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.
