Nursing Diagnosis Guide
The nursing diagnosis is a clinical determination of an individual’s, family, group’s, or community’s response to health conditions/life processes or susceptibility to that response.
A nursing diagnosis is a basis for determining the nursing interventions necessary to achieve the outcomes for which the nurse is accountable.
Based on the information acquired during the nursing assessment, nursing diagnoses are formed, allowing the nurse to develop a treatment plan. The formulation and application of a nursing diagnostic assist nurses in determining the optimal treatment plan for their patients.
After carefully considering a patient’s physical assessment, nursing diagnoses are formulated. They can be used to monitor the development of the patient’s treatment plan and influence potential interventions for the patient, family, and community nursing diagnosis. Some nurses may view nursing diagnosis as antiquated and time-intensive. Nonetheless, it is a crucial tool for enhancing patient safety by applying evidence-based nursing research.
Purpose of Nursing Diagnosis
NANDA International defines a nursing diagnosis as “a conclusion based on a comprehensive nursing evaluation.” It is based on the patient’s current condition and health assessment, allowing nurses and other medical professionals to view the patient holistically.
The objectives of nursing diagnosis include the following:
1) It facilitates the identification of nursing priorities and the direction of nursing interventions based on these identified priorities.
2) It facilitates the formulation of expected results for third-party payer quality assurance requirements.
3) It assists in determining how a client or group reacts to current or anticipated health and life processes and identifies the client’s or group’s strengths that you can utilize to prevent or resolve problems.
4) It provides a common language and a foundation for communication between nursing professionals and the rest of the healthcare team, allowing them to communicate and understand one another.
5) It provides a basis for determining whether the patient’s nursing care was beneficial and cost-effective.
6) It is an effective instructional tool for nursing students who wish to enhance their problem-solving and critical thinking skills.
7) An accurate nursing diagnosis provides patient safety, superior care, and increased reimbursement from private health insurance, Medicare, and Medicaid.
History of Nursing Diagnosis
Formerly known as the North American Nursing Diagnosis Association (NANDA), NANDA–International is the foremost organization for global defining, disseminating, and integrating standardized nursing diagnoses.
In the nursing literature, the term “nursing diagnosis” first appeared in the 1950s. Saint Louis University’s Kristine Gebbie and Mary Ann Lavin identified the need to clarify the function of nurses in ambulatory care settings. In 1973, the NANDA held its first national meeting to define, create, and classify nursing diagnoses formally.
There were national conferences in 1975, 1980, and every two years. North American Nursing Diagnosis Association (NANDA) was created in 1982 to recognize the participation of nurses from the United States and Canada. NANDA was renamed NANDA International (NANDA-I) in 2002 due to its rapid expansion outside North America.
The acronym NANDA was kept in the name due to its significance. Each biennial conference examines, develops, and analyzes diagnostic labels, including considering new and updated titles. Nurses can submit diagnoses for review by the Diagnostic Review Committee.
The NANDA-I board of directors provides final approval for adding a diagnosis to the official label list. As of 2021, NANDA-I had approved 267 diagnoses for clinical use, testing, and refinement.
According to its website, NANDA International has the following mission:
1) To determine interventions and outcomes, present the world’s top nursing diagnoses supported by evidence for use in practice.
2) To increase patient safety, include terminology based on scientific knowledge in clinical practice and decision-making.
3) Contributes to research funding through the NANDA-I Foundation
4) Be a thriving and supportive global network of nurses committed to improving the quality of nursing care and patient safety via evidence-based practice.
Nursing Diagnosis Classification or Taxonomy II
How are nursing diagnoses categorized, listed, and organized? In 2002, Taxonomy II, an evaluation framework based on Dr. Mary Joy Gordon’s Functional Health Patterns, was accepted.
The three levels of Taxonomy II are Domains, Classes, and nursing diagnoses. In place of Gordon’s patterns, nursing diagnoses are coded according to seven axes: diagnostic concept, time, unit of care, age, health condition, descriptor, and topology.
In addition, diagnoses are now arranged alphabetically by the concept instead of by the first word.
Types of Nursing Diagnosis
There are four categories of Nursing diagnoses provided by the NANDA-I system:
1) Problem-Focused Nursing Diagnosis
A problem-focused diagnostic refers to a client issue (also known as actual diagnosis) existing at the time of the nursing evaluation.
These diagnoses are based on the presence of accompanying signs and symptoms. A risk diagnosis can be a patient’s priority in various scenarios.
Problem-focused nursing diagnoses consist of three components: (1) nursing diagnosis, (2) related factors, and (3) defining characteristics. These are Examples of nursing diagnosis statements:
a) The use of accessory muscles to breathe, pursed-lip breathing, complaints of discomfort during inhalation, and dyspnea are indicators of an ineffective breathing pattern associated with Pain.
b) Anxiety resulting from stress manifests in increased tension, anxiousness, and verbalizations of concern about the upcoming surgery.
c) Acute Pain resulting from the decreased myocardial blood supply, manifested by irritation, verbalization of Pain, and protective behavior
d) Impaired Skin Integrity results from pressure over a bony prominence, manifested by acute Pain, skin breaks, redness, and wound drainage.
2) Risk Nursing Diagnosis
The second type of nursing diagnosis is a risk nursing diagnosis. Although these are clinical determinations that no problem exists, the presence of risk signs means that a problem will develop if nurses do not intervene.
There are no etiological variables or associated factors for risk diagnosis. Due to risk factors, the individual or group is more likely than others in the same or comparable situation to develop the ailment. For instance, if an elderly patient with diabetes and vertigo has difficulty walking and refuses to ask for help, they may be categorized as at Risk for Injury.
Two components comprise a risk nursing diagnosis: (1) a diagnostic label and (2) risk variables. The following are examples of nursing diagnoses that pose a risk:
a) Fall hazard evidenced by bodily malaise
b) Injury Risk as Evidenced by Gait and Balance Problems
c) Immunosuppression demonstrates an elevated risk for infection.
d) Probability of an Ineffective Childbearing Procedure
e) Possibility of Impaired Oral Mucosal Membrane Integrity
3) Health Promotion Diagnosis
A health promotion diagnosis, also known as a wellness diagnosis, is a professional evaluation of a person’s motivation and desire to improve their health.
The aim of health promotion diagnosis is the movement of a person, family, or community from one degree of wellness to a higher level. Typically, the only component of a health promotion diagnosis is the diagnostic label or a simple remark. Listed below are examples of health promotion diagnoses:
a) Readiness for Improved Spiritual Health
b) Capacity for Improved Self-Care
c) Readiness for Improved Parenting
d) Readiness for Improved Daily Participation
e) Readiness for Improved Sleeping Pattern
4) Syndrome Diagnosis
A syndrome diagnosis is a clinical diagnosis made in response to a cluster of issues or risk nursing diagnoses that are anticipated to appear due to a specific disease or event.
Syndrome diagnoses are written as one-part statements requiring only the diagnostic label. The following are instances of nursing syndrome diagnoses:
a) Chronic Pain Disorder
b) Post-trauma Syndrome
c) Frail Elderly Syndrome
d) Reduction in cardiac output
e) Poor cerebral tissue perfusion
Possible Nursing Diagnosis
Actual, danger, health promotion, and syndrome are all forms of nursing diagnoses, but possibly not one of them.
Possible nursing diagnoses are statements that describe a condition for which additional information is required to confirm or rule out.
It enables the nurse to alert other nurses that additional data gathering is required to exclude or confirm the diagnosis. Here are several examples:
1) Possible Chronic Low Self-Esteem
2) Possible Social Isolation
3) Possible Nutritional Imbalance
Components of Nursing Diagnosis
1) Problem and Definition
The problem statement, often known as the diagnostic label, is a concise summary of the health problem or response that requires nursing care. A diagnostic label typically consists of a qualification and the diagnosis itself. Qualifiers (sometimes modifiers) are words added to specific diagnostic labels to add more meaning, limit, or specify the diagnostic statement. One-word nursing diagnoses (e.g., Anxiety, Constipation, Diarrhea, Nausea, etc.) are exempt from this criterion because their qualifier and emphasis are implicit in the single term.
2) Etiology
The nursing diagnosis etiology, or similar aspects, component of a nursing diagnosis label reveals one or more probable causes of the health problem, directs the necessary nursing therapy, and enables the nurse to individualize patient care. Nursing interventions must target etiological variables to eradicate the underlying cause of the nursing diagnosis. The phrase “related to” links the etiology to the statement of the problem, as in
• Decreased activity tolerance related to widespread weakness
• Reduced physical mobility resulting from enforced bed rest
• Impaired urine excretion as a result of intense Pain
• Altered mentation associated with delirium
3) Risk Factors
Instead of etiological considerations, risk factors are used in nursing diagnosis. Risk factors are forces that raise an individual’s (or a group’s) susceptibility to disease. Typically, risk factors are written before “as demonstrated by” in the diagnostic statement.
1) Problems with gait and balance indicate a higher risk for falls.
2) Infection risk manifested by a breach in the skin’s integrity.
3) Risk for dehydration as shown by low skin turgor.
4) Injury risk associated with altered mobility
5) Increased the risk of aspiration due to an increase in mucus production
6) Defining Characteristics
Defining characteristics are the clusters of signs and symptoms that indicate the presence of a particular diagnostic label. In nursing diagnosis, the identified signs and symptoms of the patient are the defining characteristics.
Because there are no visible signs or symptoms in a risk nursing diagnosis, the etiology of the problem consists of the circumstances that make the client more vulnerable to the problem. In the diagnostic statement, defining qualities are written after the words “as proven by” or “as manifested by.”
Diagnostic Process: How to Diagnose
1) Analyzing Data
Data analysis includes comparing patient data to standards, clustering cues, and discovering gaps and contradictions.
2) Identifying Health Problems, Risks, and Strengths
In this decision-making process, the nurse and client identify difficulties that support tentative actual, risk and probable diagnoses following data analysis. It involves determining if a problem is a nursing diagnosis, medical diagnosis, or collaborative issue. During this phase, the nurse and client also specify the client’s strengths, resources, and coping skills.
3) Writing Nursing Diagnostic Statement
The formulation of diagnostic statements is the final step of the diagnostic process, in which the nurse creates a diagnostic statement through a process. The procedure is detailed below:
How to Write a Nursing Diagnosis Statement
When writing nursing diagnostic statements, describe the individual’s health status and the contributing circumstances. There is no requirement to disclose all diagnostic signs. The format of diagnostic statements will vary depending on the type of nursing diagnosis.
PES Format
The PES format, which stands for the problem (diagnostic label), Etiology (associated causes), and Signs/Symptoms (defining characteristics), is an alternative method for writing nursing diagnostic statements. In the PES format, diagnostic statements may be one-part, two-part, or three-part statements.
a) One-Part Nursing Diagnosis Statement
Since related variables are always the same, health promotion nursing diagnoses are commonly stated as one-part statements: the phrase “motivated to achieve a higher degree of wellness through related factors” may be used to enhance the selected diagnostic. There are no factors associated with syndrome diagnoses. The following are examples of nursing diagnosis statements with a single component:
• Preparedness for improved parenting
• Preparedness for improved coping
b) Two-Part Nursing Diagnosis Statement.
The first element of risk or potential nursing diagnosis is the diagnostic label, and the second is the validation for a risk nursing diagnosis or the presence of risk variables. Due to the absence of signs and symptoms, the third part for risk or possible diagnoses is not possible. The following are examples of nursing diagnosis statements with two parts:
• Risk for Ineffective Tissue Perfusion due to Abnormal Blood Profile
• Possible Self-Isolation with unidentified etiology
c) Three-Part Nursing Diagnosis Statement.
Actual or problem-focused nursing diagnoses consist of a three-part statement: diagnostic name, contributing cause (“connected to”), and signs and symptoms (“as demonstrated by” or “as manifested by”). Problem, Etiology, and Signs and Symptoms are the three components of the nursing diagnosis statement, often known as the PES format. The following are examples of nursing diagnosis statements with three parts:
• Impaired Physical Mobility as a result of diminished muscle control, as indicated by difficulty moving the lower extremities.
• Acute Pain attributable to tissue ischemia, as demonstrated by the expression “I have extreme head pain!”
American Nursing Diagnosis vs. International Nursing Diagnosis
Currently, there are no differences between American and foreign nursing diagnoses. Because NANDA-I is a global organization, the accepted nursing diagnoses are identical.
There may be discrepancies when the grammar and structure of a nursing diagnostic are altered through translation. However, because NANDA-I has offices worldwide, nursing diagnoses in languages other than English are substantially the same.
Variations in Basic Nursing Diagnosis Format
Variations in the format of introductory nursing diagnosis statements include the following:
• To make the diagnostic statement more descriptive and informative, use “secondary to” to break the etiology into two parts. Typically, the phrase “secondary to” is followed by a pathophysiologic, disease process, or medical diagnostic.
Example: Risk of Decreased Cardiac Output attributable to Reduced Preload Following Myocardial Infarction
• “Complex factors” is used when there are too many etiologic factors or when they are too complex to convey in a single sentence.
Example: Chronic Imbalanced Nutrition: less than the body’s nutritional needs due to complicated circumstances.
• “Unknown etiology” is used when the defining criteria are present, but the nurse is unaware of the cause or contributing circumstances.
Examples: Ineffective coping with an unidentified etiology
Situational Low Self-Esteem with an Unknown Cause
• Specify a second component of the general answer or NANDA label to add specificity. Example: Impaired Skin Integrity (right chest) due to skin surface damage resulting from a burn injury.
Examples of Nursing Diagnosis
• Nursing Diagnosis for Activity Intolerance
• Nursing Diagnosis for Acute Pain
• Nursing Diagnosis for Altered Mental Status
• Nursing Diagnosis for Anemia
• Nursing Diagnosis for Ankylosing Spondylitis
• Nursing Diagnosis for Anxiety
• Nursing Diagnosis for Asthma
To sum up
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