What is a Nursing Diagnosis?
A nursing diagnosis is defined as a clinical judgment made by nurses. This judgment concerns a human response to health conditions, life processes, or a vulnerability to such responses, within individuals, families, groups, or communities. It serves as the foundation for selecting nursing interventions aimed at achieving specific patient outcomes, for which nurses are accountable. Nursing diagnoses are formulated based on data gathered during a thorough nursing assessment, and they are essential for developing effective nursing care plans. For those looking to streamline this process, especially with readily available resources, exploring Free Online Nursing Diagnosis Care Plans can be an invaluable starting point.
Purposes of Nursing Diagnosis
Nursing diagnoses serve multiple critical purposes in healthcare:
- Enhancing Problem-Solving and Critical Thinking: For nursing students, working with nursing diagnoses is an excellent educational tool. It sharpens their problem-solving abilities and hones critical thinking skills, essential for effective patient care.
- Identifying Nursing Priorities and Directing Interventions: Nursing diagnoses are instrumental in pinpointing the most pressing patient needs. This prioritization directly guides nursing interventions, ensuring that care is focused and efficient.
- Formulating Expected Outcomes for Quality Assurance: These diagnoses play a key role in establishing measurable expected outcomes. This is vital for meeting the quality assurance standards required by healthcare organizations and third-party payers.
- Understanding Patient Responses and Resource Identification: Nursing diagnoses help healthcare professionals understand how patients or groups react to actual or potential health challenges and life events. They also aid in identifying patient strengths and resources that can be utilized to overcome or prevent health issues.
- Facilitating Communication and Understanding: By providing a common language, nursing diagnoses create a framework for clear and effective communication among nursing professionals and across the entire healthcare team. This shared understanding is crucial for coordinated patient care.
- Providing a Basis for Evaluation of Care Effectiveness: Nursing diagnoses are fundamental for evaluation. They allow healthcare providers to assess whether the nursing care provided was beneficial to the patient and if it was delivered in a cost-effective manner. This evaluative aspect is key to continuous improvement in nursing practice.
Differentiating Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems
The term nursing diagnosis holds different layers of meaning within the nursing context. It can refer to the second distinct phase in the nursing process, specifically the diagnosis stage (the “D” in ADPIE – Assessment, Diagnosis, Planning, Implementation, Evaluation). Additionally, nursing diagnosis is used as a label itself, assigned when nurses interpret collected patient data and categorize it appropriately.
For example, during a nursing assessment, a nurse might observe that a patient is experiencing anxiety, feelings of fear, and difficulty with sleep. These observations are then translated into specific nursing diagnoses: Anxiety, Fear, and Disturbed Sleep Pattern, respectively. Here, the nursing diagnosis is rooted in the patient’s response to their medical condition, rather than the condition itself. It’s termed a ‘nursing diagnosis’ because it addresses areas where nurses have the autonomy to act independently, based on their professional judgment, in response to a patient’s disease or condition. This encompasses physical, mental, and even spiritual responses, emphasizing the holistic nature of nursing care. Consequently, a nursing diagnosis is fundamentally care-focused.
COMPARISON: Nursing diagnoses vs. medical diagnoses vs. collaborative problems.
In contrast, a medical diagnosis is the domain of physicians or advanced healthcare practitioners. It focuses on the disease, medical condition, or pathological state itself, which only medical practitioners are authorized to treat. Through their expertise, doctors pinpoint the precise clinical entity causing the illness, enabling them to prescribe the appropriate medication or treatment to cure the disease. Examples of medical diagnoses include Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. Medical diagnoses typically remain constant throughout a patient’s care. Nurses play a crucial role in implementing physician’s orders and executing prescribed treatments and therapies.
Collaborative problems represent potential health issues that nurses manage using a combination of independent nursing interventions and physician-prescribed treatments. These are conditions that require both medical and nursing interventions. The nursing role in collaborative problems centers on diligently monitoring the patient’s condition and proactively preventing potential complications. In managing these complex situations, nurses often find free online nursing diagnosis care plans helpful, as they can provide a structured approach to monitoring and intervention strategies.
As explained above, the distinction between nursing and medical diagnoses becomes clearer. Nursing diagnosis prioritizes the patient and their individual physiological and psychological responses to illness. Conversely, medical diagnosis is centered on the disease or medical condition itself. The focus is on the pathology of the illness.
Classification of Nursing Diagnoses (Taxonomy II)
Nursing diagnoses are systematically listed, arranged, and classified to provide a standardized framework for nursing practice. In 2002, Taxonomy II was adopted, which is based on Dr. Mary Joy Gordon’s Functional Health Patterns assessment framework. Taxonomy II is structured across three levels: Domains (13), Classes (47), and individual nursing diagnoses. Importantly, nursing diagnoses are no longer grouped according to Gordon’s patterns but are instead coded based on seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology. Furthermore, diagnoses are now listed alphabetically by their concept, rather than by the first word in the diagnostic phrase.
NURSING DIAGNOSIS TAXONOMY II. Taxonomy II for nursing diagnosis contains 13 domains and 47 classes. Image via: Wikipedia.com
- 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
Nursing Process
The nursing process is a systematic, five-stage approach to patient care. These stages are assessment, diagnosis, planning, implementation, and evaluation. Critical thinking is paramount in every stage of the nursing process. Beyond simply understanding nursing diagnoses and their definitions, nurses must develop a keen awareness of the defining characteristics and behaviors associated with each diagnosis. They also need to understand related factors that contribute to the chosen nursing diagnoses and identify appropriate interventions for addressing these diagnoses. Many nurses leverage resources like free online nursing diagnosis care plans to better understand the application of these processes in real-world scenarios.
For a more comprehensive understanding of the steps, significance, purposes, and characteristics of the nursing process, refer to: “The Nursing Process: A Comprehensive Guide“
Types of Nursing Diagnoses
There are four primary types of nursing diagnoses: Actual (Problem-Focused), Risk, Health Promotion, and Syndrome. Understanding these categories is crucial for selecting the most appropriate diagnosis for a given patient situation.
TYPES OF NURSING DIAGNOSES. The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.
Problem-Focused Nursing Diagnosis
A problem-focused diagnosis, also known as an actual diagnosis, identifies a client problem that is present at the time of the nursing assessment. These diagnoses are substantiated by observable signs and symptoms. It’s important to note that actual nursing diagnoses shouldn’t be considered inherently more critical than risk diagnoses; in many situations, a risk diagnosis might take precedence in a patient’s care plan. For practical examples and structures, nurses often consult free online nursing diagnosis care plans to understand how these diagnoses are applied in different patient scenarios.
Problem-focused nursing diagnoses are structured with three essential components: (1) the nursing diagnosis label, (2) related factors, and (3) defining characteristics. Examples of actual nursing diagnoses include:
Risk Nursing Diagnosis
The risk nursing diagnosis is the second category, representing a clinical judgment that a problem does not currently exist. However, it indicates that risk factors are present, significantly increasing the likelihood of a problem developing if preventive nursing interventions are not implemented. A risk diagnosis is grounded in a patient’s current health status, their past health history, and the presence of specific risk factors that elevate their susceptibility to a health issue. These diagnoses are integral to proactive nursing care, enabling nurses to identify potential problems early and take preemptive measures to minimize or eliminate the risk. When formulating these diagnoses, resources like free online nursing diagnosis care plans can offer templates and examples for various risk factors.
Unlike problem-focused diagnoses, risk diagnoses do not include etiological factors (related factors). The increased susceptibility of the individual (or group) to developing the problem, compared to others in similar circumstances, is solely due to the identified risk factors. For instance, an elderly patient with diabetes and vertigo, who experiences difficulty walking and refuses assistance during ambulation, might be appropriately diagnosed with risk for injury or risk for falls.
IMPORTANT: In risk nursing diagnoses, the phrase “as evidenced by” is used to link the risk diagnosis label directly to the risk factors, rather than to defining characteristics. Therefore, the components of a risk nursing diagnosis are:
- Risk diagnostic label, connected by “as evidenced by”
- Risk factors
Examples of risk nursing diagnoses include:
- Risk for Injury as evidenced by reduced cognitive awareness and use of sedative medications.
- Risk for Infection as evidenced by surgical wound, compromised immune system, and prolonged hospitalization.
- Risk for Falls as evidenced by muscle weakness, history of previous falls, impaired mobility, and use of assistive devices.
Health Promotion Diagnosis
A health promotion diagnosis, also known as a wellness diagnosis, is a clinical judgment concerning a patient’s motivation and desire to enhance their well-being. It’s a statement acknowledging a patient’s readiness to engage in activities that promote better health and overall wellness. For example, if a new mother expresses keen interest in learning the proper techniques for breastfeeding, a nurse might make a health promotion diagnosis of “Readiness for Enhanced Breastfeeding.” This diagnosis then guides nursing interventions aimed at supporting the patient in learning about and successfully implementing proper breastfeeding practices. For nurses seeking to develop effective interventions, free online nursing diagnosis care plans focused on health promotion can provide valuable guidance.
Furthermore, health promotion diagnoses are concerned with facilitating an individual’s, family’s, or community’s transition from their current level of wellness to a higher level. Components of a health promotion diagnosis typically include just the diagnostic label, forming a one-part statement. However, for added clarity, related factors can be included. Examples of health promotion diagnoses:
Syndrome Diagnosis
A syndrome diagnosis is a clinical judgment that identifies a cluster of actual or risk nursing diagnoses that are likely to occur together due to a particular situation or event. These diagnoses are also written as one-part statements, requiring only the diagnostic label. Examples of syndrome nursing diagnoses include:
Possible Nursing Diagnosis
A possible nursing diagnosis is technically not a distinct type of diagnosis like actual, risk, health promotion, or syndrome diagnoses. Instead, it represents a statement describing a suspected problem that requires further data to either confirm or rule out. It serves as a communication tool among nurses, indicating that a diagnosis is being considered, but more data collection is necessary to validate or dismiss the suspicion. Examples include:
Components of a Nursing Diagnosis
A standard nursing diagnosis typically comprises three key components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (specifically for risk diagnoses). Understanding these components is crucial for constructing accurate and effective nursing diagnoses, and resources like free online nursing diagnosis care plans often illustrate these components in practice.
Problem and Definition
The problem statement, or diagnostic label, is a concise description of the client’s health issue or response that necessitates nursing intervention. A diagnostic label generally has two parts: a qualifier and the focus of the diagnosis. Qualifiers (also known as modifiers) are words added to some diagnostic labels to provide additional context, specificity, or limitation to the diagnostic statement. One-word nursing diagnoses (e.g., Anxiety, Constipation, Diarrhea, Nausea, etc.) are exceptions, as their qualifier and focus are inherent within the single 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
The etiology, or related factors, component of a nursing diagnosis label identifies the probable causes of the health problem. These are the conditions that have contributed to the development of the problem. Identifying the etiology is crucial as it guides the direction of necessary nursing therapy and allows for the individualization of patient care. Nursing interventions should be specifically targeted at addressing the etiological factors to resolve the underlying cause of the nursing diagnosis. Etiology is linked to the problem statement using the phrase “related to,” for example:
Risk Factors
Risk factors are used in place of etiological factors for risk nursing diagnoses. Risk factors are conditions or situations that increase an individual’s or group’s vulnerability to an unhealthy event or condition. In a diagnostic statement, risk factors are written following the phrase “as evidenced by.”
- Risk for falls as evidenced by old age and use of walker.
- Risk for infection as evidenced by break in skin integrity.
Defining Characteristics
Defining characteristics are clusters of signs and symptoms that collectively indicate the presence of a particular diagnostic label in an actual nursing diagnosis. These are the observable cues that the nurse identifies during assessment. For risk nursing diagnoses, defining characteristics are not present; instead, the risk factors that make the client more susceptible to the problem constitute the basis of the diagnosis. Defining characteristics are included in the diagnostic statement after the phrase “as evidenced by” or “as manifested by.” To ensure comprehensive diagnosis and care planning, nurses often refer to resources like free online nursing diagnosis care plans to understand the typical defining characteristics associated with various diagnoses.
Diagnostic Process: How to Diagnose
The diagnostic process in nursing involves three key phases: (1) data analysis, (2) identification of the client’s health problems, health risks, and strengths, and (3) formulation of diagnostic statements.
Analyzing Data
Data analysis involves a systematic comparison of patient data against established health standards, clustering related cues together, and identifying any gaps or inconsistencies in the information.
Identifying Health Problems, Risks, and Strengths
Following data analysis, the nurse collaborates with the client in this decision-making step to identify problems that support potential actual, risk, and possible diagnoses. This involves distinguishing between a nursing diagnosis, a medical diagnosis, or a collaborative problem. Crucially, this stage also includes recognizing the client’s strengths, available resources, and their capacity to cope with health challenges.
Formulating Diagnostic Statements
The final step in the diagnostic process is formulating diagnostic statements. This involves synthesizing the analyzed data and identified problems into clear, concise, and accurate nursing diagnosis statements, which then guide the subsequent stages of the nursing process.
How to Write a Nursing Diagnosis?
Writing nursing diagnostic statements effectively involves describing an individual’s health status along with the contributing factors. It’s not always necessary to include every type of diagnostic indicator; the specifics of writing diagnostic statements vary based on the type of nursing diagnosis.
WRITING DIAGNOSTIC STATEMENTS. Your guide on how to write different nursing diagnostic statements.
PES Format
Another widely used method for writing nursing diagnostic statements is the PES format. PES is an acronym that stands for Problem (diagnostic label), Etiology (related factors), and Signs/Symptoms (defining characteristics). Using the PES format, diagnostic statements can be structured as 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 Statement
Health promotion nursing diagnoses are typically written as one-part statements. This is because the related factors are consistently the same: the patient is motivated to achieve a higher level of wellness. While related factors can be included to enhance clarity, they are often implied. Syndrome diagnoses also inherently lack related factors, making them suitable for one-part statements. Examples of one-part nursing diagnosis statements include:
- Readiness for enhanced coping
- Rape Trauma Syndrome
Two-Part Nursing Diagnosis Statement
Risk and possible nursing diagnoses are formulated as two-part statements. The first part is the diagnostic label, and the second part provides the validation for a risk nursing diagnosis or identifies the risk factors present. It’s not possible to have a third part for risk or possible diagnoses because, by definition, the signs and symptoms of the problem are not yet present. Examples of two-part nursing diagnosis statements include:
- Risk for Infection as evidenced by weakened immune system response
- Risk for Injury as evidenced by unstable hemodynamic profile
Three-part Nursing Diagnosis Statement
An actual or problem-focused nursing diagnosis is constructed as a three-part statement. This format includes the diagnostic label, the contributing factor (“related to”), and the defining signs and symptoms (“as evidenced by” or “as manifested by”). The three-part nursing diagnosis statement is synonymous with the PES format, encompassing the Problem, Etiology, and Signs and Symptoms. Example of three-part nursing diagnosis statements include:
Variations on Basic Statement Formats
Variations in writing nursing diagnosis statement formats include the following:
Nursing Diagnosis for Care Plans
This section provides a valuable list or database of common nursing diagnosis examples that can be utilized in developing comprehensive nursing care plans. For nurses seeking to create effective care plans efficiently, exploring free online nursing diagnosis care plans can offer templates and examples to guide their practice.
See also: Nursing Care Plans (NCP): Ultimate Guide and List
Recommended Resources
Below are recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We highly recommend this book for its evidence-based approach to nursing interventions. This handbook offers a simple, three-step system to guide you through client assessment, nursing diagnosis, and care planning. It provides clear, step-by-step instructions on how to implement care and evaluate patient outcomes, effectively building your skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
This resource features over two hundred care plans, all updated to reflect the most current evidence-based guidelines in nursing practice. New additions to this edition include ICNP diagnoses, specialized care plans addressing LGBTQ health issues, and comprehensive coverage of electrolyte and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
This quick-reference tool is essential for efficiently identifying correct diagnoses and planning patient care. The sixteenth edition is fully updated with the latest nursing diagnoses and interventions and includes an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual is designed to help nurses identify appropriate interventions for planning, individualizing, and documenting care for over 800 diseases and disorders. Unique to this manual are features such as subjectively and objectively organized information for each diagnosis, sample clinical applications, prioritized actions/interventions with rationales, and a dedicated documentation section, among other valuable resources.
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
This comprehensive e-book includes over 100 care plans spanning medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health nursing. It emphasizes interprofessional “patient problems,” helping nurses to effectively communicate and collaborate with patients and other healthcare professionals.
See also
Other recommended site resources for this nursing care plan:
References and Sources
References for this Nursing Diagnosis guide and recommended resources to further your reading.
- 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.
