Understanding Nursing Diagnosis
A nursing diagnosis represents a nurse’s clinical judgment concerning a patient’s response to health conditions, life processes, or vulnerabilities. This judgment, applicable to individuals, families, groups, or communities, forms the bedrock for selecting nursing interventions. These interventions are designed to achieve specific patient outcomes for which nurses are accountable. Nursing diagnoses are not arbitrary; they are meticulously developed using data gathered during a comprehensive nursing assessment. This crucial step allows nurses to create tailored care plans, addressing the unique needs of each patient.
The Significance of Nursing Diagnosis
Why are nursing diagnoses so vital in healthcare? Their purposes are multifaceted and contribute significantly to effective patient care and professional development:
- Enhancing Critical Thinking: For nursing students, formulating nursing diagnoses is an invaluable exercise. It hones problem-solving and critical thinking skills, preparing them for complex clinical scenarios.
- Prioritizing Care: Nursing diagnoses act as a compass, guiding nurses to identify and prioritize patient needs. This prioritization ensures that interventions are directed where they are most urgently required.
- Outcome-Driven Care: These diagnoses are instrumental in formulating expected outcomes. This is crucial for quality assurance, especially when dealing with third-party payers who require evidence of effective and goal-oriented care.
- Resource Identification: Nursing diagnoses illuminate how patients or groups respond to health challenges and life events. Importantly, they also help identify existing strengths and resources that can be leveraged to prevent or resolve health issues.
- Facilitating Communication: By providing a common language, nursing diagnoses foster clear and effective communication among nursing professionals and the broader healthcare team. This shared understanding is essential for coordinated and seamless patient care.
- Evaluating Care Effectiveness: Nursing diagnoses serve as a benchmark for evaluation. They help determine if the nursing care provided was beneficial to the patient and if it was delivered in a cost-effective manner.
Nursing Diagnosis vs. Medical Diagnosis vs. Collaborative Problems
It’s crucial to differentiate nursing diagnoses from medical diagnoses and collaborative problems to understand their distinct roles in patient care.
Nursing diagnoses focus on the patient’s response to a health condition. They are within the nurse’s domain of practice and guide independent nursing actions. For instance, if a patient expresses feelings of unease, fear, and struggles with sleep, a nurse might identify nursing diagnoses such as Anxiety, Fear, or Disturbed Sleep Pattern. These diagnoses stem from the patient’s reaction to their medical condition and are addressed through nursing care.
Medical diagnoses, on the other hand, are made by physicians or advanced practitioners. They pinpoint the specific disease, pathology, or medical condition that only a physician can treat. Examples include Diabetes Mellitus, Tuberculosis, or Hepatitis. Medical diagnoses are disease-focused, and nurses implement physician-prescribed treatments to manage these conditions.
Collaborative problems represent potential health issues managed through a combination of independent nursing interventions and physician-prescribed treatments. These are complications requiring both medical and nursing expertise. The nursing focus in collaborative problems is often on monitoring patient status and preventing potential complications from developing.
In essence, nursing diagnoses center on the patient’s holistic response to health issues, guiding patient-centered care. Medical diagnoses target the illness itself, directing medical treatment. Understanding these distinctions is fundamental for effective interprofessional collaboration and comprehensive patient management.
Taxonomy of Nursing Diagnoses
Nursing diagnoses are systematically organized using a classification system known as Taxonomy II. Adopted in 2002 and based on Dr. Mary Joy Gordon’s Functional Health Patterns, Taxonomy II provides a structured framework. It comprises three levels: 13 Domains, 47 Classes, and the individual nursing diagnoses. This system moves 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 listed alphabetically by concept for easier navigation.
NURSING DIAGNOSIS TAXONOMY II. Taxonomy II for nursing diagnosis contains 13 domains and 47 classes. Image via: Wikipedia.com
Domains and Classes within 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
The Nursing Process and Diagnosis
The nursing process is a systematic, five-stage approach to patient care: assessment, diagnosis, planning, implementation, and evaluation. Diagnosis, the second step, is intrinsically linked to understanding nursing diagnoses. Each stage demands critical thinking from the nurse. Beyond simply knowing the definitions of nursing diagnoses, nurses must recognize the defining characteristics and behaviors associated with each diagnosis, identify related factors, and determine appropriate interventions.
For a more in-depth exploration of the nursing process, refer to “The Nursing Process: A Comprehensive Guide“.
Types of Nursing Diagnoses
Nursing diagnoses are categorized into four primary types: Problem-Focused (Actual), Risk, Health Promotion, and Syndrome. Understanding these types is crucial for accurate diagnosis and care planning.
TYPES OF NURSING DIAGNOSES. The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.
Problem-Focused (Actual) Nursing Diagnosis
A problem-focused nursing diagnosis, also known as an actual diagnosis, identifies a client problem present at the time of assessment. It’s substantiated by observable signs and symptoms. It’s important to note that actual diagnoses are not inherently more critical than risk diagnoses; in many situations, a risk diagnosis might take precedence in patient care.
Problem-focused diagnoses are structured with three key components:
- Nursing Diagnosis Label: A concise term describing the health problem.
- Related Factors: Conditions or circumstances contributing to the problem (etiology).
- Defining Characteristics: Observable signs and symptoms demonstrating the presence of the problem.
Examples of Problem-Focused Nursing Diagnoses:
- Pain related to surgical incision as evidenced by patient report of pain at incision site and guarding behavior.
- Impaired Physical Mobility related to musculoskeletal impairment as evidenced by limited range of motion and difficulty ambulating.
- Deficient Knowledge related to lack of exposure to information resources as evidenced by patient’s questions about postoperative care and incorrect statements about wound management.
Risk Nursing Diagnosis
Risk nursing diagnoses identify potential problems that do not currently exist but are likely to develop if no nursing intervention occurs. They are clinical judgments based on risk factors that increase a patient’s vulnerability. These diagnoses are proactive, enabling nurses to implement preventive measures.
Risk diagnoses differ from problem-focused diagnoses in that they do not have defining characteristics (signs and symptoms) because the problem hasn’t yet manifested. Instead, they focus on risk factors.
Components of a Risk Nursing Diagnosis:
- Risk Diagnostic Label: Identifies the potential problem.
- Risk Factors: Conditions increasing susceptibility, linked by “as evidenced by”.
Examples of Risk Nursing Diagnoses:
- Risk for Infection as evidenced by surgical incision, immunocompromised status, and invasive procedures.
- Risk for Falls as evidenced by muscle weakness, history of falls, impaired balance, and use of psychoactive medications.
- Risk for Impaired Skin Integrity as evidenced by immobility, incontinence, and poor nutritional status.
Health Promotion Nursing Diagnosis
Health promotion diagnoses, also termed wellness diagnoses, focus on a patient’s desire and motivation to enhance well-being. They identify a patient’s readiness to engage in health-promoting behaviors. These diagnoses are used to guide interventions that support patients in achieving higher levels of wellness.
Health promotion diagnoses often consist of a one-part statement – the diagnostic label – as related factors are often implied (motivation to improve health). However, related factors can be added for clarity.
Examples of Health Promotion Nursing Diagnoses:
- Readiness for Enhanced Nutrition
- Readiness for Enhanced Knowledge related to diabetes management
- Readiness for Enhanced Family Coping
Syndrome Nursing Diagnosis
A syndrome diagnosis describes a cluster of nursing diagnoses predicted to occur together due to a specific event or situation. They are also written as one-part statements, using only the diagnostic label.
Examples of Syndrome Nursing Diagnoses:
- Rape Trauma Syndrome
- Disuse Syndrome
- Relocation Stress Syndrome
Possible Nursing Diagnosis
A possible nursing diagnosis indicates a suspected problem requiring further data collection to confirm or rule out. It’s a temporary designation to signal a potential issue needing investigation.
Examples of Possible Nursing Diagnoses:
- Possible Spiritual Distress related to uncertainty about illness and prognosis (needs further assessment of spiritual beliefs and concerns).
- Possible Situational Low Self-Esteem related to job loss (requires further assessment of self-perception and emotional response to job loss).
Components of a Nursing Diagnosis Statement
A comprehensive nursing diagnosis statement typically includes three parts:
- Problem (Diagnostic Label): A concise description of the patient’s health issue.
- Etiology (Related Factors): The cause or contributing factors to the problem.
- Defining Characteristics (Signs/Symptoms): Evidence validating the presence of an actual problem, or risk factors for risk diagnoses.
Problem and Definition (Diagnostic Label)
The problem statement, or diagnostic label, succinctly describes the patient’s health problem or response requiring nursing intervention. It usually includes a qualifier (modifier) and the focus of the diagnosis. Qualifiers add specificity to the diagnosis.
| Qualifier | Focus of the Diagnosis |
|---|---|
| Deficient | Fluid Volume |
| Imbalanced | Nutrition: Less Than Body Requirements |
| Impaired | Gas Exchange |
| Ineffective | Tissue Perfusion |
| Risk for | Injury |
Etiology (Related Factors)
The etiology, or related factors, identifies the probable causes of the health problem. It provides context and direction for nursing interventions by highlighting the underlying causes. Etiology is linked to the problem statement using the phrase “related to.” Nursing interventions should aim to address these etiological factors.
Example:
- Impaired Skin Integrity related to prolonged pressure and moisture.
Risk Factors
For risk nursing diagnoses, risk factors replace etiological factors. These are conditions or situations that increase vulnerability to a potential health problem. Risk factors are connected to the diagnostic label with “as evidenced by.”
Examples:
- Risk for Falls as evidenced by history of falls and impaired mobility.
- Risk for Infection as evidenced by surgical incision and immunosuppression.
Defining Characteristics (Signs and Symptoms)
Defining characteristics are clusters of signs and symptoms that confirm the presence of an actual nursing diagnosis. For problem-focused diagnoses, these are the patient’s observable symptoms. For risk diagnoses, defining characteristics are absent, and risk factors serve as the validating evidence. Defining characteristics are linked to the diagnostic statement using “as evidenced by” or “as manifested by.”
The Diagnostic Process
The diagnostic process involves three key phases:
- Data Analysis: Comparing patient data to norms, clustering cues, and identifying gaps or inconsistencies.
- Problem Identification: Identifying health problems, risks, and strengths based on analyzed data. Differentiating between nursing diagnoses, medical diagnoses, and collaborative problems.
- Diagnostic Statement Formulation: Creating clear and concise nursing diagnosis statements.
Analyzing Data
Data analysis involves a systematic review of collected assessment data. Nurses compare data against established health standards to identify deviations. They then group related cues together to recognize patterns and pinpoint areas of concern. Finally, they identify any missing information or inconsistencies in the data that require further investigation.
Identifying Health Problems, Risks, and Strengths
Following data analysis, nurses collaborate with patients to identify specific health problems, potential risks, and existing strengths. This step involves determining if a problem falls within the domain of nursing diagnosis, medical diagnosis, or collaborative problem. Recognizing patient strengths and resources is equally important, as these can be leveraged in the care plan.
Formulating Diagnostic Statements
The final phase is formulating the nursing diagnosis statement itself. This involves selecting the appropriate diagnostic label, identifying related factors (for problem-focused diagnoses), and listing defining characteristics. The statement should be clear, concise, and accurately reflect the patient’s health status.
Writing Effective Nursing Diagnosis Statements: The PES Format and Examples
Writing clear and accurate nursing diagnosis statements is essential for effective communication and care planning. A widely used method is the PES format, which stands for:
- P – Problem (Diagnostic Label)
- E – Etiology (Related Factors)
- S – Signs/Symptoms (Defining Characteristics)
Nursing diagnosis statements can be one-part, two-part, or three-part, depending on the type of diagnosis. The three-part statement, using the PES format, is particularly useful for problem-focused (actual) nursing diagnoses, allowing for a comprehensive and detailed description of the patient’s condition.
PES FORMAT. Writing nursing diagnoses using the PES format.
One-Part Nursing Diagnosis Statements
Health promotion and syndrome diagnoses are typically written as one-part statements. For health promotion diagnoses, related factors are often implied as the patient’s motivation for higher wellness. Syndrome diagnoses, by definition, are clusters of diagnoses without specific related factors.
Examples of One-Part Nursing Diagnosis Statements:
- Readiness for Enhanced Coping
- Rape Trauma Syndrome
Two-Part Nursing Diagnosis Statements
Risk and possible nursing diagnoses usually use two-part statements. The first part is the diagnostic label, and the second part provides validation—either risk factors for risk diagnoses or the reason for suspecting a possible diagnosis. Signs and symptoms are not included as they are not yet present.
Examples of Two-Part Nursing Diagnosis Statements:
- Risk for Infection as evidenced by compromised immune system.
- Risk for Injury as evidenced by unsteady gait and cognitive impairment.
- Possible Deficient Fluid Volume related to reported decreased oral intake (needs further assessment of hydration status).
Three-Part Nursing Diagnosis Statements: PES Format in Action
Three-part nursing diagnosis statements, employing the PES format, are used for actual or problem-focused diagnoses. They include:
- Problem (P): The diagnostic label.
- Etiology (E): Related factors, linked by “related to.”
- Signs and Symptoms (S): Defining characteristics, linked by “as evidenced by” or “as manifested by.”
This three-part structure provides a complete picture of the patient’s nursing diagnosis, including the problem, its cause, and the supporting evidence. This format is invaluable for clear communication and targeted care planning.
Examples of Three-Part Nursing Diagnosis Statements (Three Part Nursing Diagnosis Examples):
-
Problem: Acute Pain
- Etiology: related to surgical tissue trauma
- Signs/Symptoms: as evidenced by patient reporting pain as 7/10, guarding incision site, and increased heart rate.
- Full Statement (PES): Acute Pain related to surgical tissue trauma as evidenced by patient reporting pain as 7/10, guarding incision site, and increased heart rate.
-
Problem: Impaired Gas Exchange
- Etiology: related to fluid accumulation in lungs
- Signs/Symptoms: as evidenced by shortness of breath, oxygen saturation of 90% on room air, and audible crackles in lung bases.
- Full Statement (PES): Impaired Gas Exchange related to fluid accumulation in lungs as evidenced by shortness of breath, oxygen saturation of 90% on room air, and audible crackles in lung bases.
-
Problem: Anxiety
- Etiology: related to uncertainly about upcoming surgery
- Signs/Symptoms: as evidenced by patient stating “I’m really worried about the surgery,” restlessness, and increased respiratory rate.
- Full Statement (PES): Anxiety related to uncertainty about upcoming surgery as evidenced by patient stating “I’m really worried about the surgery,” restlessness, and increased respiratory rate.
These three part nursing diagnosis examples demonstrate how the PES format creates a comprehensive and actionable nursing diagnosis statement. By clearly outlining the problem, its cause, and the supporting evidence, nurses can develop targeted interventions to effectively address patient needs.
Nursing Diagnosis for Care Plans
Nursing diagnoses are foundational for developing effective nursing care plans. They provide the framework for identifying patient needs, setting goals, and selecting appropriate nursing interventions. A comprehensive list of nursing diagnoses serves as a valuable resource for creating individualized care plans.
See also: Nursing Care Plans (NCP): Ultimate Guide and List
Recommended Resources
To deepen your understanding of nursing diagnosis and care planning, consider these recommended resources:
Disclosure: Affiliate links from Amazon are included below. We may earn a small commission from purchases, at no additional cost to you. For more information, please see our privacy policy.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
See also
Explore these additional resources for further learning:
References and Sources
- 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.
