Nursing diagnoses are fundamental to delivering high-quality patient care. They serve as the cornerstone of the nursing process, guiding nurses in addressing patient responses to medical conditions. This article delves into the concept of nursing diagnoses, exploring their significance, common examples, and how they differ from medical diagnoses. We will also provide a comprehensive Nursing Care Plan Diagnosis List to aid nurses in their practice.
Understanding Nursing Diagnosis
A nursing diagnosis is a clinical judgment made by a registered nurse. It identifies a patient’s health conditions, life processes, or vulnerabilities, and importantly, their response to these situations. According to NANDA International, Inc., the leading authority in standardized nursing diagnostic terminology, 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 selecting nursing interventions to achieve outcomes for which the nurse has accountability.”
This definition underscores the crucial role of nursing diagnoses in creating personalized and effective nursing care plans. It moves beyond simply identifying a disease (medical diagnosis) to understanding how that disease impacts the patient’s life and well-being.
Common Nursing Diagnoses Examples
Nurses collaborating in a healthcare setting, emphasizing teamwork and patient care. Nursing care plan diagnosis list relevance.
Nursing diagnoses cover a broad spectrum of patient needs. Some of the most frequently encountered diagnoses include:
- Pain Management:
- Chronic Pain
- Acute Pain
- Respiratory Function:
- Impaired Gas Exchange
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Infection Risk:
- Risk for Infection
- Activity & Mobility:
- Activity Intolerance
- Impaired Physical Mobility
- Mental Status & Well-being:
- Acute Confusion
- Anxiety
- Skin Integrity:
- Impaired Skin Integrity
- Cardiovascular Function:
- Decreased Cardiac Output
- Gastrointestinal Function:
- Diarrhea
This list is not exhaustive but provides a glimpse into the diverse range of issues nurses address through nursing diagnoses and subsequent care plans.
Medical Diagnosis vs. Nursing Diagnosis
It’s crucial to differentiate between medical and nursing diagnoses. A medical diagnosis is established by physicians or advanced practitioners to identify a specific disease, injury, or condition. It focuses on the pathology of the illness.
In contrast, a nursing diagnosis centers on the patient’s response to their medical condition. Registered Nurses are responsible for formulating these diagnoses. While a medical diagnosis is a prerequisite for a nursing diagnosis, the latter delves into the patient’s lived experience of their health issues.
For instance, patients with the same medical diagnosis, such as diabetes, may have vastly different nursing diagnoses. One patient might struggle with “Ineffective Health Management” due to lack of knowledge about diabetes self-care, while another may experience “Risk for Impaired Skin Integrity” due to diabetic neuropathy. The nursing diagnosis captures the individual patient’s unique needs and challenges.
The Nursing Process: A Framework for Diagnosis
The nursing process is a systematic, five-step approach that guides nurses in providing patient-centered care. Nursing diagnosis is the second critical step within this process:
- Assessment: Gathering comprehensive patient data – physiological, psychological, social, cultural, lifestyle, economic, and spiritual aspects are all considered. A thorough head-to-toe assessment is a key component of this stage.
- Diagnosis: Formulating nursing diagnoses based on clinical judgment and the patient’s condition. This step directly informs the nursing care plan.
- Outcomes/Planning: Setting patient-centered goals and developing a treatment plan to achieve desired outcomes. This plan is built upon the identified nursing diagnoses.
- Implementation: Executing the nursing interventions outlined in the care plan. This includes actions like medication administration, patient education, and vital sign monitoring.
- Evaluation: Continuously assessing the patient’s progress and the effectiveness of the care plan. Adjustments to the plan are made based on this ongoing evaluation.
Understanding the 7 Diagnostic Axes
To ensure comprehensive and standardized nursing diagnoses, NANDA International utilizes a seven-axis system, aligned with the International Standards Reference Model for Nursing Diagnosis. These axes represent different dimensions of the patient’s response that nurses must consider:
Axis 1: Diagnostic Focus
This is the core concept of the nursing diagnosis – the patient’s response itself. It could be a single word or phrase like “anxiety,” “impaired mobility,” or “knowledge deficit.”
Axis 2: Subject of Diagnosis
This specifies who the diagnosis is about. It could be:
- Individual: The patient themselves.
- Caregiver: Focuses on the caregiver’s needs and responses.
- Family: Addresses family dynamics and responses to a member’s health.
- Group: Relevant in community or group health settings.
- Community: Broader population-level diagnoses.
Axis 3: Judgment
This is a modifier that clarifies the diagnostic focus, such as “ineffective,” “impaired,” “readiness for enhanced.” It adds specificity to the diagnosis.
Axis 4: Location
Specifies the body part or function affected, e.g., “cardiac,” “respiratory,” “urinary.”
Axis 5: Age
Considers the patient’s age group: fetus, neonate, infant, child, adolescent, adult, older adult. Age is a significant factor influencing health responses.
Axis 6: Time
Describes the duration of the issue: acute (less than 3 months), chronic (more than 3 months), intermittent, or continuous.
Axis 7: Status of Diagnosis
Categorizes the type of nursing diagnosis: problem-focused, health promotion, risk, or syndrome.
While not all axes are explicitly stated in every diagnosis, understanding them ensures a thorough and well-rounded diagnostic process.
Types of Nursing Diagnoses for Care Plans
Nurses utilize four main types of nursing diagnoses to develop effective care plans:
1. Problem-Focused Nursing Diagnosis
This type identifies existing problems – undesirable patient responses to health conditions. They are supported by defining characteristics (signs and symptoms) and related factors (etiological factors contributing to the problem). An example is “Acute Pain related to surgical incision as evidenced by patient report of pain at 7/10 and guarding behavior.”
2. Health-Promotion Nursing Diagnosis
These diagnoses focus on a patient’s desire to improve their well-being and health potential. They are applicable to any health state when a patient expresses readiness to enhance their health. For example, “Readiness for Enhanced Nutrition as evidenced by patient expressing interest in learning about healthy eating habits.”
3. Risk Nursing Diagnosis
Risk diagnoses identify vulnerabilities – potential problems a patient is susceptible to developing. They are supported by risk factors that increase vulnerability. An example is “Risk for Infection related to surgical incision and invasive procedures.”
4. Syndrome Nursing Diagnosis
Syndrome diagnoses are used when a cluster of nursing diagnoses frequently occur together and can be addressed with similar interventions. For example, “Disuse Syndrome” might encompass diagnoses like “Risk for Impaired Skin Integrity,” “Constipation,” and “Impaired Physical Mobility” in an immobilized patient.
NANDA Nursing Diagnosis List Examples by Domain
The NANDA-I nursing diagnosis list is organized by domains, encompassing various aspects of human health. Here are examples across different domains, demonstrating the breadth of nursing diagnoses relevant to creating a nursing care plan diagnosis list:
| Domain | Class | Examples of Nursing Diagnoses
