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An overview of Nursing Diagnoses and Using Your Nursing Diagnosis Book

First off, every instructor has their own way of implementing how they want to formulate and
structure a nursing diagnosis. This is my way, using your Nursing Diagnosis book, so do not take this as
the end all and be all of how to do it. First, we will go over a few rules regarding submitting a nursing
diagnosis for your clinical worksheets:

1. Only One Risk for types of diagnosis will be accepted. If I see more than one Risk for nursing
diagnosis, I will return your paper and ask you to use another diagnosis.
2. Try not to use Acute Pain as your first nursing diagnosis, unless clinically, its justifiable. For
example, if pain is interfering with all other outcomes you want your patient to achieve,
especially if you have enough both objective and subjective data, then I can see why it would be
a #1 nursing diagnosis priority. However, if I can see that a different nursing diagnosis should be
a priority vs pain or if I dont see enough justification to use pain then you should not use it.
3. Remember, you cannot use a medical diagnosis to explain your related to section. For
example, Acute pain related to Myocardial Infarction (MI). MI is considered a medical
diagnosis. If you had Acute pain related to myocardial injury that would be acceptable.

Steps to formulate your Nursing Diagnosis

1. Your assessment. You need to include both your subjective information (meaning your
patients statements) and your objective information (from the computerized chart, physical
chart, etc). When you are listing your subjective information, please dont forget to include
quotation marks and to use the phrase, patient states prior to you quoting your patients
words verbatim. Make sure ALL your information matches your notes (meaning that your
physical assessment content should match with your nursing diagnosis along with your lab data
and medication content, if applicable). You will also need to know how to analyze and interpret
your data that you have gathered. You may want to figure out how to organize your
information into sections that you can prioritize effectively.
2. Prioritizing. Nursing Diagnoses are prioritized by what is the immediate threat to patient safety.
This is also the foundation on which you need to think as a nurse. This is usually accomplished
by using our ABCs (Airway, Breathing, Circulation) while using Maslows Hierarchy of Needs as a
guide. Usually, physiological problems take precedence over psychological because of the
immediate threat to the patients life. However, from my experience, psychological problems
can be a high priority if the psychological problems are causing problems with compliance to
medical treatment. Sometimes, you need to prioritize psychological types of nursing diagnoses
in order for patients to be compliant with medical treatment. So, use your best judgment if you
are facing this problem. If you have questions about prioritizing when it comes to physiological
vs psychological, please speak with me.
3. Using the Nursing Diagnosis terminology. Lets take Activity Intolerance as an example. Activity
Intolerance as defined by Ackley (2011) states Insufficient physiological or psychological energy
to endure or complete required or desired daily activities (p.119). So the definition, should
match what the patient maybe experiencing from your observations or per the patients
statements.
Related Factors
Related factors are your factors that demonstrate a relationship with issues that are
related to your patients condition. Remember, these are factors that we, as nurses can care for
and treat. This is not a medical diagnosis. Using Activity Intolerance as an example, some of the
relating factors are bed rest, generalized weakness, imbalance between oxygen
supply/demand, immobility, sedentary lifestyle, etc. When you are writing your nursing
diagnosis, pick the best related factors that matches with your patients condition. So, Activity
Intolerance related to sedentary lifestyle AEB exertional dyspnea is one example. If there is
none you can find from your book, then please come speak with me and we can figure it out
together.
Defining Characteristics
The defining characteristics is your signs and symptoms that your patient has either
stated or the information you have gathered during your assessment. This can then be applied
by using the phrase as evidenced by (AEB) to help connect the source of the problem. For
example, activity intolerance related to imbalance oxygen supply and demand AEB abnormal
blood pressure response to activity or AEB EKG changes reflecting arrhythmias is acceptable,
and you notice there is a cardiac component to the problem. Activity Intolerance usually has a
cardiac component to it, however if there is none from your data, then you need to make sure
your defining characteristics matches your related factors with regards to patient data.
Outcomes
Some instructors would like outcomes that are expected by patient discharge, while
others would like to see what you can do for the day for the patient. If possible, I would rather
you have outcomes that you can do on your clinical day. If not, then you can do outcomes that
are expected by patient discharge, but please let me know ahead of time if you do. Also, you
must be specific in your outcomes that are measureable and observable. For example, patient
will have improved lung sounds is not really measureable and observable. A better example
might be Patient will have clear lung sounds in all lobes by day two/three of hospital stay is
something you can track and measure to see if you are meeting that goal.
Interventions
Please make sure you are using interventions that will demonstrate how you will reach
your outcomes/goals for your patient. In addition, be sure to use interventions that are
evidence-based (usually from your book) and that best matches with interventions you will use
during your clinical day. I would like a minimum of 3-5 interventions for each nursing
diagnosis. Please be specific and describe what you will be doing and do not use simple one
sentence statements.
Evaluation
In your Evaluation section, please do not write, Patient met all outcomes. You need
to be specific on which outcomes/goals were met, and if not, what needs to be revised or
implemented that you think would help your patient meet the goal(s) or needs to be changed.
Guide to Using Ackley
On pages 14-115, there is a wonderful guide that has a listing of symptoms, medical
diagnoses, psychiatric diagnoses, and clinical states. Please use it if you dont know where to
begin after you have gathered all the necessary data. There, it will contain a list of possible
nursing diagnoses. However, I will say that I should not expect to only see diagnoses listed from
the guide, simply because you are not providing individualized care if you are just going by this
guide only. Your data will have to justify and explain how you are tailoring your care to each
patient that you will be caring for. If you are having problems with tailoring your patients care,
please come speak to me.

Finally, please use mainly NANDA-I nursing diagnoses. If you are not using NANDA-I
nursing diagnoses, please let me know ahead of time and your justification.

I hope this overview helps explain and spell out what I expect from your nursing diagnoses.
Nursing diagnoses can help develop nurse thinking and overall, the nursing process. You may
find that facilities may use it for their documentation or use it in a variety of ways. So, you are
expected to be familiar with formulating nursing diagnoses.

Reference
Ackley, B. J., (2011). Activity intolerance. In B. J. Ackley and G. B. Ladwig (Eds.), Nursing
Diagnosis Handbook (9th ed., pp. 119-124). St. Louis, MO: Mosby.