Nursing Diagnosis

The nurse develops a nursing diagnosis after analyzing information gained from assessing the patient. A nursing diagnosis is a statement that describes the patient's actual or potential response to a health problem that the nurse is licensed and competent to treat. The North American Nursing Diagnosis Association (NANDA) developed a guide used by many nurses to arrive at a nursing diagnosis.

A physician or advanced practitioner uses the medical diagnosis to prescribe a treatment for combating the disease. This might involve medication and/or a change in the patient's lifestyle. A nurse uses the nursing diagnosis to develop a comprehensive quality care plan to restore the patient to a state where the patient can return to activities of normal living.

For example, a physician might diagnose a patient as having diabetes and prescribes glucose monitoring and insulin injections to control the disease. The nursing diagnosis might be a knowledge deficit about the disease and the medications to treat it. The nurse teaches the patient how to monitor glucose and give injections as well as how to identify adverse side effects of the medication and of the disease. Furthermore, the nurse determines if the patient has the financial, social, and mental capacity to self-medicate. The nurse then develops a plan to enlist the healthcare team to assist the patient if the patient lacks the capacity.

The nursing diagnosis consists of a problem statement that identifies the potential or actual health problem that the nurse is licensed and accountable to treat. A nursing diagnosis may also include the cause of the problem—such as alteration in mobility related to right sided paralysis—which are factors related to or associated with the patient's problem and symptoms that manifested the problem.

A common nursing diagnosis related to drug therapy might be:

• Knowledge deficit of disease and medication related to inability to understand English

This occurs when the patient doesn't understand the language used by healthcare professionals such as when healthcare is provided in English and English is the patient's second language.

• Risk for injury related to side effects of drug

The patient may be given medication such as narcotic analgesics for pain that impairs the patient's activities of normal daily life such as driving a car.

Alteration in thought processes related to drug action

Some drugs such as barbiturates, sedatives, and mood-altering medication interrupt the patient's normal thought process, which could confuse the patient (and the patient's family and friends) if they are unaware of such a side effect of the drug.

Constipation related to drug action or side effect

Morphine sulfate and other opioids cause a reduction in intestinal movement resulting in constipation that might make the patient uncomfortable. Knowing this, the nurse might instruct the patient about foods and fluids that might increase intestinal motility such as bran and increased water intake.

• Fluid volume deficit related to drug action

Diuretic medication such as furosemide (Lasix) causes the patient to lose more than the normal volume of fluid in an effort to counteract a disease that results in the retention of fluids. The nurse alerts the patient to the likely increase in urination and also monitors the patient's fluid intake and output to assure that the patient maintains an adequate fluid level.

• Breathing pattern ineffective related to drug side effects

Opioids, such as morphine sulfate, can reduce the patient's breathing to a level where the patient's respiration is no longer effective. It might mean not moving enough air or blowing off too much CO2. The nurse should monitor the patient's respiratory rate on a regular basis.

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