How to Write a Nursing Diagnosis (Full Step-By-Step Guide)

In this video, I am walking you through one of the most common struggles that we hear over and over again from nursing students. How do you get the hang of care plans and have them not take you a thousand hours to complete? Seriously, Tell me about it, my friend. I've been there. I've done that. I totally get it. Care plans are a big part of your clinical grade, so it's really important to do them right. Right. So let's walk through the steps for how to do it and make sure that you follow all of these steps, including the last one, because that one is really one of the biggest ones that nursing students forget about and your grade might suffer. So I'm going to tell you what that is and how to do it right. Let's do it. Now, here's something most nursing students don't think about. The key to creating care plans is understanding what your instructor wants. You gotta know what they're looking for so that you can do just that and ace your your care plan. Now, I'll tell you exactly what they're looking for. They want to know that you know why you are doing everything that you're doing. So you need to make sure that you prove that you know why you're choosing that nursing diagnosis, not just randomly picking one. That sounds cool. And here's how to do it. The best way to make sure that you prove that you know why. The why behind your care plan. Right. And the nursing diagnosis is to fully assess your patient. This is step one of choosing the best nursing diagnosis. You need to assess your patient. Sounds easy, right? But no, you need to actually know your patient. So spend time with them, assess them, get to know them and understand their needs. So that when you actually know your patient and have assessed them fully, you can choose the most appropriate nursing diagnosis that is specific for them. That's the key. It's got to be specific. And here's something that you need to know, like absolutely need to know about clinical. Your clinical instructor might just be talking with your patients when you're not around. Sounds crazy, right? I know. So they will actually know things about your patient, too. So do not try to fake your care plan, my friend. Your instructor will catch you. Okay. Keep that in mind. So be sure to actually assess your patient. Because when your instructor sees that you're not nursing diagnosis actually matches their condition and your assessment of them. That is the first step, improving to your instructor that you know what you're doing, which is a huge part of acing your nursing school care plans. Now, step number Two, you have to pick the best nursing diagnosis for your specific patient. And if you want to know the secret to picking the best nursing diagnosis, I will tell you how to do that in this video. So be sure to check that one out. After you watch this video, walk through how to do that. So now that you have fully assessed your patient and you've selected a nursing diagnosis that applies to your patient, specifically to your patient, the next step is to figure out what's called the related to part of your nursing diagnosis. Now, the related to portion is the etiology or the pathophysiology. Right? So this part is where you show your instructor that you know what is happening inside your patient's body. It's the related to part. You're showing why the problem for your patient is. Is happening. Why is that going on? What's happening based on that pathophysiology? Essentially, you're starting, you're. You're seeing what your patient's problem is, that nursing diagnosis, and then you're relating it back to the pathophysiology, the etiology. So do you see why it's important to assess your patient? First, you need to know what is happening and why it's happening in order to impress your clinical instructor with your care plan. Now, step number four is the signs and symptoms. You, you need to show evidence for why you picked the nursing diagnosis that you picked. This is where you list out those signs and symptoms that your patient is having to further prove that the etiology and the nursing diagnoses fit. Now, I have two examples for you, so you can actually see how this works. Okay? Deficient fluid volume related to or rt, inadequate fluid intake as evidenced by poor PO intake, dry mucous membranes, and decreased urine output. So our nursing diagnosis is deficient fluid volume. Right. Then the next step, they're related to etiology or pathophysiology is inadequate fluid intake. So the patient isn't taking in enough fluids. Right. Now, final part is listing off these signs and symptoms. The as evidenced by. So dry mucous membranes. Right. Decreased urine output, things like. Like that. Now let's do one more to make sure that you really got the hang of it. Okay, so this one is impaired gas exchange related to ineffective airway clearance, as evidenced by copious tracheostomy secretions, decrease in O2 saturations, and increased work of breathing, or wob. Now, our nursing diagnosis is impaired gas exchange. Here, we picked it right out of the textbook. Then the related to is ineffective airway clearance, so the patient is able to move Air freely and the symptoms make sense. They're copious tracheostomy secretions, decrease in O2 saturations and increased work of breathing. Now my friend, if you want more nursing care plan examples, I put some more in a PDF for you to download. So you could just click the link in the description to get those to help this all make more sense. And this next tip I have for you is huge. It's one that so many nursing students just totally forget about or they have no idea how to do it. And this is that you need to prioritize your your nursing diagnoses. You have to show your clinical instructor which nursing diagnosis is more critical to the patient and then put them in order for which one you'll solve first, second, third and so forth. Now this is how you can show your instructor that you are critically thinking, right? So this just means that you are doing the most important things first for your patient, showing your instructor that you know what you need to be doing first, second, third, etc. And why. So for example, if you have a patient come in and they are clearly having trouble breathing, but they're also super hungry because they didn't eat breakfast and lunch, well, as the nurse, you're not going to be as worried about their hunger needs right in that moment. No, of course not. Because that's not your priority, right? You need to get their breathing, their circulation stable first and then we can move on to other things, right? Like feeding them. So how do you do this? How do you make sure that you are prioritizing your nursing diagnoses correctly for most important, so the highest priority or the very first thing that you'll focus on to the least important or the lesser priority or you know, the next things or the last thing that you'll focus on. So order your nursing diagnosis based on what you will focus on first, so second, third and so on. And here is how to do this. There are two principles that you need to use for prioritization. Mouse's hierarchy of needs and the ABCs. So with mouse's hierarchy of needs, you need to make sure that you are dealing with the patient's physiological needs and their safety needs first before you deal with things like their self esteem needs, self actualization. So that makes sense, right? And then this goes along with the ABCs, which stands for airway, breathing and circulation, meaning that you want to make sure that your patient is breathing and their blood is circulating first before you solve anything else. It's very important. Like I said before, it all starts with picking the best nursing diagnosis. So how do you do that the right way? Well, I'm going to show you in this video. So click on that. Watch that next. You can find out how to do it and go become the nurse that God created only you to be. And I will see you over there in that next video.