2023 Nursing Diagnosis: A Complete Guide
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- What is a Nursing Diagnosis?
- The 3 Components of a Nursing Diagnosis
- NANDA Nursing Diagnosis – The 4 Types
- How to Write a Nursing Diagnosis
- Basic Nursing Diagnosis Examples
As a nurse, you will be expected to develop and implement nursing diagnoses to determine how you will care for your patients and improve their overall health and well-being. This often means using evidence-based nursing practices.
As you prepare for a career in nursing, it’s essential to understand the value of a nursing diagnosis in health management, how it fits into a care plan, and how to write a nursing diagnosis of your own.
We’ll walk you through each part so you can better understand this critical part of your nursing career.
What is a Nursing Diagnosis?
A nursing diagnosis is a clinical judgment you make about an individual’s or group’s health conditions and needs or their vulnerabilities to particular conditions or life processes — in other words, the human responses to those conditions or vulnerabilities.
Using your nursing diagnosis, you’ll determine the nursing interventions that will have the greatest positive impact on this individual or group.
A nursing diagnosis is based on data collected, observations, education, and experience. Carefully creating a nursing diagnosis can help you measure outcomes as you follow your planned interventions. Measuring outcomes allows you to compare the patient’s initial state with their current state and the impact of your interventions so you know when to adjust your actions and how to best help the patient.
This critical component of the nursing process will allow you to create a nursing care plan that will guide how you care for the patient. It’s important to note that a nursing diagnosis isn’t the same as a medical diagnosis!
While a medical diagnosis focuses on the disease or condition, such as pneumonia. The nursing diagnosis focuses more on the patient’s experiences such as, “Ineffective airway clearance.” Both play a critical role in clinical practice.
What is a nursing diagnosis used for?
A nursing diagnosis calls for a thorough, holistic nursing assessment of the patient — examining their health and condition from a variety of different angles. As nurses carefully assess all of these different data points and create a comprehensive assessment, it can increase patient safety and help patients receive the appropriate care they need.
The diagnosis will then guide patient care moving forward. As a nurse, you’ll use the diagnosis to determine the appropriate interventions and evaluate the patient’s progress. This process will allow you to communicate with other staff members to provide care.
The 3 Components of a Nursing Diagnosis
As you develop nursing diagnoses, you’ll encounter three main components as part of the assessment. Depending on the type of diagnosis you make, you’ll use different combinations of these components.
- The problem and its definition. You’ll need to give a problem statement, also known as the diagnostic label, articulating the patient’s condition. It might include modifiers or qualifiers that give additional information about the diagnosis. You’ll also have a focus. The focus of the diagnosis explains the center point of the diagnosis.
- Etiology. Also known as the related factors, the etiology describes the likely causes of the health problem at hand. It generally uses vocabulary like “related to” to associate the diagnosis with the likely causes. For example, you might note problems like “chronic low self-esteem” or “disturbed thought processes” for a medical diagnosis of depression. For physical issues such as a gastrointestinal bleed, you may find “Ineffective tissue perfusion.”
- Defining characteristics or risk factors offer further information about the diagnosis. If the diagnosis focuses on patient risk, these factors might be listed instead of etiology. A person immobilized in their bed might be at risk for impaired skin integrity. Defining characteristics provide information about the signs that point to the diagnosis, using language such as “as evidenced by immobility,” to connect the characteristics with the diagnosis.
Now that you know the main components of a nursing diagnosis, let’s explore the different types of diagnoses you might encounter throughout your nursing career.
NANDA Nursing Diagnosis – The 4 Types
The North American Nursing Diagnosis Association International (NANDA-I) is the organization that articulates the standards used for creating nursing diagnoses. The standards that they create are used worldwide.
The origins of the standards date back to the 1950s when the importance of articulating nursing roles began to emerge. About 20 years later, the first national conference was held to begin classifying the different nursing diagnoses.
The meetings have continued to be held to define diagnoses further. Nurses can also submit new diagnoses that they think should be included to the organization for review.
There are four main categories of nursing diagnoses that you’ll encounter.
1. Problem-Focused Diagnosis
A problem-focused diagnosis revolves around the symptoms and signs that the patient presents with. This category comprises the largest proportion of nursing diagnoses. The diagnosis in this situation aims to identify a central problem that the patient faces and might be quickly resolved or long-lasting.
The problem-focused diagnosis includes three main parts:
- The nursing diagnosis itself
- Any related factors
- Any defining characteristics
2. Risk Nursing Diagnosis
Risk nursing diagnoses are used to determine the types of nursing interventions needed to prevent certain medical conditions or other problems from developing. Nurses will need to use their training and experience to help them see the risks that will impact their patient.
A risk nursing diagnosis will include:
- The nursing diagnosis
- Any risk factors
3. Health Promotion Diagnosis
A health promotion diagnosis is drafted to help improve the health of the patient or group the nurse treats. These diagnoses take a holistic look at the patient or group being treated and determine how interventions can help the patient improve their condition globally. These diagnoses help to promote self-care in patients.
A health promotion diagnosis will include:
- The nursing diagnosis
- Any defining characteristics
However, the health promotion diagnosis can be done with just a diagnosis label.
4. Syndrome Diagnosis
A syndrome diagnosis looks for patterns or clusters of nursing diagnoses that all call for related nursing interventions. For example, you might note that an elderly person meets the requirements for Frail Elderly Syndrome.
This syndrome requires related interventions all targeted at helping the patient improve their quality of life while remaining protected from common risks and ailments that come with advanced aging.
A syndrome diagnosis will require only the diagnostic label component.
How to Write a Nursing Diagnosis
A nursing diagnosis should be a short, concise statement articulating your understanding of the problem. You’ll use your nursing knowledge to record the issue and how you arrived at your patient’s care plan.
Writing a nursing diagnosis should follow an exact formula. Using this formula means that you ascribe to the standards of the profession. It also makes it easier for others in the medical field, including other nurses contributing to patient care, to understand your diagnosis so they can understand the chosen nursing interventions.
Below are model sentences you can use to help you draft these important sentences for patient care.
Problem-Focused Diagnosis
The statement you create for a problem-focused diagnosis will contain each of your three components:
[Problem/diagnostic label] related to [related factors] as evidenced by [defining characteristics]
Risk diagnosis
The statement for a risk diagnosis will articulate your two main components:
[Risk diagnosis/diagnostic label] as evidenced by [risk factors]
Health Promotion Diagnosis
Your health promotion diagnosis will also include your two main characteristics:
[Health promotion label] as evidenced by [defining characteristics]
Syndrome Diagnosis
A syndrome diagnosis label, as you recall, only needs to list the syndrome diagnosis or diagnostic label. So, all that’s needed for this statement is:
[Syndrome diagnosis/ diagnostic label]
Possible Diagnosis
A possible diagnosis statement is needed when you suspect a particular health problem or situation but don’t have enough information to either confirm or rule out this issue.
As a nurse, you’ll work with others on the health care team to try to collect more information so you can make the appropriate decision about whether this is a valid diagnosis.
To write a possible diagnosis statement, you’ll write:
Possible [diagnostic label]
Basic Nursing Diagnosis Examples
Now that you know the basic structure of the diagnostic sentences, let’s explore a few examples so you can better understand how these sentences come together to create a nursing diagnosis.
- Problem-focused diagnosis: “Ineffective breathing patterns related to pneumonia as evidenced by ineffective cough and excessive secretions.”
- Risk diagnosis: “Risk for infection as evidenced by a breach of primary defenses and trauma to the vascular area.”
- Health promotion: “Readiness for enhanced nutrition/improved wellness as evidenced by an expressed willingness to improve nutrition.”
- Syndrome: “Chronic Pain Syndrome”
We Can Help You Pass Your Exams the First Time
As you prepare to enter an exciting new career in nursing, you’ll want to ensure you have a thorough understanding of drafting a nursing diagnosis.
As a nursing postgrad, you’ll also need to spend time preparing for the critical exams that allow you to earn a BSN or an MSN and find your chosen career in nursing, like the NCLEX.
That’s where SimpleNursing can help. We provide comprehensive resources right at your fingertips to help you study smarter. We’ll help you break down the content you need to know to excel, find any weak points where you should focus your study time, and help you work your way through the material for the exam.
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