What is a Nursing Diagnosis?
In healthcare, a nursing diagnosis stands as a critical clinical judgment. It pinpoints a patient’s response to health conditions, life processes, or their vulnerability to such responses. This judgment applies not just to individuals, but also to families, groups, and communities. The essence of a nursing diagnosis is to lay the groundwork for selecting effective nursing interventions. These interventions are designed to achieve specific patient outcomes, for which nurses are accountable. Nursing diagnoses are meticulously crafted from data gathered during a thorough nursing assessment. This assessment is the cornerstone that enables nurses to formulate and implement personalized nursing care plans.
The Importance of Nursing Diagnosis
Nursing diagnosis serves several vital purposes in healthcare:
- Enhancing Critical Thinking: For nursing students, engaging with nursing diagnoses is an invaluable educational exercise. It sharpens their problem-solving abilities and cultivates critical thinking skills essential for patient care.
- Prioritizing Care: Nursing diagnoses play a crucial role in identifying immediate nursing priorities. This prioritization directly informs and guides nursing interventions, ensuring that the most pressing needs are addressed promptly and effectively.
- Quality Assurance and Accountability: Nursing diagnoses are instrumental in formulating expected patient outcomes. These outcomes are essential for meeting quality assurance standards, particularly for third-party payers who require evidence of effective and goal-oriented care.
- Understanding Patient Responses: By using nursing diagnoses, healthcare professionals can better understand how patients or groups react to both existing and potential health challenges. It also highlights the resources and strengths patients possess that can be leveraged to overcome or prevent health issues.
- Facilitating Communication: Nursing diagnoses provide a standardized language, fostering clear and effective communication among nursing professionals and the broader healthcare team. This common language is vital for collaborative patient care.
- Evaluating Care Effectiveness: Nursing diagnoses form a basis for evaluation, allowing healthcare providers to determine the effectiveness and cost-efficiency of the nursing care provided. This evaluation loop is crucial for continuous improvement in patient care delivery.
Nursing Diagnosis vs. Medical Diagnosis vs. Collaborative Problems
It’s essential to distinguish nursing diagnoses from other related healthcare terms. The term itself can refer to the second step in the nursing process, the ‘Diagnosis’ phase within the ADPIE (Assess, Diagnose, Plan, Implement, Evaluate) framework. Furthermore, “nursing diagnosis” is the label assigned when nurses interpret collected patient data and categorize it appropriately. For example, a nurse assessing a patient might note feelings of anxiety, fear, and sleep disturbances. These observations lead to nursing diagnoses such as Anxiety, Fear, and Disturbed Sleep Pattern. Here, the nursing diagnosis is rooted in the patient’s response to their medical condition. It’s termed ‘nursing diagnosis’ because it addresses areas where nurses have the autonomy to act, independent of specific medical treatments for a disease. This encompasses physical, mental, and emotional responses, making nursing diagnosis fundamentally care-focused.
COMPARISON: Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems
Conversely, a medical diagnosis is the domain of physicians or advanced practitioners. It concentrates on diseases, medical conditions, or pathological states that only medical practitioners are qualified to treat. Through their expertise, doctors pinpoint the precise clinical entity causing the illness, enabling them to prescribe appropriate medication and treatments to cure the disease. Examples include Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. Medical diagnoses generally remain constant. Nurses are responsible for adhering to physician’s orders and implementing prescribed medical treatments and therapies.
Collaborative problems represent potential complications managed by nurses using a blend of independent nursing interventions and physician-prescribed treatments. These are conditions demanding both medical and nursing interventions. The nursing role primarily involves vigilant monitoring of the patient’s condition and proactive prevention of potential complications.
As outlined, the distinction becomes clearer: nursing diagnosis is patient-centered, focusing on physiological and psychological responses, while medical diagnosis is disease-centered, focusing on the illness itself.
Taxonomy II: Classifying Nursing Diagnoses
Nursing diagnoses are systematically organized using a classification system. In 2002, Taxonomy II was adopted, based on Dr. Mary Joy Gordon’s Functional Health Patterns. Taxonomy II is structured into three levels: 13 Domains, 47 Classes, and the individual nursing diagnoses. This system moved away from Gordon’s patterns, instead coding diagnoses across seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology. Diagnoses are now listed alphabetically by concept, not the first word.
NURSING DIAGNOSIS TAXONOMY II. Taxonomy II organizes nursing diagnoses into 13 domains and 47 classes, providing a structured framework for nursing practice. Image source: Wikipedia.com
Here’s a glimpse into the Domains and Classes:
- 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
The Nursing Process and Diagnosis
The nursing process, a cornerstone of patient care, comprises five interconnected stages: assessment, diagnosing, planning, implementation, and evaluation. Critical thinking is paramount in each step. Beyond simply understanding nursing diagnoses, nurses must recognize the defining characteristics, related factors, and appropriate interventions for each diagnosis.
For a deeper understanding of the steps, significance, and characteristics of the nursing process, refer to: “The Nursing Process: A Comprehensive Guide“
Types of Nursing Diagnoses: Focusing on Risk Diagnosis
Nursing diagnoses are categorized into four main types: Actual (Problem-Focused), Risk, Health Promotion, and Syndrome. Among these, risk diagnosis is particularly vital for preventive care.
TYPES OF NURSING DIAGNOSES. Understanding the four types—Actual, Risk, Health Promotion, and Syndrome—is crucial for effective nursing practice.
Problem-Focused Nursing Diagnosis
A problem-focused diagnosis, also known as an actual diagnosis, identifies a present client problem at the time of nursing assessment. It’s confirmed by observable signs and symptoms. It’s crucial to note that actual diagnoses are not inherently more critical than risk diagnoses. In many cases, a risk diagnosis may hold the highest priority for a patient, especially in preventative care.
Problem-focused nursing diagnoses have three components: (1) the nursing diagnosis label, (2) related factors contributing to the problem, and (3) defining characteristics, the signs and symptoms. Examples include: (Examples were removed as the focus is Risk Diagnosis)
Risk Nursing Diagnosis: Proactive Patient Care
The risk nursing diagnosis is a clinical judgment that a problem does not currently exist. However, it identifies the presence of risk factors that significantly increase the likelihood of a problem developing if no nursing intervention is implemented. A risk diagnosis is grounded in the patient’s current health status, health history, and other risk factors that elevate their susceptibility to health issues. These diagnoses are integral to proactive nursing care, enabling early identification of potential problems and allowing nurses to implement preventive measures or mitigate risks.
Unlike problem-focused diagnoses, risk diagnoses do not have etiological (related) factors in the traditional sense. Instead, the focus is on risk factors. These factors make an individual or group more vulnerable to developing a specific problem compared to others in similar situations. For instance, an elderly patient with diabetes and vertigo, who struggles with walking and refuses assistance during ambulation, would be appropriately diagnosed with Risk for Injury or Risk for Falls.
KEY POINT: For risk nursing diagnoses, the phrase “as evidenced by” connects the risk diagnosis label directly to the risk factors, not to defining characteristics, as there are no current signs or symptoms. Therefore, the components of a risk nursing diagnosis are:
- Risk diagnostic label, linked by “as evidenced by”
- Risk factors
Examples of risk nursing diagnoses are:
- Risk for Injury as evidenced by impaired cognitive awareness and use of sedative medications.
- Risk for Infection as evidenced by surgical wound, compromised immune system, and prolonged hospitalization.
- Risk for Falls as evidenced by muscle weakness, history of previous falls, impaired mobility, and use of assistive devices.
Risk diagnosis is paramount in creating effective nursing care plans. By identifying potential problems before they occur, nurses can tailor care plans to include preventive strategies. This proactive approach is especially critical in areas like fall prevention, infection control, and managing complications in chronic conditions. A well-constructed Risk Diagnosis Nursing Care Plan not only addresses current needs but also anticipates and mitigates future health risks, significantly improving patient outcomes and safety.
Health Promotion Diagnosis
Health promotion diagnosis, also known as wellness diagnosis, is a clinical judgment concerning a patient’s motivation and desire to enhance their well-being. It’s a positive statement that identifies a patient’s readiness to engage in health-promoting activities. For example, a new mother eager to learn about breastfeeding could receive a health promotion diagnosis of “Readiness for Enhanced Breastfeeding.” This diagnosis then guides nursing interventions aimed at supporting her learning and successful breastfeeding practices.
Health promotion diagnoses focus on transitions from a current wellness level to a higher one for individuals, families, or communities. They typically include just the diagnostic label, a one-part statement, but can be clarified with related factors. Examples include: (Examples were removed as the focus is Risk Diagnosis)
Syndrome Diagnosis
A syndrome diagnosis is a clinical judgment about a cluster of actual or risk nursing diagnoses predicted to occur together due to a specific event or situation. Like health promotion diagnoses, they are often one-part statements requiring only the diagnostic label. Examples include: (Examples were removed as the focus is Risk Diagnosis)
Possible Nursing Diagnosis
A possible nursing diagnosis signals a suspected problem requiring further data collection to confirm or rule out. It’s not a definitive diagnosis type like actual, risk, health promotion, or syndrome, but rather a preliminary statement indicating a potential issue. It prompts nurses to communicate a potential diagnosis that needs further data collection to verify or negate. Examples include: (Examples were removed as the focus is Risk Diagnosis)
Components of a Nursing Diagnosis: Essential Elements for Clarity
A nursing diagnosis generally comprises three key components: (1) the problem and its definition, (2) the etiology or related factors (or risk factors for risk diagnoses), and (3) defining characteristics (for actual diagnoses) or risk factors (for risk diagnoses).
Problem and Definition: The Diagnostic Label
The problem statement, or diagnostic label, concisely describes the patient’s health issue or response requiring nursing intervention. A diagnostic label typically has two parts: a qualifier and the focus of the diagnosis. Qualifiers (or modifiers) add specific meaning, limitation, or detail to the diagnostic statement. One-word diagnoses like Anxiety, Constipation, Diarrhea, Nausea are exceptions, as their qualifier and focus are inherent.
| Qualifier | Focus of the Diagnosis |
|---|---|
| Deficient | Fluid volume |
| Imbalanced | Nutrition: Less Than Body Requirements |
| Impaired | Gas Exchange |
| Ineffective | Tissue Perfusion |
| Risk for | Injury |
For risk diagnosis nursing care plan development, the “Risk for” qualifier is particularly important. It immediately signals a proactive approach to care planning, focusing on prevention.
Etiology and Related Factors
The etiology, or related factors, identifies the probable causes of the health problem. These are conditions involved in the problem’s development, guiding nursing therapy and enabling individualized patient care. Nursing interventions should target these etiological factors to address the root cause of the nursing diagnosis. Etiology is linked to the problem statement using “related to”. Example: (Example was removed as the focus is Risk Diagnosis)
Risk Factors: Identifying Vulnerabilities
Risk factors are used instead of etiological factors for risk nursing diagnoses. They represent vulnerabilities that increase an individual’s or group’s susceptibility to an unhealthy condition. Risk factors are written after “as evidenced by” in the diagnostic statement.
- Risk for falls as evidenced by advanced age and use of a walker.
- Risk for infection as evidenced by a break in skin integrity.
Identifying risk factors is crucial for designing preventive interventions within a risk diagnosis nursing care plan.
Defining Characteristics: Signs and Symptoms
Defining characteristics are clusters of signs and symptoms indicating a specific diagnostic label in actual nursing diagnoses. These are the observable signs and symptoms presented by the patient. For risk nursing diagnoses, where no signs and symptoms exist yet, the risk factors themselves form the basis of the diagnosis. Defining characteristics are noted after phrases like “as evidenced by” or “as manifested by”. (Examples were removed as the focus is Risk Diagnosis)
The Diagnostic Process: A Step-by-Step Approach
The diagnostic process involves three key phases: (1) data analysis, (2) identification of health problems, risks, and strengths, and (3) formulation of diagnostic statements.
Analyzing Data: Interpretation and Organization
Data analysis involves comparing patient data against established norms, clustering related cues, and identifying any gaps or inconsistencies. This rigorous analysis is foundational for accurate diagnosis.
Identifying Health Problems, Risks, and Strengths: Decision-Making
Following data analysis, nurses and patients collaborate to identify problems that support potential actual, risk, and possible diagnoses. This decision-making step includes differentiating between nursing diagnoses, medical diagnoses, and collaborative problems. Importantly, this stage also involves recognizing the patient’s strengths, resources, and coping abilities, which are vital for holistic care planning.
Formulating Diagnostic Statements: Clear Communication
Formulating diagnostic statements is the final step, where nurses create clear and concise diagnostic statements that communicate the patient’s health status and needs accurately.
Writing Effective Nursing Diagnoses: Clarity and Precision
Writing nursing diagnostic statements effectively involves describing a patient’s health status and the contributing factors. Not all diagnostic indicators are required in every statement. The format varies based on the type of nursing diagnosis.
WRITING DIAGNOSTIC STATEMENTS. This guide clarifies how to write different types of nursing diagnostic statements for effective care planning.
PES Format: Structuring Diagnostic Statements
The PES format (Problem, Etiology, Signs/Symptoms) is a structured approach to writing nursing diagnostic statements. It facilitates clear and comprehensive communication. Diagnostic statements can be one-part, two-part, or three-part using the PES format, depending on the diagnosis type.
PES FORMAT. This image explains how to utilize the PES format in writing nursing diagnoses, enhancing clarity and structure.
One-Part Nursing Diagnosis Statement
Health promotion and syndrome nursing diagnoses are typically written as one-part statements because related factors are inherent or consistently understood. Examples include: (Examples were removed as the focus is Risk Diagnosis)
Two-Part Nursing Diagnosis Statement
Risk and possible nursing diagnoses use two-part statements. The first part is the diagnostic label, and the second validates the risk or potential problem by listing risk factors. A third part is not applicable as signs and symptoms are not yet present. Examples include:
- Risk for Infection as evidenced by compromised immune system response.
- Risk for Injury as evidenced by unstable hemodynamic profile.
Three-part Nursing Diagnosis Statement
Actual or problem-focused nursing diagnoses use three-part statements (PES format): diagnostic label, contributing factor (“related to”), and signs and symptoms (“as evidenced by” or “as manifested by”). Example: (Example was removed as the focus is Risk Diagnosis)
Nursing Diagnosis for Care Plans: Guiding Patient Care
This section provides a foundation for developing nursing care plans using common nursing diagnoses. Risk diagnosis nursing care plans are particularly crucial for preventative care and patient safety.
See also: Nursing Care Plans (NCP): Ultimate Guide and List
Recommended Resources for Nursing Diagnosis and Care Planning
These resources are recommended for further study in nursing diagnosis and care plan development.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care – Valuable for its evidence-based approach to nursing interventions and step-by-step guidance through assessment, diagnosis, and care planning.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) – Features over two hundred care plans reflecting current evidence-based guidelines, including new content on ICNP diagnoses and LGBTQ health issues.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales – A quick-reference tool for identifying correct diagnoses and efficient care planning, updated with the latest nursing diagnoses and interventions.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care – Essential for planning, individualizing, and documenting care for over 800 conditions, offering prioritized interventions and rationales.
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health – Includes over 100 care plans across various specialties, emphasizing interprofessional patient problem focus.
See also
Further resources on nursing care planning and related topics are available on our site.
References and Sources
References for this guide and additional resources for further reading.
- Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s Fundamentals of Nursing: Concepts, process and practice. Boston, MA: Pearson.
- 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.
