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Coming Up With a Nursing Diagnosis and Care Plan Doesn’t Have to Give You Hypertension (alternate title: 5 steps to writing a nursing diagnosis)

Coming Up with a Nursing Diagnosis Doesn’t Have to Give You Hypertension

When you’re coming up with a care plan, establishing the diagnosis can be the most frustrating aspect. But it doesn’t have to be! Here are some tips on making this process go from feel like gut punch …

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to a high five.

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SIDE NOTE: We’ve written a MASTER POST on nursing care plans. Click HERE to read.

Step 1 – Collect your information

This information can come from various sources. One of the most valuable places to get this information is from the patient themself. Complete your assessment and talk to your patient.

Tip! Don’t walk into information collection with a mission of figuring out a nursing diagnosis because you may be so focused on the diagnosis aspect that you fail to get a full clinical picture.

Listen to report, read the chart.

Go see your patient and get your assessment completed. Between your physical assessment (don’t know how to do one? Check out this awesome video!) and your discussion with the patient, you will learn a lot.

 

After you’ve done all of the above, go back to the chart and look at it with new and more informed eyes. Having a physical assessment and conversation with the patient and their loved ones can really help make the chart make more sense.

Step 2 – Stop and reflect

Now that you have all of your information in front of you… what do you think about all of it? Without trying to speak in nurse-diagnosis terminology.. what are your thoughts? No pressure. No need to perform or get the perfect answer the first time. Just think about the information in front of you and what may be important to that patient.
Write your initial thoughts down on a blank sheet of paper or blank document on your computer. Don’t worry about it looking pretty or using the right terminology. Just word vomit on your work document (ha!).

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Example
Hummm… he said he’s had a lot of pain since the surgery… he also hasn’t had a bowel movement since the day before surgery, which was 5 days ago and he said he feels all blocked up… man, I hate it when I can’t poop. His bowel sounds were definitely hypoactive on assessment and when I looked in chart, all of the previous nurses charted hypoactive bowel sounds as well.

Now go take a break. It helps to have fresh eyes between this step and the next one.

Step 3 – Analyze

Go grab whatever textbook you are using as a reference guide.

Get your notes you took before and any assessment data you’ve got.

Take a look and highlight anything you’ve written that sticks out as a potential thing for you to focus on or address during the shift. Think about things that you want him to progress in, or things you want to get better during your time with him.

 

I want him to have less pain
I want him to poop

Step 4 – Translate

What nursing diagnoses can match up with my goals for this guy? Let’s take our words above and translate them into nursing diagnosis words/terminology. Think about a fancier way to say the basic things you’ve identified.

Pain becomes “acute pain”
Can’t poop becomes “constipation”

Now we have a starting point.

Step 5 – Transcribe

Let’s take those words and finish up the diagnosis. We’ll try to think about what these problems could be related to and how we figured out they were an issue in the first place.

He just had abdominal surgery. He said he was in pain. He moans and grimaces when he moves.

Becomes

Acute pain related to abdominal surgery as evidenced by self report and grimacing and moaning during movement.

He had abdominal surgery and many opioids since. He has not had a bowel movement in 5 days. His bowel sounds are hypoactive and he said he has not passed much gas

Becomes

Constipation related to abdominal surgery and post-op opioid use as evidenced by no bowel movement in 5 days, self-report of discomfort, and minimal flatus.

Step 6 – Time to party because you’re DONE.

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Date Published - Sep 30, 2016
Date Modified - Jun 25, 2018

Kati Kleber RN CCRN

Written by Kati Kleber RN CCRN

Kati Kleber RN CCRN is a Neuro ICU nurse with experience in MedSurg. She joined the NRSNG team in 2016. Her passion lies in helping new grads navigate the complexity of being a new nurse. She runs the blog: NurseEyeRoll.com and is a published author.