How to select the right Nursing Diagnosis - Turn cue clusters into Nursing Diagnoses the easy way.

Do NOT focus on making a Nursing Diagnosis when you should be focusing on Assessing the patient!

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References:
Ackley, B., & Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care. St. Louis: Elsevier.
Carpenito, J. (2013). Nursing Diagnosis: Application to Clinical Practice. Philadelphia: Lippincott.
Doenges, M. E., & Moorhouse, M. F. (2008). Application of nursing process and nursing diagnosis. Philadelphia: Davis.
Potter, P. A., & Perry, A. G. (2014). Canadian fundamentals of nursing (5th ed.). Toronto: Elsevier.


Many students try to make nursing diagnoses the hard way. They make the mistake of jumping to conclusions during the assessment phase. They try to skip cue clustering and just guess at a nursing diagnosis right away instead of doing a thorough assessment. Then end up comparing the defining characteristics that are listed in their handbook for each diagnosis to their patient’s assessment data. Could you imagine going through all of the nursing diagnoses for each patient … Wow! You would never get your assignment done! Plus, if you do that it is likely that you will miss important information and important diagnoses. You might also misdiagnose the patient because you will be tempted to just use the first diagnosis that sort of matches what is going on. Dangerous!

During assessment if you think you know what the diagnosis might be don’t jump to conclusions - make sure you have asked enough questions and gathered enough data to support your inference. It is good to note your inference then ask more questions or collect more data to confirm or exclude your inference.

Always assess your patient first. The easy way to make nursing diagnoses is to assess first, cluster cues, investigate any inferences then identify one or more nursing diagnoses. During your assessment identify any abnormal data. The abnormal data that you collect will often become the defining characteristics in the nursing diagnosis. When you construct a nursing diagnosis you essentially work backwards from the defining characteristics to the diagnostic label, but we will go over the components of nursing diagnoses in another video.

Once you have identified clusters of cues that seem to fit together it is time to think critically about what the problem could be. Match your cue clusters to one or more nursing diagnoses by looking up the ones you think match the assessment data. Then, pick the best nursing diagnoses for your patient.

In the real world it is impossible to find and treat all nursing diagnoses at once, especially when hospital stays are short. Focus on the most important areas for your patient when creating your diagnoses.

Keep in mind that not all of the conclusions you draw from your assessment will lead to a nursing diagnosis. If you have identified information that just does not fit into a nursing diagnosis it is possible that it isn’t meant to. The data could be related to a collaborative problem or medical diagnosis instead.

Don’t panic, you can still have nursing interventions without a nursing diagnosis. For example, you will still give your patient medication for a medical diagnoses that is not the main focus of nursing care.

If you aren’t sure what the differences are between a medical diagnosis, nursing diagnosis and collaborative problem please watch that video. Also, remember that there are many types of nursing diagnoses, including health promotion diagnoses. We will discuss the types of nursing diagnoses in a subsequent video.

Do you have any tips for creating nursing diagnoses from your assessment data? Please share them below.

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