Nursing Diagnoses

 Nursing diagnoses are developed by professional nurses and are used as a means of
communicating and sharing information about the patient and the patient experience.
 Nursing diagnoses are the result of clinical judgement about a human response to health
conditions and/or life processes, critical thinking, creativity, and accurate collection of data
regarding the patient as well as the drug.

Nursing diagnoses related to drug therapy will most likely grow out of data associated with the
following:

 deficient knowledge;
 risk for injury;
 noncompliance;
 and various disturbances,
 deficits,
 excesses,
 impairments in bodily functions,
 and/or other problems or concerns as related to drug therapy.

Once the assessment phase has been completed, the nurse analyzes objective and subjective data about
the patient and the drug and formulates nursing diagnoses.

Formulation of nursing diagnoses

The following is an example of a nursing diagnosis statement:

"Knowledge, Deficient" written out as "Deficient knowledge related to lack of experience with
medication regimen and second-grade reading level as an adult as evidenced by inability to perform a
return demonstration and inability to state adverse effects to report to the prescriber."

This statement of the nursing diagnosis can be broken down into three parts, as follows:

Part 1- "Knowledge, Deficient" stated as Deficient Knowledge"

 This is the statement of the human response of the patient to illness, injury, medications, or
significant change.
  This can be an actual response, an increased risk, or an opportunity to improve the patient's
health status. The nursing diagnosis related to knowledge may be identified as either "Deficient"
or "Readiness for Enhanced."

Part one of the statement is the human response of the patient to illness, injury, or significant change.
This response may be an actual problem, an increased risk or vulnerability of developing a problem, or
an opportunity/intent to improve the human response by the patient, family, group, or community.

Part 2- "Related to lack of experience with medication regimen and second-grade reading level as an
adult."

 This portion of the statement identifies factors related to the response; it often includes
multiple factors with some degree of connection between them.
 The nursing diagnosis statement does not necessarily claim that there is a cause-and-effect link
between these factors and the response, only that there is a connection.

Part two of the nursing diagnosis statement is labeled as defining characteristics and identifies the
factor(s) related to the response, with more than one factor often named. The nursing diagnosis
statement does not necessarily claim a cause-and-effect link between these factors and the response; it
indicates only that there is a connection between them.

Part 3- "As evidenced by inability to perform a return demonstration and inability to state adverse
effects to report to the prescriber."

 This statement lists clues, cues, evidence, and/or data that support the nurse's claim that the
nursing diagnosis is accurate.

Part three of the nursing diagnosis statement contains a listing of clues, cues, evidence, signs,
symptoms, or other data that support the nurse's claim that this diagnosis is accurate.

Nursing diagnoses are prioritized in order of criticality based on patient needs or problems.

The ABCs of care are often used as a basis for prioritization:

a) airway
b) breathing
c) circulation

Prioritizing always begins with the most important, significant, or critical need of the patient. Nursing
diagnoses that involve actual responses are always ranked above nursing diagnoses that involve only
risks.
These nursing diagnoses, as well as all other phases of the nursing process, will be presented in the
chapters that follow because the nursing process provides the framework of practice for all professional
nurses and is also used to organize the nursing sections of this textbook.