You've done the assessment, clustered the cues, and picked the diagnosis type. Now the care plan template is waiting for the full statement, and the part after the diagnosis label is where the second-guessing starts.
Does a nursing diagnosis have to include the phrases "as evidenced by" or "related to"? How do you know which to use?
It depends on which of the 4 diagnosis types you’re writing:
- Problem-focused and syndrome diagnoses use both phrases.
- Risk diagnoses use only "related to."
- Health promotion diagnoses use only "as evidenced by."
Those phrases connect the components of a nursing diagnosis: the diagnosis label, the related or risk factors, and the defining characteristics. So if you know the components, you already know what goes where.
This guide provides the format for each type with examples, the steps for moving from assessment data to a finished statement, and what NANDA-I actually says belongs in the chart.
The PES format for problem-focused and syndrome diagnoses
Most nursing programs teach the PES format—problem, etiology, signs and symptoms: [diagnosis] related to [related factors] as evidenced by [defining characteristics].
For example: Excessive fluid volume related to excessive fluid intake, as evidenced by bilateral basilar crackles, bilateral 2+ pitting edema of the ankles and feet, a 10 lb weight gain, and the patient's report that "my ankles are so swollen."
A syndrome is a cluster of problem-focused diagnoses that occur together, so it takes the same 3 parts. The difference is that its defining characteristics are themselves nursing diagnoses.
For example: Decreased self-care ability syndrome related to prolonged inactivity and weakness, as evidenced by decreased bathing abilities and decreased dressing abilities.
Why risk nursing diagnoses don't use "as evidenced by"
Risk diagnoses are the one type that never uses “as evidenced by,” and this is often where common formatting mistakes in student care plans happen.
A risk diagnosis describes a susceptibility—something that hasn't happened yet. Because the problem hasn't occurred, there are no defining characteristics to observe, and nothing to put after "as evidenced by."
NANDA-I's format for a risk diagnosis is 2 parts and uses "related to": risk for [diagnosis] related to [risk factors].
For example: Risk for adult falls related to decreased lower extremity strength and fear of falling.
You might see "as evidenced by" used with risk diagnoses in some textbooks and course materials, but it isn't NANDA-I's current format.
Health promotion diagnoses drop the "related to"
Health promotion diagnoses invert the pattern. There's no etiology to name—the patient's readiness is the finding: readiness for [diagnosis] as evidenced by [defining characteristics].
For example: Readiness for enhanced health self-management as evidenced by expressed desire to learn more about the treatment plan.
Steps for writing your nursing diagnosis
Now, let's use the excessive fluid volume from the PES example above and take it through the steps of writing a diagnosis.
1. Analyze the data
Look for patterns in the subjective and objective data from the head-to-toe assessment. Say it turns up bilateral basilar crackles, 2+ pitting edema in both ankles and feet, and a 10 lb gain since the last recorded weight. The patient says, "My ankles are so swollen." Intake is well above output, and the patient describes drinking far more fluid than the care team recommended.
2. Develop a hypothesis
Crackles, edema, rapid weight gain, and intake exceeding output cluster as the defining characteristics of excessive fluid volume. Inadequate fluid volume would show the opposite pattern, so the data points one way.
3. Confirm the label and identify the related factors
Excess fluid volume is a current diagnosis in the 13th edition of the NANDA-I classification. Among its related factors, excessive fluid intake matches the intake history. The patient's chronic kidney disease is an associated condition, so it stays out of the "related to" slot.
4. Write and document
This is a problem-focused diagnosis, so the statement takes all 3 parts: Excessive fluid volume related to excessive fluid intake, as evidenced by bilateral basilar crackles, bilateral 2+ pitting edema of the ankles and feet, a 10 lb weight gain, and the patient's report that "my ankles are so swollen." In the chart, the label goes on the problem list, and the cues stay in the assessment.
Disclaimer: This example is hypothetical and provided for illustration only. It does not describe a real patient and is not a substitute for clinical judgment, facility documentation policies, or the edition of the NANDA-I classification your program or employer uses.
What goes in the chart
NANDA-I's own position is that the PES format is a teaching tool. In clinical practice, documenting the diagnosis label alone is often appropriate, as long as the related factors, risk factors, and defining characteristics appear elsewhere in the record—the assessment data, nursing notes, or plan of care.
Some electronic charting systems don't even include "related to" and "as evidenced by" fields. The full diagnosis statement builds the clinical reasoning; the chart needs the diagnosis label plus the supporting data.
You'll also see nursing diagnosis shortened to Nsg Dx in handoff notes, care plan templates, and study guides.
Write the statement, chart the label
The phrasing follows the diagnosis type. Problem-focused and syndrome diagnoses take all 3 parts of the PES format, risk diagnoses take "related to" and the risk factors, and health promotion diagnoses take "as evidenced by" and the defining characteristics.
The full diagnosis statement is a reasoning tool more than a documentation requirement. It forces you to tie the diagnosis label to the evidence behind it and to factors a nurse can act on, which is the thinking that holds up when an instructor or a charge nurse asks why.
In practice, the chart usually gets the diagnosis label alone, with the supporting data in the assessment and nursing notes.
Once the diagnosis is written, it becomes the starting point for the nursing care plan. Our guide to nursing care plans covers what comes next.
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