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

[sad]

I am a first semester nursing student. I having trouble with trying to figure out how to come up with a nursing diagnosis. Can you explain a simple procedure to learn how to do this.

Thank you

[P_RN, ADN, RN]

Potential for injury related to impaired tissue integrity left foot as evidenced by full thickness lesion 1cm x 2 cm dorsum left foot.

I love potential fors......

[boggle, ASN, RN]

If you are a student nurse now, you are probably using NANDA nursing diagnoses.

Coming up with a Nursing diagnosis involves several steps:

First assess your patient. Look for what is abnormal and significant in your assessment findings.

Cluster your abnormal and significant findings by body system or functional patterns. Then search index or appendix in your NANDA book for a NANDA label that looks like it will fit. Med surg texts are using NANDA now too. (You may find a nursing diagnosis already written for you in the chapter pertaining to your patient's disorder.)

Make sure the NANDA definition fits what you feel is the patient's problem.

Add Defining Characteristics (also called "as evidenced by"). This is a listing of your assessment findings that show the patient has the problem.

Then add "Related To" factors (etiology). These are not medical diagnoses. These are body and behavior functions that a nurse can do something about. For example for that diabetic patient with the foot ulcer, you might have: r/t impaired circulation to lower extremities secondary to diabetes.)

Do you also have to use the NOC and NIC process in your care plans?

Good luck!

[leslie :-D]

shoot, i remember the priority dx's of being abc, airway breathing circulation.

this is certainly a circulatory or perfusion issue.

there are nsg dx's r/t the ulcer....

altered tissue perfusion r/t decreased circulation aeb plantar ulcer...

something along those lines.