5 Tips on Writing a Nurse DiagnosisHigher Education Articles August 19, 2013
The North American Nursing Diagnosis Association (NANDA) standards are used to write nursing diagnosis in language that accurately conveys patient information to colleagues and other health care professionals. This standard approach to reporting allows information to be easily read and understood by those familiar with the standards. The goal is accuracy and a reduction in interpretation mistakes.
Writing a nursing diagnosis is easier by breaking it down into individual pieces on which to focus. Unlike a medical diagnosis that relates to physician-related conditions, the nursing diagnosis focuses on the items that are of importance to nursing staff. The physician diagnosis will use terminology from the International Statistical Classification of Diseases and Related Health Problems or ICD-9 codes. The nursing diagnosis uses the NANDA standards to achieve a similar level of consistency.
Complete a nursing assessment to bring together all of the data you need, being focused only on the information and not the interpretation. An early interpretation can prove to be false based on subsequent data received from examination or tests. Use patient interviews, physical exams, medical records reviews, and input from other health care providers working with the patient as the source of your information. Include the results from any diagnostic tests.
Get the Big Picture
With all of the data in front of you, get a sense of what is going on with the patient. Think in terms of how various systems in the body are not functioning in a normal manner and in cooperation. Looking at limited information may not give you the clues to the patient’s true status. One assessment could be completely changed with the addition of the patient’s blood pressure trends over a few weeks. Another could change with a review of medical records from a previous admission. Have all of the pieces together and look for the bigger picture that represents this patient’s current health.
Find the Standard Terminology
Look through the NANDA list of diagnoses and find what matches your own assessment. There are numerous resources online that list these or your facility may have its own references. Some work places provide quick reference guides at the nursing stations. If you are just getting familiar with writing nurse diagnoses, refer to those written by other staff that has more experience. The goal is good communication, and you may learn some tips from others to create clear and crisp statements.
Write the Nursing Diagnosis Statement
The basic nursing diagnosis is composed of three parts connected by the standard phrases:
2.“related to” or abbreviated “r/t”
3.The processes causing the symptoms
4.“As evidenced by” or abbreviated “aeb”
5.The observed physiology or behavior
A “risk for” nursing diagnosis will only have the first two pieces without the “as evidenced by” portion. Some health care facilities require an additional clause, “secondary to,” followed by the medical diagnosis.
Examples of the use of this syntax include:
•Imbalanced Nutrition: less than body requirements related to gastric ulcer as evidenced by lost 10 pounds in the past 2 weeks because of reduced food intake
•Ineffective clearing of airway related to accumulated secretions as evidenced by reduced breath sounds on both sides and persistent coughing
•Risk for infection related to possible exposure to a family member with tuberculosis
Medical or Nursing Diagnosis
Nurses are prohibited by law from making medical diagnoses. The intervention in a medical diagnosis is directed by a physician. The nursing diagnosis specifies a condition that can be addressed by nursing practices. Review your statement and ask “What nursing interventions would be used to address this condition?” Nursing diagnoses feed into the patient care plan created by the nursing team. It is important to have a clear nursing diagnosis statement versus a medical diagnosis.
Following these guidelines will help you create consistent and useful nursing diagnoses. Discuss your statement with your peers and learn their own techniques. It will soon become second nature and a part of your professional nursing skills.