nursing diagnosis is a clinical judgment that assists nurses in determining the best course of care for their patients. These diagnoses influence potential interventions for the patient, family, and community. Understanding how to write a nursing diagnosis is crucial for all nursing students.
A nursing diagnosis is created with careful consideration for a patient’s physical examination and can aid in measuring results for nursing diagnosis for nursing care plans. This article will look at the components of a nursing diagnosis, examples of nursing diagnosis, and the types of nursing diagnoses. Let’s begin by understanding what nursing diagnosis entails.
Definition of a nursing diagnosis
A nursing diagnosis refers to a care plan involving an individual, family, group, or society’s feedback on health conditions/life processes or risk to that response. A nursing diagnosis is a foundation for choosing treatment strategies to achieve organizational objectives for which the nurse is responsible. Nursing diagnoses are generated based on data gathered during the nursing assessment, allowing the nurse to create the treatment plan.
What are the benefits of nursing diagnosis?
A nursing diagnosis serves the following functions:
- Enables the identification of nursing priorities and the direction of nursing interventions based on the recognized preferences.
- Assists in preparing possible results for third-party payer quality assurance specifications.
- Nursing diagnoses assist in determining how a client or group reacts to current or potential health and life systems. It helps in understanding the available strengths and resources that can be used to prevent or resolve issues.
- Establishes a common language and serves as a foundation for understanding and interaction among healthcare practitioners.
- It provides a foundation for determining whether nursing care is beneficial to the patient and cost-effective.
- Nursing diagnosis is an effective learning tool for nursing students as it helps you advance your problem-solving and critical-thinking skills.
What does the nursing process entail?
We can’t discuss nursing diagnosis without first explaining what the nursing process is and how the diagnosis fits perfectly into the bigger picture. The nursing process focuses on five stages, the second one being diagnosis.
1. Assessment
The first step in the nursing process is to evaluate the patient thoroughly. This step includes gathering data like vital signs, health history, and psychological or socioeconomic assessments.
2. Diagnosis
After completing the assessment, the nurse can establish a nursing diagnosis based on the data gathered. The nursing diagnosis specifies the type of nursing care that will be provided to the patient.
3. Planning and results
In the third nursing process step, the health practitioner creates a care plan based on the nursing diagnosis. Measurable and goal-oriented planning is required.
4. Implementation
This is the stage of the nursing process in which the treatment plan is implemented. It occurs throughout the patient’s hospitalization until they are discharged.
5. Evaluation
The nursing process concludes with an evaluation of the care plan based on the initial targets and intended results. In situations where the results do not match, the care plan can be modified to meet the patient’s needs.
How to write a nursing diagnosis
To begin with, carefully examine the data and identify the patient’s health issues, risks, and strengths. After gathering all the relevant information, you can start writing nursing diagnosis statements. NANDA International strongly advises that diagnoses adhere to a specific template. This enables nurses and other healthcare team members to make accurate, concise, and legitimate diagnoses.
Certain information must be included in each type of nursing diagnosis. The outline for writing nursing diagnoses and examples are provided below.
• Problem-focused diagnosis
Impaired bed movement due to musculoskeletal impairment, as evidenced by an inability to reposition oneself in bed. Constipation is caused by poor toileting habits, as demonstrated by a change in bowel pattern.
• Risk diagnosis
Changes in heart rhythm indicate a risk of reduced cardiac output. Insufficient conformity to the incontinence treatment regimen illustrates adult pressure injury risk.
• Health promotion diagnosis
Inadequate motivation for physical activity indicates a sedentary lifestyle. Family health self-management is ineffective, as evidenced by difficulties adhering to the prescribed regimen.
• Syndrome diagnosis
This involves two types of syndromes: post-trauma syndrome and chronic pain syndrome.
Examples of nursing diagnosis
The following are the three main components of a nursing diagnosis:
- The issue in discussion and its definition
- Nursing diagnosis etiology
- Defining characteristics or risk factors
Examples of effective nursing diagnosis and treatment include the following:
“Ineffective breathing patterns associated with pulmonary hypoplasia, as evidenced by intermittent clavicular and anterior denials, tachypnea, abdomen respiration, and the need for continuous oxygen supply.”
Or
“Inadequate airway clearance attributable to gastroesophageal reflux, as evidenced by regurgitation, upper airway congestion, and continual coughing.”
How to write a Nanda nursing diagnosis
NANDA diagnoses enhance nurses’ understanding, clinical skills, and professional abilities. NANDA is a competent organization established in 1982 to conduct research, disseminate information, and revise nursing terminologies. North American Nursing Diagnosis Association was the abbreviation for NANDA. It was rebranded to NANDA International in 2002 due to the institution’s drastic growth in memberships worldwide.
According to NANDA International’s online platform, its mission is to:
- Make available the world’s leading evidence-based nursing diagnoses to be utilized in practice, as well as initiatives and outcomes.
- Improve patient safety by incorporating evidence-based terms into clinical practice and clinical decision-making.
- Contribute to research through the NANDA-I Foundation.
- Be a helpful and vibrant worldwide network of nurses dedicated to enhancing nursing care quality and patient safety through evidence-based practice.
NANDA members are located worldwide, including Brazil, Colombia, Ecuador, Mexico, Peru, Portugal, Germany, Austria, Switzerland, the Netherlands, Belgium, and Nigeria-Ghana.
The 4 types of nursing diagnoses
According to NANDA-I, there are four types of nursing diagnoses. They are as follows:
1. Problem-focused diagnosis
A problem-focused diagnosis is identified during a nursing evaluation of a patient. In most cases, the problem persists across several shifts or throughout a patient’s hospital treatment. Depending on the nursing and medical care, it can also be resolved during a shift.
Problem-focused diagnoses are comprised of three components:
- Nursing Assessment
- Linked Evaluation Factors
- Distinguishing Features
These are some examples of nursing diagnoses:
- Reduced heartbeat rates
- Chronic operational bloating
- Gas exchange impairment
Problem-focused nursing diagnosis and treatment are typically based on the patient’s clinical symptoms. They are the most prevalent and relatively easy-to-recognize nursing diagnoses.
2. Risk nursing diagnosis
A risk nursing diagnosis is given when risk factors necessitate involvement from the nurse and healthcare team before a real problem arises. These are some examples of nursing diagnoses related to risk nursing diagnosis:
- The danger of fluid volume imbalance
- The danger of ineffective childbirth operation
- The danger of impaired oral mucosa stability
Clinical rationale and nursing judgment are frequently required for this type of diagnosis.
3. Health promotion diagnosis
A health promotion nursing diagnosis aims to enhance an individual’s, family’s, or community’s nursing diagnosis. Common examples of this nursing diagnosis include the following:
- Prepared for enhanced family dynamics
- Prepared for enhanced hope
- Sedentary way of life
4. Syndrome diagnosis
A syndrome diagnosis is a group of nursing diagnoses that happen in a predictable pattern or can all be treated with the same or similar treatment plans. Here are some examples of this diagnosis:
- Reduced cardiac output
- Reduced cardiac tissue perfusion
- Inadequate cerebral tissue perfusion
- Poor peripheral tissue perfusion
Components of a nursing diagnosis
A nursing diagnosis consists of three major components:
1. Problem and its definition
The problem statement describes the patient’s current health condition and the nursing interventions required to care for the patient.
2. Etiology or risk factors
Etiology, or related aspects, describes the possible causes of the problem or the circumstances under which it emerged. These interconnected factors guide treatment strategies.
3. Defining features or risk factors
Finally, defining characteristics involve the signs and symptoms that enable a specific diagnostic brand to be applied. For risk nursing diagnosis, risk factors are used instead of identifying features. They relate to factors that make the patient more susceptible to health problems.
Writing nursing diagnosis statements
Problem-focused and risk diagnoses are the most complex nursing diagnoses to write. The proper nursing diagnosis format to follow for you to understand how to write a nursing diagnosis statement is as follows:
Examples of nursing diagnosis statements
- Problem-focused diagnosis
Problem-Focused diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics).
- Risk diagnosis
The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced by __________________________ (Risk Factors).
Nursing diagnosis classification
NANDA- I embraced Taxonomy II after due deliberation and partnership with the National Library of Medicine (NLM) regarding healthcare terminology codes. Domains, classes, and nursing diagnoses are the three levels of Taxonomy II.
At the moment, there are 13 domains and 47 classes:
Domain 1 – Promoting Health
- Health Awareness
- Healthcare Administration
Domain 2 – Nutrition
- Consumption
- Breakdown of food
- Permeation
- Biotransformation
- Fluid intake
Domain 3 – Elimination/Exchange
- Urinary System Operations
- Digestive Function
- Dermatological Function
- Breathing Function
Domain 4 – Activity/Rest
- Relax/Take Enough Sleep
- Regular Exercise/Fitness
- Energy Stabilization
- Cardiovascular-Pulmonary Reactions
- Self-Care
Domain 5 – Perception/Cognition
- Awareness
- Alignment
- Proprioceptive
- Cognitive processing
- Interaction
Domain 6 – Self-Perception
- Self-concept
- Self-awareness
- Physical appearance
Domain 7 – Role Relationship
- Responsibilities of Healthcare Practitioners
- Relationships with Family
- Achievement in their Role
Domain 8 – Sexuality
- Sexual Orientation
- Sexual Performance
- Conception
Domain 9 – Coping/Stress Tolerance
- Posttraumatic Reactions
- Learning to Cope Reaction
- Hippocampal Neurogenesis Anxiety
Domain 10 – Life Principles
- Morals
- Perceptions
- Value/Belief Activity Conformance
Domain 11 – Safety/Protection
- Infectious Disease
- Physiological Injury
- Crime
- Environmental Dangers
- Defensive Mechanisms
- Thermoregulatory Mechanisms
Domain 12 – Comfort
- Physical Soothe
- Environmental Pleasure
- Social Affability
Domain 13 – Growth/Development
- Advancement
- Progression
This streamlined Taxonomy is centered on Dr. Mary Joy Gordon’s Functional Health Patterns evaluation approach. The NLM also recommended changes because the Taxonomy I code structure included details about the diagnosis’s location and level.
NANDA-I nursing diagnoses and Taxonomy II diagnoses adhere to the International Standards Organization (ISO) terms and concepts model for a nursing diagnosis.
The terminology has also been registered with Health Level Seven International (HL7), an international data in healthcare guideline that enables nursing diagnoses to be recognized in specific electronic messages exchanged between clinical information systems.
Nursing diagnosis for care plans
This section contains a list of data systems of prevalent NANDA examples of nursing diagnosis that you can use to create nursing care plans.
- Activity Discomfort
- Acute Distress
- Nervousness
- Chronic Pain
- Bloating
- Reduced Cardiac Output
- Inadequate Fluid Volume
- Deficiency Awareness
- Diarrhea
- The abundance of Fluid Volume
- Exertion • Despair
- Peril for Falls
- The danger of Impaired Skin Decency
- Threat of Infection
- Risk of Injury or death
- Feeling depressed
- Desperation
- Desensitization
- Hypertension
- Unevenly distributed Diet: Lower than the average Body’s Needs
- Inadequate Gas Exchange
- Inhibited Tissue (Skin) Decency
- Impaired Urinary Eradication
- Unproductive Airway Clearance
- Inefficient Breathing Pattern
American Nursing Diagnosis vs International Nursing Diagnosis
There is no significant distinction between American and international Nursing Diagnoses for Care Plans. These two authorized nursing diagnoses are the same because NANDA-I is an international organization.
Disagreements regarding the syntax and nursing diagnosis formats altered by translation into another language may occur. Since NANDA-I offices are located worldwide, non-English nursing diagnoses are essentially the same.
Small afterword
Nursing diagnoses are a helpful tool that helps nurses provide safe, high-quality, evidence-based care. They are an essential component of patient care that every nurse should be able to utilize, develop, and write. Every detail in this article will help you improve your skills as a student and nurse.
At nursingessayexamples.com, we have the proper expertise to help you understand how to write a nursing diagnosis of unmatched quality. We can also help you complete your nursing diagnosis essay that guarantees top grades.
Also Read: How to write a nursing essay