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Frustrated with learning and using nursing diagnoses? Does it seem complex and cumbersome? You're not alone! Those of us who are NANDA-I members experienced this frustration too, both in our education and in clinical practice. Each of us had an "AHA!" moment when it all came to together - when we understood.

Your “AHA!” Moment: Imagine This…
Your mom has been admitted to the emergency room for shortness of breath and chest pain. She has her tests done, is assessed by her nurse and her doctor and they come in to tell you what’s happening. The doctor says to you, “Your mom has an alteration in NANDA International Nursing Diagnosis Blogcardiac rhythm and we can control this with meds.” A half an hour later, the doctor comes back in and tells you, “Your mom has had a myocardial infarction and needs immediate surgery.”

Huh?!? You would, of course, have many questions to ask. For the purpose of this post, let’s focus on one: Which diagnosis is right and based on what criteria?

When we receive a medical diagnosis for ourselves or a family member, we naturally expect to be told the basis for it – in detail. And we should, to ensure the care received is safe and appropriate.

Do You Feel Their Pain?

The foundation of diagnostic decisions is equally critical to the care nurses provide. Let’s take the concept of pain.

Let’s say you label a patient’s problem as Pain. The next day you review the chart and see that a colleague has changed your conclusion for this same patient, calling the problem Acute Pain. In comes a third nurse, who labels the problem Chronic Pain. Why did three skilled and knowledgeable nurses looking at same patient use three different diagnostic labels? What would you think if medical diagnoses were so easily tossed around or changed?

Diagnostic Accuracy: Critical to Patient Safety
The primary problem with this is patient safety – if we do not have nursing diagnoses with clear definitions and diagnostic criteria then how do we know that we are making the correct diagnosis in the first place? And how do we know the interventions we choose are going to be effective?

Chronic pain and acute pain, for example, have different underlying etiologies and require very different interventions. If we do not know how the diagnosis was made (by referring to the assessment criteria used to make the diagnosis) and we do not have a clear diagnostic definition, then we do not have a way to ensure that we are providing the best and safest care for our patients.

Nurses Don’t Just DO:
We Assess, Think and Make Informed Patient Care Decisions

Nursing is so much more than following doctor’s orders, isn’t it?

Like all other healthcare disciplines, we need to have a language that allows us to identify and communicate our knowledge – to one another, our health care partners and to our patients.

Is the NANDA-I language perfect? Absolutely not!

Does it need clarification, revision, expansion? Most definitely!

Without it, we go backwards to the days when nurses wrote paragraphs in patient charts that nobody else read. Or we describe our contribution to patient care as a list of tasks in an electronic record, often leading administrators to conclude, "we don’t need licensed nurses to do that.”

What do you think? Have you had an “AHA!” moment that made nursing diagnosis more meaningful in your practice?

Dr. T. Heather Herdman, PhD, RN
Executive Director
NANDA International, Inc.

Comments
lisa
5/6/2013
When does a nursing xare plan need revision? After evaluation I did not use an assessment to evaluate, but was told I still needed to revise the item ?I did not use for evaluation?
Dr. T. Heather Herdman
5/6/2013
Hi Lisa - thank you for your question! There is not a clear cut standard for the frequency for revision - it depends on the patient's condition, the severity and complexity of care, as well as organizational standards. In general, a minimum guideline would be once every 24 hours - but in intensive care environments or with complex patient conditions, it is often done one or more time per shift.
For more information, please review this FAQ in our Knowledgebase:
When does a nursing care plan need revision?
James
5/25/2013
Nursing diagnosis are a joke. I saw a patient in the ED today. He was a heroin junkie and an alcoholic. He was having right sided abdominal pain that radiated to his right shoulder. His diagnosis was pancreatitis not acute pain secondary to an inflammatory process, or anxiety related to not knowing where his next shot of heroin was coming from. I guess you might have a use in nursing schools, but not so much in the real world.
Dr. T. Heather Herdman
5/27/2013
Dear James: I’m sorry to hear you don't feel nursing diagnosis have a place in the "real world." I didn't assess the patient, but I'm sure you did & I hope you addressed his acute pain in a manner appropriate to the etiology. I hope you reconsider; if nurses can't identify the unique knowledge they bring to patient care, and teach it, research it and practice based on it (as well as document it), what will stop other disciplines from taking over more of our practice? What will stop organizations from deciding that all RNs do is follow orders, and there might be cheaper ways of doing that than hiring a nurse? RNs use nursing diagnosis globally in daily practice, to improve safe communication, direct interventions, let patients understand what nurses know & enable effective documentation. Interdisciplinary rounds are led by RNs in some sites, using nursing diagnoses: all disciplines understand & respect these, along with the medical diagnoses. There’s a significant difference in treating a disease & treating a patient's response to it; one is physiologically focused, the other includes physiology but from an integrated, holistic view.
Mary
7/14/2013
This is a late post but I will comment anyway. I actually agree (in some aspects) with both of the last 2 posts. I would think that the most accurate and CLEAR NDX would be Acute Pain: abdominal r/t dx of acute pancreatitis. Now it would be clear to all who care for this patient the focus of care and the etiology.
Jon
9/17/2013
As an LPN, I actually see the use in nursing diagnoses. I wish we actually used them in practice, esp. in places filled with nurses. They serve a lot of use in goal setting. The problem however, is that they aren't as accepted because they aren't listed in the patient's chart on any documents other than the nurses' notes. I think that where we've been written off, we need to enforce the use of nursing Dx rather than allow it to fall by the wayside. Nurses have come up with revolutionary tactics to advance care, but we've already given too much of it away. Occupational Therapy, Respiratory Therapy, Physiotherapy - all separate fields (despite some remaining nursing fields) for which nursing could have advanced. It's time we allowed nursing diagnoses to help guide our practice outside of pure scholarship so that we can all see the good it does for the patient. We have been contributing for ages to the good of care, nursing diagnoses can help us continue.
Heather Herdman
9/17/2013
Jon, I couldn't agree with you more!
mitra
1/3/2014
hi, I am confused. does nursing process a substitute for nurses notes?
Nolen Oribello
6/3/2014
Has nursing diagnosis writing changed? When I went to school we were not able to use medical diagnoses in our nursing diagnosis. If we did, we first had to make a correct RELATED TO statement and then say SECONDARY TO before writing a medical diagnosis. Also, RISK FOR and POTENTIAL FOR diagnoses did NOT have an AS EVIDENCED BY or AS MANIFESTED BY statement because there is no sign or symptom for a potential problem. Now it seems that there is evidence, however, no etiology and you should leave the RELATED TO statement out. If this is the case, please let me know, - also, it would be helpful to know when this all changed as I have been doing this wrong for quite some time if the change was not recent.
Heather Herdman
6/20/2014
Hi Nolen, A big part of the problem, historically, has been that schools have taught students how to diagnose and how to chart those diagnoses differently, based on what textbook(s) were adopted for the nursing process curriculum. NANDA-I has always said (and continues to say) that basing a nursing diagnosis SOLELY on a medical diagnosis is poor practice - we should never assume that human responses are always the same. In other words, every woman having a mastectomy does not experience body image disturbance; every parent of a premature infant hospitalized in a NICU does not experience the phenomena of impaired parenting. However, we have often had medical diagnoses/conditions noted in related factors or risk factors. Diabetes mellitus is certainly a risk factor for alterations in tissue perfusion and therefore for the nursing diagnosis of Risk for decreased cardiac tissue perfusion, for example. This is an area of confusion, in that we cannot independently intervene on, or these related factors/risk factors (often nonmodifiable conditions)- yet it is important for the nurse to know and be aware that certain conditions put patients at risk for or may lead to particular human responses. We are currently considering how to provide this information related to associated conditions, as well as populations which might be at risk for certain conditions, to nurses while not including them as "related factors" or "risk factors". The documentation format you refer to (related to/secondary to) was proposed by some authors, and it sounds as if your school probably adopted this format - it wasn't a "NANDA-I format", however. . Until recently, NANDA-I never formerly identified what it believed to be the proper method for documentation. For some, this format was more of a teaching tool - a way to gauge and support clinical reasoning - than a recommendation for documentation within a clinical practice setting. Today NANDA-I recommends the following format for documentation, while recognizing that within electronic health records, systems may not yet allow direct linkage of assessment data (defining characteristics) or history/interview data (related factors or risk factors) to the nursing diagnoses themselves: [PROBLEM-FOCUSED NURSING DIAGNOSIS] related to [RELATED FACTORS] as evidenced by [DEFINING CHARACTERISTICS]. For example: Ineffective breathing pattern related to respiratory muscle fatigue, pain and obesity, as evidenced by nasal flaring, tachypnea, use of accessory muscles to breathe, alterations in depth of breathing. The format recommended for RISK DIAGNOSES (RISK DIAGNOSIS as evidenced by RISK FACTORS) - reflects the fact that the human response is a potential response – a risk – it does not yet exist - so there is no cause/etiology to associate with a response, rather there are risk factors that can be observed or subjectively identified (just as defining characteristics can be observed or subjectively indicated for problem-focused diagnoses). For example: Risk for thermal injury as evidenced by intoxication, smoking, unsafe environment and neuropathy HEALTH PROMOTION DIAGNOSES generally do not have related factors (etiologies), so they are written as: Readiness for enhanced comfort as evidenced by expressed desire to enhance feeling of contentment and to enhance comfort. This is a long answer to your question, but I hope it helps. The bottom line is this: knowledge is constantly expanding, and we are constantly reconsidering how we apply knowledge in clinical practice. There are many organizations in which the only thing that is documented is the nursing diagnosis label itself. You have to scour the nursing assessment and patient history to find the defining characteristics, related factors or risk factors. This makes things difficult for nurses to communicate with clarity to one another, and isn’t the best format for quality, safe patient care. However, it is often the reality – which is why we really need, as a profession, to teach these diagnoses, their definitions and diagnostic indicators to ensure that every nurse knows exactly what is meant when a nursing diagnosis is used in practice.
sebert taylor
9/5/2014
Having nursing diagnoses is fine,but it should also make note of the medical diagnosis,this is to prevent confusion at change of shifts for nurses and other medical professionals.Everybody needs to have a clear understanding of the etiolgy of the disease.
K ANIL KUMAR
1/10/2015
I work as a Registered Nurse in a Government General Hospital, in India for the past 10 years. I have been trying to implement nursing care plan formats in patient records. We have designed & developed a format according to our convenient, keeping in mind the principles of nursing care plan. We have also listed out the nursing diagnosis according to the NANDA list of 2014. We have conducted training for nursing staff on nursing care plan and their documentation. We record all documents manually. Due to heavy work load and shortage of staff, we find very difficult to record care plans. We need to develop an easier method of documenting nursing care plans. A simpler method should be found so that the nurses ready accept it and should never feel as a burden for their routine task.
Victor
3/21/2016
I'm a nursing student and I really found Dr. Heather Herdman's write-up educative. I wish to regularly have updates on nursing issues in my mail. And lest I forget I'm a male Nurse in view of naval service.
Victor
3/21/2016
I'm a nursing student and I really found Dr. Heather Herdman's write-up educative. I wish to regularly have updates on nursing issues in my mail. And lest I forget I'm a male Nurse in view of naval service.
Victor
3/21/2016
I'm a nursing student and I really found Dr. Heather Herdman's write-up educative. I wish to regularly have updates on nursing issues in my mail. And lest I forget I'm a male Nurse in view of naval service.
asekaleselase
8/31/2016
it s good. why do you get component of nursing assesement detail
asekaleselase
8/31/2016
imani
9/16/2016
I think nurses must be educated about nursing diagnosis in academic sites. today,some of nursing academic members educate their student about medical diagnosis.
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