Nursmg
VOLUME 15, NUMBER 3, MARCH 1985
NURSING
DIAGNOSIS
JUST WHAT List is nursing diagnosis?
You've probably asked yourself that ques-
tion more than once. You may have thought
that developing nursing diagnoses for each
of your patients was a luxury—and who
has time for luxuries these days?
But applying nursing diagnosis to your
daily practice is important...more so than
you may think. For nursing diagnosis ac-
tually defines the practice of nursing. At
a time when we nurses are fighting to keep
our jobs, the use of nursing diagnosis de-
fines what it is that we do.,.and demon-
strates convincingly how what we do is
distinct from what doctors and other health
care professionals do.
On a more immediate level, the use of
nursing diagnosis actually saves time by
improving communication among staff
members and ensuring consistent care.
Once every nurse on the unit has learned
how to develop care plans based on nursing
diagnoses, patient care is bound to im-
prove. The reason is simple: Each nurse
who cares for a particular patient will
know exactly what his problems and goals
are and what must be done to solve those
problems and meet those goals.
Developing a nursing diagnosis is not
diftieult. but it does take some practice.
Before discussing how to develop one.
though, let s look at what it is,
A nursing diagnosis is a statement of
the patient's response to his condition or
situation that is actually or potentially un-
healthful. The unhealthful response (the
problem) must be one that nursing inter-
vention can help to change to a healthful
response. An unhealthful response is an
aetual or potential change, dysfunction,
impairment, defieit. or disturbance in the
patient's behavior or health status.
Nursing diagnosis takes the familiar
practice of problem identification several
34 Nursing85, March
BY MICHAEL J. TARTAGLIA, RN As you think about these questions,
Hospice Coordinator you'll probably find your initial assump-
Veterans Administration Medical Center
Denver, Colorado tions challenged. You may find, for ex-
ample, that the noncompliant diabetic
patient is neither stubborn nor eareless but
steps further. To identify a patient's prob- in fact was never taught the connectitin
lem in terms of nursing diagnosis, you between blood glucose control and diet,
must view it from the patient's perspeetive. medication, and exercise. Or that the teen-
not yours. age girl who cries endlessly and complains
that nobody believes she's in pain isn't a
identifying the problenns spoiled child but actually is afraid she'll
The first step in developing nursing diag- die in the hospital; in her experience, a
noses is identifying the unhealthful re- hospital is a place where people go to die.
sponses. Although you can get this How accurately you analyze the data
information from many sources, the pri- determines how accurate your nursing
mary source must be the patient; his per- diagnoses will be,
ception of his problems is what counts.
The best way to get the information, of A difficult patient?
course, is to ask him. His answers to your Here's how the concept of nursing diag-
questions and findings from your physical nosis was used to pinpoint and resolve the
assessment will form the basis of your problems of Joe Kingsley. who was labeled
diagnoses. Your secondary sources of data a difficult patient after just 3 days in the
are the documentation in his chart (ad- hospital,
mission notes, history, laboratory test re- Mr, Kingsley. a 24-year-old father of
sults, multidisciplinary progress notes) and two young children, was brought to the
the information given to you by his family hospital the evening of March 3 suffering
and friends. from acute appendicitis. An emergency
When interviewing and assessing the appendectomy was performed. When he
patient, analyze the data you're getting by was transferred to the surgical unit a few
asking yourself these questions: hours later, he was awake and alert and
• What is happening to the patient phys- said he had "just a little pain,"
iologically, emotionally, socially, and spir- On March 4 he walked a short distance
itually? but became pale and diaphoretic and had
What clinical signs is he showing? to return to bed. He said his pain was
What is his past experience with illness? worse. On Mareh 5 he held himself rigid,
What are his strengths and weaknesses? refusing to turn or get out of bed and re-
What support does he have? questing pain medication every 30 to 60
How do the patient and his family per- minutes. He resisted all attempts to get
ceive what's happening? What are their him to cough, deep breathe, and walk.
reaetions and attitudes; how are they cop- By midafternoon of the same day, he
ing? What do they expeet will be the out- told his primary nurse he wouldn't do any-
come of the illness? thing until he got relief from his abdtiminal «
• Is there a problem that nursing inter- pain. She realized then that the standard ^
vention can help to resolve? postoperativeeareplan wasn't working and ™
 NURSING

JUST
ASA
KEYSTONE
WEDGES
THE
BLOCKS
OF A N
ARCH
I i
IK^'-'V FIRMLY IN
PLACE,
SO DO
NURSING
DIAGNOSES
HOLD
YOUR CARE
PLAN
TOGETHER.
WITHOUT
THE
STABILIZL,
DIAGNOSES,
YOUR
GOALS AND
INTERVENTIONS
MAY
VERY WELL
FALL
APART.
L.;

Nursing85, March 35
she'd have to revise it. The first step would
be a thorough reassessment.
After doing a general assessment, '^he
rnovcd to his abdomen, making the fol-
lowing notes:
In.spection: operative site free of drainage.
redness: abdomen slightly distended
Auscultation: high-pitched (inkling sounds:
occasional gurgle, splash
Percussion: slightly tympanic
Palpation: abdomen slightly tense; sensi-
tive to pressure.
She then asked Mr, Kingsley how he
felt and what he was thinking about. He
said he was scared and lonely. His family
was almost 50 miles away, and his wife
couldn't visit because she had to stay home
with the children. "It all happened so
fast." he told her, "One minute we were
calling the ambulance, and the next I was
in the hospital. Someone in the emergency
room said tiot to worry: it was a simple
operation and wouldn't hurt much. Who
was he kidding? This really hurts! Every
time I tiiove or cough, il hurts and I feel
sick. I'm beginning to think something
serious must be wrong and people aren't
telling me about it."
The nurse analyzed her information and
concluded that Mr. Kingsley's tTiost seri-
ous problems were his pain, anxiety, atid
unfamiliarity with what was happening to
hitii. all of which were preventing him
from complying with the postop regimen.
She fc'lt that his pain was caused in part
by constipation and ga^. so she targeted
resolving those as her first priority. She
also noted that his pain medication was
tneffcclivc and decided to ask the doetor
to increase ihc dosage.
She felt that once his pain was relieved,
he would fee! less anxious and would be
more open to patient teaching. Since he was
eager to return home, she planned to ctnpha-
si?e ihat his compliance with the postop
regimen could hasten his discharge.
After gathering and analyzing her data,
she was reaily to redefine Mr, Kingsley's
probletns through nursing diagnosis.
Writing; the nursinf^ diu)>no.ses
A nursing diagnosis has (wo parts. The
first part states the patient's unhealthful
response (the problem), e.g,. constipation.
The second part states the probable cause
of the problem, e.g., decreased activity.
The two phrases are connected by either
related to or associated with. This com-
pleted nursing diagnosis would read: con-
stipation related to decreased activity. If
the problem is n potential one, use the
words potential for or (// risk for before
the problem {potential for constipation re-
lated to decreased activity).
36 Nursing85, March
to the family that they must accept their
father's dying")
• a medical diagnosis ("cervical cancer")
or treatment) "cathctcrize after each void-
ing for residual urine").
At first, these distinctions may not be
clear. The following exatnples should help
clarify what a nursing diagnosis is and how-
to develop it,
• Don't state a need instead of a problem,
Ineorreet: //»/(/ replacement related to fever
Correct: dehydration related to fever
• Don't reverse the two parts of the state-
ment.
Incorrect: tack oj knowledge related to
noncompliame with diabetic diet
Correct: noncompliance with diabetic diet
related to lack of knowledge
• Don't identify an untrcatable condition
instead of the actual problem it indicates
(which can be treated).
Incorrect: inability to speak related to lar-
yngectomy
Correct; social isolation related to inability
to speak because of taryngectomy
• Don't write a legally inadvisable state-
ment.
Incorrect: red sacrutn related to itnproper
positioning
Correct: impaired skin integrity related to
immobility
Bach nursing diagnosis, when correetly • Don't identify as unhealthful a response
written, can accomplish two things. One. that would be appropriate, allowed for. or
by identifying the unhealthful response, it culturally acceptable.
tells you exacdy what should change. This Incorrect: anger related to terminal illness
change is what the patien( goals in your Correct: noncompliame with prescribed
care plan will describe. And two. by iden- regimen related to anger over terminal ill-
tifying the probable cause of the unhealth- ness
ful response, it tells you what (o do to • Don't make a tautological statement (one
effect the change. What you should do is in which both parts of (he statement say
wha( the nursing interventions in your care the same thing).
plan will deseribe. In other words, youll Incorrect: alteration in comfort related to
treat the cause to change the response. pain
The major pitfall in developing a nursing Correct: alteration in comfort I pain) re-
diagnosis is writing one that nursing in- lated to postop abdominal distension and
tervention can't treat- A nursing diagnosis, anxiety
as defined earlier, isastatement of ahealth • Don't identify a nursing problem instead
problem (hat a nurse is licensed to treat, of a patient problem.
a problem for which she will assume re- Incorrect: difficulty suctioning related to
sponsibility for therapeutic decisions and thick secretions
accountability for the outcomes. Correct: potential airway obstruction re-
A nursing diagnosis is not: lated to thick trachea! secretions
• a diagnostic test ("schedule for cardiac
angiography") Determinin}> priorities
• a piece of equipment ("se( up iiKermit- Mr. Kingsley's nurse kept these examples
tent suctit>n apparatus") in mind as she developed her nursing diag-
• a probletn with equipment ("the patient noses for him. After analyzing the un-
has trouble using a ctnntnode"! heaMhful responses to his illness, she
• a nurse's problem with a patieni ("Mr, determined which ones were most signif-
Jones is a difficult patient; he's rude and icant and wrote (he following diagnoses
won't take his medication") on his care plan:
• a nursing goal ("encourage fluids up (o • pain related to flatus, constipation,
2,000 ml per day") wound
• a nursing need ("I have to get through • noncompliance with prescribed postop
acrivilics related to pain, and to lark of problem causes the patient the greatest dis-
knowledge uiul an.xiciy ahout condition. tress.' Which problem, if managed first,
Note how the second part of each state- will help resolve the other problems, either
ment—the probable cau.sc phrase—^idcn- direetly or indirectly?
titics causes that ihc nur.sc can treat Of course, your diagnoses will change
ihroujih nursing intervention. as the patient's responses to his problems
Several other nursing diagnoses wuuki change. You'll delete some and develop
have been possible for thi.-i patient: new ones according to the patient's needs.
• cotistipttlion related lo decreased activ-
ity and narcotic pain medications Writing the patient j>oals
• lack of knowledge abotit condition and and nursing interventions
expected postop course related to lack of Once Mr, Kingsley's nurse was salislied
preop teaching with her diagnoses, she discussed them
• anxU'tv relatcil to lack of knowledge with her patient. She asked it" he agreed
ahout condition and separation from famil\ with them and if he'd like to change any-
• impaired physical tnohilit\ related lo thing or add to the list.
postop pain anil amstipaiion Together they worked out the patient
• polential for impaired skin intefiritv re- goals. For the first diagnosis (pain related
laifd to mmcompliance with presiiihcd lo flatus, con si i pat ion. wound), they
po.siop activities agreed on one goal: stales that he is com-
• potential for ineffective airmiv clear- fortable within 24 hours. For the second
ance related lo noncompliance wilh pre- diagnosis (noncompliance with preseribcd
scribed po.stop (utivities. postttp activities related m pain, and to
You can sec how these diagnoses are lack of knowledge and anxiety about con-
interrelated. Your analysis of the infor- dition), they established two goals: (I) b\
mation you gather during the assessment end of day shift. March 6, performs ac-
and paticnl interview determines which tivirifs with assi.stance: (2) hy end oj eve-
problems you'll consider priorilies. The ning shift. March 6. only needs reminders
easiest way to son out which problems are to perform activities.
most signifieant is to ask yourself: Which If you look closely at these goals, you'll
Patient Care Plan Josepb Kingsley
3/5/85 Postappendectomy
Nursing Patient Nursing
Diagnoses Goals interventions
1 1
Pain related lo fta- States tt^at he is 1 Apply heat to abdomen; try sitz
lus, constipation, comfortable within bath, rectal tube, or carminative.
wound 24 hrs. 2 Try suppository, iaxative. or enema
3 Assess diet
4 Assist to toilet q4h
5 Continue pain meds, as ordered
6 Get order for less constipating
pain med
7 Assess need to change pain med
regimen
8 Continue comfort measures. Assist
with position changes, splinting.
teach relaxation techniques.
9, Encourage walking and light
activity
II II II
Noncompliance 1 By end of day 1 Continue pain interventions (above)
witti prescribed sfiift 3/6, performs 2, Give facts about appendectomy
postop activities activities with and expected recovery time, includ-
related to pain, and assistance ing expected daily progress
to lack ot knowl- 2, By end of eve-
3, Teach activities to relieve pain and
edge and anxiety ning shift, 3/6, only promote recovery Emphasize that ac-
about condition needs reminders to tive participation hastens recovery
perform activities 4, Praise when paiient performs activ-
ities, and poini out progress.
5, Encourage questions about con-
dition and treatment Reinforce
teaching
6. Encourage family to call
see they direcliy relate to the first phrase
in each nursing diagnosis, the phrase that
states the unheatthful response. The goals
clearly identify how each response will
change. Note also that the goals arc
patient-centered, specifie. realistic, and
measurable—that is. they tell you when to
look for the desired change.
With the diagnoses and goals iJentilied.
the nurse wrote the nursing interventions
and explained them to Mr. Kingsley. (See
interventions in the insert. Patient Care
Flan: Joseph Kiniisley.)
II you study the interventions, you'll see
that each relates to the seeond phrase of
its respective diagnosis, the phrase thai
states the probable cause of the unhealth-
lul response. The interventions tell the
nurse what she must do l<i treat the cause.
The larper picture
As you can see from this portion of the
care plan, the nursing diagnoses LID indeed
hold together the goals and interventions.
But developing the nursing diagnoses is
just part of the larger picture: llie nursing
proeess. Once you've written this part of
the care plan, you've completed the firsi
two parts of the process: assessment (gath
ering and analysing the data, developing
the diagnoses) and planninii (Jcvcloping
the patient goals and nursing interventions
based on the nursing diagnoses). To follow
through with your plan, you must com-
plete the implementation of your interven-
tions and the evaluation o!" whether the
goats were met. Then you can return to
assessment...to discard some diagnoses
and develop others as needed.
Writing nursing diagnoses correctly
takes practice and some research. By re-
viewing the selected references listed be-
low, you can get a feet for the language
used by various experts to phrase the diag-
noses. Some language is more formal than
others.
What you want to remember when de-
veloping your diagnoses is to tailor them
to the patient's needs, not the other way
around. You shouldn't have trouble doing
this if you keep sight of why you develop
nursing diagnoses in the first plaee: to help
the patient and family cope with all aspects
of his illness or injury.
Carpenili), L.: Niirsinii liiii)(n<)\i>,. AppUfuiinii loCtiii-
iialFmaicf. Ptiitadelphia. J.B. LippincodCn,. 14K,l,
Uurilim. M,: Munuul of Siir\ii>K t)itlxlll•si^. The Na-
Ijnnul t'(.inrereni.L' Gri.iiip lor Classsrii-utiiiti ul Nursing
DiagniisiN, New Yi.rk. Mctiraw-ltitl Biiok Cii.. 1982.
Cjoulim. M , Sweeney. VI . el al "NurMfif; Diagnosis
Looking ^il lis I'se m ilie flinkal Area." Aiiicnuin
Jtiiirntil of Nurmig m.bll. ^pv^\ 198(1.
Kim. Mi Ja. McFartand. G.. ei al: Pockri Guide tn
NiiniHs Oiiitiiti'ses. Si. Louis. C'.V. Miwby Cu,, 1984,
Lengel, N. Handbook of Nursinx DUiiino.sis. Bowie.
Mii.. Roberi J. Brady C o . . 1982.
Nursing85, March 37