Learn about nursing diagnoses. Understand how to write a nursing diagnosis, identify the types of nursing diagnoses, and examine their purpose and components.
Updated: 05/09/2022
Nursing Diagnosis | Process and Types
What is a Nursing Diagnosis?
The nurse is an essential component of the medical team and is the liaison between the medical provider and the patient. The nurse identifies patient concerns and forms a nursing diagnosis based on their initial evaluation.
A nursing diagnosis is a judgment made after a comprehensive assessment of a patient to determine their overall well-being, as well as their physical and mental state. There is a nursing process that is defined by a series of steps:
- Assessment - The evaluation of the patient, both physically and mentally. The assessment will include the subjective symptoms and objective findings on exam, the vital signs, pertinent history (including family and social factors), and their overall mental health.
- Nursing diagnosis - A nursing judgment based on the comprehensive evaluation of the patient
- Plan - Developing a care plan based on findings and the nursing diagnosis
- Implementation - Ensures continuity of care by initiating a care plan and putting it into action
- Evaluation - Ensuring the plan of care corresponds with stated goals and desired outcome
A nursing diagnosis provides a preliminary assessment of the patient's concerns and needs prior to the medical evaluation and diagnosis. A good nursing diagnosis is personalized to each patient's situation and focuses not only on the medical needs but also the social, mental, and economic needs of the patient.
The North American Nursing Diagnosis Association (NANDA)
The North American Nursing Diagnosis Association (NANDA) was formed in 1982 at an International Nursing Conference in Canada. The goal was to develop a coordinated nursing care approach in the United States and Canada. In 2002, NANDA expanded internationally to include worldwide input. The function of NANDA is to standardize the language and procedures used to develop a nursing diagnosis.
The goal of NANDA:
- Conduct and fund research to refine nursing diagnoses and outcomes
- Develop standards in nursing care and diagnosis
- Standardize the nursing terminology internationally to improve patient safety
- Become an international network to improve nursing care
What Is NANDA?
NANDA International, originally known as the North American Nursing Diagnosis Association, was founded in 1982. The purpose of NANDA is to develop standardized terminology so nurses can have a common language to communicate the needs of their patients and more easily understand what needs to be done for patients.
NANDA members perform research, refining and setting criteria for each diagnosis and placing each in its proper place with the taxonomy of nursing diagnoses. Once the new terminology is finalized, NANDA distributes the new information to nurses worldwide.
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How to Write a Nursing Diagnosis
Standardizing how to write a nursing diagnosis makes for consistent and safe nursing practices. A well-written nursing diagnosis is personalized to the patient's situation and status in life. A nursing diagnosis will identify the patient's problem and the associated signs and symptoms and will determine any related factors that could affect the patient's care.
A properly written nursing diagnosis includes:
- Nursing personal judgment - describing the main issue and any complicating patient variables
- The diagnostic focus or reason for evaluation - the chief complaint as to why the patient sought medical care
- Subject - identification of the patient involved, an explanation of the patient demographics
Types of Nursing Diagnoses
There are different types of nursing diagnoses that focus on a specific area of patient care and management. The different types of nursing diagnoses include:
- Problem-Focused Diagnosis
- Health Promotion Diagnosis
- Risk Diagnosis
- Syndrome Diagnosis
These will be explored in more detail below.
Problem-Focused Diagnosis
A problem-focused diagnosis centers on a specific condition or issue. This nursing diagnosis is based on the symptoms of the patient. The nurse will observe associated concerns, stressors, or potential complications associated with the condition and develop a plan of care.
An example of a problem-focused diagnosis is recognizing the signs of respiratory distress. The nurse will observe the patient struggling to breathe with rapid respirations, low pulse oximetry, and the use of accessory muscles to inhale. This information is passed along to the medical provider to assist in making a diagnosis. The nursing diagnosis guides further nursing decisions by assessing the need for further support or oxygen.
Health Promotion Diagnosis
A health promotion diagnosis aims to improve the overall health and well-being of a patient. It is a statement of the patient's motivation to succeed or make a change. An example of a health promotion nursing diagnosis would be to document and acknowledge barriers to overcoming a sedentary lifestyle.
Risk Diagnosis
A risk diagnosis is a nursing diagnosis used to identify when a patient might be a risk for an issue. The nursing diagnosis requires nursing judgment and reasoning. The goal of risk diagnosis is to identify potential issues for harm that could be improved prior to the occurrence of an adverse incident. An example of a risk diagnosis would be to acknowledge the risk for COVID-19 infection and death in an unvaccinated or immunosuppressed individual.
Syndrome Diagnosis
Syndrome diagnosis refers to nursing diagnoses centered around a cluster of issues. For example, chronic pain syndrome refers to persistent pain and debility due to past injuries. These patients might require more social and psychological support.
Nursing vs. Medical Diagnosis
There is a difference between a nursing diagnosis and a medical diagnosis. A medical diagnosis identifies the cause of the patient's symptoms and names the disorder. A nursing diagnosis targets the patient's response to the disorder. For example, the patient observed to have a fever, shortness of breath, and rapid respirations will have a nursing diagnosis of respiratory distress. The medical diagnosis associated with this patient might include influenza or covid infection.
The medical doctor will order tests to determine the cause of a patient's signs and symptoms to make a diagnosis. The nurse will ensure that the patient understands the illness and has the means to obtain treatment.
Lesson Summary
A nursing diagnosis is a judgment based on a patient's symptoms, physical signs, mental health, and socioeconomic stressors. In order to make a nursing diagnosis, the appropriate sequence of evaluation is necessary. This nursing process includes the steps of assessment, nursing diagnosis, plan, implementation, and then evaluation. A nursing diagnosis addresses the patient's response to a disorder, while a medical diagnosis identifies the disorder and its cause. There are four main types of nursing diagnoses. Problem-focused diagnosis focuses on a specific problem noted on the exam or in observation. A risk diagnosis identifies when a patient is at risk for future problems based on their current state. Health promotion diagnosis identifies ways that the patient's overall well-being can be improved. Syndrome diagnosis coordinates a series of medical issues to provide comprehensive care.
The North American Nursing Diagnosis Association, or NANDA, was founded in 1982 in North America to organize the standards for nursing diagnosis. NANDA is an international professional nursing organization that conducts research and develops standard nursing terminology worldwide. When preparing a nursing diagnosis, a properly written diagnosis is personalized to a patient's situation. It will include nursing judgment, diagnostic focus, and the subject involved.
What Is a Nursing Diagnosis?
Nurses learn the nursing process as part of their education. The nursing process starts with the nursing assessment, which involves collecting information from and about the patient. From that information, the nurse uses nursing judgment to identify what kind of response the patient is experiencing as a result of their health condition or other life process. The terms used to fashion this response into a usable summary statement of the problem is the nursing diagnosis.
The nursing diagnosis guides the next step of the nursing process: planning and goal setting. In the planning step, a nurse chooses appropriate interventions to personalize the care of the patient. These interventions are chosen specifically to move the patient toward the desired goals or outcomes. The next step is the actual implementation of the chosen interventions. The final step of the nursing process is evaluation or re-assessment to measure how well each planned intervention is working.
Types of Nursing Diagnoses
There are four types of nursing diagnoses. Let's consider them individually.
The first type is a problem-focused nursing diagnosis, which reflects 'a clinical judgment concerning an undesirable human response to health conditions or life processes that exists in a patient.' To make this diagnosis, certain elements must be present, including: defining characteristics (signs and/or symptoms) that can be grouped to form recognizable patterns and related factors that are somehow related to, contribute to, or led up to the identified problem.
Examples of problem-focused nursing diagnoses include:
- Sleep deprivation related to pain
- Impaired bed mobility related to left-sided paralysis
- Decreased cardiac output due to myocardial infarction
The second type of nursing diagnosis is the health promotion diagnosis, which concerns the motivation and desire to increase well-being and to move closer to a person's own optimum health potential. These diagnoses use terms related to a patient's readiness for specific health behaviors. To make a health-promotion diagnosis, there must be defining characteristics that begin with the phrase, 'Expresses desire to enhance. . .'
Examples of health promotion nursing diagnoses include:
- Sedentary lifestyle
- Risk-prone behavior
- Readiness for enhanced immunization status
A third type of diagnosis is the risk nursing diagnosis. This examines the patient's vulnerability for developing an undesirable response to a health condition or life process. It requires identification of specific, personalized risk factors, such as smoking, advanced age, and obesity.
Examples of risk nursing diagnosis include:
- Risk for infection
- Risk for falls
- Risk for SIDS
The final nursing diagnosis is the syndrome. This diagnosis identifies specific groups of diagnoses that occur together in a pattern and are best addressed together through similar nursing interventions. Making a syndrome diagnosis requires two or more nursing diagnoses that serve as defining characteristics and related factors, if they add clarity. However, related factors are not required.
An example of a syndrome diagnosis is a risk for decreased cardiac tissue perfusion, ineffective cerebral tissue perfusion, and ineffective peripheral tissue perfusion related to dysfunctional ventilatory weaning response
Nursing vs. Medical Diagnosis
To understand the difference between a medical diagnosis and a nursing diagnosis, let's first examine the purpose of a medical diagnosis. A medical diagnosis identifies the disorder, disease, or cause of symptoms. In contrast, a nursing diagnosis identifies the problems; in other words, the human responses that result from that disorder or disease.
For example, a medical diagnosis of stroke tells us about the cause of the symptoms. The nursing diagnosis might include impaired verbal communication, risk for falls, interrupted family processes, and powerlessness. The nursing diagnosis helps us understand the impact of that stroke on the patient and his family, as well as identifying which nursing interventions would best achieve patient-specific goals or outcomes.
There are seven elements that might be included in a nursing diagnosis, though not every element is needed in every diagnosis. The ones in italics are essential:
- Diagnostic focus: the fundamental and essential part of the diagnostic concept
- Subject of the diagnosis: the patient, caregiver, family, group, or community
- Judgment: for example, impaired or ineffective
- Location: for example, bladder or auditory
- Age: fetus, infant, child, adolescent, adult, or older adult
- Time: chronic, acute, intermittent
- Status of the diagnosis: actual vs. potential; problem-focused, risk, or health promotion
The diagnostic focus, together with the nurse's judgment about it, forms the basic diagnosis and is called the diagnosis label. The defining characteristics are observable cues or inferences that cluster into patterns that can be identified as problem-focused, health-promotion diagnosis, or syndrome.
Risk factors include environmental factors and physiological, psychological, genetic, or chemical elements that increase the vulnerability of a patient to an unhealthy event. Only risk diagnoses have risk factors. Related factors are those that seem to have some kind of relationship with the nursing diagnosis; in other words, leading up to, contributing to, making it better or worse. Only problem-focused nursing diagnoses and syndromes must have related factors. Health-promotion diagnoses might have related factors, if they help to clarify the diagnosis.
Putting It All Together
So what would a nursing diagnosis look like? Let's consider a patient with a medical diagnosis of stroke. Potential nursing diagnoses might be:
- Risk for falls related to left-sided paralysis and forgetfulness, especially when needing to void.
- Risk for impaired swallowing related to inability to feel food on the right side of mouth and inability to follow directions.
- Powerlessness related to inability to move independently and inability to communicate needs.
Keep in mind that any nursing diagnosis is personalized to the specific patient and their situation. You can search online using NANDA to find the list of current and newly-approved nursing diagnoses.
Lesson Summary
Let's review. This lesson introduced the concept of a nursing diagnosis and where it fits into the nursing process. Key elements in this lesson included:
NANDA International: formerly North American Nursing Diagnosis Association, started in 1982. It's an international, professional nursing organization that develops standardized terminology for nurses worldwide.
Nursing process: this is an organized, problem-solving approach used by professional nurses to assess and identify nursing diagnoses, plan, implement, and evaluate nursing care.
Nursing diagnosis: this a statement that summarizes the clinical judgment of the patient's response to his health condition or life process.
Four types of nursing diagnoses were identified: problem-focused, health promotion, risk, and syndrome. We also covered the seven elements that might be part of a nursing diagnosis: diagnostic focus, subject, judgment, location, age, time, and status. And, finally, we stressed that every nursing diagnosis should be personalized to the specific patient's situation.
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Video Transcript
What Is NANDA?
NANDA International, originally known as the North American Nursing Diagnosis Association, was founded in 1982. The purpose of NANDA is to develop standardized terminology so nurses can have a common language to communicate the needs of their patients and more easily understand what needs to be done for patients.
NANDA members perform research, refining and setting criteria for each diagnosis and placing each in its proper place with the taxonomy of nursing diagnoses. Once the new terminology is finalized, NANDA distributes the new information to nurses worldwide.
What Is a Nursing Diagnosis?
Nurses learn the nursing process as part of their education. The nursing process starts with the nursing assessment, which involves collecting information from and about the patient. From that information, the nurse uses nursing judgment to identify what kind of response the patient is experiencing as a result of their health condition or other life process. The terms used to fashion this response into a usable summary statement of the problem is the nursing diagnosis.
The nursing diagnosis guides the next step of the nursing process: planning and goal setting. In the planning step, a nurse chooses appropriate interventions to personalize the care of the patient. These interventions are chosen specifically to move the patient toward the desired goals or outcomes. The next step is the actual implementation of the chosen interventions. The final step of the nursing process is evaluation or re-assessment to measure how well each planned intervention is working.
Types of Nursing Diagnoses
There are four types of nursing diagnoses. Let's consider them individually.
The first type is a problem-focused nursing diagnosis, which reflects 'a clinical judgment concerning an undesirable human response to health conditions or life processes that exists in a patient.' To make this diagnosis, certain elements must be present, including: defining characteristics (signs and/or symptoms) that can be grouped to form recognizable patterns and related factors that are somehow related to, contribute to, or led up to the identified problem.
Examples of problem-focused nursing diagnoses include:
- Sleep deprivation related to pain
- Impaired bed mobility related to left-sided paralysis
- Decreased cardiac output due to myocardial infarction
The second type of nursing diagnosis is the health promotion diagnosis, which concerns the motivation and desire to increase well-being and to move closer to a person's own optimum health potential. These diagnoses use terms related to a patient's readiness for specific health behaviors. To make a health-promotion diagnosis, there must be defining characteristics that begin with the phrase, 'Expresses desire to enhance. . .'
Examples of health promotion nursing diagnoses include:
- Sedentary lifestyle
- Risk-prone behavior
- Readiness for enhanced immunization status
A third type of diagnosis is the risk nursing diagnosis. This examines the patient's vulnerability for developing an undesirable response to a health condition or life process. It requires identification of specific, personalized risk factors, such as smoking, advanced age, and obesity.
Examples of risk nursing diagnosis include:
- Risk for infection
- Risk for falls
- Risk for SIDS
The final nursing diagnosis is the syndrome. This diagnosis identifies specific groups of diagnoses that occur together in a pattern and are best addressed together through similar nursing interventions. Making a syndrome diagnosis requires two or more nursing diagnoses that serve as defining characteristics and related factors, if they add clarity. However, related factors are not required.
An example of a syndrome diagnosis is a risk for decreased cardiac tissue perfusion, ineffective cerebral tissue perfusion, and ineffective peripheral tissue perfusion related to dysfunctional ventilatory weaning response
Nursing vs. Medical Diagnosis
To understand the difference between a medical diagnosis and a nursing diagnosis, let's first examine the purpose of a medical diagnosis. A medical diagnosis identifies the disorder, disease, or cause of symptoms. In contrast, a nursing diagnosis identifies the problems; in other words, the human responses that result from that disorder or disease.
For example, a medical diagnosis of stroke tells us about the cause of the symptoms. The nursing diagnosis might include impaired verbal communication, risk for falls, interrupted family processes, and powerlessness. The nursing diagnosis helps us understand the impact of that stroke on the patient and his family, as well as identifying which nursing interventions would best achieve patient-specific goals or outcomes.
There are seven elements that might be included in a nursing diagnosis, though not every element is needed in every diagnosis. The ones in italics are essential:
- Diagnostic focus: the fundamental and essential part of the diagnostic concept
- Subject of the diagnosis: the patient, caregiver, family, group, or community
- Judgment: for example, impaired or ineffective
- Location: for example, bladder or auditory
- Age: fetus, infant, child, adolescent, adult, or older adult
- Time: chronic, acute, intermittent
- Status of the diagnosis: actual vs. potential; problem-focused, risk, or health promotion
The diagnostic focus, together with the nurse's judgment about it, forms the basic diagnosis and is called the diagnosis label. The defining characteristics are observable cues or inferences that cluster into patterns that can be identified as problem-focused, health-promotion diagnosis, or syndrome.
Risk factors include environmental factors and physiological, psychological, genetic, or chemical elements that increase the vulnerability of a patient to an unhealthy event. Only risk diagnoses have risk factors. Related factors are those that seem to have some kind of relationship with the nursing diagnosis; in other words, leading up to, contributing to, making it better or worse. Only problem-focused nursing diagnoses and syndromes must have related factors. Health-promotion diagnoses might have related factors, if they help to clarify the diagnosis.
Putting It All Together
So what would a nursing diagnosis look like? Let's consider a patient with a medical diagnosis of stroke. Potential nursing diagnoses might be:
- Risk for falls related to left-sided paralysis and forgetfulness, especially when needing to void.
- Risk for impaired swallowing related to inability to feel food on the right side of mouth and inability to follow directions.
- Powerlessness related to inability to move independently and inability to communicate needs.
Keep in mind that any nursing diagnosis is personalized to the specific patient and their situation. You can search online using NANDA to find the list of current and newly-approved nursing diagnoses.
Lesson Summary
Let's review. This lesson introduced the concept of a nursing diagnosis and where it fits into the nursing process. Key elements in this lesson included:
NANDA International: formerly North American Nursing Diagnosis Association, started in 1982. It's an international, professional nursing organization that develops standardized terminology for nurses worldwide.
Nursing process: this is an organized, problem-solving approach used by professional nurses to assess and identify nursing diagnoses, plan, implement, and evaluate nursing care.
Nursing diagnosis: this a statement that summarizes the clinical judgment of the patient's response to his health condition or life process.
Four types of nursing diagnoses were identified: problem-focused, health promotion, risk, and syndrome. We also covered the seven elements that might be part of a nursing diagnosis: diagnostic focus, subject, judgment, location, age, time, and status. And, finally, we stressed that every nursing diagnosis should be personalized to the specific patient's situation.
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