How to Write a Nursing Diagnosis the Correct Way
What is nursing diagnosis? It’s a statement that describes a patient’s current or potential health problem within the nurse’s scope to address. Diagnoses are crucial in administering healthcare and supporting evidence based practice approaches. So you, being a nurse, need to know how to make ones properly. These nursing documents are commonly used in the care process and include information about comprehensively assessing the patient’s current condition, planning interventions, implementing treatment plans, and evaluating outcomes. So let’s check out how to write good diagnoses generally and using NANDA.
How Do You Write a Diagnosis?
Want to know how to write a nursing diagnosis? There are a few standardized steps you must follow:
- Collect comprehensive data from the client’s medical history, physicals, lab tests & other sources.
- Analyze the data to identify any patterns or gaps.
- Compare the data with standardized NANDA-1 taxonomy criteria.
- Formulate a diagnostic statement.
- Validate the accuracy of the assessment with the patient and other healthcare professionals.
- Document the verdict in the client’s care plan and communicate it to other team members.
How to Write a NANDA Nursing Diagnosis
Such a nursing diagnosis is formulated using the standardized terminology and classification system provided by NANDA International. NANDA International is an organization that develops and maintains a comprehensive list of nursing diagnoses to help nurses identify and address patients’ health concerns. NANDA nursing diagnosis consists of three main components.
The Problem – a clear and concise description of the patient’s health issue. It identifies what the client is experiencing or at risk of experiencing. Check out nursing diagnosis examples to get more ideas on this.
Etiology or Risk Factors with insights into the possible causes or contributing factors that lead to the identified potential issues. It aims to help nurses understand why the problem exists.
Signs and Symptoms – clues or evidence pointing to a problem’s presence. They are useful for different types of diagnoses, including a nursing diagnosis pain. Diagnoses related to pain address the patient’s experience of discomfort or stress. They identify different types of pain, such as acute, chronic & phantom, to help specialists identify underlying causes.