Nursing diagnosis is a cornerstone of modern healthcare, providing a structured approach to patient care. For nursing students and practicing nurses alike, understanding how to formulate a nursing diagnosis statement is crucial for effective care planning and patient outcomes. This guide will delve into the concept of nursing diagnosis, its types, components, and, most importantly, provide clear examples of nursing diagnosis statements to enhance your clinical practice.
What is a Nursing Diagnosis?
A nursing diagnosis is defined as a clinical judgment about individual, family, group, or community responses to actual or potential health problems or life processes. It’s essentially a nurse’s professional interpretation of a patient’s condition, based on comprehensive assessment data. This diagnosis serves as the foundation for selecting nursing interventions and achieving specific patient outcomes for which nurses are accountable. Nursing diagnoses are not simply labels; they are derived from thorough nursing assessments, enabling nurses to create personalized and effective care plans.
Purposes of Nursing Diagnosis
Nursing diagnoses serve several vital purposes in healthcare:
- Enhancing Critical Thinking: For nursing students, formulating nursing diagnoses is an invaluable educational tool. It sharpens problem-solving and critical thinking skills, essential for clinical practice.
- Prioritizing Care: Nursing diagnoses help in identifying and prioritizing patient needs. This prioritization guides the direction of nursing interventions, ensuring that the most critical issues are addressed first.
- Formulating Expected Outcomes: They are instrumental in setting measurable and realistic expected outcomes. This is crucial for quality assurance and meeting the requirements of healthcare payers.
- Understanding Patient Responses: Nursing diagnoses facilitate a deeper understanding of how patients respond to health conditions, whether actual or potential. Recognizing patient strengths and available resources becomes easier, enabling nurses to leverage these for problem resolution and prevention.
- Facilitating Communication: They provide a standardized language for communication among nursing professionals and the broader healthcare team. This common language ensures clarity and understanding in patient care discussions.
- Evaluating Care Effectiveness: Nursing diagnoses form the basis for evaluation, helping to determine if the nursing care provided was beneficial and cost-effective for the patient.
Differentiating Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems
It’s crucial to distinguish between nursing diagnoses, medical diagnoses, and collaborative problems.
A nursing diagnosis focuses on the patient’s response to a health condition. For instance, a patient diagnosed with pneumonia (a medical diagnosis) might experience “Ineffective Airway Clearance” (a nursing diagnosis) due to excessive mucus and difficulty breathing. The nursing diagnosis addresses what nurses can treat independently within their scope of practice.
Medical diagnoses, on the other hand, are made by physicians or advanced practitioners and identify diseases or pathological states that only medical professionals can treat. Examples of medical diagnoses include Diabetes Mellitus, Pneumonia, or Appendicitis. Medical diagnoses remain constant and guide medical treatments like medication and surgery. Nurses implement physician’s orders related to these medical diagnoses.
Collaborative problems are potential or actual health complications that require both medical and nursing interventions. These are often physiological complications of medical conditions. For example, a patient post-surgery is at risk for “Risk for Infection” (nursing diagnosis), but also a collaborative problem of potential surgical site infection requiring medical interventions like antibiotics and nursing interventions like wound care and monitoring. Nurses manage collaborative problems by monitoring for changes in patient status and implementing interventions both independently and in collaboration with physicians.
In essence, nursing diagnoses are patient-centered and focus on responses to illness, while medical diagnoses are disease-centered, and collaborative problems bridge both medical and nursing management.
Classification of Nursing Diagnoses (Taxonomy II)
Nursing diagnoses are systematically classified under Taxonomy II, adopted in 2002 and based on Dr. Mary Joy Gordon’s Functional Health Patterns. This taxonomy provides a structured framework with three levels: Domains (13), Classes (47), and individual nursing diagnoses. Taxonomy II organizes diagnoses into domains and classes, coded across seven axes, including diagnostic concept, time, unit of care, age, health status, descriptor, and topology. Diagnoses are listed alphabetically by concept for easier navigation.
Here’s a brief overview of the 13 Domains:
- Domain 1. Health Promotion: Focuses on awareness and management of wellness.
- 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, rest, activity, exercise, energy balance, cardiovascular/pulmonary responses, and self-care.
- Domain 5. Perception/Cognition: Deals with attention, orientation, sensation/perception, cognition, and communication.
- Domain 6. Self-Perception: Encompasses self-concept, self-esteem, and body image.
- Domain 7. Role Relationship: Focuses on caregiving roles, family relationships, and role performance.
- Domain 8. Sexuality: Addresses sexual identity, function, and reproduction.
- Domain 9. Coping/Stress Tolerance: Covers post-trauma responses, coping mechanisms, and neurobehavioral stress.
- Domain 10. Life Principles: Includes values, beliefs, and value/belief/action congruence.
- Domain 11. Safety/Protection: Addresses infection, physical injury, violence, environmental hazards, defensive processes, and thermoregulation.
- Domain 12. Comfort: Includes physical, environmental, and social comfort.
- Domain 13. Growth/Development: Focuses on growth and developmental milestones.
Understanding this classification helps nurses categorize and select appropriate nursing diagnoses.
Nursing Process and Nursing Diagnosis
Nursing diagnosis is the second critical step in the nursing process, following assessment and preceding planning, implementation, and evaluation. The nursing process is a systematic, patient-centered approach to care. After the nurse assesses the patient and gathers data, the diagnostic phase involves analyzing this data to identify health problems. This analysis leads to the formulation of nursing diagnoses. These diagnoses then drive the planning of care, guiding interventions (implementation) and ultimately the evaluation of the effectiveness of care provided.
The nursing process is iterative, meaning that it’s a continuous cycle of assessment, diagnosis, planning, implementation, and evaluation, constantly adapting to the patient’s changing needs. A strong understanding of nursing diagnoses is essential for each step of this process, ensuring patient-centered and effective care.
Types of Nursing Diagnoses: Detailed Examples
There are four main types of nursing diagnoses: Problem-Focused (Actual), Risk, Health Promotion, and Syndrome. Each type addresses different aspects of a patient’s health status and requires a slightly different approach in formulation.
Problem-Focused Nursing Diagnosis (Actual Diagnosis)
A problem-focused nursing diagnosis, also known as an actual diagnosis, identifies a current problem experienced by the patient at the time of assessment. These diagnoses are supported by defining characteristics – observable signs and symptoms. While actual diagnoses address existing problems, it’s important to recognize that risk diagnoses can be equally or even more critical in preventing potential complications.
Example Of A Nursing Diagnosis Statement (Problem-Focused):
- Problem: Impaired Physical Mobility
- Related Factors: Pain in joints, decreased muscle strength, reluctance to move.
- Defining Characteristics: Limited range of motion, difficulty turning in bed, unsteady gait.
- Full Nursing Diagnosis Statement: Impaired Physical Mobility related to pain in joints and decreased muscle strength as evidenced by limited range of motion, difficulty turning in bed, and unsteady gait.
Other Examples of Problem-Focused Nursing Diagnosis Statements:
- Acute Pain related to surgical incision as evidenced by patient report of pain at 7/10, guarding behavior, and increased heart rate.
- Deficient Knowledge related to new diagnosis of diabetes mellitus as evidenced by patient asking questions about insulin administration and dietary management.
- Ineffective Breathing Pattern related to pneumonia as evidenced by shortness of breath, use of accessory muscles, and abnormal breath sounds.
Risk Nursing Diagnosis
A risk nursing diagnosis describes potential problems that a patient is particularly vulnerable to developing. These diagnoses are not based on current signs and symptoms but on the presence of risk factors that increase the patient’s susceptibility. Risk diagnoses are proactive, allowing nurses to implement preventative measures.
Example of a Nursing Diagnosis Statement (Risk):
- Risk Diagnosis: Risk for Infection
- Risk Factors: Surgical incision, compromised immune system (due to chemotherapy), prolonged hospitalization.
- Nursing Diagnosis Statement: Risk for Infection as evidenced by surgical incision, compromised immune system, and prolonged hospitalization.
Other Examples of Risk Nursing Diagnosis Statements:
- Risk for Falls as evidenced by history of falls, impaired balance, and use of sedatives.
- Risk for Impaired Skin Integrity as evidenced by immobility, incontinence, and poor nutritional status.
- Risk for Unstable Blood Glucose Level as evidenced by inconsistent meal intake, lack of adherence to medication regimen, and insufficient knowledge of diabetes management.
Important Note: For risk diagnoses, the phrase “as evidenced by” connects the diagnostic label to risk factors, not defining characteristics, as the problem hasn’t yet manifested.
Health Promotion Diagnosis
A health promotion diagnosis identifies a patient’s desire and motivation to improve their health and well-being. These diagnoses focus on strengths and readiness to enhance wellness. They are often one-part statements, though related factors can be added for clarity.
Example of a Nursing Diagnosis Statement (Health Promotion):
- Health Promotion Diagnosis: Readiness for Enhanced Nutrition
- Defining Characteristic: Expresses desire to improve dietary habits to enhance health.
- Nursing Diagnosis Statement: Readiness for Enhanced Nutrition as evidenced by expressed desire to improve dietary habits to enhance health.
Other Examples of Health Promotion Nursing Diagnosis Statements:
- Readiness for Enhanced Knowledge related to infant care as evidenced by asking questions and seeking information about newborn care.
- Readiness for Enhanced Self-Care as evidenced by expressing interest in learning new self-care techniques.
- Readiness for Enhanced Family Coping as evidenced by family members expressing willingness to participate in care planning and support the patient.
Syndrome Diagnosis
A syndrome diagnosis is a clinical judgment describing a cluster of nursing diagnoses that frequently occur together due to a specific event or situation. These are also typically one-part statements, using only the diagnostic label.
Example of a Nursing Diagnosis Statement (Syndrome):
- Syndrome Diagnosis: Rape Trauma Syndrome
- Defining Characteristics: Cluster of symptoms following sexual assault, including anxiety, fear, sleep disturbances, and emotional distress.
- Nursing Diagnosis Statement: Rape Trauma Syndrome.
Other Examples of Syndrome Nursing Diagnosis Statements:
- Relocation Stress Syndrome. (Cluster of diagnoses related to stress from moving to a new environment)
- Chronic Pain Syndrome. (Cluster of diagnoses associated with persistent pain)
- Post-Trauma Syndrome. (Cluster of diagnoses following a traumatic event)
Possible Nursing Diagnosis
While not a formal type like the others, a possible nursing diagnosis is used when a nurse suspects a problem but lacks sufficient evidence to confirm it. It indicates a need for further data collection. It’s a temporary label to communicate a potential issue requiring investigation.
Example of a Possible Nursing Diagnosis Statement:
- Possible Diagnosis: Possible Bowel Obstruction
- Reason for Suspicion: Patient reports abdominal pain and distension, has not had a bowel movement in 3 days.
- Nursing Documentation Note (instead of statement): “Possible Bowel Obstruction suspected, further assessment and physician notification needed.”
Components of a Nursing Diagnosis
A well-formed nursing diagnosis typically has three components, especially for problem-focused diagnoses, often referred to as the PES format.
- Problem (Diagnostic Label): A concise term or phrase describing the patient’s health problem or response.
- Etiology (Related Factors): Identifies the probable cause(s) or contributing factors to the problem.
- Defining Characteristics (Signs and Symptoms): Observable cues that cluster together as manifestations of the diagnosis (for actual diagnoses) or risk factors (for risk diagnoses).
Problem and Definition (Diagnostic Label)
The problem statement or diagnostic label is a standardized term from a nursing diagnosis taxonomy (like NANDA-I). It should be concise and clear. Qualifiers or modifiers are words that add specific meaning to the label, except for one-word diagnoses where the qualifier is inherent (e.g., Anxiety).
| Qualifier | Focus of the Diagnosis | Example Nursing Diagnosis |
|---|---|---|
| Deficient | Fluid volume | Deficient Fluid Volume |
| Imbalanced | Nutrition: Less Than Body Needs | Imbalanced Nutrition: Less Than Body Needs |
| Impaired | Gas Exchange | Impaired Gas Exchange |
| Ineffective | Tissue Perfusion | Ineffective Tissue Perfusion |
| Risk for | Injury | Risk for Injury |
Etiology (Related Factors)
The etiology identifies factors contributing to the nursing diagnosis. These are not medical diagnoses but rather conditions or circumstances that influence the patient’s response. Etiology is linked to the problem statement using “related to.” Interventions should ideally address these etiological factors to resolve the underlying cause of the nursing diagnosis.
Example: Ineffective Coping related to situational crises and lack of support systems.
Risk Factors
For risk nursing diagnoses, risk factors are used instead of etiological factors. These are circumstances or vulnerabilities that increase the likelihood of a problem developing. Risk factors are connected using “as evidenced by.”
Example: Risk for Falls as evidenced by history of falls and impaired mobility.
Defining Characteristics
Defining characteristics are the observable signs and symptoms that indicate the presence of an actual nursing diagnosis. For risk diagnoses, these are the risk factors themselves. Defining characteristics are linked using “as evidenced by” or “as manifested by.”
Example: Acute Pain related to surgical incision as evidenced by patient reporting pain of 8/10, guarding incision site, and facial grimacing.
Diagnostic Process: How to Diagnose
The diagnostic process involves three key phases:
- Data Analysis: Comparing patient data to norms, clustering related cues, and identifying any gaps or inconsistencies in the data.
- Identification of Health Problems, Risks, and Strengths: Based on data analysis, identifying actual problems, potential risks, and patient strengths and resources. Differentiating between nursing diagnoses, medical diagnoses, and collaborative problems is crucial here.
- Formulation of Diagnostic Statements: Creating clear and concise nursing diagnosis statements based on the identified problems and supporting data.
Analyzing Data
Data analysis involves organizing and interpreting the assessment data. This includes:
- Comparing data against standards: Identifying deviations from normal health patterns.
- Clustering cues: Grouping related data to identify patterns and potential problems.
- Identifying gaps and inconsistencies: Recognizing missing information or contradictory data that needs further investigation.
Identifying Health Problems, Risks, and Strengths
This step involves clinical judgment to determine the patient’s health status. It requires:
- Problem Identification: Determining the specific health issues the patient is facing.
- Risk Identification: Recognizing potential problems based on risk factors.
- Strength Identification: Acknowledging patient resources and coping mechanisms that can be leveraged in care planning.
- Diagnosis Differentiation: Distinguishing between nursing diagnoses, medical diagnoses, and collaborative problems.
Formulating Diagnostic Statements
The final step is to write the nursing diagnosis statement. This involves using standardized language and following the appropriate format for the type of diagnosis (problem-focused, risk, health promotion, or syndrome).
How to Write a Nursing Diagnosis Statement: Practical Guide
When writing nursing diagnosis statements, focus on describing the patient’s health status and the factors contributing to it. Not all components are needed for every type of diagnosis. The format varies depending on the diagnosis type.
PES Format Explained
The PES format is a common and helpful structure for writing nursing diagnoses, particularly for problem-focused diagnoses. PES stands for:
- P – Problem (Diagnostic Label)
- E – Etiology (Related Factors)
- S – Signs/Symptoms (Defining Characteristics)
One-Part Nursing Diagnosis Statement
Health promotion and syndrome diagnoses are often one-part statements, using only the diagnostic label. For health promotion diagnoses, the related factor is often inherent (motivation to improve wellness).
Examples of One-Part Nursing Diagnosis Statements:
- Readiness for Enhanced Coping
- Rape Trauma Syndrome
- Readiness for Enhanced Spiritual Well-being
Two-Part Nursing Diagnosis Statement
Risk and possible nursing diagnoses are typically two-part statements. The first part is the diagnostic label, and the second is the risk factors (for risk diagnoses) or reason for suspicion (for possible diagnoses). Signs and symptoms are not applicable as the problem is either potential or suspected.
Examples of Two-Part Nursing Diagnosis Statements:
- Risk for Infection as evidenced by weakened immune system response.
- Risk for Injury as evidenced by unstable hemodynamic profile.
- Possible Bowel Obstruction related to reported abdominal pain and distension (needs further data).
Three-part Nursing Diagnosis Statement
Problem-focused (actual) nursing diagnoses are best written as three-part statements using the PES format. This provides a comprehensive picture of the patient’s problem, its cause, and the evidence supporting it.
Example of a Three-Part Nursing Diagnosis Statement (PES Format):
- Problem (P): Acute Pain
- Etiology (E): related to surgical incision
- Signs/Symptoms (S): as evidenced by patient report of pain at 8/10, guarding behavior, and increased heart rate.
- Full Statement (PES): Acute Pain related to surgical incision as evidenced by patient report of pain at 8/10, guarding behavior, and increased heart rate.
Examples of Nursing Diagnosis Statements for Various Conditions
To further illustrate, here are more examples of nursing diagnosis statements for different health conditions, categorized by type:
Problem-Focused Examples:
- Constipation related to decreased physical activity and inadequate fluid intake as evidenced by reported infrequent bowel movements and hard, dry stools.
- Anxiety related to unfamiliar hospital environment and upcoming surgery as evidenced by patient verbalizing feelings of worry, restlessness, and increased heart rate.
- Self-Care Deficit: Bathing related to physical weakness secondary to stroke as evidenced by inability to wash body and requiring assistance with hygiene.
- Disturbed Sleep Pattern related to hospital noise and pain as evidenced by patient reporting difficulty falling asleep and frequent awakenings.
Risk Examples:
- Risk for Aspiration as evidenced by impaired swallowing and decreased level of consciousness.
- Risk for Pressure Injury as evidenced by immobility, prolonged bed rest, and poor nutrition.
- Risk for Spiritual Distress as evidenced by facing life-threatening illness and lack of social support.
- Risk for Falls as evidenced by medication side effects (dizziness), age over 65, and history of falls.
Health Promotion Examples:
- Readiness for Enhanced Parenting as evidenced by expressed interest in learning effective parenting techniques and positive interaction with infant.
- Readiness for Enhanced Spiritual Well-being as evidenced by seeking to strengthen connection with faith community and expressing peace and meaning in life.
- Readiness for Enhanced Health Management as evidenced by expressing desire to learn more about managing chronic condition and actively seeking health information.
Syndrome Examples:
- Failure to Thrive Syndrome.
- Disuse Syndrome.
- Impaired Environmental Interpretation Syndrome.
Nursing Diagnosis for Care Plans
Nursing diagnoses are integral to developing comprehensive nursing care plans. They provide the framework for:
- Setting Patient Goals and Outcomes: Diagnoses guide the development of patient-centered goals and measurable outcomes.
- Selecting Nursing Interventions: Interventions are chosen to address the etiology and defining characteristics of each nursing diagnosis.
- Evaluating Care Effectiveness: Outcomes are evaluated based on the nursing diagnoses, determining if interventions were successful in resolving or managing the identified problems.
By accurately formulating nursing diagnoses, nurses create focused and effective care plans that improve patient outcomes and experiences.
Recommended Resources
To deepen your understanding of nursing diagnosis, consider these valuable resources:
- Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care: An excellent resource for evidence-based interventions and care planning.
- Nursing Care Plans – Nursing Diagnosis & Intervention: Provides numerous care plans with current guidelines.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales: A quick reference tool for diagnoses and interventions.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care: Comprehensive guide for planning and documenting individualized care.
- All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health: Offers a wide range of care plans across specialties.
These resources can further enhance your skills in formulating and utilizing nursing diagnoses effectively in your practice.
Conclusion
Mastering nursing diagnosis is a continuous journey for nurses. By understanding the types, components, and formulation of nursing diagnoses, and by reviewing examples of nursing diagnosis statements, you can significantly improve your clinical reasoning and patient care planning. Accurate nursing diagnoses lead to targeted interventions, better patient outcomes, and a more fulfilling nursing practice. Continuously refining your diagnostic skills is essential for providing high-quality, patient-centered care.
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.
