Nursing diagnoses are a standardized language used to describe the client’s health problem and the nurse’s plan of care. This can be done in two ways:
- The nurse completes a nursing assessment that includes identifying client data, performing a focused physical exam and completing subjective data collection (e.g., recording pain scores).
- The nurse uses standardized language to write down this information in the form of an organized list called a nursing diagnosis (aka “Nanda-Approved Nursing Diagnosis”).
Nanda Approved Nursing Diagnosis
1. Acute pain related to tissue ischemia secondary to external compression of the popliteal artery by the meniscus
- Acute pain related to tissue ischemia secondary to external compression of the popliteal artery by the meniscus.
- Low oxygen supply to tissues resulting in tissue damage, which causes pain and reduces mobility.
- Nervous system response: Pain is a sensation that occurs when specialized nerve endings called nociceptors are stimulated by mechanical, thermal or chemical means; it can be characterized as sharp (fast) or dull (slow).
- What causes this condition? This condition occurs when pressure on the area where your knee bends compresses a major artery that provides blood flow through the leg; this can cause swelling around your leg and foot along with pain.
- How long will I be in pain? The amount of time you experience symptoms depends on whether you have an acute injury such as an ankle sprain or a chronic injury such as osteoarthritis that has progressed over years.
2. Risk for infection related to the presence of a foreign body and disruption of skin integrity
- Risk for infection related to the presence of a foreign body and disruption of skin integrity
The presence of a foreign body is defined as an object or substance that has been introduced into the body by an artificial or traumatic route, or remains in place after its natural route of elimination. Examples include: objects such as bullets and broken glass; infected tissue removed during surgery; sutures used to close wounds on internal organs; allografts (tissue transplanted from one individual to another); prostheses (artificial devices used externally). Disruption of skin integrity refers to any interruption in the normal structure or function of the integumentary system. Examples include: cuts, burns, scrapes and abrasions sustained during medical procedures such as surgery or radiation therapy; bedsores from immobility; pressure ulcers resulting from positioning without adequate support beneath bony prominences like ankles and heels when sitting/lying down for long periods due to illness/injury requiring hospitalization
3. Alteration in tissue perfusion related to decreased blood flow through the popliteal artery
This diagnosis is an alteration in tissue perfusion related to decreased blood flow through the popliteal artery. Decreased blood flow can lead to pain and damage to the soft tissues of the lower leg, which may result in hypoxemia (lack of oxygen), ischemia (reduced supply of nutrients and oxygen), or necrosis (premature cell death). The popliteal artery is compressed by the meniscus during knee flexion. When this happens, pain occurs as a symptom of tissue ischemia at rest or with activity; it also causes muscle weakness and swelling. Pain from popliteal artery compression can be treated non-surgically with exercise restriction, physical therapy modalities such as ultrasound or electrical stimulation therapy; some patients may require surgery if conservative measures fail to provide relief.
4. Chronic pain related to repeated microtrauma to soft tissue secondary to retinaculum overuse
Pain is a common symptom of chronic overuse. Pain is not a diagnostic finding, it’s a sign of an underlying problem. It’s not possible to diagnose pain and therefore this diagnosis cannot be used as such.
However, it is important to note that pain can be used as a diagnostic tool when it persists and causes dysfunction beyond what would be expected for the nature of the injury (e.g., if you have severe pain in your knee after getting out of bed in the morning). Pain should also always be assessed for its location, intensity and quality (e.g., sharp vs dull), time course (e.g., constant vs intermittent) and duration (e.g., sudden onset vs gradual onset).
5. Risk for impaired skin integrity related to surgical incision and prolonged use of special equipment
- Incisional wound and skin disorders are common complications of medical procedures, particularly those involving surgical incisions.
- Risk for impaired skin integrity is increased when patients have a weakened immune system or nutritional deficiencies.
- To prevent or reduce risk for impaired skin integrity, nurses should:
- Monitor the status of surgical incisions during treatment and healing.
- Teach patients about appropriate care for their wounds, including appropriate dressing changes and pain management techniques. This will help ensure that patients receive adequate care without compromising their safety (e.g., by delaying treatment).
- If you suspect that a patient’s wound has become infected or otherwise compromised, seek immediate assistance from your supervisor before beginning any procedures using special equipment near the area in question.
6 These are a sample of nursing diagnoses.
Nursing diagnoses are used to identify the patient’s problems, plan care, evaluate the effectiveness of your care plan, and assess the patient’s progress.
Nursing diagnoses are organized in a hierarchical format that facilitates problem identification and resolution. Each nursing diagnosis has been carefully selected from an extensive list of general nursing diagnoses that accurately describes clinical situations encountered by nurses today. All nursing diagnoses have been reviewed by experts in their respective fields to ensure they accurately reflect current practice standards.
The NANDA-I nursing diagnoses are a great resource for nurses to use when they are working with patients. They provide a set of standardized nursing diagnoses that allow you to easily communicate your assessment findings with other nurses and doctors. The diagnoses can be used in any setting where there is an acute care setting available, including hospitals, clinics or private practices.