Help in Writing a Nursing Diagnosis for Student Nurses

Understanding a little of the history of the nursing diagnosis will aid the student in writing the
diagnosis; thus this guide begins by explaining why nursing diagnoses are considered necessary to
patient care. Although the actual directions for writing the nursing diagnosis are in the last two
sections of this article, you will improve your writing skills if you establish a rationale for the writing
your diagnoses and care plans; you can also explain to your instructor why you chose your diagnosis
and subsequent care plan.
The nurse's diagnosis is distinct from the physician's medical diagnosis. The North American
Nursing Diagnosis Associations (NANDA) sets the guidelines for nurses to write nursing diagnoses.
In distinguishing between the nursing diagnosis and the physician diagnosis, NANDA explains that
"A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human
response to actual or potential health problems and life processes."
The explanation continues with an example of "a medical diagnosis of Cerebrovascular Attack (CVA
or Stroke)." The companion nursing diagnosis is "Impaired verbal communication, risk for falls,
interrupted family processes and powerlessness." The nursing diagnosis focuses on the client's
physical response, risks of health problems, and the family's reaction to the client's condition.
Nurses Controlled by Physicians
Some nursing students may wonder why the patient receives two separate diagnoses. An age-old
conflict between nurses and physicians is the explanation. In the earliest days of nursing, the nurse
was literally a handmaiden to the doctor.
M. Berghs, B. Casterle, and C. Gastmans describe the public's poor perception of nurses in 2006
Journal of Medical Ethics article, "Nursing, Obedience, and Complicity with Eugenics: a Contextual
Interpretation of Nursing Morality at the Turn of the Twentieth Century." The authors write, "Before
Florence Nightingale's Notes on Nursing, nursing as a profession was not held in high esteem: a
physician of the time described nurses as: '...dull, unobservant, untaught women; of the best it could
be said that they were kindly and careful and attentive in doing what they were told.' "
The authors add that "The dominant public perception of nurses during Nightingale's time was that
they were either drunks or prostitutes, for a "refined woman" would never be allowed to work
outside of the home." In the early 20th century, the nurse worked for the physician and commanded
little power, authority or respect.
Nurses and College Degrees
But in 2010 Laura Stokowski protested the assertion "Physicians are nurses' superiors in the
hospital hierarchy - nurses 'work for' physicians." Stokowski wrote in the Medscape article, "A Letter
to Hollywood: Nurses are not Handmaidens" that it is "Not true" that nurses work for physicians.
She adds that "Nursing is a separate, autonomous profession. We work with, not for physicians. We
have our own leaders, and we regulate, license, and manage ourselves. Nurses decide what nurses
do, not physicians." Establishing a separate diagnosis is a part of maintaining separation of the two
practices.
The nursing diagnosis is also a response to individuals like Minette Marrin, author of November

2009 Sunday Times article, "Oh Nurse, Your Degree is a Symptom of Equality Disease." Marrin
complains that "Nurses -- or rather those who claim to represent them -- want to have the status of
professionals, on a level with doctors." Writes Marrin, "part of being a professional is having a
degree. So nurses must have degrees."
Nurses Fighting for Respect
Marrin opposes a mandate for degreed nursing and complains, "All sorts of people who might make
excellent nurses will be put off, and lost to nursing: anyone who is not particularly academic; anyone
who -- frankly -- is not particularly bright; anyone who has a vocation to care for patients without
wishing for the most high-tech training; anyone who is unable to take on a mass of student debt on a
nurse's poor pay; any late entrants -- and this at a time when the NHS (National Health Service on
Britain) is desperately short of nurses."
The counter-argument is that without high-tech training, a nurse in the 21st century cannot provide
competent care. Nurses must understand the medical technologies and life-support systems that
sustain their clients. Nurses require advanced knowledge and medical training to save patient's lives
and respond to medical emergencies.
Writing a Nursing Diagnosis Statement
Returning to the subject of writing the nursing diagnosis, it has three main parts: health problem, a
"related to" (r/t) phrase or etiology and the "as evidenced by" phrase which is followed by the signs
or symptoms you observe during assessment.
1. Find a list of NANDA-approved diagnoses. You can use reference books that list medical diagnoses
alongside the related nursing diagnoses to save time.
2. After choosing a NANDA diagnosis, follow it with "related to" followed by the associated factors.
The related factors are the physiological processes that produce the symptoms. A Mendicino College
Powerpoint entitled "The Nursing Diagnosis Statement" uses the following example:
Etiology (r/t statement) - "poor blood flow due to congested veins and arteries and cellular damage
in tissues"
Health problem - "ineffective tissue perfusion"
After the related to (r/t) phrase, you will list factors that are related to the condition. These factors
define the medical condition; for example, instead of writing the medical diagnosis of congestive
heart failure, the nurse writes "poor blood flow due to congested veins and arteries and cellular
damage in tissues."
3. Write the "As evidenced by" statement followed by the sign and symptoms you observed during
the assessment. Let's assume that your client has a capillary refill time of 5 seconds; this is one of
the signs of congestive heart failure (CHF).
Below is a completed nursing diagnosis for the medical diagnosis of congestive heart failure:
Ineffective tissue perfusion related to poor blood flow due to congested veins and arteries as
evidenced by capillary refill time of 5 seconds.

Tips for Writing the Nursing Diagnosis Statement

Begin your statement with a NANDA-approved nursing diagnosis; otherwise, no matter how well
reasoned the diagnosis, the instructor is likely to disapprove. The Mendocino College Powerpoint
presentation "The Nursing Diagnosis Statement," uses the following example:
Incorrect diagnosis--poor sleep patterns
NANDA approved/correct nursing diagnosis--sleep pattern, disturbed
Follow the first part of diagnosis with the "related to" statement. Galanes & Gualnick list the
following related factors for a diagnosis of disturbed sleeping patterns:
- Pain/discomfort
- Environmental changes
- Anxiety/fear
- Depression
- Medications
- Excessive or inadequate stimulation
- Abnormal physiological status or symptoms (dyspnea, hypoxia, neurological dysfunction, and
others)
- Normal changes associated with aging
R/T - Related to - Describe the physiological processes that cause the signs and symptoms.
AEB - As evidenced by - List signs and symptoms following this phrase.
Secondary to - Write the medical diagnosis after this statement. You may not have to include this
statement because some instructors prefer no mention of medical diagnoses in the nurse's diagnosis.
Check with your instructor.
A completed nursing diagnosis for a patient in the hospital who complains, "I can't sleep for all the
noise and lights in this hospital" might look like this:
Disturbed sleeping pattern r/t environmental changes AEB patient's statement "I can't sleep for all
the noise and lights in this hospital."
In prioritizing your diagnoses, consider that (1) an actual injury or illness takes priority over a risk of
injury or illness (2) A threat to airway, breathing, or circulation will be your highest priority
diagnosis.
Search the Internet for helpful websites, but ensure that you utilize sites that provide reliable, wellresearched information.

Nurses struggle for recognition among healthcare professionals and the public. Although the
nursing diagnosis may seem redundant, it is part of this struggle, and a required subject in nursing
schools. Student nurses who master the basic principles of writing the nursing diagnosis statement
will appreciate the benefits to their school work.
Sources
Galanes, S, Gulanick, N. "Nursing Diagnosis, Care Plans." Elsevier.
Lyer, Patricia. Nursing Malpractice. Tucson, Arizona: Lawyers and Judges. 2001
Mendicino College Powerpoint. "The Nursing Diagnosis Statement."
Stokowski, Laura. "A Letter to Hollywood: Nurses are not Handmaidens." Medscape. 2010.
Kansas State University. The Nursing Process.
Porterville College. Nursing Process, Nursing Fundamentals.

NANDA. Nursing Diagnosis Frequently Asked Questions.

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