A nursing diagnosis is a cornerstone of effective patient care. It serves as a critical tool for nurses and the broader healthcare team, guiding personalized interventions and improving patient outcomes.
This comprehensive guide delves into the essential aspects of nursing diagnosis, exploring its pivotal role within the nursing process. We will examine the various types and classifications of diagnoses, and provide practical examples of alterations in health that necessitate diagnostic adjustments. Furthermore, we will detail how to formulate and utilize nursing diagnoses to enhance patient care.
Let’s begin by understanding the foundational nursing process and the strategic placement of diagnosis within it.
The Nursing Process: A Step-by-Step Approach to Patient Care
Before exploring nursing diagnosis in detail, it’s crucial to understand its context within the broader nursing process. Diagnosis is the second of five essential steps that provide a structured framework for nursing care.
Assessment: This initial phase involves a thorough evaluation of the patient. Nurses collect comprehensive data, including vital signs, medical history, psychological assessments, and socioeconomic factors, to gain a holistic understanding of the patient’s condition.
Diagnosis: Following the assessment, nurses analyze the gathered data to formulate a nursing diagnosis. This diagnosis is a clinical judgment that identifies the patient’s health problems and guides the subsequent nursing care plan. This is where recognizing alterations in health becomes crucial for accurate diagnosis.
Outcomes and Planning: In this stage, nurses develop a patient-centered care plan based on the nursing diagnosis. The plan outlines measurable and achievable goals, ensuring that interventions are targeted and effective.
Implementation: This phase involves putting the care plan into action. Nurses implement specific interventions throughout the patient’s care journey, from hospitalization to discharge, continually monitoring and adjusting as needed.
Evaluation: The final step involves evaluating the effectiveness of the care plan against the established goals and desired outcomes. If outcomes are not met, the care plan is revised based on the patient’s evolving needs and alterations in their health status.
Defining Nursing Diagnosis: A Foundation for Patient-Centered Care
As established, nursing diagnosis is a vital step in the nursing process. It represents a structured and evidence-based method for nurses to articulate their professional clinical judgments to patients, nursing colleagues, interdisciplinary team members, and the wider public. Developed from the comprehensive data collected during the assessment phase, the nursing diagnosis is the basis for creating individualized care plans and measuring patient outcomes.
NANDA International (NANDA-I), the globally recognized authority, standardizes nursing diagnoses. NANDA-I defines a nursing diagnosis 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.”
This definition highlights the crucial role of nurses in identifying and addressing patient responses to health issues, emphasizing accountability for achieving positive outcomes.
Distinguishing Nursing Diagnosis from Medical and Collaborative Diagnoses
While nursing diagnosis is central to nursing practice, it’s essential to differentiate it from other types of diagnoses encountered in healthcare: medical diagnosis and collaborative diagnosis.
Nursing Diagnosis: This is the process and the standardized label nurses use to interpret patient data gathered during assessment. These labels are derived from the NANDA-I approved nursing diagnosis taxonomy. For example, observing a patient coughing before swallowing, exhibiting poor laryngeal elevation, and reporting a sensation of “food stuck” could lead to the nursing diagnosis of impaired swallowing. This is an example of diagnosing an alteration in the normal health process of swallowing.
Examples of nursing diagnoses illustrating alterations in health:
- Risk for impaired liver function (identifies a potential alteration in organ function)
- Urinary retention (alteration in elimination)
- Disturbed sleep pattern (alteration in rest)
- Decreased cardiac output (alteration in cardiovascular function)
Medical Diagnosis: Made by physicians or advanced medical practitioners, a medical diagnosis focuses on identifying diseases, medical conditions, or pathological states. This falls within the specialized expertise of medical professionals. Unlike nursing diagnoses, which can evolve with patient conditions, medical diagnoses are generally more permanent and become part of the patient’s long-term medical record.
Examples of medical diagnoses, representing identified diseases or conditions:
- Atrial fibrillation
- Hepatitis
- Chronic kidney disease
- Hypertension
Collaborative Diagnoses: These diagnoses necessitate both nursing and medical interventions, highlighting interprofessional teamwork. Nurses monitor for health problems, while physicians prescribe medications and order diagnostic tests. These often involve complex conditions requiring a combined approach.
Examples of collaborative diagnoses, requiring joint medical and nursing management:
- Respiratory insufficiency
NANDA-I Nursing Diagnosis Classification: Organizing Diagnoses for Clarity
To ensure consistent and organized use of nursing diagnoses, NANDA-I employs a classification system called Taxonomy II. This system, utilized for over two decades, arranges diagnoses into a hierarchical structure with three levels: 13 domains, 47 classes, and 267 distinct nursing diagnoses.
Taxonomy II provides a framework for nurses to locate and apply the most appropriate diagnosis based on patient assessments. The domains represent broad areas of health, while classes narrow down to specific aspects within each domain.
Domains and Classes within NANDA-I 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
Categories of Nursing Diagnoses: Problem-Focused, Risk, Health Promotion, and Syndrome
NANDA-I categorizes nursing diagnoses into four distinct types, each addressing different aspects of patient health and nursing intervention.
Problem-Focused Diagnoses: These diagnoses, also known as actual diagnoses, identify existing patient problems evident during assessment. They are characterized by the presence of defining signs and symptoms. A problem-focused diagnosis includes three components: the diagnostic label, related factors, and defining characteristics. These diagnoses directly address current alterations in health.
Risk Diagnoses: Risk diagnoses are clinical judgments about a patient’s vulnerability to developing health problems if no nursing intervention occurs. They indicate potential future problems based on identified risk factors. Risk diagnoses consist of two components: the risk diagnostic label and risk factors. They are crucial for proactive care, preventing potential alterations in health.
Health Promotion Diagnoses: Also termed wellness diagnoses, these focus on a patient’s motivation and desire to enhance well-being and achieve their full health potential. They reflect a patient’s readiness to improve specific health behaviors and can apply to individuals, families, groups, or communities. These diagnoses support patients in optimizing their health and preventing future alterations in health.
Syndrome Diagnoses: Syndrome diagnoses are less frequent and represent clinical judgments about clusters of nursing diagnoses that typically occur together and are managed with similar interventions. They recognize patterns of alterations in health that often co-exist.
Examples of Nursing Diagnosis Categories:
| Problem Focused Diagnosis | Risk Diagnosis |
|---|---|
| – Decisional conflict | – Risk for chronic functional constipation |
| – Ineffective airway clearance | – Risk for acute confusion |
| – Impaired oral mucous membrane integrity | – Risk for autonomic dysreflexia |
| – Hyperthermia | – Risk for adult falls |
| – Dysfunctional ventilatory weaning response | – Risk for peripheral neurovascular dysfunction |
| Health Promotion Diagnosis | Syndrome Diagnosis |
| – Readiness for enhanced spiritual well-being | – Frail elderly syndrome |
| – Readiness for enhanced coping | – Chronic pain syndrome |
| – Readiness for enhanced self-care | – Disturbed family identity syndrome |
| – Readiness for enhanced parenting | – Relocation stress syndrome |
| – Readiness for enhanced exercise engagement | – Post-trauma syndrome |
Key Components of a Nursing Diagnosis Statement
Formulating a clear and comprehensive nursing diagnosis statement requires specific components. These components may vary slightly depending on the diagnosis type, but generally include:
Diagnosis Label: A concise name that represents the diagnostic focus and the nurse’s clinical judgment.
Examples: ineffective health self-management; acute pain; impaired skin integrity.
Definition: A precise description of the diagnosis, differentiating it from similar diagnoses.
Example: For “imbalanced nutrition: less than body requirements,” the definition is: “intake of nutrients insufficient to meet metabolic needs.”
Defining Characteristics: Observable cues (signs and symptoms) that confirm the presence of a problem-focused, health promotion diagnosis, or syndrome. These can be seen, heard, touched, smelled, or reported by the patient or family. These characteristics are evidence of the alteration in health.
Example: For “impaired gas exchange,” defining characteristics may include: abnormal arterial blood gasses; abnormal skin color (pale, dusky, cyanosis); and headache upon awakening.
Risk Factors: Environmental, physiological, psychological, genetic, or chemical factors that increase a patient’s vulnerability to a health problem. Risk factors are specific to risk diagnoses and highlight potential alterations in health.
Example: For “risk for infection,” risk factors might include: chronic illness (e.g., diabetes); inadequate vaccination; invasive procedures; malnutrition.
Related Factors: Factors that have a connection to the nursing diagnosis. These may be antecedent, associated with, contributing to, or exacerbating the diagnosis. Related factors are primarily used in problem-focused nursing diagnoses and syndromes, and sometimes in health promotion diagnoses. These factors often explain the underlying causes of the alteration in health.
Example: For “ineffective peripheral tissue perfusion,” hypertension is a potential related factor, along with diabetes mellitus, smoking, or sedentary lifestyle.
Writing Effective Nursing Diagnosis Statements: Templates and Examples
To ensure clarity and consistency, NANDA International recommends using specific templates for writing nursing diagnosis statements. These templates vary slightly based on the diagnosis category.
Templates and Examples for Writing Nursing Diagnoses:
-
Problem-focused diagnosis: Use a three-part statement (PES): Problem, Etiology (related factors), and Signs/Symptoms (defining characteristics).
Example: Impaired bed mobility related to musculoskeletal impairment as evidenced by impaired ability to reposition self in bed.
Example: Constipation related to inadequate toileting habits as evidenced by change in bowel pattern.
-
Risk Diagnosis: Use a two-part statement: Risk diagnostic label and Risk factors.
Example: Risk for decreased cardiac output as evidenced by alteration in heart rhythm.
Example: Risk for adult pressure injury as evidenced by Inadequate adherence to incontinence treatment regimen.
-
Health Promotion Diagnosis: Typically a one-part statement, focusing on the desire for enhanced wellness. Can sometimes include “as evidenced by” to indicate patient expressions of readiness.
Example: Sedentary lifestyle as evidenced by insufficient motivation for physical activity.
Example: Ineffective family health self-management as evidenced by difficulty with the prescribed regimen.
-
Syndrome Diagnosis: Usually a one-part statement, simply stating the syndrome name.
Example: Post-trauma syndrome
Example: Chronic pain syndrome
Expanding Your Nursing Diagnosis Vocabulary: Additional Examples
The NANDA-I nursing diagnosis list, with 267 diagnoses, offers a comprehensive resource for nurses. The examples throughout this guide are drawn from the NANDA-I 2021-2023 handbook. Here are additional nursing diagnosis examples to further enhance your ability to develop comprehensive care plans, addressing various alterations in health:
- Decreased activity tolerance
- Risk for surgical site infection
- Deficient knowledge
- Decreased cardiac output
- Deficient fluid volume
- Ineffective coping
- Acute pain
- Ineffective thermoregulation
- Ineffective breathing pattern
- Risk for electrolyte imbalance
- Bathing/dressing/feeding self-care deficit
- Risk for ineffective childbearing process
- Risk for injury
- Fatigue
- Impaired physical mobility
- Ineffective airway clearance
- Readiness for enhanced communication
- Impaired comfort
- Obesity
- Risk for metabolic syndrome
- Disturbed body image
- Deficient community health
- Neonatal hypothermia
- Risk for bleeding
- Risk for vascular trauma
Mastering Nursing Diagnosis: A Critical Skill for Quality Care
Nursing diagnoses are indispensable tools that empower nurses to deliver safe, high-quality, and evidence-based patient care. Understanding how to accurately formulate and utilize nursing diagnoses is a fundamental competency for every nurse. By mastering this critical aspect of patient care, nurses can effectively address alterations in health, promote wellness, and contribute significantly to positive patient outcomes.
