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Nursmg

VOLUME 15, NUMBER 3, MARCH 1985

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

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