you can find help with composing diagnoses and writing care plans
on these two threads on allnurses. be sure to review the information in them:
first, let me explain that nanda, the north american nursing diagnosis association, has been the foremost authority on developing and defining nursing diagnoses since the 1970's. along with research done by the university of utah on nursing outcomes and nursing interventions their mission is to standardize all these components of care plans so they can be coded and stored as numerical data in computerized systems. there are currently 172 nursing diagnoses. each one has a definition, specified causes (nanda refers to them as "related factors"), what i like to simply call symptoms (nanda refers to them as "defining characteristics"), nursing outcomes classification (outcomes), and nursing interventions classifications (nursing interventions).
what makes it somewhat confusing to new learners of this system is all the language and wording that nanda uses. i'll be the first to say that it sounds like a bunch of gobbledygook. it is. but, as with medical terminology
, as you use and learn it, it becomes more familiar and it isn't long before all these terms are just rolling off your tongue.
for nursing school, most students are required to use nursing diagnostic statements on their care plans. schools do this to help you learn to put all the elements of a nursing diagnosis together so you learn them and learn how to use them. remember, as i said above, each nursing diagnosis has it's own set of causes and symptoms that has already been decided upon by nanda.
the easiest way to write a diagnostic statement is to follow this mnemonic: pes
. it stands for p (problem)
, e (etiology)
and s (symptoms)
. this is the nursing diagnosis. a nursing diagnosis is nothing more than a label that has been decided by nanda to belong with a group of related problems the patient has.
. this is what is causing, or is a major contributing factor to, the problem. in nursing diagnostic statements it is the information that immediately follows the r/t (related to) part.
. this is the patient data, signs and symptoms that you discovered in your physical assessment and review of the patient's chart. this is the evidence that supports the p (problem). these are also the items that any nursing interventions you decide to use will be focused on. in nursing diagnostic statements these are the items that immediately follow the aeb (as evidenced by) part.
it's very natural to end up with some reference to medical diagnoses at first because we know and understand how that terminology works. you just have to be constantly on your toes to watch for those little slips when you write a nursing diagnosis. nanda wants us to never use any reference to medical diagnoses in our nursing diagnostic statements. there are a very few rare exceptions where they allow it. the only reason is because they haven't yet figured out the non-medical language to use in those specific cases--yet.
so, a nursing diagnostic statement is going to be put together like this:
- problem r/t etiology aeb symptoms, or
- nursing diagnosis r/t related factors aeb defining characteristics (using nanda terminology)
here are some examples of some nursing diagnostic statements. in each, you can clearly identify all three components:
- activity intolerance r/t imbalance between oxygen supply and demand aeb dyspnea and the need for oxygen supplementation for an hour after physical therapy
- activity intolerance r/t bedrest and weakness aeb restlessness
- nausea r/t postsurgical effects of anesthesia and manipulation of bowel aeb increased salivation, tachycardia and patient statements of being nauseated
- impaired skin integrity r/t surgical disruption of tissues aeb surgical incision
- acute pain r/t surgical disruption of tissues aeb patient reports of pain, restlessness, guarding, and changes in vital signs
- ineffective health maintenance r/t knowledge deficiency in caring for disease condition aeb inability (or refusal) to recognize symptoms of illness
- ineffective breathing pattern r/t hyperventilation aeb dyspnea
- ineffective tissue perfusion r/t reduction of arterial and venous blood flow aeb dysrhythmias, abnormal abgs, oliguria and anuria
- acute confusion r/t ethylene glycol ingestion aeb confusion, slurred speech, and hallucinations
- impaired urinary elimination r/t urinary tract infection aeb dysuria, urgency and frequency
the best thing you can do for yourself to help you with care plan writing is to get yourself a good book that explains each of the nursing diagnoses. there are a number of nursing diagnosis handbooks on the market that do this. this is the one of the ones that i have and find extremely useful: nursing diagnosis handbook: a guide to planning care
, 7th edition, by betty j. ackley and gail b. ladwig. there is a shortened version of it (by shortened i mean it has about 300 less pages) printed under the title of mosby's handbook of nursing diagnosis
. ackley and ladwig follow nanda terminology to the letter. you will not find any complete listing of nanda diagnoses on the internet because nanda owns the copyrights to them and will only sell the right to print them. so, the only way you can get your hands on them is to find one of these nursing diagnosis or nursing care plan books. lynda juall carpenito-moyet has written a number of care planning books with nursing diagnosis emphasis over the years. she has been a member of nanda for many years and knows how all this nursing diagnosis is supposed to be put together and work. some people find her books to be a bit difficult to understand at times, however. i, however, find things her her books that other authors don't address. if you do not already have some sort of supplement book to help you with nursing diagnosis, you can browse through choices that are available on the amazon
and barnes and noble websites.
hope this helps you out and hasn't scared you more than you already might be. you can always post a new thread asking for help and assistance with a care plan or a nursing diagnosis you are working on. the nursing student forums have many of these kinds of threads. learning to choose nursing diagnoses and write care plans is a nursing skill like any other. it involves the use of your mind and some critical thinking rather than physical adeptness. like learning to tie your shoes when you were a kid, you have to make attempts at them again and again. the going is slow at first. i didn't really start to fully understand the written care plan process until i was well out of school and on the job. at that time (back in the 70's) nanda nursing diagnoses hadn't even been introduced to the general nursing staffs. i didn't learn about this stuff until the 80's when i went back to school for my bsn and, believe me, i struggled with it. i will help you with this if you only ask.
see you here on the forums. welcome to allnurses!