How to Write a Nursing Diagnosis in 3 Simple Steps

Hey there, friend. My name is Christina Rafano from nursingsos.com and in this video today we are walking through how to write a perfect nursing diagnosis. Because care plans are a big deal in nursing school, right? You are gonna write them all the time, and the nursing diagnosis is a huge part of your care plan. So we'll walk through how to pick the right nursing diagnosis for your specific patient, where to find the nursing diagnoses in the first place, and the main parts of it that you will need to include to pass your nursing care plan. So hit that subscribe button and click the notification bell, and let's dive in. So first things first, let's talk about where do you find the nursing diagnosis in the first place? Now, when I started nursing school, I. I was so confused about care plans. Like, to be honest, I had no idea what the instructors were talking about. I had no idea what a care plan was. I honestly, to be honest, I had no idea really what nurses did. When I started nursing school, I knew that I was supposed to be there. So when I started nursing school, care plans were a completely, like, out of left field. I had no idea what I was doing. So I had wished that I knew about textbooks or care plan books like this sooner. So here's the secret for you, my friend. If you are just starting nursing school or if you are like me, in the middle of your program and have no idea what you're doing, don't worry, all right? This book or a nursing diagnosis book like this is going to save your life. I had this one in nursing school and it was so, so handy because it basically writes your care plans for you. So I'm going to kind of walk you through how it works and where to find the nursing diagnoses, which are right here, right on the front of the book, which is so cool. So first tip really for you, though, is that you do not write your own nursing diagnos, all right? They are standardized. They are found in your textbooks that you will be given in nursing school. So your textbooks will have them. There's just literally a list. And you will pick from the list what nursing diagnosis fits your patient best. So that's really a big hurdle that I see a lot of nursing students go through. Same with me. It's like, you don't actually have to make them up yourself. You just pick from that list super easy. So that is where to find the nursing diagnosis in the first place, is make sure that you are selecting from the list from any of your nursing textbooks or if you get A care plan book like this one. This is the Nursing Diagnosis Handbook by Ackley and Ludwig. Like I said, it's the one that I used in nursing school and I loved it. So I really recommend it to you because it really helps a lot. So check that out if you are interested. Now, let's talk about how to pick the best nursing diagnosis for your patient. Now, this is something that your nursing instructors are going to be looking at. The thing about care plans is that you're going to write a whole lot of them in nursing school. And at least for my nursing school, we had to write usually like three or four care plans per patient. So if you had three patients that you saw at clinical, or even if you had just one or two, that's three care plans or six care plans that you have to write for that clinical day. So you're going to be writing a whole lot of care plans in nursing school. So you want to make sure that you are showing your instructors that you are really critically thinking and really thinking about your patients and what is actually happening with them. We want to make sure that we are choosing nursing diagnoses that are specific to your patient. So that is key. Okay, pick one. Pick a nursing diagnosis that is specific to your patient. Now, what's really cool about this book is that here in the front, like, I don't know if you can see that, but there's this green sec tabbed section there that is kind of called out there on the binding. And this section walks you through different disorders that your patients might have. And then it gives you some possible nursing diagnoses that you could use. So let's find. Let's use diabetes as an example. Cause that's a really common one. So diabetes for a patient with diabetes, they literally just walk you through, through some possible nursing diagnosis that you can use, like vision loss, a risk for injury or risk for infection, readiness for enhanced health literacy. Let's see, ineffective health maintenance, risk for overweight. See, all of these would be really, really good nursing diagnoses to use for a patient with diabetes. And so that's what's part of what's really cool about this book, is that it gives you a whole lot of ideas. And like I said, it kind of basically writes your care plans for you, which is pretty nice when you have to write six of them every day in nursing school, so it will save you time. But that whole section walks through possible nursing diagnoses for whatever issue that your patient might have. So heart surgery, hemodialysis, heart failure, I mean the H's. So it's just, it's a very cool resource for you to use. Highly recommend that. So you're going to want to go through that list and make sure that you pick a specific nursing diagnosis that is very specific for your patient. So if your patient. What did we use for? We can use diabetes as an example. If your patient does not have like, they have diabetes, but they don't have vision loss, then you wouldn't put a nursing diagnosis of vision loss. All right, you see how that works? So we want to make sure that your nursing diagnosis is specific to your patient. If you have a patient that is really struggling with their diagnosis of diabetes, then you could do something like ineffective health maintenance because they just like, related to. They just, they just don't, like, they're not quite ready to hear that diagnosis in a way. Like they're not. They're just not there yet. Okay. So things like that, you want to really be thinking about what your patient is experiencing, what they're actually going through, and then pick a nursing diagnosis that is specific to their situation. Because there's a whole lot of patients with diabetes that you might have at clinical, but they're all going to be different and have different needs. But ultimately, here with the nursing diagnoses, don't make it more complicated than it needs to be. Really, you can just pick from the list. Try to make it as specific to your patient as possible, but don't spend a ton of time on it. Don't overthink it. Just pick one. And that is going to help you to move on in your care plan because the care plan has an awful lot of steps to them. And this is just the first one. So picking that nursing diagnosis, yes, you want it to be specific to your patient, but don't make it overly complicated. Just pick one that fits your patient really well. So that is the first part of your nursing diagnosis. That's the actual nursing diagnosis part where you're going to pick the diagnosis right here in the front of, of this book. And then you're going to find them in your other nursing textbooks that you. They're going to have NANDA nursing diagnoses in there. So just check out whatever textbook you have and you'll find these in your nursing textbooks. So that's the first part of the nursing diagnosis is to just pick the actual NANDA nursing diagnosis. Now the second part of this is the, what we call the related to. So this is the really the reason behind why that nursing diagnosis is important to your patient. So why are you giving your patient this specific nursing diagnosis that's the related to Now I always like to challenge our nursing students to think about the pathophysiology behind whatever the patient is experiencing and going through. So whatever disorder they have or disease or whatever, think through the pathophysiology of what is happening and that's going to be part of your related to section of your nursing diagnosis. So let's walk through some examples. I pulled these out of our nursing SOS membership community, the NMC and our our members inside the NMC have access to my whole care plan database. So if you're interested in that, definitely check out the link below. I would love to get these over to you. I also have a free care plan pack that you can check out. I'll put the link down below in the description for you to snag that. It's just a free pack of 10 care plans, but I do have more inside the nursing SOS membership community. But if you're not a member, be sure to snag that free care plan pack. So let's walk through a care plan Nursing diagnosis for asthma. So this is a fantastic example of a related two factor that's related to pathophysiology. So if we wanted to, if we had a patient with asthma we could use a nursing diagnosis like impaired gas exchange or ineffective airway clearance or ineffective breathing pattern. And the related to we need to say like why, like why are we picking that nursing diagnosis? What is it related to? See how that works. It's the related to factor. So what is it related to? And I like to think of this as the pathophysiology. So when you do your related to try to think about the patho so here for asthma it could be things like inflammation in the airway. So with asthma there's inflammation in the airway and that's restricting their breathing. Bronchial secretions again restricting their breathing or or obstruction of the airway. Of course that's restricting breathing too. So you would just choose a related to factor for whatever your specific patient is going through. If your patient has a lot of inflammation in the airway but they're not necessarily totally obstructed or if that's really not as much of a problem, of course there is some obstruction but it's not like that doesn't fit totally. If it's just more inflammation, then you would just put inflammation in the airway or something similar to that. So with your nursing diagnosis you want to make sure that you are choosing a related to or writing your related to factor as if it's like the pathophysiology that explains why you chose that nursing diagnosis. So that's the second part to that, the related to. Now the third piece of your nursing diagnosis is what we call the as evidenced by or the aeb. Now this is pretty fancy, it's pretty quite easy, which is very nice. It is just the signs and symptoms. So you will literally just list the signs and symptoms that you are seeing in your patient. That basically gives evidence to support why you chose the nursing diagnosis. So in this case, if we chose a nursing diagnosis for asthma as like impaired gas exchange or ineffective airway clearance. So their airway, you know, is, is, well, ineffective. So their airway is tighter than normal, then it could be as evidenced by things like a coug cough or decreased oxygen saturation, increased work of breathing, so they're having to work harder. Okay. Increased respiratory rate, adventitious breath sounds, things like wheezing and then abnormal ABG results. So those are just examples of things that you could use as your signs and symptoms. Whatever you're seeing in your patient, that's what you're going to want to list here. That gives evidence for why you chose your nursing diagnosis. So make sure that you are assessing your patient really, really well at clinical. So, you know these. So you know, like, hey, I had a patient with asthma and they had impaired gas exchange or ineffective airway clearance. And it's related to inflammation in the lungs, inflammation in the airway, and they had a cough, they had wheezes, they had increased work of breathing, they had retractions in their rib cage, they had an increased respiratory rate. So all of those things could be good evidences for why you chose that nursing diagnosis of ineffective airway clearance. So basically it's, it's pretty simple as you just write out the signs and symptoms of what you had assessed your patient for. That's it. It's not super complicated, which is quite nice actually. When you get into care plans, we don't want to make it overly complicated. The thing I will say about this is to make sure that you actually assessed your patient and you're actually using things and that your patient had. So you're not going to make things up in your care plan. Okay? We want to stay in integrity. Don't make things up, please. So if your patient did not have abnormal ABG results, if your patient did not have a, a significantly high respiratory rate, like you wouldn't put those things in your care plan. If Your patient didn't have them. So we want to make sure that you are actually writing things out that your patient actually had. What are the signs and symptoms that they had that will corroborate or provide evidence for that nursing diagnosis that you chose? So those are the three main parts of most nursing diagnosis that you will write in nursing school. You've got the NANDA nursing diagnosis, you've got the related two factor and you have the as evidenced by which is basically those symptoms right now. A big difference here for your care plans is risk for nursing diagnoses. So let's see if I can find one. There's lots. So let's see. Risk for hypothermia. Okay. Risk for, let's see. Oh, constipation. There you go. Risk for bleeding. That's a good one. Risk for activity, intolerance. So these are all examples of nursing diagnoses that would be risk for. For. Now here's what this means is a patient has a risk for bleeding, but they don't necessarily have bleeding. Okay. They would be at risk for unstable blood pressure, but they don't necessarily have unstable blood pressure, if that makes sense. So they, they're at risk for those things, but they don't yet have those things. Now here's where this kind of gets different with your nursing care plans. For risk for nursing diagnosis, you don't necessarily have the signs and symptoms because there are none. You don't necessarily have that related to because they don't actually have that bleeding or they don't actually have the. Whatever their risk for is, they don't have that yet. It's just a risk. So what we say here is that they have the risk for nursing diagnosis and then they have risk factors. All right, so this one, any of your risk for nursing diagnoses. Those are not three part nursing diagnoses. They don't have the NANDA nursing diagnosis and then the related to factor and then the. As evidenced by. They have two parts. Okay. They have that risk for NANA nursing diagnosis and then they have the risk factors. So those risk factors are just the things that put them more at risk of that thing. So if you have a patient who has risk for bleeding, actually, let's just go there because this might. This is going to be a really good example. It says page one. Let's see if you have a patient with. Oh, did I find it? Nope, not yet. Patient with risk for bleeding. Oh, and I don't really like this example. Let's see. Risk for bleeding. Where am I at There. If you have a patient with risk for bleeding. What they say here, this is kind of lame. I would add more, but they say insufficient knowledge of bleeding precautions. But if you have a patient with, if they're on taking blood thinners or things like heparin, if they are taking medications that put them at a higher risk for bleeding, you could include that under your risk factors. If you have a patient that has more thin skin or maybe they have an autoimmune condition that puts them at a higher risk for bleeding, you could include those things as risk factors. So you would put like risk for bleeding and then include why they are at a higher risk for bleeding. Let me see if we can find a better example. Let's try Risk for autonomic dysreflexia 1 63. I think that was the one right before it. Haha. Maybe I like this one better. Oh yeah, that was on the same page, so. Oh, this is a better one. Okay. Risk for autonomic dysreflexia. So here are the risk factors that the book just gives and you can choose whatever works for your patient. So this would be a patient with a spinal cord cord injury. Okay. So risk factors for having autonomic dysreflexia could be bowel distension, constipation, skin irritation or a wound. Oh for sure. Irritating stimuli below the level of entry or painful stimuli below the level of injury. Constrictive clothing, bladder distension. That's a big one. Bladder spasms. Those could all be risk factors and put the patient more at risk for developing autonomic dysreflexia. So that is. That's a really good example of what a risk for nursing diagnosis might look like. So you will include that Nanda nursing diagnosis and then just put their risk factors for it. So what puts the patient more at risk now? If you're struggling with writing your care plans in nursing school, definitely check out my whole care plan playlist right here where I walk you through full care plans for different disorders and things. You can check those out right up here. And be sure to write love in the comments below if you loved this video. And as always, my friend, go become the nurse that God created only you to be. And I'll see you over there in that next video.