3 Easy Steps to Forming a Nursing Diagnosis
When I first started nursing school and was faced with my first care plan, fear gripped me. I was sooo confused about how to choose nursing diagnosis (N.D.) and there was so much information that I didn't know where to begin. It's because of that, I felt the need to spare other new students the horror I felt and provide 5 steps that helped me overcome the dreaded care plan.
Step 1 Understand the Medical Diagnosis
It's the medical diagnosis that is the basis of your nursing diagnosis, so you must understand it fully. That is understanding the pathophysiology of the disease/condition. What causes this disease and why does this particular patient have it.
Step 2 Choose your NANDA (North American Nursing Diagnosis Association) nursing diagnosis
Choose your nursing diagnosis rom the NANDA listing. Your instructor should inform you if it will be a two-fold or three-fold diagnosis. Your diagnosis should be based on the problem(s) that can stem from the medical diagnosis. This is where understanding the pathophysiology comes in handy.
Here is the NANDA :http://bit.ly/1yBOgQ
Step 3 Confirm that your diagnoses matches your assessment(s)
There is nothing an instructor dislikes more than not being able to tie your diagnosis back to your assessment. Otherwise you're just pulling diagnosis out of the air. Show them proof of why you chose your N.D.
O.k. Now that you have this info, let's put it to work.
Your patient has a medical Diagnosis of Diabetes Mellitus (DM)
NANDA approved nursing diagnosis: Risk for Infection
Two fold diagnosis: Risk for infection r/t high glucose levels
Three fold diagnosis : Risk for infection r/t high glucose levels aeb A1C is 8.2%
These 3 steps should help you started and take some of the anxiety away from doing care plans.