A nursing diagnosis has been defined as a clinical judgment that concerns how humans respond to health conditions/life processes. Compared to medical diagnosis, this analyzes the needs of the patient.
Step by Step Guide on How to Write a Nursing Diagnosis
Step 1. Check the symptoms of the patient
Observe the injuries of the patient or signs and symptoms of their state. Then describe the problem of the patient depending on the signs and symptoms that you’re able to see. For instance, if your patient got involved in a car accident and they may be confused. In this case, you can write that the patient doesn’t seem to understand what happened or where they are.
At this point, it’s not a must to use official terms. Instead, you can just observe the patient and describe them in your terms then you can change later.
Step 2. Ask the patient and the family how they’re feeling
Your nursing diagnosis is the information that you gather from the patient and the people around him. The patient’s family can let you know how they’re feeling and if the condition is affecting them. The patient on the other hand should be asked how they’re feeling to know how they’re managing the symptoms.
Step 3. Assess how the patient is responding to the symptoms
Take a look at the patient to find out how they’re coping with the pain or loss of functioning in various organs. Check how the patient is treating those around him, including the nurses and the family. If the patient is attacking the nurses, it could be they’re in severe pain or their anxiety level has risen.
Step 4. Know the difference between objective and subjective data
Subjective data is the information the patient provides you about how they’re feeling. Objective data, on the other hand, is gathered from the observations made and can be measured and verified using scientific analysis.
The data that supports the real diagnosis can either be objective or subjective. Objective data is more crucial because that’s what’s being used to get to the bottom of the diagnosis. Subjective data on the other hand is important in determining the care plan that’s best for the patient.
Step 5. Take note of the problem that your nursing diagnosis will tackle
Take a look at the signs and symptoms and the data you’ve gathered to direct you to the right diagnosis. Always concentrate on how the patient is feeling and the family and friends. Do not put so much focus on the medical diagnosis
For instance, your patient has been diagnosed with a brain injury. Your nursing diagnosis is going to be about what the patient requires to help with their condition.
Step 6. Examine the source of the problem of the patient
Once you have noted the problem that you’ll handle from your nurse’s perspective, get to know why the patient experiencing that problem. It is going to guide you in terms of the nursing interventions that will solve the problem.
For instance, if the patient has been diagnosed with a severe headache. The patient has a recent brain injury. The brain injury could be the cause of that severe headache.
Step 7. Analyze the health history of the patient
Take a look at the patient’s chart to find out if there’s anything related to the current condition. It is also important to go through the lab reports of the patient.
Step 8. Identify possible related problems during examination
Once you have noted the patient’s condition, check other issues that the patient might encounter while going through the treatment. For instance, if your patient has been having persistent headaches, lack of sleep is related to the headache which was the initial diagnosis. Knowing these other problems will help you in determining the best treatment for your patient.
Step 9. Gather your related factors for your diagnosis
Outline the related elements of the patient’s diagnosis. Related elements form the second part of your nursing diagnosis. For instance, if your patient is experiencing severe pain and confusion due to a brain injury. You can put this down as “severe pain r/t brain injury” or “severe confusion secondary to brain injury confirmed by MRI.”
Ensure that you perform your duties within the doctor’s diagnosis. If the diagnosis is not ending, you can mention the working diagnosis.
Step 10. Summarize your data
Go through the data you have collected to single out the factors that show the problem you have diagnosed.
The best nursing diagnosis is going to inform the doctor what could be the issue with the patient. Nevertheless, it doesn’t make a diagnosis. A doctor will diagnose the patient, hence your nursing diagnosis shouldn’t conclude about what the diagnosis is going to be. We hope this guide is going to help you in writing a nursing diagnosis. In case you need more help, you can visit collegenursinghelp.com for more assistance.