Nursing diagnosis is a cornerstone of effective patient care. It serves as a critical link between patient assessment and the development of individualized care plans. For nurses and healthcare professionals, a strong grasp of nursing diagnoses is essential for delivering quality, evidence-based care. This guide will delve into the fundamental aspects of nursing diagnosis, with a specific focus on the 3 Types Of Nursing Diagnosis that are most frequently utilized in clinical practice.
The Role of Nursing Diagnosis in the Nursing Process
To fully appreciate the significance of nursing diagnosis, it’s important to understand its place within the broader nursing process. The nursing process is a systematic, five-step approach that nurses use to provide patient care. Nursing diagnosis is the second crucial step, following assessment.
The Five Steps of the Nursing Process:
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Assessment: This initial phase involves a thorough evaluation of the patient’s condition. Nurses gather comprehensive data, including vital signs, medical history, physical examinations, and psychosocial assessments. This data collection forms the foundation for the subsequent steps.
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Diagnosis: Based on the data gathered during the assessment, nurses formulate a nursing diagnosis. This is a clinical judgment that identifies actual or potential health problems or life processes. The nursing diagnosis guides the direction of patient care.
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Outcomes Identification and Planning: In this step, nurses develop a patient-centered care plan. This plan outlines specific, measurable, achievable, relevant, and time-bound (SMART) goals and interventions based on the nursing diagnosis.
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Implementation: This phase involves putting the care plan into action. Nurses implement the planned interventions, continuously monitoring the patient’s response and adjusting care as needed.
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Evaluation: The final step involves evaluating the effectiveness of the care plan in achieving the desired patient outcomes. Nurses assess the patient’s progress, determine if the goals have been met, and make necessary modifications to the care plan.
What Exactly is a Nursing Diagnosis?
A nursing diagnosis is more than just identifying a patient’s problem; it’s a standardized, evidence-based statement that describes a patient’s health condition from a nursing perspective. It’s a way for nurses to communicate their clinical judgments clearly and concisely to other healthcare team members, patients, and their families. Rooted in the assessment phase, the nursing diagnosis is the crucial step that leads to the creation of a targeted care plan, enabling measurable patient outcomes.
NANDA International (NANDA-I), the globally recognized authority on nursing diagnosis, defines it as:
“A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.”
Differentiating Nursing Diagnosis from Medical and Collaborative Diagnoses
It is essential to distinguish nursing diagnoses from other types of diagnoses used in healthcare, specifically medical diagnoses and collaborative problems.
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Nursing Diagnosis: As discussed, this focuses on the patient’s response to health conditions. It identifies areas where nurses can independently intervene to help patients achieve their health goals. An example of a nursing diagnosis is Impaired Swallowing. This diagnosis might be made when a nurse observes a patient coughing before swallowing, having difficulty with throat elevation, and reporting a sensation of food being “stuck.”
Examples of Nursing Diagnoses: Risk for Infection, Acute Pain, Deficient Knowledge, Impaired Physical Mobility.
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Medical Diagnosis: This is made by a physician or advanced practice provider and identifies a specific disease, illness, or injury. Medical diagnoses focus on pathology and are used to guide medical treatment. A medical diagnosis for the patient with swallowing difficulties might be Dysphagia secondary to stroke. Medical diagnoses generally remain constant throughout a patient’s illness.
Examples of Medical Diagnoses: Pneumonia, Diabetes Mellitus, Myocardial Infarction, Stroke.
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Collaborative Problems: These are potential or actual health complications that require both medical and nursing interventions. They are often physiological complications that nurses monitor to detect onset or changes in status. An example is Potential Complication: Respiratory Insufficiency. In this case, nurses monitor respiratory status and implement nursing interventions, while physicians may prescribe medications or other medical treatments.
Exploring the Core: The 3 Types of Nursing Diagnosis
While NANDA-I officially recognizes four categories of nursing diagnoses, for practical purposes and clinical relevance, we often focus on three primary types: Problem-Focused, Risk, and Health Promotion diagnoses. These three categories encompass the vast majority of diagnoses nurses encounter and utilize daily in patient care. Syndrome diagnoses, while recognized by NANDA-I, are less frequently used in general practice.
Let’s explore each of these 3 types of nursing diagnosis in detail:
1. Problem-Focused Nursing Diagnosis (Actual Diagnosis)
Problem-focused diagnoses, also known as actual diagnoses, identify existing patient problems that are present at the time of assessment. These diagnoses are based on the presence of defining characteristics – observable signs and symptoms that indicate the presence of the problem. A problem-focused nursing diagnosis has three essential components:
- Diagnostic Label: A concise term or phrase that represents the patient’s problem. Example: Acute Pain.
- Related Factors: These are the factors that are causing or contributing to the problem. They provide context and help guide interventions. Example: related to surgical incision.
- Defining Characteristics: The observable signs and symptoms that provide evidence of the problem. Example: as evidenced by patient report of pain level 7/10, guarding behavior, and increased heart rate.
Example of a Problem-Focused Nursing Diagnosis:
- Nursing Diagnosis: Acute Pain related to surgical incision as evidenced by patient report of pain level 7/10, guarding behavior, and increased heart rate.
2. Risk Nursing Diagnosis
Risk diagnoses identify potential problems or vulnerabilities that a patient does not currently have but is at high risk of developing. These diagnoses are based on the presence of risk factors – conditions or circumstances that increase the patient’s vulnerability. Risk diagnoses are crucial for preventative care. A risk nursing diagnosis has two key components:
- Risk Diagnostic Label: A label indicating the patient is at risk for a particular problem. Example: Risk for Infection.
- Risk Factors: Factors that increase the patient’s vulnerability to the problem. Example: related to surgical wound, invasive procedures, and compromised immune system.
Example of a Risk Nursing Diagnosis:
- Nursing Diagnosis: Risk for Infection related to surgical wound, invasive procedures, and compromised immune system.
3. Health Promotion Nursing Diagnosis (Wellness Diagnosis)
Health promotion diagnoses, also known as wellness diagnoses, focus on a patient’s desire and motivation to improve their well-being and enhance their health. These diagnoses are used when a patient is already functioning effectively but wants to achieve an even higher level of wellness. Health promotion diagnoses emphasize strengths and potential for growth. A health promotion nursing diagnosis has two components:
- Diagnostic Label: Indicates the patient’s readiness to enhance a specific health behavior. Example: Readiness for Enhanced Nutrition.
- Defining Characteristics: Evidence of the patient’s motivation and desire to improve health behaviors. Example: expressed interest in learning about healthy eating, willingness to make dietary changes.
Example of a Health Promotion Nursing Diagnosis:
- Nursing Diagnosis: Readiness for Enhanced Nutrition as evidenced by expressed interest in learning about healthy eating and willingness to make dietary changes.
Syndrome Diagnosis: An Additional Category
As mentioned, NANDA-I also recognizes Syndrome diagnoses. These diagnoses represent a cluster of nursing diagnoses that frequently occur together and are addressed with similar interventions. Syndrome diagnoses are less common than the other three primary types but can be useful in specific clinical situations.
- Example of a Syndrome Diagnosis: Post-Trauma Syndrome, Chronic Pain Syndrome.
Components Essential for Constructing a Nursing Diagnosis
Regardless of the type, a well-written nursing diagnosis incorporates specific components to ensure clarity and guide effective care planning. These components provide a standardized structure for communicating patient needs.
- Diagnostic Label: This is the concise name for the nursing diagnosis, as approved by NANDA-I. It provides a standardized terminology for communication. Examples: Ineffective Airway Clearance, Impaired Skin Integrity.
- Definition: A clear and precise description of the diagnosis, differentiating it from similar diagnoses. Example: For “Impaired Gas Exchange,” the definition is: “Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.”
- Defining Characteristics: Observable cues (signs and symptoms) that indicate the presence of a problem-focused or health promotion diagnosis. Example: For “Impaired Gas Exchange,” defining characteristics might include: abnormal blood gases, cyanosis, and confusion.
- Risk Factors: Factors that increase a patient’s vulnerability to a risk diagnosis. Example: For “Risk for Infection,” risk factors could include: immunosuppression, surgical incision, and invasive devices.
- Related Factors: Factors that contribute to or are associated with a problem-focused diagnosis or syndrome. Example: For “Ineffective Peripheral Tissue Perfusion,” related factors might include: atherosclerosis, smoking, and hypertension.
Formulating Your Nursing Diagnoses: A Practical Approach
Writing accurate and effective nursing diagnoses is a skill that develops with practice. Here’s a step-by-step guide to help you formulate each of the 3 types of nursing diagnosis:
1. Problem-Focused Diagnosis:
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Identify the Problem: Based on your assessment data, pinpoint the patient’s health problem.
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Determine Related Factors: Explore what is causing or contributing to the problem.
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Identify Defining Characteristics: Note the signs and symptoms that confirm the problem is present.
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Write the Statement: Combine these components using the format: Diagnostic Label related to Related Factors as evidenced by Defining Characteristics.
- Example: Impaired Physical Mobility related to pain and stiffness as evidenced by limited range of motion and difficulty ambulating.
2. Risk Diagnosis:
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Identify Potential Problem: Determine what problems the patient is at risk for based on your assessment.
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Identify Risk Factors: List the factors that increase the patient’s risk.
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Write the Statement: Combine these components using the format: Risk for Diagnostic Label as evidenced by Risk Factors.
- Example: Risk for Falls as evidenced by history of falls, weakness, and unsteady gait.
3. Health Promotion Diagnosis:
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Identify Area for Enhancement: Determine the area where the patient is motivated to improve their health.
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Identify Defining Characteristics (Readiness Cues): Note the patient’s expressed desire and actions indicating readiness for improvement.
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Write the Statement: Combine these components using the format: Readiness for Enhanced Diagnostic Label as evidenced by Defining Characteristics.
- Example: Readiness for Enhanced Knowledge related to medication management as evidenced by patient asking questions about medications and expressing interest in learning more.
4. Syndrome Diagnosis:
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Identify the Syndrome: Recognize clusters of diagnoses that commonly occur together.
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Write the Statement: Use the diagnostic label for the syndrome.
- Example: Relocation Stress Syndrome
