RN, MSN, Chief Nursing Officer
Nurses must possess the skills to properly formulate a nursing diagnosis. Each patient cared for must have a medical plan of care for a nurse to provide effective interventions for the patient.
The way in which a nursing diagnosis is formulated is initially based on the physical assessment of the patient and can be changed or altered as nursing care continues to be provided.
The most approved and effective means of nursing care plans are developed by The North American Nursing Diagnosis Association (NANDA) and are formulated by evidence-based research.
The offical definition of the nursing diagnosis according to NANDA (2013) is:
“Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”
A nursing diagnosis can be defined as part of the nursing process that comprises clinical judgment and allows the nurse to determine and develop the best plan of care for his/her patients.
The main focus of a nursing diagnosis is the development of interventions that can be implemented for each patient and the measurable outcomes of the interventions.
Nursing diagnoses are carefully created based on a patient’s physical assessment and promotes patient safety by utilizing evidence-based nursing research.
Nursing diagnoses have three components that need to be followed in order to effectively create the plan of care for each patient. The three components are as follows:
The problem is actually considered the “nursing diagnosis” related to the medical issues of the patient.
Etiology is known as the related factor and what causes the problem and results in the symptoms presented by the patient.
These are the “symptoms” noted in the patient during a physical assessment.
They can be signs/symptoms of the medical disease, responses to the disease, problems associated with the disease, and any evidence that proves the existence of the problem. The sypmtoms are the focus of the nursing interventions and goals
According to NANDA, there are four types of nursing diagnoses:
Problems noted and present during a nursing assessment are known as a problem-focused diagnosis. Typically, the problems are noted throughout an entire hospital stay of the patient or are noticed consistenly by several nurses caring for the patient. The problem may be resolved fairly quickly based on the nursing and medical care given.
These type of diagnoses are the most common and easiest to identify due to the signs/symptoms present in the patient. A few examples of this type of nursing diagnosis includes:
Risk factors or problems require intervention from the nurse and healthcare providers before a real and visible problem develops. Examples of risk nursing diagnoses inlcude:
These types of diagnoses typically require nursing judgment and clinical reasoning in order to formulate the proper nursing diagnosis.
Improves the overall well-being of indivduals, families, or communities. Example of health promotion diagnoses inlcude:
References a cluster of nursing diagnoses that occur in patterns or can be addressed through similar nursing interventions. Examples of syndrome diagnoses include:
It is important to keep in mind that a nursing diagnosis is initiated by a nurse and typically describes a response to the medical diagnosis. Contrary, a medical diagnosis is given to a patient by a doctor or advanced health care practitioner in order to define a medical disease, condition, or injury.
For example, a medical diagnosis is specific to its pathology and focuses on the illness. A nursing diagnosis on the other hand focuses on the actual patient, the physiological, and the psychological responses to the diagnosis.
Example of Nursing Diagnosis: Risk for impaired skin integrity; urinary retention; decreased cardiac output; and disturbed sleep patterns.
Example of Medical Diagnosis: Alzheimer’s disease, diabetes, arrhythmias, arthritis, and chronic kidney disease.
NANDA collaborated with the National Library of Medicine (NLM) regarding healthcare terminology and has three levels: domains, classes, and nursing diagnoses. Currently, there are 13 domains and 47 classes and the domains are listed below:
Health Awareness
Management of Health
Ingestion
Absorption
Digestion
Metabolism
Hydration
Urinary Function
Integumentary Function
Respiratory Function
Gastrointestinal Function
Sleep/Rest
Energy Balance
Self Care
Cardiovascular/Pulmonary Responses
Activity/Exercise
Attention
Communication
Cognition
Orientation
Sensation/Perception
Body Image
Self-esteem
Self-concept
Role Performance
Caregiving Roles
Family Relationships
Reproduction
Sexual Function
Sexual Identity
Coping Response
Neuro-Behavioral Stress
Post-traumatic Responses
Beliefs
Values
Value/Belief Congruence
Infection
Violence
Thermoregulation
Physical Injury
Defensive Processes
Environmental Hazards
Physical Comfort
Social Comfort
Environmental Comfort
Growth
Development
It is imperative for nurses to remember that the purpose of a nursing care plan consists of nursing diagnoses that document the patient’s needs, wants, and nursing interventions that are implemented in an effort to meet those specific needs.
The nursing care plan assists in establishing continuity of care and allows the best possible interventions to be offered to patients. Adjustments are also able to be made to the nursing care plan as diagnoses or issues change or evolve with a patient’s medical status.
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