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How To Use A Nursing Diagnosis Handbook
As an intro to The Nursing Care Plan series I am creating, I figured I would begin by explaining how to use a nursing diagnosis handbook.
It is a straightforward process, but it is important to understand how to fully utilize the nursing diagnosis handbook.
It will be your best friend while creating nursing care plans! These nursing diagnosis handbooks help enormously with the task of creating nursing care plans.
So how do we use this nursing diagnosis handbook? I am going to lay it out step by step for you!
Before you read on be sure to review the nursing process to get the most out of this post.
Assessment
The first thing you will need to do is assess your patient during your clinical rotations. Complete a full head-to-toe assessment and take note of all the pertinent information. Gather as much information as you can about your patient- pretend you are a detective who is investigating a case and trying to gather as much information as possible.
For the sake of illustration, let’s say you find the following abnormal findings when assessing your patient:
- Admitted for COPD exacerbation
- Oxygen at 2L via nasal cannula- 91% oxygen saturation
- Dyspnea upon exertion
- Audible wheezing
- Non-productive cough
- Stage 1 to right heel
- Abrasion to left elbow, left shoulder, and above left eyebrow after a fall at home
- +1 pitting edema to ankles
- Hx: diabetes mellitus II, heart failure, COPD, kidney disease
As you can probably tell, I am choosing to focus on the respiratory system for this specific example, so I have kept the list of assessment data to a minimum. When you complete your assessment, you will likely have a lot more data to sort through (assessment findings, medications, labs, etc.)
Once you have all your information, you can crack open your book and begin creating your nursing diagnosis.
Creating the diagnosis
The first section to focus on is what is titled in my handbook as the “Guide to Nursing Diagnoses”. This section is “an alphabetical listing of client symptoms, client problems, medical diagnoses, psychosocial diagnoses, and clinical states” (Ackley and Ladwig, 2014). This section lists possible nursing diagnoses for problems or diagnoses your patient has.
In our example, we can look at the symptom dyspnea and the diagnosis COPD to see what diagnoses are suggested.
When we search these terms, we find the following:
There are quite a few diagnoses to choose from!
Do they all apply to our patient?
Not necessarily. We must use our assessment data to decide which of the suggested diagnoses are applicable to our patient.
Let us look at some of the suggested nursing diagnoses for “COPD” and see which of the suggested diagnoses are applicable to our patient.
Activity Intolerance- it is reasonable to conclude our patient is experiencing activity intolerance as the patient experienced dyspnea upon exertion during our time with the patient. Our patient experienced shortness of breath when ambulating in the room, his respirations rose to 34 during toileting, and his oxygen saturation drops to 85-88% during activity. This seems like an appropriate diagnosis.
Interrupted Family Process- During conversations with our patient we asked about his family and he gave no indication that there were any current issues. He is a retired plant worker who lives with his wife. They have 2 children and 5 grandchildren. All his family is excited for him to return home once he feels better. He has been admitted to the hospital in the past for COPD exacerbations and states his family is understanding and supportive of his chronic condition. This does not seem to be an appropriate diagnosis.
Sleep Deprivation- When we asked our patient if he was getting plenty of rest at night, he stated that he was unable to sleep much the past few nights due to his breathlessness. He had several pillows propping him up in bed but said he would much rather sleep in a recliner. He only got a total of 3 hours of sleep the previous night, per his report, and took several cat naps throughout the day. This seems like an appropriate diagnosis.
Impaired Social Interaction- Throughout the time with our patient, he seemed to be in good spirits and was always very talkative despite his shortness of breath. He often would take several pauses throughout conversation, but he always had plenty to talk about and loved to cut up. He mentioned he is highly active in his church and had many visitors throughout the day. This does not seem like an appropriate diagnosis.
You can see that when evaluating whether a diagnosis is applicable to our patient, we focus on the assessment data. Therefore, the assessment data you collect during your interactions with your patient is so important. It is also important to note that a lot of the data we are referencing were not all “signs and symptoms” as you might naturally think. We use data such as the patient’s family dynamics and sleep patterns. This is why it is crucial that you talk to your patients.
Once you have decided which nursing diagnosis is appropriate for your patient you will begin forming the full diagnosis. Thankfully, our handy dandy handbook helps us out a lot in this department, as well.
In my handbook this section is titled “Guide to Planning Care”. This section contains all the nursing diagnosis and related information.
Let us look at the nursing diagnosis “Activity Intolerance” since we decided it would be an appropriate diagnosis for our patient.
The first section we see here has a definition, defining characteristics, and related factors. The defining characteristics and related factors are two extremely helpful subsections to help us create our nursing diagnosis.
Think of the defining characteristics as the signs and symptoms that a patient exhibits that would justify labeling them with the nursing diagnosis in question. For this example, we see characteristics such as exertional dyspnea, verbal report of fatigue, verbal report of weakness, etc. These characteristics are your “evidence” that you could include to support the diagnosis of activity intolerance.
The related factors (or related/to) are the possible factors that have caused the patient to be experiencing the problem in question. In terms of our nursing diagnosis, it is the etiology. In this example, they list bed rest, generalized weakness, immobility, imbalance between oxygen supply/demand etc. as possible factors causing a patient to experience activity intolerance.
As before with the suggested nursing diagnoses, these are suggestions. Not all the defining characteristics and related factors will be applicable to your individual patient. You must choose what is most appropriate for your patient, again, based on the assessment data.
For our patient, the following is a potential nursing diagnosis:
Activity intolerance r/t imbalance between oxygen supply and demand AEB dyspnea upon exertion, increased respirations of 34 breaths per minute when walking to the restroom, decreased oxygen saturation (85-88%) during activity, patient experiences shortness of breath during casual conversation, patient stated “I get so winded after the simplest activities”
You will notice that I included some examples from the handbook as well as the assessment data to create the “as evidenced by” portion of the diagnosis. It is acceptable (and encouraged) to use inspiration from the handbook (as long as it applies to the patient).
Now that the diagnosis is complete, we can move onto the planning phase.
Begin planning
The step of planning includes creating the goals for the patient and listing out nursing interventions that the nurse can implement.
Goals
If you turn your attention to the section labeled “Nursing Outcome Classification”, you will see recommendations for your goal/outcome for the “activity intolerance” diagnosis.
For this example, an appropriate goal for our patient could be the suggested outcome “Activity Tolerance AEB oxygen saturation during activity remains above 90%, patient does not report fatigue with ADLs, patient walks to bathroom without experiencing dyspnea (respirations do not increase above 22 respirations), patient can carry on a conversation without getting short of breath”.
This part of creating a care plan is pretty straight forward, so I won’t spend too much time on this area. Just be aware that this section can offer you ideas if you are struggling to create an appropriate goal for your patient.
Nursing Interventions
The next section to focus on is labeled “Nursing Interventions Classification”. This must be my favorite part of this handbook. When I was in nursing school, we had to write 10 nursing interventions for each nursing diagnosis, so the long list of nursing interventions included in this handbook really felt like the motherload!
As you might imagine, there are a lot of interventions included in this list that will not apply to your individual patient. The best approach is to read through each intervention until you find one that is appropriate for your patient.
For our example, the following would be one of many appropriate nursing interventions:
“The nurse will monitor and record the client’s ability to tolerate activity when it occurs. The nurse will assess dyspnea, reports of fatigue, skin color, and oxygen saturation.”
Your nursing instructors will let you know how many interventions to list, so simply sort through the interventions until you meet your required amount. If your instructors require you to list a rationale for each intervention, then simply explain how each nursing intervention is relevant and helpful to the problem your patient is experiencing.
Conclusion
That pretty much wraps up how to use a nursing diagnosis handbook to help create a bomb nursing care plan! The steps of implementation and evaluation are not something that the handbook can really assist with.
I hope this was helpful! Please reach out to me if you have any questions. 🙂
Happy Nursing!
References:
“Guide to Nursing Diagnoses.” Nursing Diagnosis Handbook: an Evidence-Based Guide to Planning Care, by Betty J. Ackley and Gail B. Ladwig, Mosby Elsevier, 2014, pp. 17–17.