What is a Nursing Diagnosis?
In line with NANDA nursing diagnosis 2020, a nursing diagnosis can be defined as:
“A clinical judgment done on an individual, family, or community responses to potential or actual health problems or life processes”.
In this, a nursing diagnosis acts as the basis for the selection of nursing interventions intended to achieve outcomes that the nurse is accountable for.
Just like writing a nursing care plan, writing a nursing diagnosis is a common undertaking for both nursing professionals and students.
Purpose of Nursing Diagnosis
Good practices in writing a nursing diagnosis demand a clear understanding of the purpose the diagnosis seeks to fulfill.
Key purposes include:
1. Acts as a teaching tool for nursing students that is essential in sharpening their critical thinking and problem solving skills.
2. Identification of nursing priorities and direction of nursing interventions in line with identified priorities.
3. Formulation of expected outcomes to help realize third-party payers’ quality assurance requirements.
4. Identification of client or group response to potential or actual health and life processes as well as ascertainment of available strength resources they can depend on to help resolve or prevent problems.
5. Acts as a common language and basis of communication and understanding among nursing professionals and the overall healthcare team.
6. Acts as an evaluation basis for determining nursing care client benefits and its cost-effectiveness.
Differences between Nursing Diagnosis, Medical Diagnosis, and Collaborative Problems
Knowledge and skills key to writing a nursing diagnosis require clarity on the distinction between nursing, medical, and collaborative diagnosis.
This distinction is as explained below.
Nursing diagnosis may refer to 3 concepts:
1. The second step in process of nursing, i.e., diagnosis.
2. The label derived from assigning meaning to data collected according to NANDA-I nursing diagnosis, e.g., for a patient feeling anxious, the diagnosis is labeled as anxiety.
3. A category among the diagnoses established by NANDA classification system. This diagnosis depicts patient’s response to the medical condition.
Medical diagnosis entails the identification done by a physician handling the disease or medical condition.
It involves finding the actual possible cause of the illness or condition by a doctor; in this, nursing diagnosis examples may include anemia or tuberculosis.
Collaborative problems on the other hand refer to potential problems managed by nurses by employing both independent judgment and physician-directed interventions.
Nursing Diagnosis Classification
It is also important to consider the different classification of nursing diagnosis when writing a nursing diagnosis.
These classifications can be found in the NANDA nursing diagnosis 2020.
At the center of writing a nursing diagnosis, is the nursing process.
The nursing process comprises five distinctive phases, with diagnosis as the second one. These phases are as illustrated below.
This phases encompasses patient data collection.
The nurse is expected to conduct an assessment of the patient’s condition, including their physiological, emotional, and psychological state.
This phase entails identifying the problem facing the patient.
The nurse seeks to use the collected patient data to identify the condition and medical needs of the patient.
It requires the nurse to make an educated judgment about an actual or potential health problem.
This phase looks at how to manage the problem.
It requires the nurse to come up with a treatment course that factors in both short-term and long-term goals.
This is after agreeing on the diagnosis with the patient and supervising medical staff.
The phase involves actualizing the action plan.
It requires the nurse to effect the treatment plan by carrying out required medical interventions.
Implementation actions examples in this phase may include care for the patient, patient signs monitoring to ascertain change or improvement, patient follow-up or referral, and patient education.
This phase seeks to determine whether the plan worked as expected.
The nurse or the clinical team has to establish whether; 1) the condition of the patient improved, 2) the condition of the patient stabilized, or 3) the condition of the patient worsened.
Types of Nursing Diagnoses
Skills key in writing a nursing diagnosis demand a clear understanding of the different types of diagnoses.
These diagnoses include:
1. Problem-Focused Nursing Diagnosis
This type of diagnosis is also referred to as actual diagnosis and occurs when a patient’s problem presents during assessment.
The diagnosis is founded on the presence of signs and symptoms.
It has three components: 1) nursing diagnosis, 2) related factors, and 3) defining characteristics.
Nursing diagnosis examples under this category may include:
2. Impaired skin integrity
3. Acute pain
This entails assessment indicating the absence of a problem but risk factors presence showing the likelihood of problem development unless there is a nursing intervention.
There are no related or etiological factors for risk diagnosis.
It is noted that an individual is predisposed to the problem compared to others in a similar situation due to existing risk factors.
For example, an elderly patient with diminished immune response and using invasive feeding tubes could be diagnosed with risk for infection.
Risk nursing diagnosis encompasses two main components that include 1) risk diagnostic label and 2) risk factors.
Nursing diagnosis examples in this category may include:
1. Risk for infection
2. Risk for injury
3. Risk for falls
3. Health Promotion Diagnosis
This is also referred to as wellness diagnosis and entails a clinical assessment on the motivation and desire to improve well-being.
It is concerned with the scaling up of wellness levels for individuals, families, or community.
Nursing diagnosis examples in this category include:
1. Readiness for improved parenting
2. Readiness for improved individual spiritual wellbeing
3. Readiness for improved family coping
4. Syndrome Diagnosis
This involves a clinical assessment on a cluster of risk diagnoses or problems predicted to present due to a particular event or situation.
1. Post-trauma syndrome
2. Chronic pain syndrome
3. Frail elderly syndrome
Possible Nursing Diagnosis
This entail statements on a suspected problem that required further data for confirmation or ruling out.
It facilitates communication between a nurse and other clinical staffs on the potential presence of a diagnosis.
Nursing diagnosis examples under this may include:
1. Possible social isolation
2. Possible chronic low self esteem
Nursing Diagnosis Components
When it comes to writing a nursing diagnosis, you have to appreciate the different essential components.
The components include:
1. Problem and its Definition
This entails a concise description of the health problem or the response the nursing therapy is given for.
The diagnostic label has two key parts that are:
1. Qualifier (modifiers): These are words added to certain diagnostic labels to provide additional meaning, specify or limit the diagnostic statement.
2. Diagnosis focus: These entail the actual diagnostic statement.
This involves the related factors and as a nursing diagnosis label component it identifies:
1. The probable cause(s) of the problem.
2. Whether the conditions are involved in problem development.
3. Provides direction for required nursing therapy, and
4. Facilitates the provision of individualized patient care.
3. Risk Factors
These are used in risk nursing diagnosis in the place of etiological factors.
They are considered as forces that predispose an individual or a group or increase their vulnerability to a condition.
When writing the risk factors in the diagnostic statement, they have to be preceded by the phrase:
“As evidenced by…”
4. Defining Characteristics
These entail signs and symptoms clusters that act as an indication of the presence of a certain diagnostic label.
For actual diagnosis, defining characteristics entail signs and symptoms presenting on the patient.
In the case of risk diagnosis, signs and symptoms are not present and as such the predisposing factors are the defining characteristics.
When writing the defining characteristics, they should be preceded by the statement:
“As manifested by…”
When it comes to writing a nursing diagnosis, there are 3 key phases that include:
1. Data analysis
2. Patient’s health problem, health risks, and strengths identification
3. Diagnostic statements formulation
In line with the NANDA nursing diagnosis 2020, these phases are as discussed below.
1. Data Analysis
This encompasses a comparison of patient data with set standards, clustering of cues, and identification of entailed gaps and inconsistencies.
2. Health Problems, Risks, and Strengths Identification
This phase requires the nurse to work together with the client to identify problems supporting tentative, actual, risk, and possible diagnoses in the decision making process.
The nurse has to determine whether the entailed problem is a nursing diagnosis, a medical diagnosis, or a collaborative diagnosis.
The nurse also has to work with the patient in identifying the patient’s strengths, available resources, and capacities to cope.
3. Diagnostic Statement Formulation
This phase requires the nurse to write a nursing statement.
Writing a Nursing Diagnosis
Good skills when writing a nursing diagnosis require the nurse to describe patient’s health status and the contributing factors.
The PES format (Problem-Etiology-Signs/Symptoms) is one of the common approaches used in writing nursing diagnosis.
Following this format, diagnostic statements can be as explained below.
1. One-Part Nursing Diagnosis Statement
Under this statement is where you find health promotion nursing diagnosis examples.
Health promotion diagnoses are usually one-part statements since the entailed related factors are always similar.
“Motivated towards achieving a higher wellness level”.
As well, syndrome diagnoses don’t comprise related factors.
One-part health promotion nursing diagnosis examples may include:
- Readiness for enhanced nutrition.
2. Two-Part Nursing Diagnosis Statement
The two-part statement is usually for risk and possible nursing diagnosis.
While the first part entails the diagnostic label, the second one encompasses the validation for risk diagnosis/ risk factors presence.
There are no signs and symptoms and therefore a third part is not feasible.
Two-part nursing diagnosis examples may include:
1. Risk for falls as evidenced by impaired judgment.
2. Risk for injury as evidenced by muscular incoordination.
3. Three-Part Nursing Diagnosis Statement
Parts for this nursing diagnosis statement include: 1) diagnostic label, 2) contributing factor, and 3) signs and symptoms.
It is the real reference for the PES format.
3 part nursing diagnosis examples may include:
1. Mild malnutrition related to decreased appetite and taste changes secondary to chemotherapy treatment as evidenced by mild muscle mass loss.
2. Swallowing difficulty related to apoplexy (CVA) accident as evidenced by repetitive swallowing and hoarse voice during feeding.
Note that the 3 part nursing diagnosis examples could widely vary based on the entailed problem.