Master Guide: How to Write a Nursing Diagnosis Statement

Nursing diagnoses are fundamental to effective patient care. As a cornerstone of the nursing process, they bridge assessment and intervention, ensuring that care plans are tailored to the patient’s unique needs. This guide provides a comprehensive walkthrough on crafting impactful nursing diagnosis statements, essential for both nursing students and practicing professionals.

Understanding Nursing Diagnosis

A nursing diagnosis is defined as a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems and life processes. It’s a statement that pinpoints the issues a nurse is qualified and licensed to treat. Nursing diagnoses provide the foundation for selecting nursing interventions to achieve specific patient outcomes. They are derived from meticulous data collection during the nursing assessment, forming the bedrock of an individualized care plan.

Why Nursing Diagnoses Matter

Nursing diagnoses serve multiple critical purposes in healthcare:

• Enhancing Critical Thinking: For nursing students, formulating diagnoses is an invaluable exercise in sharpening problem-solving and critical thinking skills.
• Prioritizing Care: They clearly identify nursing priorities, guiding interventions toward the most pressing patient needs.
• Outcome Measurement: Nursing diagnoses facilitate the establishment of measurable outcomes, crucial for quality assurance and accountability to healthcare payers.
• Resource Identification: They help recognize how patients respond to health issues and identify internal and external resources that can aid in problem resolution.
• Professional Communication: Nursing diagnoses establish a common language, fostering clear communication and collaboration among nurses and the broader healthcare team.
• Evaluating Care Effectiveness: They provide a benchmark for evaluating the effectiveness of nursing care and its cost-efficiency.

Nursing Diagnosis vs. Medical Diagnosis vs. Collaborative Problems

It’s crucial to differentiate nursing diagnoses from medical diagnoses and collaborative problems.

• Nursing Diagnosis: Focuses on the patient’s response to illness or health conditions. It’s within the nurse’s scope of practice to address these diagnoses independently. For instance, a patient with pneumonia might have a nursing diagnosis of Ineffective Airway Clearance related to increased mucus production.
• Medical Diagnosis: Identifies diseases or pathological states that only physicians or advanced practitioners can treat. Examples include Pneumonia, Diabetes Mellitus, or Heart Failure. Medical diagnoses guide medical treatments, while nursing diagnoses guide patient care.
• Collaborative Problems: These are potential or actual health complications that require both medical and nursing interventions. Nurses monitor for and manage these problems using protocols and in collaboration with physicians. An example is Potential Complication: Respiratory Insufficiency in a patient with pneumonia.

The key distinction is that nursing diagnoses are centered on patient-centered care and responses, whereas medical diagnoses are disease-focused. Collaborative problems bridge both medical and nursing responsibilities.

Classifying Nursing Diagnoses: NANDA-I Taxonomy

The most widely recognized classification system for nursing diagnoses is the NANDA-I (North American Nursing Diagnosis Association International) taxonomy. This system provides a standardized language to identify patient problems and responses.

NANDA-I organizes diagnoses into a multi-axial system, but for practical application, it’s helpful to understand the broad domains:

NANDA-I Domains (Examples):

• Domain 1: Health Promotion: Focuses on the awareness of well-being and health management.
• Domain 2: Nutrition: Addresses activities related to intake, digestion, absorption, metabolism, and hydration.
• Domain 3: Elimination and Exchange: Concerns bodily waste elimination and fluid and electrolyte balance.
• Domain 4: Activity/Rest: Covers sleep, rest, activity, exercise, and energy balance.
• Domain 5: Perception/Cognition: Deals with sensory and cognitive functions.
• Domain 6: Self-Perception: Relates to self-concept, self-esteem, and body image.
• Domain 7: Role Relationship: Focuses on caregiver roles, family dynamics, and role performance.
• Domain 8: Sexuality: Addresses sexual identity, function, and reproduction.
• Domain 9: Coping/Stress Tolerance: Concerns stress responses and coping mechanisms.
• Domain 10: Life Principles: Addresses values, beliefs, and spiritual practices.
• Domain 11: Safety/Protection: Focuses on safety, injury prevention, and infection control.
• Domain 12: Comfort: Relates to physical, environmental, and social comfort.
• Domain 13: Growth/Development: Addresses age-appropriate growth and development.

These domains provide a structured framework for nurses to categorize and select appropriate nursing diagnoses.

The Nursing Process and Nursing Diagnosis

Nursing diagnosis is the second step of the nursing process, following assessment and preceding planning, implementation, and evaluation. The nursing process is a systematic, patient-centered approach to care.

1. Assessment: Gathering subjective and objective data about the patient’s health status.
2. Diagnosis: Analyzing assessment data to identify patient problems and formulate nursing diagnoses.
3. Planning: Developing a care plan with patient-centered goals and nursing interventions.
4. Implementation: Carrying out the nursing interventions.
5. Evaluation: Assessing the effectiveness of interventions and patient progress toward goals.

Nursing diagnosis is the critical link between assessment and the rest of the care plan. Accurate diagnoses ensure that interventions are targeted and effective.

Types of Nursing Diagnoses Explained

There are several types of nursing diagnoses, each serving a distinct purpose:

• Problem-Focused (Actual) Diagnosis: Describes a current problem the patient is experiencing, supported by defining signs and symptoms. Example: Acute Pain related to surgical incision as evidenced by patient report of pain at 7/10, guarding behavior, and increased heart rate.
• Risk Diagnosis: Identifies potential problems a patient is vulnerable to developing. It’s supported by risk factors. Example: Risk for Infection as evidenced by surgical incision, presence of invasive lines, and immunocompromised state.
• Health Promotion Diagnosis: Focuses on a patient’s desire to enhance well-being and health. Example: Readiness for Enhanced Nutrition as evidenced by patient expressing interest in learning about healthy eating and requesting dietary information.
• Syndrome Diagnosis: A cluster of actual or risk diagnoses that occur together due to a specific event or situation. Example: Rape-Trauma Syndrome as evidenced by anxiety, flashbacks, and sleep disturbance following sexual assault.
• Possible Diagnosis: Used when more data is needed to confirm or rule out a suspected diagnosis. It indicates a need for further assessment. Example: Possible Spiritual Distress related to uncertainty about illness outcome (requires further assessment of patient’s spiritual beliefs and concerns).

Key Components of a Nursing Diagnosis Statement

A well-written nursing diagnosis statement typically includes three parts, especially for problem-focused diagnoses, often remembered by the acronym PES:

1. Problem (Diagnostic Label): A concise term or phrase describing the patient’s health problem or response. NANDA-I provides a standardized list of diagnostic labels. This part often includes a qualifier to add specificity (e.g., Deficient, Impaired, Ineffective, Risk for).

   Qualifier	Focus of Diagnosis	Example Nursing Diagnosis
   Deficient	Fluid Volume	Deficient Fluid Volume
   Imbalanced	Nutrition: Less Than Body Needs	Imbalanced Nutrition: Less Than Body Requirements
   Impaired	Gas Exchange	Impaired Gas Exchange
   Ineffective	Tissue Perfusion	Ineffective Tissue Perfusion
   Risk for	Injury	Risk for Injury

   

   

   

2. Etiology (Related Factors): Identifies the probable cause(s) or contributing factors to the problem. This is linked to the problem statement with the phrase “related to.” Etiology guides interventions by addressing the root cause. Example: related to surgical incision.

3. Signs and Symptoms (Defining Characteristics): The observable cues, inferences, or clinical manifestations that provide evidence for the nursing diagnosis. For problem-focused diagnoses, this section is crucial. It’s linked using the phrase “as evidenced by” or “as manifested by.” Example: as evidenced by patient report of pain at 7/10 and guarding behavior.

For risk diagnoses, instead of defining characteristics, you use risk factors following “as evidenced by.” Risk factors are circumstances or conditions that increase vulnerability to a problem. Example: Risk for Infection as evidenced by surgical incision and immunocompromised state.

Health promotion and syndrome diagnoses are often one-part statements, using only the diagnostic label.

The Diagnostic Process: A Step-by-Step Guide

Formulating a nursing diagnosis involves a systematic diagnostic process:

1. Data Analysis:

   • Compare Data to Standards: Identify deviations from normal health patterns.
   • Cluster Cues: Group related data to identify patterns and relationships.
   • Identify Gaps and Inconsistencies: Recognize missing information or conflicting data that needs further investigation.

2. Identify Health Problems, Risks, and Strengths:

   • Based on data analysis, determine the patient’s health problems, potential risks, and strengths.
   • Differentiate between nursing diagnoses, medical diagnoses, and collaborative problems.
   • Recognize patient strengths and resources that can be leveraged in the care plan.

3. Formulate Diagnostic Statements:

   • Construct clear, concise, and accurate nursing diagnosis statements using the appropriate format (one-part, two-part, or three-part PES).
   • Ensure the statement reflects the patient’s individual situation and is supported by assessment data.

Step-by-Step: How to Write a Nursing Diagnosis Statement

Let’s break down how to write effective nursing diagnosis statements based on the type of diagnosis:

1. Problem-Focused (Actual) Nursing Diagnosis (Three-Part Statement – PES Format):

• P (Problem): Choose a NANDA-I diagnostic label that accurately describes the patient’s problem. Example: Acute Pain.
• E (Etiology): Identify related factors contributing to the problem. Use “related to.” Example: related to surgical incision.
• S (Signs and Symptoms): List defining characteristics observed in the patient’s assessment. Use “as evidenced by.” Example: as evidenced by patient report of pain at 7/10, guarding behavior, and increased heart rate.

Complete Statement Example: Acute Pain related to surgical incision as evidenced by patient report of pain at 7/10, guarding behavior, and increased heart rate.

2. Risk Nursing Diagnosis (Two-Part Statement):

• Diagnostic Label: Begin with “Risk for” followed by the NANDA-I diagnosis. Example: Risk for Infection.
• Risk Factors: Identify factors that increase the patient’s risk. Use “as evidenced by.” Example: as evidenced by surgical incision, presence of invasive lines, and immunocompromised state.

Complete Statement Example: Risk for Infection as evidenced by surgical incision, presence of invasive lines, and immunocompromised state.

3. Health Promotion Nursing Diagnosis (One-Part Statement):

• Diagnostic Label: Use a “Readiness for Enhanced…” NANDA-I diagnosis. Example: Readiness for Enhanced Nutrition.

Complete Statement Example: Readiness for Enhanced Nutrition. (Related factors are implied – motivation to improve health).

4. Syndrome Nursing Diagnosis (One-Part Statement):

• Diagnostic Label: Use the NANDA-I syndrome diagnosis name. Example: Rape-Trauma Syndrome.

Complete Statement Example: Rape-Trauma Syndrome. (Defining characteristics are implied within the syndrome definition).

Variations in Statement Formats:

While PES format is common for problem-focused diagnoses, remember that statement formats can vary based on the type of diagnosis. Always ensure clarity and accuracy in conveying the patient’s health status.

Nursing Diagnoses in Care Plans

Nursing diagnoses are the backbone of nursing care plans. They directly inform the goals, interventions, and evaluation criteria within the plan. A well-formulated nursing diagnosis leads to targeted and effective nursing care, ultimately improving patient outcomes.

For a comprehensive list of nursing diagnoses to use in care plans, refer to resources like the NANDA-I handbook or nursing diagnosis manuals.

Recommended Resources for Mastering Nursing Diagnosis

To deepen your understanding and skills in writing nursing diagnoses, consider these resources:

• Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care: Praised for its evidence-based approach and step-by-step guidance on assessment, diagnosis, and care planning.
• Nursing Care Plans – Nursing Diagnosis & Intervention: Offers a vast collection of care plans reflecting current evidence-based practices, including ICNP diagnoses and emerging health topics.
• Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales: A quick-reference tool for accurate diagnosis identification and efficient care planning, updated with the latest diagnoses and interventions.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care: Provides detailed information for over 800 diseases and disorders, including interventions, rationales, and documentation guidance.
• All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health: A comprehensive resource covering diverse patient populations and healthcare settings, with over 100 care plans.

These resources, along with practice and experience, will empower you to master the art of writing effective nursing diagnosis statements, ultimately enhancing your nursing practice and patient care.

References

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• 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.