Except for "risk for" which have 2 parts, nursing diagnosis have 3 parts:

1. The NANDA diagnosis label,
2. The "related to" (r/t) portion, and
3. The "as evidenced by" (AEB) portion.

STEPS

Often it helps to look at the NANDA list first, and see if there is one particular diagnosis that seems to fit the situation. Then look up that diagnosis in the Nursing Diagnosis book. Look at their definition, to see if it fits your patient.
Then look for the defining characteristics or evidence: These are the signs and symptoms you have seen in the patient. They will be the "as evidenced by" or AEB of the diagnosis statement.
Next, look for the related factors:
These are the "related to" or R/T part of the statement. Remember, avoid using the medical diagnosis as a "related to" part. However, it may be used as a "secondary to" statement.

Then change it around to make the sentence read: NANDA Diagnosis…RT…AEB…
For example, if my patient has sores on his legs, and he also has Diabetes Mellitus, you might use the statement:
Decreased blood flow and nutrients to tissues of the lower extremities, secondary to Diabetes Mellitus AEB a 2 cm skin lesion on the left great toe, and a 4 cm lesion on the inner aspect of the right ankle."

Nursing diagnoses that are in the "risk for" categories do not need the AEB portion of the statement, since there is no actual evidence. However, you should avoid using too many "risk for" diagnosis. One or two, out of eight to ten, is acceptable.

Assessment abnormalities should always be reflected in the nursing diagnosis, and subjective and objective data. If the assessment data is not there, you have no evidence.

Gradually, with practice, you will find that nursing diagnoses are easier and easier to develop.

GOALS or OUTCOMES:

Next you'll want to develop patient goals or the "patient will" statements. These must be specific, measurable, attainable, realistic, timed, and dated. Collaborate with the patient, to gain cooperation with the planned goals. They should also be measurable, and include a time frame, and a date. Goals should conform to the nursing diagnosis. Make them specific to your patient's problem.

• They should be individualized to your patient, not just "canned" from the book.
• They should be attainable for your patient.
• Then look in the Nursing Diagnosis book for nursing interventions that could be used to assist the patient to attain the goal(s), you have established.
• Next, find the rationale that match the intent of the interventions and goals.
• And finally, evaluate the outcome of the interventions. These statements should match the wording used in the goal column, and be followed by the statement as to whether the goal was "met, partially met, or not met.
• You may use other nursing books, to supplement the information found in the Nursing Diagnosis book. Generally, the "computerized care plan programs" are not acceptable for nursing school.
 

Copyright © 7/1999 - /2007 Tess Pape, PhD, MSN, BSN, RN, CNOR