How to Write a Risk for Nursing Diagnosis

Registered nurses are considered practitioners, and their job is to take care of their patients from a nursing perspective, which includes making decisions on plans of care and treatment within their scope of practice. Nurses make diagnoses that can include identifying potential medical complications and risks, which are known as "at-risk" nursing diagnoses.

Instructions

• 1

  Evaluate your patient. Follow nursing clinical pathways to examine all aspects of what may be going on with your patient including psychological and emotional factors.

• 2

  Use a critical eye to look for issues that may arise as a result of your patient's condition or planned treatments.Identify a list of potential risks for which you and your nursing staff colleagues should be watching.

• 3

  Match your "at-risk" diagnoses points to the North American Nursing Diagnosis Association International list of risk diagnoses. NANDA-I catalogs nursing terminology so that all clinicians involved in patient care are using the same language. Use of NANDA-I terms ensures your team will deliver the right care to your patient.

• 4

  Write the diagnoses into the patient's plan of care. List the conditions or complications the patient is at risk for followed by supporting information for the diagnosis. For example, "Patient is risk for bleeding due to newly increased dosage of anti-coagulent."

• 5

  Revise your nursing diagnoses as the patient's condition changes. For instance, if a patient was at risk for wound infection, but the incision has begun to heal, you can eliminate the diagnosis. Similarly, if a patient hospitalized for pneumonia turns out to be a sleepwalker, you have a new set of "at-risk" diagnoses to write.