A nursing diagnosis is a way for nurses to use a common language to communicate about their patients. This includes the health issues they face and the interventions nurses can provide. Show
NANDA International, Inc. (NANDA-I) is the organization that develops and publishes evidence-based standardized language including lists of approved nursing diagnoses. This article will cover: What is a nursing diagnosis?A nursing diagnosis applies a nurse’s clinical judgment about the patient’s response to a potential or actual health condition. It may include circumstances where a patient is at risk of getting sicker or not responding well to the current situation.
Our easy online CE courses are ANCC-accredited and 100% free for nurses. Get startedA nursing diagnosis can incorporate a physical change from an illness or injury or an emotional response to being sick. Choosing a nursing diagnosis is 1 step in the nursing process. The nursing process has 5 steps:
The nursing process is most often used for individual patients. However, a nurse could apply the same process to a family, group, or community. NANDA-I continues to refine the list of approved nursing diagnoses over time. New diagnoses are added while others are removed. The Twelfth Edition of NANDA International Nursing Diagnoses: Definitions and Classifications, 2021-2023 was published in February 2021. Some of the nursing diagnoses from that edition include:
How does a nursing diagnosis differ from a medical diagnosis?A healthcare provider like a doctor or nurse practitioner can provide a medical diagnosis. These are usually focused on naming a disease, illness, or other health condition and generally match up with a diagnosis code that is used for insurance and billing. The medical diagnosis is typically determined by signs, symptoms, and other tests. NANDA-I defines a nursing diagnosis as: “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response…” that “…provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” Overall, a nursing diagnosis looks at the whole person and how the health issue is affecting them. There is also a focus on the actions a nurse can take to help care for the patient. Nursing diagnoses are written into the nursing care plan. The care plan allows nurses to communicate with the healthcare team. What are the types of nursing diagnoses?NANDA-I divides nursing diagnoses into four categories:
NANDA-I publishes a handbook with definitions for each approved nursing diagnosis. The classification rules are also included for reference. How to determine a nursing diagnosisEstablishing a nursing diagnosis is the second part of the nursing process. First, the nurse assesses the patient. This can include a medical chart review, health history, vital signs, physical assessment, listening to the patient’s description of the issue, and more. Then, the nurse considers the most pressing issues, the desired outcomes, and the nursing interventions (actions) that could potentially help to resolve the problem. What are the 3 parts of a nursing diagnosis?Each nursing diagnosis is written in the same pattern for consistency and to establish clear communication. A nursing diagnosis may include: be
The parts of the nursing diagnosis are then combined to make a cohesive statement using the following pattern: Problem statement related to etiology as evidenced by defining characteristics. The final statement structure may differ depending on the nursing diagnosis category (see below). Some examples of possible nursing diagnoses include:
The nursing diagnoses options are currently divided into 13 domains: health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationships, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development. Following up on a nursing diagnosisThe nursing diagnosis is only 1 step in the nursing process. It is also the foundation of the nursing care plan. A nursing care plan is just what it sounds like—it is a written action plan for the nurse about the care they will provide for the patient. The focus is on actions that are in the nurses’ scope of practice. Planning is the third step in the nursing process. NANDA-I has also standardized the actions and the goals that can be used in the planning process for nurses. The care plan also helps to ensure that nursing care is consistent for the patient even when different nurses are working. Care plans are specifically made for each patient. They are tailored to the individual but focus on ensuring holistic care. There is some overlap with the nursing process, which may include: assessment, diagnosis, expected outcomes (goals), planned interventions, and evaluation (assessment of effectiveness). Next StepsUnderstanding and applying nursing diagnoses can initially challenge nurses. However, having a consistent framework to use when choosing how to provide the best care for patients makes you a better nurse. It is a skill that develops over time. During your orientation at your workplace, you should be introduced to the care plan tool that is used. Be sure to ask questions about how to customize it for your patient. You can also apply the nursing process to your own self-care as a nurse. Nurses are human and have challenges with their health, role, stress, and other domains of life. Nurses can set goals and choose from standardized interventions to improve their own well-being.
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. |
What are the 3 parts of a nursing diagnosis?
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