Steps to Write the Nursing Diagnosis

How to Format a Nursing Diagnosis?

A nursing diagnosis is a statement having three parts (Please read: NURSING DIAGNOSIS - SECOND COMPONENT) which is the basis of nursing care plan (NCP). Nursing care plan is a critical thinking exercise for nursing students by analyzing the patient’s need for recovering from the disease process.

FORMATTING OF NURSING DIAGNOSIS STATEMENT

1 - ONE PART STATEMENT consist of one statement such as in wellness or syndrome diagnosis For example: Readiness for Enhanced Coping

2 - TWO PART STATEMENT is used for risk, high risk, potential and possible nursing diagnosis. For example: Risk for Infection related to compromised host defenses

3 - THREE PART STATEMENT used for actual nursing diagnosis. This format is called PES. For example: Impaired Physical Mobility related to decreased muscle control as evidenced by inability to control lower extremities.

Steps to Write the Nursing Diagnosis

1- Collect & Analyze Information/Data

• Note down the patient's injuries or symptoms of the condition.
• Formulate a basic description of problems which seems to have, based on the signs and symptoms you observed.
• Actual nursing diagnosis includes information/data from the patient, family members and friends, who can provide details about changes in the patient's behavior and appearance.

Some possible questions to Ask

• What makes the symptom better or worse?
• What have you done to get relief?
• How would you characterize the symptom?
• How does the symptom rate on a severity scale of 1 to 10?
• When did the symptom start? Is the onset sudden or gradual?
• How long does the symptom last?

• Assess the patient's response to the symptoms beside what patient has done to relieve the symptoms and how they are coping with any pain or loss of functioning. Consider the patient's attitude and treatment of people around them, including friends, family and health care providers.
• Distinguish between objective and subjective data. As it support the actual diagnosis may be either objective or subjective. Objective data is generally more important in forming the basis of diagnosis. However, subjective data, especially regarding the patient's pain level, can be important to both your diagnosis and overall care plan.
• Identify the problem that nursing diagnosis will address. Do not focus on medical diagnosis rather to focus on the experience of the patient and people around them

2- Identifying Related Factors

• Initially identify the source of patient’s problem.
• Analyze the patient’s history by reviewing patient’s record, charts but determine factors related to their current condition. Lab reports and conversations with other health care team members may also be relevant.
• Include potential problems when determining related factors. List down the symptoms or issues they might experience due to their current symptoms while undergoing treatment.

3- Making Your Clinical Judgment

• Finding the most appropriate nursing diagnosis.
• Looking in the official terminology for the problems observed.
• Use the NANDA-I and any other nursing textbooks for guidance. Click for NANDA List
• Write down the official terminology which best suits the needs and condition of the patient.
• After nursing diagnosis, look for the potential outcomes and nursing interventions that are appropriate for the patient
• List down the related factors or causes of the patient's problem
• Summarize the data in an "AEB" statement. (Abbreviation for "as evidenced by")

Verify the nursing diagnosis with the patient, family, or another nurse before starting work on treatment plan.

For example, if a patient with a traumatic brain injury and a nurse diagnosed as "chronic confusion," nurse might talk to family and other nurses to confirm that the patient seems consistently confused and disoriented or not.

Steps to Write the Nursing Diagnosis | POST RN BSN Nursing Resources

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