Know the concepts behind nursing diagnosis (NDx) in this ultimate tutorial and list. Learn what is a nursing diagnosis, the nursing process, the different types, and how to write NANDA nursing diagnoses correctly. Included also in this guide are tips on how you can formulate better nursing diagnosis plus a list of NANDA-I diagnoses that you can use in creating your nursing care plans (NCP).
- 1 What is a nursing diagnosis?
- 2 Nursing Processes
- 3 Types of Nursing Diagnoses
- 4 How to Write Nursing Diagnosis?
- 5 Nursing Diagnosis List
What is a nursing diagnosis?
A nursing diagnosis (NDX) may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses are developed based on data obtained during the nursing assessment.
NANDA–International earlier known as the North American Nursing Diagnosis Association (NANDA) is the principal organization for defining, distribution and integration of standardized nursing diagnoses worldwide.
Difference of Medical and Nursing Diagnoses
The term nursing diagnosis is associated with three different concepts. It may refer to the distinct second step in the nursing process, diagnosis. Also, nursing diagnosis applies to the label when nurses assign meaning to collected data appropriately labeled with NANDA-approved nursing diagnosis. During the assessment, the nurse may recognize that the client is feeling anxious, fearful, and finds it difficult to sleep. It is those problems which are labeled with nursing diagnoses: respectively, Anxiety, fear, and Disturbed Sleep Pattern. Lastly, a nursing diagnosis refers to one of many diagnoses in the classification system established and approved by NANDA. In this context, a nursing diagnosis is based upon the response of the patient to the medical condition. It is called a ‘nursing diagnosis’ because these are matters that hold a distinct and precise action that is associated with what nurses have autonomy to take action about with a specific disease or condition. This includes anything that is a physical, mental, and spiritual type of response. Hence, a nursing diagnosis is focused on care.
A medical diagnosis, on the other hand, is made by the physician or advance health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat. Moreover, through experience and know-how, the specific and precise clinical entity that might be the possible cause of the illness will then be undertaken by the doctor, therefore, providing the proper medication that would cure the illness. Examples of medical diagnoses are Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. The medical diagnosis normally does not change. Nurses are required to follow the physician’s orders and carry out prescribed treatments and therapies.
As explained above, now it is easier to distinguish nursing diagnosis from that of a medical diagnosis. Nursing diagnosis is directed towards the patient and his physiological and psychological response. A medical diagnosis, on the other hand, is particular with the disease or medical condition. Its center is on the illness.
In the diagnostic process, the nurse is required to have critical thinking. Apart from the understanding of nursing diagnoses and their definitions, the nurse promotes awareness of defining characteristics and behaviors of the diagnoses, related factors to the selected nursing diagnoses, and the interventions suited for treating the diagnoses
What data is collected? The first step of the nursing process is called assessment. When the nurse first encounters a patient, the former is expected to perform an assessment to identify the patient’s health problems as well as the physiological, psychological, and emotional state. The most common approach to gathering important information is through an interview. Physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to collect assessment data.
What is the problem? Once the assessment is completed, the nurse will take all the gathered information into consideration and diagnose the patient’s condition and medical needs. This involves a nurse making an educated judgment about a potential or actual health problem with a patient. More than one diagnoses are sometimes made for a single patient.
How to manage the problem? When the nurse, any supervising medical staff, and the patient agree on the diagnosis, the nurse will plan a course of treatment that takes into account short- and long-term goals. Each problem is committed to a clear, measurable goal for the expected beneficial outcome. The planning step of the nursing process is discussed in detail in Nursing Care Plans (NCP): Ultimate Guide and Database.
Putting the plan into action. The implementing phase is when the nurse put the treatment plan into effect. This typically begins with the medical staff conducting any needed medical interventions. Interventions should be specific to each patient and focus on achievable outcomes. Actions associated in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or conducting important medical tasks, educating and guiding the patient about further health management, and referring or contacting the patient for a follow-up.
Did the plan work? Once all nursing intervention actions have taken place, the team now learns what works and what doesn’t by evaluating what was done beforehand. The possible patient outcomes are generally explained under three terms: patient’s condition improved, patient’s condition stabilized, and patient’s condition worsened. Accordingly, evaluation is the last, but if goals were not sufficed, the nursing process begins again from the first step.
Types of Nursing Diagnoses
Here are the five categories/structures of nursing diagnosis provided by NANDA-I system:
Problem Nursing Diagnosis
A problem diagnosis (or also called actual diagnosis) is a client problem that is present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms. Examples: Ineffective Breathing Pattern and Anxiety, Acute Pain, and Impaired Skin Integrity.
Risk Nursing Diagnosis
A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client’s health status.
Wellness Diagnoses (or also called health promotion diagnosis) describe human responses to levels of wellness in an individual, family or community that have a readiness for enhancement. Examples of wellness diagnosis would be Readiness for Enhanced Spiritual Well Being or Readiness for Enhanced Family Coping.
A syndrome diagnosis is associated with a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event. Example is Rape Trauma Syndrome.
Possible Nursing Diagnosis
Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem. A possible nursign diagnosis also provides the nurse the ability to communicate to other nurses that a diagnosis may be present but additional data collection is indicated to rule out or confirm the diagnosis. Examples include Possible Chronic Low Self-Esteem, Possible Social Isolation.
How to Write Nursing Diagnosis?
Nursing diagnostic statements describe the health status of an individual and the factors that have contributed to the status. Diagnostic statements can be one-part, two-part, or three-part statements.
One-Part Nursing Diagnosis Statement
Wellness nursing diagnoses are written as one-part statements because related factors are always the same: motivated to achieve a higher level of wellness. Syndrome diagnoses also have no related factors. Examples include:
- Readiness for Enhance Breastfeeding
- Readiness for Enhanced Coping
- Rape Trauma Syndrome
Two-Part Nursing Diagnosis Statement
Risk and possible nursing diagnoses have two-part statements: the first part is the diagnostic label and the second is the validation for a risk nursing diagnosis or the presence of risk factors. It’s not possible to have a third part for risk or possible diagnoses because signs and symptoms do not exist. Examples include:
- Risk for Infection related to compromised host defenses
- Risk for Injury related to abnormal blood profile
- Possible Social Isolation related to unknown etiology
Three-part Nursing Diagnosis Statement
An actual or problem nursing diagnosis have three-part statements: diagnostic label, contributing factor (“related to”), and signs and symptoms (“as evidenced by”). Three-part nursing diagnosis statement is also called the PES format which includes the Problem, Etiology, and Signs and Symptoms. Examples include:
- Impaired Physical Mobility related to decreased muscle control as evidenced by inability to control lower extremities.
- Acute Pain related to tissue ischemia as evidenced by statement of “I feel severe pain on my chest!”
Variations on Basic Statement Formats
Variations in writing nursing diagnosis statement formats include the following:
- Using “secondary to” to divide the etiology into two parts to make the diagnostic statement more descriptive and useful. Following the “secondary to” is often a pathophysiologic or diseases process or a medical diagnosis. For example: Risk for Decreased Cardiac Output related to reduced preload secondary to myocardial infarction.
- Using “complex factors” when there are too many etiologic factors or when they are too complex to state in a brief phrase. For example: Chronic Low Self-Esteem related to complex factors.
- Using “unknown etiology” when the defining characteristics are present but the nurse does not know the cause or contributing factors. For example: Ineffective Coping related to unknown etiology.
- Specifying a second part to the general response or NANDA label to make it more precise. For example: Impaired Skin Integrity (Right Anterior Chest) related to disruption of skin surface secondary to burn injury.
Nursing Diagnosis List
In this section is the list or database of nursing diagnoses (NDx) with their definitions that you can read to learn more about them or use them in developing your nursing care plans. Click on the links to visit the complete guide.
nursing diagnoses definitions and classification
- Activity Intolerance: Insufficient physiologic or psychological energy to endure or complete required or desired daily activities.
- Acute Confusion: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or the sleep/wake cycle.
- Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.
- Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.
- Caregiver Role Strain: Difficulty in performing family caregiver role.
- Chronic Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage…a duration of greater than 6 months.
- Constipation: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.
- Decreased Cardiac Output: Inadequate blood pumped by the heart to meet the metabolic demands of the body.
- Deficient Fluid Volume: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.
- Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
- Diarrhea: This nursing diagnosis is defined as passage of loose, unformed stools.
- Disturbed Body Image: Confusion in mental picture of one’s physical self.
- Disturbed Thought Processes: The state in which an individual experiences a disruption in such mental activities as conscious thought, reality orientation, problem solving, judgment, and comprehension related to coping, personality, and/or mental disorder.
- Excess Fluid Volume: Increased isotonic fluid retention.
- Fatigue: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.
- Fear: Response to perceived threat that is consciously recognized as danger.
- Hopelessness: Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf.
- Hyperthermia: Body temperature elevated above normal range.
- Hypothermia: Body temperature below normal range.
- Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.
- Imbalanced Nutrition: More Than Body Requirements: Intake of nutrients that exceeds metabolic needs.
- Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
- Impaired Oral Mucous Membrane: Disruption of the lips and/or soft tissue of the oral cavity.
- Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.
- Impaired Swallowing: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function.
- Impaired Tissue (Skin) Integrity: Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.
- Impaired Urinary Elimination: Dysfunction in urinary elimination.
- Insomnia: A disruption in amount and quality of sleep that impairs functioning.
- Functional Urinary Incontinence: Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine.
- Reflex Urinary Incontinence: Involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached.
- Stress Urinary Incontinence: Sudden leakage of urine with activities that increase intraabdominal pressure.
- Urge Urinary Incontinence: Involuntary passage of urine occurring soon after a strong sense of urgency to void.
- Impaired Verbal Communication: Decreased, reduced, delayed, or absent ability to receive, process, transmit, and use a system of symbols.
- Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
- Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation.
- Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.
- Ineffective Therapeutic Regimen Management: Pattern of regulating and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals.
- Ineffective Tissue Perfusion: Decrease in oxygen, resulting in failure to nourish tissues at capillary level.
- Insomnia: A disruption in amount and quality of sleep that impairs functioning.
- Latex Allergy Response: A hypertensive reaction to natural latex rubber products.
- Powerlessness: Perception that one’s own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening.
- Rape Trauma Syndrome: Sustained maladaptive response, violent sexual penetration against the victim’s will and consent.
- Risk for Aspiration: At risk for entry of gastrointestinal secretions, oropharyngeal secretion, solids, or fluids into tracheobronchial passages.
- Risk for Bleeding: At risk for a decrease in blood volume that may compromise health.
- Risk for Falls: Increased susceptibility to falling that may cause physical harm.
- Risk for Impaired Skin Integrity: At risk for skin being adversely altered.
- Risk for Infection: At increased risk for being invaded by pathogen organisms.
- Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
- Risk for Suicide: At risk for self-inflicted, life-threatening injury.
- Risk for Unstable Blood Glucose Level: Risk for variation of blood glucose/sugar levels from the normal range.
- Self-Care Deficit: Impaired ability to perform or complete activities of daily living for oneself, such as feeding, dressing, bathing, toileting.
- Urinary Retention: Incomplete emptying of the bladder.