Nursing diagnoses are not medical diagnoses. They do not identify a disease but rather existing or potential health problems that require intervention. There is a guideline created by the North American Nursing Diagnosis Association (NANDA) that should be followed but can be slightly customized depending on the work-place policy.
Types
There are five types of nursing diagnoses. An actual diagnosis is based on a definable problem, such as pain. A risk diagnosis is made based on the likelihood of a problem occurring and begins with risk for. A possible diagnosis refers to a problem that is suspected but not confirmed. This alerts other caregivers to watch for signs of an actual problem. A wellness diagnosis is made when a patient shows the desire to take control of her own well-being. An example is Readiness for Enhanced Parenting, meaning the patient has indicated a readiness to learn more about parenting. Last, there is the syndrome diagnosis, which represents a cluster of actual or risk diagnoses such as Rape-Trauma syndrome. (Fundamentals of Nursing, pg 273)
Writing the Diagnosis
Nurses must follow a set guideline for writing the diagnosis. The first part is the problem and states what health concern is being diagnosed. The second part, the etiology, explains the reason it exists and contains the words related to, or RT for short. The third part is the defining characteristic, and begins with as manifested by, or AMB. Some diagnoses do not need the third part. A risk or possible diagnosis will not have defining characteristics because they haven't occurred yet or been proven; however, every diagnosis will contain the first two parts. (Fundamentals of Nursing, pg. 273)
Interventions and Rationales
Every diagnosis must have possible interventions, and those interventions must have rationales. If a patient is diagnosed with a noncompliance, the nurse needs to identify ways to overcome this problem, and those ways need to have a sound medical basis. A possible intervention for noncompliance is to include the patient in planning treatment so he feels he has more control over the situation. (Elsevier Health)
Common Errors
Use evidence, not assumptions. Do not assume that a patient recently diagnosed with cancer is suffering from fear. Look for patterns, not single instances. A new mother who has difficulty breast feeding one out of five times is not ineffective at breastfeeding. Five times in a row is a pattern. Avoid judgmental terms. A patient does not have ineffective coping because he's lazy but because he lacks motivation due to a situational crisis. Prioritize your diagnosis and interventions. A learning deficit cannot be corrected if the patient is suffering from acute pain. (Fundamentals of Nursing, pg.279)
Examples
An example of a three-part diagnosis is acute pain RT knee surgery AMB patient verbalizing pain. A two part diagnosis would read risk for disuse syndrome RT immobility. A possible intervention for acute pain is to respond to the patient's complaint of pain promptly. The rationale is that this establishes trust between the patient and the nurse and decreases anxiety. (Elsevier)
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