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Creating a nursing diagnosis is a critical part of providing patient care and is a vital step of the nursing process. By understanding how to create a nursing diagnosis, you can help improve patient outcomes, improve communication among the medical health team, and organize your day. Both the nursing process and nursing diagnoses help ensure and promote evidence-based, safe practices. In this guide, you will learn what a nursing diagnosis is, why it is important, and a general overview of how to perform a nursing diagnosis. The Nursing ProcessYou can't discuss a nursing diagnosis without discussing the nursing process. The nursing process has five steps: 1. Assessment: Assessment is a thorough and holistic evaluation of a patient. It includes the collection of both subjective and objective patient data such as vital signs, a health history, head-to-toe physical, and a psychological, socioeconomic, and spiritual evaluation. 2. Diagnosis: Diagnosis is formed by the nurse and is based on the data collected during the assessment. The nursing diagnosis directs nursing-specific patient care. In this step, the nurse forms a diagnosis based on the patient's specific medical and/or social needs. The diagnosis leads to the creation of goals with measurable outcomes. The diagnosis must be one that has been approved by NANDA International (NANDA-I), formerly known as North American Nursing Diagnosis Association. NANDA-I is responsible for developing and standardizing nursing diagnoses. Used internationally, the NANDA-I vision and mission is to use evidence-based, universal nursing terminology to promote safe patient care. NANDA-I defines a nursing diagnosis as follows:
"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." A nursing diagnosis generally has three components: a diagnosis approved by NANDA-I, a related to statement which defines the cause of the NANDA-I diagnosis, and an as evidenced by statement that uses specific patient data to provide a reason for the NANDA-I diagnosis and related to statement. Risk-related diagnoses only contain a NANDA-I diagnosis and an as evidenced by statement because it is describing a vulnerability, not a cause. For example, a nurse may use a nursing diagnosis such as "risk for pressure ulcer as evidenced by lack of movement, poor nutrition, and hydration." 3. Outcomes and Planning: Outcome and planning involves developing a patient care plan based on the nursing diagnosis. Planning should be measurable and goal-oriented for the patient and/or their family members. 4. Implementation: Implementation is when nurses initiate the care plan and put it into action. This step provides the continuation of care during hospitalization until discharge. 5. Evaluation: Evaluation is the final step of the nursing process. A patient care plan is evaluated based on specific goals and desired outcomes and may be adjusted based on the patient's needs. How Do Nursing Diagnoses Differ From Medical Diagnoses?To best understand a nursing diagnosis, it may help to first understand how it differs from a medical diagnosis. A nursing diagnosis is initiated by a nurse and describes a response to the medical diagnosis. A medical diagnosis is given by a doctor to a patient to define a medical condition/disease or injury.
Example: Ineffective breathing pattern related to impaired inhalation and exhalation as evidenced by the use of accessory muscles
Example: Asthma 4 Categories of Nursing DiagnosesThe need for standardized language, respecting nurses' clinical judgment, and providing care for patients with measurable results defines the use of a nursing diagnosis. The nursing diagnosis can be divided into four main categories. Please note all examples are taken from the Nursing Diagnoses Definitions and Classification 2015-2017.
A nursing diagnosis related to a patient's problem. It can be used throughout the course of the patient's hospitalization or be resolved by the end of the shift. Example: Anxiety related to situational crises and stress (related factors) as evidenced by restlessness, insomnia, anguish, and anorexia (defining characteristics)
A nursing diagnosis that identifies when the patient is at risk for developing a problem. NANDA-I describes it as a vulnerability the patient has encountered. Example: Risk for infection as evidenced by inadequate vaccination and immunosuppression (risk factors)
A nursing diagnosis used to identify how to help improve the health of a patient. Health-promotion diagnosis includes the patient and their family/community members. Example: Readiness for enhanced self-care as evidenced by expressed desire to enhance self-care
A nursing diagnosis identifying a cluster of diagnoses for a patient. These nursing diagnoses are best described together. The patient may be experiencing a number of health problems forming a pattern. Example: Chronic pain syndrome Nursing Diagnosis ClassificationNANDA-I created Taxonomy II after collaborating with the National Library of Medicine. By definition, taxonomy is the "practice and science of categorization and classification." The NANDA-I Taxonomy currently has 235 nursing diagnoses with 13 categories of nursing practice:
They also have 47 classes related to each category.
Nurses complete five steps to carry out a strong, accurate nursing diagnosis. All nurses should follow the nursing process: Having a solid understanding of nursing science and theory provides a strong foundation for patient care. It is also the first step in initiating a nursing diagnosis and care plan that is holistic and patient-centered. During the assessment, nurses gather medical, surgical, and social history. They also perform a physical on the patient. Nurses then ask themselves: What is the current and priority health problem(s) the patient is experiencing? This information is applied to creating a nursing diagnosis.
Types and Components of Nursing Diagnoses
Problem-Focused Nursing Diagnoses1 A problem-focused nursing diagnosis “describes human responses to health conditions/life processes that exist in an individual, family, or community. It is supported by defining characteristics (manifestations, signs, and symptoms) that cluster in patterns of related cues or inferences” (NANDA-I, 2009). This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factors.
The label should be in clear, concise terms that convey the meaning of the diagnosis.
For problem-focused nursing diagnoses, defining characteristics are signs and symptoms that, when seen together, represent the nursing diagnosis. If a diagnosis has been researched, defining characteristics can be separated into major and minor designations. Table 3.1 represents major and minor defining characteristics for the researched diagnosis, Defensive Coping (Norris & Kunes-Connell, 1987).
Most defining characteristics listed under a nursing diagnosis are not separated into major and minor.
In problem-focused nursing diagnoses, related factors are contributing factors that have influenced the change in health status. Such factors can be grouped into four categories:
Risk and High-Risk Nursing Diagnoses NANDA-I defines a risk nursing diagnosis as “human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability” (NANDA-I, 2009). The concept of “at risk” is useful clinically. Nurses routinely prevent problems in people experiencing similar situations such as surgery or childbirth who are not at high risk. For example, all postoperative individuals are at risk for infection. All women postdelivery are at risk for hemorrhage. Thus, there are expected or predictive diagnoses for all individuals who have undergone surgery while on chemotherapy or with a fractured hip. All persons admitted to the hospital are at Risk for Infection related to increased microorganisms in the environment, risk of person-to-person transmission, and invasive tests and therapies. Refer to Box 3.1 for an illustration of this standard diagnosis and how it is individualized to become a high-risk diagnosis. The high-risk concept is very useful for persons who have additional risk factors that make them more vulnerable for the problem to occur. In the hospital or other health care facilities, individuals should be assessed if they are at high risk for falls, infection, or delayed transition. High-risk individuals need additional preventive measures.
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What are the four types of nursing diagnosis?
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