A good nursing diagnosis is needed to come up with a working care plan. Nursing students who are just starting out often have difficulty in formulating a working nursing diagnosis because of lack of understanding of the principles behind it. Here are some tips to understand the nursing diagnosis better and easily come up with a nursing diagnosis.
Defining a Nursing Diagnosis
Students should first understand what a nursing diagnosis should be about. A nursing diagnosis is a statement of a client’s potential or actual health problem resulting from assessment. It is the problem statement that the nurse makes regarding a client’s condition which she uses to communicate professionally. It uses critical thinking skills to identify client strengths & health problems that can be resolved or prevented by collaborative and independent nursing interventions.
Activities in Nursing Diagnosis
- Analysis- going through the information gathered from assessment
- Problem Identification- use of critical thinking to point out problems from the data gathered in assessment
- Formulation of Nursing Diagnosis- coming up with a a nursing diagnosis based on the problems identified, etiology and symptoms
Characteristics of Nursing Diagnosis
A nursing diagnosis should state a clear and concise health problem, should be derived from existing evidences from the client, potentially amenable to nursing interventions and most importantly, it should be the basis for planning and carrying out nursing care.
Components of a Nursing Diagnosis
It contains two or three parts. the problem, etiology and defining characteristics or otherwise known as the signs and symptoms. Nursing diagnosis/ problem statements may be referred from the North American Nursing Diagnosis Association (NANDA) guidelines.
Types of Nursing Diagnosis
These types are arranged according to which should be prioritized first.
- Actual Nursing Diagnosis – a client problem that is present at the time of the nursing assessment. It is based on the presence of signs and symptoms. Further prioritizing is done for actual problems. eg.Ineffective airway clearance r/t to viscous secretions
- Potential Nursing Diagnosis- one in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it; or the causative factors are unknown but a problem is only considered possible to occur. eg.Possible altered thought processes r/t unfamiliar surroundings
- Risk Nursing diagnosis – is a clinical judgment that a problem does not exist, therefore no signs and symptoms are present, but the presence of risk factors indicate that a problem is likely to develop unless a nurse does something about it. eg.Risk for infection r/t compromised immune system.
John is a 65 year old retired soldier who was constantly having cough during the last 2 weeks before he was brought to the hospital by his youngest daughter. Lately, he has been experiencing troubles in breathing. He described it as a difficulty in expiration during breathing. For this reason, he asked his youngest daughter who is living just two blocks away from him to take him to the hospital.
John admits to be a chronic smoker, consuming two packs per day and drinks alcoholic beverages regularly with his friends. After undergoing a thorough examination, his physician ordered a series of sputum tests and other lung tests. Chronic infection was detected in the lungs most probably due to smoking which irritates the bronchi and bronchioles. There was also obstruction of the airways which is responsible for John’s difficulty in expiration. He was diagnosed to have chronic obstructive pulmonary disease (COPD).
Actual Nursing Diagnosis
- Ineffective airway clearance related to excessive and tenacious secretions
- Activity intolerance related to fatigue and inadequate oxygenation for activities
Potential Nursing Diagnosis
- sleep pattern disturbance related to cough, inability to assume recumbent position and environmental stimuli
Risk Nursing Diagnosis
- risk for altered nutrition: less than body requirements related to anorexia secondary to dyspnea
Formulating a good nursing diagnosis could be difficult at first but with a lot of practice, student nurses will have this skill come to the naturally. Refer to your nursing textbooks for more sample situations with nursing diagnoses.