A nursing diagnosis is a standardized way of communicating the specific and ultimately measurable problems that nurses observe during their assessment of patients. By using a nursing diagnosis, nurses are able to communicate their observations to other members of the healthcare team in a concise and uniform manner. This allows for better collaboration and overall patient care.
So, what goes into a nursing diagnosis? A nursing diagnosis has three parts: the problem (also known as the “diagnosis”), the etiology (or “related factors”), and the defining characteristics (or “signs and symptoms”). Let’s take a closer look at each of these three parts.
The Problem (Diagnosis)
The problem, or diagnosis, is the actual nurse-observed problem. For example, if a patient comes into the emergency room with chest pain, the nurse’s diagnosis would be “chest pain.” It’s important to note that this part of the nursing diagnosis should be written in unambiguous terms so that there can be no misunderstanding about what problem is being addressed.
The Etiology (Related Factors)
The etiology, or related factors, are those conditions which are either direct causes or predisposing factors for the nurse-observed problem. Continuing with our example from above, possible etiologies for chest pain could include heart disease, high blood pressure, smoking, or stress.
The Defining Characteristics (Signs and Symptoms)
The final part of the nursing diagnosis is the defining characteristics, or signs and symptoms. These are observable manifestations of the problem that can be corroborated by both the patient and nurse. In our chest pain example, some possible defining characteristics could include shortness of breath, anxiety, sweating, or dizziness. By having both the patient and nurse confirm that these Signs and Symptoms are present, it helps to ensure an accurate nursing diagnosis.
Conclusion:
As you can see, writing a nursing diagnosis is not as difficult as it may seem at first glance. By following the three-part structure outlined above—problem/diagnosis, etiology/related factors, and defining characteristics/signs and symptoms—you can be sure to communicate your observations in a clear and concise manner. Doing so will help to improve collaboration with other members of the healthcare team and ultimately lead to better patient care.
