For example, if you have a patient who was diagnosed with a traumatic brain injury, they may seem confused and disoriented. You could write down that they don’t seem to understand where they are, or why they are in the hospital. Don’t worry about using official terminology at this point. You can “translate” your observations later. Focus on getting down what you see in your own words.
Ask the patient questions to better understand their response to their condition and how they are coping with various symptoms. For example, if you have a patient who was diagnosed with a traumatic brain injury, you might ask if they know where they are or why they’re there. You also might ask them what day it is, or who the president is, to get a better understanding of their connection to reality. The response and attitude of friends and family may also impact the patient’s problems. For example, if the patient’s spouse is stressed out or anxious, they may increase the patient’s anxiety.
For example, if the patient is defiant and lashes out at loved ones or at health care providers, they may be in a lot of pain or have high levels of anxiety.
Data to support your actual diagnosis may be either objective or subjective. Objective data is generally more important in forming the basis of your diagnosis. However, subjective data, especially regarding the patient’s pain level, can be important to both your diagnosis and overall care plan. For example, subjective data would be the patient saying they felt dizzy or confused. That subjective data can be quantified using objective data, such as that the patient’s blood pressure is 90/60 and their pulse is 110.
Focus on the experience of the patient and those around them, not the medical diagnosis. A nursing diagnosis reflects the individual. No two nursing diagnoses will be alike, even for two patients diagnosed with the same condition. For example, let’s say your patient is diagnosed with a concussion. Your nursing diagnosis will include what your patient needs to help with this condition. It might include regular checks to make sure the patient stays awake. Ask questions like “what day is it?” and “where are you?”, to make sure the patient is oriented with time and place, and also watch for signs of confusion. Patients often will have more than one problem that needs to be addressed. Diagnose each problem separately.
For example, suppose you’ve diagnosed chronic pain. The patient has a recent spinal cord injury. The spinal cord injury is most likely the cause or source of that pain. The patient’s medical diagnosis can provide some guidance here. For example, if you have a patient who was recently diagnosed with chronic obstructive pulmonary disease (COPD), that disease is most likely the source of your nursing diagnosis of a persistent cough. Keep in mind that patients may have more than one diagnosis. It’s best to rank them in order of severity to make it easier to address the patient’s needs. You may find them listed in order of concern on the doctor’s synopsis. It’s normal for the order to change over the course of treatment, so be mindful of the patient’s changing needs.
For example, if the patient is a chronic smoker, their smoking may be a related factor in their persistent cough or difficulty breathing. The patient and their loved ones can also offer you insight into the patient’s medical history and tell you about recent changes in behavior.
For example, if you have a patient who has a persistent cough, sleep pattern disturbance related to the cough would be a potential problem related to the initial diagnosis. Anticipating these potential problems helps you customize treatment for the patient.
Once you have the nursing diagnosis, you can also look up potential outcomes and nursing interventions that are appropriate for your patient. Consider how each of these applies to this particular patient.
The related factors form the second part of your nursing diagnosis. After the specific diagnosis, write “related to” (also abbreviated “r/t”) or secondary to, followed by the list of sources or causes you’ve found for that problem. For example, suppose you have a patient with chronic confusion after a traumatic brain injury. You might write this up as “chronic confusion r/t possible traumatic brain injury” or “chronic confusion secondary to traumatic brain injury confirmed by MRI. " Make sure you work within the doctor’s diagnosis. If the diagnosis is not final, refer to the working diagnosis as “possible. "
Your textbooks will likely have lists of characteristics to look for that are related to a particular diagnosis. However, include only the characteristics that you have observed in this patient. Note whether the data is subjective or objective.
