How to Write a Nursing Diagnosis: Full Guide

Learn the concepts behind writing NANDA nursing diagnoses in this ultimate guide and nursing diagnosis list. Learn how to write a nursing diagnosis, their history and evolution, the nursing process, the various types and classifications, and how to correctly write NANDA nursing diagnoses. This guide also includes tips on how to create better nursing diagnoses, as well as guides on how to use them in developing nursing care plans.

How to write a nursing diagnosis statement

A nursing diagnosis is a clinical judgment that assists nurses in determining the best course of treatment for their patients. In addition, these diagnoses influence the potential actions of the patient, family, and community. They are created with careful consideration for a patient’s physical examination and may aid in measuring outcomes for the nursing care plan. This post will look at the NANDA nursing diagnostic list, nursing diagnosis examples, and the four categories.

Some nurses may see nursing diagnoses as archaic and time-consuming. However, it is an important tool for promoting patient safety via evidence-based nursing research.

The formal definition of the nursing diagnostic, according to NANDA-I, is:

“A nursing diagnosis is a clinical decision concerning an individual’s, family, or community’s reaction to present or future health problems/life processes.” A nursing diagnosis is a foundation for choosing nursing actions to accomplish outcomes for which the nurse is responsible.”

Components of a Nursing Diagnosis

In most cases, a nursing diagnosis is comprised of the following three elements:

• The issue and its description

• The Nursing Diagnosis etiology

• The distinguishing features or risk factors (for risk diagnosis)

1) The Issue and Its Definition

Concisely describing the client’s health issue or the reaction to which nursing care is provided is the responsibility of the problem statement, also known as the diagnostic label. Qualifier and emphasis of the diagnosis are typically the two components that make up a diagnostic label. Qualifiers are words that have been added to some diagnostic labels to give the diagnostic statement extra significance, restrict it, or define it. These words are also referred to as modifiers. This guideline does not apply to nursing diagnoses that consist of just one word (such as “anxiety,” “constipation,” “diarrhea,” “nausea,” etc.) since the qualifier and focus of these illnesses are already included in the single phrase.

2) Nursing Diagnosis Etiology

The etiology, also known as related factors, element of a nursing assessment label distinguishes one or more possible reasons for the health issue, are the conditions associated with the development of the issue, provides guidance to the necessary nursing therapy, and empowers the nurse to personalize the client’s care. In addition, the etiology element of a nursing assessment label identifies one or more circumstances engaged in creating the problem. Therefore, to eliminate the underlying reason of the nursing diagnosis, nursing interventions should focus on the elements that contribute to its etiology. Etiology is connected to the issue statement by the use of the word “related to,” such as in the following examples:

• Reduced tolerance to physical exercise due to widespread weakness

• Limited ability to move about due to being forced to bed rest

1) Risk Factors

For risk nursing diagnosis, etiological variables are often replaced with risk factors. A person (or group) is said to be more susceptible to an unhealthy state if they are exposed to risk factors, which are influences that might put them at risk. After the words “as demonstrated by,” the risk factors section of the diagnostic statement comes next.

The use of a walker and the fact that the person is elderly increase the risk of falling.

A breach in the patient’s skin integrity poses a potential risk of infection.

Writing Nursing Diagnosis Statement

How do you go about writing a diagnostic statement for a problem-focused diagnosis, a risk diagnosis, or a health promotion diagnosis?

When we write a diagnostic statement using the Problem-etiology-symptom (PES) technique, we communicate a significant amount of information to our fellow medical professionals. The actual diagnosis comes first, and then we go on to the reasons that contributed to it (related factors in an actual diagnosis). In the end, we determine the primary signs and symptoms (defining features) manifesting themselves in the patient in cases when real diagnoses are being made. In the case of risk and health promotion diagnoses, no etiologic variables apply; consequently, we identify critical predisposing a physician to a possible issue for risk diagnosis and treatment or proof that implies a possibility for health promotion (Defining characteristics) for a promoting health diagnosis.

Nursing Diagnosis for Care Plans

A nursing care plan, also known as an NCP, is a structured procedure that accurately identifies current requirements and acknowledges any possible needs or dangers. Care plans facilitate communication between nurses and their patients, as well as between nurses and other healthcare professionals, intending to improve patient outcomes. The nurse care planning process ensures that patients get high-quality care that is consistent throughout their episodes of care.

Nursing care planning starts when the patient is admitted to the facility, and it is regularly revised in response to the patient’s shifting conditions and assessments of their level of attainment of their goals during their stay. The foundation of exceptional nursing practice is the planning and execution of personalized care, sometimes known as patient-centered care.

Types of Nursing Diagnoses

A nursing care plan (NCP) is a structured procedure that accurately identifies current requirements and anticipated needs or dangers. Care plans facilitate communication between nurses, patients, and other healthcare professionals to improve health outcomes. Without nursing care planning, patient care would lack quality and consistency.

Nursing care planning starts when the client is accepted to the agency and is regularly revised in response to the client’s condition changes and assessment of goal attainment. Planning and providing personalized or patient-centered care is the foundation of nursing practice excellence.

1) Problem-Focused Nursing Diagnosis

An issue-focused diagnostic (also known as an actual diagnosis) is a client problem that is apparent during the nursing evaluation. These diagnoses are based on the existence of corresponding symptoms and indications. Actual nursing diagnoses should not be prioritized above risk diagnoses. However, there are several occasions when a risk diagnosis might be the highest priority diagnostic for a patient.

The three components of problem-focused nursing diagnoses are the nursing diagnostic, relevant factors, and defining features. Actual examples of nursing diagnosis include:

• Ineffective Breathing Patterns as shown by pursed-lip breathing, discomfort claims during inhalation, and the usage of auxiliary muscles to breathe.

• Anxiety resulting from stress is shown by increased tension, nervousness, and expressions of worry about the forthcoming operation.

• Acute Pain is attributable to reduced myocardial blood flow, as shown by grimacing, expressing Pain, and guarding behavior.

• Impaired Skin Integrity due to pressure on a lateral epicondyle, as indicated by Pain, bleeding, redness, and drainage from the wound.

2) Risk Nursing Diagnosis

Risk nursing diagnosis is the second category of nursing diagnosis. These are clinical determinations that no issue exists, but risk indicators suggest that a problem is likely to emerge if nurses do not intervene. There are no etiological (related) variables associated with risk diagnosis. However, due to risk factors, the person (or group) is more prone to acquiring the condition than others in the same or comparable scenario. For instance, if an older client with diabetes and vertigo who has trouble walking and refuses to ask for help during ambulation is classified with Risk for Injury, the diagnosis is accurate.

Risk nursing diagnoses consist of (1) a risk diagnostic label and (2) risk variables. Examples of hazardous nursing diagnoses include:

• Muscle weakness increases the danger of falling

• Mobility impairment indicates a risk for injury.

• Immunosuppression is indicative of an Infection Risk.

3) Promotion of Health Diagnosis

A health promotion diagnosis, also known as a wellness diagnosis, is a professional evaluation of the motivation and desire to improve health. The diagnosis of health promotion is concerned with the movement of a person, family, or community from a given degree of well-being to a greater level of wellness. A health promotion diagnosis typically comprises the diagnostic label or a simple remark. Diagnostic examples for health promotion:

• Readiness for Improved Spiritual Health

• Readiness for Improved Family Adaptation

• Preparedness for Improved Parenting

4) Syndrome Diagnosis

A syndrome diagnostic is a clinical determination of a cluster of issue or risk nursing diagnoses anticipated to manifest as a result of a certain scenario or incident. Similarly, they are expressed as one-part statements that need just the diagnostic label. Examples of nursing syndrome diagnoses include:

• Chronic Pain Disorder

• Post-trauma Syndrome

• Frail Aged Syndrome

American Nursing Diagnosis vs. International Nursing Diagnosis

Nursing diagnoses globally are defined, distributed, and integrated by NANDA-International, formerly known as the North American Nursing Diagnosis Association (NANDA).

NANDA International (NANDA-I) was established in 2002 as a reaction to NANDA’s rapid expansion outside of North America. The abbreviation NANDA was kept in the name because of its familiarity.

As new and updated diagnostic labels are considered at each biannual conference, the review, refining, and study of these labels continue. The Diagnostic Evaluation Committee is open to nurses who want to submit diagnoses for review. However, the ultimate say is held by the NANDA-I board of directors, who approve the diagnosis’ inclusion in the official list of labels. NANDA-I has authorized two hundred sixty-seven diagnoses for clinical use, testing, and refining as of 2021.

Nursing Diagnosis Classification

How are nursing diagnoses sorted, classified, and listed in their respective categories? In 2002, acceptance was given to Taxonomy II, which was constructed using a framework for assessing functional health patterns developed by Dr. Mary Joy Gordon. The three layers that makeup Taxonomy II are the Domains, the Classes, and the clinical diagnoses. Instead of Gordon’s patterns, nursing diagnostics are now categorized according to seven axes: the diagnostic concept, time, care unit, age, health condition, descriptor, and topology. In addition, diagnoses are now organized alphabetically by the idea rather than by the first word in the name of the diagnosis.

How to write a Nanda nursing diagnosis

The drafting of a nursing diagnosis consists of two primary phases; each stage is broken down into multiple sections. The process of developing a diagnosis is referred to in the first stage, while the writing process is discussed in the second step. We will begin by investigating the diagnostic procedure, broken down into three stages.

Step 1

The first step is Data analysis. Before beginning the data analysis, you should ensure that you have all of the pertinent details concerning the patient’s current health condition. Typically, this information is gathered during the nursing evaluation, derived from the most recent medical observations and test results. To effectively assess this data, you need to examine it according to standards, bringing attention to any discrepancies and anomalies you find.

Step 2

The second step is identifying any health concerns, potential dangers, and positive aspects. To complete this phase, a patient and a nurse must work together to identify the challenges, threats, and opportunities. The patient has inner health resources that will assist them in overcoming the health concerns and reducing the dangers. These strengths are referred to as the patient’s strengths. You should also determine if the current condition results from a nursing diagnostic, a medical diagnosis, or combining nursing and medical diagnoses.

Step 3

Formulation of diagnostic claims is the third step. Again, you need to expand on the major points of your nursing diagnosis as soon as the data has been reviewed and difficulties have been found, which will happen once the data has been analyzed. At this point in the process, you need to highlight the significant inferences and conclusions you have derived in the earlier stages.

Nursing diagnosis writing is the fourth step. After that, you will need to move on to the actual writing process. In your nursing diagnosis, you should elaborate on a patient’s current state of health and emphasize the circumstances that have contributed to their condition. Consider the fact that there are a few different forms of nursing diagnoses. Therefore, the diagnostic statements will change depending on the kind of paper that is being examined. Let’s get to the bottom of what’s going on here.

Examples of nursing diagnosis

Three distinct ideas might be connected to the word “nursing diagnostic.” First, this may be a reference to the separate second phase in the nursing process, which is diagnosis. In addition, a nursing diagnosis is applied to the label whenever registered nurses provide meaning to data that has been adequately labeled using a nursing diagnosis that NANDA-I has authorized. During the evaluation, the nurse may become aware, for instance, that the patient has feelings of anxiety and terror and has trouble falling or staying asleep. Nursing diagnoses have been assigned to these issues, referred to as Anxiety, Fear, and Disturbed Sleep patterns.

Nursing diagnosis format

• Evaluation

Evaluation, also known as an assessment, is an in-depth and comprehensive examination of a patient. It comprises collecting patient data that is both subjective and objective, including vital signs, a health history, a head-to-toe physical, and an assessment of the patient’s psychological, economical, and spiritual well-being.

• Diagnosis

The nurse is the one who makes the diagnosis, and it is based on the information that was gathered during the assessment. The nursing diagnostic guides nursing care that is particular to the patient.

At this point, the nurse formulates a diagnosis by considering the patient’s unique medical and social requirements. The diagnosis prompts the formulation of objectives that may be evaluated according to their success.

NANDA International (NANDA-I), previously known as the North American Nursing Diagnosis Association, is the organization that must validate the diagnosis before it can be used. In addition, NANDA-I is in charge of developing new nursing diagnoses and standardizing existing ones. The NANDA-I nomenclature is used worldwide, and its vision and goal are centered on utilizing evidence-based, universal nursing terminology to promote safe patient care.

• Outcomes and Planning

Creating a patient treatment plan based on the nursing diagnosis is part of the outcomes and planning process. The patient and their family should have quantifiable goals in mind while the planning process is carried out.

• Implementation

During the implementation phase, nurses are responsible for initiating and implementing the care plan. This phase ensures that patients get continuous care from when they are admitted to the hospital until they are discharged.

• Evaluation

This stage, which comes at the end of the nursing process, is called evaluation. A patient care plan is assessed according to certain objectives and results sought, and the plan may be modified according to the patient’s requirements.

Examples of nursing diagnosis statements

During the Assessment phase, nurses gather patient data and attach meaning to it using a procedure and label known as a nursing diagnosis. A NANDA-I-approved nursing diagnosis is attached to the data. For example, patients who exhibit signs such as excessive coughing before swallowing food, poor laryngeal elevation, or complaints of “something stuck” in their throat may need further evaluation by a nurse. An impeded swallowing diagnosis may be made by the nurse using these signs. Nursing diagnoses might include the possibility of reduced liver function, urine retention, sleep disturbances, and decreased cardiac output, to name a few.

Sample nursing diagnosis

Client: Jon Stark

Care Plan by: W. Smith, RN

Date initiated: 12-29-2018

Community nursing diagnosis

There are two types of community nursing diagnoses: those made by nurses and those made by patients. Diagnosis indicates a health condition within the nurse’s scope of practice. The “patient” may be an individual, a group, or a community. Through the application of nursing diagnosis, the RN serves as a diagnostician. Making clinical decisions based on obtained data is part of this procedure. The nurse’s urgent requirements are revealed via assessment results using strong diagnostic reasoning. Directing the nursing process, a diagnosis incorporates a tailored approach to the patient’s circumstances, personal preferences, and requirements. There are three stages: pre-planning, implementation, and follow-up. Using NANDA-approved diagnoses and supporting words in clinical papers is essential for patient care and educational institutions. NANDA-approved language is a guide to getting the nursing process off to a solid start in the real world of clinical practice.

In summary

It is critical for nurses to remember that the objective of a nursing diagnosis document is to document the patient’s needs, wants, and nursing interventions that are implemented to meet those specific needs. Understanding how to write a nursing diagnosis helps in the establishment of continuity of care and allows patients to receive the best possible interventions. Adjustments to the nursing care plan are also possible as diagnoses or issues change or evolve with a patient’s medical status.

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