.

Esme12, ASN, BSN, RN · Feb 13, 2015

My baby had really nothing wrong with him so
I was thinking on this nursing diagnosis:
Readiness for extrauterine life r/t ?????
I am stumped on how to "technically" word it.
Would it be something on the order of having normal respiration's and heart rate and temperature??? (of course I would be more in depth of the numbers relating to hr and resp.)
Any ideas would be greatly appreciated!

What resource are you using for your care plans? This is not an approved NANDA diagnosis.