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AppendixCNursing Diagnoses
with Defining
CharacteristicsRefer to Chapter 3 Diagnosis, p. 93
Nursing DiagnosisDefining CharacteristicsRelated FactorsActivity intolerance
(actual)Excessive fatigue with
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How to fill out nursing diagnoses
How to fill out nursing diagnoses:
01
Begin by assessing the patient's symptoms, medical history, and current health status. This will help you gather relevant information for the nursing diagnoses.
02
Use a standardized nursing diagnosis handbook or software to identify appropriate nursing diagnoses based on the patient's assessment findings.
03
Each nursing diagnosis should include the problem or health issue, related factors or causes, and defining characteristics or signs and symptoms.
04
Prioritize the nursing diagnoses based on their urgency and impact on the patient's health and well-being.
05
Collaborate with the patient, their family, and the healthcare team to validate the nursing diagnoses and ensure they are accurate and comprehensive.
06
Develop specific and measurable goals for each nursing diagnosis to guide the nursing care plan.
07
Implement evidence-based nursing interventions that are tailored to address each nursing diagnosis and promote the patient's health and recovery.
08
Regularly evaluate the effectiveness of the nursing interventions and reassess the patient's condition to determine if modifications to the nursing diagnoses are needed.
09
Document the nursing diagnoses, goals, interventions, and outcomes in the patient's medical record for communication and continuity of care.
Who needs nursing diagnoses:
01
Registered Nurses (RNs) and Advanced Practice Registered Nurses (APRNs) use nursing diagnoses to provide individualized and holistic care to their patients.
02
Nursing students learn about nursing diagnoses as part of their education and training to develop critical thinking skills and clinical judgment.
03
Interdisciplinary healthcare teams, including physicians, therapists, and social workers, may utilize nursing diagnoses to collaborate in the comprehensive management of patient care.
04
Patients benefit from nursing diagnoses as it ensures that their unique health needs are identified, addressed, and monitored throughout their healthcare journey.
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What is nursing diagnoses?
Nursing diagnoses are clinical judgments about actual or potential health problems made by a nurse.
Who is required to file nursing diagnoses?
Registered nurses are required to file nursing diagnoses.
How to fill out nursing diagnoses?
Nursing diagnoses are filled out by assessing the patient's symptoms, medical history, and conducting physical examinations.
What is the purpose of nursing diagnoses?
The purpose of nursing diagnoses is to identify health problems that can be addressed through nursing interventions.
What information must be reported on nursing diagnoses?
Nursing diagnoses must include patient data, health problems, and possible interventions.
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