Understanding Potential Nursing Diagnosis: A Comprehensive Guide for Nurses

Nursing diagnosis is a cornerstone of effective patient care. It serves as a critical tool for nurses and the broader healthcare team, guiding personalized interventions and promoting optimal patient outcomes.

This guide provides an in-depth exploration of nursing diagnosis, with a particular focus on potential nursing diagnoses, often referred to as risk diagnoses. We will delve into the role of diagnosis within the nursing process, explore different types and classifications, and provide practical insights on formulating and utilizing nursing diagnoses to enhance patient care.

Let’s begin by understanding the foundational concept: the nursing process.

The Nursing Process: A Framework for Patient Care

Before we can fully grasp the significance of nursing diagnosis, it’s essential to understand its place within the nursing process. This systematic approach to patient care consists of five interconnected steps, with diagnosis as the crucial second step.

1. Assessment: This initial phase involves a thorough evaluation of the patient. Nurses gather comprehensive data, including vital signs, medical history, psychological status, and socioeconomic factors. This holistic assessment forms the basis for subsequent steps.

2. Diagnosis: Following the assessment, nurses analyze the collected data to formulate a nursing diagnosis. This clinical judgment identifies the patient’s health problems, risks, and needs that nurses are qualified and licensed to treat. A key aspect of nursing diagnosis includes identifying potential problems, or risks, which we will explore in detail. The nursing diagnosis directly informs the individualized nursing care plan.

3. Outcomes and Planning: In this stage, nurses develop a patient-centered care plan based on the nursing diagnosis. This plan outlines specific, measurable, achievable, relevant, and time-bound (SMART) goals and nursing interventions designed to address the identified needs and achieve desired patient outcomes.

4. Implementation: This is the action phase where the nursing care plan is put into practice. Nurses implement the planned interventions, continually monitoring the patient’s response and making adjustments as needed. This phase continues throughout the patient’s care, from admission to discharge.

5. Evaluation: The final step involves evaluating the effectiveness of the care plan in achieving the established goals and outcomes. Nurses assess the patient’s progress, analyze the results of interventions, and determine if the care plan needs modification. This iterative process ensures continuous improvement and patient-centered care.

Defining Nursing Diagnosis: A Clinical Judgment

As highlighted earlier, a nursing diagnosis is a critical step in the nursing process. It represents a structured and evidence-based method for nurses to communicate their professional clinical judgments about patients to other healthcare professionals, patients themselves, and the wider public. Nursing diagnoses are derived from the comprehensive data gathered during the assessment phase. They serve as the foundation for developing individualized care plans and subsequently evaluating the effectiveness of care.

NANDA International (NANDA-I), the globally recognized authority in nursing diagnosis, provides a standardized language and classification system. According to NANDA-I, the formal definition of a nursing diagnosis is:

“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 underscores the crucial aspect of vulnerability, directly relating to potential nursing diagnoses or risk diagnoses. Nurses are not only concerned with existing problems but also proactively identify and address potential health issues before they arise.

Differentiating Nursing Diagnosis from Other Diagnoses

It’s important to distinguish nursing diagnosis from other types of diagnoses encountered in healthcare settings. The primary distinctions lie between nursing diagnosis, medical diagnosis, and collaborative problems.

A nursing diagnosis focuses on the patient’s response to health conditions or life processes. It describes a patient’s health state or vulnerability from a nursing perspective, identifying areas where nurses can independently intervene to promote health, prevent problems, or facilitate coping. Nurses use NANDA-I approved diagnoses to label patient data gathered during assessment. For example, observing a patient coughing before swallowing, exhibiting poor laryngeal elevation, and reporting a sensation of “food stuck” in their throat might lead to the nursing diagnosis: Impaired Swallowing.

Examples of nursing diagnoses: Risk for Infection, Acute Pain, Impaired Physical Mobility, Anxiety.

A medical diagnosis, on the other hand, is made by a physician or advanced medical practitioner. It identifies a disease, pathology, or medical condition. Medical diagnoses focus on the etiology of disease and remain relatively constant throughout the patient’s medical history. Medical diagnoses guide medical treatment, while nursing diagnoses guide nursing care.

Examples of medical diagnoses: Pneumonia, Diabetes Mellitus, Myocardial Infarction, Appendicitis.

Collaborative problems are certain physiological complications that are monitored by nurses but require both medical and nursing interventions. These are potential or actual complications of medical diagnoses or treatments. Nurses monitor for the onset of collaborative problems and implement physician-prescribed and nursing-prescribed interventions to minimize complications.

Examples of collaborative problems: Complications of surgery, Side effects of chemotherapy, Unstable blood glucose related to diabetes mellitus.

The NANDA-I Nursing Diagnosis Classification System

To ensure clarity and consistency, nursing diagnoses are organized within a standardized classification system. NANDA-I’s Taxonomy II provides a hierarchical structure for organizing diagnoses. This system is organized into three levels:

• Domains (13): Broad areas of human experience, such as Health Promotion, Nutrition, Activity/Rest, Safety/Protection, etc.
• Classes (47): Subcategories within each domain, providing more specific groupings, such as Health Management (within Health Promotion), Ingestion (within Nutrition), Sleep/Rest (within Activity/Rest), Infection (within Safety/Protection).
• Nursing Diagnoses (267): Specific, standardized diagnostic labels within each class, such as Readiness for Enhanced Health Management, Imbalanced Nutrition: Less Than Body Requirements, Insomnia, Risk for Infection.

Here is a summary of the NANDA-I Domains and Classes to illustrate the comprehensive scope of nursing diagnoses:

• 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: Problem-Focused, Risk, Health Promotion, and Syndrome

NANDA-I further categorizes nursing diagnoses into four main types, each serving a distinct purpose in guiding nursing care. Understanding these categories is crucial for selecting the most appropriate diagnosis for a given patient situation, especially when considering potential nursing diagnoses.

1. Problem-Focused Diagnoses: These diagnoses, also known as actual diagnoses, describe existing patient problems that are present at the time of assessment. They are supported by defining characteristics – observable signs and symptoms. A problem-focused diagnosis has three components:

   • Diagnostic Label: The NANDA-I approved name for the diagnosis (e.g., Acute Pain).
   • Related Factors: Factors contributing to or associated with the problem (e.g., surgical incision).
   • Defining Characteristics: Observable cues and symptoms that indicate the presence of the problem (e.g., patient report of pain, guarding behavior).

2. Risk Diagnoses (Potential Nursing Diagnoses): These diagnoses are clinical judgments about a patient’s vulnerability to developing a problem. They indicate that a problem does not currently exist, but risk factors are present that increase the likelihood of the problem occurring if nurses do not intervene. Risk diagnoses are crucial for preventative care. They have two components:

   • Risk Diagnostic Label: The NANDA-I approved name, often starting with “Risk for” (e.g., Risk for Infection).
   • Risk Factors: Factors that increase the patient’s vulnerability to the potential problem (e.g., presence of invasive devices, compromised immune system).

3. Health Promotion Diagnoses: These diagnoses focus on a patient’s desire and motivation to improve their well-being and optimize their health. They identify a patient’s readiness to enhance specific health behaviors. Health promotion diagnoses 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 nursing interventions. Syndrome diagnoses recognize patterns of problems rather than isolated issues.

The table below provides examples of each type of nursing diagnosis, drawn from the NANDA-I resource, Nursing Diagnosis: Definitions and Classifications, 2021-2023.

Problem-Focused Diagnosis	Risk Diagnosis (Potential Nursing Diagnosis)	Health Promotion Diagnosis	Syndrome Diagnosis
– Decisional Conflict	– Risk for Chronic Functional Constipation	– Readiness for Enhanced Spiritual Well-Being	– Frail Elderly Syndrome
– Ineffective Airway Clearance	– Risk for Acute Confusion	– Readiness for Enhanced Coping	– Chronic Pain Syndrome
– Impaired Oral Mucous Membrane Integrity	– Risk for Autonomic Dysreflexia	– Readiness for Enhanced Self-Care	– Disturbed Family Identity Syndrome
– Hyperthermia	– Risk for Adult Falls	– Readiness for Enhanced Parenting	– Relocation Stress Syndrome
– Dysfunctional Ventilatory Weaning Response	– Risk for Peripheral Neurovascular Dysfunction	– Readiness for Enhanced Exercise Engagement	– Post-Trauma Syndrome

Key Components of a Nursing Diagnosis Statement

Regardless of the category, a well-written nursing diagnosis statement includes specific components. These components ensure clear communication and provide a comprehensive picture of the patient’s needs. The components may vary slightly depending on the diagnosis type, but generally include:

• Diagnostic Label: A concise name that represents the focus of the diagnosis and the nursing judgment. Examples: Ineffective Health Management, Acute Pain, Risk for Impaired Skin Integrity.

• Definition: A clear and precise description of the diagnosis, which helps differentiate 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, inferences, and symptoms that cluster as manifestations of a problem-focused diagnosis, health promotion diagnosis, or syndrome. These are the “evidence” that supports the diagnosis. Example: For “Impaired Gas Exchange,” defining characteristics might include: abnormal arterial blood gases, abnormal skin color (pallor, cyanosis), and headache upon awakening.

• Risk Factors: Environmental, physiological, psychological, genetic, or chemical elements that increase a patient’s vulnerability to a risk diagnosis. 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 are associated with a problem-focused nursing diagnosis or syndrome. Related factors are not used in risk diagnoses (as the problem doesn’t yet exist). Example: For “Ineffective Peripheral Tissue Perfusion,” related factors might include hypertension, diabetes mellitus, smoking, or sedentary lifestyle.

Formulating a Nursing Diagnosis Statement: A Step-by-Step Approach

Accurate and well-formulated nursing diagnosis statements are essential for effective care planning. NANDA International recommends using specific formats to ensure clarity, precision, and validity. The format varies slightly depending on the type of diagnosis.

Here are examples of how to write nursing diagnosis statements for each category:

• Problem-Focused Diagnosis (using a three-part statement: Problem + Related to + As evidenced by):

  Impaired Bed Mobility related to musculoskeletal impairment as evidenced by impaired ability to reposition self in bed.

  Constipation related to inadequate toileting habits as evidenced by change in bowel pattern.

• Risk Diagnosis (Potential Nursing Diagnosis) (using a two-part statement: Problem + As evidenced by/Risk factors):

  Risk for Decreased Cardiac Output as evidenced by alteration in heart rhythm.

  Risk for Adult Pressure Injury as evidenced by inadequate adherence to incontinence treatment regimen.

• Health Promotion Diagnosis (using a two-part statement: Diagnosis label + As evidenced by):

  Readiness for Enhanced Knowledge as evidenced by expressed interest in learning and asks questions about their condition. (Example modified from original article structure for clarity)

  Ineffective Family Health Self-Management as evidenced by difficulty with the prescribed regimen. (This example is slightly adapted to better fit the Health Promotion category as the original example seemed more problem-focused, but it illustrates the two-part structure).

• Syndrome Diagnosis (using a one-part statement: Syndrome Label):

  Post-Trauma Syndrome

  Chronic Pain Syndrome

Expanding Your Nursing Diagnosis Vocabulary: Additional Examples

The NANDA-I list is a comprehensive resource with 267 diagnoses, providing a robust tool for nurses worldwide. We have explored several examples throughout this guide. Here are additional examples of nursing diagnoses across different categories to further enhance your understanding and application in care planning:

• 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/Dressing/Feeding 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: Enhancing Patient Care

Nursing diagnoses, including the critical consideration of potential nursing diagnoses (risk diagnoses), are invaluable tools that empower nurses to deliver safe, high-quality, and evidence-based care. They are fundamental to patient-centered healthcare, enabling nurses to proactively address patient needs, prevent potential problems, and promote optimal health outcomes. Proficiency in formulating and utilizing nursing diagnoses is an essential competency for every nurse, contributing directly to improved patient well-being and the overall effectiveness of healthcare delivery.