Nursing Diagnosis Guide

Nursing Diagnosis Guide

How can I utilize the nursing process and nursing diagnosis in my practice? This guide provides insights into understanding, writing, and using nursing diagnoses, as well as distinguishing between nursing and medical diagnoses. Crafting a nursing diagnosis is a pivotal element in delivering patient care and is a fundamental step within the nursing process.

Comprehending the art of creating a nursing diagnosis equips you to enhance patient outcomes, foster communication among the healthcare team, and better organize your daily tasks. Both the nursing process and nursing diagnoses contribute to ensuring and advocating evidence-based and secure practices. In this guide, you’ll grasp the meaning of a nursing diagnosis, its significance, and a general overview of conducting a nursing diagnosis.

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The Nursing Process

A comprehensive discussion of nursing diagnosis necessitates addressing the nursing process. The nursing process involves five phases:

1. Assessment

Assessment constitutes a thorough and holistic evaluation of a patient. It encompasses collecting both subjective and objective patient data such as vital signs, medical history, a head-to-toe physical examination, and a psychological, socioeconomic, and spiritual assessment.

2. Diagnosis

Diagnosis is formulated by the nurse based on the data amassed during the assessment. The nursing diagnosis directs patient care tailored to nursing.

In this stage, the nurse formulates a diagnosis derived from the patient’s specific medical and/or social needs. This diagnosis then leads to creating goals with measurable outcomes.

The diagnosis must align with the approved standards of NANDA International (NANDA-I), previously known as North American Nursing Diagnosis Association. NANDA-I is responsible for developing and standardizing nursing diagnoses. Operating internationally, NANDA-I’s vision and mission involve employing evidence-based, universal nursing terminology to advance secure 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 typically comprises three components: an approved diagnosis by NANDA-I, a “related to” statement delineating the cause of the NANDA-I diagnosis, and an “as evidenced by” statement utilizing specific patient data to elucidate the rationale behind the NANDA-I diagnosis and the associated “related to” statement.

Risk-related diagnoses exclusively feature a NANDA-I diagnosis and an “as evidenced by” statement, as they pertain to vulnerabilities rather than causes. For instance, a nursing diagnosis might be “risk for pressure ulcer as evidenced by lack of movement, poor nutrition, and hydration.”

3. Outcomes and Planning

Outcomes and planning entail formulating a patient care plan based on the nursing diagnosis. The planning should be quantifiable and focused on goals for the patient and/or their family members.

4. Implementation

Implementation is the phase where nurses initiate the care plan and put it into effect. This step ensures the continuity of care from hospitalization to discharge.

5. Evaluation

Evaluation marks the final step of the nursing process. A patient care plan undergoes evaluation based on specific goals and desired outcomes, and adjustments may be made based on the patient’s requirements.

Distinguishing Nursing Diagnoses From Medical Diagnoses

To gain a comprehensive understanding of a nursing diagnosis, it’s beneficial to first discern how it contrasts with a medical diagnosis.

A nursing diagnosis is initiated by a nurse and characterizes a response to the medical diagnosis. Conversely, a medical diagnosis is provided by a physician to a patient to define a medical condition, disease, or injury.

Nursing Diagnosis

Grounded in the patient’s immediate circumstance
Initiated to address a health issue
Enhances communication within healthcare teams
Embraces a comprehensive approach to patient care

Example: Ineffective breathing pattern related to impaired inhalation and exhalation as evidenced by the use of accessory muscles

Medical Diagnosis

Initiated by a medical doctor or specialist
Defines a medical condition, disease, or injury
Describes the signs and symptoms of the ailment

Example: Asthma

Four Categories of Nursing Diagnoses

The necessity for standardized language, respect for nurses’ clinical judgment, and provision of care with measurable outcomes underscore the utility of a nursing diagnosis. Nursing diagnoses can be categorized into four primary groups. Please note that all examples are extracted from Nursing Diagnoses Definitions and Classification 2015-2017.

Problem-focused Diagnosis

A nursing diagnosis linked to a patient’s specific issue. It can span the patient’s entire hospitalization or be resolved by the end of a shift.

Example: Anxiety related to situational crises and stress (related factors) as evidenced by restlessness, insomnia, anguish, and anorexia (defining characteristics)

Risk Diagnosis

A nursing diagnosis indicating the patient’s susceptibility to developing an issue. NANDA-I characterizes it as a vulnerability the patient encounters.

Example: Risk for infection as evidenced by inadequate vaccination and immunosuppression (risk factors)

Health-promotion Diagnosis

A nursing diagnosis employed to identify ways to enhance a patient’s health. Health-promotion diagnosis involves the patient as well as their family/community members.

Example: Readiness for enhanced self-care as evidenced by expressed desire to enhance self-care

Syndrome Diagnosis

A nursing diagnosis recognizing a collection of diagnoses applicable to a patient. These nursing diagnoses are best understood collectively, as the patient might be experiencing various health problems forming a pattern.

Example: Chronic pain syndrome

Nursing Diagnosis Classification

NANDA-I formulated Taxonomy II in collaboration with the National Library of Medicine. Taxonomy, by definition, is the “practice and science of categorization and classification.” The NANDA-I Taxonomy encompasses 235 nursing diagnoses across 13 categories of nursing practice:

• Health promotion
• Nutrition
• Elimination and exchange
• Activity/rest
• Perception/cognition
• Self-perception
• Role relationships
• Sexuality
• Coping/stress tolerance
• Life principles
• Safety/protection
• Comfort
• Growth/development

Additionally, there are 47 classes associated with each category.

How to Execute a Nursing Diagnosis

Nurses follow five steps to execute a robust and accurate nursing diagnosis. Adherence to the nursing process is essential for all nurses:

1. Nursing Science

A solid grasp of nursing science and theory forms a strong foundation for patient care. It also serves as the initial step in launching a nursing diagnosis and care plan rooted in a holistic, patient-centric approach.

2. Assessment

During assessment, nurses gather medical, surgical, and social history. They also conduct a physical examination of the patient.

Nurses then ponder: What are the current and prioritized health problems the patient is confronting? This information informs the creation of a nursing diagnosis.

3. Identifying Potential Diagnoses

Once the health problem or human response to the health problem is pinpointed, nurses ask another question: What pertinent information is relevant to the health issue, and what is extraneous?

This query aids in generating a potential nursing diagnosis. Nurses subsequently:

• Determine the category of the nursing diagnosis
• Confirm or eliminate other diagnoses
• Formulate new diagnoses

The nursing diagnosis must be verified and thought through critically. NANDA-I suggests employing an in-depth assessment to validate or rule out a diagnosis.

NANDA-I advises structuring a nursing diagnosis in the format of “related factors” and “defining characteristics,” as initially proposed by Marjory Gordon, Ph.D. This format accentuates the strength and precision of the nursing diagnosis.

4. Implementation of a Care Plan

A nursing diagnosis shapes the care plan. Nurses create attainable, measurable goals along with corresponding interventions. They then take action by administering the planned interventions.

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5. Evaluation

Nurses continuously evaluate their patients. A nursing diagnosis is frequently assessed to ensure the efficacy of the care plan. If the plan is not yielding the desired outcomes, nurses must contemplate alternative measures to enhance the patient’s well-being.

An Essential Element of Care

Nurses serve as the patient’s advocates and communicators. They bridge the gap between the medical healthcare team and the patient along with their family. Grasping the potency and utility of a nursing diagnosis constitutes a pivotal aspect of patient care. Each patient is distinct and intricate. The nursing process and nursing diagnosis facilitate the provision of secure, individualized, and evidence-based care.