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How to Write a NANDA Nursing Diagnosis

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How to Write a NANDA Nursing Diagnosis

NANDA-panda and Diagnostic-computer
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The NANDA nursing diagnosis enables nurses to determine an appropriate plan of care for their patients. Nurses write nursing diagnoses based on their assessment of the patient. Nursing diagnoses must include the problem and its definition, the etiology of the problem, and the defining characteristics or risk factors of the problem. The problem statement explains the patient’s current health problem and the nursing interventions needed to care for the patient. The etiology describes possible causes for the current health problem. The defining characteristics are the signs and symptoms of the health problem. A medical diagnosis can be referenced as part of an interdisciplinary assessment of care but cannot be included in the written nursing diagnosis. Types of nursing diagnoses include problem-focused diagnoses, risk diagnoses, health promotion diagnoses, and syndrome diagnoses. When writing a problem-focused diagnosis, the formula is: (Problem-Focused Diagnosis) related to________(Related Factors) as evidenced by _____________ (Defining Characteristics). When writing a risk diagnosis, the formula is as follows: Risk for_____as evidenced by_____(Risk Factors).
10 KEY FACTS
Nursing Diagnosis
Nurse and Diagnostic-computer

NANDA International standardizes nursing terminology, specifically nursing diagnoses. Nurses use collected patient data to formulate nursing diagnoses or determine health problems better managed by physicians (medical diagnoses) or collectively with other health care professionals (collaborative problems).

NURSING DIAGNOSIS COMPONENTS
Problem Statement
Problem-cube with Statement

Nursing diagnoses are made up of three components: problem statement, the etiology/related factors, and defining characteristics/risk factors. The problem statement pertains to the patient’s current health problem and needed nursing interventions.

Etiology
E.T. Causing the Problem

Nursing diagnoses are made up of three components: problem statement, the etiology/related factors, risk factors, and defining characteristics. The etiology, or related factors, identifies probable causes of the health problem, and/or the conditions involved in the development of the problem.

Defining Characteristics or Risk factors
Dictionary and Game of Risk

Defining characteristics are the groups of signs and symptoms that indicate the presence of a particular diagnostic label. An example of a written nursing diagnosis using all three components is as follows: “Ineffective airway clearance (problem statement) related to bronchial airway inflammation (etiology/related factor) as evidenced by coarse rhonchi to bilateral apices heard on auscultation (defining characteristics).” Risk factors can be used in place of defining characteristics and encompass the patient’s vulnerability toward their health problem. An example would be something such as, “Risk for infection as evidenced impaired skin integrity.”

4 TYPES OF NURSING DIAGNOSES
Problem-Focused
Problem-cube

A problem-focused diagnosis is the patient's problem that is present at the time of the nursing assessment. This nursing diagnosis is based on the signs and symptoms present in this assessment. Examples are decreased cardiac output and impaired gas exchange. Problem-focused nursing diagnoses include three components: (1) nursing diagnosis, (2) related factors, and (3) defining characteristics.

Risk
Risk

This nursing diagnosis identifies interventions needed to decrease the risk related to a patient’s problem. There are no etiological factors (related factors) for risk diagnoses. The components of a risk nursing diagnosis include (1) risk diagnostic label and (2) risk factors. An example of a risk diagnosis would be “Risk for infection as evidenced by a suppressed inflammatory response.”

Health Promotion
Health Promoter

The purpose of this kind of nursing diagnosis is to improve individual patient, family, or community health and well-being. Examples include readiness for enhanced family coping. Components of a health promotion diagnosis generally include only the diagnostic label or a one-part statement. An example would be something such as Readiness for Enhanced Family Coping.

Syndrome
Syndrome

These diagnoses are used when the patient is experiencing multiple health problems forming a pattern that are responsive to similar nursing interventions. Syndrome Diagnoses are written as a one-part statement requiring only the diagnostic label. Examples include decreased cardiac output or decreased tissue perfusion.

STEPS FOR WRITING A PROBLEM-FOCUSED DIAGNOSIS
(Problem-Focused Diagnosis) related to________(Related Factors) as evidenced by _____________ (Defining Characteristics).
Problem-Focused Diagnosis Formula

To write a problem-focused diagnostic statement, use the problem-etiology-symptom (PES) method. Start with the diagnosis itself, followed by the etiologic factors (related factors in an actual diagnosis), then identify the major signs/symptoms (defining characteristics) that are appearing in the patient. This is for an actual diagnosis, not a risk diagnosis. An example would be: (Impaired physical mobility) related to (decreased muscle control) as evidenced by (the inability to control lower extremities).

STEPS FOR WRITING A RISK DIAGNOSIS
Risk for_____as evidenced by_____(Risk Factors).
Risk Diagnosis Formula

For risk diagnoses, there are no related factors (etiological factors) as you are identifying a vulnerability in a patient for a potential problem; the problem is not yet present. Therefore, you identify the risk factors that predispose the individual to a potential problem. An example would be “Risk for (infection) as evidenced by (suppressed inflammatory response).”

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