TIPS ON WRITING A GOOD NURSING DIAGNOSES

   
When we were in school of nursing, and even as we write series of exams, there seems to be a stereotyped way of writing nursing diagnoses: It’s always something like this:

Nursing Diagnosis: "Altered Body Comfort-Pain Related To Inflammation And Oedema."

If you are a nurse I know you must have written something like this several times or even discussed an argued about it in the course of your study. You can be able to write a long diagnosis when you are in a less busy unit but when you are in a tight unit, it becomes unnecessary. It is useless to write a nursing diagnosis that your colleagues would not understand.It doesn’t help anybody especially the patient.. Below is a practical tip and writing a good nursing diagnosis and care plan that works:

1. State the nursing diagnosis using simple language. Don't be afraid to include the medical diagnosis.

Everyone on your nursing team needs to be able to understand the patient's problems. If the patient has pneumonia, say so.

The nursing diagnosis, "Ineffective Breathing Patterns related to infection as evidenced by a change in respiratory pattern and tachypnea." becomes "Shortness of Breath (SOB) Secondary to Pneumonia."

2. Write the plan backwards

If you have difficulty coming up with the goal, start with the interventions first. Then write the goal. The goal can be the opposite of the nursing diagnosis.

"No SOB" might be too short.

"Within the next 2 weeks, the patient will no longer have SOB or any other signs or symptoms of pneumonia." is more specific about the outcome you want.

3. Say plainly what you are going to do

Your language does not have to be fancy, just understandable. "Elevate Head of the Bed (HOB) at least 30 degrees" is a clear and concise directive.

4. Eliminate obvious interventions

Don't waste time and energy by saying the obvious like: "Give prescribed antibiotics"

What nurse would not give an ordered medication? Instead, use interventions that remind you what to do such as, "Watch for side effects of antibiotic such as rash, diarrhoea, nausea."

Don't be intimidated when writing nursing care plans. You don't have to write them the way you did in nursing school. Write them the way they are, the way you see it right there. State the problem so everyone can understand it. The goal is often the opposite of the nursing diagnosis. You know what needs to be done.

Don't be afraid to write those interventions down. If you follow these guidelines, you will find that writing the nursing diagnoses and nursing care plan will not only be easier, but will help you take more consistent care of the patients on your shift and from shift to shift.

Be the Best Nurse You Can Be!