The Nebulous Concept Known As The Nursing Diagnosis

THE MAJORITY OF NURSING STUDENTS WHEN FACED WITH WRITING ACTUAL* NURSING DIAGNOSIS FOR A CAREPLAN:

Currently we're in peds rotation and our clinical instructor (who loves nursing diagnosis) gave us a case study and then asked us to identify two "actual" nursing diagnosis.  Our class collectively froze.

For some reason, no one really knows how to create a nursing diagnosis.  Or at least, I've never met anyone who could clearly and concisely explain the etiology section of the nursing diagnosis.  I've had several clinical instructors try to explain it, only to pause, then say some variation of "You don't need to worry about that.  You don't have to do it in real life.  And if you ever do, there are drop down options on the computer."

And no, I have not yet found a nursing diagnosis book that illuminated my poor, confused soul.  The best book I've come across is the Handbook of Nursing Diagnosis by Carpenito (which I only just discovered after being in school for 1.5 years and it is a huge step up from the books I've been using before).  If you have a better book, I encourage you to post the title and author(s) in the comments section, because (sweet Mary mother of Jesus) we all need help when it comes to this.  As it is, I'm not claiming any of this is correct, but I'll do my best to recreate the process my instructor went through with us.

Before I jump into reenacting constructing a nursing diagnosis, let me try to review the skeleton of the nursing diagnosis.  You will need:

1) NANDA nsg dx label--this list updates year to year, so you'll have to find the most updated version.  Usually the diagnosis is either actual or potential (although our professor mentioned wellness and syndrome diagnosis--which I'm not familiar with).

2) Etiology--pathophysiological, treatment related, situational, social, spiritual, maturational, environmental.  Etiology is the most difficult part of the nursing diagnosis as most people won't be able to see beyond the medical diagnosis (they're so beautifully succinct).  It's hard to write an inference that is related to, yet cohesive and separate from the symptoms.  Ask yourself what are the factors that caused this problem?

For example, constipation is a diagnosis, but decrease intake of fiber, decrease intake of fluids, decreased ambulation, (age related/drug related) decrease in peristalsis all result in constipation, so any of those could be your etiology.

Any time you feel tempted to stick a medical diagnosis in right after the R/T, stop yourself, move your pen over two inches and write "secondary to __insert medical diagnosis here_," then go back and write the etiology of the medical diagnosis.

For example, if you are tempted to write "anxiety R/T agoraphobia" shift over and write "anxiety R/T __________________________secondary to agoraphobia."  Then ask yourself, what is it about this patient that sets of his or her agoraphobia?  Is it fear of humiliation?  Fear of bodily harm? Uncertainty of surroundings?  Overwhelming feelings of fear?  What etiology do the symptoms suggest?  All of those could be secondary to the medical diagnosis of agoraphobia.

3) S/S--this should be the easiest part--the signs and symptoms are the evidence with which you use to select your label and infer your etiology.

When you string those three things together, you get a structure like this:

NANDA approved nsg diagnostic label R/T etiology (that is NOT the medical diagnosis--don't be afraid to let this be as long as you need it to be, a whole sentence if necessary) AEB s/s that relate to the actual diagnostic label.




Here's the case study we were presented with:

I like to work in the reverse of the diagnosis construction.  I look at my symptoms, gather my diagnosis if there is one, and (as I recently discovered) etiologies.

SYMPTOMS:
-swelling/inflammation
-pain
-purulent drainage
-tender to touch
-slight red streaks extending from cuticle up the finger

DX:
-cellulitis

NURSING DIAGNOSIS LABELS:
-We know she has infection, but that's not on the NANDA approved list, so we can't use that one. I don't know why it's not on the list.  (Our professor said "it's because now we have a medical diagnosis for what kind of infection, and we can't prevent the infection..." which doesn't make any sense to me, but, alright, whatever.)
-We know that she's been gouging her cuticles out and biting them, so there's bound to be some kind of impaired skin integrity.
-We know that she's in acute pain.
-We know that the mother allowed the child to get this sick, so there is some kind of deficient knowledge.

ETIOLOGIES:
-We already have a medical diagnosis (cellulitis), so we know that at least one of the nursing diagnosis will be "______________secondary to cellulitis" to treat the medical diagnosis.  Drawing a blank?  So did we.  As our professor said "what caused the cellulitis?"  In other words, what was the etiology?  Layman's terms: biting cuticles, and poking cuticles with pens or pencils.  Fancy terms: tissue destruction.

Usually, I'd write the nursing diagnosis based on priority.  In this case, pain would be a priority because it's unlikely I'd get much compliance from a child in pain.  So here's my attempt at a nursing diagnosis for pain.  (Yes, I made up some s/s.)
Acute pain R/T nerve stimulation from swelling secondary to cellulitis AEB child flinching when finger is touched, stating "it hurts," and indicating 4/10 pain.


*Actual as in not a "risk for."