In this detailed guide, we will explore the essential concepts of nursing diagnosis, focusing on wellness diagnosis. We will journey through the history, evolution, and application of nursing diagnosis within the nursing process. You will learn about the different types and classifications of nursing diagnoses and gain expertise in formulating them accurately. This guide also offers practical tips for creating effective nursing diagnoses and integrating them into your nursing care plans to enhance patient wellness.
Understanding Nursing Diagnosis
A nursing diagnosis is defined as a clinical judgment made by a registered nurse concerning a patient’s response to actual or potential health conditions and life processes. This response can be observed in an individual, family, group, or community. It serves as the foundation for selecting specific nursing interventions aimed at achieving defined outcomes for which nurses are accountable. Nursing diagnoses are meticulously developed based on comprehensive data gathered during the nursing assessment. They are crucial in enabling nurses to create and implement personalized care plans that address patient needs effectively.
The Significance of Nursing Diagnosis
Nursing diagnosis plays several vital roles in healthcare:
- Educational Tool: For nursing students, it is an invaluable tool for developing problem-solving and critical thinking skills essential for effective patient care.
- Prioritization of Care: It helps in identifying and prioritizing patient needs, guiding the direction of nursing interventions based on these priorities to ensure timely and effective care.
- Quality Assurance: Nursing diagnoses facilitate the formulation of expected outcomes, which are crucial for meeting the quality assurance requirements demanded by healthcare payers.
- Resource Identification: They aid in understanding how patients respond to health issues and life events, identifying available strengths and resources that can be utilized to prevent or resolve health problems.
- Communication Enhancement: Nursing diagnoses provide a standardized language, fostering clear and effective communication among nursing professionals and the broader healthcare team, ensuring cohesive care delivery.
- Evaluation of Care Effectiveness: They serve as a basis for evaluating the effectiveness of nursing care, determining if the interventions were beneficial to the patient and cost-effective for the healthcare system.
Distinguishing Nursing, Medical, and Collaborative Approaches
It’s essential to differentiate between nursing diagnoses, medical diagnoses, and collaborative problems:
The term nursing diagnosis is multifaceted. It represents the second critical step in the nursing process—diagnosis—within the ADPIE framework (Assessment, Diagnosis, Planning, Implementation, Evaluation). It also refers to the standardized label nurses use to interpret and assign meaning to patient data. For example, a nurse assessing a patient might observe symptoms like anxiety, fear, and insomnia. These observations are then categorized under nursing diagnoses such as Anxiety, Fear, and Disturbed Sleep Pattern. In this context, a nursing diagnosis is rooted in the patient’s response to their medical condition, focusing on aspects within the nurse’s scope of autonomous action. This encompasses physical, emotional, and spiritual responses, emphasizing a holistic approach to patient care.
In contrast, a medical diagnosis is the responsibility of a physician or advanced practitioner. It identifies a disease, medical condition, or pathology that only medical practitioners are licensed to treat. Medical diagnoses involve determining the specific clinical entity causing the illness, leading to medical treatments such as medication to cure the disease. Examples include Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. Medical diagnoses typically remain constant throughout treatment. Nurses are responsible for adhering to physician’s orders and implementing prescribed medical treatments and therapies.
Collaborative problems are potential health complications that nurses manage using both independent nursing interventions and physician-prescribed treatments. These situations require a collaborative approach, where nursing care focuses on monitoring patient conditions and preventing potential complications, alongside medical interventions.
Understanding these distinctions is crucial. Nursing diagnosis centers on the patient’s physiological and psychological responses to illness, whereas medical diagnosis is disease-specific. This patient-centered approach of nursing diagnosis ensures comprehensive care that addresses all aspects of a patient’s health and well-being.
Taxonomy II: Classifying Nursing Diagnoses
In 2002, Nursing Diagnosis Taxonomy II was adopted, organizing diagnoses based on Dr. Mary Joy Gordon’s Functional Health Patterns. This system comprises three levels: 13 Domains, 47 Classes, and numerous nursing diagnoses. Unlike earlier classifications, Taxonomy II does not group diagnoses by Gordon’s patterns but codes them across seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology. Diagnoses are listed alphabetically by concept for easier navigation.
The 13 Domains of Taxonomy II are:
- Domain 1. Health Promotion: Focuses on the awareness and management of wellness.
- Class 1. Health Awareness
- Class 2. Health Management
- Domain 2. Nutrition: Addresses activities related to intake, digestion, absorption, metabolism, and hydration.
- Class 1. Ingestion
- Class 2. Digestion
- Class 3. Absorption
- Class 4. Metabolism
- Class 5. Hydration
- Domain 3. Elimination and Exchange: Covers excretory functions and fluid and electrolyte balance.
- Class 1. Urinary function
- Class 2. Gastrointestinal function
- Class 3. Integumentary function
- Class 4. Respiratory function
- Domain 4. Activity/Rest: Includes exercise, sleep, rest, energy balance, and cardiovascular and respiratory responses to activity.
- 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: Deals with sensory and cognitive processes, including attention, orientation, and communication.
- Class 1. Attention
- Class 2. Orientation
- Class 3. Sensation/Perception
- Class 4. Cognition
- Class 5. Communication
- Domain 6. Self-Perception: Concerns self-concept, self-esteem, and body image.
- Class 1. Self-concept
- Class 2. Self-esteem
- Class 3. Body image
- Domain 7. Role relationship: Focuses on caregiving roles, family, and social relationships.
- Class 1. Caregiving roles
- Class 2. Family relationships
- Class 3. Role performance
- Domain 8. Sexuality: Addresses sexual identity, function, and reproduction.
- Class 1. Sexual identity
- Class 2. Sexual function
- Class 3. Reproduction
- Domain 9. Coping/stress tolerance: Covers stress responses, coping mechanisms, and post-trauma behaviors.
- Class 1. Post-trauma responses
- Class 2. Coping responses
- Class 3. Neurobehavioral stress
- Domain 10. Life principles: Involves values, beliefs, and congruence between values, beliefs, and actions.
- Class 1. Values
- Class 2. Beliefs
- Class 3. Value/Belief/Action congruence
- Domain 11. Safety/Protection: Includes protection from harm, infection, injury, violence, and environmental hazards, as well as defensive and thermoregulatory processes.
- Class 1. Infection
- Class 2. Physical injury
- Class 3. Violence
- Class 4. Environmental hazards
- Class 5. Defensive processes
- Class 6. Thermoregulation
- Domain 12. Comfort: Addresses physical, environmental, and social comfort.
- Class 1. Physical comfort
- Class 2. Environmental comfort
- Class 3. Social comfort
- Domain 13. Growth/Development: Focuses on age-appropriate physical growth and psychosocial development.
- Class 1. Growth
- Class 2. Development
This taxonomy provides a structured framework for nurses to classify and understand the various dimensions of patient health and wellbeing, facilitating comprehensive and targeted care planning.
The Nursing Process and Diagnosis
The nursing process is a systematic, five-stage approach to patient care: assessment, diagnosis, planning, implementation, and evaluation. Each stage necessitates critical thinking from the nurse. Beyond understanding nursing diagnoses and their definitions, nurses must recognize the defining characteristics and behaviors associated with each diagnosis, identify related factors, and determine appropriate interventions.
The nursing process is iterative and dynamic, allowing nurses to adapt care plans as patient conditions change. A deeper understanding of the nursing process can be found in “The Nursing Process: A Comprehensive Guide“.
Types of Nursing Diagnoses
Nursing diagnoses are categorized into four main types: Problem-Focused (Actual), Risk, Health Promotion, and Syndrome diagnoses.
Problem-Focused Nursing Diagnosis
A problem-focused diagnosis, also known as an actual diagnosis, identifies an existing patient problem at the time of nursing assessment. These diagnoses are supported by observable signs and symptoms. It’s important to note that actual diagnoses are not inherently more critical than risk diagnoses; in many cases, a risk diagnosis might be the priority for preventative care.
Problem-focused diagnoses are structured around three components:
- Nursing diagnosis label
- Related factors contributing to the problem
- Defining characteristics that provide evidence of the problem
Examples of problem-focused nursing diagnoses include:
Risk Nursing Diagnosis
Risk nursing diagnoses are clinical judgments that a problem does not currently exist but is likely to develop without nursing intervention. These diagnoses are based on risk factors that heighten a patient’s vulnerability. Risk diagnoses are crucial for preventative care, enabling nurses to identify potential problems early and implement measures to reduce or avoid risks.
Risk diagnoses are formulated based on:
- Patient’s current health status
- Past health history
- Specific risk factors
Unlike problem-focused diagnoses, risk diagnoses do not have etiological (related) factors but rather risk factors. For example, an elderly patient with diabetes and vertigo who is unwilling to use assistive devices for ambulation might receive a risk diagnosis of Risk for Injury or Risk for Falls.
Crucially, risk nursing diagnoses use “as evidenced by” to link the diagnosis label to risk factors, not defining characteristics. The components of a risk nursing diagnosis are:
- Risk diagnostic label, connected by “as evidenced by”
- Risk factors
Examples of risk nursing diagnoses include:
- Risk for Injury as evidenced by reduced cognitive awareness and use of sedative medications.
- Risk for Infection as evidenced by a 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.
Health Promotion Diagnosis
Health promotion diagnosis, also known as Wellness Diagnosis Nursing, is a clinical judgment concerning a patient’s motivation and readiness to enhance their well-being. It focuses on the patient’s desire to engage in health-promoting behaviors. For instance, a new mother eager to learn about breastfeeding might receive a health promotion diagnosis of “Readiness for Enhanced Breastfeeding.” This diagnosis guides nursing interventions aimed at supporting and educating the patient in proper breastfeeding techniques.
Health promotion diagnoses address transitions from one level of wellness to a higher level for individuals, families, or communities. Typically, they include only the diagnostic label, a one-part statement, but can be clarified with related factors. Examples of health promotion diagnoses include:
Syndrome Diagnosis
A syndrome diagnosis is a clinical judgment describing a cluster of nursing diagnoses that are likely to occur together due to certain events or situations. These are also written as one-part statements, requiring only the diagnostic label. Examples of syndrome nursing diagnoses include:
Possible Nursing Diagnosis
A possible nursing diagnosis indicates a suspected problem requiring additional data to confirm or rule out. It is not a definitive diagnosis type like actual, risk, health promotion, or syndrome diagnoses, but rather a preliminary statement used to communicate potential issues that need further investigation. Examples include:
Components of a Nursing Diagnosis Statement
A complete nursing diagnosis statement typically includes three parts:
- The problem and its definition
- The etiology (related factors)
- The defining characteristics or risk factors (for risk diagnoses)
Problem and Definition
The problem statement, or diagnostic label, concisely describes the patient’s health issue or response requiring nursing intervention. It usually consists of two parts: a qualifier and the focus of the diagnosis. Qualifiers (or modifiers) add specific meaning or context to the diagnostic label, except for one-word diagnoses like Anxiety, Constipation, Diarrhea, Nausea, where the 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 |
Etiology
The etiology, or related factors, identifies the probable causes of the health problem. These factors are conditions that contribute to the development of the problem, guide nursing therapy, and help personalize patient care. Nursing interventions should aim to address these etiological factors to resolve the underlying cause of the nursing diagnosis. Etiology is linked to the problem statement using the phrase “related to,” for example:
Risk Factors
Risk factors are used instead of etiological factors for risk nursing diagnoses. They are conditions that increase an individual’s or group’s vulnerability to an unhealthy event. Risk factors are included in the diagnostic statement following “as evidenced by.”
- Risk for falls as evidenced by old age and use of walker.
- Risk for infection as evidenced by break in skin integrity.
Defining Characteristics
Defining characteristics are clusters of signs and symptoms that indicate the presence of an actual nursing diagnosis. For problem-focused diagnoses, these are the observable signs and symptoms presented by the patient. Risk diagnoses do not have defining characteristics; instead, the risk factors themselves form the basis of the diagnosis. Defining characteristics are written after the phrase “as evidenced by” or “as manifested by” in the diagnostic statement.
The Diagnostic Process
The diagnostic process involves three key phases:
- Data analysis
- Identification of health problems, risks, and strengths
- Formulation of diagnostic statements
Analyzing Data
Data analysis involves comparing patient data to established norms, clustering related cues, and identifying any gaps or inconsistencies in the data.
Identifying Health Problems, Risks, and Strengths
Following data analysis, nurses and patients collaboratively identify health problems, risks, and potential diagnoses. This step involves determining whether a problem is a nursing diagnosis, medical diagnosis, or a collaborative problem. It also includes recognizing the patient’s strengths, resources, and coping abilities.
Formulating Diagnostic Statements
The final step in the diagnostic process is formulating clear and concise diagnostic statements. The process for writing these statements is detailed below.
Writing Effective Nursing Diagnoses
Writing effective nursing diagnostic statements involves accurately describing a patient’s health status and the contributing factors. It’s not necessary to include all types of diagnostic indicators in every statement. The format for writing diagnostic statements varies depending on the type of nursing diagnosis.
PES Format
The PES format is a structured approach to writing nursing diagnostic statements, encompassing:
- Problem (diagnostic label)
- Etiology (related factors)
- Signs/Symptoms (defining characteristics)
Diagnostic statements can be one-part, two-part, or three-part using the PES format.
One-Part Nursing Diagnosis Statement
Health promotion nursing diagnoses are generally written as one-part statements because the related factor is always the same: a desire for enhanced wellness. Related factors may be added to provide further clarity. Syndrome diagnoses also typically do not include related factors. Examples of one-part nursing diagnosis statements:
- Readiness for enhanced coping
- Rape Trauma Syndrome
Two-Part Nursing Diagnosis Statement
Risk and possible nursing diagnoses are usually two-part statements. The first part is the diagnostic label, and the second part is the evidence for risk or the risk factors present. A third part is not applicable because signs and symptoms are not yet present in risk or possible diagnoses. Examples of two-part nursing diagnosis statements:
- Risk for Infection as evidenced by weakened immune system response
- Risk for Injury as evidenced by unstable hemodynamic profile
Three-part Nursing Diagnosis Statement
Actual or problem-focused nursing diagnoses are typically three-part statements, following the PES format: diagnostic label, related factors (“related to”), and defining characteristics (“as evidenced by” or “as manifested by”). This three-part statement is also known as the PES format, including Problem, Etiology, and Signs and Symptoms. Examples of three-part nursing diagnosis statements include:
Variations in Statement Formats
Variations in writing nursing diagnosis statements can include specifying locations, using “secondary to” to indicate underlying medical diagnoses, and adding a second part to health promotion diagnoses to clarify the area of desired enhancement.
Nursing Diagnoses for Care Plans
Nursing diagnoses are integral to developing comprehensive nursing care plans. They provide a structured framework for addressing patient needs and planning individualized care.
See also: Nursing Care Plans (NCP): Ultimate Guide and List
Recommended Resources
Enhance your understanding and application of nursing diagnoses with these recommended books and resources.
Disclosure: The following are affiliate links from Amazon. We may earn a small commission from purchases, at no additional cost to you. For more details, please refer to our privacy policy.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
This handbook is praised for its evidence-based approach to nursing interventions. It utilizes a simple three-step system to guide users through assessment, diagnosis, and care planning. It includes detailed instructions on implementing care and evaluating outcomes, enhancing diagnostic reasoning and critical thinking skills.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
This resource features over two hundred care plans based on the latest evidence-based guidelines. The new edition includes ICNP diagnoses, care plans for LGBTQ health issues, and information on electrolyte and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
A quick-reference tool that provides essential information for identifying correct diagnoses and planning patient care efficiently. The sixteenth edition includes updated nursing diagnoses and interventions, with an alphabetized list covering over 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual helps identify interventions for planning, individualizing, and documenting care for over 800 diseases and disorders. It uniquely offers subjective and objective sample clinical applications, prioritized actions/interventions with rationales, and a dedicated documentation section for each diagnosis.
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans across medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health settings. It uses an interprofessional “patient problems” approach to enhance communication with patients.
Further Reading
Explore these resources for more information on nursing diagnosis and related topics:
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.
