Student Resources: Nursing Diagnosis

How do nursing diagnoses fit in the nursing process and why are they so critical to safe, effective nursing care?

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A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and/or potential health problems or life processes. A medical diagnosis, on the other hand, is the identification of a disease based on its signs and symptoms.

The professional practice of nursing is the diagnosing and treatment of these basic human responses. Nurses need a common language to describe the human responses of individuals, families, and communities to health threats. NANDA strives to classify in a scientific manner these basic human responses.

Nursing diagnoses are based on assessment data and are classified under the concepts of ingestion, digestion, absorption, metabolism, urinary/gastrointestinal elimination, sleep/rest, activity/exercises, energy balance, sexuality, post trauma responses, comfort, and growth and development.

Identification of human responses to health problems and life processes is the basis for the nurses' decisions on how to best intervene to help people heal or improve their quality of life. With nursing diagnoses, emphasis is placed upon achievement of the client's maximum health potential. The nurse gathers the assessment data and from this data, identifies high-priority nursing diagnoses. The nursing diagnoses then provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

The patient (not the nurse) is central to the nursing process. The nursing process involves looking at the whole patient at all times. It personalizes the patient. Nursing care needs to be directed at all times for improving outcomes for the patient.

In order to tailor the nursing process to the patient, you need to identify the patient's problems related to the objective and subjective assessment data. Then you need to formulate a nursing diagnosis for each of these problems. You will also prioritize the problems in formulating your plan and goals (according to the ABC's and Maslow's Hierarchy of Needs).

Nursing diagnoses are written in "PES" format

  • "P" stands for problem
  • "E" stands for etiology or cause of problem
  • "S" stands signs and symptoms of problem

However, if you identify a high-priority "risk for" nursing diagnosis, then you do not put the signs and symptoms (in other words, no "aeb"). How can you have evidence (signs and symptoms) for something that is only a risk and not a manifested problem?

Nursing goals are simply the antithesis of the nursing diagnostic statement with a reasonable time frame. In other words, diagnostic statements are "problems" (negative). goals are "positive" (turn the nursing diagnostic statement around). If the nursing diagnosis is "Risk for Infection R/T..." for instance, then the goal statement might be "Client will not experience infection throughout hospital stay AEB clear lung sounds, afebrile, WBC count between 5,000 and 11,000, wound site well approximated with no purulent drainage." Goal statements always begin with "The patient/ client will..." and have a specified time element.

Nursing interventions are the "meat and gravy" of the nursing process and flow from the "etiology" part of the nursing diagnostic statement. Nursing interventions are either independent (such as teaching/learning or safety) or collaborative/ dependent (require a physician's order, such as administration of medications). The nurse must use his or her critical thinking skills to plan, coordinate, and implement nursing interventions, and then evaluate the effect of these interventions in achieving the desired patient goal. Nursing interventions always begin with "Student nurse will..." or "Nurse will..." and are very specific, as well as being realistic to the client situation (not just "cookie-cutter" interventions copied from a nursing care plan book).

Nursing interventions must be backed up with a scientific rationale - otherwise, this action is just your opinion and has no merit. Remember, everything in nursing must be evidenced-based. Provide a citation for your scientific rationale, in APA 6th Edition Format, from a peer-reviewed source: professional journal, textbook, lecture.

When evaluating your goals, you need to state specifically: goal met, goal not met, goal partially met, or unable to evaluate goal due to time constraints. If the latter is the case (unable to evaluate goal due to time constraints), then you need to state what outcome criteria would be needed in order to state goal met. In other words, if I were present (at specified time element), I would look for the following outcome criteria in order to state, "goal met." Then you list the desired outcome criteria. Remember, you are evaluating the goals, not the interventions.

So you see, it is an orderly, evidenced-based process and not that difficult with practice. Nurses cannot know what interventions to select or which outcomes to project unless they have accurate representations of what patients are experiencing (using a common reference language, NANDA).

References

NANDA Nursing Diagnoses

Nursing Diagnoses 2012 - 2014.pdf

Specializes in Staff Nurse LTC/ CALA.

I will be referring back to this again and again...thanks!

Hey guys im doing my first care plan (group presentation, 1 ns diagnosis per person) and have to come up with a nursing diagnosis for a young jewish mother of 2 toddlers who has been diagnosed with hyperthyroidism. This is what i came up withe for the diagnosis part:

activity intolerance r/t generalized weakness and fatigue aeb inability to perform daily physical activities.

i was wondering if the related factors have to be listed in the nanda book or not because i used fatigue as a realted factor although it is not listed. also id like to know if my aeb is too broad ? should i make it more specific such as "aeb patient verbalization of weakness/ exhaustion?" all help is appreciated ... please let me know anything else im missing my teacher did explain this very well!!

thank a lot.......very very useful.....

I need a nursing diagnosis for chronic renal failure

Specializes in Psychiatry.

Outstanding resource. Thanks so much. I can't stop hitting those links. Like Christmas.

Specializes in Critical Care, Emergency, Education, Informatics.

I'm an old fart and I remember when nursing DX first came about. I remember the we'll be able to bill for our own nursing servicves arguments.

One path that I've taken when trying to teach nursing dx, especially to people who already have predjudice against them, is that it's a way of thinking. It's a way to teach yourself an organized, systomatic way to approach your patient. When you start, it takes thought, but after you get experience, you learn to do it on the fly. IF YOU"VE LEANED THE CONCEPTS.

When a patient comes into the unit, it really doesn't matter what their medical dx is. The nursing care is directed by their problem. IT really doesn't matter that much in the first few minutes or hours even if your DIB pt has pneumonia, CHF, ,COPD or whatever. it's the hypoxia and the recognition that it's a pulmonary cause and not a cardiac or whatever. (overly sipmlistic example alert)

The question I have, is this, and it's a question, because I don't know. Is nursing DX one of those things that need to be changed. Either how it's normally taught, or the importance it's given?

Specializes in Gerontological, cardiac, med-surg, peds.

Nursing Diagnosis

Health Promotion

  • deficient diversional activity
  • sedentary lifestyle
  • deficient community health
  • risk-prone health behavior
  • ineffective health maintenance
  • readiness for enhanced immunization status
  • ineffective protection
  • ineffective self-health management
  • readiness for enhanced self-health management
  • ineffective family therapeutic regimen management

Nutrition

  • insufficient breast milk
  • ineffective infant feeding pattern
  • imbalanced nutrition: less than body requirements
  • imbalanced nutrition: more than body requirements
  • risk for imbalanced nutrition: more than body requirements
  • readiness for enhanced nutrition
  • impaired swallowing
  • risk for unstable blood glucose level
  • neonatal jaundice
  • risk for neonatal jaundice
  • risk for impaired liver function
  • risk for electrolyte imbalance
  • readiness for enhanced fluid balance
  • deficient fluid volume
  • excess fluid volume
  • risk for deficient fluid volume
  • risk for imbalanced fluid volume

Elimination and Exchange

  • functional urinary incontinence
  • overflow urinary incontinence
  • reflex urinary incontinence
  • stress urinary incontinence
  • urge urinary incontinence
  • risk for urge urinary incontinence
  • impaired urinary elimination
  • readiness for enhanced urinary elimination
  • urinary retention
  • constipation
  • perceived constipation
  • risk for constipation
  • diarrhea
  • dysfunctional gastrointestinal motility
  • risk for dysfunctional gastrointestinal motility
  • bowel incontinence
  • impaired gas exchange

Activity / Rest

  • insomnia
  • sleep deprivation
  • readiness for enhanced sleep
  • disturbed sleep pattern
  • risk for disuse syndrome
  • impaired bed mobility
  • impaired physical mobility
  • impaired wheelchair mobility
  • impaired transfer ability
  • impaired walking
  • disturbed energy field
  • fatigue
  • wandering
  • activity intolerance
  • risk for activity intolerance
  • ineffective breathing pattern
  • decreased cardiac output
  • risk for ineffective gastrointestinal perfusion
  • risk for ineffective renal perfusion
  • impaired spontaneous ventilation
  • ineffective peripheral tissue perfusion
  • risk for decreased cardiac tissue perfusion
  • risk for ineffective cerebral tissue perfusion
  • risk for ineffective peripheral tissue perfusion
  • dysfunctional ventilatory weaning response
  • impaired home maintenance
  • readiness for enhanced self-care
  • bathing self-care deficit
  • dressing self-care deficit
  • feeding self-care deficit
  • toileting self-care deficit
  • self-neglect

Perception / Cognition

  • unilateral neglect
  • impaired environmental interpretation syndrome
  • acute confusion
  • chronic confusion
  • risk for acute confusion
  • ineffective impulse control
  • deficient knowledge
  • readiness for enhanced knowledge
  • impaired memory
  • readiness for enhanced communication
  • impaired verbal communication

Self-Perception

  • hopelessness
  • risk for compromised human dignity
  • risk for loneliness
  • disturbed personal identity
  • risk for disturbed personal identity
  • readiness for enhanced self-control
  • chronic low self-esteem
  • risk for chronic low self-esteem
  • risk for situational low self-esteem
  • situational low self-esteem
  • disturbed body image
  • stress overload
  • risk for disorganized infant behavior
  • autonomic dysreflexia
  • risk for autonomic dysreflexia
  • disorganized infant behavior
  • readiness for enhanced organized infant behavior
  • decreased intracranial adaptive capacity

Role Relationships

  • ineffective breastfeeding
  • interrupted breastfeeding
  • readiness for enhanced breastfeeding
  • caregiver role strain
  • risk for caregiver role strain
  • impaired parenting
  • readiness for enhanced parenting
  • risk for impaired parenting
  • risk for impaired attachment
  • dysfunctional family processes
  • interrupted family processes
  • readiness for enhanced family processes
  • ineffective relationship
  • readiness for enhanced relationship
  • risk for ineffective relationship
  • parental role conflict
  • ineffective role performance
  • impaired social interaction

Sexuality

  • sexual dysfunction
  • ineffective sexuality pattern
  • ineffective childbearing process
  • readiness for enhanced childbearing process
  • risk for ineffective childbearing process
  • risk for disturbed maternal-fetal dyad

Coping / Stress Tolerance

  • post-trauma syndrome
  • risk for post-trauma syndrome
  • rape-trauma syndrome
  • relocation stress syndrome
  • risk for relocation stress syndrome
  • ineffective activity planning
  • risk for ineffective activity planning
  • anxiety
  • compromised family coping
  • defensive coping
  • disabled family coping
  • ineffective coping
  • ineffective community coping
  • readiness for enhanced coping
  • readiness for enhanced family coping
  • death anxiety
  • ineffective denial
  • adult failure to thrive
  • fear
  • grieving
  • complicated grieving
  • risk for complicated grieving
  • readiness for enhanced power
  • powerlessness
  • risk for powerlessness
  • impaired individual resilience
  • readiness for enhanced resilience
  • risk for compromised resilience
  • chronic sorrow
  • stress overload
  • risk for disorganized infant behavior
  • autonomic dysreflexia
  • risk for autonomic dysreflexia
  • disorganized infant behavior
  • readiness for enhanced organized infant behavior
  • decreased intracranial adaptive capacity

Life Principles

  • readiness for enhanced hope
  • readiness for enhanced spiritual well-being
  • readiness for enhanced decision-making
  • decisional conflict
  • moral distress
  • noncompliance
  • impaired religiosity
  • readiness for enhanced religiosity
  • risk for impaired religiosity
  • spiritual distress
  • risk for spiritual distress

Safety / Protection

  • risk for infection
  • ineffective airway clearance
  • risk for aspiration
  • risk for bleeding
  • impaired dentition
  • risk for dry eye
  • risk for falls
  • risk for injury
  • impaired oral mucous membrane
  • risk for perioperative positioning injury
  • risk for peripheral neurovascular dysfunction
  • risk for shock
  • impaired skin integrity
  • risk for impaired skin integrity
  • risk for sudden infant death syndrome
  • risk for suffocation
  • delayed surgical recovery
  • risk for thermal injury
  • impaired tissue integrity
  • risk for trauma
  • risk for vascular trauma
  • risk for other-directed violence
  • risk for self-directed violence
  • self-mutilation
  • risk for self-mutilation
  • risk for suicide
  • contamination
  • risk for contamination
  • risk for poisoning
  • risk for adverse reaction to iodinated contrast media
  • risk for allergy response
  • latex allergy response
  • risk for latex allergy response
  • risk for imbalanced body temperature
  • hyperthermia
  • hypothermia
  • ineffective thermoregulation

Comfort

  • impaired comfort
  • readiness for enhanced comfort
  • nausea
  • acute pain
  • chronic pain
  • impaired comfort
  • readiness for enhanced comfort
  • social isolation

NANDA

Nursing Diagnoses 2012 - 2014.pdf

Personally, I think we do students a great disservice to give them that list and no guidance as to how to use it. It's important for them to know that you can't just look at that list and pick something you think sounds about right for your patient. You must must must have assessment data that indicate your diagnosis was made in agreement with the real, scientifically-based defining characteristics and approved causes for each. These criteria cannot be found in "nursing care plan handbooks." They are found only in the NANDA-I 2012-014 (as of the time of this writing, the current edition), because NANDA-I understandably doesn't give blanket permission to reprint their entire work to every handbook author that comes down the pike. Not to any of them, actually. $29 at Amazon with free two-day delivery, or instant to your iPad or Kindle for $25.

How does one reconcile these 12 domains with Gordon's 11 functional health patterns? Some seem identical; though, I only just glanced.

Thanks for the great resource.

Specializes in MedSurg, Tele, ER, ICU, Float.

Thank you for being so thorough. Checking Amazon in this instant.

Specializes in Medical/Surgical/Telemetry RN.

Thank you for this! I really appreciate it. Nurses Rock!