Nursing diagnosis is the cornerstone of effective patient care. For nurses and the broader healthcare community, it serves as an indispensable tool, guiding care and ensuring patient needs are met with precision and empathy.
In this comprehensive guide, we will delve into the essential aspects of nursing diagnosis. We’ll explore its definition and role within the nursing process, the various types and classifications, and, most importantly, how to accurately formulate and utilize a nursing diagnosis to develop robust nursing care plans. Understanding how to arrive at the correct nursing diagnosis is crucial for tailoring interventions and achieving positive patient outcomes. So, let’s begin our exploration into effectively Figuring Out Our Nursing Diagnosis For A Nursing Care Plan.
Understanding the Nursing Process
Before we can fully grasp the significance of nursing diagnosis, it’s essential to understand the framework in which it operates: the nursing process. This systematic approach to patient care consists of five interconnected steps, with diagnosis being the critical second step.
Assessment: This initial phase involves a thorough evaluation of the patient. Nurses gather comprehensive data, including vital signs, medical history, psychological assessments, and socioeconomic factors. This holistic data collection is foundational for the subsequent steps.
Diagnosis: Following the assessment, nurses analyze the collected data to identify patterns and draw conclusions about the patient’s health status. This leads to the formulation of a nursing diagnosis, which is a clinical judgment that pinpoints specific health challenges and needs that nursing interventions can address. This is where we begin figuring out our nursing diagnosis for a nursing care plan.
Outcomes and Planning: In this stage, the nursing diagnosis becomes the basis for developing a patient-centered care plan. Nurses set measurable, realistic goals and plan specific interventions designed to achieve these outcomes. The nursing diagnosis directly informs the direction of the care plan.
Implementation: This is the action phase where the nursing care plan is put into practice. Interventions are carried out, and care is delivered throughout the patient’s healthcare journey, from admission to discharge.
Evaluation: The final step involves a critical review of the care plan’s effectiveness. Nurses evaluate whether the desired outcomes were achieved based on the established goals. If necessary, the care plan is adjusted to better meet the patient’s evolving needs.
What Exactly is a Nursing Diagnosis?
As highlighted earlier, a nursing diagnosis is a pivotal component of the nursing process. It represents a clear and evidence-based method for nurses to articulate their professional judgments about a patient’s health status. This communication is vital not only among nurses but also with other healthcare professionals, patients, and their families. It’s the result of the assessment phase, and it sets the stage for creating a targeted care plan and subsequently measuring patient outcomes.
NANDA International (NANDA-I), the globally recognized authority in nursing diagnosis, defines it 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.”
Essentially, figuring out our nursing diagnosis for a nursing care plan means identifying and clearly stating the patient’s health problems that nurses are qualified and accountable to treat.
Distinguishing Nursing Diagnoses from Other Types
It’s important to differentiate nursing diagnoses from other types of diagnoses encountered in healthcare. The primary distinctions lie between nursing diagnoses, medical diagnoses, and collaborative problems.
A nursing diagnosis is formulated by nurses after analyzing patient data collected during the assessment. It focuses on the patient’s response to health conditions. Nurses use NANDA-I approved diagnostic labels to standardize communication. For example, observing a patient coughing before swallowing, exhibiting poor throat elevation, and reporting a “stuck” sensation might lead to the nursing diagnosis of impaired swallowing.
Examples of nursing diagnoses: risk for unstable blood glucose level; urinary incontinence; disturbed thought processes; decreased tissue perfusion.
Conversely, a medical diagnosis is made by a physician or advanced practice provider. It identifies a disease, illness, or pathological condition. Medical diagnoses are focused on the pathology of the disease and remain a part of the patient’s permanent medical record. While a nursing diagnosis can change as a patient’s condition evolves, a medical diagnosis typically remains constant.
Examples of medical diagnoses: asthma; pneumonia; type 2 diabetes mellitus; coronary artery disease.
Collaborative problems are certain physiological complications that are monitored by nurses in collaboration with physicians. These are potential problems that require both medical and nursing interventions. Nurses monitor for the onset of complications and implement physician-prescribed and nursing-prescribed interventions to minimize the complications of the events.
Examples of collaborative problems: potential complication of hemorrhage; potential complication of paralytic ileus.
NANDA-I Nursing Diagnosis Classification
To ensure clarity and organization, nursing diagnoses are systematically classified by NANDA-I in Taxonomy II, a hierarchical structure used for over two decades. This taxonomy is organized into three levels: 13 domains, 47 classes, and 267 distinct nursing diagnoses.
This classification system helps nurses navigate the extensive list of diagnoses and accurately select the most appropriate one for their patient. Understanding this classification is part of figuring out our nursing diagnosis for a nursing care plan effectively.
Here’s a brief overview of the Domains and Classes:
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Domain 1: Health Promotion
- Class 1. Health Awareness
- Class 2. Health Management
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Domain 2: Nutrition
- Class 1. Ingestion
- Class 2. Digestion
- Class 3. Absorption
- Class 4. Metabolism
- Class 5. Hydration
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Domain 3: Elimination and Exchange
- Class 1. Urinary Function
- Class 2. Gastrointestinal Function
- Class 3. Integumentary Function
- Class 4. Respiratory Function
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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
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Domain 5: Perception/Cognition
- Class 1. Attention
- Class 2. Orientation
- Class 3. Sensation/Perception
- Class 4. Cognition
- Class 5. Communication
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Domain 6: Self-Perception
- Class 1. Self-Concept
- Class 2. Self-Esteem
- Class 3. Body Image
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Domain 7: Role Relationship
- Class 1. Caregiving Roles
- Class 2. Family Relationships
- Class 3. Role Performance
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Domain 8: Sexuality
- Class 1. Sexual Identity
- Class 2. Sexual Function
- Class 3. Reproduction
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Domain 9: Coping/Stress Tolerance
- Class 1. Post-Trauma Responses
- Class 2. Coping Responses
- Class 3. Neurobehavioral Stress
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Domain 10: Life Principles
- Class 1. Values
- Class 2. Beliefs
- Class 3. Value/Belief/Action Congruence
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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
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Domain 12: Comfort
- Class 1. Physical Comfort
- Class 2. Environmental Comfort
- Class 3. Social Comfort
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Domain 13: Growth/Development
- Class 1. Growth
- Class 2. Development
Types of Nursing Diagnoses
NANDA-I categorizes nursing diagnoses into four main types: problem-focused, risk, health promotion, and syndrome. Recognizing these categories is essential when figuring out our nursing diagnosis for a nursing care plan, as each type guides different aspects of care.
Problem-Focused Diagnoses: These diagnoses, also known as actual diagnoses, describe existing patient problems identified during the assessment. They are supported by defining signs and symptoms. A problem-focused diagnosis has three components: the diagnostic label, related factors, and defining characteristics.
Risk Diagnoses: These clinical judgments describe a patient’s vulnerability to developing a health problem if nursing intervention is not implemented. Risk diagnoses indicate potential problems, not current ones. They consist of two components: a risk diagnostic label and risk factors.
Health Promotion Diagnoses: These diagnoses reflect a patient’s desire and motivation to improve their well-being and health. They focus on enhancing health behaviors and can apply to individuals, families, groups, or communities.
Syndrome Diagnoses: These represent clinical judgments about a cluster of nursing diagnoses that frequently occur together and are addressed with similar interventions. They are less common but important for recognizing patterns in patient care.
Examples of each type of nursing diagnosis, based on NANDA-I guidelines, include:
| Problem-Focused Diagnosis | Risk Diagnosis |
|---|---|
| – Acute Pain | – Risk for Infection |
| – Ineffective Breathing Pattern | – Risk for Falls |
| – Impaired Physical Mobility | – Risk for Pressure Injury |
| – Deficient Knowledge | – Risk for Aspiration |
| Health Promotion Diagnosis | Syndrome Diagnosis |
|---|---|
| – Readiness for Enhanced Nutrition | – Chronic Pain Syndrome |
| – Readiness for Enhanced Self-Care | – Post-Trauma Syndrome |
| – Readiness for Enhanced Knowledge | – Frail Elderly Syndrome |
| – Readiness for Enhanced Parenting | – Relocation Stress Syndrome |
Key Components of a Nursing Diagnosis Statement
Constructing a nursing diagnosis statement involves specific components that ensure clarity and accuracy. These components vary slightly depending on the type of diagnosis but generally include: Mastering these components is key to figuring out our nursing diagnosis for a nursing care plan effectively.
Diagnostic Label: This is a concise name that identifies the nursing diagnosis. It should be a NANDA-I approved label.
Examples: Ineffective Airway Clearance, Anxiety, Impaired Skin Integrity.
Definition: A clear, precise description of the diagnosis, helping to differentiate it from similar diagnoses.
Example: For Deficient Fluid Volume, the definition is: “Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.”
Defining Characteristics: Observable cues and inferences that cluster as manifestations of an actual diagnosis or health promotion diagnosis. These are the signs and symptoms.
Example: For Acute Pain, defining characteristics might include: reported pain, guarding behavior, facial grimacing, changes in vital signs.
Risk Factors: Environmental, physiological, psychological, genetic, or chemical elements that increase a patient’s vulnerability to a potential health problem. These are only relevant for risk diagnoses.
Example: For Risk for Infection, risk factors could include: inadequate vaccination, chronic disease (e.g., diabetes), invasive procedures, malnutrition.
Related Factors: Conditions, circumstances, or etiologies that contribute to or are associated with a problem-focused diagnosis. They provide context for the diagnosis. Related factors are used only for problem-focused nursing diagnoses and syndromes.
Example: For Impaired Skin Integrity, related factors might include: immobility, altered nutritional status, moisture, pressure.
Step-by-Step Guide: Writing a Nursing Diagnosis
Formulating a nursing diagnosis involves a systematic approach. Here’s a step-by-step guide to help you in figuring out our nursing diagnosis for a nursing care plan:
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Data Analysis: Thoroughly review all collected assessment data to identify significant cues, patterns, and deviations from normal health patterns.
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Problem Identification: Based on your analysis, pinpoint the patient’s health problems, risks, and strengths.
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Diagnosis Formulation: Construct the diagnostic statement using the appropriate NANDA-I format for the type of diagnosis.
Here are examples of constructing each type of nursing diagnosis statement:
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Problem-Focused Diagnosis: Use a three-part statement (PES format):
- Problem (Nursing Diagnostic Label) + Etiology (Related Factors) + Signs/Symptoms (Defining Characteristics)
Example: Acute Pain related to surgical incision as evidenced by patient reporting pain of 7/10 and guarding incision site.
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Risk Diagnosis: Use a two-part statement:
- Risk Diagnostic Label + Risk Factors
Example: Risk for Infection as evidenced by presence of surgical incision and invasive intravenous line.
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Health Promotion Diagnosis: Use a two-part statement:
- Nursing Diagnostic Label + Defining Characteristics
Example: Readiness for Enhanced Knowledge related to medication regimen as evidenced by patient expressing interest in learning more about new medications and asking relevant questions.
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Syndrome Diagnosis: Use a one-part statement:
- Syndrome Diagnostic Label
Example: Post-Trauma Syndrome
Additional Nursing Diagnosis Examples for Care Plan Development
The NANDA-I list, with its 267 diagnoses, offers a comprehensive resource for nurses. Here are more examples to aid you in figuring out our nursing diagnosis for a nursing care plan and developing effective interventions:
- Ineffective peripheral tissue perfusion
- Risk for electrolyte imbalance
- Impaired verbal communication
- Bathing self-care deficit
- Situational low self-esteem
- Disturbed sleep pattern
- Ineffective health maintenance
- Deficient diversional activity
- Risk for falls
- Unilateral neglect
- Spiritual distress
- Chronic sorrow
- Powerlessness
- Impaired memory
- Social isolation
- Readiness for enhanced spiritual well-being
- Wandering
- Delayed surgical recovery
- Risk for constipation
- Nausea
Mastering Nursing Diagnosis for Superior Patient Care
Nursing diagnoses are indispensable tools that empower nurses to deliver safe, high-quality, and evidence-based care. The ability to accurately formulate and utilize nursing diagnoses is a critical skill for every nurse. By mastering the art of figuring out our nursing diagnosis for a nursing care plan, nurses can ensure that patient care is targeted, effective, and truly patient-centered, leading to improved health outcomes and enhanced well-being.
