How to Come Up With a Nursing Diagnosis

In today's practice of medicine, nurses are independent practitioners who are responsible for their patients' nursing needs. Although medical diagnoses are reserved for physicians---and in some cases, physician assistants and nurse practitioners---nurses diagnose patients' needs for observations, care taking and nursing interventions. To do this, nurses have two primary resources: 1) the North American Nursing Diagnosis Association (NANDA) standardized list of nursing diagnoses; and 2) the use of nursing clinical pathways. Nurses rely on their critical thinking skills and diagnostic training as they apply these resources.

Instructions

• 1

  Review the patient's chart and medical diagnoses or orders left by a physician. Look through the notes left by other clinicians, as well as laboratory or diagnostic test results. Pay special attention to blood values, electrocardiographic readings and available medical history.

• 2

  Begin your evaluation by following the ABCs of nursing---Airway, Breathing and Circulation. Look for any medical conditions or issues that could interfere with your patient's airway. Find corresponding NANDA diagnoses that describe airway problems, precautions or interventions you plan to take and observations you and other nurses need to make. Then, do the same for breathing and circulation. An example diagnosis might be "Airway clearance, ineffective" or "Gas exchange, impaired."

• 3

  Follow clinical pathways to examine other logical problems. For example, if a patient is hemorrhaging from the ears, eyes or anywhere on the head, you will need to examine potential neurological issues and formulate diagnoses, such as, "Confusion, acute" or "Thought process, altered."

• 4

  Evaluate your patient's psychosocial condition. Even if a patient arrives with a straightforward physical issue like a broken arm, nurses need to evaluate and plan his/her care to address the patient's emotions and cognitive abilities. Additionally, good nursing diagnostics can uncover more issues. For example, if your patient is a child with bruises and a broken arm and you observe either unusually histrionic or withdrawn behavior, this should flag you to follow clinical diagnostic pathways for child abuse. Make note of psychosocial behaviors, using NANDA labels as you proceed.

• 5

  Follow each diagnosis with "at risk" diagnoses, whenever appropriate. A patient having just given birth under stressful conditions or with a history of urinary or gynecological problems may need the NANDA nursing diagnosis of "at risk for prolapsed uterus."

• 6

  Use nursing diagnoses to drive your plan of care for your patient. "At risk" diagnoses should help you identify appropriate interventions and observations to prevent potential issues and complications. Similarly, primary diagnoses inform which immediate actions to take that may include alerting a physician for an urgently needed or revised medical diagnosis. As a nurse, your job is to protect and advocate for your patient.