Nursing Diagnosis + Free Download

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Hello ADPIE Friends!

We're so thrilled to have you with us for another post. As promised, this week we are discussing Diagnosis.

After you have gathered your patient data, we begin to group it together and decide how we can improve this patient's situation. This could mean that we want to help them move better, meet their nutritional needs, improve communication, or improve their mental health. It is all driven by the patient's condition and their goals! You need to include your patient in the plan of care for it to be truly beneficial for them.

First we need to be very clear that nurses cannot create medical diagnoses for patients! This is outside our scope of practice unless otherwise stated by your job title or advanced nursing degree. As we gain experience and increase our knowledge, the nurse can infer or discuss with the primary care provider what diagnosis might be appropriate for the patient. This knowledge is by no means an invitation to diagnose your patient in a formal manner. Always refer to your employer and appropriate laws. Nurses can only create nursing diagnoses. These can occasionally be driven by medical diagnoses, but you want to be a little more thorough; we'll explain further in a moment.

Diagnosis usually follows this formula:

Problem related to supporting data as evidenced by the root cause of your problem.

We used the example of anxiety before, so we'll explore it further here:

Anxiety as evidence by expressed concerns due to change in life, fidgeting, insomnia, and increased tension related to situational crisis

You have the problem: Anxiety
As evidenced by: expressed concerns due to change in life, fidgeting, insomnia, and increased tension
Related to: situational crisis

You problem will usually come out of a nursing diagnostic handbook. There are thousands of these to choose from and they help nurses speak in a common language to one another and other disciplines of medicine. Nursing is not a new profession, but we are one that is trying to create a legitimate image of ourselves. Towards this end, formal systems need to be in place to regulate our profession and create trust.

Your evidence is the data you have gathered to support your diagnosis. This is also listed in your diagnostic handbook and helps you narrow down the data that you are using. This is both subjective (data this is opinion or told to you) and objective (that which you can directly observe or measure) data. Objective data, is best for most things and that is true here. However, your patient stating their emotional state is subjective, but is very important to the nurse.

When you are trying to find what in the patient's life is relating back to the problem you are trying to do a root cause analysis of the patient and define why they are having this problem in the first place. Again, this portion of the nursing diagnosis is also found in your diagnostic handbook.

While we said that most if not all portions of the nursing diagnosis are found in your handbook that you get for school, you can always make one that is more appropriate for your patient that is not covered by the handbook.

As you gain experience, you won't even really think about these things. It is nice to refresh your basic knowledge and get back to what makes nursing great. ADPIE helps to set nursing apart from other disciplines of medicine. We should respect that and remember what we learned in school. Nursing diagnoses help guide the nurse and the patient in Planning the patient's care, which we will cover later! To read that post now, follow this link here.

For those of you who are on our mailing list, you have already received you free download! If you have not subscribed, add your email above to get yours in your mailbox. This worksheet includes some basic nursing diagnoses and helps you to formulate a complete nursing diagnosis for your patient. Feel free to post questions here or on our social media! In the mean time...please continue to monitor...