I need help writing my nursing diagnosis statement

greenbeanio · Apr 10, 2009

I don't know about your school, but we're only allowed to use NANDA approved diagnoses so if I were writing it, the first part of it would have to be "Risk for Deficient Fluid Volume". For the "as evidenced by" part, I'd look up the defining characteristics in your nursing diagnosis book and use the relevant one. Are there any symptoms you've observed in your assessment (other than the lab results) that would have made you come to the same diagnosis? Because that could be your "evidence". Hope that helps!

Check out this link here: https://allnurses.com/general-nursing-student/help-care-plans-286986.html

I have to get started on my next care plan tomorrow - not looking forward to it. Good luck! :)

jewels91463 · Apr 10, 2009

thanks! we have to use NANDA diagnoses as well..which is what that is...I just hate not having my other assessment form graded before this one is due..oh well..live and learn I suppose. now just have to work on the pathophysiology, which besides the nursing diagnosis is the hardest part of the assessment form. good luck to you.

Daytonite, BSN, RN · Apr 10, 2009

potential volume deficit as evidenced by elevated bun and creatinine is an incorrect way to write a diagnostic statement. (1) potential (now called "risk for") diagnoses cannot have as evidenced by items attached to them. the as evidenced by items are supporting symptoms that prove the existence of a problem. since this is a potential problem there can be no symptoms. if you have symptoms, then you have diagnosed the problem incorrectly. (2) this diagnostic statement is missing the etiology, or related factor, which tells why the problem is happening. the related factor for potential volume deficit must state how the body could be losing the fluid (diarrhea, vomiting, diuretics, drainage tubes, disease processes) and this is determined through assessment and knowledge of the pathophysiology of the patient's medical diseases and conditions. before you can determine a patient's nursing diagnoses a thorough nursing assessment must be done. assessment consists of:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking

a nursing diagnostic statement contains 3 elements:

p (problem) - e (etiology) - s (symptoms)

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by nanda, this is what is causing the problem and resulting in the symptoms. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this. etiologies, if they are other than of a medical source, are often the focus of outcomes and long term goals.
symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they could be signs and symptoms of the medical disease the patient has, their responses to their disease, problems accomplishing their adls. they are evidence that prove the existence of the problem. if you are unsure that a symptom belongs with a problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals. a potential problem will not have symptoms because it does not exist yet.

there is information on writing care plans and diagnosing on this sticky thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

greenbeanio · Apr 10, 2009

Potential Volume Deficit as evidenced by elevated BUN and creatinine is an incorrect way to write a diagnostic statement. (1) Potential (now called "Risk for") diagnoses cannot have as evidenced by items attached to them. The as evidenced by items are supporting symptoms that prove the existence of a problem. Since this is a Potential problem there can be no symptoms. If you have symptoms, then you have diagnosed the problem incorrectly. (2) This diagnostic statement is missing the etiology, or related factor, which tells why the problem is happening.

Oops! I knew that. Not a good sign that I forgot. Even worse that I misled someone else... Sorry! :imbar Glad you stepped in, Daytonite!

jewels91463 · Apr 10, 2009

ok thanks! that's what I thought, I stated it... potential volume deficit related to elevated BUN and creatinine levels...I think... I had to turn the paper in this morning soo...I suppose I will see when I get it back on Tuesday.

Daytonite, BSN, RN · Apr 11, 2009

The Potential (for) Volume Deficit, or dehydration, would be caused by some pathophysiology going on in the patient. The elevated BUN and creatinine levels are just indicators that something is brewing. This is why you have to investigate the patient's medical diseases and conditions. If none are listed then you have to consider what medical conditions may be the cause of elevated BUN and creatinine levels and theorize if any of them might be likely in this case when you put all the evidence together. The thing is, however, that Potential (for) Volume Deficit is an anticipated problem which may, or may not, happen. The purpose in diagnosing it is to prevent it or its complications from happening. The goals for these diagnoses is for the problem not to occur.