A nursing diagnosis stands as a cornerstone within the nursing process, serving as an indispensable tool for nurses and the broader healthcare ecosystem.
This comprehensive guide is designed to explore every facet of nursing diagnosis, a critical element in patient care. We will delve into its definition, its pivotal role in the nursing process, the various types and classifications of diagnoses, and the essential steps involved in formulating and applying a nursing diagnosis effectively.
Let’s begin our exploration.
Understanding the Nursing Process
Before we can fully grasp the concept of a nursing diagnosis, it’s crucial to understand its context within the nursing process. The nursing process is a systematic, five-step approach to patient care, with diagnosis being the second vital step.
The five steps are:
Assessment – This initial phase involves a thorough evaluation of the patient. Nurses collect comprehensive data, including vital signs, medical history, psychological assessments, and socioeconomic factors. This holistic data gathering is fundamental to understanding the patient’s overall health status.
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 problems and guides the subsequent nursing care plan. It’s a crucial step in tailoring care to the patient’s specific needs.
Outcomes and Planning – In this phase, nurses develop a patient-centered care plan based on the nursing diagnosis. This plan outlines specific, measurable, achievable, relevant, and time-bound (SMART) goals and interventions aimed at addressing the identified health issues.
Implementation – This stage is where the care plan is put into action. Nurses carry out the planned interventions, continuously monitoring the patient’s response and adjusting care as needed throughout their hospitalization or care period.
Evaluation – The final step involves a critical evaluation of the effectiveness of the care plan. Nurses assess whether the desired outcomes have been achieved. If not, the care plan is revised and adjusted based on the patient’s progress and evolving needs, ensuring continuous improvement in care.
Alt text: A diagram illustrating the five steps of the nursing process: Assessment, Diagnosis, Outcomes and Planning, Implementation, and Evaluation, emphasizing the cyclical and interconnected nature of patient care.
Defining Nursing Diagnosis
As established, a nursing diagnosis is a pivotal stage in the nursing process. It represents a structured and evidence-based method for nurses to articulate their expert clinical judgments to patients, nursing colleagues, other healthcare professionals, and the wider public. It is derived from the comprehensive data gathered during the assessment phase. Crucially, the nursing diagnosis serves as the foundation for creating a tailored care plan and for subsequently evaluating patient care outcomes.
NANDA International (NANDA-I), the globally recognized authority, is responsible for standardizing nursing diagnoses. NANDA-I officially defines a nursing diagnosis as:
“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.”
In simpler terms, a nursing diagnosis is a nurse’s professional judgment about a patient’s health problem, potential health problem, or opportunity to improve health. It focuses on the patient’s experiences and responses to illness, injury, or life changes.
Distinguishing Nursing Diagnosis from Other Diagnoses
It’s important to differentiate nursing diagnosis from other types of diagnoses encountered in healthcare. The primary distinctions lie between nursing diagnoses, medical diagnoses, and collaborative problems.
A nursing diagnosis is formulated by a registered nurse (RN). It is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems and life processes. Nursing diagnoses are patient-centered and focus on responses to illness. For example, during a patient assessment, a nurse observes coughing before swallowing, weak throat muscles during swallowing tests, and patient reports of food feeling “stuck.” Based on these findings, the nurse may formulate the nursing diagnosis: Impaired Swallowing.
Examples of nursing diagnoses: Risk for unstable blood glucose level; Urinary incontinence; Disturbed sleep pattern; Decreased cardiac output.
Conversely, a medical diagnosis is made by a physician or advanced medical practitioner. Medical diagnoses identify diseases, medical conditions, or pathologies. They focus on the pathology of organs or body systems and remain constant throughout the patient’s medical history.
Examples of medical diagnoses: Pneumonia; Type 2 Diabetes Mellitus; Chronic Obstructive Pulmonary Disease (COPD); Stroke.
Collaborative problems are potential or actual physiological complications that nurses monitor to detect the onset of changes in patient status. These problems require both medical and nursing interventions. Nurses manage collaborative problems using physician-prescribed and nursing-prescribed interventions to minimize complications.
Examples of collaborative problems: Potential Complication: Hemorrhage; Potential Complication: Paralytic Ileus.
Alt text: A nurse attentively assesses a patient in a hospital bed, demonstrating the crucial assessment phase that precedes formulating a nursing diagnosis for effective pain management.
Classification of Nursing Diagnoses
To ensure clarity and organization, nursing diagnoses are systematically classified. NANDA-I employs Taxonomy II, a hierarchical system used for over two decades. This taxonomy organizes diagnoses into three levels: 13 domains, 47 classes, and 267 distinct nursing diagnoses.
Here’s a breakdown of the 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
Alt text: A nurse thoughtfully reviews patient data, illustrating the process of analyzing assessment findings to formulate an accurate and effective nursing diagnosis.
Categories of Nursing Diagnoses
NANDA-I recognizes four main categories of nursing diagnoses: Problem-Focused, Risk, Health Promotion, and Syndrome.
Problem-focused diagnoses (also known as actual diagnoses) describe existing patient problems identified during the assessment. They are supported by defining signs and symptoms. A problem-focused diagnosis has three components: the diagnostic label, related factors, and defining characteristics.
Risk diagnoses are clinical judgments about a patient’s vulnerability to developing a problem if nursing interventions are not implemented. Risk diagnoses indicate that a problem doesn’t currently exist, but risk factors are present. Risk diagnoses include two components: a risk diagnostic label and risk factors.
Health promotion diagnoses (or wellness diagnoses) are clinical judgments about a patient’s motivation and desire to enhance well-being and actualize human health potential. These diagnoses express a readiness to improve specific health behaviors and can apply to individuals, families, groups, or communities.
Syndrome diagnoses represent clinical judgments about a cluster of nursing diagnoses that frequently occur together and are addressed with similar interventions. They represent a constellation of related nursing diagnoses.
Examples of each category, drawn from NANDA-I’s Nursing Diagnosis: Definitions and Classifications 2021-2023:
| Problem-Focused Diagnosis | Risk Diagnosis |
|---|---|
| – Decisional conflict | – Risk for chronic kidney disease |
| – Ineffective airway clearance | – Risk for falls |
| – Impaired oral mucous membrane integrity | – Risk for infection |
| – Hyperthermia | – Risk for pressure ulcer |
| – Acute pain | – Risk for aspiration |
| Health Promotion Diagnosis | Syndrome Diagnosis |
| – Readiness for enhanced knowledge | – Chronic pain syndrome |
| – Readiness for enhanced nutrition | – Frail elderly syndrome |
| – Readiness for enhanced self-care | – Post-trauma syndrome |
| – Readiness for enhanced parenting | – Relocation stress syndrome |
| – Readiness for enhanced spiritual well-being | – Risk for disuse 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 diagnosis category. Key components include:
Diagnostic Label: A concise name representing the diagnostic focus and nursing judgment.
Examples: Ineffective breathing pattern; Acute pain; Impaired skin integrity.
Definition: A 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.”
Defining Characteristics: Observable cues and inferences that cluster as manifestations of an actual diagnosis or health promotion diagnosis. These are the signs and symptoms.
Example: For “Impaired Gas Exchange,” defining characteristics may include: Abnormal arterial blood gases; Cyanosis; Restlessness; Confusion.
Risk Factors: Environmental, physiological, psychological, genetic, or chemical elements that increase vulnerability to a risk diagnosis. Applicable only to risk diagnoses.
Example: “Risk for Infection” may have risk factors such as: Chronic disease (e.g., diabetes); Immunosuppression; Invasive procedures; Malnutrition.
Related Factors: Conditions, circumstances, or etiologies that contribute to or are associated with a problem-focused diagnosis. Used with problem-focused and syndrome diagnoses (and sometimes health promotion diagnoses).
Example: For “Ineffective Peripheral Tissue Perfusion,” related factors could include: Diabetes mellitus; Hypertension; Smoking; Sedentary lifestyle.
Alt text: A close-up of the NANDA-I Nursing Diagnosis book, symbolizing the authoritative resource for standardized nursing diagnoses and their application in patient care.
Writing a Nursing Diagnosis Statement
Accurate and standardized nursing diagnosis statements are crucial for clear communication and effective care planning. NANDA International recommends specific formats for different types of nursing diagnoses. These formats ensure consistency and understanding across healthcare teams.
Here’s a guide to writing nursing diagnosis statements, with examples:
- Problem-Focused Diagnosis (using a three-part statement: Problem + Etiology + Signs/Symptoms – PES):
Impaired Physical Mobility related to musculoskeletal impairment as evidenced by limited range of motion and difficulty turning in bed.
Acute Pain related to surgical incision as evidenced by patient report of pain at incision site, rating pain 7/10, and guarding behavior.
- Risk Diagnosis (using a two-part statement: Problem + Risk Factors):
Alt text: A nurse in a hospital setting attentively reviews a patient’s chart, highlighting the critical role of documentation and accurate diagnosis in effective patient care management.
Risk for Infection related to invasive procedure and compromised skin integrity.
Risk for Falls related to muscle weakness and impaired balance.
- Health Promotion Diagnosis (using a two-part statement: Diagnosis Label + Defining Characteristics):
Readiness for Enhanced Nutrition as evidenced by expresses desire to improve dietary habits and increased intake of fruits and vegetables.
Readiness for Enhanced Family Coping as evidenced by family members actively seeking information and support resources.
- Syndrome Diagnosis (using a one-part statement – the Syndrome Label):
Alt text: A list of NANDA-I nursing diagnoses displayed on a tablet, representing the comprehensive and readily accessible resources available to nurses for accurate and effective patient care planning.
Rape-Trauma Syndrome
Chronic Pain Syndrome
Further Examples of Nursing Diagnoses
The NANDA-I list offers 267 diagnoses, providing a comprehensive resource for nurses. Here are additional examples to broaden your understanding and assist in care plan development:
- Activity intolerance
- 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
- Self-care deficit (bathing, dressing, feeding)
- 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: A Key to Quality Care
Nursing diagnoses are indispensable tools for nurses, enabling the delivery of safe, high-quality, and evidence-based patient care. Proficiency in understanding, formulating, and utilizing nursing diagnoses is a fundamental competency for every nurse. By mastering this critical component of the nursing process, nurses can significantly enhance patient outcomes and contribute to a more effective and patient-centered healthcare system.
