Nursing Diagnosis Examples: A Comprehensive Guide for Healthcare Professionals

A nursing diagnosis is a cornerstone of effective patient care. It serves as a critical tool for nurses and the broader healthcare team, guiding interventions and ensuring patient needs are accurately addressed.

This in-depth guide explores everything you need to understand about nursing diagnoses. We will cover the role of nursing diagnosis within the nursing process, delve into different types and classifications, and provide practical guidance on writing and utilizing nursing diagnoses effectively. We will also focus heavily on Nursing Diagnosis Examples to illustrate key concepts.

Let’s begin by understanding the framework in which nursing diagnosis operates: the nursing process.

Understanding the Nursing Process

Before diving into nursing diagnosis itself, it’s essential to grasp its place within the broader nursing process. The nursing process is a systematic, five-step approach that nurses use to provide patient care. Diagnosis is the crucial second step.

1. Assessment: This initial phase involves a comprehensive evaluation of the patient. Nurses gather a wide range of data, including vital signs, medical history, psychological and social assessments, and more. This thorough data collection forms the foundation for the subsequent steps.

2. Diagnosis: Following assessment, nurses analyze the collected data to formulate a nursing diagnosis. This diagnosis is a clinical judgment that identifies specific health problems or vulnerabilities that nursing interventions can address. The nursing diagnosis example of “Impaired Swallowing” discussed later in this article is a direct outcome of this step.

3. Outcomes and Planning: Based on the nursing diagnosis, the nurse develops a patient-centered care plan. This plan outlines measurable goals and specific nursing interventions designed to achieve those outcomes. Planning is crucial for providing targeted and effective care.

4. Implementation: This is the action phase where the care plan is put into practice. Nurses implement the planned interventions throughout the patient’s care, from admission to discharge. This step requires ongoing monitoring and adjustment as needed.

5. Evaluation: The final step involves evaluating the effectiveness of the care plan. Nurses assess whether the desired outcomes have been achieved and if the interventions were successful. If necessary, the care plan is revised based on the evaluation findings and the patient’s evolving needs.

Defining Nursing Diagnosis

As established, nursing diagnosis is a vital stage in the nursing process. It is a structured and evidence-based method for nurses to articulate their professional clinical judgments to patients, fellow nurses, other healthcare professionals, and the wider public. It is derived from the data gathered during the assessment phase. Importantly, a well-formulated nursing diagnosis then directs the creation of a personalized care plan, which subsequently allows for the measurement of patient care outcomes.

NANDA International (NANDA-I), the globally recognized authority, standardizes nursing diagnosis terminology and processes. NANDA-I defines a nursing diagnosis 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.”

This definition emphasizes that nursing diagnoses focus on human responses to health issues, rather than the medical disease itself. Understanding this distinction is key to differentiating nursing diagnosis from other types of diagnoses.

Distinguishing Nursing Diagnosis from Other Diagnoses

It’s crucial to differentiate nursing diagnosis from other forms of diagnosis encountered in healthcare. The primary distinctions lie between nursing diagnoses, medical diagnoses, and collaborative problems.

A nursing diagnosis, as we’ve discussed, is formulated by nurses to describe a patient’s health condition from a nursing perspective. It focuses on the patient’s response to illness or life situations. Nurses use NANDA-I approved diagnoses to label patient data collected during assessment. For example, observing a patient cough before swallowing, exhibit poor laryngeal elevation, and report food feeling “stuck” leads to the nursing diagnosis example of Impaired Swallowing.

Further Nursing Diagnosis Examples:

• Risk for Unstable Blood Glucose Level
• Urinary Incontinence, Functional
• Disturbed Sleep Pattern
• Decreased Cardiac Output

Conversely, a medical diagnosis is made by a physician or advanced medical practitioner. It identifies a disease, pathology, or medical condition and falls within the medical domain of expertise. Medical diagnoses are typically more fixed and represent the underlying pathology.

Examples of Medical Diagnoses:

• Myocardial Infarction
• Pneumonia
• Chronic Kidney Disease
• Diabetes Mellitus Type 2

Collaborative Problems (often incorrectly termed “collaborative diagnoses”) are certain physiological complications that nurses monitor to detect onset or changes in status. If these problems are detected, nurses manage them using physician-prescribed and nurse-prescribed interventions to minimize complications. They are not nursing diagnoses because they are primarily medical problems. An example is “Risk for Complications of Medication Therapy.” While nurses monitor and intervene, the primary management often involves medical interventions.

Nursing Diagnosis Classifications: NANDA-I Taxonomy II

To ensure clarity and organization, nursing diagnoses are systematically classified by NANDA-I within Taxonomy II. This hierarchical system, refined over two decades, provides a standardized structure. Taxonomy II is organized into three levels:

• 13 Domains: Broad areas of human experience (e.g., Health Promotion, Nutrition, Activity/Rest).
• 47 Classes: Subcategories within domains (e.g., within Nutrition: Ingestion, Digestion, Metabolism).
• 267 Nursing Diagnoses: Specific, standardized diagnostic labels.

Here’s a concise overview of the Domains and Classes within NANDA-I Taxonomy II:

• 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

Categories of Nursing Diagnoses

NANDA-I categorizes nursing diagnoses into four main types, each serving a distinct purpose in patient care:

1. Problem-Focused Diagnoses (Actual Diagnoses): These diagnoses describe existing patient problems identified during assessment. They are supported by defining signs and symptoms. A problem-focused diagnosis has three components: the diagnosis label, related factors, and defining characteristics.

2. Risk Diagnoses: These are clinical judgments about a patient’s vulnerability to developing a problem. The problem is not yet present, but risk factors indicate a potential issue. Risk diagnoses have two components: a risk diagnostic label and risk factors. A nursing diagnosis example here is “Risk for Infection” in a post-operative patient.

3. Health Promotion Diagnoses (Wellness Diagnoses): These diagnoses focus on a patient’s desire and motivation to improve their health and well-being. They indicate a readiness to enhance specific health behaviors and can be applied to individuals, families, groups, or communities.

4. Syndrome Diagnoses: These diagnoses represent a cluster of nursing diagnoses that frequently occur together and are addressed with similar interventions. They are less common than other categories.

The table below provides nursing diagnosis examples for each category, drawn from NANDA-I’s Nursing Diagnosis: Definitions and Classifications, 2021-2023:

Problem Focused Diagnosis	Risk Diagnosis
– Decisional conflict	– Risk for chronic functional constipation
– Ineffective airway clearance	– Risk for acute confusion
– Impaired oral mucous membrane integrity	– Risk for autonomic dysreflexia
– Hyperthermia	– Risk for adult falls
– Dysfunctional ventilatory weaning response	– Risk for peripheral neurovascular dysfunction
Health Promotion Diagnosis	Syndrome Diagnosis
– Readiness for enhanced spiritual well-being	– Frail elderly syndrome
– Readiness for enhanced coping	– Chronic pain syndrome
– Readiness for enhanced self-care	– Disturbed family identity syndrome
– Readiness for enhanced parenting	– Relocation stress syndrome
– Readiness for enhanced exercise engagement	– Post-trauma syndrome

Components of a Nursing Diagnosis Statement

A well-written nursing diagnosis statement includes specific components. These components can vary depending on the diagnosis type, but generally encompass the following:

• Diagnostic Label: This is the standardized name for the nursing diagnosis, reflecting the focus of the diagnosis.

  • Examples: Ineffective Health Management; Acute Pain; Impaired Skin Integrity.

• Definition: A clear and 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: Observable cues and inferences that cluster as manifestations of an actual diagnosis, health promotion diagnosis, or syndrome. These are the signs and symptoms the nurse identifies.

  • Example: For “Impaired Gas Exchange,” defining characteristics may include: abnormal arterial blood gases, cyanosis, and headache upon awakening.

• Risk Factors: Environmental, physiological, psychological, genetic, or chemical elements that increase a patient’s vulnerability to a potential health problem. Only applicable to risk diagnoses.

  • Example: For “Risk for Infection,” risk factors could include: chronic illness (e.g., diabetes), inadequate vaccination, invasive procedures, malnutrition.

• Related Factors: Conditions, circumstances, or etiologies that contribute to or show a patterned relationship with a problem-focused diagnosis or syndrome. Primarily used with problem-focused diagnoses.

  • Example: For “Ineffective Peripheral Tissue Perfusion,” related factors might include: hypertension, diabetes mellitus, smoking, or sedentary lifestyle.

How to Formulate a Nursing Diagnosis Statement

Formulating an accurate nursing diagnosis involves careful data analysis and a structured approach. NANDA International recommends a specific format for diagnosis statements to ensure clarity, precision, and validity. The format varies slightly depending on the type of diagnosis. Here are examples of how to write each type, incorporating nursing diagnosis examples:

1. Problem-Focused Diagnosis (using a three-part statement – PES):

• P (Problem): The NANDA-I diagnostic label (e.g., Impaired Bed Mobility).

• E (Etiology/Related Factors): The “related to” phrase, indicating contributing factors (e.g., musculoskeletal impairment).

• S (Signs/Symptoms/Defining Characteristics): The “as evidenced by” phrase, listing observable data (e.g., impaired ability to reposition self in bed).

  • Example: Impaired bed mobility related to musculoskeletal impairment as evidenced by impaired ability to reposition self in bed.

  • Another Example: Constipation related to inadequate toileting habits as evidenced by change in bowel pattern.

2. Risk Diagnosis (using a two-part statement – PR):

• P (Problem): The NANDA-I diagnostic label, preceded by “Risk for” (e.g., Risk for Decreased Cardiac Output).

• R (Risk Factors): The “as evidenced by” phrase, listing risk factors (e.g., alteration in heart rhythm).

  • Example: Risk for decreased cardiac output as evidenced by alteration in heart rhythm.

  • Another Example: Risk for adult pressure injury as evidenced by Inadequate adherence to incontinence treatment regimen.

3. Health Promotion Diagnosis (using a two-part statement – PE, or sometimes just the label):

• P (Problem): The NANDA-I diagnostic label, often preceded by “Readiness for Enhanced” (e.g., Readiness for Enhanced Family Coping).

• E (Evidence/Defining Characteristics): The “as evidenced by” phrase, listing cues indicating readiness (e.g., expresses willingness to enhance family coping). Sometimes this is implied and just the label is used.

  • Example: Readiness for enhanced family coping as evidenced by expresses willingness to enhance family coping.

  • Simplified Example (Label only): Sedentary lifestyle (Implies readiness for enhanced activity).

4. Syndrome Diagnosis (typically just the label is used, as it’s a cluster of diagnoses):

• Label: The NANDA-I syndrome diagnosis label (e.g., Post-Trauma Syndrome, Chronic Pain Syndrome). The definition of the syndrome inherently includes the related cluster of nursing diagnoses.

  • Examples: Post-trauma syndrome; Chronic pain syndrome.

Additional Nursing Diagnosis Examples for Care Planning

The NANDA-I list offers a comprehensive resource with 267 diagnoses, providing nurses with a robust toolkit for care planning. We’ve already used numerous nursing diagnosis examples throughout this guide. Here are further examples from the NANDA-I handbook (2021-2023) to broaden your understanding and application:

• Decreased Activity Tolerance
• Risk for Surgical Site Infection
• Deficient Knowledge
• Decreased Cardiac Output
• Deficient Fluid Volume
• Ineffective Coping
• Acute Pain
• Ineffective Thermoregulation
• Ineffective Breathing Pattern
• Risk for Electrolyte Imbalance
• Bathing Self-Care Deficit
• Risk for Ineffective Childbearing Process
• Risk for Injury
• Fatigue
• Impaired Physical Mobility
• Ineffective Airway Clearance
• Readiness for Enhanced Communication
• Impaired Comfort
• Obesity
• Risk for Metabolic Syndrome
• Disturbed Body Image
• Deficient Community Health
• Neonatal Hypothermia
• Risk for Bleeding
• Risk for Vascular Trauma

Mastering Nursing Diagnosis: A Key to Quality Care

Nursing diagnoses are indispensable tools for nurses, enabling the delivery of safe, high-quality, and evidence-based patient care. Proficiency in understanding, formulating, and utilizing nursing diagnoses is a fundamental skill for every nurse. By mastering this critical component of care, nurses can significantly enhance patient outcomes and contribute to a more effective and patient-centered healthcare system.