A nursing diagnosis is a critical component of patient care, and it is a powerful tool that helps nurses accurately record the patients' conditions and predict the patient's care outcomes.
Diagnoses appreciate the uniqueness of each patient and are, therefore, different for every patient. A proper nursing diagnosis helps provide patients with patient-centered, evidence-based, safe, and quality-focused care.
Diagnosis is fundamental to nursing: assessment, diagnosis, outcomes and planning, implementation, and evaluation. Student nurses must write diagnoses based on case scenarios, vignettes, and sometimes actual patient data from shadowing experiences or practicum.
If you are a nursing student who wishes to learn how to write a nursing diagnosis either as a stand-alone assignment or as part of a formal nursing care plan, you have come to the right place.
Let's begin by looking at the definition of a nursing diagnosis so that we start from what we know.
A nursing diagnosis is an evidence-based means for nurses to communicate their professional judgments to patients, interprofessional team members, the public, and other healthcare professionals.
The diagnosis is developed based on the assessment of the information gathered in the assessment phase of the nursing process.
After a concrete and comprehensive diagnosis, a nurse student or practitioner develops a nursing care plan to initiate independent nursing interventions, measure outcomes, and evaluate the patient's progress in the continuum of care.
NANDA-I is the custodian of defining, distributing, and integrating standardized diagnoses globally in nursing. And as per NANDA-I, a nursing diagnosis is a clinical judgment relating to the human response to specific health conditions, life processes, or vulnerability to the same response. It offers a basis for selecting plausible nursing interventions that, if implemented well, can achieve better outcomes for accountable nurses. You can write a nursing diagnosis statement for different nursing care plan scenarios for your nursing school assignments or nursing practice.
A typical nursing diagnosis has three major components: (1) problem, (2) etiology or risk factors, and (3) defining characteristics.
The problem statement also contains its definition. A problem statement, or diagnostic label, describes the patient's health problem or the response to which nursing intervention is given concisely.
The diagnostic label has two critical parts: the qualifiers and the modifiers. The qualifiers or modifiers are words that are added to the problem statement or diagnostic label to give additional meaning, limit, or specificity to the diagnostic statement, and they are not included in one-word nursing diagnoses. The qualifiers include deficient, ineffective, impaired, risk for, or imbalanced, and they precede the focus of the diagnosis.
Etiology or related factors component of a nursing diagnosis identifies the probable cause or causes of the health problem. It refers to the conditions involved in developing the problem, and they give direction to the required nursing intervention. The nursing interventions should address the etiological or causative factors to remove the underlying cause of the nursing diagnosis. In a nursing diagnosis, the etiology is linked to the problem statement/diagnostic label using the statement "related to."
The risk factors are used instead of the etiological factors when writing a risk nursing diagnosis. The risk factors are the forces or push factors that increase a patient or group's vulnerability to a given unhealthy condition. When writing a diagnostic statement, "as evidenced by" comes before listing all the risk factors.
The defining characteristics are the cluster of signs and symptoms that indicate the presence of a given diagnostic label or patient problem. In a problem-focused nursing diagnosis, these are usually the signs and symptoms of the patient. In a risk nursing diagnosis, they are the factors that cause the patient to be susceptible to the problem. They come after the statements "as evidenced by."
In the continuum of care, there exist other diagnoses other than nursing diagnoses. Understanding the difference between these types of diagnosis is vital so that you don't confuse one for the other.
A nursing diagnosis is an evidence-based mechanism nurses use to communicate their professional judgments of patients' problems and issues to fellow nursing professionals, healthcare practitioners, the public, patients, and other healthcare stakeholders. Nurses use it as a label to assign meaning to the patient data collected during the assessment phase.
Let's look at medical and collaborative diagnoses to make things clear.
Unlike a nursing diagnosis, a medical diagnosis is made by a doctor or an advanced healthcare practitioner. The main focus of such a diagnosis is on the patient's medical condition, pathological state, and disease. A medical diagnosis can be informed by a nursing diagnosis, not the other way. A medical diagnosis remains part of a patient's medical history and cannot be altered. Medical diagnoses include jaundice, Type II diabetes mellitus, congestive heart failure, heart attack, diabetes insipidus, meningitis, scoliosis, and stroke.
A third type of diagnosis is collaborative diagnosis, which combines nursing and medical interventions. It is based on working together as part of an interprofessional healthcare team. The nurses can focus on the health problems, whereas the medical practitioners prescribe drugs and order more diagnostic tests to exhaustively address the patient's healthcare needs. A good example is respiratory failure or inefficiency, where doctors and nurses collaborate through different interventions to stabilize the patient's condition.
Related: SOAP notes writing guide for nursing students
Nursing diagnosis has evolved through the years. To track nursing diagnoses, there is a need to follow specific conventions. The NANDA-I has a list, arrangement, and classification of the nursing diagnosis in a register referred to as the Taxonomy II, which has been used for over two decades. Taxonomy Ii has three levels:
Let's have an overview of each because they are instrumental in formulating a diagnosis when writing a nursing care plan for the patient. Taxonomy II is approved in collaboration with the National Library of Medicine (NMLM), considering the healthcare terminology codes. It is also based on the Functional Health Patterns assessment framework Dr. Mary Joy Gordon developed. It also complies with the Internal Standards Organization (ISO) terminology model for a nursing diagnosis. The terminology is also registered with the Health Level Seven International (HL7), an international healthcare informatics standard that helps identify nursing diagnoses in specific electronic messages among different clinical information systems.
There are currently 13 domains and 47 classes:
Domain 1 - Health Promotion
Domain 2 - Nutrition
Domain 3 - Elimination/Exchange
Domain 4 - Activity/Rest
Domain 5 - Perception/Cognition
Domain 6 - Self-Perception
Domain 7 - Role Relationship
Domain 8 - Sexuality
Domain 9 - Coping/Stress Tolerance
Domain 10 - Life Principles
Domain 11 - Safety/Protection
Domain 12 - Comfort
Domain 13 - Growth/Development
Here is a list of potential nursing diagnoses examples that you can consider as you formulate a nursing care plan:
The four main categories of nursing diagnoses recognized by the NANDA-I include problem-focuses (actual), risk, health promotion, and syndrome diagnosis.
An actual or problem-focused nursing diagnosis is a patient/client problem present during a nursing assessment. The diagnosis is based on the presence of associated signs and symptoms, and it contains three components: (a) Nursing diagnosis, (b) related factors, and (c) defining characteristics. Actual diagnoses can be used throughout the course of a patient�s stay in the hospital or can be solved by the end of a given shift.
The template for a problem-focused diagnosis is
Problem-focused diagnosis related to����. (Related Factors) as evidenced by ��. (defining characteristics).
Examples of problem-focused diagnoses include:
The risk nursing diagnosis is also technical as the problem-focused nursing diagnosis. It is a clinical judgment that a problem does not exist. However, the presence of risk factors indicates that the problem will likely develop unless nursing interventions are activated.
A risk diagnosis is based on the current health status of the patient, their past medical or health history, and other risk factors that make a patient vulnerable to experiencing a specific health problem or a set of health problems. It is an important part of nursing care planning as it allows the identification and treatment or management of problems early enough through mitigation measures. When writing a risk diagnosis, the focus is not on the etiological factors, and instead, it is assumed that an individual or a group is more susceptible to developing a health problem than others in the same situation due to the risk factors.
The critical components of a risk nursing diagnosis are the risk diagnostic label and the risk factors. The template for a risk nursing diagnosis is as follows:
Risk diagnosis or diagnostic label (Risk for) �.as evidenced by (AEB)�. (Risk factors)
Examples of risk nursing diagnoses include:
The health promotion diagnosis is also known as a wellness diagnosis. Nurses make a clinical judgment about the client's motivation, desire, and need to achieve well-being. It identifies the readiness of the patients to engage in activities that promote their health and well-being. Such diagnoses help guide independent nursing interventions to support the patients in learning and adhering to health promotion patterns and programs. Health promotion diagnoses go beyond the patient to cover family and community transition to attain higher levels of wellness. The components of health promotion diagnosis include the diagnostic label or a one-part statement.
The template for a health promotion diagnosis is as follows:
[Health Promotion Label] as evidenced by (defining characteristics)
Examples of health promotion diagnoses include:
A syndrome diagnosis is a clinical judgment relating to a cluster of problems or risk nursing diagnoses predicted to present due to a certain event or situation. Like the health promotion diagnosis, they are also a one-part statement where the diagnostic label is enough, but you can add the defining characteristics.
The template for syndrome diagnosis is:
Syndrome diagnosis or diagnostic label
Examples of syndrome diagnosis include:
As a nursing student, there are specific steps you need to take when writing a nursing diagnosis. Remember, a nursing diagnosis is a short statement that constantly forms the basis of care planning. You must draft hypothetical nursing care plans based on case studies, vignettes, or patient data to hone your clinical judgment, decision-making, problem-solving, and critical thinking. Here are the steps when formulating a nursing diagnosis
The first step when assigned to write a nursing diagnosis is to observe the presenting symptoms of the patient. Read the case study or vignette or check the patient information/data to describe the patient's problem based on the signs and symptoms.
Look at what the patient has done to alleviate the symptoms and how they cope with pain, loss of functioning, or discomfort. Look at both the subjective and objective information.
Subjective data is what the patient says about their feelings, whereas objective data comes from measurable and verifiable observations using scientific methods.
Examples of objective information include vital signs and diagnostic/lab results/findings. You should also identify the specific problem you will address in the nursing diagnosis.
It is a matter of prioritizing care to stabilize the patient. You should also look for the source of the problem the patient is experiencing. For instance, if you diagnose a chronic patient, check for injuries or burns related to it.
Check the past medical diagnosis and be open to the fact that the patient can have multiple diagnoses. Your diagnosis should also include the potential problems related to the related factors.
To make an effective clinical judgment, look up the official terminology for your observed problem. For this, you can use the NANDA-I nursing diagnosis categories. You should, at this point, confirm and rule out other diagnoses or create new diagnoses.
Nursing diagnosis helps you implement dependent and interdependent nursing care plans for the patient. You can create measurable and achievable goals and come up with evidence-based interventions.
After implementing the nursing care plan, the next step is to constantly evaluate the patient's progress to identify if the current interventions are effective or should be altered. A nursing diagnosis is assessed to ensure the care plan works well.
We have done our part as concerns arise about raising all-rounded nurses whose grades reflect skills. Nursing schools are means for you to learn how to become an effective nurse, and knowing how to write nursing diagnoses will boost your grade and enable you to offer patient-centered care.
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As part of the care planning process, you will have to conduct a patient assessment (check the vital signs), observe the patient's health, write a nursing diagnosis statement, come up with appropriate health system interventions, develop desired outcomes, and offer holistic care to the patient, whether real or hypothetical.
A proper nursing diagnosis is required for quality care of the patients. As you write the student nursing care plans, you should be able to proceed well, given your understanding of nursing diagnosis writing. Nursing diagnosis is also part of the electronic health record and facilitates evidence-based nursing care.
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