Nursing Care Plan: How to Write a Diagnosis – A Comprehensive Guide

Understanding Nursing Diagnosis in Care Planning

In the realm of healthcare, particularly in nursing, crafting an effective nursing care plan is paramount for delivering patient-centered care. A cornerstone of this plan is the nursing diagnosis, a critical judgment that guides interventions and outcomes. This guide provides an in-depth exploration of how to write a nursing diagnosis within the context of creating robust nursing care plans. We will delve into the definition, purpose, types, and essential components of nursing diagnoses, equipping you with the knowledge to formulate them accurately and effectively.

What is a Nursing Diagnosis?

A nursing diagnosis is defined as a clinical judgment concerning a human response to health conditions, life processes, or vulnerabilities. It applies to individuals, families, groups, or communities. This diagnosis serves as the foundation for selecting nursing interventions aimed at achieving specific patient outcomes, for which nurses are accountable. Nursing diagnoses are formulated based on data gathered during a thorough nursing assessment, enabling nurses to develop personalized care plans.

The Purpose of Nursing Diagnoses in Healthcare

Nursing diagnoses serve several crucial purposes in healthcare settings:

• Enhancing Critical Thinking: For nursing students, formulating diagnoses is an invaluable educational tool, honing problem-solving and critical thinking skills essential for effective patient care.
• Prioritizing Care: Nursing diagnoses facilitate the identification of patient care priorities, guiding nurses in directing interventions based on the most pressing needs.
• Quality Assurance: They aid in the formulation of expected outcomes, which are vital for meeting quality assurance requirements and demonstrating the effectiveness of care to third-party payers.
• Understanding Patient Responses: Diagnoses help healthcare professionals understand how patients or groups respond to actual or potential health issues and life changes, recognizing their strengths and resources for problem resolution.
• Facilitating Communication: Nursing diagnoses establish a common language, fostering clear communication and understanding among nursing professionals and the broader healthcare team.
• Evaluating Care Effectiveness: They provide a basis for evaluating the benefits and cost-effectiveness of nursing care delivered to patients, ensuring optimal resource utilization and patient outcomes.

Nursing Diagnosis vs. Medical Diagnosis vs. Collaborative Problems

It’s essential to differentiate between nursing diagnoses, medical diagnoses, and collaborative problems to understand the nurse’s role in patient care fully.

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. For example, a patient with pneumonia may have a nursing diagnosis of “Ineffective Airway Clearance” related to increased mucus production.

Medical Diagnosis: Identified by a physician or advanced practitioner, it deals with the disease, pathology, or medical condition itself. Only medical practitioners can treat the disease directly. For instance, a medical diagnosis might be “Pneumonia.” Nurses follow medical orders but also address patient responses to this medical condition through nursing diagnoses.

Collaborative Problems: These are potential health complications that nurses monitor and manage using both independent nursing interventions and physician-prescribed treatments. They require a collaborative approach. An example might be “Risk for Complications related to Pneumonia,” such as sepsis, which requires both medical and nursing interventions for prevention and management.

Understanding these distinctions is crucial for nurses to define their scope of practice and contribute effectively to patient care.

Classification of Nursing Diagnoses: Taxonomy II

Nursing diagnoses are systematically classified to provide a standardized framework for communication and practice. Taxonomy II, adopted in 2002 and based on Dr. Mary Joy Gordon’s Functional Health Patterns, organizes diagnoses into a multi-axial system.

Taxonomy II includes three levels:

• Domains (13): Broad areas of health (e.g., Health Promotion, Nutrition, Elimination and Exchange).
• Classes (47): Subcategories within domains (e.g., Health Awareness, Ingestion, Urinary Function).
• Nursing Diagnoses: Specific diagnostic labels.

Diagnoses are coded across seven axes, including diagnostic concept, time, unit of care, age, health status, descriptor, and topology, and are listed alphabetically by concept for easier navigation.

Domains and Classes within Taxonomy II:

• Domain 1: Health Promotion
  • Class 1: Health Awareness
  • Class 2: Health Management
• Domain 2: Nutrition
  • Class 1: Ingestion
  • Class 2: Digestion
  • Class 3: Absorption
  • Class 4: Metabolism
  • Class 5: Hydration
• Domain 3: Elimination and Exchange
  • Class 1: Urinary function
  • Class 2: Gastrointestinal function
  • Class 3: Integumentary function
  • Class 4: Respiratory function
• Domain 4: Activity/Rest
  • Class 1: Sleep/Rest
  • Class 2: Activity/Exercise
  • Class 3: Energy balance
  • Class 4: Cardiovascular/Pulmonary responses
  • Class 5: Self-care
• Domain 5: Perception/Cognition
  • Class 1: Attention
  • Class 2: Orientation
  • Class 3: Sensation/Perception
  • Class 4: Cognition
  • Class 5: Communication
• Domain 6: Self-Perception
  • Class 1: Self-concept
  • Class 2: Self-esteem
  • Class 3: Body image
• Domain 7: Role Relationship
  • Class 1: Caregiving roles
  • Class 2: Family relationships
  • Class 3: Role performance
• Domain 8: Sexuality
  • Class 1: Sexual identity
  • Class 2: Sexual function
  • Class 3: Reproduction
• Domain 9: Coping/Stress Tolerance
  • Class 1: Post-trauma responses
  • Class 2: Coping responses
  • Class 3: Neurobehavioral stress
• Domain 10: Life Principles
  • Class 1: Values
  • Class 2: Beliefs
  • Class 3: Value/Belief/Action congruence
• Domain 11: Safety/Protection
  • Class 1: Infection
  • Class 2: Physical injury
  • Class 3: Violence
  • Class 4: Environmental hazards
  • Class 5: Defensive processes
  • Class 6: Thermoregulation
• Domain 12: Comfort
  • Class 1: Physical comfort
  • Class 2: Environmental comfort
  • Class 3: Social comfort
• Domain 13: Growth/Development
  • Class 1: Growth
  • Class 2: Development

This structured classification aids nurses in selecting the most appropriate diagnosis from a standardized list, ensuring consistency and clarity in patient care documentation and planning.

The Nursing Process and Diagnosis

The nursing process is a systematic approach to patient care, consisting of five stages:

1. Assessment: Gathering patient data.
2. Diagnosis: Analyzing data to identify health problems.
3. Planning: Setting goals and designing interventions.
4. Implementation: Carrying out the planned interventions.
5. Evaluation: Assessing the effectiveness of interventions.

Nursing diagnosis is the second critical step in this process. It requires nurses to use critical thinking to interpret assessment data and select relevant diagnoses. A thorough understanding of nursing diagnoses, their characteristics, related factors, and appropriate interventions is essential for effective nursing practice.

Types of Nursing Diagnoses: Choosing the Right Category

There are four main types of nursing diagnoses, each serving a distinct purpose in care planning:

1. Problem-Focused (Actual) Diagnosis: Describes a current problem identified during patient assessment. It’s supported by defining signs and symptoms. Example: “Acute Pain related to surgical incision as evidenced by patient report of pain at 7/10 and guarding behavior.”
2. Risk Diagnosis: Indicates a potential problem that does not currently exist but is likely to develop if interventions are not implemented. It’s based on risk factors. Example: “Risk for Infection as evidenced by surgical incision and compromised immune system.”
3. Health Promotion Diagnosis: Focuses on a patient’s desire to improve their well-being and health status. Example: “Readiness for Enhanced Nutrition as evidenced by patient expressing interest in learning about healthy eating habits.”
4. Syndrome Diagnosis: Groups a cluster of actual or risk diagnoses that frequently occur together due to a specific event or situation. Example: “Rape Trauma Syndrome.”

Problem-Focused Nursing Diagnosis: Addressing Current Issues

A problem-focused diagnosis is used when a patient presents with an existing health issue at the time of assessment. It’s crucial to identify the defining characteristics (signs and symptoms) that support the diagnosis. These diagnoses are not inherently more critical than risk diagnoses; in some cases, a risk diagnosis may take higher priority.

Problem-focused diagnoses are structured with three components:

1. Nursing Diagnosis Label: The standardized name for the health problem (e.g., Acute Pain).
2. Related Factors: The factors contributing to the problem (e.g., surgical incision).
3. Defining Characteristics: The observable signs and symptoms (e.g., patient report of pain, guarding behavior).

Risk Nursing Diagnosis: Preventing Potential Problems

Risk nursing diagnoses identify vulnerabilities. They are clinical judgments that a problem is likely to develop in the absence of nursing intervention. These diagnoses are based on risk factors – conditions or situations that increase a patient’s susceptibility to a problem. They are proactive and essential for preventive care.

Risk diagnoses consist of two key components:

1. Risk Diagnostic Label: The potential health problem (e.g., Risk for Infection).
2. Risk Factors: The factors increasing the risk (e.g., surgical wound, compromised immune system).

The phrase “as evidenced by” connects the diagnostic label to the risk factors.

Health Promotion Diagnosis: Enhancing Wellness

A health promotion diagnosis is made when a patient expresses a desire to improve their health. It focuses on the patient’s motivation to achieve a higher level of wellness. These diagnoses are about enhancing existing strengths and promoting optimal health.

Health promotion diagnoses typically include:

1. Diagnostic Label: The area of health promotion (e.g., Readiness for Enhanced Breastfeeding).
   • Related factors may be added for clarity but are not always necessary as the motivation for improvement is inherent.

Syndrome Diagnosis: Recognizing Clusters of Diagnoses

A syndrome diagnosis is applied when a cluster of nursing diagnoses are likely to occur together in certain situations. These are also one-part statements, focusing on the syndrome label itself. Example: “Relocation Stress Syndrome.”

Possible Nursing Diagnosis: Investigating Suspected Problems

A possible nursing diagnosis is used when a nurse suspects a problem but needs more information to confirm or rule it out. It indicates a need for further data collection. It’s not a definitive diagnosis but a placeholder for potential issues requiring investigation.

Components of a Nursing Diagnosis Statement: Building Blocks

A well-written nursing diagnosis statement typically includes three components:

1. Problem (Diagnostic Label) and Definition: A concise description of the patient’s health problem.
2. Etiology (Related Factors): The cause(s) or contributing factors to the problem (for actual diagnoses).
3. Defining Characteristics (or Risk Factors for risk diagnoses): The signs and symptoms or risk factors that support the diagnosis.

Problem and Definition: The Diagnostic Label

The problem statement, also known as the diagnostic label, is a standardized term that concisely describes the health issue. It often includes a qualifier (modifier) and the focus of the diagnosis. Qualifiers add specificity to the diagnostic statement.

Etiology: Identifying Related Factors

Etiology, or related factors, identifies the probable causes of the health problem. Understanding etiology is critical because nursing interventions should aim to address these underlying causes. Etiology is linked to the problem statement using the phrase “related to.” Example: “Acute Pain related to surgical incision.”

Risk Factors: Identifying Predisposing Conditions

For risk nursing diagnoses, risk factors are used instead of etiological factors. These are conditions that increase vulnerability to a potential health problem. Risk factors are connected to the diagnostic statement with the phrase “as evidenced by.” Example: “Risk for Falls as evidenced by history of falls and impaired mobility.”

Defining Characteristics: Recognizing Signs and Symptoms

Defining characteristics are the observable signs and symptoms that cluster together to indicate a particular problem-focused diagnosis. For risk diagnoses, defining characteristics are not present; instead, risk factors serve as evidence. Defining characteristics are linked to the diagnostic statement using “as evidenced by” or “as manifested by.” Example: “Impaired Physical Mobility related to pain as evidenced by limited range of motion and reluctance to move.”

The Diagnostic Process: A Step-by-Step Approach

The diagnostic process involves three key phases:

1. Data Analysis: Comparing patient data to norms, clustering cues, and identifying gaps or inconsistencies.
2. Problem Identification: Identifying health problems, risks, and strengths based on analyzed data.
3. Diagnostic Statement Formulation: Creating clear and concise nursing diagnosis statements.

Analyzing Data: Interpretation and Organization

Data analysis involves:

• Comparing Data to Standards: Determining if patient data deviates from expected norms.
• Clustering Cues: Grouping related data to identify patterns and potential problems.
• Identifying Gaps and Inconsistencies: Recognizing missing information or contradictory data that need further investigation.

Identifying Health Problems, Risks, and Strengths: Decision-Making

This stage involves:

• Distinguishing between Nursing, Medical, and Collaborative Problems: Determining the nature of the identified issues.
• Identifying Actual and Potential Problems: Differentiating between current problems and risks for future problems.
• Recognizing Patient Strengths: Identifying resources and coping mechanisms that can be leveraged in the care plan.

Formulating Diagnostic Statements: Articulating the Diagnosis

The final step is to formulate the nursing diagnosis statement, clearly and accurately reflecting the patient’s health status.

How to Write a Nursing Diagnosis Statement: Formats and Examples

Writing effective nursing diagnosis statements is a crucial skill. The format varies slightly depending on the type of diagnosis. The PES format (Problem-Etiology-Signs/Symptoms) is commonly used for problem-focused diagnoses.

PES Format: Problem, Etiology, Signs/Symptoms

The PES format is a structured approach to writing three-part nursing diagnosis statements for problem-focused diagnoses:

• P (Problem): The diagnostic label (e.g., Impaired Physical Mobility).
• E (Etiology): Related factors (e.g., pain).
• S (Signs/Symptoms): Defining characteristics (e.g., limited range of motion, reluctance to move).

One-Part Nursing Diagnosis Statements

Health promotion and syndrome diagnoses are typically written as one-part statements, as related factors are either always the same (health promotion) or inherent in the syndrome itself.

• Example (Health Promotion): Readiness for Enhanced Coping.
• Example (Syndrome): Rape Trauma Syndrome.

Two-Part Nursing Diagnosis Statements

Risk and possible diagnoses are written as two-part statements.

• Risk Diagnoses: Diagnostic label and risk factors, connected by “as evidenced by.” Example: Risk for Infection as evidenced by surgical incision.
• Possible Diagnoses: Diagnostic label and suspected problem, indicating need for more data. Example: Possible Spiritual Distress related to uncertainty about illness (requires further assessment).

Three-Part Nursing Diagnosis Statements

Problem-focused (actual) diagnoses use three-part statements (PES format):

• Diagnostic label, related factors (“related to”), and defining characteristics (“as evidenced by”).
• Example: Acute Pain related to surgical incision as evidenced by patient report of pain at 7/10 and guarding behavior.

Nursing Diagnoses for Care Plans: Practical Application

Nursing diagnoses are the foundation of nursing care plans. They guide the entire care planning process, from setting patient goals to selecting appropriate interventions and evaluating outcomes. By accurately identifying patient problems through nursing diagnoses, nurses can create personalized and effective care plans that address patients’ unique needs and promote optimal health outcomes.

Recommended Resources for Nursing Diagnosis

To further enhance your understanding and skills in writing nursing diagnoses, consider these recommended resources:

• Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care: Known for its evidence-based approach and step-by-step guidance on assessment, diagnosis, and care planning.
• Nursing Care Plans – Nursing Diagnosis & Intervention: Offers a wide range of care plans based on evidence-based guidelines, including ICNP diagnoses and emerging health topics.
• Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales: A quick-reference tool for identifying correct diagnoses and planning efficient patient care, updated with the latest diagnoses and interventions.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care: Provides comprehensive information for planning, individualizing, and documenting care for numerous diseases and disorders, including sample applications and rationales.
• All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health: A comprehensive resource with over 100 care plans across various specialties, focusing on interprofessional patient problems.

See also

• Nursing Care Plans (NCP): Ultimate Guide and List
• The Nursing Process: A Comprehensive Guide

References and Sources

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• 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.