Please Help: Can you explain how to get a nursing diagnosis?

What does the patient need. What is wrong with the patient. What has a doctor diagnosed for this patient. Why is the patient in the hospital.

If you answer those questions you will find a nursing diagnosis for each answer.

Gather as much information as you can about the patient from the chart, the phsycial assessment, and from your interview with him/her. Look at the data you gathered regarding functional health patterns and see what stands out. Is the person in a lot of pain? Are they anxious? Are they not eliminating as much as they should be? Of course, there are a lot more diagnoses than these, but hopefully this makes sense. Get familiar with the list of nursing diagnoses so you'll "know what to look for" when gathering and reviewing the FHP's.

Hopefully some more experienced students can offer their two cents. I'm pretty new at this, too. :) Good luck!

What does the patient need. What is wrong with the patient. What has a doctor diagnosed for this patient. Why is the patient in the hospital.

If you answer those questions you will find a nursing diagnosis for each answer.

My last patient had a diabetic foot ulcer. That was his diagnosis and that is why he was in the hospital. I suppose to make some nursing diagnosis from that patient. Like what can I do to figure some diagnosis out thou?

As simply put as I can make it...a nursing diagnosis comes in three major parts.

First the nursing diagnosis itself, not a MD diagnosis mind you...but the nursing one like ineffective breathing pattern, body image disturbance, powerlessness.

Second, the "related to" phrase. This is states what may be causing or contributing to the diagnosis. There can be all sorts of reasons, but try to pick one that a nurse can actually work on (IE don't pick falure to thrive r/t prostate cancer...we can't do much about the prostate cancer...but perhaps the pain is an issue with failure to thrive, I would pick pain..this I can help!).

Then Third..the defining characteristic phrase...or the As Evidenced By (AEB) section. This is basically what makes you thing the first and second part are valid! I have used quotes, or subjective data to back me up on this many times, and seems to really help to individualize your plan of action!

SO lets take a sample...

1. Body image disturbance

2. r/t loss of hair, and change in appearance

3. AEB verbalization of fear of rejection by others by the loss of hair.

Really this is rather easy one, and more complex ones will be a snap once you get your basics down...I always remember it by "Nursing diagnosis, related to, as evidenced by" (in fact my school drilled that into us...I said it in my sleep! LOL!).

One thing us students did was to pick ANYTHING we saw and try to come up with the nursing diagnosis for it! Like we would see a dog, and make up something like "Anxiety realted to seeing cats, as evidenced by barking, drewling, and physically attacking the cat. Or a book "hopelessness, r/t thickness and absolute boring material, aeb 2 inches of visualized dust on top, and being the mandatory reading material for cardiology!" LOL!!!!!!!!!! Once you kind of make it fun, it comes more naturally!

School will have you making more complex ones than just one or two related to's or as evidenced by...then they will go on to have you form a plan of action, and sometimes quote your reference...but for now...break it down into the 1, 2, 3's!

Hope this helps..and a great GREAT book to help you would be "Nursing Diagnosis Handbook, A guide to planning care" By Ackley and Ladwig! In the back it has a list of the nursing diagnosis's that can basically get you started. I would take a situation...look at that list and find so many to start with!!!! Having that list really helped, and the book will break down each one and tell you what to look for for the r/t and aeb!!!!! That book helped me to ace this area!!! AND I still use it to this day!!!

Good luck and hope this was helpful! :) (I used examples from the book..not the dog or book one though..LOL!).

My last patient had a diabetic foot ulcer. That was his diagnosis and that is why he was in the hospital. I suppose to make some nursing diagnosis from that patient. Like what can I do to figure some diagnosis out thou?

Again, hopefully the "experts" can help out on this one, but I'm guessing that one nursing diagnosis for this patient would be Impaired Tissue Integrity. I'm having trouble with the PES (problem, etiology, signs/symptoms), though. It should be something like "Impaired tissue integrity related to [skin breakdown??] secondary to diabetic foot ulcer as evidenced by [insert signs and symptoms]. Can anyone expand on and/or correct this?

Triage RN gave a wonderfully detailed answer! I can only add that NDx's are a challenge to learn and will help you in the future(don't know how, it's kind of like geometry). I also can tell you that your care plan will never be perfect. The instructors will always find fault with them. This is normal. Just try to learn from them. Good luck.

Most of my diabetic patients with foot ulcers really don't grasp their disease process and why this is happening. Go figure, it is complicated for even us to explain at times...let alone to understand when you have no anatomy or physiology base...so I usually focus on 1. what I see is the probelm I can really help with, and 2. what is it I can do???

Say you have a patient that simply eats sugary foods without a thought to their high glucose levels. You take their CBG's and they are always in the 200's despite routine and sliding scale insulin and you found out that they are always having a double helping of deserts, or sneeking it (by family or by hording themselves)...

I would think..hmmmmm...definate knowledge deficit here!

There ya go...a nursing diagnosis!!!!! Knowledge deficit!

Okay what makes me think this...hmmmmm because they continue to go against their prescribed diet. WOW..there is my related to!!!!

Knowledge deficit related to misunderstanding of prescribed diet....

Okay why do I say they aren't following their prescribed diet? Well...they eat deserts like crazy and say they don't care...and that if their sugars are high, that is what insulin is for! Hello AEB!

Knowledge deficit related to misunderstanding of prescribed diet, as evidenced by monitoring high sugar food consumption by staff and client verbalized admission that will continue their dietary habits despite their condition.

Hey there we go! The trick is to keep it simple and not long winded or too subjective either....it must be fairly objective (ie the words monitoring and verbalized admission)...

Again...hope that helps! :)

Triage RN gave a wonderfully detailed answer! I can only add that NDx's are a challenge to learn and will help you in the future(don't know how, it's kind of like geometry). I also can tell you that your care plan will never be perfect. The instructors will always find fault with them. This is normal. Just try to learn from them. Good luck.

Thanks! And oh yes...they will find fault in your care plans..but I found that pointing out my faults was better because I learned more that way. If they didn't find faults then I wouldn't strive to be better! I would turn the situation around (okay with a few tears at times), and say...okay you, if you agree what can you do better! Or if I disagreed...exactly why! As I got better the disagreements came more often, and I would actually thrill my teachers by starting up a very heart felt converstation on what my point was! Bonus points big time yes..but I learned a ton!!!!!!!

Trust me...I can look at a nursing plan and find its faults, and someone can do it to mine just as easily...but remember..that is YOUR plan..others may differ!

"Impaired tissue integrity related to [skin breakdown??] secondary to diabetic foot ulcer as evidenced by [insert signs and symptoms]."

Okay..I tend to shy away from issues I can do nothing or little about at first...impaired tissue integrity is a good nursing diagnosis, but again..what is the underlying probelm that you can help with? It is the underlying probelms that we help that make good nurses GREAT nurses!

But lets see...hmmmm Impaired Tissue Integrity related to...okay this gets tricky...no MD diagnosis should be used...so we can't go diabetic..or neuropathy...hmmmmm..lets figure it out, why is the tissue damaged....well, most diabetics I know don't feel their injuries to their feet...so perhaps we should focus on that? Okay but how to term it without using doc speak...how about injury to foot secondary to decreased sensation to bilateral lower extemities...there we go!!!!! (secondary to is another wonderful term you can use in the related to section...we know there is a wound so go with that..but follow up with the reason for it by using seconary to! See, a little trick there!)

Now we can actually play a bit closer to doc speak in the AEB...so why do they have decreased sensation...um diabetes, well yes but too doc speak...but you can get away with it by saying "physician diagnosis of diabetic neuropathy, verbalization from patient stating lack of sensation, and visualized spreading of wound size without pain or realization by the client, and presence of necrotic tissue slough.

Wooooooohoooooooo..okay lets put it together and see if it meshes!

Impaired Tissue Integrity related to injury to foot secondary to decreased sensation to bilateral lower extemities, as evidenced by physician diagnosis of diabetic neuropathy, verbalization from patient stating lack of sensation, visualized spreading of wound size without pain or realization by the client, and presence of necrotic tissue slough.

How does that sound to you??? Now see the trick of this...the lack of sensation you may not be able to overcome, but you sure as heck can make a care plan focused on protection of the feet due to this risk factor...a lot easier to plan for than your original NDx!

Oh yeah..and if I get stuck for more than 10 minutes after a using a certain nursing diagnosis statement (the first one, and get stuck on the r/t)..I assume I have made it too complicated and I step back...if the NDx comes quicker and the r/t right there..hey, then I know I have it!!!! :)

http://www.efn.org/~nurses/nanda.html

Weren't we told that the AEB would/could be another ndx?

For example

Acute pain

AEB impaired neurovascular and tissue integrity of foot.

I really L O V E D it when NANDA came out.-not!......before that time all we had to do was take care of patients.....silly me.

It seems Maslow's Hierarchy was before NANDA am I right?

And then there was another...started with "A" maybe Abdellah?http://www.enursescribe.com/Faye_Abdellah.htm

Yeah...when I signed up for nursing I thought caring for patient's is what we did! LOL, I had no idea we were actually becoming writers for a very strange language called NANDA! LOL! If I knew that...heck I like writing, I would have taken my chances at being and author! LOL!

But seriously..oh yes Maslow was so much easier and had a goal point to achieve...even if it was one level at a time...it based things on a common foundation of needs, and really had you realize what a small break or crack in that foundation impacted everything else...very good theory of thought! I still break it down that way when I come up with plans! I just use Nanda speak to translate it into nursing term :)

I don't remember the other...but how curious :). Always loved theory...never got enough of it (I am an ASN, but research on my own to better myself, oh and to debate issues with other consultant nurses :) LOL!).

My last patient had a diabetic foot ulcer. That was his diagnosis and that is why he was in the hospital. I suppose to make some nursing diagnosis from that patient. Like what can I do to figure some diagnosis out thou?

Nursing Dx: Impaired tissue integrity related to decreased circulation secondary to chronic disease processes as evidenced by draining wound on L foot.

Nursing Dx: Pain related to draining wound on L foot second to chronic disease processes as evidence by pt statement, "it hurts."

Nursing Dx: Altered lower extremity tissue perfusion related to interrupted blood flow secondary to chronic disease processes as evidenced by draining lesion on L foot.

Nursing Dx: Risk for infection related to hyperglycemia, poor circulation, and decreased sensation secondary to chronic disease processes.

Nursing Dx: Knowledge deficit of diabetes management related to lack of teaching as evidenced by draining foot ulcer and pt statement, "I guess I don't understand how to use insulin."

And many many more....