Nursing Diagnosis: A Complete Guide for Students & Professionals

What is one of the most essential tools in a nurse’s toolkit?

If you answered a stethoscope or a blood pressure cuff, you’re right. But another important tool is the foundation of quality client care — the nursing diagnosis.

In this comprehensive guide, we’ll explore everything you need to know about nursing diagnoses, including their purpose, process, and how to write one effectively.

What is a Nursing Diagnosis?

A nursing diagnosis is a clinical judgment a nurse makes to identify client problems and their causes.

It serves as the basis for planning interventions and evaluating client outcomes.

Unlike medical diagnoses, which focus on identifying diseases, nursing diagnoses focus on:

• The client’s response to the illness
• The associated symptoms
• How the symptoms affect the client’s daily lives

For example, while a medical diagnosis might identify pneumonia, a nursing diagnosis might focus on the client’s ineffective airway clearance due to the disease. A nursing diagnosis allows nurses to create a nursing care plan (NCP) to guide how they care for the client.

NANDA International (NANDA-I) provides a comprehensive list of standardized nursing diagnoses to ensure consistency and accuracy globally. NANDA-I continuously updates its guidelines to reflect the latest in nursing knowledge, making it easier for nurses to deliver high-quality care.

The standards date back to the 1950s, and about 20 years later, NANDA-I held its first national conference to classify nursing diagnoses.

The organization continues to host these meetings to keep the definitions of diagnoses current. Nurses can also submit new diagnoses to the organization for review.

Purpose of Nursing Diagnosis

The primary purpose of nursing diagnosis is to provide a framework for identifying and addressing the client’s health needs to improve client outcomes.

It provides a holistic view of the client by considering physical, emotional, social, and environmental factors.

Here’s why nursing diagnoses matter:

1. Identification of client needs: Nursing diagnoses help nurses identify the most critical issues affecting a client’s health. By systematically assessing the client, nurses can determine the most pressing concerns, such as pain, risk of infection, or anxiety.

2. Early detection and intervention: Early identification of potential health problems allows for timely interventions, preventing complications and improving client outcomes. For example, identifying the risk for falls early on can lead to preventive measures that keep the client safe.

Guidance in developing care plans: Nursing diagnoses are integral in creating effective NCPs. They provide a clear framework for the interventions needed and the expected outcomes. This ensures that care is efficient and effective, meeting the client’s needs.

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Nursing Diagnosis within the Nursing Process

The nursing process is a systematic, client-centered method nurses use to ensure quality care.

It consists of five steps: assessment, diagnosis, planning, implementation, and evaluation (often referred to as ADPIE).

1. Assessment: Gather comprehensive information about the client’s physical, psychological, sociocultural, and spiritual needs.

2. Diagnosis: Use the data gathered during the assessment to identify the client’s problems.

3. Planning: Set measurable, achievable short- and long-term goals for the client, then identify appropriate nursing interventions.

4. Implementation: Carry out the planned interventions.

5. Evaluation: Assess the effectiveness of the interventions and adjust the care plan as necessary.

For example, a nurse might note a client experiencing shortness of breath during the assessment phase. Based on this assessment, the nurse might diagnose the client with an ineffective breathing pattern (IBP), a common nursing diagnosis.

This diagnosis will guide the care plan, which might include interventions such as oxygen therapy and teaching the client breathing exercises. The nurse will then evaluate the effectiveness of these interventions and adjust as needed to improve the client’s breathing pattern.

Nursing diagnoses are essential to the nursing process because they provide a framework for identifying and addressing the client’s needs. They also allow nurses to communicate effectively with other health care professionals, ensuring all team members work towards common goals.

Common Nursing Diagnoses

Below is a common nursing diagnosis list with brief descriptions of how nurses might apply diagnoses in different settings.

1. Acute pain: This diagnosis applies to clients experiencing pain that has a sudden onset, typically associated with injury, surgery, or a medical condition. Nurses assess the severity and cause of the pain and implement interventions such as administering pain medication or teaching relaxation techniques.

2. Impaired gas exchange: This diagnosis applies to clients with a decreased ability to oxygenate and eliminate carbon dioxide. Nurses monitor respiratory status, administer oxygen therapy as needed, and educate the client on breathing techniques.

3. Activity intolerance: An activity intolerance diagnosis applies to clients who have difficulty moving or performing activities of daily living independently. This may arise because of a medical condition or injury. Nurses assess the client’s level of mobility and implement interventions such as range-of-motion exercises, ambulation assistance, or assistive devices.

4. Ineffective airway clearance: This diagnosis applies to clients with an obstruction that hinders airflow in the respiratory tract. Nurses assess for signs and symptoms such as coughing, wheezing, or shortness of breath. They then implement interventions such as suctioning, deep breathing exercises, and chest physiotherapy.

5. Impaired skin integrity: This diagnosis is for clients with conditions that affect the skin, such as pressure ulcers, surgical wounds, or burns. Nurses would then focus on wound care, repositioning the client regularly, and using moisture barriers to protect the skin.

6. Anxiety: This diagnosis is for clients experiencing excessive worry, fear, or nervousness, often related to a medical condition or hospitalization. Interventions may include providing emotional support, teaching relaxation techniques, or referring the client to a counselor.

How to Write a Nursing Diagnosis

Writing a nursing diagnosis involves a systematic approach to ensure clarity and accuracy.

The PES format is widely used in nursing and stands for Problem, Etiology, and Symptoms.

• Problem (P): Give a problem statement, also known as the diagnostic label, articulating the client’s condition. It might include modifiers or qualifiers that provide additional information about the diagnosis. You’ll also have a focus that explains the diagnosis’ center point.

• Etiology (E): This refers to the cause or contributing factors of the problem. It’s linked to the problem using the phrase “related to.” For example, “related to immobility” or “related to surgical incision.”

• Symptoms (S): These are the signs and symptoms the nurse identified during the assessment, providing evidence for the nursing diagnosis. They’re linked to the etiology using the phrase “as evidenced by.” For example, “as evidenced by redness and swelling at the incision site” or “as evidenced by a pain rating of 8/10.”

Correctly written nursing diagnosis example:

• Acute pain related to a surgical incision as evidenced by a pain rating of 8/10 and guarding behavior.

Incorrectly written nursing diagnosis example:

• Pain due to surgery.

The incorrect example is vague and lacks the structure to create an effective care plan. It doesn’t follow the PES format or provide clear evidence to support the diagnosis.

NANDA-I Nursing Diagnosis: 4 Types

There are four main categories of nursing diagnoses.

1. Problem-Focused

A problem-focused diagnosis revolves around the symptoms and signs that the client presents with.

This category comprises the largest proportion of nursing diagnoses. The diagnosis in this situation aims to identify the client’s central problem.

The problem-focused diagnosis includes three main parts:

• The nursing diagnosis itself
• Any related factors
• Any defining characteristics

2. Risk

Nurses use risk nursing diagnoses to determine the interventions needed to prevent certain medical conditions or other problems from developing.

Nurses must use their training and experience to help them see the risks that will impact the client.

A risk nursing diagnosis will include:

• The nursing diagnosis
• Any risk factors

3. Health Promotion

A nurse uses this diagnosis to help improve the client’s health.

These diagnoses take a holistic look at the client treated and determine how interventions can help them improve their condition globally. These diagnoses help to promote self-care.

A health promotion diagnosis will include:

• The nursing diagnosis
• Any defining characteristics

However, a nurse can complete the health promotion diagnosis with just a diagnostic label.

4. Syndrome

A syndrome diagnosis looks for patterns or clusters of nursing diagnoses that all call for related interventions.

For example, a nurse might note that an older adult meets the requirements for frail elderly syndrome. This syndrome requires related interventions that are all targeted at helping the client improve their quality of life while remaining protected from common risks and ailments that come with advanced aging.

A syndrome diagnosis requires only the diagnostic label component.

6 Tips for Writing a Nursing Diagnosis

1. Use clear and specific terms to describe the PES.

2. Avoid using medical jargon or abbreviations.

3. Refer to evidence-based resources such as NANDA-I or your institution’s standardized nursing language.

4. Collaborate with the client to verify accuracy and gather additional information.

5. Continuously reassess and revise the nursing diagnosis as the client’s condition changes.

6. Seek guidance from experienced nurses or use tools such as concept maps or care plans to develop a comprehensive and individualized nursing diagnosis.

Nursing Diagnoses and Care Plans

Nursing diagnoses are the foundation upon which nurses build NCPs.

They provide the basis for:

• Setting goals
• Selecting interventions
• Evaluating outcomes

A well-formulated care plan ensures targeted, effective interventions and better health outcomes.

For example, if a nurse diagnoses a client with a “knowledge deficit” about administering medication, the care plan should include education on drug safety and correct administration techniques. By addressing this problem directly, the nurse can improve client understanding and decrease medication errors.

Effective nursing diagnoses also involve collaboration with clients. Clients often have valuable insight into their health and can provide information to help accurately identify problems.

By involving clients in the process, nurses promote autonomy and encourage active participation in their care. Additionally, collaborating with clients helps build trust between the nurse and client, leading to better communication.

Sample Care Plan Including Nursing Diagnoses

In this sample care plan, the nursing diagnosis of “risk for injury” directly addresses the identified problem and sets specific goals or interventions to decrease the risk of falls.

• Diagnosis: Risk for injury related to unsteady gait and decreased muscle strength secondary to Parkinson’s disease.
• Goals: Client will maintain safety during daily activities.
• Interventions:
  • Educate client on proper use of assistive devices, such as a walker or cane.
  • Ensure clear pathways and remove any potential tripping hazards in the home environment.
  • Assist client with transfers and ambulation as needed.
• Evaluation: After two weeks, the client has not experienced any falls or injuries, demonstrating improved safety during daily activities.

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Interventions Based on Nursing Diagnoses

Selecting appropriate interventions is critical to addressing the issues identified in the nursing diagnosis.

Tailor interventions to the client’s unique needs and circumstances. This will ensure the most effective and individualized care plan.

Interventions can include independent nursing and collaborative actions with other health care professionals.

For example, in the case of a client with diabetes who is at risk for infection due to poor wound healing, an independent intervention is educating the client on proper wound care and hygiene. A collaborative intervention could involve consulting with a wound care specialist or dietitian to develop a specialized diet plan to promote healing.

Nurses should also incorporate evidence-based practices and standards of care when selecting interventions, ensuring they’re rooted in current research and best practices. Here are more examples of interventions based on common nursing diagnoses.

Risk for surgical site infection

• Educate client and family on proper wound care techniques.
• Monitor the incision site and look for signs of infection, such as redness or drainage.

Impaired physical mobility

• Encourage regular range of motion exercises to maintain joint mobility.
• Collaborate with physical therapy to develop an exercise plan.

Deficient fluid volume

• Monitor fluid intake and output.
• Provide oral or IV fluids as prescribed.

Ineffective coping

• Encourage the client to express their concerns and feelings.
• Refer to counseling or support groups as needed.

Learn more about nursing interventions and what they are with SimpleNursing.

NANDA-I Nursing Diagnoses: Key Updates

Staying current with NANDA-I guidelines is essential for accurate nursing diagnosis and effective intervention selection.

Here are some key updates from the latest version of NANDA-I:

• Introduced 54 new diagnoses

• Revised 98 diagnoses

• Retired 46 diagnoses
  • Retired unilateral neglect (00123) due to a lack of research evidence to support diagnoses
  • Retired “constipation” and “diarrhea,” which are now defining characteristics in a new diagnosis — impaired intestinal elimination (00344)
  • Retired “decreased cardiac output” because it’s another name for a medical diagnosis instead of an independent nursing judgment
  • Insomnia and sleep are now diagnostic indicators of an ineffective sleep pattern (00337)

• Revised nursing diagnosis definitions, including those related to risk diagnoses

• Standardized terminology for diagnostic indicators — associated conditions, at-risk populations, defining characteristics, related factors, and risk factors — to provide clarity

• Updated nursing diagnosis labels that align with current literature and accurately represent human responses

Keep Learning with SimpleNursing

Nursing diagnoses are an essential tool for providing high-quality client care.

They help nurses identify and address the most pressing health issues, guide the development of care plans, and ultimately improve client outcomes. To continue learning about nursing diagnoses, interventions, and other important topics in nursing, check out SimpleNursing’s nursing school resources.

Our platform offers a range of materials, including video lectures, quizzes, and study tools to help you succeed.

Join SimpleNursing today to enhance your nursing knowledge and provide the best possible care for clients.