Nursing diagnosis stands as a cornerstone of the nursing process, serving as an indispensable tool for nurses and the wider healthcare community. It’s more than just a label; it’s a critical element in delivering effective and patient-centered care.
This guide delves into the essential aspects of diagnosis in healthcare, focusing on the “Three Diagnosis Care Plan”. We will explore what constitutes a nursing diagnosis, its crucial role within the nursing process, and how it interplays with medical and collaborative diagnoses to form a holistic approach to patient care. Understanding the types and classifications of diagnoses, and mastering the art of formulating and utilizing them are key skills for any healthcare professional. Let’s embark on this exploration to enhance our diagnostic capabilities.
Understanding the Nursing Process: The Foundation of Diagnosis
Before we delve into the specifics of nursing diagnosis, it’s crucial to understand the broader framework in which it operates: the nursing process. Think of the nursing process as a systematic, five-step approach to patient care. Diagnosis is the second vital step, building upon the initial assessment and guiding subsequent care planning and implementation.
Assessment – This initial phase involves a thorough evaluation of the patient. It’s about gathering comprehensive data – vital signs, medical history, psychological and social background – essentially painting a complete picture of the patient’s current health status.
Diagnosis – Following assessment, nurses formulate a nursing diagnosis. This isn’t just about identifying a problem; it’s about interpreting the assessment data to define the patient’s health needs from a nursing perspective. The nursing diagnosis directly informs the specific nursing interventions required.
Outcomes and Planning – With a clear nursing diagnosis in place, the next step is to develop a patient-centered care plan. This plan outlines measurable goals and desired outcomes, all driven by the insights from the diagnosis. Effective planning ensures targeted and goal-oriented care.
Implementation – This is where the care plan comes to life. Implementation involves putting the planned interventions into action, providing direct care, and continuously monitoring the patient’s response. This phase extends throughout the patient’s care journey.
Evaluation – The final step is crucial for ensuring effectiveness. Evaluation involves assessing the care plan’s success in achieving the desired outcomes. It’s a reflective process – if goals aren’t met, the care plan is adjusted, ensuring adaptive and responsive patient care.
What is a Nursing Diagnosis? Defining its Role in the Three-Diagnosis Care Plan
As established, nursing diagnosis is a pivotal step within the nursing process and integral to a “three diagnosis care plan.” It’s a structured and evidence-based method for nurses to articulate their professional judgments about a patient’s health status to various stakeholders – patients themselves, fellow nurses, other medical professionals, and the wider public. Developed from the assessment phase data, the nursing diagnosis is the lynchpin for creating a tailored care plan and subsequently measuring the effectiveness of patient care.
NANDA International (NANDA-I), the globally recognized authority, standardizes nursing diagnosis. Their official definition clarifies its essence:
“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 that nursing diagnosis focuses on the patient’s response to health issues, not just the health issue itself. It’s about identifying what nurses can do to help the patient achieve better health outcomes. This understanding is crucial when considering the “three diagnosis care plan,” which encompasses nursing, medical, and collaborative diagnoses for a holistic patient view.
Differentiating Nursing, Medical, and Collaborative Diagnoses: Cornerstones of the Three-Diagnosis Care Plan
Within the “three diagnosis care plan,” it’s vital to distinguish between nursing, medical, and collaborative diagnoses. While all contribute to patient care, they originate from different perspectives and guide distinct interventions. Understanding these differences is key to effective interprofessional collaboration and comprehensive patient management.
A nursing diagnosis is the nurse’s interpretation and labeling of patient data gathered during assessment, aligned with NANDA-I approved diagnoses. For example, observing a patient coughing before swallowing, exhibiting poor throat elevation, and reporting food “sticking” could lead to a nursing diagnosis of impaired swallowing. This diagnosis directs nursing interventions focused on improving the patient’s ability to swallow safely and effectively.
Examples of nursing diagnoses: risk for unstable blood glucose level; stress urinary incontinence; disturbed thought processes; activity intolerance.
In contrast, a medical diagnosis, made by a physician or advanced practitioner, identifies the patient’s disease, pathology, or medical condition. This diagnosis falls within the medical domain and typically remains constant throughout the patient’s medical history. While a nursing diagnosis can evolve as patient responses change, a medical diagnosis provides a fixed point of reference regarding the underlying disease process.
Examples of medical diagnoses: myocardial infarction; asthma; type 2 diabetes mellitus; osteoarthritis.
Collaborative diagnoses represent health problems requiring both medical and nursing interventions. These diagnoses highlight the need for teamwork. Nurses monitor for complications and changes in patient status, while physicians prescribe medical treatments and further diagnostics. Effective management of collaborative problems depends on seamless communication and shared responsibility between medical and nursing teams, forming an integral part of the “three diagnosis care plan.”
Examples of collaborative diagnoses: potential complication of electrolyte imbalance; hemorrhage; paralytic ileus.
Nursing Diagnosis Classification: Organizing Care within the Three-Diagnosis Plan
To effectively manage and utilize nursing diagnoses within the “three diagnosis care plan,” a standardized organizational system is essential. NANDA-I provides this through Taxonomy II, a hierarchical classification system used globally for over two decades. Taxonomy II organizes diagnoses into three levels: 13 domains (broad areas of health), 47 classes (subcategories within domains), and 267 specific nursing diagnoses.
This structured approach allows nurses to quickly locate and apply the most relevant diagnoses, ensuring consistency and clarity in communication and care planning across healthcare settings. Understanding this classification system enhances the application of nursing diagnoses within a comprehensive “three diagnosis care plan.”
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: Tailoring the Three-Diagnosis Care Plan
NANDA-I categorizes nursing diagnoses into four main types, each playing a specific role within the “three diagnosis care plan”: problem-focused, risk, health promotion, and syndrome diagnoses. Understanding these categories allows for precise diagnosis selection and targeted intervention planning.
Problem-focused diagnoses (actual diagnoses) identify existing patient problems evident during assessment through signs and symptoms. These diagnoses have three components: the diagnostic label, related factors (causes or contributors), and defining characteristics (observable cues).
Risk diagnoses identify vulnerabilities – potential health problems a patient may develop without nursing intervention. They indicate that a problem doesn’t currently exist, but risk factors are present. These diagnoses include two components: a risk diagnostic label and risk factors.
Health promotion diagnoses (wellness diagnoses) focus on a patient’s desire and motivation to enhance well-being and health potential. They express a readiness to improve specific health behaviors and can apply to individuals, families, groups, or communities.
Syndrome diagnoses are less frequent and represent clusters of nursing diagnoses that typically occur together and are managed with similar interventions. These diagnoses recognize patterns of problems requiring a coordinated approach within the “three diagnosis care plan.”
Examples of each category, adapted from NANDA-I’s Nursing Diagnosis: Definitions and Classifications, 2021-2023:
| Problem Focused Diagnosis | Risk Diagnosis |
|---|---|
| – Acute pain | – Risk for infection |
| – Impaired physical mobility | – Risk for falls |
| – Deficient knowledge | – Risk for imbalanced fluid volume |
| – Ineffective breathing pattern | – Risk for impaired skin integrity |
| Health Promotion Diagnosis | Syndrome Diagnosis |
| – Readiness for enhanced nutrition | – Chronic pain syndrome |
| – Readiness for enhanced self-care | – Post-traumatic stress syndrome |
| – Readiness for enhanced family coping | – Frailty syndrome |
| – Readiness for enhanced spiritual well-being | – Disuse syndrome |
Key Components of a Nursing Diagnosis: Building Blocks of the Three-Diagnosis Care Plan
Formulating a robust nursing diagnosis, essential to the “three diagnosis care plan,” requires understanding its core components. These components ensure clarity, accuracy, and effective communication of patient needs. While specific components vary by diagnosis type, the following provide a general overview:
Diagnosis Label: A concise name summarizing the diagnostic focus and nursing judgment.
Examples: Acute pain, Impaired gas exchange, Deficient fluid volume.
Definition: A clear, precise description of the diagnosis, differentiating it from similar diagnoses.
Example (Deficient Fluid Volume): “Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.”
Defining Characteristics: Observable cues (signs and symptoms) that indicate a problem-focused, health promotion, or syndrome diagnosis. These are what the nurse assesses – what they see, hear, feel, smell, or what the patient reports.
Example (Impaired Gas Exchange): Dyspnea, confusion, abnormal arterial blood gases, cyanosis.
Risk Factors: Environmental, physiological, psychological, genetic, or chemical elements increasing vulnerability to an unhealthy event. Only applicable to risk diagnoses.
Example (Risk for Infection): Chronic disease (e.g., diabetes), immunosuppression, invasive procedures, malnutrition.
Related Factors: Conditions or circumstances associated with or contributing to a problem-focused diagnosis or syndrome. These factors may precede, be associated with, or contribute to the diagnosis. Primarily for problem-focused diagnoses and syndromes; less common in health promotion diagnoses.
Example (Ineffective Airway Clearance): Excessive mucus, fatigue, decreased level of consciousness, presence of artificial airway.
Writing Effective Nursing Diagnoses: Practical Application in the Three-Diagnosis Care Plan
Accurate and clear nursing diagnosis statements are crucial for effective communication and care planning within the “three diagnosis care plan.” NANDA International recommends specific formats to ensure precision and understanding across healthcare teams. The format varies slightly depending on the diagnosis category.
Following are templates and examples for writing each type of nursing diagnosis, demonstrating their practical application in patient care:
-
Problem-focused Diagnosis:
- Format: Diagnosis Label related to Related Factors as evidenced by Defining Characteristics.
- Example: Acute pain related to surgical incision as evidenced by patient report of pain 7/10, guarding behavior, and increased heart rate.
-
Risk Diagnosis:
- Format: Risk for [Diagnosis Label] as evidenced by Risk Factors.
- Example: Risk for infection as evidenced by presence of surgical incision, invasive intravenous line, and immunocompromised state.
-
Health Promotion Diagnosis:
- Format: Readiness for Enhanced [Diagnosis Label] as evidenced by Defining Characteristics (expressions of desire to improve health).
- Example: Readiness for enhanced nutrition as evidenced by patient expressing interest in learning about healthy eating and requesting dietary information.
-
Syndrome Diagnosis:
- Format: Syndrome Diagnosis Label. (Defining characteristics and related factors are inherent in the syndrome diagnosis itself.)
- Example: Post-trauma syndrome.
Expanding Your Diagnostic Toolkit: Further Examples for Comprehensive Three-Diagnosis Care Plans
The NANDA-I list, with 267 diagnoses, offers a comprehensive resource for nurses worldwide, enabling the creation of detailed and effective “three diagnosis care plans.” Throughout this guide, we’ve utilized examples from the NANDA-I 2021-2023 handbook. Here are additional nursing diagnosis examples to further broaden your understanding and application in developing robust care plans:
- Impaired comfort
- Ineffective coping
- Deficient fluid volume
- Impaired skin integrity
- Ineffective thermoregulation
- Disturbed sleep pattern
- Activity intolerance
- Anxiety
- Fear
- Powerlessness
- Spiritual distress
- Impaired social interaction
- Risk for loneliness
- Readiness for enhanced knowledge
- Readiness for enhanced self-concept
Ready to Master the Three-Diagnosis Care Plan?
Nursing diagnoses are indispensable tools empowering nurses to deliver safe, high-quality, and evidence-based care within a “three diagnosis care plan” framework. They are fundamental to patient healthcare, and proficiency in their use, formulation, and documentation is a core competency for every nurse. By understanding and applying the principles of nursing, medical, and collaborative diagnoses, healthcare professionals can ensure comprehensive and patient-centered care, leading to improved outcomes and enhanced patient well-being.
