What Is a Nursing Diagnosis?

- rain

Nursing Diagnosis:
A clinical judgment concerning a human response to health conditions/life processes, or a
susceptibility to that response, by an individual, caregiver, family, group, or community. A
nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes
for which the nurse has accountability
Observable cues/inferences that cluster as manifestations of a problem-focused, health
promotion diagnosis or syndrome. This implies not only those things that the nurse can see, but
also things that are seen, heard (e.g., the patient/family tells us), touched, or smelled.

Each nursing diagnosis has a label and a clear definition. It is important to state that merely
having a label or picking from a list of labels is insufficient. It is critical that nurses know the
definitions of the diagnoses they most commonly use.

– Problem-focused diagnosis – a clinical judgment concerning an undesirable human response

to a health condition/life process that exists in an
individual, caregiver, family, group, or community
– Risk diagnosis – a clinical judgment concerning the susceptibility of an
individual, caregiver, family, group, or community for developing an
undesirable human response to health conditions/life processes
– Health promotion diagnosis – a clinical judgment concerning motivation
and desire to increase well-being and to actualize health potential. These responses are
expressed by a readiness to enhance specific health behav- iors, and can be used in any health
state. In cases where individuals are unable to express their own readiness to enhance health
behaviors, the nurse may determine that a condition for health promotion exists and then act on
the client’s behalf. Health promotion responses may exist in an individual, caregiver, family,
group, or community.

reference: NURSING
DIAGNOSES
Definitions and Classification
2021–2023
Twelfth Edition

• Purpose of a Nursing Diagnosis- tangub / silao

Diagnosis is formed by the nurse and is based on the data collected during the assessment. The
nursing diagnosis directs nursing-specific patient care.

In this step, the nurse forms a diagnosis based on the patient’s specific medical and/or social
needs. The diagnosis leads to the creation of goals with measurable outcomes.

The diagnosis must be one that has been approved by NANDA International (NANDA-I),
formerly known as North American Nursing Diagnosis Association. NANDA-I is responsible for
developing and standardizing nursing diagnoses. Used internationally, the NANDA-I vision and
mission is to use evidence-based, universal nursing terminology to promote safe patient care.

NANDA-I defines a nursing diagnosis as follows:

● “a clinical judgment concerning a human response to health conditions/life processes, or

a vulnerability for that response, by an individual, family, group or community. A nursing
diagnosis provides the basis for selection of nursing interventions to achieve outcomes
for which the nurse has accountability.”
● A nursing diagnosis generally has three components: a diagnosis approved by NANDA-I,
a related to statement which defines the cause of the NANDA-I diagnosis, and an as
 evidenced by statement that uses specific patient data to provide a reason for the
NANDA-I diagnosis and related to statement.
● Risk-related diagnoses only contain a NANDA-I diagnosis and as evidenced by the
statement because it is describing a vulnerability, not a cause. For example, a nurse may
use a nursing diagnosis such as “risk for pressure ulcer as evidenced by lack of
movement, poor nutrition, and hydration.”

Reference: Nursing Diagnosis Guide | NurseJournal.org. (n.d.).

https://nursejournal.org/resources/nursing-diagnosis-guide/

● A "nursing diagnosis" is a vital part of the nursing process that plays a significant
role in ensuring quality patient care.
● A nursing diagnosis requires an accurate assessment and contributes to the
effective treatment of a patient, as addressed from the unique perspective of the
discipline of nursing.
● Nursing diagnoses essentially provide a comprehensive framework for
identifying and documenting the clinical judgments that nurses make. These
judgments are based on the nurse’s expertise and education, offering a unique
vantage point that distinguishes them from other healthcare professionals.

But the significance of nursing diagnoses extends beyond direct patient care – it also
ensures that the nursing profession remains indispensable within the healthcare
landscape!

Nursing diagnoses offer the means necessary for illustrating this distinct value. By
accurately documenting their judgments, nurses contribute essential insights into the
overall picture of a patient’s health, creating a holistic understanding for all members
involved in patient care.

In this way, nursing diagnoses are not only essential for patient care, but also serve as a
means of establishing the irreplaceable role of the nursing profession.That’s why
nursing diagnoses remain vitally important.

Reference: Herdman, T. H., & Herdman, T. H. (2023, June 5). Why are Nursing Diagnoses
Still Important? | NANDA International, Inc. NANDA International, Inc
• What is a nursing process?-raah& tan

In 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined
as a systematic approach to care using the fundamental principles of critical thinking, problem
solving and client-centered approaches to treatment, goal-oriented tasks, evidence-based practice
(EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated
to provide the basis for compassionate, quality-based care.
The nursing process functions as a systematic guide to client-centered care with 5 sequential
steps. It is summarized in the acronym ADPIE. These are assessment, diagnosis, planning,
implementation, and evaluation.
Assessment
Assessment is the first step and involves critical thinking skills and data collection; subjective
and objective. Subjective data involves verbal statements from the patient or caregiver. Objective
data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Diagnosis
The formulation of a nursing diagnosis by employing clinical judgment assists in the planning
and implementation of patient care.
The North American Nursing Diagnosis Association (NANDA) provides nurses with an
up-to-date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a
clinical judgment about responses to actual or potential health problems on the part of the
patient, family, or community.
A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and plan
care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy
based on basic fundamental needs innate to all individuals. Basic physiological needs/goals must
be met before higher needs/goals can be achieved such as self-esteem and self-actualization.
Physiological and safety needs provide the basis for the implementation of nursing care and
nursing interventions. Thus, they are at the base of Maslow's pyramid, laying the foundation for
physical and emotional health.[4][5]
Maslow's Hierarchy of Needs

● Basic Physiological Needs: Nutrition (water and food), elimination (Toileting), airway
(suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs),
sleep, sex, shelter, and exercise.
● Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation,
suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of
trust and safety (therapeutic relationship), patient education (modifiable risk factors for
stroke, heart disease).
● Love and Belonging: Foster supportive relationships, methods to avoid social isolation
(bullying), employ active listening techniques, therapeutic communication, and sexual
intimacy.
● Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of
control or empowerment, accepting one's physical appearance or body habitus.
● Self-Actualization: Empowering environment, spiritual growth, ability to recognize the
point of view of others, reaching one's maximum potential.

Planning
The planning stage is where goals and outcomes are formulated that directly impact patient care
based on EDP guidelines. These patient-specific goals and the attainment of such assist in
ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care
plans provide a course of direction for personalized care tailored to an individual's unique needs.
Overall condition and comorbid conditions play a role in the construction of a care plan. Care
plans enhance communication, documentation, reimbursement, and continuity of care across the
healthcare continuum.

1. The planning stage is where goals and outcomes are formulated that directly impact
patient care based on EDP guidelines. These patient-specific goals and the attainment of
such assist in ensuring a positive outcome. Nursing care plans are essential in this phase
of goal setting. Care plans provide a course of direction for personalized care tailored to
an individual's unique needs. Overall condition and comorbid conditions play a role in
the construction of a care plan. Care plans enhance communication, documentation,
reimbursement, and continuity of care across the healthcare continuum.
2.

Implementation
Implementation is the step that involves action or doing and the actual carrying out of nursing
interventions outlined in the plan of care. This phase requires nursing interventions such as
applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard
treatment protocols, and EDP standards.
Evaluation
This final step of the nursing process is vital to a positive patient outcome. Whenever a
healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the
desired outcome has been met. Reassessment may frequently be needed depending upon overall
patient condition. The plan of care may be adapted based on new assessment data.
Toney-Butler, T. J., & Thayer, J. M. (2023, April 10). Nursing process. StatPearls - NCBI

Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK499937/

• NANDA Diagnosis -sepaya/ rivera

A Clinical judgment concerning a human response to health conditions/life processes, or a

vulnerability for that response, by an individual, family, group or community.“

The NANDA nursing diagnosis enables nurses to determine an appropriate plan of care for their
patients. Nurses write nursing diagnoses based on their assessment of the patient. NANDA
International standardized nursing terminology, specifically nursing diagnoses. Nurses use
collected patient data to formulate nursing diagnoses or determine health problems better
managed by physicians (medical diagnoses) or collectively with other health care professionals
(collaborative problems). A nursing diagnosis refers to the process and, subsequently, the label
nurses use to assign meaning to patient data collected in the Assessment phase. The data is
labeled with NANDA-I approved nursing diagnosis.

Ref: picmonic.com

NANDA nursing diagnoses are categorized into several domains, including physiological,
psychosocial, and environmental factors. Examples of NANDA nursing diagnoses include
"Impaired Gas Exchange," "Acute Pain," "Ineffective Coping," and "Risk for Falls," among many
others.
• Types of Nursing Diagnoses-Paesaje/ Parrenas

4 Types of Nursing Diagnoses

1. Problem-Focused Nursing Diagnosis
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. Problem-focused nursing diagnoses have three components: (1) nursing
diagnosis, (2) related factors, and (3) defining characteristics.
Examples of actual nursing diagnoses are:
● Anxiety related to stress as evidenced by increased tension, apprehension, and
expression of concern regarding upcoming surgery.
● Acute pain related to decreased myocardial flow as evidenced by grimacing,
expression of pain, guarding behavior.

2. Health-Promotion Nursing Diagnosis

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. This motivation may
exist in individuals, families, groups, or communities and applies to any health state. Nurses can
make this type of diagnosis when patients express a desire to enhance their health.
Components of a health promotion diagnosis generally include only the diagnostic label or a
one-part statement.

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.”

3. 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 an 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. Components of a risk nursing diagnosis include (1) risk
diagnostic label, and (2) risk factors.
Examples of risk nursing diagnosis are:
● Risk for injury
● Risk for infection

4. Syndrome 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. Nurses can make this type of
diagnosis when two or more nursing diagnoses are present as defining characteristics. Although
not required, nurses may also use related factors to clarify the definition.
Example of a syndrome nursing diagnosis is:
 ● Chronic Pain Syndrome

References:
● Ighani, L. (2024, April 9). Understanding the NANDA Nursing Diagnosis List with

Examples. Find Nursing Jobs Near You | Nursa.

https://nursa.com/blog/nanda-nursing-diagnosis-list-examples

● Bsn, M. V., RN. (2024, March 4). Nursing Diagnosis Guide: All you need to know

to Master Diagnosing. Nurseslabs.

https://nurseslabs.com/nursing-diagnosis/?fbclid=IwAR2fOv2Hf7IlLdAZXjAebdRv

izpP1GvdR7gH3VkaVH4kwIMLCmCbbVK2Snw#h-types-of-nursing-diagnoses

• Nursing Diagnosis Components-Panes/siccio

Components of a Nursing Diagnosis

A nursing diagnosis typically has three components:
(1) the problem and its definition
(2) the etiology, and
(3) the defining characteristics or risk factors (for risk diagnosis).

Problem and Definition

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

Etiology
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:

-Activity intolerance is related to generalized weakness.

-Decreased cardiac output related to abnormality in blood profile
-Impaired urinary elimination related to enlarged prostate gland
-Impaired skin integrity related to prolonged pressure on bony prominences.
-Susceptible to damage to vein and its surrounding tissues related to the
presence of a catheter.
-Impaired physical mobility related to fractured femur
-Impaired gas exchange related to chronic obstructive pulmonary disease.
-Susceptible to damage to vein and its surrounding tissues related to the
presence of a catheter and/or infused solutions, which may compromise health.

Defining Characteristics

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.

Risk Factors
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.

-Risk for falls as evidenced by old age and use of walkers.

-Risk for infection as evidenced by break in skin integrity.
-Risk for imbalanced nutrition as evidenced by poor appetite.
-Risk for aspiration related to dysphagia as evidenced by difficulty swallowing.
-Risk for deficient fluid volume as evidenced by fluid loss through abnormal route.
-Risk for ineffective breathing pattern as evidenced by productive cough.
-Risk for ingestion as evidenced by being overweight.
-Chronic confusion manifested by impairment in cognitive functions
-Risk for infection as evidenced by inadequate vaccination and immunosuppression.

REFERENCES:

Bsn, M. V., RN. (2024, March 4). Nursing Diagnosis Guide: All you need to know to Master
Diagnosing. Nurseslabs.

Examples. Find Nursing Jobs Near You | Nursa.

https://nursa.com/blog/nanda-nursing-diagnosis-list-examples

Bsn, M. V., RN. (2024b, March 4). Nursing Diagnosis Guide: All you need to know to

Master Diagnosing. Nurseslabs. https://nurseslabs.com/nursing-diagnosis/

Nursing CE Central. (2022b, June 3). Nursing Diagnosis: A complete guide for nurses.

https://nursingcecentral.com/nursing-diagnosis-a-complete-guide-for-nurses/
• Classification of Nursing Diagnoses (Discuss each classification)- opeña/ palencia

Nursing diagnoses are classified into four main categories according to the North American
Nursing Diagnosis Association International (NANDA-I).
These categories help nurses identify and address actual or potential health problems that fall
within their scope of practice.

➢ Problem-Focused Nursing Diagnoses- These diagnoses identify current health

problems that a patient is experiencing. They are based on signs and symptoms
collected during the nursing assessment.
● The nursing diagnosis: This is the specific health problem the patient is experiencing,
like deficient fluid volume or impaired skin integrity.
● Related factors (etiology): These are the factors contributing to the problem, such as
excessive vomiting and diarrhea for deficient fluid volume.
● Defining characteristics: These are the signs and symptoms that support the nursing
diagnosis, like dry mucous membranes, poor skin turgor, and decreased urine output for
deficient fluid volume.

Example: Deficient fluid volume related to excessive vomiting and diarrhea evidenced by dry
mucous membranes, poor skin turgor, and decreased urine output.

➢ Risk Diagnoses- These diagnoses identify a patient's vulnerability to developing a

future health problem. They are based on risk factors identified during the assessment.
● The risk for + nursing diagnosis: This identifies the specific health problem the patient
is at risk for developing, like risk for impaired skin integrity.
● Related factors: These are the factors that increase the patient's risk, such as
immobility and decreased sensation for risk for impaired skin integrity.

Example: Risk for impaired skin integrity related to immobility and decreased sensation.

➢ Health Promotion Diagnosis-These diagnoses identify a patient's potential for

improving their health and well-being. They are used to identify opportunities for
preventive care and health education.
● Health promotion + desired outcome: This identifies the area where the patient
has the potential for improvement, like health promotion: readiness for enhanced
nutritional intake.

Example: Health promotion: readiness for enhanced nutritional intake.

➢ Syndrome Diagnoses- These diagnoses are a cluster of signs and symptoms that
occur together. They describe a complex health problem that may have multiple
contributing factors.
● The syndrome diagnosis: This identifies the specific cluster of signs and symptoms,
like impaired gas exchange.
● Related factors (etiology): These are the factors contributing to the syndrome.
● Defining characteristics: These are the signs and symptoms that support the
syndrome diagnosis.

Example: Impaired gas exchange related to pneumonia evidenced by dyspnea, tachypnea, and
hypoxia.

REFERENCE: https://gemini.google.com/u/2/app/4436658414ed110a
• Nursing Diagnosis vs Medical Diagnosis -salvilla/mosqueda

Medical Diagnosis:

Medical diagnosis identifies a specific illness or medical condition based on the patient's
symptoms, medical history, and the results of medical tests and treatments. This procedure is
carried out by medical physicians, including general practitioners, specialists like cardiologists
and dermatologists, and other healthcare providers who
have the authority to diagnose ailments. The primary goal of medical diagnosis is to determine
the underlying cause and nature of a patient's health problem. The process
helps categorize the sickness or condition using existing medical knowledge and criteria.

Examples: such as respiratory infections, Type 2 diabetes, hypertension, appendicitis, and

breast cancer require medical attention.

Nursing diagnosis:

A nursing diagnosis is a clinical assessment conducted by registered nurses (RNs) and

advanced practice nurses, such as nurse practitioners and clinical nurse specialists, to
understand how a patient reacts to current or potential health problems. This assessment
considers the patient's psychological, social, physical, and environmental aspects. The primary
goal of a nursing diagnosis is to identify the patient's existing or probable health issues and their
impact on well-being. Through a comprehensive examination, nurses use their expertise to
develop nursing diagnoses, which guide them in creating effective nursing care plans and
actions. These efforts aim to improve patient health and meet

Examples: Nursing diagnoses include poor mobility, inefficient coping, fall risk, and impaired
cognition. These diagnoses are based on the patient's reaction to the sickness or condition and
dictate nurse actions and care.

In Comparison
A nursing diagnosis made by a nurse primarily aims to provide care to the patient, such as
evaluating a patient's heartbeat. In contrast, a medical diagnosis made by a doctor seeks to
identify the patient's medical condition. The process of medical diagnosis focuses on identifying
the presence of a disease or condition, whereas nursing diagnosis analyzes the patient's
response to health concerns to create appropriate care plans. Both are essential in delivering
comprehensive healthcare, necessitating collaboration between physicians and nurses to
ensure holistic patient care. The key distinction lies in medical diagnoses pinpointing the
pathology of diseases or illnesses, whereas nursing diagnoses concentrate on the patient's
physiological and psychological responses.

References:

Semwal , Dr. T. J. (2023, July 14). The difference between nursing and medical diagnosis.
SemwalDiagnostics.
https://www.semwaldiagnostics.com/the-difference-between-nursing-and-medical-diagnosi
s/

Charlotte, B., Smith, S., Carlie, A., Steve, G., Hunter, D., Richards, H., Powell, P., Dennis,
P., Richardson, J., Jim, C., Jackson, B., & James, R. (2023, June 20). Nursing vs medical
diagnosis: Difference and comparison. Ask Any Difference.
https://askanydifference.com/difference-between-nursing-diagnosis-and-medical-diagnosi
s/

Yadav, P. (2022, July 15). Nursing diagnosis vs medical diagnosis. NurseStudy.Net.

https://nursestudy.net/nursing-diagnosis-vs-medical-diagnosis/