If you’re in nursing school you are probably familiar with term nursing diagnosis. It is something that, if it’s not already, will become a part of your nursing school journey to help you become a better nurse and eventually it will be second nature in your critical thinking. They can be a helpful tool to prioritize your care and set out a plan of actions for you to follow. Ready to find out more? Let’s get in to it!
What is a nursing diagnosis?
The North American Nursing Diagnosis Association International (NANDA-I) has created an official definition for a nursing diagnosis.
Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
Nursing diagnoses help to guide and prioritize your care as well as promote the health and safety of your patients.
4 Types of Nursing Diagnoses
- Problem-focused. (most common) Something found during a nursing assessment and can last the entire stay at facility or a single shift. Examples: decreased cardiac output, activity intolerance, impaired skin integrity
- Risk. Identifies areas for prevention of a problem through nursing interventions. Examples: risk for falls, risk for infection, risk for injury.
- Health Promotion. Improving the overall well-being of the patient or community. Examples: readiness for enhanced nutrition, readiness for smoking cessation, health-seeking behaviors.
- Syndrome. A cluster of nursing diagnoses that can be resolved with the same or similar nursing interventions.
What makes up a nursing diagnosis?
There are 3 parts to a nursing diagnosis:
The problem related to the cause as evidenced by the defining subjective (direct patient quotes) and objective (your observations) characteristics
An example of a problem-focused diagnosis:
Ineffective airway clearance related to increased sputum production as evidenced by subjective: “This stuff is so thick I can barely cough it up.” objective: thick, yellow sputum, rhonchi auscultated over bilateral lower lobes, and tachypnea.
An example of a risk diagnosis:
Risk for falls as evidenced by subjective: “I feel like I’m going to lose my balance when I stand up from my chair.” objective: mechanical fall on 12/2/20 per chart, patient has unsteady gait when ambulating.
So how do you write a diagnosis?
- Stick to basics. Refer back to your patient’s medical diagnosis. Are there in the hospital with pneumonia? Pick a diagnosis related to the respiratory system. Do they have skin breakdown? Use an integumentary system diagnosis. Remember! Simple can be better.
- At Risk versus Has. Keypoint: if your patient has a skin ulcer and you want to write about it, do not use an “at risk for” diagnosis because they clearly already have the issue. “At risk for” diagnoses are used when you want to prevent something from occurring, not from getting worse.
- Details, details, details. Collect as much information as you can to support your diagnosis. Use direct quotes from your patient whenever possible and include your personal observations as well as the data from their charts. The more details you have the better your diagnosis is.
- Relevant? Does it actually pertain to your patient? You’d be surprised the number of times where I someone put a nursing diagnosis thinking it meant one thing and related to their patient when in reality it really means something else and isn’t actually relevant at all (ex. activity intolerance). Make sure you read the definition of the diagnosis in your school recommended care plan book to ensure you’re fully understanding the diagnosis. You don’t want to mislabel your patient!
- Is it something you can help with? This one can be tricky. Some of the psychosocial diagnosis can be hard to try and help with, especially given that you’re not with your patient more than a shift sometimes. If it’s something that you are able to help change in a shift by all means go for it but you’d have better luck sticking with something pertaining to the rest of the person.
Did you find this list helpful? If so, leave me a comment below! We can chat all about nursing diagnosis. Need help with yours? Send me an e-mail at the link in the sidebar. Good luck!
