Nursing Diagnosis Guide and Nursing Care Plan

Nursing Diagnosis Guide

Nursing diagnosis is a clinical judgment about a person’s, families, groups, or community response to health conditions/life processes or vulnerability to that response.

A nursing diagnosis serves as the foundation for deciding which nursing actions to use in order to accomplish outcomes for which the nurse is responsible.

Nursing diagnoses are made based on the information gathered during the nursing assessment and allow the nurse to create a care plan. The development and implementation of a nursing diagnosis help nurses determine the best course of treatment for their patients.

Nursing diagnoses are created after thoughtful consideration of a patient’s physical assessment. They can be used to track the patient’s care plan’s progress and influence the possible intervention for the patient, family, and community. Some nurses may regard nursing diagnoses as archaic and time-consuming. It is, nevertheless, an essential tool for promoting patient safety through the use of evidence-based nursing research.

Purpose of Nursing Diagnosis

According to NANDA International, a nursing diagnosis is “a judgment based on a comprehensive nursing evaluation.” It is based on the patient’s current status and health assessment, allowing nurses and other healthcare providers to see a patient holistically.

The following are the purposes of nursing diagnosis:

It helps identify nursing priorities and the direction of nursing interventions based on identified priorities.
It assists in formulating expected outcomes for third-party payer quality assurance requirements.
It helps determine how a client or group reacts to current or projected health and life processes and identifies the strengths that may be used to prevent or resolve problems.
It provides a common language and forms a basis for communication between the nursing professionals and the healthcare team to communicate and comprehend one another.
It provides a foundation for determining whether nursing treatment was beneficial and cost-effective for the patient.
It is an effective teaching tool for nursing students who want to improve their problem-solving and critical thinking skills.
An accurate nursing diagnosis provides patient safety, excellent care, and enhanced reimbursement from commercial health insurance, Medicare, and Medicaid.

History of Nursing Diagnosis

NANDA–International, formerly known as the North American Nursing Diagnosis Association (NANDA), is the leading organization for defining, disseminating, and integrating standardized nursing diagnoses worldwide.

In the 1950s, the term “nursing diagnosis” was first used in nursing literature. Kristine Gebbie and Mary Ann Lavin, both of Saint Louis University, saw the need to define the role of nurses in ambulatory care settings. The first national meeting of the NANDA was convened in 1973 to identify, create, and classify nursing diagnoses formally.

National conferences were held in 1975, 1980, and every two years after that. In 1982, the association adopted the name North American Nursing Diagnosis Association (NANDA) to acknowledge the involvement of nurses from the United States and Canada. NANDA was renamed NANDA International (NANDA-I) in 2002 due to its significant membership growth outside of North America.

Because of its prominence, the acronym NANDA was retained in the name. Each biennial conference continues to review, develop, and investigate diagnostic labels, with new and updated labels being considered. Nurses can submit diagnoses to the Diagnostic Review Committee for review.

The NANDA-I board of directors gives final approval for the diagnosis to be added to the official label list. NANDA-I approved 267 diagnoses for clinical use, testing, and refining as of 2021

According to its website, NANDA international’s mission is as follows:

To determine interventions and outcomes, provide the world’s leading evidence-based nursing diagnoses for use in practice.
Integrate evidence-based terminology into clinical practice and clinical decision-making to improve patient safety.
Helps to fund research through the NANDA-I Foundation
Be a vibrant and supportive global network of nurses dedicated to enhancing the quality of nursing care and patient safety via evidence-based practice.

The Evolution of Nursing Diagnosis

Nursing diagnosis emerged from the need for nurses to gain professional status, the increasing use of computers in hospitals for accrediting documentation, and the demand for a standardized language from nurses.
Following WWII, the number of nurses returning from military service increased in the United States. These nurses were experts in working with doctors to treat medical diagnoses. When nurses returned to peacetime work, they were confronted with renewed physician dominance and social pressures to return to historically defined female positions with lower status in order to create a way in the workforce for returning male troops. Nurses felt more pressure to redefine their distinct status and value as a result.
In a clinical practice situation, the nursing diagnosis was considered as the strategy that could provide the “frame of reference from which nurses might choose what to do and what to expect.”
Nursing diagnoses were also created to establish nursing’s distinct boundaries in relation to medical diagnoses. The first step toward letting insurance companies pay nurses directly for their care, according to NANDA, was to standardize nursing language through nursing diagnosis.
In 1953, the term “nursing diagnosis” was introduced by Virginia Fry and R. Louise McManus to define a step in the development of a nursing care plan.
Diagnoses were recognized as part of the legal domain of professional nursing by the New York State Nurse Practice Act in 1972. The Act was the first legislative honor of nursing’s independent role and diagnostic function.
The development of nursing diagnosis formally began in 1973, when two Saint Louis University faculty members, Kristine Gebbie and Mary Ann Lavin, saw a need to identify nurses’ roles in ambulatory care settings. In the same year, the Saint Louis University School of Nursing and Allied Health Professions hosted the first national conference to identify nursing diagnoses.
Diagnosing as a function of professional nursing was included in the American Nurses Association’s Standards of Practice in 1973. Diagnosing became a part of the nursing process. The nursing process was developed to standardize and define the concepts of nursing care in the hopes of achieving professional status.
Nursing was described as “the diagnosis and treatment of human response to real or potential health problems” by the American Nurses Association (ANA) in its Social Policy Statement in 1980.
The First Canadian Conference in Toronto (1977) and the International Nursing Conference (1987) in Alberta, Canada, brought international credibility to the conferences and the development of nursing diagnosis.
To recognize the participation and contribution of nurses in the United States and Canada, the conference group accepted the name “North American Nursing Diagnosis Association (NANDA)” in 1982. The newly created NANDA utilized Sr. Callista Roy’s “nine patterns of unitary man” as an organizing principle since the first taxonomy listed nursing diagnosis alphabetically – which was deemed unscientific.
Based on the work of Marjorie Gordon, NANDA renamed “patterns of unitary man” as “human response patterns” in 1984. Taxonomy II is the current name of the taxonomy.
During NANDA’s 9th conference in 1990, the organization accepted an official definition of nursing diagnosis.
NANDA’s official journal, “Nursing Diagnosis” was changed to “Nursing Diagnosis: The International Journal of Nursing Terminologies and Classifications” in 1997.
NANDA was renamed NANDA International (NANDA-I) in 2002 to better reflect the worldwide interest in nursing diagnosis. Taxonomy II, based on a revised version of Gordon’s Functional health patterns, was released the same year.
NANDA-I approved 244 diagnoses for clinical use, testing, and refining as of 2018.
There are 267 approved diagnoses for clinical use, testing, and refining by the year 2021.

Classification of Nursing Diagnoses or Taxonomy II

How are nursing diagnoses organized, categorized, and listed? Taxonomy II, based on Dr. Mary Joy Gordon’s Functional Health Patterns assessment framework, was accepted in 2002.

Domains, Classes, and nursing diagnoses are the three levels of Taxonomy II. Nursing diagnoses are now coded according to seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology, rather than Gordon’s patterns.

Furthermore, diagnoses are now listed alphabetically by concept rather than by the first word.

Types of Nursing Diagnosis

There are four categories of Nursing diagnoses provided by NANDA-I system:

1. Problem-Focused Nursing Diagnosis

A client problem that exists at the time of the nursing assessment is referred to as a problem-focused diagnosis (also known as actual diagnosis).

The presence of associated signs and symptoms is used to make these diagnoses. Actual nursing diagnoses should not be viewed as more important than risk diagnoses. A risk diagnosis can be the highest priority for a patient in many situations.

There are three parts to problem-focused nursing diagnoses: (1) nursing diagnosis, (2) related factors, and (3) defining characteristics. Examples of actual nursing diagnoses are the following:

Ineffective Breathing Pattern related to pain as evidenced by the use of accessory muscles to breathe, pursed-lip breathing, reports of pain during inhalation, and dyspnea.
Anxiety related to stress as evidenced by increased tension, nervousness, and verbalization of concern regarding the upcoming surgery.
Acute Pain related to decreased myocardial flow as evidenced by irritability, verbalization of pain, and guarding behavior.
Impaired Skin Integrity related to pressure over bony prominence as evidenced by acute pain, breaks on the skin, redness, and wound drainage.

2. Risk Nursing Diagnosis

A risk nursing diagnosis is the second category of nursing diagnosis. Although these are clinical judgments that a problem does not exist, the presence of risk indicators implies that unless nurses intervene, a problem will arise.

Risk diagnoses have no etiological variables or related factors. Because of risk factors, the individual or group is more likely to acquire the condition than others in the same or comparable situation. For example, if an older patient with diabetes and vertigo has difficulties walking and refuses to ask for help, the patient may be classified with Risk for Injury.

A risk nursing diagnosis consists of two parts: (1) a risk diagnostic label and (2) risk factors. The following are some examples of risk nursing diagnoses:

Risk for Falls as evidenced by body malaise
Risk for Injury as evidenced by problems in gait and balance
Risk for Infection as evidenced by immunosuppression
Risk for Ineffective Childbearing Process
Risk for Impaired Oral Mucous Membrane Integrity

3. Health Promotion Diagnosis

A clinical judgment concerning motivation and desire to improve well-being is known as a health promotion diagnosis, also known as wellness diagnosis.

The transition of an individual, family, or community from a certain level of wellness to a higher level of wellness is the focus of health promotion diagnosis. The diagnostic label or a one-part statement is usually the only component of a health promotion diagnosis. The following are some examples of health promotion diagnoses:

Readiness for Enhanced Spiritual Well-being
Readiness for Enhanced Self-care
Readiness for Enhanced Parenting
Readiness for Enhanced Participation in Daily Activities
Readiness for Enhanced Sleeping Pattern

4. Syndrome Diagnosis

A syndrome diagnosis is a clinical decision made in response to a cluster of problems or risk nursing diagnoses that are expected to manifest due to a certain condition or incident.

Syndrome diagnoses are also written as a one-part statement requiring only the diagnostic label. The following are some examples of syndrome nursing diagnoses:

Possible Nursing Diagnosis

Actual, danger, health promotion, and syndrome are all types of nursing diagnoses, but a possible nursing diagnosis is not one of them.

Possible nursing diagnoses are statements that describe a suspected condition that requires additional information to confirm or rule out.

It allows the nurse to inform other nurses that a condition may be present, but that additional data collection is needed to rule out or confirm the diagnosis. Here are several examples:

Possible Chronic Low Self-Esteem
Possible Social Isolation
Possible Nutritional Imbalance

Components of Nursing Diagnosis

A nursing diagnosis usually consists of three parts: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis).

Problem and Definition

The problem statement, also known as the diagnostic label, is a brief description of the client’s health problem or response for which nursing care is provided. A diagnostic label normally consists of two parts: a qualifier and the focus of the diagnosis. Qualifiers (also known as modifiers) are words added to some diagnostic labels to give additional meaning, limit, or specify the diagnostic statement. One-word nursing diagnoses (e.g., Anxiety, Constipation, Diarrhea, Nausea, etc.) are exempt from this rule because their qualifier and focus are inherent in the one term.

Examples:

Qualifier	Focus of the Diagnosis
Deficient	Fluid volume
Impaired	Mobility
Imbalanced	Nutrition: More than body requirements
Ineffective	Coping mechanism
Risk for	Injury

Etiology

The etiology, or related factors, component of a nursing diagnosis label identifies one or more probable causes of the health problem, the conditions involved in the problem’s development directs the required nursing therapy, and allows the nurse to personalize the patient’s care. In order to eliminate the underlying cause of the nursing diagnosis, nursing interventions should be directed at etiological factors. With the term “related to,” etiology is linked to the problem statement, such as

Decreased activity tolerance related to generalized weakness.
Decreased physical mobility related to imposed bed rest.
Impaired urinary elimination related to acute pain.
Altered mentation related to delirium.

Risk Factors

For risk nursing diagnosis, risk factors are used instead of etiological factors. Risk factors are forces that put an individual (or group) at an increased vulnerability to an unhealthy condition. Risk factors are normally written before the phrase “as evidenced by” in the diagnostic statement.

Risk for Falls as evidenced by problems in gait and balance.
Risk for Infection as evidenced by a break in skin integrity.
Risk for dehydration as evidenced by poor skin turgor.
Risk for Injury related to altered mobility.
Risk for aspiration related to increased mucus production.

Defining Characteristics

The clusters of signs and symptoms that indicate the presence of a specific diagnostic label are known as defining characteristics. The identified signs and symptoms of the patient are the defining characteristics in actual nursing diagnoses. Because no signs or symptoms are apparent in a risk nursing diagnosis, the factors that make the client more susceptible to the problem create the etiology of the problem. Defining characteristics are written following the phrase “as evidenced by” or “as manifested by” in the diagnostic statement.

Diagnostic Process: How to Diagnose

The diagnostic process is divided into three phases: (1) data analysis, (2) identification of the client’s health problems, risks, and strengths, and (3) formulation of diagnostic statements.

Analyzing Data

Comparing patient data to standards, clustering cues, and identifying gaps and inconsistencies are all part of analyzing data.

Identifying Health Problems, Risks, and Strengths

Following data analysis, the nurse and the client identify problems that support tentative actual, risk, and possible diagnoses in this decision-making process. It entails identifying whether a problem is a nursing diagnosis, a medical diagnostic, or a collaborative problem. This is also the stage in which the nurse and the client determine the client’s strengths, resources, and coping abilities.

Formulating Diagnostic Statements

The last part of the diagnostic process is the formulation of diagnostic statements, in which the nurse develops a diagnostic statement through a process. The process is listed below,

How to Write a Nursing Diagnosis

When writing nursing diagnostic statements, describe an individual’s health status and the factors that have contributed to that status. It is not necessary to provide all diagnostic indicators. The format of diagnostic statements varies depending on the type of nursing diagnosis.

PES Format

The PES format, which stands for Problem (diagnostic label), Etiology (related factors), and Signs/Symptoms (defining characteristics), is another approach to writing nursing diagnostic statements. Diagnostic statements in the PES format might be one-part, two-part, or three-part statements.

One-Part Nursing Diagnosis Statement. Health promotion nursing diagnoses are frequently written as one-part statements since related factors are always the same: inspired to reach a greater level of wellness through related factors may be used to enhance the chosen diagnosis. There are no related factors on syndrome diagnoses. The following are some examples of one-part nursing diagnosis statements:
Readiness for enhanced parenting
Readiness for enhanced coping

Two-Part Nursing Diagnosis Statement. The first component of risk or possible nursing diagnosis is the diagnostic label, and the second part is the validation for a risk nursing diagnosis or the presence of risk factors. Because signs and symptoms do not present, a third part for risk or possible diagnoses is not possible. The following are some examples of two-part nursing diagnosis statements:
Risk for Infection as evidenced by compromised host defenses
Risk for Ineffective tissue perfusion as evidenced by abnormal blood profile
Possible Self Isolation related to unknown etiology

Three-Part Nursing Diagnosis Statement. A three-part statement makes up an actual or problem-focused nursing diagnosis: diagnostic label, contributing factor (“related to”), and signs and symptoms (“as evidenced by” or “as manifested by”). The three-part nursing diagnosis statement is also known as the PES format that contains the Problem, Etiology, and Signs and Symptoms. The following are some examples of three-part nursing diagnosis statements:
Impaired Physical Mobility related to decreased muscle control as evidenced by difficulty to move lower extremities.
Acute Pain related to tissue ischemia as evidenced by statement of “I feel severe pain on my head!”

Variations on Basic Statement Formats

Variations in writing basic nursing diagnosis statement formats include the following:

To make the diagnostic statement more descriptive and informative, use “secondary to” to break the etiology into two parts. A pathophysiologic or disease process, or a medical diagnosis, commonly follows the “secondary to.”

Example: Risk for Decreased Cardiac Output related to reduced preload secondary to myocardial infarction

When there are too many etiologic factors or when they are too complex to explain in a single statement, the phrase “complex factors” is used.

Example: Chronic Imbalanced Nutrition: Less than body requirements related to complex factors.

When the defining characteristics are present but the nurse is unsure of the cause or contributing factors, “unknown etiology” is used.

Examples: Ineffective Coping related to unknown etiology

Situational Low Self Esteem related to unknown etiology

Specify a second part of the general response or NANDA label to make it more particular. Example: Impaired Skin Integrity (right side of the chest) related to damage of skin surface secondary to burn injury.

List of Nursing Diagnosis Examples

A:

Activity Intolerance Nursing Diagnosis
Acute Pain Nursing Diagnosis
Altered Mental Status Nursing Diagnosis
Anemia Nursing Diagnosis
Ankylosing Spondylitis Nursing Diagnosis
Antisocial Nursing Diagnosis
Anxiety Nursing Diagnosis
Asthma Nursing Diagnosis

B:

Bell’s Palsy Nursing Diagnosis

C:

CHF Nursing Diagnosis
Chronic Pain Nursing Diagnosis
Constipation Nursing Diagnosis
COPD Nursing Diagnosis
Cytomegalovirus CMV Nursing Diagnosis

D:

Deficient Knowledge
Dehydration Nursing Diagnosis
Dentition Impaired Nursing Diagnosis
Depression Nursing Diagnosis
Diabetes Nursing Diagnosis

E:

E. Coli Nursing Diagnosis
Electrolyte Imbalance Nursing Diagnosis
Excess Fluid Volume Nursing Diagnosis

F:

Fluid Volume Excess Nursing Diagnosis

G:

GI Bleed Nursing Diagnosis

H:

HF Nursing Diagnosis
Hodgkin’s Lymphoma Nursing Diagnosis
Hypertension Nursing Diagnosis

I:

Imbalanced Nutrition Less than Body Requirements
Imbalanced Nutrition More than Body Requirements
Impaired Dentition
Impaired Gas Exchange
Impaired Physical Mobility
Impaired Skin Integrity
ineffective breathing pattern nursing diagnosis
Ineffective Coping
Infection

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Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon