Nursing diagnoses are the cornerstone of effective patient care. As a vital step in the nursing process, accurate nursing diagnoses ensure that patient needs are correctly identified and addressed. This guide delves into the essential concepts of nursing diagnosis, with a special focus on the 2 Part Nursing Diagnosis, its significance, components, and application in creating robust nursing care plans.
Understanding Nursing Diagnosis
A nursing diagnosis is a clinical judgment made by a registered nurse about a patient’s response to actual or potential health problems or life processes. It provides the foundation for selecting nursing interventions to achieve specific patient outcomes. Nursing diagnoses are derived from patient data collected during the nursing assessment, enabling nurses to formulate personalized care plans.
The Importance of Nursing Diagnosis
Nursing diagnoses serve several crucial purposes in healthcare:
- Enhancing Critical Thinking: For nursing students, formulating diagnoses sharpens problem-solving and critical thinking skills, essential for effective patient care.
- Prioritizing Care: Nursing diagnoses help nurses prioritize patient needs and direct nursing interventions based on these priorities.
- Outcome Measurement: They facilitate the establishment of expected outcomes, crucial for quality assurance and accountability to healthcare payers.
- Understanding Patient Responses: Nursing diagnoses illuminate how patients respond to health issues and identify patient strengths that can be leveraged for problem resolution.
- Facilitating Communication: They establish a common language among nurses and the broader healthcare team, fostering clear and effective communication.
- Evaluating Care Effectiveness: Nursing diagnoses provide a basis for evaluating the effectiveness and cost-efficiency of nursing care.
Nursing Diagnosis vs. Medical Diagnosis vs. Collaborative Problems
It is critical to differentiate between nursing diagnoses, medical diagnoses, and collaborative problems:
- Nursing Diagnosis: Focuses on the patient’s response to a medical condition. It addresses physical, psychological, and spiritual responses that nurses are qualified and authorized to treat independently. For instance, a patient with pneumonia (medical diagnosis) might have a nursing diagnosis of “Ineffective Airway Clearance” related to increased mucus production.
- Medical Diagnosis: Identifies diseases or pathological states that only physicians or advanced practitioners can treat. Examples include Diabetes Mellitus, Tuberculosis, or Hepatitis. Medical diagnoses guide medical treatment, while nursing diagnoses guide patient care.
- Collaborative Problems: Potential health issues that nurses manage in collaboration with physicians. These conditions require both medical and nursing interventions. Nurses monitor for complications and implement physician-prescribed treatments alongside independent nursing actions.
Nursing diagnoses are patient-centered, addressing responses to health conditions, whereas medical diagnoses are disease-centered, focusing on the pathology itself.
Classification of Nursing Diagnoses: Taxonomy II
The Nursing Diagnosis Taxonomy II provides a standardized classification system. Adopted in 2002 and based on Gordon’s Functional Health Patterns, it organizes diagnoses into a three-level hierarchy:
- Domains (13): Broad areas of health, such as Health Promotion, Nutrition, Elimination and Exchange, Activity/Rest, Perception/Cognition, Self-Perception, Role Relationship, Sexuality, Coping/Stress Tolerance, Life Principles, Safety/Protection, Comfort, and Growth/Development.
- Classes (47): Subcategories within domains, further specifying the area of focus (e.g., within Nutrition, classes include Ingestion, Digestion, Absorption).
- Nursing Diagnoses: Specific diagnostic labels organized alphabetically by concept.
This taxonomy ensures a consistent and structured approach to nursing diagnosis.
The Nursing Process and Diagnosis
Diagnosis is the second step in the five-step nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation). Each step demands critical thinking. Nurses must understand nursing diagnoses, their defining characteristics, related factors, and appropriate interventions.
The nursing process is a systematic approach to patient care, detailed in resources like “The Nursing Process: A Comprehensive Guide.”
Types of Nursing Diagnoses: Including 2-Part Diagnoses
Nursing diagnoses are categorized into four main types, and within these, the concept of a 2 part nursing diagnosis is crucial, particularly for risk and health promotion diagnoses:
1. Problem-Focused Nursing Diagnosis (Actual Diagnosis)
This diagnosis identifies a current problem present at the time of assessment, supported by signs and symptoms. It has three components (PES format):
- Problem (P): The nursing diagnosis label.
- Etiology (E): Related factors contributing to the problem.
- Signs/Symptoms (S): Defining characteristics evidenced by the patient.
Example: “Impaired Physical Mobility related to postoperative pain as evidenced by reluctance to move and verbal report of pain.”
2. Risk Nursing Diagnosis (A Key 2 Part Diagnosis)
A risk nursing diagnosis indicates a potential problem that does not currently exist but is likely to develop without intervention. It’s a 2 part nursing diagnosis, comprising:
- Risk Diagnostic Label: The potential health problem.
- Risk Factors: Factors increasing the patient’s vulnerability.
Crucially, risk diagnoses do not include defining characteristics (signs and symptoms) because the problem has not yet occurred. The two parts are linked by “as evidenced by.”
Example: “Risk for Infection as evidenced by surgical incision and compromised immune system.”
3. Health Promotion Diagnosis (Another Form of 2 Part Diagnosis)
A health promotion diagnosis focuses on a patient’s desire to improve well-being and health. It’s also often a 2 part diagnosis, though sometimes presented as a one-part statement with optional related factors for clarity. The core is:
- Diagnostic Label: Reflecting readiness to enhance health.
- (Optional) Related Factors: Factors influencing the desire for improvement.
Example: “Readiness for Enhanced Nutrition, related to expressed interest in healthy eating habits.” Often, the “related to” part is inherent in the diagnosis itself.
4. Syndrome Diagnosis
A syndrome diagnosis is a cluster of nursing diagnoses predicted to occur together due to a specific event or situation. It is a one-part statement, using only the diagnostic label.
Example: “Rape Trauma Syndrome.”
5. Possible Nursing Diagnosis (Not a True Type, but a Stage in Diagnostic Reasoning)
A possible nursing diagnosis describes a suspected problem requiring further data to confirm or rule out. It is not a formal type but a preliminary step in the diagnostic process.
Example: “Possible Risk for Ineffective Coping related to unknown stressors.” (Requires further assessment to confirm).
Components of a Nursing Diagnosis: Understanding the 2 Parts
A complete nursing diagnosis, especially a 2 part nursing diagnosis and 3-part diagnosis, has specific components:
1. Problem and Definition (Diagnostic Label)
The problem statement, or diagnostic label, concisely describes the patient’s health issue. It usually consists of:
- Qualifier (Modifier): Words adding specific meaning (e.g., Deficient, Impaired, Ineffective, Risk for).
- Focus of the Diagnosis: The health concept being affected (e.g., Fluid Volume, Gas Exchange, Injury).
In 2 part nursing diagnoses, the problem is clearly stated in the diagnostic label.
| Qualifier | Focus of the Diagnosis |
|---|---|
| Deficient | Fluid volume |
| Imbalanced | Nutrition |
| Impaired | Gas Exchange |
| Ineffective | Tissue Perfusion |
| Risk for | Injury |
2. Etiology (Related Factors)
Etiology identifies the probable causes or contributing factors to the health problem. It’s linked to the problem statement with “related to.” In 2 part nursing diagnoses like risk diagnoses, etiology becomes “risk factors.”
Example (3-part): “Deficient Fluid Volume related to excessive vomiting…”
3. Risk Factors (For 2 Part Risk Diagnoses)
Risk factors are crucial in 2 part risk nursing diagnoses. They are factors increasing vulnerability to a potential problem, written after “as evidenced by.”
Example (2-part Risk): “Risk for Falls as evidenced by history of falls and impaired mobility.”
4. Defining Characteristics (Signs and Symptoms)
Defining characteristics are clusters of signs and symptoms indicating an actual problem. They are present in problem-focused (actual) diagnoses, but absent in 2 part risk and health promotion diagnoses. They are written after “as evidenced by” or “as manifested by.”
Example (3-part): “Anxiety related to upcoming surgery as evidenced by restlessness, increased heart rate, and verbalization of worry.”
The Diagnostic Process: Identifying 2 Part Diagnoses
The diagnostic process involves three phases:
- Data Analysis: Comparing patient data to norms, clustering cues, and identifying gaps.
- Problem Identification: Identifying health problems, risks, and strengths. This includes differentiating between nursing, medical, and collaborative problems and recognizing potential 2 part diagnoses like risk diagnoses based on risk factors identified in the assessment.
- Formulating Diagnostic Statements: Creating clear and concise diagnostic statements, including 2 part statements for risk and health promotion diagnoses.
Writing Nursing Diagnoses: Mastering 2-Part Statements
Writing diagnostic statements varies by diagnosis type. The PES format (Problem, Etiology, Signs/Symptoms) is a helpful structure. Understanding how to write 2 part nursing diagnoses is essential for risk and health promotion categories.
PES Format: 1-Part, 2-Part, and 3-Part Statements
- One-Part Statements: Primarily for health promotion and syndrome diagnoses. Example: “Readiness for Enhanced Coping.”
- Two-Part Statements (Key for Risk and Health Promotion):
- Risk Diagnoses: Diagnostic label + Risk factors (“as evidenced by”). Example: “Risk for Infection as evidenced by immunosuppression.”
- Health Promotion Diagnoses: Diagnostic label + (optional) Related factors. Example: “Readiness for Enhanced Breastfeeding.”
- Three-Part Statements: For problem-focused (actual) diagnoses – Problem, Etiology (“related to”), Signs/Symptoms (“as evidenced by”). Example: “Acute Pain related to surgical incision as evidenced by patient report of pain and guarding behavior.”
Focus on 2-Part Nursing Diagnosis:
For 2 part nursing diagnoses, specifically risk diagnoses, remember:
- Clearly state the ‘Risk for’ diagnosis.
- Identify and list the specific risk factors that justify this diagnosis, connecting them with “as evidenced by.”
- Avoid including signs and symptoms, as the problem is potential, not actual.
Nursing Diagnoses for Care Plans
Nursing diagnoses are the foundation of nursing care plans. They guide the selection of interventions and the development of patient-centered goals. A comprehensive list of nursing diagnoses is invaluable for creating effective care plans.
Recommended Resources:
To deepen your understanding and skills in nursing diagnosis, consider these resources:
- Ackley and Ladwig’s Nursing Diagnosis Handbook: An evidence-based guide to care planning.
- Nursing Care Plans – Nursing Diagnosis & Intervention: A comprehensive guide with numerous care plans.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales: A quick reference tool for diagnosis and intervention.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care: Detailed guidance for care planning and documentation.
- All-in-One Nursing Care Planning Resource – E-Book: Care plans across various specialties.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Conclusion
Mastering nursing diagnosis, particularly the nuances of the 2 part nursing diagnosis for risk and health promotion, is fundamental to providing safe, effective, and patient-centered care. By understanding the types, components, and process of formulating nursing diagnoses, nurses can accurately identify patient needs, prioritize interventions, and contribute significantly to positive patient outcomes. Continuous learning and utilization of available resources are key to refining diagnostic skills and enhancing patient care.
References
- Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s Fundamentals of Nursing: Concepts, process and practice. Boston, MA: Pearson.
- Edel, M. (1982). The nature of nursing diagnosis. In J. Carlson, C. Craft, & A. McGuire (Eds.), Nursing diagnosis (pp. 3-17). Philadelphia: Saunders.
- Fry, V. (1953). The Creative approach to nursing. AJN, 53(3), 301-302.
- Gordon, M. (1982). Nursing diagnosis: Process and application. New York: McGraw-Hill.
- Gordon, M. (2014). Manual of nursing diagnosis. Jones & Bartlett Publishers.
- Gebbie, K., & Lavin, M. (1975.) Classification of nursing diagnoses: Proceedings of the First National Conference. St. Louis, MO: Mosby.
- McManus, R. L. (1951). Assumption of functions in nursing. In Teachers College, Columbia University, Regional planning for nurses and nursing education. New York: Columbia University Press.
- Powers, P. (2002). A discourse analysis of nursing diagnosis. Qualitative health research, 12(7), 945-965.
