A nursing diagnosis is a critical element of the nursing process, serving as the foundation for personalized and effective patient care. For nurses, understanding and applying nursing diagnoses is indispensable, as it directly informs the development of nursing care plans. This guide will delve into the essentials of nursing diagnoses, providing comprehensive Nursing Care Plan Diagnosis Examples to enhance your understanding and practice.
Understanding the Nursing Process and the Role of Diagnosis
Before exploring nursing diagnosis examples, it’s crucial to understand its place within the broader nursing process. This systematic approach ensures patient care is organized, patient-centered, and outcome-driven. The nursing process comprises five interconnected steps:
Assessment: This initial phase involves a thorough evaluation of the patient’s health status. Nurses collect comprehensive data, including vital signs, medical history, physical examinations, and psychosocial assessments. This data collection is the bedrock upon which all subsequent steps depend.
Diagnosis: Following assessment, nurses analyze the collected data to identify patient health problems. This step involves formulating a nursing diagnosis, a clinical judgment about individual, family, or community responses to actual or potential health problems and life processes. It’s not a medical diagnosis but focuses on the patient’s experience of health issues.
Outcomes and Planning: Based on the nursing diagnosis, the nurse collaborates with the patient and healthcare team to set measurable and realistic goals. A nursing care plan is then developed, outlining specific nursing interventions designed to achieve these outcomes and address the identified diagnoses.
Implementation: This is the action phase where the nursing care plan is put into practice. Interventions are carried out, which may include direct patient care, education, medication administration, and coordination with other healthcare providers.
Evaluation: The final step involves evaluating the effectiveness of the nursing care plan. Nurses assess the patient’s progress toward the set goals. If outcomes are not met, the care plan is reviewed and revised, ensuring a dynamic and responsive approach to patient needs.
What Exactly is a Nursing Diagnosis?
A nursing diagnosis is more than just a label; it’s a professional nurse’s clinical judgment. It’s a precise and evidence-based method for nurses to articulate their expert opinions about a patient’s health status to the patient, other nurses, medical professionals, and anyone involved in the patient’s care. Derived from the assessment phase, the nursing diagnosis guides the creation of a nursing care plan and serves as a benchmark for measuring patient outcomes.
NANDA International (NANDA-I), the globally recognized authority, defines a nursing diagnosis 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 selection of nursing interventions to achieve outcomes for which the nurse has accountability.”
In simpler terms, a nursing diagnosis identifies what health issues a nurse is qualified and licensed to treat. It focuses on patient responses to illness, rather than the disease process itself. This distinction is critical in differentiating nursing diagnoses from medical diagnoses.
Nursing Diagnosis vs. Medical and Collaborative Diagnoses
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.
Nursing Diagnosis: This is the nurse’s professional judgment about a patient’s response to health conditions. It identifies problems that nurses can independently address within their scope of practice. For example, observing a patient coughing before swallowing, experiencing difficulty lifting their larynx, and reporting food getting “stuck” in their throat might lead to the nursing diagnosis: Impaired Swallowing. This diagnosis directs nursing interventions such as feeding techniques, diet modifications, and swallowing exercises.
Nursing Diagnosis Examples:
- Risk for unstable blood glucose level
- Urinary incontinence, functional
- Disturbed sleep pattern
- Decreased cardiac output
Medical Diagnosis: This is made by a physician or advanced practice provider and focuses on identifying diseases or pathological conditions. Medical diagnoses are concerned with the disease etiology and pathology, remaining constant throughout the patient’s medical history. For example, a patient exhibiting symptoms might receive a medical diagnosis of pneumonia. This diagnosis directs medical treatments like antibiotics, antiviral medications, or surgery.
Medical Diagnosis Examples:
- Myocardial infarction
- Pneumonia
- Type 2 Diabetes Mellitus
- Asthma
Collaborative Problems: These are potential or actual physiological complications that nurses monitor to detect onset or changes in status. They involve both nursing and medical interventions. Nurses manage collaborative problems using physician-prescribed and nurse-prescribed interventions to minimize complications. An example of a collaborative problem is potential complication: respiratory failure. Nurses monitor respiratory status, administer oxygen as prescribed, and collaborate with physicians for medical treatments.
Collaborative Diagnosis Examples:
- Potential Complication: Electrolyte Imbalance
- Potential Complication: Sepsis
- Potential Complication: Withdrawal
Classifying Nursing Diagnoses: NANDA-I Taxonomy II
To standardize and organize nursing diagnoses, NANDA-I developed Taxonomy II. This system categorizes diagnoses into a hierarchical structure consisting of 13 domains, 47 classes, and 267 specific nursing diagnoses. This classification ensures clarity and consistency in nursing practice and research.
Here’s a brief overview of the Domains and Classes within NANDA-I Taxonomy II:
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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
Four Main Categories of Nursing Diagnoses
NANDA-I further categorizes nursing diagnoses into four types, each serving a distinct purpose in patient care planning:
Problem-Focused Diagnosis (Actual Diagnosis): These 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 Diagnosis: These diagnoses identify patient vulnerabilities to developing health problems. They indicate that a problem doesn’t exist yet, but risk factors are present that increase the likelihood of it occurring without nursing intervention. A risk diagnosis includes two components: the risk diagnostic label and risk factors.
Health Promotion Diagnosis (Wellness Diagnosis): These diagnoses focus on a patient’s desire and motivation to improve their health status and well-being. They describe a readiness to enhance specific health behaviors in individuals, families, or communities. Health promotion diagnoses have two components: the diagnostic label and defining characteristics.
Syndrome Diagnosis: These diagnoses represent a cluster of nursing diagnoses that frequently occur together and are addressed with similar nursing interventions. Syndrome diagnoses are less common but useful for complex patient situations. A syndrome diagnosis has a diagnostic label only.
Here are examples of each type of nursing diagnosis, derived from NANDA-I’s “Nursing Diagnosis: Definitions and Classifications, 2021-2023”:
| Problem-Focused Diagnosis Examples | Risk Diagnosis Examples |
|---|---|
| – Acute Pain | – Risk for Infection |
| – Ineffective Breathing Pattern | – Risk for Falls |
| – Impaired Physical Mobility | – Risk for Pressure Ulcer |
| – Deficient Knowledge | – Risk for Aspiration |
| – Anxiety | – Risk for Spiritual Distress |
| Health Promotion Diagnosis Examples | Syndrome Diagnosis Examples |
| – Readiness for Enhanced Nutrition | – Rape-Trauma Syndrome |
| – Readiness for Enhanced Knowledge | – Relocation Stress Syndrome |
| – Readiness for Enhanced Power | – Impaired Environmental Interpretation Syndrome |
| – Readiness for Enhanced Family Coping | – Chronic Pain Syndrome |
| – Readiness for Enhanced Self-Care | – Post-Trauma Syndrome |
Key Components of a Nursing Diagnosis Statement
A well-written nursing diagnosis statement is essential for clear communication and effective care planning. The components included depend on the type of diagnosis. Here’s a breakdown of the components:
Diagnostic Label: This is a concise term or phrase representing the patient’s health problem. It’s standardized by NANDA-I to ensure universal understanding.
Examples: Ineffective Airway Clearance, Acute Pain, Impaired Skin Integrity.
Definition: Provides a clear, precise description of the diagnosis, differentiating it from similar diagnoses.
Example: For “Imbalanced Nutrition: Less Than Body Requirements,” the definition is: “Intake of nutrients insufficient to meet metabolic needs.”
Defining Characteristics: These are observable cues and inferences that cluster as manifestations of an actual diagnosis or health promotion diagnosis. They are the signs and symptoms the nurse identifies during assessment.
Example: For “Impaired Gas Exchange,” defining characteristics might include: abnormal arterial blood gases, cyanosis, confusion, and dyspnea.
Risk Factors: These are environmental, physiological, psychological, genetic, or chemical elements that increase a patient’s vulnerability to a potential health problem. They are only applicable to risk diagnoses.
Example: For “Risk for Infection,” risk factors may include: immunosuppression, chronic diseases (like diabetes), invasive procedures, and malnutrition.
Related Factors: These are conditions or circumstances that contribute to or are associated with a problem-focused nursing diagnosis. They can be pre-existing, associated with, or contribute to the diagnosis. Related factors are used only in problem-focused nursing diagnoses and sometimes in health promotion diagnoses.
Example: For “Ineffective Peripheral Tissue Perfusion,” related factors could include: hypertension, diabetes mellitus, smoking, and sedentary lifestyle.
Constructing Nursing Diagnosis Statements: Examples for Care Plans
Formulating accurate nursing diagnosis statements involves analyzing assessment data and using a standardized format. NANDA International recommends specific formats for each type of diagnosis to ensure clarity and consistency in nursing care plans.
Here are examples of how to write nursing diagnosis statements for each category, directly applicable to nursing care plans:
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Problem-Focused Diagnosis (P-E-S Format):
This format includes three parts: Problem (diagnostic label), Etiology (related factors), and Symptoms (defining characteristics).
Example 1: Ineffective Airway Clearance related to excessive mucus as evidenced by ineffective cough and abnormal breath sounds (rhonchi).
Example 2: Acute Pain related to surgical incision as evidenced by patient report of pain at 7/10, guarding behavior, and increased heart rate.
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Risk Diagnosis (Two-Part Statement):
This format includes two parts: Risk (risk diagnostic label) and Risk Factors.
Example 1: Risk for Infection as evidenced by break in skin integrity and invasive procedure (IV insertion).
Example 2: Risk for Falls as evidenced by history of falls and impaired mobility.
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Health Promotion Diagnosis (Two-Part Statement):
This format includes two parts: Diagnostic Label and Defining Characteristics.
Example 1: Readiness for Enhanced Nutrition as evidenced by patient expresses interest in learning about healthy eating and makes positive food choices.
Example 2: Readiness for Enhanced Knowledge (Medication Regimen) as evidenced by patient actively seeks information about medications and asks relevant questions.
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Syndrome Diagnosis (One-Part Statement):
This format uses only the Diagnostic Label. The defining characteristics and related factors are inherent in the syndrome diagnosis.
Examples: Rape-Trauma Syndrome, Relocation Stress Syndrome, Chronic Pain Syndrome. These diagnoses are used when a cluster of nursing diagnoses are present.
Additional Nursing Diagnosis Examples for Care Plan Development
To further assist in developing comprehensive nursing care plans, here are more nursing diagnosis examples categorized by common patient needs:
Activity and Exercise:
- Activity Intolerance
- Sedentary Lifestyle
- Impaired Transfer Ability
- Risk for Falls
Comfort:
- Chronic Pain
- Nausea
- Impaired Comfort
- Readiness for Enhanced Comfort
Coping and Stress Tolerance:
- Anxiety
- Ineffective Coping
- Stress Overload
- Post-Trauma Syndrome
Elimination:
- Constipation
- Bowel Incontinence
- Urinary Retention
- Diarrhea
Nutrition and Hydration:
- Imbalanced Nutrition: Less Than Body Requirements
- Risk for Deficient Fluid Volume
- Overweight
- Impaired Swallowing
Safety and Protection:
- Risk for Infection
- Impaired Skin Integrity
- Risk for Bleeding
- Risk for Injury
Self-Perception:
- Disturbed Body Image
- Chronic Low Self-Esteem
- Readiness for Enhanced Self-Concept
Sleep and Rest:
- Insomnia
- Sleep Deprivation
- Disturbed Sleep Pattern
Teaching and Learning:
- Deficient Knowledge
- Readiness for Enhanced Learning
- Noncompliance
By utilizing these nursing care plan diagnosis examples and understanding the principles of nursing diagnosis, nurses can create individualized, effective care plans that address the holistic needs of their patients, leading to improved health outcomes and patient satisfaction. Mastering nursing diagnosis is a cornerstone of professional nursing practice, ensuring safe, quality, and patient-centered care.
