Copyright

Nursing Diagnosis | Process and Types

Pat Mccaw, Zona Taylor
  • Author
    Pat Mccaw

    Pat McCaw MD is a family physician and author. She earned her BS in Biology and MD in Medicine from the University of Iowa in 1998. She subsequently received her MFA in Creative Writing from Hamline University in 2016. She works part-time in family medicine while pursuing her love of writing. She has over 20 years of medical experience with an excellent grasp of the sciences, sociology, behavior, and emotional health. She writes middle grade and young adult fiction, and has experience with professional blog content from GILI Sports. She also maintains her own blog, Pat's Chat, and teaches online classes to educators on inventive ways to use picture books in the classroom to augment their curriculum, and fun exercises to teach creative writing.

  • Instructor
    Zona Taylor

    Zona has taught Nursing and has a master's degree in Nursing Education and Maternal-Infant Nursing from University of Maryland Baltimore.

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

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.

An error occurred trying to load this video.

Try refreshing the page, or contact customer support.

Coming up next: What Is PPE? - Definition, Safety & Requirements

You're on a roll. Keep up the good work!

Take Quiz Watch Next Lesson
 Replay
Your next lesson will play in 10 seconds
  • 0:04 What Is NANDA?
  • 0:40 What Is a Nursing Diagnosis?
  • 1:40 Types of Nursing Diagnoses
  • 4:10 Nursing vs. Medical Diagnosis
  • 6:39 Putting It All Together
  • 7:21 Lesson Summary
Save Save Save

Want to watch this again later?

Log in or sign up to add this lesson to a Custom Course.

Log in or Sign up

Timeline
Autoplay
Autoplay
Speed Speed

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.

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.

To unlock this lesson you must be a Study.com Member.
Create your account

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.

To unlock this lesson you must be a Study.com Member.
Create your account

Register to view this lesson

Are you a student or a teacher?

Unlock Your Education

See for yourself why 30 million people use Study.com

Become a Study.com member and start learning now.
Become a Member  Back
What teachers are saying about Study.com
Try it now
Create an account to start this course today
Used by over 30 million students worldwide
Create an account