Nursing Diagnosis..Please help!!

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

"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." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)

I had a patient who had a total knee replacement of the left knee. When I saw him, he was 2 days post op. He was in a lot of pain, seven on a scale of 0-10 after his dose of 5mg of Oxycodone. He was weight bearing as tolerated and actually moved from his bed to the chair with the use of his walker. His vitals were BP: 145/95 T 98.7 HR 94 and O2 Sat 94%. His Foley was removed at 0645 and by 1200; he had not voided his bladder. The nurse said if he had not urinated by 1300 they would have to straight cath, I unfortunately left the floor before then, so I do not know what happened.

I have to come up with three nursing diagnosis for this patient. Looking at my care plan I think I would need to do one for is respiratory, pain level and maybe his limited mobility. This is what I have come up with so far. Am I on the right path?

1. Acute pain related to subjective data as evidenced by pain level scale.
   

2. Impaired physical mobility related to muscoskeletal impairment associated with surgery as evidenced by decreased strength.

Does you really know he has musculoskeletal impairment because you observed he has decreased strength? Or is his mobility decreased because he has too much pain to move well? Pain is a listed cause of impaired mobility in your NANDA-I. So you have, "Impaired physical mobility due to pain, as evidenced by (patient behavior x, y, z...)" Does that make sense?

1. Impaired respiratory levels related surgery as evidenced by shortness of breath..
   

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.)Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (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 2012-2014, 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. 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. 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.

Oooh, and I just got a great book for interventions. The 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 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.

Holy cow! :) Thank you so much!! I am going to have to reread a couple of things to let it sink in. This is my 2nd attempt at doing nursing diagnosis and I really appreciate all the information you gave me. I will definitely look for that book!! It sounds like it would be very helpful for me. Thanks again!!

It is best to assess your patient's comfort level if you are going with a Dx of pain.