Nursing Diagnosis
Nursing diagnoses?
What’s up with that?

Nursing diagnoses are what you get when you finish
your assessment and look at your data.

Nursing diagnoses describe patient needs or responses
to health conditions and treatments

Nursing diagnoses reflect the patient’s level of health or
response to disease, emotional state, socio-cultural
phenomenon, or developmental stage
Medical vs. nursing diagnoses

Medical diagnosis- Identifies disease or pathology

Nursing diagnosis- Identifies patient’s response to said
disease or pathology

Medical diagnosis goal- to cure the disease

Nursing diagnosis goal- to direct the nursing plan of care
to meet the patient’s needs
Nursing diagnoses

Help facilitate communication between members of the
nursing staff

Help prioritize the needs of the patient

Help to guide charting
In practice, you…

Do your assessment and think “My patient is in pain!”

Take your impressions and put fancy labels on them like
“impaired comfort” or “acute pain”

Those are nursing diagnoses in a nutshell
When I’m at work…

The first thing I do is get report on my patients- from the
ER or the previous nurse

As I am getting report, I am thinking about what I will
have to keep in mind when I am caring for my patients…

For a postop patient, I might be thinking:





Check on pain
Check the lungs- potential for pneumonia or atalectasis
Check for constipation from narcotic pain meds
Check the incision
Check if the patient has been out of bed yet
Then off to see the patient…

When I go to do my assessment on the patient, I keep all
those things in mind…

I talk to the patient to see:




Then I do a physical assessment to check on:




How the pain is doing
When the last BM was
If she has been out of bed yet
Lungs- check for diminished breath sounds or fluid
Incision- check for redness or drainage
Legs- check for clot
When I am done, I consider all of my findings and come
up with some conclusions…
And I come up with…

The patient is in a fair amount of pain- I need to give her
some pain medication ASAP

Her lungs are clear but there is still the potential for
pneumonia

She has not had a BM in 3 days- pain medications are
getting her constipated

The incision looks OK- no signs of infection

The patient got out of bed last night and sat in the chair,
but needs to ambulate
To turn these findings
into nursing diagnoses…
I check the NANDA list to see what fits my findings…





My patient is in pain- that could be “impaired comfort” or “acute
pain”
She doesn’t have pneumonia right now, but she’s still at risk for
it- that could be “potential impaired gas exchange”
No BM in 3 days- sounds like “constipation” to me!
Her incision is OK but it could still become infected- how about
“risk for infection”
She’s not moving so well- “impaired physical mobility” might
work. “Risk for falls” might be good, too, since she’s taking
narcotic pain medicines
To write or not to write?

When I work with patients in the hospital, I formulate
nursing diagnoses for my patients in my head
automatically as I am getting report and doing my
assessments

I also refer to the nursing care plan in the patient’s chart
to see what other nursing diagnoses have been selected
by the staff

Nursing students get to write everything out- to show the
instructor and help it become second nature in practice
after graduation
At clinical, you will…
1.
Get report on your patients first
2.
Go meet with your patients and do a physical
assessment
3.
Formulate your nursing diagnoses
4.
Develop a care plan based on your assessment and
nursing diagnoses
You got to stick with NANDA!

Unfortunately, you are not allowed to make up new and
creative nursing diagnoses for your patients

No matter how much your patient merits a nursing
diagnosis of “persistent stupidity” or “constant whining”
you just can’t do it!

Some authors like Carpenito have developed nursing
diagnoses similar to NANDA’s, they will be acceptable at
our university, but NANDA will be preferred.
Writing nursing diagnoses

The first part is the NANDA nursing diagnosis statement

If your patient doesn’t meet the criteria for the diagnosis
yet, you put “Risk for…” in front of the diagnosis



Risk for nausea
Risk for deficient fluid volume
After the diagnosis, you put why you chose the diagnosis
for the patient with a “related to” (R/T) statement…



Risk for nausea R/T side effects from chemotherapy medications
Risk for deficient fluid volume R/T poor fluid intake and high
temperature
Sleep deprivation R/T busy ICU environment
For my earlier postop patient:



Acute pain R/T tissue damage from surgical incision
Potential impaired gas exchange R/T shallow breathing
postoperatively
Constipation R/T slowed bowel motility from narcotic pain
medications and bed rest

Risk for infection R/T new surgical incision

Impaired physical mobility R/T postoperative weakness

Risk for falls R/T dizziness from narcotic pain medications
“Related to” statements

Should be within the scope of nursing practice, not
medical practice (like a medical diagnosis or treatment)

Related to statements should include information such
as:




Symptoms or situations that can be addressed with nursing care
Patient responses to diseases or conditions
Treatments that can be performed by a nurse
Developmental or maturational stages
Writing “related to” statements


Don’t put medical diagnoses or diagnostic tests like
pneumonia, hip fracture, or angioplasty in the “related to”
statement.
Do put factors that you can take care of with nursing
interventions…
BAD
Impaired gas exchange R/T
increased blood CO2 levels
BETTER!!
Impaired gas exchange R/T
shallow breathing postop
Diarrhea R/T C. difficile infection Diarrhea R/T food intolerance
Acute pain R/T hip fracture
Acute pain R/T swelling and
tissue damage
More examples…
Bad
Good
Why??
Risk for aspiration Risk for aspiration
R/T stroke
R/T impaired
swallowing
Nurses can work with
patients to improve
swallowing ability
Acute pain R/T hip Acute pain R/T
fracture
tissue damage and
swelling in right hip
Nurses can give medications
to help relieve pain from
tissue damage, and provide
ice to reduce swelling
Risk for falls R/T
Multiple Sclerosis
Nurses can help patients with
transfers to compensate for
poor balance and weakness
Risk for falls R/T
poor balance and
leg weakness
After the R/T statement…

After you say why you chose the diagnosis for the
patient with the “related to” statement, include an “as
evidenced by” statement that includes specific signs and
symptoms of the particular patient

This step is not needed when there is only “Risk for …”
diagnoses, as the patient is only at risk for the condition
and has not actually developed it yet

You can use “AEB” for “as evidenced by” so that you
don’t need to write it out
Some examples from
my postop patient…

Acute pain R/T tissue damage from surgical incision,
AEB patient reports of pain rating of 8 on 1-10 scale,
visible grimacing with movement

Constipation R/T slowed bowel motility from narcotic
pain medications and bed rest, AEB no BM for 3 days

Impaired physical mobility R/T postoperative weakness,
AEB patient unable to move from bed to chair without
assistance
AEB statements

Don’t include prejudicial statements such as:


Risk for impaired skin integrity R/T poor hygiene
habits, AEB foul stench from perineal area
Instead, you could use:

Risk for impaired skin integrity R/T inability to reach
perineal area to clean, AEB patient verbalized
need for nursing assistance with perineal care
Diagnostic testing…

Don’t use diagnostic tests specifically in nursing
diagnoses like:


Anxiety R/T cardiac catheterization, AEB patient
statements of uneasiness and nervously pacing floor
Instead, focus on patient responses to the tests:

Anxiety R/T awaiting of cardiac catheterization
results, AEB patient statements of uneasiness
and nervously pacing floor
Phrasing diagnoses

Don’t use blaming phrases or ones that could imply
negligence or malpractice, like:
 Excess fluid volume R/T IV infused too quickly
 Acute pain R/T improper placement of epidural
catheter

Don’t overload diagnoses…
 Constipation and abdominal pain should be 2 different
nursing diagnoses
 Noncompliance and knowledge deficit should be 2
different diagnoses