Nursing diagnosis is a cornerstone of effective patient care within the nursing process. For nurses and the broader healthcare community, it serves as a vital framework for structuring and delivering patient-centered care.
This guide offers an in-depth exploration of nursing diagnosis, with a particular focus on Wellness Diagnosis Nursing Examples. We will examine the role of nursing diagnosis in the nursing process, delve into various types and classifications, and provide practical insights into formulating and utilizing nursing diagnoses to enhance patient outcomes and promote well-being.
Let’s begin by understanding the broader context within which nursing diagnosis operates – the nursing process itself.
Understanding the Nursing Process
Before diving into the specifics of nursing diagnosis, it’s crucial to understand its place within the comprehensive nursing process. The nursing process is a systematic, five-step approach to patient care, with diagnosis being the second critical stage.
1. Assessment: This initial phase involves a thorough evaluation of the patient. Nurses collect comprehensive data, including vital signs, medical history, psychosocial assessments, and socioeconomic factors. This holistic data collection forms the foundation for all subsequent steps.
2. Diagnosis: Following the assessment, nurses analyze the collected data to formulate a nursing diagnosis. This diagnosis is a clinical judgment that identifies the patient’s health needs and guides the subsequent nursing care plan. It is where “wellness diagnosis nursing examples” become particularly relevant, focusing on patient strengths and potential for enhanced well-being.
3. Outcomes and Planning: In this stage, nurses develop a patient-centered care plan based on the nursing diagnosis. The plan outlines measurable and achievable goals, focusing on desired patient outcomes. This planning stage is directly informed by the diagnostic insights gained in the previous step.
4. Implementation: This is the action phase where the care plan is put into practice. It involves the delivery of nursing interventions throughout the patient’s care journey, from admission to discharge.
5. Evaluation: The final step involves evaluating the effectiveness of the care plan against the established goals and outcomes. If necessary, the care plan is adjusted based on the patient’s response and evolving needs, ensuring continuous improvement and patient-centered care.
Defining Nursing Diagnosis: Focusing on Wellness
As established, a nursing diagnosis is a pivotal step in the nursing process. It serves as a structured and evidence-based method for nurses to articulate their professional judgments to patients, nursing colleagues, interdisciplinary teams, and the wider public. It is derived from the comprehensive data gathered during the assessment phase. Crucially, a well-defined nursing diagnosis sets the stage for creating a targeted care plan and measuring patient outcomes effectively.
NANDA International (NANDA-I), the globally recognized authority for standardizing nursing terminology, provides the official definition:
“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.”
Within this definition, “wellness diagnosis nursing examples” fall under the category of “health conditions/life processes” and the potential for positive “human response.” Wellness diagnoses specifically focus on the patient’s strengths and their readiness to enhance their well-being, moving beyond just addressing deficits or problems.
Differentiating Nursing Diagnosis from Other Diagnostic Types
It’s important to distinguish nursing diagnosis from other types of diagnoses encountered in healthcare. The primary distinctions lie between nursing diagnosis, medical diagnosis, and collaborative problems.
Nursing Diagnosis: This is the process and label nurses use to interpret patient data collected during the assessment phase. These interpretations are standardized using NANDA-I approved diagnoses. For instance, observing a patient with frequent coughing before swallowing, poor laryngeal elevation, and complaints of food “sticking” in their throat might lead to the nursing diagnosis of impaired swallowing. Importantly, “wellness diagnosis nursing examples” here would shift the focus to identifying patient strengths in swallowing and readiness to improve, rather than just the impairment.
Examples of nursing diagnoses: risk for infection, acute pain, readiness for enhanced self-care, and, crucially, readiness for enhanced spiritual well-being (a key example of wellness diagnosis).
Medical Diagnosis: This is made by a physician or advanced medical practitioner and focuses on identifying diseases, medical conditions, or pathological states. Medical diagnoses fall within the medical domain of expertise and are generally fixed, becoming part of the patient’s permanent medical record.
Examples of medical diagnoses: pneumonia, diabetes mellitus, myocardial infarction.
Collaborative Problems: These are health issues that require both nursing and medical interventions. They necessitate a team approach where nurses monitor patient status and medical professionals prescribe treatments and further investigations.
Examples of collaborative problems: potential complication of hemorrhage, risk for complications of medication therapy.
Classification of Nursing Diagnoses: NANDA-I Taxonomy II
To ensure clarity and organization, nursing diagnoses are systematically categorized within the NANDA-I Taxonomy II. This classification system, used for over two decades, organizes diagnoses into a three-tiered structure: 13 domains, 47 classes, and 267 individual nursing diagnoses.
This structured approach facilitates consistent communication and understanding of patient needs across healthcare settings. The domains and classes provide a framework for locating specific diagnoses and understanding their broader context.
Domains and Classes within NANDA-I Taxonomy II:
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Domain 1: Health Promotion
- Class 1. Health Awareness
- Class 2. Health Management
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Domain 2: Nutrition
- Class 1. Ingestion
- Class 2. Digestion
- Class 3. Absorption
- Class 4. Metabolism
- Class 5. Hydration
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Domain 3: Elimination and Exchange
- Class 1. Urinary function
- Class 2. Gastrointestinal function
- Class 3. Integumentary function
- Class 4. Respiratory function
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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
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Domain 5: Perception/Cognition
- Class 1. Attention
- Class 2. Orientation
- Class 3. Sensation/Perception
- Class 4. Cognition
- Class 5. Communication
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Domain 6: Self-Perception
- Class 1. Self-concept
- Class 2. Self-esteem
- Class 3. Body image
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Domain 7: Role relationship
- Class 1. Caregiving roles
- Class 2. Family relationships
- Class 3. Role performance
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Domain 8: Sexuality
- Class 1. Sexual identity
- Class 2. Sexual function
- Class 3. Reproduction
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Domain 9: Coping/stress tolerance
- Class 1. Post-trauma responses
- Class 2. Coping responses
- Class 3. Neurobehavioral stress
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Domain 10: Life principles
- Class 1. Values
- Class 2. Beliefs
- Class 3. Value/Belief/Action congruence
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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
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Domain 12: Comfort
- Class 1. Physical comfort
- Class 2. Environmental comfort
- Class 3. Social comfort
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Domain 13: Growth/Development
- Class 1. Growth
- Class 2. Development
Categories of Nursing Diagnosis: Including Wellness Focus
NANDA-I recognizes four primary categories of nursing diagnoses, each serving a distinct purpose in patient care. Understanding these categories is essential for selecting the most appropriate diagnosis for a given patient situation, particularly when focusing on “wellness diagnosis nursing examples.” The categories are: problem-focused, risk, health promotion (wellness), and syndrome diagnoses.
1. Problem-Focused Diagnosis: These diagnoses, also known as actual diagnoses, identify existing patient problems that are observable and present at the time of assessment. They are characterized by the presence of defining signs and symptoms. A problem-focused diagnosis includes three components: the diagnostic label, related factors, and defining characteristics.
2. Risk Diagnosis: These are clinical judgments about a patient’s vulnerability to developing health problems in the future if nursing interventions are not implemented. Risk diagnoses indicate potential problems that do not yet exist but are likely to occur due to identified risk factors. They include two components: a risk diagnostic label and risk factors.
3. Health Promotion Diagnosis (Wellness Diagnosis): These diagnoses are clinical judgments concerning a patient’s motivation and desire to enhance their well-being and actualize their health potential. They express a patient’s readiness to improve specific health behaviors and can be applied at the individual, family, group, or community level. “Wellness diagnosis nursing examples” fall squarely into this category, emphasizing strengths and potential for growth.
4. Syndrome Diagnosis: These are diagnoses representing clinical judgments about a cluster of nursing diagnoses that frequently occur together and are addressed with similar nursing interventions. Syndrome diagnoses are less common than the other categories in the NANDA-I taxonomy.
Examples of Nursing Diagnosis Categories:
| Problem Focused Diagnosis | Risk Diagnosis | Health Promotion Diagnosis (Wellness 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 |
Components of a Nursing Diagnosis Statement
Formulating a clear and comprehensive nursing diagnosis statement requires specific components. These components may vary slightly depending on the category of diagnosis. Here’s an overview of the essential elements:
1. Diagnostic Label: This is a concise name or term that represents the diagnostic focus and the nurse’s clinical judgment.
Examples: Ineffective Health Management, Acute Pain, Readiness for Enhanced Nutrition.
2. Definition: A clear and precise description of the diagnosis, differentiating it from similar diagnoses.
Example: For Imbalanced Nutrition: Less Than Body Requirements, the definition is: “Intake of nutrients insufficient to meet metabolic needs.”
3. Defining Characteristics: These are observable cues, inferences, and clinical findings that signal the presence of a problem-focused diagnosis, health promotion diagnosis, or syndrome. They include signs, symptoms, and patient statements.
Example: For Impaired Gas Exchange, defining characteristics might include: abnormal arterial blood gases, cyanosis, and confusion.
4. Risk Factors: These are environmental, physiological, psychological, genetic, or chemical elements that increase a patient’s susceptibility to a negative health event. Risk factors are only relevant to risk diagnoses.
Example: For Risk for Infection, risk factors might include: chronic disease (e.g., diabetes), immunosuppression, and invasive procedures.
5. Related Factors: These are factors that appear to have a relationship with a problem-focused nursing diagnosis or syndrome. They may be antecedents, associated conditions, or contributing factors. While less common, health promotion diagnoses may also sometimes include related factors.
Example: For Ineffective Peripheral Tissue Perfusion, related factors could include: hypertension, diabetes mellitus, and smoking.
Writing a Nursing Diagnosis Statement: Examples Across Categories
Following a standardized format is crucial for clear and effective communication of nursing diagnoses. NANDA International recommends specific templates for each diagnosis category to ensure accuracy and consistency.
Here are examples of how to construct nursing diagnosis statements for each category, including “wellness diagnosis nursing examples”:
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Problem-Focused Diagnosis:
- Impaired Bed Mobility related to musculoskeletal impairment as evidenced by impaired ability to reposition self in bed.
- Acute Pain related to surgical incision as evidenced by patient report of pain 7/10 and guarding behavior.
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Risk Diagnosis:
- Risk for Falls as evidenced by history of falls and impaired mobility.
- Risk for Infection as evidenced by invasive procedure and compromised immune system.
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Health Promotion Diagnosis (Wellness Diagnosis Examples):
- Readiness for Enhanced Spiritual Well-being as evidenced by expressed desire to enhance spiritual connection and engage in spiritual practices.
- Readiness for Enhanced Nutrition as evidenced by expressed interest in improving dietary habits and knowledge of healthy eating.
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Syndrome Diagnosis:
- Post-Trauma Syndrome
- Rape-Trauma Syndrome
Further Nursing Diagnosis Examples for Care Planning
The NANDA-I nursing diagnosis list, with its 267 entries, offers a comprehensive resource for nurses worldwide. Building upon the examples provided throughout this guide, here are additional nursing diagnosis examples to inform your nursing care plans, encompassing various categories:
- 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 for Enhanced Patient Care
Nursing diagnoses are indispensable tools that empower nurses to deliver safe, high-quality, and evidence-based care. They represent a critical element of patient healthcare, and proficiency in using, formulating, and writing nursing diagnoses is essential for every nurse. By understanding the nuances of different diagnosis types, including “wellness diagnosis nursing examples,” nurses can create truly patient-centered care plans that address both needs and strengths, ultimately promoting optimal patient outcomes and well-being.
