Writing Nursing Diagnoses

[Etak, BSN, RN]

Help!

I need some direction on writing nursing diagnoses. I'm 7 weeks into 1st semester, have passed my first set of midterms, maintained solid grades, haven't even had a melt down yet. BUT. There's nothing that makes me feel dumber than trying to write a nursing diagnosis.

We were given a NANDA list of med/surge acute care diagnoses. But feel helpless when trying to come up with a diagnosis on my own. I usually end up googling for assigned, hypothetical case studies and patient care plans for clinicals. I feel like I know a good diagnosis when I see one, but am useless at writing my own.

What did you do to learn how to do this well (and efficiently?) I spend WAY too much time trying to come up with them, and it's so frustrating when I have 45 other things on my to do list.

Thank you for any advice!

[Rose_Queen, BSN, MSN, RN]

Is one of your textbooks a nursing diagnosis handbook? If not, you will want to add one to your resources. A list of diagnoses isn’t going to help you formulate the “secondary to” and “as evidenced by” parts the way a handbook can.

[Etak, BSN, RN]

5 minutes ago, Rose_Queen said:

Is one of your textbooks a nursing diagnosis handbook? If not, you will want to add one to your resources. A list of diagnoses isn’t going to help you formulate the “secondary to” and “as evidenced by” parts the way a handbook can.

I feel ridiculous even saying this, but yes and I haven't even cracked it open. We had to buy a required book bundle, I opened it and took out the 4 books with required reading so far and haven't even looked at the rest yet until just now.

Thank you. The r/t and AEB are exactly where I am having trouble coming up with my own diagnoses.

[JKL33]

15 hours ago, Etak said:

I feel ridiculous even saying this, but yes and I haven't even cracked it open.

Crack it! ??

When there's so much to keep track of it's natural that something ends up on the back burner for a while. But now you know you need it. ?

Good luck ~

[TheDudeWithTheBigDog, ADN, RN]

"Nursing diagnosis" is an overcomlicated way of saying: symptom, risk, or habit, and the reason.

At some point someone decided that nursing needs to be more "science-y" so instead of saying "trouble breathing" they changed it to "ineffective breathing pattern" Then they add in the related to, which would be the pneumonia that they're in the hospital for. And then "as evidenced by" the painfully obvious labored breathing.

Use your book for a list of the diagnoses, and then just use common sense and find a symptom or a risk that's a priority, and then just find whatever diagnosis on that list fits with it. The good news is it seems like it's getting phased out and replaced with just saying the symptom, since hypothermia or fever is infinitely times infinity plus 1 more descriptive than "ineffective thermoregulation."

[amoLucia]

ineffective thermoregulation = hypo/hyper thermoregulopathy

Love to make up pseudoterminology