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Break it down into its signs and symptoms. Which of those signs and symptoms does your patient have? Those become the foundation of nursing diagnoses. We call the signs and symptoms of nursing diagnoses defining characteristics. Every nursing diagnosis consists of defining characteristics just as every medical diagnosis consists of symptoms. You need a nursing diagnosis reference to help you choose nursing diagnoses when you are fist learning to work with them because they are not the same as medical diagnoses. They are based on patient responses to what is happening to them.
how did you finish your whole careplan without a nursing dx to start it off? not trying to be rude, just curious. the nursing dx is always my very first step in writing a careplan.
"Care plan" might mean something different to the OP...for clinicals we get a 14-page packet to fill out that includes multisystem head-to-toe assessment documentation, admitting diagnosis with pathophysiology and signs/symptoms, meds, lab results, other tests and procedures, and at the very back 2 sheets labelled 'Client Care Plan' with the NANDA/NIC/NOC stuff. When one of my classmates says "Care Plan", more often than not they are referring to the entire 14-page packet, while "Nursing diagnosis sheet" refers to the pages labelled 'Client Care Plan'.
setingle
40 Posts
Depression is a medical diagnosis....how would i make it a nursing diagnosis? thanks!