In this ultimate tutorial and nursing diagnosis list, we’ll walk you through the concepts behind writing nursing diagnosis. Learn what a nursing diagnosis is, its history and evolution, the nursing process, the different types and classifications, and how to write nursing diagnoses correctly. Included also in this guide are tips on how you can formulate better nursing diagnoses, plus guides on how you can use them in creating your nursing care plans.
A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability to that response, by an individual, family, group, or community. A nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse has accountability. Nursing diagnoses are developed based on data obtained during the nursing assessment and enable the nurse to develop the care plan.
The purpose of the nursing diagnosis is as follows:
The term nursing diagnosis is associated with different concepts. It may refer to the distinct second step in the nursing process, diagnosis (“D” in “ADPIE“). Also, nursing diagnosis applies to the label when nurses assign meaning to collected data appropriately labeled a nursing diagnosis. For example, during the assessment, the nurse may recognize that the client feels anxious, fearful, and finds it difficult to sleep. Those problems are labeled with nursing diagnoses: respectively, Anxiety, Fear, and Disturbed Sleep Pattern. In this context, a nursing diagnosis is based upon the patient’s response to the medical condition. It is called a ‘nursing diagnosis’ because these are matters that hold a distinct and precise action associated with what nurses have the autonomy to take action about with a specific disease or condition. This includes anything that is a physical, mental, and spiritual type of response. Hence, a nursing diagnosis is focused on care.
On the other hand, a medical diagnosis is made by the physician or advanced health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat. Moreover, through experience and know-how, the specific and precise clinical entity that might be the possible cause of the illness will then be undertaken by the doctor, therefore, providing the proper medication that would cure the illness. Examples of medical diagnoses are Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. The medical diagnosis normally does not change. Nurses must follow the physician’s orders and carry out prescribed treatments and therapies.
Collaborative problems are potential problems that nurses manage using both independent and physician-prescribed interventions. These are problems or conditions that require both medical and nursing interventions, with the nursing aspect focused on monitoring the client’s condition and preventing the development of the potential complication.
As explained above, now it is easier to distinguish a nursing diagnosis from a medical diagnosis. Nursing diagnosis is directed towards the patient and their physiological and psychological response. On the other hand, a medical diagnosis is particular to the disease or medical condition. Its center is on the illness.
How are nursing diagnoses listed, arranged, or classified? In 2002, Taxonomy II was adopted, which was based on the Functional Health Patterns assessment framework of Dr. Mary Joy Gordon. Taxonomy II has three levels: Domains (13), Classes (47), and nursing diagnoses. Nursing diagnoses are no longer grouped by Gordon’s patterns but coded according to seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology. In addition, diagnoses are now listed alphabetically by their concept, not by the first word.
The five stages of the nursing process are assessment, diagnosing, planning, implementation, and evaluation. All steps in the nursing process require critical thinking by the nurse. Apart from understanding nursing diagnoses and their definitions, the nurse promotes awareness of defining characteristics and behaviors of the diagnoses, related factors to the selected nursing diagnoses, and the interventions suited for treating the diagnoses.
The steps, importance, purposes, and characteristics of the nursing process are discussed more in detail here: “The Nursing Process: A Comprehensive Guide“
The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome. Here are the four categories of nursing diagnoses:
A problem-focused diagnosis (also known as actual diagnosis) is a client problem present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms. Actual nursing diagnosis should not be viewed as more important than risk diagnoses. There are many instances where a risk diagnosis can be the diagnosis with the highest priority for a patient.
Problem-focused nursing diagnoses have three components: (1) nursing diagnosis, (2) related factors, and (3) defining characteristics. Examples of actual nursing diagnoses are:
The second type of nursing diagnosis is called risk nursing diagnosis. These are clinical judgments that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. A risk diagnosis is based on the patient’s current health status, past health history, and other risk factors that may increase the patient’s likelihood of experiencing a health problem. These are integral part of nursing care because they help to identify potential problems early on and allows the nurse to take steps to prevent or mitigate the risk.
There are no etiological factors (related factors) for risk diagnoses. The individual (or group) is more susceptible to developing the problem than others in the same or a similar situation because of risk factors. For example, an elderly client with diabetes and vertigo who has difficulty walking refuses to ask for assistance during ambulation may be appropriately diagnosed with risk for injury or risk for falls.
Components of a risk nursing diagnosis include (1) risk diagnostic label, and (2) risk factors. Examples of risk nursing diagnosis are:
Health promotion diagnosis (also known as wellness diagnosis) is a clinical judgment about motivation and desire to increase well-being. It is a statement that identifies the patient’s readiness for engaging in activities that promote health and well-being. For example, if a first-time mother shows interest on how to properly breastfeed her baby, a nurse make make a health promotion diagnosis of “Readiness for Enhanced Breastfeeding.” This nursing diagnosis will be then used to guide nursing interventions aimed at supporting the patient in learning about proper breastfeeding.
Additionally, health promotion diagnosis is concerned with the individual, family, or community transition from a specific level of wellness to a higher level of wellness. Components of a health promotion diagnosis generally include only the diagnostic label or a one-part statement. Examples of health promotion diagnosis:
A syndrome diagnosis is a clinical judgment concerning a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event. They, too, are written as a one-part statement requiring only the diagnostic label. Examples of a syndrome nursing diagnosis are:
A possible nursing diagnosis is not a type of diagnosis as are actual, risk, health promotion, and syndrome. Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem. It provides the nurse with the ability to communicate with other nurses that a diagnosis may be present but additional data collection is indicated to rule out or confirm the diagnosis. Examples include:
A nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis).
The problem statement, or the diagnostic label, describes the client’s health problem or response to which nursing therapy is given concisely. A diagnostic label usually has two parts: qualifier and focus of the diagnosis. Qualifiers (also called modifiers) are words that have been added to some diagnostic labels to give additional meaning, limit, or specify the diagnostic statement. Exempted in this rule are one-word nursing diagnoses (e.g., Anxiety, Constipation, Diarrhea, Nausea, etc.) where their qualifier and focus are inherent in the one term.
| Qualifier | Focus of the Diagnosis |
|---|---|
| Deficient | Fluid volume |
| Imbalanced | Nutrition: Less Than Body Requirements |
| Impaired | Gas Exchange |
| Ineffective | Tissue Perfusion |
| Risk for | Injury |
The etiology, or related factors, component of a nursing diagnosis label identifies one or more probable causes of the health problem, are the conditions involved in the development of the problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care. Nursing interventions should be aimed at etiological factors in order to remove the underlying cause of the nursing diagnosis. Etiology is linked with the problem statement with the phrase “related to” for example:
Risk factors are used instead of etiological factors for risk nursing diagnosis. Risk factors are forces that put an individual (or group) at an increased vulnerability to an unhealthy condition. Risk factors are written following the phrase “as evidenced by” in the diagnostic statement.
Defining characteristics are the clusters of signs and symptoms that indicate the presence of a particular diagnostic label. In actual nursing diagnosis, the defining characteristics are the identified signs and symptoms of the client. For risk nursing diagnosis, no signs and symptoms are present therefore the factors that cause the client to be more susceptible to the problem form the etiology of a risk nursing diagnosis. Defining characteristics are written following the phrase “as evidenced by” or “as manifested by” in the diagnostic statement.
There are three phases during the diagnostic process: (1) data analysis, (2) identification of the client’s health problems, health risks, and strengths, and (3) formulation of diagnostic statements.
Analysis of data involves comparing patient data against standards, clustering the cues, and identifying gaps and inconsistencies.
In this decision-making step, after data analysis, the nurse and the client identify problems that support tentative actual, risk, and possible diagnoses. It involves determining whether a problem is a nursing diagnosis, medical diagnosis, or a collaborative problem. Also, at this stage, the nurse and the client identify the client’s strengths, resources, and abilities to cope.
Formulation of diagnostic statements is the last step of the diagnostic process wherein the nurse creates diagnostic statements. The process is detailed below.
In writing nursing diagnostic statements, describe an individual’s health status and the factors that have contributed to the status. You do not need to include all types of diagnostic indicators. Writing diagnostic statements vary per type of nursing diagnosis (see below).
Another way of writing nursing diagnostic statements is by using the PES format, which stands for Problem (diagnostic label), Etiology (related factors), and Signs/Symptoms (defining characteristics). Diagnostic statements can be one-part, two-part, or three-part using the PES format.
Health promotion nursing diagnoses are usually written as one-part statements because related factors are always the same: motivated to achieve a higher level of wellness through related factors may be used to improve the chosen diagnosis. Syndrome diagnoses also have no related factors. Examples of one-part nursing diagnosis statements include:
Risk and possible nursing diagnoses have two-part statements: the first part is the diagnostic label and the second is the validation for a risk nursing diagnosis or the presence of risk factors. It’s not possible to have a third part for risk or possible diagnoses because signs and symptoms do not exist. Examples of two-part nursing diagnosis statements include:
An actual or problem-focus nursing diagnosis has three-part statements: diagnostic label, contributing factor (“related to”), and signs and symptoms (“as evidenced by” or “as manifested by”). The three-part nursing diagnosis statement is also called the PES format which includes the Problem, Etiology, and Signs and Symptoms. Example of three-part nursing diagnosis statements include:
Variations on Basic Statement Formats
Variations in writing nursing diagnosis statement formats include the following:
This section is the list or database of the common nursing diagnosis examples that you can use to develop your nursing care plans.
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
References for this Nursing Diagnosis guide and recommended resources to further your reading.
Matt Vera, a registered nurse since 2009, leverages his experiences as a former student struggling with complex nursing topics to help aspiring nurses as a full-time writer and editor for Nurseslabs, simplifying the learning process, breaking down complicated subjects, and finding innovative ways to assist students in reaching their full potential as future healthcare providers.
