The Nursing Diagnosis Decoded

nursing diagnosisIn your first semester of nursing school, the nursing diagnosis can seem like a really, really bizarre concept. I mean, why not just say “patient can’t breathe” instead of “impaired breathing pattern as evidenced by blah blah blah.” It can drive you bonkers if you don’t understand how to decipher them, so let’s get to it!

Nursing diagnoses vs. medical diagnoses

The first thing to understand about nursing school is that nurses don’t diagnose medical problems…that’s up to the MD. What nurses diagnose is the patient’s RESPONSE to that medical problem. So, for example…the MD might diagnose your patient with pneumonia. As the nurse, you think about how the patient responds to this pneumonia (or even how they respond to the treatment for pneumonia). What are some things that can go wrong with pneumonia and it’s treatment? Here are a few:

  • Difficulty breathing
  • Low oxygen saturation levels
  • Risk for pain (lungs might ache)
  • Risk for diarrhea (from the antibiotics)

Two kinds of nursing diagnoses

The first thing to understand is that there are two types of nursing diagnoses.  As you can see above, the first two state a problem, and the last two say “risk for.” The first two are an example of a nursing diagnoses that states a problem the patient is ACTUALLY having right now; and the bottom two state a problem the patient could POTENTIALLY have. Let’s talk about type 1 first.

Type 1: the “ACTUAL” nursing diagnosis

The easiest way to decode nursing diagnoses is to look at them like a template. They’re always written the same way, which actually makes your life easier! For ACTUAL or DEFINITIVE diagnoses, we’re going to write them out like this…the CAPITAL PINK words are the ones that change based on each situation:

NANDA DIAGNOSIS related to PATIENT’S MEDICAL PROBLEM as evidenced by DATA OBTAINED FROM ASSESSMENT OR CHART.

So let’s look at this piece by piece. You start with the “NANDA diagnosis”…NANDA is simply the governing body that develops the terminology to be used for nursing diagnoses. Note above in our bulleted list how we say something simple like “Low oxygen saturation levels?” Do you think nursing is going to keep things simple? Nope! Enter your good pals at NANDA. NANDA takes simple language and “nursifies” it. So, “low oxygen saturation levels” becomes “ineffective gas exchange.” There are books which list all the NANDA-developed nursing diagnoses and how they correlate to different medical diagnoses (I loved this one). Using a care plan book such as this is critical as your professors aren’t going to let you make up your own terminology…they’ll want you to use NANDA. Learn to love it.

The next part is to talk about what your NANDA diagnosis is related to….and it’s always going to be related to a medical problem the patient is actually having RIGHT NOW. In this case, it’s related to the patient’s pneumonia.

But, of course, you need some evidence for this right? Nursing is, after all, an “evidence-based practice!” So, what’s your evidence for this problem? It is either going to be DATA you obtain from the chart or DATA you obtain from your assessment (and yes, it can be something the patient says).

So let’s put this all together and write a definitive/actual nursing diagnosis for your patient with pneumonia.

Again, here’s our template:

NANDA DIAGNOSIS related to PATIENT’S MEDICAL PROBLEM as evidenced by DATA OBTAINED FROM ASSESSMENT OR CHART.

And here’s how we customize it for our pneumonia patient:

Ineffective gas exchange related to pneumonia as evidenced by O2 saturation level of 88% on 2L nasal cannula. 

Want to do another one? Let’s say we’re talking about a patient who had a whopper of a surgery and it hurts! Well, PAIN is always an acceptable nursing diagnosis….if you think about it, it’s the patient’s RESPONSE to their medical problem. Is it getting clearer yet?

Pain related to hysterectomy as evidenced by patient rating pain 7 out of 10.

See how this one includes data from the actual patient? Yes, you can use what your patient tells you as bona-fide data in your nursing diagnoses.

Now, what if your patient isn’t in pain now, but you expect they will be soon? That’s when you’re going to write the second type of nursing diagnosis…the one that applies to POTENTIAL problems. Let’s go!

Type 2: the “POTENTIAL” nursing diagnosis

The good nurse will try to catch problems before they become doozies, so that’s why we also think about problems the patient could POTENTIALLY have. If they don’t have it right now, they certainly could…and this type of diagnosis is written like so:

Risk for NANDA DIAGNOSIS related to PATIENT’S MEDICAL PROBLEM. 

Notice how this template is shorter? It doesn’t have the data component, as there is no data for a problem the patient doesn’t have yet…if there were data, it would be an ACTUAL nursing diagnosis (which we discussed in Type 1).

For your surgical patient, maybe they’re not in pain now because they got a hefty load of Fentanyl in PACU…but you know it’s coming!

Risk for PAIN related to HYSTERECTOMY.

Another one that’s common for surgical patients is a risk for infection. So you’d write it out like so:

Risk for INFECTION related to HYSTERECTOMY.

Note that these all use the phrase “related to.” You might also see the phrase “secondary to.” They are more or less interchangeable, so just didn’t want you to think there was yet another type of diagnosis to write!

Using nursing diagnoses in  your care plans

Now that you understand the logistics of a NANDA nursing diagnosis, what are you going to do with them? Well, develop care plans, of course! I go into much more detail about care plans in my book, but let’s just do a few practice nursing diagnoses so you can get the hang of it!

Your patient is a 22 year old male who broke both arms and a few ribs in a freak accident…attempting to take a selfie while standing on the edge of a cliff! He is now s/p surgical repair of bilateral humerus two days ago and his ribs are taped. You check his chart and find the following information: 

HR: 124  (too high)
RR: 24 (too high)
BP: 162/80 (too high)

Temp: 99.5F (slightly elevated)
Pain: 7/10 (both arms); 8/10 (ribs); Pain exacerbated by movement, coughing and deep breathing
O2 Sat: 89% RA (too low)

Lung sounds: crackles at bases (an abnormal finding)
Labs: WBC 6,000 (normal)
Meds: Morphine 2mg IV a 4 hrs prn moderate pain. Fentanyl 50mg IV q 2 hrs prn severe pain. Hydrocodone 10/325 1 tab PO q 6hrs prn mild pain.
On assessment: Patient stated, “I feel like such a loser.”

If you don’t know anything about pathophysiology yet…no worries…I’ll walk you through it! As you approach your care plans and writing out your nursing diagnoses, I like to start by writing them in plain ol’ English…no need to get fancy yet. You’re just going to look at his chart and gather information for your ACTUAL diagnoses and basically brainstorm some POTENTIAL diagnoses. Your list might look like this:

  • Tachycardia, tachypnea, hypertension…probably due to pain
  • Pain 7/10 and 8/10…woah!
  • He can’t take a deep breath, so O2 sats are low. Hmmm…
  • His lungs sound a little crackly…probably collapsed aveoli due to him not taking those deep breaths (atelectasis anyone?)
  • He’s got a temp…is it infection or just due to atelactasis?
  • He’s getting pain meds…what should I be watching out for?
  • BOTH arms are broken…this fella is having some ADL challenges, big time! How is that going to affect him?
  • Risk for infection (dude just had surgery!)
  • Risk for constipation (all those pain meds!)
  • Is he going to have issues with self esteem? He can’t even clean his own backside…hmmm…will he be depressed if he can’t do anything for himself? I probably would be! Hmmm…he did say, “I feel like such a loser.” Poor guy.

Now, look through your NANDA book and find the proper terminology for each of these! They are:

  • Decreased cardiac output (this refers to his tachycardia)
  • Ineffective breathing pattern (this refers to tachypnea…or breathing too fast.)
  • Alteration in hemodynamics (his blood pressure is too high, y’all!)
  • Pain pain and more pain. Actually this one is just “pain.” The easiest NANDA of them all!
  • Impaired gas exchange (this is the low O2 sat caused by atelectasis and his inability to take deep breaths. Atelectasis occurs when the alveoli are collapsed due to not taking nice, deep breaths. Typically this clears with some good coughing and deep breathing. Note…it also causes a slight temp!)
  • Ineffective thermoregulation (this relates to your temp)
  • Risk for infection (this occurs with all surgeries)
  • Risk for constipation (those pain meds will back you up!)
  • Ineffective coping (remember he said he felt like a loser?)

Ok, there are likely more…but this is a hefty start. Now, you go back through and add in all the “related to” and “as evidenced by” mumbo jumbo. I’ll do a few with you!

  • Ineffective breathing pattern related to rib fractures as evidenced by RR 24.
  • Pain related to bone fractures as evidenced by pt rating pain 7/10 for arms and 8/10 for ribs.
  • Impaired gas exchange secondary to pain as evidenced by O2 saturation 89% on RA.
  • Risk for constipation related to opioid administration.
  • Ineffective coping secondary to inability to perform ADLs as evidenced by patient stating, “I feel like such a loser.”

See how it works? Is it clear as mud now? Don’t worry…you’ll get it and the NANDA language will become more clear. I promise! Some doozies are:

  • Risk for ineffective activity planning: Does this mean you’ve bought a gym membership and never go? (I’m here all week, folks!)
  • Readiness for enhanced self management: Yes, this is real. It’s NANDA’s way of saying your patient is ready to learn how to care for their disease/self.
  • Imbalanced nutrition: more than body requirements: This is NANDA code for “ya eat too much, bro.”
  • Impaired home maintenance: A hoarders episode LIVE and in person!
  • Readiness for enhanced self-control: He’s not there yet…he’s still throwing his dinner tray at you, but at least he’s not throwing the lunch and breakfast trays anymore. Baby steps!

A note about medical diagnoses

Remember earlier when I said nurses don’t make medical diagnoses, and that we leave that up to our physician colleagues? Well, guess what? You still should have a pretty good idea of what the medical diagnosis will be, because guess why?  Your nursing diagnoses and interventions will play off that. Super frustrating, I know! As a student I found myself saying many times, “But I’m not the doctor…why do I need to differentiate between Addison’s and Cushings if I’m not diagnosing? You just do…so don’t think you’re getting off easy, nurslings!

Was this tutorial helpful to you? What else are you having trouble with? Let me know in the comments below!

 

 

 

 

 

 

 

 

10 thoughts on “The Nursing Diagnosis Decoded

  1. Carolina Vasquez

    This was definitely helpful. It helped but the information I read in class into perspective and made it easier to comprehend and relatable (even funny). Thanks so much!

    Reply
  2. Yvonne

    this tutorial was very helpful. I just stated fundamentals of nursing this fall (2016) and I have been struggling with assessment vital signs and head to toe (mostly the physiology behind everything e.g. blood pressure relates to heart rat, 02 sat to pulse rate, temp to all other signs etc. for head-to-toe the physiology behind each system you check). if you can do a tutorial to explain better to me, I would be very grateful. Thanks so much.

    Reply
    1. Nurse Mo Post author

      Hi Yvonne…did you take Anatomy & Physiology? A lot of what you are struggling with can be found with your basic physiology background and will become more clear the more you practice. I’ll see if I can write something up that helps you! Best of luck with school 🙂

      Reply
  3. Sammantha

    Very helpful, thank you! I am in charge of doing the ndx/dx/ddx for our group project on CHF/Pneumonia. I was at a loss for a while on how to go about it. 🙂

    thanks!!

    Reply

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