How to Write a Nursing Diagnosis
A nursing diagnosis is the standard nursing language that allows nurses to recognize patient problems in a way that can be communicated throughout clinical settings and medical personnel. A nursing diagnosis labels and classifies problems by doctors and nurses. It is important to learn the three parts of how to write a nursing diagnosis.
- Begin your nursing assessment by identifying important patient information known as the ABCs of nursing which are Airway, Breathing and Circulation. Check for any conditions that could interfere the patient's breathing and circulation.
- Review the patient's chart, interview the patient and perform a physical exam to make a proper nursing assessment. Document findings from lab tests, vital signs and other studies.
- Scan a list of approved nursing diagnoses to compare any match findings from the assessment. Carry a book of diagnoses or check online websites for quick access. Carry a card of common nursing diagnoses.
- Choose an appropriate standard diagnoses. Read the NANDA diagnosis list for different ways to fix the patient's problem. Apply one or multiple methods to help the patient feel better. A diagnoses of “pain” would have “give pain medications” as an intervention.
- Document the hopeful outcome of the patient's diagnoses by following the interventions recorded. Document an expected outcome by asking the patient what degree of pain they are experiencing. Write the outcome down to compare previous notes.
- Evaluate the patient after a couple of hours or at the end of a work shift. Assess everything you looked at the start of the patient's condition. Compare the notes from the first assessment performed. Examining the patient and notes will determine if the condition has changed. Chart the findings in the patient's medical chart.