How to Write a Nursing Diagnosis and Intervention

As a nurse, on a daily basis you will need to perform a nursing diagnosis and intervention for the patients you are taking care of. The purpose of a nursing intervention is to diagnose a problem the patient is experiencing, not a specific disease, and then implement an intervention to help manage or alleviate the problem. For example, if your patient came in with a suspected broken bone, a doctor would need to determine that; for the nurse, the top priority would be to alleviate pain and make the patient comfortable by treating certain symptoms caused by a disease or condition.

Things You'll Need

• NANDA diagnosis list
• NANDA diagnosis and rationale chart

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Instructions

• 1

  Assess the patient's condition. You will need to review both physical and mental conditions of the patient. Take vital signs, review patient charts for blood and urine analysis and interview family members. Family members know a patient best and can often give you more information on what may be wrong.

• 2

  Locate in the NANDA nursing diagnosis list an approved nursing diagnosis. NANDA is the North American Nursing Diagnosis Association. NANDA was created to help nurses with diagnosis of problems that a nurse faces on a daily basis. If your patient is suffering from pain, an appropriate nursing diagnosis would be "Pain." Write or type the diagnosis in an approved NANDA chart for nursing diagnoses and interventions.

• 3

  Study the NANDA diagnosis list for "Rationales" or "Interventions" for methods to improve or correct the problem. You can use one or several different methods to help the patient feel better. If your nursing diagnosis was "Pain," then a rationale or intervention might be to "Administer Pain Medications."

• 4

  Write down the expected outcome for your patient's condition by following the interventions you have written down. For example, if you are administering pain medications as needed, an outcome would be that the patient's pain level before pain medications on a scale from one to 10 is a 10, expected outcome after administering pain medication would be pain down from 10 to zero.

• 5

  Reassess your patient at the end of your shift or in a couple of hours. Perform again everything that you did at the beginning of your review of the patient's condition. This will determine if the patient's condition has changed or stayed the same. Write the finding in your NANDA-approved nursing chart.