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Posted: August 30th, 2022
How to Write a Nursing Diagnosis
How to Write a Nursing Diagnosis
A nursing diagnosis is a clinical judgment summarizing different health problems that a patient might have. It is a statement that indicates an individual’s response to a potential health condition. A nurse uses the diagnosis to develop appropriate interventions, including a plan of care for the patient.
A nurse develops the diagnosis from data obtained during the assessment stage. Assessment involves a physical examination of the patient, which includes measuring vital signs such as temperatures, blood pressure, heart rate, among others. The nurse should also probe and discuss with the patient any non-physical symptoms such as nausea, pain, and the health history of the patient that may influence their present condition. This is a critical process because the final diagnosis is made based on the information collected during the assessment. In some cases, a psychological or social examination might also be necessary.
How to Write a Nursing Diagnosis
A typical nursing diagnosis consists of three main parts. The problem statement, etiology, and symptoms commonly abbreviated as PES.
i. The problem Statement – Also referred to as the diagnostic label, is a brief description of the patient’s health problem or response to a particular health condition. It consists of two parts, the qualifier and focus of diagnosis. The qualifier basically, are words added on the diagnostic labels to give it a clearer, specific, or additional meaning.
ii. Etiology – These are related or risk factors that identify the probable causes of the health conditions resulting in what is referred to as symptoms. These are the conditions that influence the development of health problems and helps the nurse decide the appropriate form of therapy and provide a personalized plan of care for the patient. The interventions should solely be based on the etiological factors with the aim of eliminating the underlying causes of the diagnosis.
iii. Symptoms- or the defining characteristics are any anomalous conditions identified during assessment. These include signs and symptoms of the underlying health condition, the responses towards the condition, and any problems they may have performing normal activities. They prove that the health problem indeed exists in the patient. In a diagnostic statement, these defining characteristics are written using the phrases “as manifested by” or “as evidenced by.”
It is also important to note that not all the defining characteristics and risk factors need to be present in a patient to make a diagnosis. But only enough to support it as the most likely condition. However, all possible diagnoses need to be compared to ensure a correct final diagnosis. The final diagnosis should be specific and align with the signs and symptoms statement to allow monitoring and evaluation.
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