NursmgVOLUME 15, NUMBER 3, MARCH 1985

NURSINGDIAGNOSIS

JUST WHAT List is nursing diagnosis?

You've probably asked yourself that ques-tion more than once. You may have thoughtthat developing nursing diagnoses for eachof your patients was a luxury—and whohas time for luxuries these days?

But applying nursing diagnosis to yourdaily practice is important...more so thanyou may think. For nursing diagnosis ac-tually defines the practice of nursing. Ata time when we nurses are fighting to keepour jobs, the use of nursing diagnosis de-fines what it is that we do.,.and demon-strates convincingly how what we do isdistinct from what doctors and other healthcare professionals do.

On a more immediate level, the use ofnursing diagnosis actually saves time byimproving communication among staffmembers and ensuring consistent care.Once every nurse on the unit has learnedhow to develop care plans based on nursingdiagnoses, patient care is bound to im-prove. The reason is simple: Each nursewho cares for a particular patient willknow exactly what his problems and goalsare and what must be done to solve thoseproblems and meet those goals.

Developing a nursing diagnosis is notdiftieult. 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 ofthe patient's response to his condition orsituation that is actually or potentially un-healthful. The unhealthful response (theproblem) must be one that nursing inter-vention can help to change to a healthfulresponse. An unhealthful response is anaetual or potential change, dysfunction,impairment, defieit. or disturbance in thepatient's behavior or health status.

Nursing diagnosis takes the familiarpractice of problem identification several

34 Nursing85, March

BY MICHAEL J. TARTAGLIA, RNHospice Coordinator

Veterans Administration Medical CenterDenver, Colorado

steps further. To identify a patient's prob-lem in terms of nursing diagnosis, youmust view it from the patient's perspeetive.not yours.

identifying the problennsThe first step in developing nursing diag-noses is identifying the unhealthful re-sponses. Although you can get thisinformation from many sources, the pri-mary source must be the patient; his per-ception of his problems is what counts.

The best way to get the information, ofcourse, is to ask him. His answers to yourquestions and findings from your physicalassessment will form the basis of yourdiagnoses. Your secondary sources of dataare the documentation in his chart (ad-mission notes, history, laboratory test re-sults, multidisciplinary progress notes) andthe information given to you by his familyand friends.

When interviewing and assessing thepatient, analyze the data you're getting byasking yourself these questions:• What is happening to the patient phys-iologically, emotionally, socially, and spir-itually?

What clinical signs is he showing?What is his past experience with illness?What are his strengths and weaknesses?What support does he have?How do the patient and his family per-

ceive what's happening? What are theirreaetions and attitudes; how are they cop-ing? What do they expeet will be the out-come of the illness?• Is there a problem that nursing inter-vention can help to resolve?

As you think about these questions,you'll probably find your initial assump-tions challenged. You may find, for ex-ample, that the noncompliant diabeticpatient is neither stubborn nor eareless butin fact was never taught the connectitinbetween blood glucose control and diet,medication, and exercise. Or that the teen-age girl who cries endlessly and complainsthat nobody believes she's in pain isn't aspoiled child but actually is afraid she'lldie in the hospital; in her experience, ahospital is a place where people go to die.

How accurately you analyze the datadetermines how accurate your nursingdiagnoses will be,

A difficult patient?Here's how the concept of nursing diag-nosis was used to pinpoint and resolve theproblems of Joe Kingsley. who was labeleda difficult patient after just 3 days in thehospital,

Mr, Kingsley. a 24-year-old father oftwo young children, was brought to thehospital the evening of March 3 sufferingfrom acute appendicitis. An emergencyappendectomy was performed. When hewas transferred to the surgical unit a fewhours later, he was awake and alert andsaid he had "just a little pain,"

On March 4 he walked a short distancebut became pale and diaphoretic and hadto return to bed. He said his pain wasworse. On Mareh 5 he held himself rigid,refusing to turn or get out of bed and re-questing pain medication every 30 to 60minutes. He resisted all attempts to gethim to cough, deep breathe, and walk.

By midafternoon of the same day, hetold his primary nurse he wouldn't do any-thing until he got relief from his abdtiminal «pain. She realized then that the standard ^postoperativeeareplan wasn't working and ™

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she'd have to revise it. The first step wouldbe a thorough reassessment.

After doing a general assessment, ' hernovcd to his abdomen, making the fol-lowing notes:In.spection: operative site free of drainage.redness: abdomen slightly distendedAuscultation: high-pitched (inkling sounds:occasional gurgle, splashPercussion: slightly tympanicPalpation: abdomen slightly tense; sensi-tive to pressure.

She then asked Mr, Kingsley how hefelt and what he was thinking about. Hesaid he was scared and lonely. His familywas almost 50 miles away, and his wifecouldn't visit because she had to stay homewith the children. "It all happened sofast." he told her, "One minute we werecalling the ambulance, and the next I wasin the hospital. Someone in the emergencyroom said tiot to worry: it was a simpleoperation and wouldn't hurt much. Whowas he kidding? This really hurts! Everytime I tiiove or cough, il hurts and I feelsick. I'm beginning to think somethingserious must be wrong and people aren'ttelling me about it."

The nurse analyzed her information andconcluded that Mr. Kingsley's tTiost seri-ous problems were his pain, anxiety, atidunfamiliarity with what was happening tohitii. all of which were preventing himfrom complying with the postop regimen.She fc'lt that his pain was caused in partby constipation and ga^. so she targetedresolving those as her first priority. Shealso noted that his pain medication wastneffcclivc and decided to ask the doetorto increase ihc dosage.

She felt that once his pain was relieved,he would fee! less anxious and would bemore open to patient teaching. Since he waseager to return home, she planned to ctnpha-si?e ihat his compliance with the postopregimen could hasten his discharge.

After gathering and analyzing her data,she was reaily to redefine Mr, Kingsley'sprobletns through nursing diagnosis.

Writing; the nursinf^ diu)>no.sesA nursing diagnosis has (wo parts. Thefirst part states the patient's unhealthfulresponse (the problem), e.g,. constipation.The second part states the probable causeof the problem, e.g., decreased activity.The two phrases are connected by eitherrelated to or associated with. This com-pleted nursing diagnosis would read: con-stipation related to decreased activity. Ifthe problem is n potential one, use thewords potential for or (// risk for beforethe problem {potential for constipation re-lated to decreased activity).

Bach nursing diagnosis, when correetlywritten, can accomplish two things. One.by identifying the unhealthful response, ittells you exacdy what should change. Thischange is what the patien( goals in yourcare plan will describe. And two. by iden-tifying the probable cause of the unhealth-ful response, it tells you what (o do toeffect the change. What you should do iswha( the nursing interventions in your careplan will deseribe. In other words, youlltreat the cause to change the response.

The major pitfall in developing a nursingdiagnosis is writing one that nursing in-tervention can't treat- A nursing diagnosis,as defined earlier, isastatement of ahealthproblem (hat a nurse is licensed to treat,a problem for which she will assume re-sponsibility for therapeutic decisions andaccountability for the outcomes.

A nursing diagnosis is not:• a diagnostic test ("schedule for cardiacangiography")• a piece of equipment ("se( up iiKermit-tent suctit>n apparatus")• a probletn with equipment ("the patienthas trouble using a ctnntnode"!• a nurse's problem with a patieni ("Mr,Jones is a difficult patient; he's rude andwon't take his medication")• a nursing goal ("encourage fluids up (o2,000 ml per day")• a nursing need ("I have to get through

to the family that they must accept theirfather's dying")• a medical diagnosis ("cervical cancer")or treatment) "cathctcrize after each void-ing for residual urine").

At first, these distinctions may not beclear. The following exatnples should helpclarify what a nursing diagnosis is and how-to develop it,• Don't state a need instead of a problem,Ineorreet: //»/(/ replacement related to feverCorrect: dehydration related to fever• Don't reverse the two parts of the state-ment.Incorrect: tack oj knowledge related tononcompliame with diabetic dietCorrect: noncompliance with diabetic dietrelated to lack of knowledge• Don't identify an untrcatable conditioninstead of the actual problem it indicates(which can be treated).Incorrect: inability to speak related to lar-yngectomyCorrect; social isolation related to inabilityto speak because of taryngectomy• Don't write a legally inadvisable state-ment.Incorrect: red sacrutn related to itnproperpositioningCorrect: impaired skin integrity related toimmobility• Don't identify as unhealthful a responsethat would be appropriate, allowed for. orculturally acceptable.Incorrect: anger related to terminal illnessCorrect: noncompliame with prescribedregimen related to anger over terminal ill-ness• Don't make a tautological statement (onein which both parts of (he statement saythe same thing).Incorrect: alteration in comfort related topainCorrect: alteration in comfort I pain) re-lated to postop abdominal distension andanxiety• Don't identify a nursing problem insteadof a patient problem.Incorrect: difficulty suctioning related tothick secretionsCorrect: potential airway obstruction re-lated to thick trachea! secretions

Determinin}> prioritiesMr. Kingsley's nurse kept these examplesin mind as she developed her nursing diag-noses for him. After analyzing the un-heaMhful responses to his illness, shedetermined which ones were most signif-icant and wrote (he following diagnoseson his care plan:

• pain related to flatus, constipation,wound• noncompliance with prescribed postop

36 Nursing85, March

acrivilics related to pain, and to lark ofknowledge uiul an.xiciy ahout condition.

Note how the second part of each state-ment—the probable cau.sc phrase—^idcn-titics causes that ihc nur.sc can treatihroujih nursing intervention.

Several other nursing diagnoses wuukihave been possible for thi.-i patient:• cotistipttlion related lo decreased activ-ity and narcotic pain medications• lack of knowledge abotit condition andexpected postop course related to lack ofpreop teaching• anxU'tv relatcil to lack of knowledgeahout condition and separation from famil\• impaired physical tnohilit\ related lopostop pain anil amstipaiion• polential for impaired skin intefiritv re-laifd to mmcompliance with presiiihcdpo.siop activities• potential for ineffective airmiv clear-ance related lo noncompliance wilh pre-scribed po.stop (utivities.

You can sec how these diagnoses areinterrelated. Your analysis of the infor-mation you gather during the assessmentand paticnl interview determines whichproblems you'll consider priorilies. Theeasiest way to son out which problems aremost signifieant is to ask yourself: Which

problem causes the patient the greatest dis-tress.' Which problem, if managed first,will help resolve the other problems, eitherdireetly or indirectly?

Of course, your diagnoses will changeas the patient's responses to his problemschange. You'll delete some and developnew ones according to the patient's needs.

Writing the patient j>oalsand nursing interventionsOnce Mr, Kingsley's nurse was salisliedwith her diagnoses, she discussed themwith her patient. She asked it" he agreedwith them and if he'd like to change any-thing or add to the list.

Together they worked out the patientgoals. For the first diagnosis (pain relatedlo flatus, con si i pat ion. wound), theyagreed on one goal: stales that he is com-fortable within 24 hours. For the seconddiagnosis (noncompliance with preseribcdpostttp activities related m pain, and tolack of knowledge and anxiety about con-dition), they established two goals: (I) b\end of day shift. March 6, performs ac-tivirifs with assi.stance: (2) hy end oj eve-ning shift. March 6. only needs remindersto perform activities.

If you look closely at these goals, you'll

Patient Care Plan3/5/85

NursingDiagnoses

1Pain related lo fta-lus, constipation,wound

IINoncompliancewitti prescribedpostop activitiesrelated to pain, andto lack ot knowl-edge and anxietyabout condition

PatientGoals

1States tt at he iscomfortable within24 hrs.

II1 By end of daysfiift 3/6, performsactivities withassistance2, By end of eve-ning shift, 3/6, onlyneeds reminders toperform activities

Josepb KingsleyPostappendectomy

Nursinginterventions

1 Apply heat to abdomen; try sitzbath, rectal tube, or carminative.2 Try suppository, iaxative. or enema3 Assess diet4 Assist to toilet q4h5 Continue pain meds, as ordered6 Get order for less constipatingpain med7 Assess need to change pain medregimen8 Continue comfort measures. Assistwith position changes, splinting.teach relaxation techniques.9, Encourage walking and lightactivity

II1 Continue pain interventions (above)2, Give facts about appendectomyand expected recovery time, includ-ing expected daily progress3, Teach activities to relieve pain andpromote recovery Emphasize that ac-tive participation hastens recovery4, Praise when paiient performs activ-ities, and poini out progress.5, Encourage questions about con-dition and treatment Reinforceteaching6. Encourage family to call

see they direcliy relate to the first phrasein each nursing diagnosis, the phrase thatstates the unheatthful response. The goalsclearly identify how each response willchange. Note also that the goals arcpatient-centered, specifie. realistic, andmeasurable—that is. they tell you when tolook for the desired change.

With the diagnoses and goals iJentilied.the nurse wrote the nursing interventionsand explained them to Mr. Kingsley. (Seeinterventions in the insert. Patient CareFlan: Joseph Kiniisley.)

II you study the interventions, you'll seethat each relates to the seeond phrase ofits respective diagnosis, the phrase thaistates the probable cause of the unhealth-lul response. The interventions tell thenurse what she must do l<i treat the cause.

The larper pictureAs you can see from this portion of thecare plan, the nursing diagnoses LID indeedhold together the goals and interventions.But developing the nursing diagnoses isjust part of the larger picture: llie nursingproeess. Once you've written this part ofthe care plan, you've completed the firsitwo parts of the process: assessment (gathering and analysing the data, developingthe diagnoses) and planninii (Jcvclopingthe patient goals and nursing interventionsbased on the nursing diagnoses). To followthrough with your plan, you must com-plete the implementation of your interven-tions and the evaluation o!" whether thegoats were met. Then you can return toassessment...to discard some diagnosesand develop others as needed.

Writing nursing diagnoses correctlytakes practice and some research. By re-viewing the selected references listed be-low, you can get a feet for the languageused by various experts to phrase the diag-noses. Some language is more formal thanothers.

What you want to remember when de-veloping your diagnoses is to tailor themto the patient's needs, not the other wayaround. You shouldn't have trouble doingthis if you keep sight of why you developnursing diagnoses in the first plaee: to helpthe patient and family cope with all aspectsof 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 NursingDiagniisiN, New Yi.rk. Mctiraw-ltitl Biiok Cii.. 1982.

Cjoulim. M , Sweeney. VI . el al "NurMfif; DiagnosisLooking il lis I'se m ilie flinkal Area." AiiicnuinJtiiirntil of Nurmig m.bll. ^pv^\ 198(1.

Kim. Mi Ja. McFartand. G.. ei al: Pockri Guide tnNiiniHs Oiiitiiti'ses. Si. Louis. C'.V. Miwby Cu,, 1984,

Lengel, N. Handbook of Nursinx DUiiino.sis. Bowie.Mii.. Roberi J. Brady Co. . 1982.

Nursing85, March 37