4.3 Nursing Diagnosis and Care Planning

Nursing diagnosis and care planning are crucial skills for providing effective patient care. These tools help nurses identify and address patient problems, guiding interventions and setting measurable goals. By understanding the components and application of nursing diagnoses, nurses can create comprehensive care plans tailored to each patient's needs.

Care plans are dynamic documents that require ongoing evaluation and adjustment. As patient conditions change, nurses must reassess diagnoses, modify interventions, and track progress towards established goals. This process ensures that care remains patient-centered and responsive to evolving health needs throughout the treatment journey.

Nursing diagnosis components

Purpose and structure of nursing diagnoses

• Nursing diagnosis identifies and prioritizes patient problems addressable through independent nursing interventions
• Guides selection of appropriate nursing interventions and establishment of measurable patient outcomes
• Focuses on patient responses to actual or potential health problems, not medical conditions
• Typically follows PES format (Problem, Etiology, Signs/Symptoms)
  • Problem statement (P) describes patient health issue
  • Related factors (E) indicate causes or contributing factors
  • Defining characteristics (S) list observable signs and symptoms
• North American Nursing Diagnosis Association (NANDA) International provides standardized terminology for consistency

Dynamic nature and application

• Nursing diagnoses form basis for selecting interventions and establishing outcomes
• Require regular reassessment and modification as patient's condition changes
• Clinical judgment about actual/potential health problems of individuals, families, communities
• Used to guide nursing interventions across care settings (hospitals, clinics, home health)
• Examples of common nursing diagnoses:
  • Impaired physical mobility related to joint stiffness
  • Anxiety related to hospitalization
  • Risk for infection related to compromised immune system

Nursing vs medical diagnosis

Key differences in focus and approach

• Medical diagnosis identifies specific disease/condition
• Nursing diagnosis addresses patient's holistic response to health problems
• Physicians make medical diagnoses based on pathophysiology
• Nurses make nursing diagnoses based on physical, emotional, psychosocial assessment
• Medical diagnoses guide physician-prescribed treatments
• Nursing diagnoses guide independent nursing interventions
• Medical diagnoses typically remain constant during treatment
• Nursing diagnoses change frequently based on evolving patient needs/responses

Scope and application

• Nursing diagnoses address problems not directly related to medical diagnosis
  • Knowledge deficits about self-care
  • Ineffective coping with chronic illness
  • Risk for skin breakdown
• Use standardized NANDA terminology for clear communication
• Often complement medical diagnoses to provide comprehensive care
• Examples illustrating differences:
  • Medical diagnosis: Type 2 diabetes mellitus
    Nursing diagnoses: Ineffective health maintenance, Risk for unstable blood glucose
  • Medical diagnosis: Pneumonia Nursing diagnoses: Ineffective breathing pattern, Activity intolerance

Nursing care plan development

Key components and prioritization

• Structured, detailed plan addressing specific patient needs to achieve outcomes
• Five key components:
  1. Assessment data
  2. Nursing diagnoses
  3. Expected outcomes
  4. Nursing interventions
  5. Evaluation criteria
• Prioritize nursing diagnoses considering:
  • Life-threatening conditions
  • Patient safety concerns
  • Patient's expressed priorities
• Establish SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) for each diagnosis
• Align interventions with evidence-based practice and facility policies

Collaborative and individualized approach

• Collaborate with patient, family, healthcare team for comprehensive care
• Individualize interventions to patient's unique needs and preferences
• Include timeline for implementation and evaluation
• Incorporate patient education and discharge planning elements
• Examples of care plan components:
  • Nursing diagnosis: Impaired skin integrity related to prolonged immobility
  • Goal: Patient will demonstrate improved skin integrity within 7 days
  • Interventions:
    • Reposition patient every 2 hours
    • Apply pressure-relieving devices to bony prominences
    • Perform daily skin assessments

Nursing care plan effectiveness

Evaluation process and criteria

• Continuously evaluate care plan to determine intervention effectiveness
• Compare patient's current status to established goals and expected outcomes
• Collect and analyze objective data (vital signs, lab values) and subjective data (patient reports)
• Adjust evaluation frequency based on patient acuity and nature of nursing diagnoses
• Reassess patient and review diagnosis accuracy if goals not met
• Modify interventions as needed based on evaluation findings
• Document evaluation process, patient progress, and care plan changes

Patient-centered evaluation and outcomes

• Involve patient and family in evaluation process
• Identify barriers to achieving desired outcomes
• Promote continuity of care through thorough documentation
• Consider both short-term and long-term patient outcomes
• Examples of evaluation criteria:
  • Pain level reduced from 8/10 to 3/10 on pain scale
  • Patient demonstrates correct insulin administration technique
  • Wound healing progresses without signs of infection