How to Write a Nursing Assessment & Diagnosis

One aspect of a nurse's job is to assess a patient's condition, develop a nursing diagnosis and establish a care plan. The North American Nursing Diagnosis Association, or NANDA, defines a nursing diagnosis as "clinical judgment about individual, family, or community experiences and responses to actual or potential health problems and life processes." A medical diagnosis deals only with the patient's disease or medical condition. A nursing diagnosis assesses the human response to this illness. An accurate nursing assessment and diagnosis is imperative to a patient's overall recovery, not just the resolution of the specific illness.

Things You'll Need

• Patient's medical chart
• Stethoscope
• Thermometer
• Blood pressure cuff

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Instructions

• 1

  Ask the patient questions designed to develop a nursing history. This nursing history includes questions about the patient's overall health status and any significant injuries or illnesses in the past. Inquire about the patient's family's health, including questions about family members who have had diabetes, heart disease or other conditions.

• 2

  Solicit information about the patient's primary medical problem, including measures the patient has taken to manage his illness. This conversation gives the nurse clues to the patient's familial support structure, how he perceives his illness and how well he is managing his condition. Note this information on the patient's chart.

• 3

  Perform a physical examination of the patient, including vital signs and assessment of physical well-being. The nurse should listen for bowel sounds and for clear lungs. She should examine the musculoskeletal system and the skin for rashes, infections and lesions. Write down all observations in the patient's chart.

• 4

  Inquire about any symptoms a patient experiences, taking care to prioritize pertinent symptoms while still noting other symptoms that may not normally be indicative of the primary illness. Find out how long the patient has experienced these symptoms and what, if any, treatments seem to ease those symptoms. Write all symptoms in the patient's chart.

• 5

  Use established assessment tools. Download and print helpful assessment tools, like the Barthel Index, which was developed by the Maryland State Medical Society and is helpful for stroke patients. Universal use of these documents will give the nursing staff a uniform approach to effective treatment plans for all patients suffering common illnesses.

• 6

  Develop an individualized nursing care plan, incorporating not only the medical effects of the patient's illness but also the familial and social aspects of his condition. Determine how the illness will affect his quality of life, including mobility, work and play, and whether he will be able to live independently. Add this care plan to the patient's medical chart so that the course of treatment may be properly implemented and maintained.