Writing a Nursing Diagnosis

What is a Nursing Diagnosis? 

A nursing diagnosis is a clinical judgment about an individual, family, group, or community’s reaction to health conditions/life processes, or vulnerability to that response. A nursing diagnosis serves as the foundation for selecting nursing interventions to achieve outcomes for which the nurse is accountable. Nursing diagnoses are created based on data gathered during the nursing assessment and allow the nurse to create the care plan.

Purposes of Nursing Diagnosis

The nursing diagnosis serves the following purpose:

• Aids in the identification of nursing priorities and the direction of nursing interventions based on those priorities.
• Aids in the formulation of expected outcomes for third-party payer quality assurance requirements.
• Nursing diagnoses assist in determining how a client or group responds to actual or potential health and life processes, as well as knowing their available resources of strengths that can be used to prevent or resolve problems.
• It serves as a common language and a foundation for communication and understanding among nursing professionals and the healthcare team.
• Provides a foundation for determining whether nursing care was beneficial to the client and cost-effective.
  Nursing diagnoses are an effective teaching method for nursing learners to make them refine their problem-solving and critical thinking skills.

Differentiating Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems

The term “nursing diagnosis” refers to three distinct concepts. It could refer to the specific second step in the nursing process, diagnosis. Nursing diagnosis also applies to the label when nurses assign meaning to collected data that has been appropriately labeled with NANDA-I-approved nursing diagnosis. During the assessment, for example, the nurse may notice that the client is anxious, fearful, and has difficulty sleeping. Those issues are labeled with nursing diagnoses: Anxiety, Fear, and Disturbed Sleep Pattern, in that order. Finally, a nursing diagnosis is one of many diagnoses in the NANDA classification system that has been established and approved. A nursing diagnosis in this context is based on the patient’s reaction to the medical condition. It is referred to as a ‘nursing diagnosis’ because these are issues that have a distinct and precise action that is associated with what nurses have the authority to do with a specific disease or condition. This includes any type of physical, mental, or spiritual reaction. As a result, a nursing diagnosis focuses on care.

A medical diagnosis, on the other hand, is made by a physician or advanced health care practitioner who is more concerned with the disease, medical condition, or pathological state that only a practitioner is capable of treating. Furthermore, the doctor will undertake the specific and precise clinical entity that may be the possible cause of the illness through experience and know-how, thus providing the proper medication that would cure the illness. Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease are examples of medical diagnoses. Normally, the medical diagnosis does not change. Nurses must follow doctor’s orders and carry out prescribed treatments and therapies.

Nurses manage collaborative problems using both independent and physician-prescribed interventions. These are problems or conditions that necessitate both medical and nursing interventions, with the nursing component focusing on monitoring the client’s condition and preventing the occurrence of the potential complication. As previously stated, it is now easier to distinguish a nursing diagnosis from a medical diagnosis. Nursing diagnosis is focused on the patient’s physiological and psychological responses. A medical diagnosis, on the other hand, is specific to the disease or medical condition in question. Its focus is on the ailment.

Classification of Nursing Diagnoses

Nursing diagnoses are listed, arranged, or classified in what way? Taxonomy II, which was based on Dr. Mary Joy Gordon’s Functional Health Patterns assessment framework, was adopted in 2002. Domains (13), Classes (47), and nursing diagnoses are the three levels of Taxonomy II. Nursing diagnoses are now coded according to seven axes rather than Gordon’s patterns: diagnostic concept, time, unit of care, age, health status, descriptor, and topology. Furthermore, diagnoses are now listed alphabetically by concept rather than by the first word.

Types of Nursing Diagnoses

Actual (Problem-Focused), Risk, Health Promotion, and Syndrome are the four types of NANDA-I nursing diagnoses. The NANDA-I system provides four categories of nursing diagnoses.

Problem-Focused Nursing Diagnosis

A client problem that is present at the time of the nursing assessment is referred to as a problem-focused diagnosis (also known as an actual diagnosis). The presence of associated signs and symptoms is used to make these diagnoses. Actual nursing diagnoses should not be prioritized over risk diagnoses. In many cases, a risk diagnosis is the diagnosis with the highest priority for a patient.

There are three components to problem-focused nursing diagnoses: (1) nursing diagnosis, (2) related factors, and (3) defining characteristics. Actual nursing diagnoses include:

• Ineffective Breathing Pattern Associated with Pain, as evidenced by pursed-lip breathing, reports of pain during inhalation, and the use of accessory muscles to breathe
• Anxiety caused by stress, manifested as increased tension, apprehension, and expression of concern about upcoming surgery
• Acute pain caused by decreased myocardial flow, as evidenced by grimacing, pain expression, and guarding behavior.
• Pain, bleeding, redness, and wound drainage are symptoms of compromised skin integrity caused by pressure on a bony prominence.

Risk Nursing Diagnosis

The risk nursing diagnosis is the second type of nursing diagnosis. These are clinical decisions that no problem exists, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For risk diagnoses, there are no etiological factors (related factors). Because of risk factors, the individual (or group) is more likely to develop the problem than others in the same or similar situation. An elderly client with diabetes and vertigo who has difficulty walking and refuses to ask for assistance during ambulation, for example, may be appropriately diagnosed with Risk for Injury.

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

Muscle weakness indicates a fall risk.

Injury risk as evidenced by altered mobility

Immunosuppression indicates a risk of infection.

Health Promotion Diagnosis

A health promotion diagnosis (also known as a wellness diagnosis) is a clinical assessment of motivation and desire to improve one’s well-being. The diagnosis of health promotion is concerned with the transition of an individual, family, or community from one level of wellness to a higher level of wellness. A health promotion diagnosis typically consists of only the diagnostic label or a one-part statement. Diagnoses for health promotion include the following:

• Preparedness for Improved Spiritual Well-Being
• Preparedness for Improved Family Coping
• Preparedness for Improved Parenting

Syndrome Diagnosis

A syndrome diagnosis is a clinical decision based on a cluster of problem or risk nursing diagnoses that are expected to present as a result of a specific situation or event. They, too, are written in a one-part statement that only requires the diagnostic label. The following are some examples of syndrome nursing diagnoses:

Chronic Pain Syndrome (CPS)
Post-Traumatic Stress Disorder
Syndrome of the Frail Elderly

Components of a Nursing Diagnosis

A nursing diagnosis typically includes three components: (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, describes the client’s health problem or response to nursing therapy as succinctly as possible. A diagnostic label typically consists of two parts: the qualifier and the focus of the diagnosis. Qualifiers (also known as modifiers) are words added to some diagnostic labels to provide 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.

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 development of the problem, directs the required nursing therapy, and allows the nurse to individualize the client’s care. Nursing interventions should target etiological factors in order to address the root cause of the nursing diagnosis. The phrase “related to” is used to connect etiology to the problem statement, as in:

Reduced activity tolerance as a result of generalized weakness
Impaired physical mobility as a result of bed rest.

Risk Factors

For risk nursing diagnosis, risk factors are used instead of etiological factors. Risk factors are forces that increase an individual’s (or a group’s) vulnerability to an unhealthy condition. In the diagnostic statement, risk factors are written after the phrase “as evidenced by.”

Falls are a risk, as evidenced by old age and the use of a walker.

Infection risk as evidenced by a break in skin integrity.

Diagnostic Process: How to Diagnose

There are three phases during the diagnostic process: (1) data analysis, (2) identification of the client’s health problems, health risks, and strengths, and (3) formulation of diagnostic statements.

Analyzing Data

Analysis of data involves comparing patient data against standards, clustering the cues, and identifying gaps and inconsistencies.

Identifying Health Problems, Risks, and Strengths

In this decision-making step after data analysis, the nurse together with the client identify problems that support tentative actual, risk, and possible diagnoses. It involves determining whether a problem is a nursing diagnosis, medical diagnosis, or a collaborative problem. Also at this stage is wherein the nurse and the client identify the client’s strengths, resources, and abilities to cope.

Formulating Diagnostic Statements

Formulation of diagnostic statements is the last step of the diagnostic process wherein the nurse creates diagnostic statements. The process is detailed below.

How to Write a Nursing Diagnosis

Describe an individual’s health status and the factors that have contributed to the status in nursing diagnostic statements. You are not required to include all diagnostic indicators. Writing diagnostic statements differs depending on the type of nursing diagnosis.

One-Part Nursing Diagnosis Statement

Health promotion nursing diagnoses are usually written as one-part statements because related factors are always the same: motivated to achieve a higher level of wellness through related factors may be used to improve the chosen diagnosis. Syndrome diagnoses also have no related factors. Examples of one-part nursing diagnosis statements 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 of two-part nursing diagnosis statements include:

Three-part Nursing Diagnosis Statement

An actual or problem-focus nursing diagnosis has three-part statements: 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 called the PES format which includes the Problem, Etiology, and Signs and Symptoms. Examples of three-part nursing diagnosis statements 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 disease 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 of 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.

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