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How to Write a Nursing Diagnosis with Examples

How to write a nursing diagnosis

The nursing diagnosis is a crucial nursing process component and is the clinical judgment to assist nurses to determine their patient’s care plan. These diagnoses pilot possible patient, community, and family interventions. Nursing diagnoses are advanced with thoughtful deliberation of the physical assessment of your patient and can aid to measure the outcomes of the care of your nursing plan.

This article is a step-by-step guide on how to write a nursing diagnosis.

Writing a nursing diagnosis

Contrary to the medical diagnosis, which identifies a particular medical condition or disease, the nursing diagnosis evaluates the needs of the patient. Follow the steps below on how to write a nursing diagnosis;

The initial part of how to write a nursing diagnosis involves collecting and evaluating data;

  1. Examine your patient’s symptoms.

Note the injuries of the patient or their condition symptoms. Formulate the problem’s basic description the patient appears to have, relying on the symptoms and signs you see.

  1. Discuss with your patient and their close family concerning their feeling.

Your real nursing diagnosis involves the patient’s information together with those surrounding them. Loved ones and friends can provide details regarding the patient’s actions and appearance changes.

  1. Analyze your patient’s response to the symptoms.

Observe the patient’s actions to alleviate their symptoms and their coping mechanism with function loss or any pain. Consider the attitude of the patient and the treatment of surrounding people, including close family and medical care providers.

  1. Differentiate between subjective and objective data.

Subjective data is the patient’s perception of how they sense and it can never be verified. Objective data alternatively come from quantifiable and verifiable observations making use of scientific methods.

  1. Determine the nursing problem that will be addressed by the nursing diagnosis.

Observe the data patterns you’ve collected. Various symptoms and signs may join together the point to derive the correct diagnosis. how to write a nursing diagnosis. how to write a nursing diagnosis

The second part of how to write a nursing diagnosis includes analyzing related factors;
1.
Diagonise your patient’s problem source.

Once you’ve assessed the problem you will deal with it from the perspective of the nurse, and ascertain why your patient is experiencing the problem. This will assist you to decide on whether the nursing interventions work to ease the problem;

  1. Evaluate your patient’s general health and history.

Review the records and chart of the patient to decide the factors associated with their recent condition. Lab reports and discussions with fellow members of the medical care team can also be important.

  1. Include potential problems when deciding the associated factors.

Depending on your patient’s condition knowledge, list issues or symptoms your patient might experience as a result of their recent symptoms in the course of treatment.

The third part of how to write a nursing diagnosis includes making your medical judgment;
1. Look for relevant nursing diagnoses.

Research for a formal terminology of your observed problem. Utilize the NANDA-I or any other textbooks you have in nursing on how to write a nursing diagnosis to direct you.

  1. Combine the related factors for the diagnosis.

Your next nursing diagnosis section lists the associated factors or the causes of your patient’s problem. Seek for these factors in standardized terms in your respective textbooks on how to write a nursing diagnosis, if you aren’t aware of them already

  1. Summarize the information in your AEB statement.

The nursing abbreviation AEB stands for “as evidenced by.” Comb the information you’ve collected on how to write a nursing diagnosis to set apart characteristics that exhibit your diagnosed problem.

Types of nursing diagnosis

Apply the following four nursing diagnosis types as per NANDA-I on your how to write a nursing diagnosis process;

  1. The Problem-Focused Nursing Diagnosis

It is the client problem available in the course of your nursing assessment on how to write a nursing diagnosis. These nursing diagnoses are established on the existence of related symptoms and signs.

  1. The Risk Nursing Diagnosis

These are clinical experiences that prove there is no problem exists, but the risk factors presence demonstrates that the problem is bound to emerge unless the nurses intervene.

  1. The Health Promotion Diagnosis

It is the clinical judgment regarding the desire and inspiration to improve well-being. This statement identifies the readiness of the patient to participate in health and welfare promotion activities.

  1. The Syndrome Diagnosis

This diagnosis is the clinical judgment regarding nursing diagnoses of problems that are anticipated to occur due to a specific situation.

Medical diagnosis vs nursing diagnosis

Even though there exist similarities between nursing and medical diagnoses, including the terminology shared and clinical judgment, they are different. The differences include; all nursing designations share the nursing diagnoses, while physicians devise medical diagnoses. The medical diagnoses concentrate on the patient’s pathology or the respective disease. In contrast, nursing diagnoses focus on the response of the patient to the disease or existing condition, which is either a psychological or physiological response.

Nursing diagnosis examples

Use the below nursing diagnosis examples extracted from NANDA-I (2021-2023) complete handbook on how to write a nursing diagnosis to execute nursing care in the future;

  1. Reduced tolerance to activity
  2. Surgical infection at site risk
  3. Lack of knowledge
  4. Reduced cardiac output
  5. Lack of fluid volume
  6. Unsuccessful coping
  7. Acute pain
  8. Inefficient thermoregulation
  9. The unsuccessful pattern of breathing
  10. Electrolyte imbalance risk
  11. Unproductive plans for the childbearing process risk

What is Nanda nursing diagnosis?

The NANDA-I nursing diagnosis allows nurses to decide the appropriate care plan for their respective patients. As a nurse, your patient assessment will guide you on how to write a nursing diagnosis. Nursing diagnoses should involve the problem, its etiology, the problem definition, and the problem risk factors.

Nanda approved nursing diagnosis

In NANDA’s latest edition, (2018-2020) nursing diagnosis list, some changes have been made to the approved nursing diagnosis in comparison with the former (2015-2017) Nanda nursing diagnoses edition.

NANDA’s latest edition, (2018-2020) nursing diagnosis list consists of seventeen current nursing diagnoses that were introduced and approved. The recently approved nursing diagnoses are:

  1. Preparedness for boosted health literacy
  2. Inefficient eating dynamics in adolescents
  3. Unsuccessful eating dynamics of children
  4. Inefficient eating dynamics of Infants
  5. Metabolic imbalance syndrome risk
  6. The disparity in the energy field
  7. Unbalanced blood pressure risk
  8. Complex immigration transition risk
  9. Syndrome on neonatal abstinence
  10. Withdrawal syndrome on acute substance
  11. Withdrawal syndrome on acute substance risk
  12. Surgical infection at site risk
  13. Dry mouth risk
  14. Venous thromboembolism risk
  15. Female genital mutilation (FGM) risk
  16. Occupational injury risk
  17. Inefficient thermoregulation risk

Safety nursing diagnosis

Safety is the discipline committed to offering health care at the same time-reducing injury, errors, and risks to the patient. It involves security enhancements and protocols created to decrease injury, complications, and accidents.

Nursing diagnosis format

An alternative way how to write a nursing diagnosis is by applying the format of PES, which means Problem, Etiology, and Signs or Symptoms. Diagnostic statements utilizing the format on PES are one-part, two-part, or even three-part.
1. One-part statement on nursing diagnosis

Nursing diagnoses on health promotion are normally written in form of one-part diagnosis statements because associated factors are ever similar: inspired to attain a higher wellness level through connected factors that may be utilized to advance the diagnosis chosen.
2. Two-part statement on nursing diagnosis

Risk and possible nursing diagnoses probably have two-part nursing diagnosis statements. The initial part is your diagnostic label while the second one is the risk nursing validation diagnosis or risk factors present.
3. Three-part Statement on Nursing Diagnosis

A real or nursing diagnosis that is focused on the problem comprises three-part statements: namely diagnostic label, the factor contributing, and the signs/symptoms. The three-part statement on nursing diagnosis is also referred to as the format of PES.

Community nursing diagnosis

Community health in nursing, also called public health care, is one of the various specializations available in the professional field of nursing. Nurses who aspire to work in a setting besides the hospital and control their practice greatly can opt to specialize in nursing community health.

The bottom line of writing a compelling nursing diagnosis

Regard your nursing diagnosis to be the map that will assist the doctor make a diagnosis more easily. You are your patient’s advocate and it’s your sole duty to stand up for their requirements. A relevant nursing diagnosis must explain to the doctor your perception of what’s the matter with your patient, why, and what they require. Follow the above steps on how to write a nursing diagnosis and you’ll possess the skills of a real medic and realize your nursing dream career.

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