Nursing diagnosis

1. Nursing Diagnosis
Nursing Diagnosis

2. Nursing diagnoses?
Nursing diagnoses?
What’s up with that?
What’s up with that?
 Nursing diagnoses are what you get when you finish
Nursing 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 responses
Nursing diagnoses describe patient needs or responses
to health conditions and treatments
to health conditions and treatments
 Nursing diagnoses reflect the patient’s level of health or
Nursing diagnoses reflect the patient’s level of health or
response to disease, emotional state, socio-cultural
response to disease, emotional state, socio-cultural
phenomenon, or developmental stage
phenomenon, or developmental stage

3. Medical vs. nursing diagnoses
Medical vs. nursing diagnoses
 Medical
Medical diagnosis-
diagnosis- Identifies disease or pathology
Identifies disease or pathology
 Nursing
Nursing diagnosis-
diagnosis- Identifies patient’s response to said
Identifies patient’s response to said
disease or pathology
disease or pathology
 Medical
Medical diagnosis goal-
diagnosis goal- to cure the disease
to cure the disease
 Nursing diagnosis goal-
Nursing diagnosis goal- to direct the nursing plan of care
to direct the nursing plan of care
to meet the patient’s needs
to meet the patient’s needs

4. Nursing diagnoses
Nursing diagnoses
 Help facilitate communication between members of the
Help facilitate communication between members of the
nursing staff
nursing staff
 Help prioritize the needs of the patient
Help prioritize the needs of the patient
 Help to guide charting
Help 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 like
Take 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 nutshell
Those 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 the
The first thing I do is get report on my patients- from the
ER or the previous nurse
ER or the previous nurse
 As I am getting report, I am thinking about what I will
As 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 pain
Check on pain

Check the lungs- potential for pneumonia or atalectasis
Check the lungs- potential for pneumonia or atalectasis

Check for constipation from narcotic pain meds
Check for constipation from narcotic pain meds

Check the incision
Check the incision

Check if the patient has been out of bed yet
Check 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 all
When 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 doing
How the pain is doing

When the last BM was
When the last BM was

If she has been out of bed yet
If 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 fluid
Lungs- check for diminished breath sounds or fluid

Incision- check for redness or drainage
Incision- check for redness or drainage

Legs- check for clot
Legs- check for clot
 When I am done, I consider all of my findings and come
When 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 her
The patient is in a fair amount of pain- I need to give her
some pain medication ASAP
some pain medication ASAP
 Her lungs are clear but there is still the potential for
Her lungs are clear but there is still the potential for
pneumonia
pneumonia
 She has not had a BM in 3 days- pain medications are
She has not had a BM in 3 days- pain medications are
getting her constipated
getting her constipated
 The incision looks OK- no signs of infection
The 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 ambulate
but needs to ambulate

9. To turn these findings
To 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 comfort
impaired comfort” or “
” or “acute
acute
pain
pain”
”

She doesn’t have pneumonia right now, but she’s still at risk for
She doesn’t have pneumonia right now, but she’s still at risk for
it- that could be “
it- that could be “potential impaired gas exchange
potential impaired gas exchange”
”

No BM in 3 days- sounds like “
No BM in 3 days- sounds like “constipation
constipation” to me!
” to me!

Her incision is OK but it could still become infected- how about
Her incision is OK but it could still become infected- how about
“
“risk for infection
risk for infection”
”

She’s not moving so well- “
She’s not moving so well- “impaired physical mobility
impaired physical mobility” might
” might
work. “
work. “Risk for falls
Risk for falls” might be good, too, since she’s taking
” might be good, too, since she’s taking
narcotic pain medicines
narcotic pain medicines

10. To write or not to write?
To write or not to write?
 When I work with patients in the hospital, I formulate
When I work with patients in the hospital, I formulate
nursing diagnoses for my patients in my head
nursing diagnoses for my patients in my head
automatically as I am getting report and doing my
automatically 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 chart
I also refer to the nursing care plan in the patient’s chart
to see what other nursing diagnoses have been selected
to see what other nursing diagnoses have been selected
by the staff
by the staff
 Nursing students get to write everything out-
Nursing students get to write everything out- to show the
to show the
instructor and help it become second nature in practice
instructor and help it become second nature in practice
after graduation
after graduation

11. At clinical, you will…
At clinical, you will…
1.
1. Get report on your patients first
Get report on your patients first
2.
2. Go meet with your patients and do a physical
Go meet with your patients and do a physical
assessment
assessment
3.
3. Formulate your nursing diagnoses
Formulate your nursing diagnoses
4.
4. Develop a care plan based on your assessment and
Develop a care plan based on your assessment and
nursing diagnoses
nursing diagnoses

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

13. Writing nursing diagnoses
Writing nursing diagnoses
 The first part is the NANDA nursing diagnosis statement
The first part is the NANDA nursing diagnosis statement
 If your patient doesn’t meet the criteria for the diagnosis
If your patient doesn’t meet the criteria for the diagnosis
yet, you put “Risk for…” in front of the diagnosis
yet, you put “Risk for…” in front of the diagnosis

Risk for nausea
Risk for nausea

Risk for deficient fluid volume
Risk for deficient fluid volume
 After the diagnosis, you put why you chose the diagnosis
After 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 medications
Risk for nausea R/T side effects from chemotherapy medications

Risk for deficient fluid volume R/T poor fluid intake and high
Risk for deficient fluid volume R/T poor fluid intake and high
temperature
temperature

Sleep deprivation R/T busy ICU environment
Sleep 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 incision
Acute pain R/T tissue damage from surgical incision

Potential impaired gas exchange R/T shallow breathing
Potential impaired gas exchange R/T shallow breathing
postoperatively
postoperatively

Constipation R/T slowed bowel motility from narcotic pain
Constipation R/T slowed bowel motility from narcotic pain
medications and bed rest
medications and bed rest

Risk for infection R/T new surgical incision
Risk for infection R/T new surgical incision

Impaired physical mobility R/T postoperative weakness
Impaired physical mobility R/T postoperative weakness

Risk for falls R/T dizziness from narcotic pain medications
Risk for falls R/T dizziness from narcotic pain medications

15. “
“Related to” statements
Related to” statements
 Should be within the scope of nursing practice, not
Should 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 such
Related to statements should include information such
as:
as:

Symptoms or situations that can be addressed with nursing care
Symptoms or situations that can be addressed with nursing care

Patient responses to diseases or conditions
Patient responses to diseases or conditions

Treatments that can be performed by a nurse
Treatments that can be performed by a nurse

Developmental or maturational stages
Developmental or maturational stages

16. Writing “related to” statements
Writing “related to” statements
 Don’t
Don’t put medical diagnoses or diagnostic tests like
put 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.
 Do
Do put factors that you can take care of with nursing
put factors that you can take care of with nursing
interventions…
interventions…
BAD
BAD BETTER!!
BETTER!!
Impaired gas exchange R/T
Impaired gas exchange R/T
increased blood CO2 levels
increased blood CO2 levels
Impaired gas exchange R/T
Impaired gas exchange R/T
shallow breathing postop
shallow breathing postop
Diarrhea R/T
Diarrhea R/T C. difficile
C. difficile infection
infection Diarrhea R/T food intolerance
Diarrhea R/T food intolerance
Acute pain
Acute pain R/T hip fracture
R/T hip fracture Acute pain R/T swelling and
Acute pain R/T swelling and
tissue damage
tissue damage

17. More examples…
More examples…
Bad
Bad Good
Good Why??
Why??
Risk for aspiration
Risk for aspiration
R/T stroke
R/T stroke
Risk for aspiration
Risk for aspiration
R/T
R/T impaired
impaired
swallowing
swallowing
Nurses can work with
Nurses can work with
patients to improve
patients to improve
swallowing ability
swallowing ability
Acute pain R/T hip
Acute pain R/T hip
fracture
fracture
Acute pain R/T
Acute pain R/T
tissue damage and
tissue damage and
swelling in right hip
swelling in right hip
Nurses can give medications
Nurses can give medications
to help relieve pain from
to help relieve pain from
tissue damage, and provide
tissue damage, and provide
ice to reduce swelling
ice to reduce swelling
Risk for falls R/T
Risk for falls R/T
Multiple Sclerosis
Multiple Sclerosis
Risk for falls R/T
Risk for falls R/T
poor balance and
poor balance and
leg weakness
leg weakness
Nurses can help patients with
Nurses can help patients with
transfers to compensate for
transfers to compensate for
poor balance and weakness
poor balance and weakness

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

19. Some examples from
Some 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 movement
visible grimacing with movement
 Constipation R/T slowed bowel motility from narcotic
Constipation R/T slowed bowel motility from narcotic
pain medications and bed rest, AEB no BM for 3 days
pain 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 without
AEB patient unable to move from bed to chair without
assistance
assistance

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

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

22. Phrasing diagnoses
Phrasing diagnoses
 Don’t use blaming phrases or ones that could imply
Don’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 quickly
Excess fluid volume R/T IV infused too quickly

Acute pain R/T improper placement of epidural
Acute pain R/T improper placement of epidural
catheter
catheter
 Don’t overload diagnoses…
Don’t overload diagnoses…

Constipation and abdominal pain should be 2 different
Constipation and abdominal pain should be 2 different
nursing diagnoses
nursing diagnoses

Noncompliance and knowledge deficit should be 2
Noncompliance and knowledge deficit should be 2
different diagnoses
different diagnoses

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