Nursing diagnoses are a cornerstone of effective patient care. They represent a critical step in the nursing process, ensuring that patients receive the highest quality of care tailored to their specific needs. A nursing diagnosis, initiated by registered nurses, describes a patient’s response to their medical condition, forming the foundation for a comprehensive care plan. This “Care Plan Diagnosis List” guides nursing interventions and ultimately aims to achieve the best possible patient outcomes.
According to the North American Nursing Diagnosis Association (NANDA International, Inc.), the leading authority on standardized nursing diagnostic terminology, a nursing diagnosis is defined as:
“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 selecting nursing interventions to achieve outcomes for which the nurse has accountability.”
This definition highlights the crucial role of nursing diagnoses in creating effective care plans, essentially forming the “care plan diagnosis list” that directs patient care.
Common Nursing Diagnoses in Care Plans
Nurses in a busy hospital setting reviewing patient charts
Several nursing diagnoses frequently appear on care plan diagnosis lists across various healthcare settings. While chronic pain is a prevalent example, here are some of the more common diagnoses that inform patient care plans:
- Impaired gas exchange
- Acute pain
- Risk for infection
- Ineffective airway clearance
- Activity intolerance
- Acute confusion
- Anxiety
- Chronic pain
- Impaired skin integrity
- Decreased cardiac output
- Diarrhea
- Ineffective breathing pattern
These diagnoses represent just a fraction of the extensive “care plan diagnosis list” that nurses utilize to address diverse patient needs.
Medical Diagnosis vs. Nursing Diagnosis in Care Planning
It’s essential to differentiate between a medical diagnosis and a nursing diagnosis, especially when developing a “care plan diagnosis list”. A medical diagnosis is established by a healthcare provider (physician, PA, or ANP) and identifies a disease, injury, or condition after evaluating signs and symptoms. A medical diagnosis is a prerequisite for formulating a nursing diagnosis and subsequently, a comprehensive care plan.
Registered Nurses (RNs) are responsible for creating nursing diagnoses, which focus on the human response to health conditions and life processes, rather than the disease itself. This distinction is critical in building patient-centered care plans. While medical diagnoses address what disease a patient has, nursing diagnoses address how that disease is affecting the patient’s life, encompassing physical, emotional, and psychological responses.
For instance, two patients with the same medical diagnosis, such as diabetes, may have different nursing diagnoses on their “care plan diagnosis list”. One patient might have a nursing diagnosis of “Risk for unstable blood glucose level” due to newly diagnosed diabetes and lack of knowledge about self-management. Another patient with long-term diabetes might have a nursing diagnosis of “Chronic pain related to diabetic neuropathy” and “Ineffective coping related to chronic illness”. These individualized nursing diagnoses ensure that care plans are tailored to each patient’s unique needs.
The Nursing Process: The Foundation of the Care Plan Diagnosis List
The nursing process is a systematic approach that underpins the creation and utilization of the “care plan diagnosis list”. Regardless of the healthcare setting, nurses follow these five steps:
- Assessment: This initial step involves gathering and analyzing comprehensive patient data. This includes physiological, psychological, sociocultural, lifestyle, economic, and spiritual information. A thorough assessment is crucial for identifying potential nursing diagnoses for the “care plan diagnosis list”.
- Diagnosis: Based on the assessment data, nurses formulate nursing diagnoses. This clinical judgment about the patient’s health condition forms the core of the “care plan diagnosis list”.
- Outcomes/Planning: Nurses establish patient-centered goals and desired outcomes based on the identified nursing diagnoses. These goals are then integrated into the treatment plan, guided by the “care plan diagnosis list”.
- Implementation: This phase involves putting the care plan into action. Nurses implement and document specific nursing interventions as outlined in the care plan, addressing the diagnoses on the “care plan diagnosis list”. This may include medication administration, patient education, and vital signs monitoring.
- Evaluation: Throughout the nursing process, nurses continuously evaluate the patient’s progress and the effectiveness of the care plan. This ongoing evaluation may lead to adjustments in the care plan and the “care plan diagnosis list” to better meet the patient’s evolving needs.
Diagnostic Axes: Structuring the Care Plan Diagnosis List
To ensure comprehensive and well-structured nursing diagnoses for the “care plan diagnosis list”, NANDA outlines seven diagnostic axes, aligned with the International Standards Reference Model for Nursing Diagnosis. These axes help nurses consider all dimensions of the human response:
Axis 1: Diagnostic Focus
This axis represents the core of the nursing diagnosis – the specific human response being addressed. It is the fundamental concept of the diagnosis and can be a single word or phrase, such as “anxiety,” “impaired mobility,” or “knowledge deficit”. This focus becomes a key element in the “care plan diagnosis list”.
Axis 2: Subject of the Diagnosis
This axis specifies who the diagnosis is about. It could be:
- Individual: A single patient
- Caregiver: A person providing care for another
- Family: A group of related individuals
- Group: A collection of people with shared characteristics
- Community: A population within a specific location
Identifying the subject ensures the diagnosis is appropriately targeted within the “care plan diagnosis list”.
Axis 3: Judgment
The judgment axis involves a descriptor or modifier that clarifies the diagnostic focus. Words like “impaired,” “ineffective,” “readiness for enhanced,” or “risk for” provide essential context and direction for the care plan. This judgment refines the diagnoses on the “care plan diagnosis list”.
Axis 4: Location
This axis specifies the body part or function affected, such as “cardiac,” “respiratory,” “urinary,” or “integumentary”. Location adds precision to the diagnosis within the “care plan diagnosis list”.
Axis 5: Age
The age of the patient is a significant factor in nursing diagnoses. Categories include:
- Fetus
- Neonate
- Infant
- Child
- Adolescent
- Adult
- Older adult
Age-specificity ensures diagnoses on the “care plan diagnosis list” are developmentally appropriate.
Axis 6: Time
This axis describes the duration of the diagnostic focus:
- Acute: Short-term (less than 3 months)
- Chronic: Long-term (more than 3 months)
- Intermittent: Occurring periodically
- Continuous: Uninterrupted
Timeframe helps prioritize and manage diagnoses within the “care plan diagnosis list”.
Axis 7: Status of the Diagnosis
This axis categorizes the type of nursing diagnosis:
- Problem-focused: Addressing an existing problem
- Health promotion: Enhancing wellness
- Risk: Identifying potential problems
- Syndrome: A cluster of diagnoses
Understanding the status is crucial for selecting appropriate interventions from the “care plan diagnosis list”.
Nurses may explicitly or implicitly name these axes when formulating diagnoses for the “care plan diagnosis list”. For instance, “Ineffective airway clearance” implicitly refers to an individual (subject) and a problem-focused status. Utilizing these axes ensures that the “care plan diagnosis list” is comprehensive, specific, and patient-centered.
Types of Nursing Diagnoses for Care Plans
The type of nursing diagnosis included in a “care plan diagnosis list” depends on various patient factors, including their current health status, risk factors, and desire for health improvement. Recognizing these different types is essential for creating effective and targeted care plans.
1. Problem-Focused Nursing Diagnosis
These diagnoses address existing undesirable human responses to health conditions or life processes. They are characterized by defining characteristics (signs and symptoms) and related etiological factors. Problem-focused diagnoses form a significant part of most “care plan diagnosis lists” in acute and chronic care settings.
2. Health-Promotion Nursing Diagnosis
These diagnoses focus on a patient’s motivation and desire to enhance well-being and reach their full health potential. They are applicable to individuals, families, groups, or communities in any health state who express a readiness to improve their health. These diagnoses are increasingly important in preventative care and wellness-focused care plans.
3. Risk Nursing Diagnosis
Risk diagnoses identify vulnerabilities in individuals, families, groups, or communities to develop undesirable human responses to health conditions or life processes. The presence of risk factors is necessary for this type of diagnosis. Risk diagnoses are crucial for proactive care planning and preventing potential health problems, making them a vital component of a comprehensive “care plan diagnosis list”.
4. Syndrome Diagnosis
A syndrome diagnosis represents a cluster of nursing diagnoses that frequently occur together and can be addressed with similar interventions. Syndrome diagnoses streamline care planning when multiple related issues are present. Recognizing syndromes allows for efficient and holistic interventions within the care plan.
NANDA Nursing Diagnosis Examples for Your Care Plan Diagnosis List
The following table provides examples of NANDA nursing diagnoses categorized by domain and class. This list serves as a valuable resource for building a “care plan diagnosis list” that addresses diverse patient needs across environmental, physical, psychosocial, and spiritual dimensions.
| Domain | Class | Examples of Nursing Diagnoses |
|---|---|---|
| Health Promotion | Health Awareness | Sedentary lifestyle |
| Health Management | Frail elderly syndrome, Ineffective health maintenance | |
| Nutrition | Ingestion | Imbalanced nutrition: less than body requirements, Readiness for enhanced nutrition, Impaired swallowing |
| Metabolism | Risk for unstable blood glucose level | |
| Hydration | Risk for electrolyte imbalance, Deficient fluid volume, Excess fluid volume, Risk for imbalanced fluid volume | |
| Elimination and Exchange | Urinary function | Impaired urinary elimination, Functional urinary incontinence, Overflow urinary incontinence, Reflex urinary incontinence, Stress urinary incontinence, Urge urinary incontinence, Urinary retention |
| Gastrointestinal function | Constipation, Risk for constipation, Diarrhea, Bowel incontinence | |
| Respiratory function | Impaired gas exchange | |
| Activity/Rest | Sleep/Rest | Insomnia, Disturbed sleep pattern |
| Activity/Exercise | Risk for disuse syndrome, Impaired bed mobility, Impaired physical mobility, Impaired wheelchair mobility, Impaired sitting, Impaired standing, Impaired transfer ability, Impaired walking | |
| Energy balance | Fatigue, Wandering | |
| Cardiovascular/Pulmonary responses | Activity intolerance, Ineffective breathing pattern, Decreased cardiac output, Ineffective peripheral tissue perfusion | |
| Self-care | Bathing self-care deficit, Dressing self-care deficit, Feeding self-care deficit, Toileting self-care deficit | |
| Perception/Cognition | Attention | Unilateral neglect |
| Cognition | Acute confusion, Chronic confusion, Deficient knowledge, Readiness for enhanced knowledge, Impaired memory | |
| Communication | Readiness for enhanced communication, Impaired verbal communication | |
| Self-Perception | Self-concept | Hopelessness, Readiness for enhanced self-concept |
| Self-esteem | Chronic low self-esteem | |
| Body image | Disturbed body image | |
| Role Relationship | Caregiving roles | Caregiver role strain, Risk for caregiver role strain |
| Family relationships | Dysfunctional family processes | |
| Role performance | Impaired social interaction | |
| Sexuality | Sexual function | Sexual dysfunction |
| Coping/Stress Tolerance | Post-trauma responses | Risk for relocation stress syndrome |
| Coping responses | Anxiety, Ineffective coping, Death anxiety, Fear, Grieving, Complicated grieving, Powerlessness | |
| Neurobehavioral stress | Risk for autonomic dysreflexia | |
| Life Principles | Value/Belief/Action | Readiness for enhanced spiritual well-being, Decisional conflict, Spiritual distress |
| Safety/Protection | Infection | Risk for infection |
| Physical injury | Ineffective airway clearance, Risk for aspiration, Risk for bleeding, Risk for falls, Risk for injury, Impaired dentition, Risk for pressure ulcer, Impaired skin integrity, Impaired tissue integrity | |
| Violence | Risk for suicide | |
| Environmental hazards | Risk for poisoning | |
| Defensive processes | Risk for allergy response | |
| Thermoregulation | Hyperthermia, Hypothermia | |
| Comfort | Physical comfort | Impaired comfort, Nausea, Acute pain, Chronic pain |
| Social comfort | Risk for loneliness | |
| Growth/Development | Development | Risk for delayed development |
This table is not exhaustive but provides a starting point for understanding the breadth of nursing diagnoses relevant to care planning. Nurses should consult the full NANDA-I list for a complete “care plan diagnosis list” resource.
Writing Effective Nursing Diagnoses for the Care Plan Diagnosis List
Alt text: Nurse documenting care plan diagnosis list on a digital tablet.
According to NANDA recommendations, a well-written nursing diagnosis for a “care plan diagnosis list” includes the diagnosis label and related factors evidenced by defining characteristics. Nurses should link the defining characteristics, related factors, and risk factors identified during patient assessment.
A complete nursing diagnosis statement should include these components:
- Diagnosis Label: The standardized name for the diagnosis, reflecting the diagnostic focus and nursing judgment. It represents a pattern of related signs and symptoms.
- Definition: A clear description that differentiates the diagnosis from similar diagnoses.
- Defining Characteristics: Observable signs and symptoms that cluster to indicate a problem-focused or health-promotion nursing diagnosis or syndrome. These can be perceived through senses or communicated by the patient/family.
- Risk Factors: Components specific to risk diagnoses that increase vulnerability to an unhealthy event. These can be environmental, physiological, psychological, genetic, or chemical.
- Related Factors: Factors that appear to be associated with or contribute to the nursing diagnosis. Problem-focused diagnoses and syndromes must have related factors. Health-promotion diagnoses include related factors only for clarification.
To begin writing a nursing diagnosis for the “care plan diagnosis list”, nurses must analyze subjective and objective patient data, identifying patterns and clustering of cues. Hypotheses are then developed based on how these patterns align with the defining characteristics of specific nursing diagnoses. Crucially, the underlying cause or related factors of the patient’s problem must be identified and included in the diagnosis statement. Effective care plans aim to modify or eliminate these related factors.
Documentation is paramount. In today’s healthcare environment, digital charting systems often facilitate the creation of nursing diagnoses directly from assessment documentation, automatically adding them to the patient’s plan of care, ensuring accurate and efficient “care plan diagnosis list” management.
By understanding and effectively utilizing nursing diagnoses and the “care plan diagnosis list”, healthcare professionals can deliver patient-centered, high-quality care that addresses the holistic needs of each individual.
Sources:
NANDA International, Inc.
American Nurses Association
