The NURSING DIAGNOSES Statement

January 9th, 2010 | Posted in Nursing Diagnosis

What is a Nursing Diagnosis Statement?
? A clinical judgment about actual or potential health problems or life processes
? A standardized statement by NANDA (North American Nursing Diagnosis Association)
NANDA
? You can find NANDA approved nursing diagnoses in a nursing diagnosis book

? There is a list in the Appendix of the “Nursing Process in Action” text (but that is an outdated list!!)

? You can use a “nursing reference” card from Taber’s which also includes the latest NANDA approved nursing diagnosis list
NANDA Approved Nursing Dx is NOT a Medical Dx
? Remember that a nursing diagnosis is NOT the same as a medical diagnosis

Nursing Diagnosis vs Medical Diagnosis

? Hypotension — Medical Diagnosis

? Tissue perfusion, ineffective (cardiopulmonary) – Nursing Diagnosis

? Congestive heart failure — Medical Diagnosis

? Cardiac output, decreased — Nursing Diagnosis
Nursing Diagnosis Statement
The Three Parts
? Starts with a NANDA approved nursing diagnosis (Problem)
? Has Etiology or R/T (related to) phase or etiology
? Has Symptom section which gives defining characteristics or symptoms you identify in the assessment of the patient

Any other parts???
? You may (but don’t have to) add a further descriptor to the end of your nursing diagnosis statement
? Secondary To (2°) followed by a medical diagnosis that further describes the etiology or symptoms
Problem
? Use the exact NANDA wording to state the problem

? Examples
? Poor sleep pattern — wrong
? Sleep Pattern, disturbed — correct

? Poor circulation — wrong
? Tissue perfusion, ineffective (cardiopulmonary) — correct
Etiology
? This is the “related to” phrase that describes the cause or contributor to the problem

? The etiology is usually at the cellular level

? Think to yourself
? what is going on inside that causes the problem?
Etiology
? Indicates what may be causing or contributing to the nursing diagnosis

? Helps you plan your nursing interventions (NICs)
? If due to impaired venous and arterial circulation you could elevate and extremity
Etiology – what does this part look like?
? Examples for “Tissue perfusion, ineffective (peripheral),”
? R/T poor circulation — Wrong
? R/T poor blood flow due to congested veins and arteries and cellular damage in tissues – Correct

? R/T edema in LLL – Wrong
? R/T interruption of arterial flow and venous flow and imbalance of interstitial fluids — Correct

So far, what would this look like?
? Tissue perfusion, ineffective (peripheral), R/T interruption of arterial and venous flow & imbalance of interstitial fluids,

? Now you are ready to add on the last part of the nursing diagnosis statement
Symptoms
? This is the defining characteristics you identify in the patient assessment
? It is your as evidenced by statement (AEB)
? Examples
? Edema
? Positive Homan’s sign
? Poor hair distribution on extremities
? Skin discoloration
? Skin temperature changes
? Diminished pulses
? Abnormal labs that back you up
Symptoms
? The third part of a three-part nursing diagnosis statement

? AEB is used to connect this section to the R/T section (second-part of nursing diagnosis statement)

? It is what you assessed that got you to choose the nursing diagnosis to begin with!
Symptoms
? So let’s finish that nursing diagnosis statement!

? Tissue perfusion, ineffective (peripheral), R/T interruption of arterial and venous flow & imbalance of interstitial fluids, AEB LLE edema, weak peripheral pulses, and low albumin level.
Could we add the 2° part???
? Yes, it adds clarity and strength to the entire nursing diagnosis statement
? Remember this part is where you can put a medical diagnosis
? Example
? 2° DM type II
? 2° Htn
? 2° CHF

All together now!
? Tissue perfusion, ineffective (peripheral), R/T interruption of arterial and venous flow & imbalance of interstitial fluids, AEB LLE edema, weak peripheral pulses, and low albumin level, 2° to DM type II and PVD.
YOU DID IT!!!
Tips
? Practice, practice, practice!

? Get to know the reference book you will be using
? Nursing Diagnosis Handbook
? Textbook

? Always be precise when you write out the nursing diagnosis so it gets familiar.
Using Nursing Diagnoses Books
? Books are different, so decide if in your book you will be looking up a
? Symptom
• Dyspnea
• Fatigue
• Dysrhythmia
? Or a medical diagnosis
• COPD
• Diabetes Mellitus Type II
• First degree AV Block

STEP ONE:
Find the Assessment Finding
? For example, you find that your patient has had a stroke.
? There is weakness
? There is difficulty swallowing
? There is anxiety
Now…STEP TWO
? Based on the assessment finding you will need to find the appropriate nursing diagnosis or diagnoses
Weakness
? Weakness is a symptom not a nursing diagnosis

? From the symptom of weakness…what nursing diagnosis would be appropriate?
Possible Nursing Diagnoses for Weakness
? Disuse Syndrome, risk for
? Mobility, impaired bed
? Mobility, impaired wheelchair
? Walking, impaired
? Transfer Ability, impaired
? Falls, risk for
? Injury, risk for
? Mobility, impaired physical
? Skin Integrity, risk for impaired
Choosing the Nursing Diagnosis
? Out of all those listed for weakness
? Which one meets your specific patient needs the best?
? Which one is most important in regards to your patient?
? Any of them A-B-C related? (always most important)
After you choose…
? You need to then put on the next two parts of the nursing diagnosis statement
? Etiology (R/T statement)
? Symptoms (AEB statement)

? Add the Secondary To (2°) if applicable and helpful for clarity
Let’s Try Another Example
Difficulty Swallowing (Dysphagia)
? Dysphagia is a symptom, not a nursing diagnosis.

? From the symptom of dysphagia…what nursing diagnosis would be appropriate?

Possible Nursing Diagnoses for Dysphagia
? Swallowing, impaired
? Aspiration, risk for
? Sensory perception, disturbed (gustatory)
? Self-care deficit: feeding
Choosing the Nursing Diagnosis
? Out of all those listed for dysphagia
? Which one meets your specific patient needs the best?
? Which one is most important in regards to your patient?
? Any of them A-B-C related? (always most important)

Possible Nursing Diagnoses for Anxiety
? Anxiety (specify level)
? Anxiety, death
? Coping, ineffective
? Grieving, dysfunctional
? Spiritual Distress
? Spiritual Distress, risk for

Anything Else?
? When care planning:
? Now that you have your three-part nursing diagnosis statement (and maybe a secondary to statement) you are ready to decide on
• NOC (Nursing Outcomes Classifications)
? What you want your patient outcome to be
• NIC (Nursing Interventions Classifications)
? What your intervention is to get the patient to that outcome
? NOCs and NICs will be covered in depth in a separate tutorial
Also!
? When care planning
? Don’t forget to evaluate if your outcomes were achieved
In summary
? A nursing diagnosis statement has at least three parts
? P – choose the nursing diagnosis label based on the problem
? E – the etiology of the problem, listed as a R/T statement
? S – the symptoms you assess that back you up
? 2° statement (medical diagnosis) if it adds clarity to your nursing diagnosis statement and has direct correlation
Practice and you will be a winner with nursing diagnoses statements!
by.B.J. French, PhD, MSN, RN