How To Write a Nursing Diagnosis

Last updated on January 26th, 2024 at 05:05 pm

Planning is an essential part of the nursing process in which a nurse applies critical thinking skills and evidence-based practice to outline the appropriate interventions and goals in caring for patients. Each nursing care plan is tailored to every individual patient, based on their subjective and objective data.

There are different models that can be used to create a nursing care plan, and one of the most commonly used models is the ADPIE, which stands for: Assessment, Diagnosis, Planning, Interventions, and Evaluation. This article will guide you to create an accurate nursing care plan based on these five crucial steps.

Step 1: Assessment

Assessment is all about collecting and collating all related patient information in order to create a sound nursing diagnosis. The Assessment phase is divided into two subgroups: the subjective data and the objective data. The subjective data are dependent on the patient’s thoughts, actions, and feelings, and are usually composed of:

• Patient’s verbalization / chief complaint, e.g. “My stomach is so painful.”
• Pain level on a 0 to 10 scale with 10 being the highest, and 0 being the lowest
• Behavior, e.g. refusal to eat; guarding sign on the affected area
• Feelings, e.g. “I’m stressed with these watery stools.”
• Perceptions, e.g. “I think I am not taking the anti-diarrheal drug properly.”

On the other hand, the objective data are based on measurable aspects of the condition of the patient, such as:

• Vital signs and general appearance
• Diagnostic test results
• Physical examination, e.g. cold, clammy skin, capillary refill of 4 seconds
• Assessment tools, e.g. type 6 watery stools based on the Bristol stool chart

It is important to note that all the data that you will put in the Assessment section of your nursing care plan are precise, brief, and are all able to support your nursing diagnosis.

Step 2: Diagnosis

A nursing diagnosis summarizes all the relevant patient data into one statement that answers the question, “What is the problem with the patient?”. This directs the nurse to the type and level of care that the patient requires. The formula of a nursing diagnosis is:

Diagnostic label + Related or secondary factor + Evidence = Nursing Diagnosis

Here’s an example:

Diagnostic Label: “Ineffective Airway Clearance”

Related factor: “related to pneumonia”

Evidence: “as evidenced by productive cough, shortness of breath, oxygen saturation at 91% on room air”

The North American Nursing Diagnosis Association (NANDA) is an organization that provides standardized nursing diagnoses widely used in many clinical areas across the globe. NANDA has distinguished a nursing diagnosis from a medical diagnosis. According to NANDA, a nursing diagnosis is focused on the actual and potential health problems of a patient. On the other hand, a medical diagnosis tells about a patient’s disease process or injury. For example, “Impaired Gas Exchange” is a nursing diagnosis, while “Chronic Obstructive Pulmonary Disease” is a medical diagnosis.

Step 3: Planning

The planning section involves your goals or desired outcomes to resolve the nursing diagnosis or the patient’s problem. The desired outcomes can be divided into long-term goals and short-term goals. An example of a long-term goal for Ineffective Airway Clearance is: “The patient will maintain a patent airway.” One of the short-term goals can be: “Within 4 hours, the patient will have an oxygen saturation of at least 96% on room air.” Each goal should SMART: short and specific, measurable, achievable, realistic, and time-bound.

Step 4: Intervention

This step involves the nursing actions and rationale, or the reason for doing each nursing intervention. The nursing interventions include what and when to assess and monitor in terms of patient’s vital signs and diagnostics, the nursing actions required (e.g. medication, suctioning, oxygen therapy, dressing changes) fluid and dietary requirements, mobility, as well as patient education and support. Each nursing intervention should be precise and should be backed up by a factual rationale to briefly explain why such intervention or action is needed. For example:

Intervention: Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.

Rationale: To increase the oxygen level and achieve an SpO2 value within the target range.

Step 5: Evaluation

Evaluation is the final step in the nursing care plan where in you can set parameters to check if the desired outcomes and goals are fully met, partially met, or unmet. This shows whether the nursing actions are effective, need modifications, or require to be stopped and changed. If a goal is partially met or unmet, then it is crucial to re-visit the nursing diagnosis, re-think about the goals, and change some of the nursing interventions. Here’s an example:

Evaluation: Goal met, as evidenced by patient’s increase of saturation levels from 92% to 96% on room air.

With these five steps, you will be able to create appropriate nursing care plans not only for your case studies at school but also for your future patients in any nursing workplace you decide to practice. It is important that you master these five steps to give the optimal nursing care to the patient, as well as develop your basic nursing skills and documentation skills.