Nursing DiagnosisNursing Diagnosis

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 treatmentsto 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 stagephenomenon, or developmental stage

Medical vs. nursing diagnosesMedical vs. nursing diagnoses

MedicalMedical diagnosis- diagnosis- Identifies disease or pathology Identifies disease or pathology

NursingNursing diagnosis- diagnosis- Identifies patient’s response to said Identifies patient’s response to said disease or pathologydisease or pathology

MedicalMedical 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 needsto meet the patient’s needs

Nursing diagnosesNursing diagnoses

Help facilitate communication between members of the Help 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

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 nutshellThose are nursing diagnoses in a nutshell

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 nurseER 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 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

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 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 come When I am done, I consider all of my findings and come up with some conclusions…up with some conclusions…

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 ASAPsome 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 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

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 comfortimpaired comfort” or “” or “acute acute

painpain””

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 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 about Her 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

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 assessments

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 staffby 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 graduationafter graduation

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 physical Go 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 and Develop a care plan based on your assessment and

nursing diagnosesnursing diagnoses

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 patientscreative 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’tcan’t do it! do it!

Some authors like Carpenito have developed nursing Some authors like Carpenito have developed nursing diagnoses similar to NANDA’s, they will be acceptable at diagnoses similar to NANDA’s, they will be acceptable at our university, but NANDA will be preferred. our university, but NANDA will be preferred.

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 diagnosis If 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 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 medicationsRisk 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

temperaturetemperature Sleep deprivation R/T busy ICU environmentSleep deprivation R/T busy ICU environment

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 breathing Potential impaired gas exchange R/T shallow breathing postoperativelypostoperatively

Constipation R/T slowed bowel motility from narcotic pain Constipation 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

““Related to” statementsRelated 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 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

Writing “related to” statementsWriting “related to” statements

Don’tDon’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.

DoDo put factors that you can take care of with nursing put factors that you can take care of with nursing interventions… interventions…

BADBAD BETTER!!BETTER!!

Impaired gas exchange R/T Impaired gas exchange R/T increased blood CO2 levelsincreased blood CO2 levels

Impaired gas exchange R/T Impaired gas exchange R/T shallow breathing postopshallow breathing postop

Diarrhea R/T Diarrhea R/T C. difficileC. difficile infection infection Diarrhea R/T food intoleranceDiarrhea 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 damagetissue damage

More examples…More examples…

BadBad Good Good Why??Why??Risk for aspiration Risk for aspiration R/T strokeR/T stroke

Risk for aspiration Risk for aspiration R/T R/T impaired impaired swallowingswallowing

Nurses can work with Nurses can work with patients to improve patients to improve swallowing abilityswallowing ability

Acute pain R/T hip Acute pain R/T hip fracturefracture

Acute pain R/T Acute pain R/T tissue damage and tissue damage and swelling in right hipswelling 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 swellingice to reduce swelling

Risk for falls R/T Risk for falls R/T Multiple SclerosisMultiple Sclerosis

Risk for falls R/T Risk for falls R/T poor balance and poor balance and leg weaknessleg weakness

Nurses can help patients Nurses can help patients with transfers to compensate with transfers to compensate for poor balance and for poor balance and weaknessweakness

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 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 condition diagnoses, 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 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

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 movementvisible 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 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 without AEB patient unable to move from bed to chair without assistanceassistance

AEB statementsAEB statements

Don’tDon’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 areahabits, 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 careneed for nursing assistance with perineal care

Diagnostic testing…Diagnostic testing…

Don’t use diagnostic tests Don’t use diagnostic tests specificallyspecifically in nursing in nursing diagnoses like:diagnoses like:

Anxiety R/T Anxiety 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/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 floorand nervously pacing floor

Phrasing diagnosesPhrasing 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 quicklyExcess fluid volume R/T IV infused too quickly Acute pain R/T improper placement of epidural Acute pain R/T improper placement of epidural

cathetercatheter

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 diagnosesnursing diagnoses Noncompliance and knowledge deficit should be 2 Noncompliance and knowledge deficit should be 2

different diagnosesdifferent diagnoses