Nursing diagnosis

1. Nursing DiagnosisNursing Diagnosis

2. Nursing diagnoses?Nursing diagnoses?
What’s up with that?What’s up with that?
 Nursing diagnoses are what you get when you finishNursing diagnoses are what you get when you finish
your assessment and look at your data.your assessment and look at your data.
 Nursing diagnoses describe patient needs or responsesNursing diagnoses describe patient needs or responses
to health conditions and treatmentsto health conditions and treatments
 Nursing diagnoses reflect the patient’s level of health orNursing diagnoses reflect the patient’s level of health or
response to disease, emotional state, socio-culturalresponse to disease, emotional state, socio-cultural
phenomenon, or developmental stagephenomenon, or developmental stage

3. Medical vs. nursing diagnosesMedical vs. nursing diagnoses
 MedicalMedical diagnosis-diagnosis- Identifies disease or pathologyIdentifies disease or pathology
 NursingNursing diagnosis-diagnosis- Identifies patient’s response to saidIdentifies patient’s response to said
disease or pathologydisease or pathology
 MedicalMedical diagnosis goal-diagnosis goal- to cure the diseaseto cure the disease
 Nursing diagnosis goal-Nursing diagnosis goal- to direct the nursing plan of careto direct the nursing plan of care
to meet the patient’s needsto meet the patient’s needs

4. Nursing diagnosesNursing diagnoses
 Help facilitate communication between members of theHelp facilitate communication between members of the
nursing staffnursing staff
 Help prioritize the needs of the patientHelp prioritize the needs of the patient
 Help to guide chartingHelp to guide charting

5. In practice, you…In practice, you…
 Do your assessment and think “My patient is in pain!”Do your assessment and think “My patient is in pain!”
 Take your impressions and put fancy labels on them likeTake your impressions and put fancy labels on them like
“impaired comfort” or “acute pain”“impaired comfort” or “acute pain”
 Those are nursing diagnoses in a nutshellThose are nursing diagnoses in a nutshell

6. When I’m at work…When I’m at work…
 The first thing I do is get report on my patients- from theThe first thing I do is get report on my patients- from the
ER or the previous nurseER or the previous nurse
 As I am getting report, I am thinking about what I willAs I am getting report, I am thinking about what I will
have to keep in mind when I am caring for my patients…have to keep in mind when I am caring for my patients…
 For a postop patient, I might be thinking:For a postop patient, I might be thinking:

Check on painCheck on pain

Check the lungs- potential for pneumonia or atalectasisCheck the lungs- potential for pneumonia or atalectasis

Check for constipation from narcotic pain medsCheck for constipation from narcotic pain meds

Check the incisionCheck the incision

Check if the patient has been out of bed yetCheck if the patient has been out of bed yet

7. Then off to see the patient…Then off to see the patient…
 When I go to do my assessment on the patient, I keep allWhen I go to do my assessment on the patient, I keep all
those things in mind…those things in mind…
 I talk to the patient to see:I talk to the patient to see:

How the pain is doingHow the pain is doing

When the last BM wasWhen the last BM was

If she has been out of bed yetIf she has been out of bed yet
 Then I do a physical assessment to check on:Then I do a physical assessment to check on:

Lungs- check for diminished breath sounds or fluidLungs- check for diminished breath sounds or fluid

Incision- check for redness or drainageIncision- check for redness or drainage

Legs- check for clotLegs- check for clot
 When I am done, I consider all of my findings and comeWhen I am done, I consider all of my findings and come
up with some conclusions…up with some conclusions…

8. And I come up with…And I come up with…
 The patient is in a fair amount of pain- I need to give herThe patient is in a fair amount of pain- I need to give her
some pain medication ASAPsome pain medication ASAP
 Her lungs are clear but there is still the potential forHer lungs are clear but there is still the potential for
pneumoniapneumonia
 She has not had a BM in 3 days- pain medications areShe has not had a BM in 3 days- pain medications are
getting her constipatedgetting her constipated
 The incision looks OK- no signs of infectionThe incision looks OK- no signs of infection
 The patient got out of bed last night and sat in the chair,The patient got out of bed last night and sat in the chair,
but needs to ambulatebut needs to ambulate

9. To turn these findingsTo turn these findings
into nursing diagnoses…into nursing diagnoses…
I check the NANDA list to see what fits my findings…I check the NANDA list to see what fits my findings…

My patient is in pain- that could be “My patient is in pain- that could be “impaired comfortimpaired comfort” or “” or “acuteacute
painpain””

She doesn’t have pneumonia right now, but she’s still at risk forShe doesn’t have pneumonia right now, but she’s still at risk for
it- that could be “it- that could be “potential impaired gas exchangepotential impaired gas exchange””

No BM in 3 days- sounds like “No BM in 3 days- sounds like “constipationconstipation” to me!” to me!

Her incision is OK but it could still become infected- how aboutHer incision is OK but it could still become infected- how about
““risk for infectionrisk for infection””

She’s not moving so well- “She’s not moving so well- “impaired physical mobilityimpaired physical mobility” might” might
work. “work. “Risk for fallsRisk for falls” might be good, too, since she’s taking” might be good, too, since she’s taking
narcotic pain medicinesnarcotic pain medicines

10. To write or not to write?To write or not to write?
 When I work with patients in the hospital, I formulateWhen I work with patients in the hospital, I formulate
nursing diagnoses for my patients in my headnursing diagnoses for my patients in my head
automatically as I am getting report and doing myautomatically as I am getting report and doing my
assessments (after 15 years, it is almost second nature)assessments (after 15 years, it is almost second nature)
 I also refer to the nursing care plan in the patient’s chartI also refer to the nursing care plan in the patient’s chart
to see what other nursing diagnoses have been selectedto see what other nursing diagnoses have been selected
by the staffby the staff
 Nursing students get to write everything out-Nursing students get to write everything out- to show theto show the
instructor and help it become second nature in practiceinstructor and help it become second nature in practice
after graduationafter graduation

11. At clinical, you will…At clinical, you will…
1.1. Get report on your patients firstGet report on your patients first
2.2. Go meet with your patients and do a physicalGo meet with your patients and do a physical
assessmentassessment
3.3. Formulate your nursing diagnosesFormulate your nursing diagnoses
4.4. Develop a care plan based on your assessment andDevelop a care plan based on your assessment and
nursing diagnosesnursing diagnoses

12. You got to stick with NANDA!You got to stick with NANDA!
 Unfortunately, you are not allowed to make up new andUnfortunately, you are not allowed to make up new and
creative nursing diagnoses for your patientscreative nursing diagnoses for your patients
 No matter how much your patient merits a nursingNo matter how much your patient merits a nursing
diagnosis of “persistent stupidity” or “constant whining”diagnosis of “persistent stupidity” or “constant whining”
you justyou just can’tcan’t do it!do it!
 Some authors like Carpenito have developed nursingSome authors like Carpenito have developed nursing
diagnoses similar to NANDA’s, but thediagnoses similar to NANDA’s, but the OU SONOU SON
professors requireprofessors require onlyonly NANDA diagnosesNANDA diagnoses for your carefor your care
plans and papersplans and papers

13. Writing nursing diagnosesWriting nursing diagnoses
 The first part is the NANDA nursing diagnosis statementThe first part is the NANDA nursing diagnosis statement
 If your patient doesn’t meet the criteria for the diagnosisIf your patient doesn’t meet the criteria for the diagnosis
yet, you put “Risk for…” in front of the diagnosisyet, you put “Risk for…” in front of the diagnosis

Risk for nauseaRisk for nausea

Risk for deficient fluid volumeRisk for deficient fluid volume
 After the diagnosis, you put why you chose the diagnosisAfter the diagnosis, you put why you chose the diagnosis
for the patient with a “related to” (R/T) statement…for the patient with a “related to” (R/T) statement…

Risk for nausea R/T side effects from chemotherapy medicationsRisk for nausea R/T side effects from chemotherapy medications

Risk for deficient fluid volume R/T poor fluid intake and highRisk for deficient fluid volume R/T poor fluid intake and high
temperaturetemperature

Sleep deprivation R/T busy ICU environmentSleep deprivation R/T busy ICU environment

14. For my earlier postop patient:For my earlier postop patient:

Acute pain R/T tissue damage from surgical incisionAcute pain R/T tissue damage from surgical incision

Potential impaired gas exchange R/T shallow breathingPotential impaired gas exchange R/T shallow breathing
postoperativelypostoperatively

Constipation R/T slowed bowel motility from narcotic painConstipation R/T slowed bowel motility from narcotic pain
medications and bed restmedications and bed rest

Risk for infection R/T new surgical incisionRisk for infection R/T new surgical incision

Impaired physical mobility R/T postoperative weaknessImpaired physical mobility R/T postoperative weakness

Risk for falls R/T dizziness from narcotic pain medicationsRisk for falls R/T dizziness from narcotic pain medications

15. ““Related to” statementsRelated to” statements
 Should be within the scope of nursing practice, notShould be within the scope of nursing practice, not
medical practice (like a medical diagnosis or treatment)medical practice (like a medical diagnosis or treatment)
 Related to statements should include information suchRelated to statements should include information such
as:as:

Symptoms or situations that can be addressed with nursing careSymptoms or situations that can be addressed with nursing care

Patient responses to diseases or conditionsPatient responses to diseases or conditions

Treatments that can be performed by a nurseTreatments that can be performed by a nurse

Developmental or maturational stagesDevelopmental or maturational stages

16. Writing “related to” statementsWriting “related to” statements
 Don’tDon’t put medical diagnoses or diagnostic tests likeput medical diagnoses or diagnostic tests like
pneumonia, hip fracture, or angioplasty in the “related to”pneumonia, hip fracture, or angioplasty in the “related to”
statement.statement.
 DoDo put factors that you can take care of with nursingput factors that you can take care of with nursing
interventions…interventions…
BADBAD BETTER!!BETTER!!
Impaired gas exchange R/TImpaired gas exchange R/T
increased blood CO2 levelsincreased blood CO2 levels
Impaired gas exchange R/TImpaired gas exchange R/T
shallow breathing postopshallow breathing postop
Diarrhea R/TDiarrhea R/T C. difficileC. difficile infectioninfection Diarrhea R/T food intoleranceDiarrhea R/T food intolerance
Acute painAcute pain R/T hip fractureR/T hip fracture Acute pain R/T swelling andAcute pain R/T swelling and
tissue damagetissue damage

17. More examples…More examples…
BadBad GoodGood Why??Why??
Risk for aspirationRisk for aspiration
R/T strokeR/T stroke
Risk for aspirationRisk for aspiration
R/TR/T impairedimpaired
swallowingswallowing
Nurses can work withNurses can work with
patients to improvepatients to improve
swallowing abilityswallowing ability
Acute pain R/T hipAcute pain R/T hip
fracturefracture
Acute pain R/TAcute pain R/T
tissue damage andtissue damage and
swelling in right hipswelling in right hip
Nurses can give medicationsNurses can give medications
to help relieve pain fromto help relieve pain from
tissue damage, and providetissue damage, and provide
ice to reduce swellingice to reduce swelling
Risk for falls R/TRisk for falls R/T
Multiple SclerosisMultiple Sclerosis
Risk for falls R/TRisk for falls R/T
poor balance andpoor balance and
leg weaknessleg weakness
Nurses can help patients withNurses can help patients with
transfers to compensate fortransfers to compensate for
poor balance and weaknesspoor balance and weakness

18. After the R/T statement…After the R/T statement…
 After you say why you chose the diagnosis for theAfter you say why you chose the diagnosis for the
patient with the “related to” statement, include an “aspatient with the “related to” statement, include an “as
evidenced by” statement that includes specific signs andevidenced by” statement that includes specific signs and
symptoms of the particular patientsymptoms of the particular patient
 This step is not needed when there is only “Risk for …”This step is not needed when there is only “Risk for …”
diagnoses, as the patient is only at risk for the conditiondiagnoses, as the patient is only at risk for the condition
and has not actually developed it yetand has not actually developed it yet
 You can use “AEB” for “as evidenced by” so that youYou can use “AEB” for “as evidenced by” so that you
don’t need to write it outdon’t need to write it out

19. Some examples fromSome examples from
my postop patient…my postop patient…
 Acute pain R/T tissue damage from surgical incision,Acute pain R/T tissue damage from surgical incision,
AEB patient reports of pain rating of 8 on 1-10 scale,AEB patient reports of pain rating of 8 on 1-10 scale,
visible grimacing with movementvisible grimacing with movement
 Constipation R/T slowed bowel motility from narcoticConstipation R/T slowed bowel motility from narcotic
pain medications and bed rest, AEB no BM for 3 dayspain medications and bed rest, AEB no BM for 3 days
 Impaired physical mobility R/T postoperative weakness,Impaired physical mobility R/T postoperative weakness,
AEB patient unable to move from bed to chair withoutAEB patient unable to move from bed to chair without
assistanceassistance

20. AEB statementsAEB statements
 Don’tDon’t include prejudicial statements such as:include prejudicial statements such as:

Risk for impaired skin integrity R/TRisk for impaired skin integrity R/T poor hygienepoor hygiene
habits, AEB foul stench from perineal areahabits, AEB foul stench from perineal area
 Instead, you could use:Instead, you could use:

Risk for impaired skin integrity R/TRisk for impaired skin integrity R/T inability to reachinability to reach
perineal area to clean, AEB patient verbalizedperineal area to clean, AEB patient verbalized
need for nursing assistance with perineal careneed for nursing assistance with perineal care

21. Diagnostic testing…Diagnostic testing…
 Don’t use diagnostic testsDon’t use diagnostic tests specificallyspecifically in nursingin nursing
diagnoses like:diagnoses like:

Anxiety R/TAnxiety R/T cardiac catheterizationcardiac catheterization, AEB patient, AEB patient
statements of uneasiness and nervously pacing floorstatements of uneasiness and nervously pacing floor
 Instead, focus on patient responses to the tests:Instead, focus on patient responses to the tests:

Anxiety R/TAnxiety R/T awaiting of cardiac catheterizationawaiting of cardiac catheterization
results, AEB patient statements of uneasinessresults, AEB patient statements of uneasiness
and nervously pacing floorand nervously pacing floor

22. Phrasing diagnosesPhrasing diagnoses
 Don’t use blaming phrases or ones that could implyDon’t use blaming phrases or ones that could imply
negligence or malpractice, like:negligence or malpractice, like:

Excess fluid volume R/T IV infused too quicklyExcess fluid volume R/T IV infused too quickly

Acute pain R/T improper placement of epiduralAcute pain R/T improper placement of epidural
cathetercatheter
 Don’t overload diagnoses…Don’t overload diagnoses…

Constipation and abdominal pain should be 2 differentConstipation and abdominal pain should be 2 different
nursing diagnosesnursing diagnoses

Noncompliance and knowledge deficit should be 2Noncompliance and knowledge deficit should be 2
different diagnosesdifferent diagnoses

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