Nursing diagnosis is a cornerstone of modern healthcare, providing a structured approach for nurses to identify, address, and monitor patient health needs. This guide delves into the essential concepts of nursing diagnosis, exploring its definition, purpose, classification, and application within the nursing process. Understanding how nursing diagnoses are manifested by patient signs and symptoms is crucial for effective care planning and positive patient outcomes.
Understanding Nursing Diagnosis
A nursing diagnosis is defined as a clinical judgment concerning a patient’s response to actual or potential health conditions and life processes. This response can be observed in an individual, family, group, or community. It forms the foundation for selecting targeted nursing interventions aimed at achieving specific patient outcomes, for which nurses are accountable. The development of a nursing diagnosis relies on meticulous data collection during the nursing assessment, serving as the linchpin for creating a personalized care plan. It is through careful assessment that the nuances of patient conditions are revealed, as manifested by observable signs and symptoms.
The Significance of Nursing Diagnosis
Nursing diagnoses serve multiple critical purposes within healthcare:
- Educational Tool: For nursing students, formulating diagnoses enhances problem-solving and critical thinking skills.
- Prioritization of Care: It aids in identifying and prioritizing patient needs, guiding nursing interventions accordingly.
- Quality Assurance: Nursing diagnoses contribute to the formulation of expected outcomes, essential for quality assurance and third-party payer requirements.
- Resource Identification: They help pinpoint how patients respond to health challenges and identify available resources to resolve or prevent problems.
- Communication Enhancement: Nursing diagnoses establish a common language for effective communication among nursing professionals and the broader healthcare team.
- Evaluation Framework: They provide a basis for evaluating the effectiveness and cost-efficiency of nursing care.
Nursing Diagnosis vs. Medical Diagnosis vs. Collaborative Problems
It’s essential to distinguish nursing diagnoses from related concepts. The term “nursing diagnosis” can refer to the diagnosis phase of the nursing process itself, or to the diagnostic label assigned to patient problems. For instance, a patient exhibiting restlessness, rapid heart rate, and verbalization of worry might be diagnosed with “Anxiety.” This diagnosis is based on the patient’s response to their health condition and focuses on aspects within the nurse’s scope of practice. These responses are manifested by the signs and symptoms observed during assessment.
In contrast, a medical diagnosis, made by a physician, identifies a disease or pathological condition that only a physician can treat. Examples include Diabetes Mellitus or Pneumonia. Medical diagnoses focus on the illness itself and typically remain constant. Nurses implement physician-prescribed treatments and therapies to address these medical conditions.
Collaborative problems represent potential health issues managed through both independent nursing interventions and physician-prescribed treatments. These situations necessitate collaborative care, with nurses monitoring patient conditions and preventing potential complications.
The key difference lies in focus: nursing diagnoses address patient responses, while medical diagnoses target diseases. Nursing diagnoses are concerned with the patient’s experience of health and illness, as manifested by their physical, emotional, and psychological responses.
Taxonomy II: Classifying Nursing Diagnoses
Nursing diagnoses are systematically classified using Taxonomy II, adopted in 2002 and based on Dr. Mary Joy Gordon’s Functional Health Patterns. This taxonomy organizes diagnoses into three levels: 13 Domains, 47 Classes, and individual nursing diagnoses. Diagnoses are categorized across seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology, and are listed alphabetically by concept.
NURSING DIAGNOSIS TAXONOMY II. Taxonomy II for nursing diagnosis contains 13 domains and 47 classes. Image via: Wikipedia.com
Domains of Taxonomy II:
- Domain 1. Health Promotion: Focuses on health awareness and management.
- Domain 2. Nutrition: Addresses ingestion, digestion, absorption, metabolism, and hydration.
- Domain 3. Elimination and Exchange: Covers urinary, gastrointestinal, integumentary, and respiratory functions.
- Domain 4. Activity/Rest: Includes sleep, activity, energy balance, cardiovascular/pulmonary responses, and self-care.
- Domain 5. Perception/Cognition: Encompasses attention, orientation, sensation/perception, cognition, and communication.
- Domain 6. Self-Perception: Deals with self-concept, self-esteem, and body image.
- Domain 7. Role Relationship: Focuses on caregiving roles, family relationships, and role performance.
- Domain 8. Sexuality: Includes sexual identity, function, and reproduction.
- Domain 9. Coping/Stress Tolerance: Addresses post-trauma responses, coping mechanisms, and neurobehavioral stress.
- Domain 10. Life Principles: Covers values, beliefs, and value/belief/action congruence.
- Domain 11. Safety/Protection: Includes infection, physical injury, violence, environmental hazards, defensive processes, and thermoregulation.
- Domain 12. Comfort: Addresses physical, environmental, and social comfort.
- Domain 13. Growth/Development: Focuses on growth and development across the lifespan.
The Nursing Process and Nursing Diagnosis
The nursing process, a cyclical framework for patient care, consists of five interconnected stages: assessment, diagnosing, planning, implementation, and evaluation. Nursing diagnosis is the crucial second step, relying heavily on data gathered during assessment. Each stage necessitates critical thinking and a deep understanding of nursing diagnoses, including their defining characteristics, related factors, and appropriate interventions. The nursing process provides a systematic approach to patient care, where nursing diagnoses guide the subsequent planning and implementation phases.
Further information on the nursing process can be found in “The Nursing Process: A Comprehensive Guide.”
Types of Nursing Diagnoses
There are four primary types of nursing diagnoses: Problem-Focused (Actual), Risk, Health Promotion, and Syndrome. Each type addresses different aspects of patient health and needs.
TYPES OF NURSING DIAGNOSES. The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.
Problem-Focused Nursing Diagnosis (Actual Diagnosis)
A problem-focused diagnosis, or actual diagnosis, describes a current patient problem identified during the nursing assessment. These diagnoses are supported by defining characteristics, which are signs and symptoms manifested by the patient. Although not inherently more critical than risk diagnoses, actual diagnoses address present health issues requiring immediate attention. They consist of three components: the nursing diagnosis label, related factors (etiology), and defining characteristics.
Risk Nursing Diagnosis
Risk nursing diagnoses identify potential problems that do not currently exist but are likely to develop without nursing intervention. They are clinical judgments based on risk factors that increase a patient’s vulnerability to a health problem. Risk diagnoses are essential for proactive care, allowing nurses to implement preventative measures. They are manifested by the presence of risk factors, not signs and symptoms. The components include the risk diagnostic label and risk factors, connected by “as evidenced by.”
Health Promotion Diagnosis (Wellness Diagnosis)
A health promotion diagnosis, also known as a wellness diagnosis, focuses on a patient’s motivation and desire to enhance well-being. It identifies a patient’s readiness to engage in health-promoting behaviors. For example, “Readiness for Enhanced Breastfeeding” indicates a mother’s willingness to learn and improve breastfeeding practices. These diagnoses are manifested by expressed desire to improve health. They typically include only the diagnostic label, although related factors can be added for clarity.
Syndrome Diagnosis
Syndrome diagnoses represent a cluster of actual or risk nursing diagnoses that are predicted to occur together due to a specific event or situation. They are written as one-part statements with only the diagnostic label. Examples include Rape Trauma Syndrome or Relocation Stress Syndrome. The syndrome itself is manifested by the presence of the associated cluster of diagnoses.
Possible Nursing Diagnosis
Possible nursing diagnoses indicate suspected problems requiring further data collection to confirm or rule out. They are not a formal type of diagnosis like the others, but rather a tool for communication and further investigation. They highlight areas where more assessment is needed to determine the definitive diagnosis.
Components of a Nursing Diagnosis Statement
A complete nursing diagnosis statement typically includes three key components: the problem (diagnostic label), the etiology (related factors), and the defining characteristics or risk factors.
Problem and Definition (Diagnostic Label)
The problem statement, or diagnostic label, concisely describes the patient’s health issue. It usually consists of a qualifier (modifier) and the focus of the diagnosis. Qualifiers add specificity to the diagnostic statement. For single-word diagnoses like “Anxiety,” the qualifier and focus are inherent within the term.
| Qualifier | Focus of the Diagnosis |
|---|---|
| Deficient | Fluid volume |
| Imbalanced | Nutrition: Less Than Body Requirements |
| Impaired | Gas Exchange |
| Ineffective | Tissue Perfusion |
| Risk for | Injury |
Etiology (Related Factors)
The etiology, or related factors, identifies the probable causes or contributing factors to the health problem. Understanding the etiology guides nursing interventions aimed at addressing the root cause of the diagnosis. Etiology is linked to the problem statement using the phrase “related to.”
Risk Factors
Risk factors are used in risk nursing diagnoses instead of etiological factors. They represent vulnerabilities that increase an individual’s risk of developing a health problem. Risk factors are connected to the diagnostic statement using “as evidenced by.”
Defining Characteristics (Signs and Symptoms)
Defining characteristics are clusters of signs and symptoms that indicate the presence of an actual nursing diagnosis. They are observable cues that validate the diagnosis and are linked to the problem statement using “as evidenced by” or “as manifested by.” In risk diagnoses, risk factors serve a similar validating role, as the problem is potential rather than present. These characteristics are the observable evidence of the patient’s condition, as manifested by objective and subjective data.
The Diagnostic Process: A Step-by-Step Approach
The diagnostic process involves three phases: data analysis, problem identification, and diagnostic statement formulation.
Analyzing Data
Data analysis includes comparing patient data to established standards, clustering related cues, and identifying any gaps or inconsistencies in the data.
Identifying Health Problems, Risks, and Strengths
Following data analysis, nurses identify potential actual, risk, and possible diagnoses. This step involves differentiating between nursing diagnoses, medical diagnoses, and collaborative problems. Crucially, patient strengths, resources, and coping abilities are also identified at this stage.
Formulating Diagnostic Statements
The final step is formulating clear and concise diagnostic statements that accurately reflect the patient’s health status and contributing factors.
Writing Effective Nursing Diagnosis Statements: The PES Format
Nursing diagnosis statements can be written using the PES format, which stands for Problem, Etiology, and Signs/Symptoms. This format can be adapted into one-part, two-part, or three-part statements depending on the type of diagnosis.
PES FORMAT. Writing nursing diagnoses using the PES format.
One-Part Nursing Diagnosis Statements
Health promotion and syndrome diagnoses are typically written as one-part statements, as related factors are often inherent in the diagnosis itself or are consistently “motivated to enhance wellness.”
Two-Part Nursing Diagnosis Statements
Risk and possible nursing diagnoses use two-part statements: the diagnostic label and the validation (risk factors for risk diagnoses). Signs and symptoms are not applicable to these types of diagnoses.
Three-Part Nursing Diagnosis Statements
Actual or problem-focused nursing diagnoses use three-part statements, the PES format: Problem (diagnostic label), Etiology (“related to”), and Signs and Symptoms (“as evidenced by” or “as manifested by“). This comprehensive format clearly articulates the patient’s problem, its contributing factors, and the evidence supporting the diagnosis. The phrase “as manifested by” is particularly useful in highlighting the observable clinical evidence that confirms the nursing diagnosis.
Nursing Diagnosis for Care Planning
Nursing diagnoses are fundamental to developing individualized nursing care plans. They provide a structured framework for addressing patient needs and guiding nursing interventions.
See also: Nursing Care Plans (NCP): Ultimate Guide and List
Recommended Resources for Nursing Diagnosis
Several excellent resources are available to further enhance understanding and application of nursing diagnoses:
- 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
- All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
See also
Other helpful resources on nurseslabs.com:
References and Sources
- 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.
