Nursing Diagnosis is an essential part of the nursing process that helps nurses to assess a patient’s condition and develop appropriate treatment plans. It involves identifying health problems by evaluating a patient’s physical, mental, social, and spiritual needs. We will see how Nursing Diagnosis helps formulate a comprehensive, individualized plan of care tailored to meet the patient’s unique needs.
Table of Contents
What is a Nursing Diagnosis?
A nursing diagnosis is a statement that describes an individual patient’s actual or potential health problems. It typically includes the patient’s diagnosis and can include:
- Associated signs and symptoms.
- Risk factors.
- Etiologic or related factors.
- Other relevant information.
A nursing diagnosis is used to identify each patient’s unique needs to provide effective evidence-based care.
It is the basis of nursing interventions and goals, helping to ensure that quality care is provided for each patient. Nursing diagnoses are based on a comprehensive assessment of the patient’s condition’s physiological and psychosocial aspects.
Examples of Nursing Diagnosis
1. Risk for Impaired Skin Integrity: This diagnosis is based on the patient’s risk of developing skin breakdown due to decreased mobility, decreased sensation, or other factors that could lead to pressure ulcers and other skin damage. Signs and symptoms may include dryness, peeling, redness, itching, tenderness/painful areas, and an open wound.
2. Risk for Infection: This diagnosis is based on the patient’s risk of developing infection due to a weakened immune system or the presence of a foreign body in the body, such as a catheter or intravenous line. Signs and symptoms may include fever, chills, malaise, redness at the insertion site, and drainage from the insertion site.
3. Anxiety: This diagnosis is based on the patient’s uneasiness or apprehension due to real or perceived stressors. Signs and symptoms may include rapid heart rate, tremors, sweating, shortness of breath, trembling hands, restlessness, difficulty concentrating, thoughts of harm/death or other negative thoughts, and avoidance of certain activities.
4. Pain: This diagnosis is based on the patient’s experience of physical or psychological discomfort due to an injury, illness, or another condition. Signs and symptoms may include localized tenderness/sensitivity, aching pain, sharp pains, muscle tightness/stiffness, restricted range of motion, difficulty sleeping/concentrating, and decreased appetite.
5. Risk for Ineffective Coping: This diagnosis is based on the patient’s potential to respond inadequately to a stressful situation due to a lack of problem-solving skills or other factors. Signs and symptoms may include difficulty adapting to new conditions, avoidance of complex tasks/situations, feelings of helplessness and hopelessness, using unhealthy methods (such as substance abuse or self-harm) to cope, and feelings of isolation.
6. Risk for Falls: This diagnosis is based on the patient’s potential to fall due to weakened muscle strength, poor balance, medication side effects, etc. Signs and symptoms may include difficulty walking/standing, dizziness/lightheadedness, weak grip strength, unsteady gait/unsteady stance, and confusion.
7. Risk for Fluid Volume Deficit: This diagnosis is based on the patient’s potential to develop a decreased volume of body fluids due to inadequate fluid intake, increased fluid output (such as vomiting or diarrhea), and/or other factors. Signs and symptoms may include thirst, dry mouth, headache, fatigue, decreased urine output, and dark-colored urine.
8. Risk for Self-Mutilation: This diagnosis is based on the patient’s potential to engage in self-injurious behaviors such as cutting, burning, hitting, or scratching. Signs and symptoms may include increased aggressive behavior/thoughts, a preoccupation with thoughts of harm/death, withdrawal from social activities/relationships, and increased isolation.
What are the Components of Nursing Diagnosis?
Nursing Diagnosis is the nurse’s clinical judgment about the client’s health. It is based on the assessment of the patient and supported by evidence from data collected during the physical examination, laboratory studies, psychosocial assessment, and observational findings. The components of Nursing Diagnosis include:
• Problem/Diagnostic Label: This is the statement of the problem that defines the patient’s response to an actual or potential health issue. It should be concise, reflect current nursing language and accurately describe the problem. Examples include “Risk for Impaired Skin Integrity Related to Immobility” and “Impaired Home Maintenance Management Related to Cognitive Impairment.”
• Etiology/Related Factors: This is the cause of the problem and includes specific risk factors, contributing conditions, or environmental influences. In this section, it is vital to be as detailed as possible and specify the underlying conditions affecting the patient’s health. Examples include “sedating medications, decreased activity level, inadequate nutrition” and “inadequate financial resources, poor knowledge of available community resources.”
• Signs and Symptoms: This section is intended to describe the patient’s physical, mental, or emotional changes due to the problem. It should include all relevant data collected during the assessment, such as vital signs, physical examination findings, laboratory results, and behavioral indicators. Examples include “decreased mobility evidenced by the refusal of activity, redness on the lower extremity,” and “inability to identify available community resources.”
• Associated Factors: These are the factors that can have a significant impact on the patient’s response to the problem or its resolution. Examples include “limited financial resources, language barrier, family stressors” and “cognitive limitations, anxiety, fear of the unknown.”
• Goals/Outcome: These are the patient-specific objectives that must be achieved for the problem to be resolved or improved. The goals should be realistic and measurable within a specific timeframe. Examples include “Patient will demonstrate safe ambulation within four weeks” and “Patient will be able to identify available community resources within two weeks.”
• Nursing Interventions: This is the list of interventions the nurse plans to carry out to achieve the desired goal. The interventions should be specific, measurable, and based on evidence-based practice guidelines. Examples include “Assess the current level of mobility and develop a plan to increase activity level” and “Provide the patient with information about available community resources.”
What is the Purpose of Nursing Diagnosis?
Nursing Diagnosis aims to provide a comprehensive assessment of the patient’s health and set appropriate goals for treatment. It also serves as a basis for planning, implementing, and evaluating nursing care. The purpose of nursing diagnosis include:
• Identification of Health Problems: Nursing diagnosis facilitates the identification of existing and potential health problems. It allows the nurse to assess the patient’s physical, psychological, and social needs to develop a comprehensive care plan.
• Establishing Treatment Goals: Nursing diagnosis is used to help set realistic goals for treatment that are specific, measurable, and achievable within a defined timeframe. Without these goals, it would be difficult to determine if treatment was successful.
• Justifying Nursing Interventions: Nursing diagnosis provides the nurse with an evidence-based justification for implementing nursing interventions. It also serves as a reference point for monitoring and evaluating patient progress.
• Facilitating Collaborative Care: Nursing diagnosis allows nurses to collaborate more effectively with other healthcare professionals by assessing the patient’s health in-depth. It also facilitates continuity of care by providing a comprehensive overview of the patient’s treatment plan and progress.
• Promoting Professional Development: Nursing diagnosis is an essential tool for promoting professional development. It encourages nurses to understand the scientific basis behind nursing interventions and use evidence-based guidelines daily. By understanding the components of nursing diagnosis, nurses can continually refine their practice and provide better care for their patients.
What are the Types of Nursing Diagnosis?
A nursing Diagnosis is a clinical judgment made by the nurse about the client’s health based on an assessment of the patient and supported by evidence from data collected during physical examination, laboratory studies, psychosocial assessment, and observational findings. The types of nursing diagnosis include:
• Actual Nursing Diagnosis: This is a diagnosis based on signs and symptoms that the patient is currently experiencing. Actual nursing diagnoses should be specific, measurable, and achievable within a defined time.
• Risk Nursing Diagnosis: This is a diagnosis based on factors that could potentially cause a patient to develop health problems in the future. It identifies modifiable risk factors that can be targeted to prevent health problems.
• Syndrome Nursing Diagnosis: This diagnosis is based on an identifiable clinical syndrome or pattern of symptoms indicative of an underlying medical condition. It identifies and treats specific conditions such as diabetes, asthma, and hypertension.
• Wellness Nursing Diagnosis: This identifies a patient’s current level of wellness and outlines strategies for maintaining or improving it. It focuses on health promotion, lifestyle changes, and disease prevention.
• Readiness for Enhanced Nursing Diagnosis: This identifies those individuals who have the potential to achieve higher levels of wellness but may need additional support to do so. It can be used to develop an individualized care plan tailored to meet the patient’s specific needs.
What is the NANDA Classification of Nursing Diagnosis:
NANDA Classification of Nursing Diagnosis is a standardized taxonomy developed by the North American Nursing Diagnosis Association (NANDA). It is a comprehensive list of nursing diagnoses organized into distinct categories. The NANDA classification system consists of five main components:
• Domain: This is the broadest level of classification and includes categories such as “health promotion,” “physiological integrity,” and “psychosocial integrity.” There are 13 domains in the NANDA Nursing Diagnosis classification.
• Class: This is a more specific category within a domain. Examples include “activity intolerance”, “disturbed sleep pattern,” and “ineffective health maintenance.” There are 47 classes in the NANDA Nursing Diagnosis classification.
• Type: This includes subcategories such as “diarrhea”, “constipation,” and “hypertension.”
• Defining Characteristics: These are the signs and symptoms associated with a nursing diagnosis. Examples include increased pulse rate, insomnia, and abdominal pain.
• Interventions: These are the specific actions the nurse plans to take to achieve a desired outcome. Examples include “Encourage the patient to engage in physical activity” and “Provide the patient with education on self-care techniques.”
The NANDA Classification of Nursing Diagnosis is used by nurses to more accurately identify health problems, determine appropriate interventions and evaluate patient outcomes. It serves as an evidence-based tool for providing quality care to patients.
Tips for Writing Effective Nursing Diagnosis Statements
- Use a standardized taxonomy, such as NANDA, to ensure accuracy.
- Be specific and use clear language when writing nursing diagnosis statements.
- Consider the patient’s present condition and potential risk factors when diagnosing.
- Make sure each nursing diagnosis statement is measurable and achievable within a defined period.
- Base nursing diagnosis statements on evidence from data collected during the physical examination, laboratory tests, psychosocial assessment, and observational findings.
- Create a plan of care for each nursing diagnosis that is tailored to meet the individual needs of the patient.
- Monitor and evaluate patient outcomes upon completion of the plan of care to determine whether it was successful.
- Document all nursing diagnosis statements to ensure they are correctly recorded and tracked.
By following these tips, nurses can ensure that their nursing diagnosis statements are clear, accurate, and effective. This enables them to provide the highest quality of care to their patients.
What is the importance of Nanda diagnosis?
As healthcare providers, we constantly seek new ways to diagnose and treat our patients better. The Nanda diagnosis system is essential in achieving this goal, as it allows us to accurately categorize patients’ conditions and understand the factors contributing to their health problems.
This diagnosis system considers various aspects, such as physical, mental, and social factors, making it a more comprehensive tool than traditional diagnoses. As a result, Nanda provides a complete understanding of patient’s needs, ultimately leading to more effective treatments and better patient outcomes.
By utilizing the Nanda diagnosis system, healthcare providers can improve patient care standards and provide a higher quality of treatment overall.
In conclusion, Nursing Diagnosis is essential to a nurse’s practice, providing them with the necessary information to judge their patient’s care. Using evidence-based standards, Nurses can create accurate diagnoses that allow tailored interventions and improved patient outcomes. With its ever-evolving clinical scope, Nursing Diagnosis is a valuable tool for nurses to use when evaluating and providing care. Nurses must continue to increase their knowledge and understanding of this critical practice to give the best possible care for their patients.
Mrs. Marie Brown has been a registered nurse for over 25 years. She began her nursing career at a Level I Trauma Center in downtown Chicago, Illinois. There she worked in the Emergency Department and on the Surgical Intensive Care Unit. After several years, she moved to the Midwest and continued her nursing career in a critical care setting. For the last 10 years of her nursing career, Mrs. Brown worked as a flight nurse with an air ambulance service. During this time, she cared for patients throughout the United States.