The information for this article was primarily sourced from NANDA International, Inc., an authority on standardized nursing diagnostic terminology, and the American Nurses Association, an organization whose mission is shaping the future of nursing and healthcare.
What Is a Nursing Diagnosis?
A nursing diagnosis is an essential step of the nursing process and is crucial to ensure quality of care. Nurses initiate the nursing diagnosis, which describes a response to the medical diagnosis.
According to the North American Nursing Diagnosis Association (NANDA), a nursing diagnosis is:
“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 selecting nursing interventions to achieve outcomes for which the nurse has accountability.”
What Are Some of the Most Common Nursing Diagnoses?
A few of the more common nursing diagnoses include the following:
- Impaired gas exchange
- Acute pain
- Risk for infection
- Ineffective airway clearance
- Activity intolerance
- Acute confusion
- Anxiety
- Chronic pain
- Impaired skin integrity
- Decreased cardiac output
- Diarrhea
- Ineffective breathing pattern
What Is a Medical Diagnosis?
A healthcare provider creates a medical diagnosis after assessing the signs and symptoms present and then identifies a condition, injury, or disease.
To create a nursing diagnosis, a medical diagnosis must first be present. Keep reading to learn more about nursing practice, a nursing diagnosis, and how to write or create one.
What Is the Nursing Process?
Regardless of a nurse’s work setting, their role revolves around implementing the five steps of the nursing process:
- Assessment: The first step of the nursing process is collecting and analyzing patient data, including physiological, psychological, sociocultural, lifestyle, economic, and spiritual information. Read more about the complete head-to-toe nursing assessment.
- Diagnosis: The next step of the process is making a diagnosis based on a clinical judgment of the patient’s medical condition. This diagnosis becomes the basis of the nursing care plan.
- Outcomes/Planning: Based on the previous steps, nurses set goals for the patient and include them in the treatment plan in order to achieve the desired outcome.
- Implementation: In this step, nurses implement and document nursing interventions according to the care plan. This may include administering medications, educating the patient, monitoring vital signs, etc.
- Evaluation: Throughout the nursing process, nurses evaluate the patient’s status and the impact of the care they provide, which can lead to modifications in the care plan.
Nursing vs. Medical Diagnoses: What’s the Difference?
The most evident difference between a medical and a nursing diagnosis is the healthcare professional who makes the diagnosis. Whereas physicians, physician’s assistants (PAs), and advanced nurse practitioners (ANPs) make medical diagnoses—registered nurses (RNs) are responsible for nursing diagnoses. They also educate patients on these diagnoses.
However, the healthcare provider’s credentials are not the only distinction. Medical diagnoses focus on diseases or other medical problems; nursing diagnoses deal with the human response to health conditions and life processes.
The nursing diagnosis contemplates the level of pain a patient reports, whether they are experiencing mental health conditions as a result of their physical illness, their attitudes, challenges, resources, etc. Therefore, two patients with the same medical diagnosis, such as pneumonia, diabetes, or hypertension, can have different nursing diagnoses.
For example, the nursing diagnosis of a patient with chronic obstructive pulmonary disease (COPD) may address the patient’s feelings of depression, hopelessness, and pessimism, commonly observed behaviors among patients with this disease.
Which Are the 7 Diagnostic Axes?
In a nursing diagnosis, the axes are the dimensions of the human response that nurses must consider. NANDA identifies seven axes in line with the International Standards Reference Model for a Nursing Diagnosis.
Axis 1: The Diagnostic Focus
This axis describes the human response at the center of the nursing diagnosis; it is the root of the diagnostic concept. The diagnostic focus may consist of one or more words, such as “nausea,” “activity intolerance,” or “spiritual distress.”
Axis 2: Subject of the Diagnosis
The subject of the diagnosis refers to the person or persons the diagnosis is for. The subject may be any of the following:
- Individual: A single human being
- Caregiver: A family member or helper who provides regular care for a child or a sick, elderly, or disabled person
- Family: Two or more people related by blood or choice who have sustained relationships, perceive reciprocal obligations, sense common meaning, and share certain obligations toward others
- Group: Several people with shared characteristics
- Community: A group of people living in the same location under the same governance, such as the same neighborhood or city
Axis 3: Judgment
A nurse’s judgment is a descriptor or modifier—such as impaired or ineffective—that limits or specifies the meaning of the diagnostic focus. The diagnostic focus and the nurse’s judgment about it form the nursing diagnosis.
Axis 4: Location
The location of the diagnosis refers to the parts of the body or their related functions: tissues, organs, anatomical sites, or structures. Examples include bladder, auditory, cerebral, etc.
Axis 5: Age
This axis refers to the age of the subject of the diagnosis:
- Fetus: An unborn human from eight weeks after conception until birth
- Neonate: A child under 28 days of age
- Infant: A child over 28 days and under one year of age
- Child: A person aged one to nine years (inclusive)
- Adolescent: A person aged 10 to 19 years (inclusive)
- Adult: A person over 19 years of age (unless national law defines a person as being an adult at an earlier age)
- Older adult: A person over 65 years of age
Axis 6: Time
This axis describes the duration of the diagnostic concept (Axis 1). Nurses can describe time with the following terms:
- Acute: Lasting less than three months
- Chronic: Lasting more than three months
- Intermittent: Occurring at intervals, periodic, cyclic
- Continuous: Uninterrupted
Axis 7: Status of the Diagnosis
The diagnosis status can also be called the categorization or type of nursing diagnosis: problem-focused, health promotion, risk, or syndrome.
Nurses may name the axes implicitly or explicitly. For example, in the diagnosis “compromised family coping,” the nurse explicitly identifies the subject and judgment. On the contrary, in an “activity intolerance” diagnosis, the subject is implied to be an individual patient. Furthermore, in other cases, an axis may not be relevant and, therefore, not mentioned either implicitly or explicitly.
As mentioned, the nursing diagnosis requires the diagnostic focus and the nurse’s judgment. On occasions, the diagnostic focus may contain the judgment, such as in a diagnosis of nausea. In this case, the judgment is implicit and, therefore, not explicitly stated in the label. Nurses may include the other axes when they are relevant to or clarify the nursing diagnosis.
4 Types of Nursing Diagnoses
The type of diagnosis a nurse can reach depends on several factors. Is the patient experiencing the effects of a medical condition, or are they at risk of developing a disease or other undesirable human response? Is the patient experiencing one cluster of related symptoms, or is the condition more complex? How involved does the patient want to be in their treatment and care plan? These factors converge to determine the type of nursing diagnosis registered nurses can reach in order to maintain optimal health status. Neglecting the nursing diagnosis increases the risk of negative outcomes.
1. Problem-Focused Nursing Diagnosis
This type of nursing diagnosis relates to undesirable human responses (a.k.a. problems) to specific conditions or life processes in individuals, families, groups, or communities. Problem-focused nursing diagnoses require defining characteristics—such as manifestations, signs, and symptoms—that cluster in patterns of related cues and etiological factors that are related to, contribute to, or are antecedent to the diagnostic focus.
2. Health-Promotion Nursing Diagnosis
A health-promotion nursing diagnosis concerns the motivation and desire to increase well-being and reach human health potential. 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.
3. Risk Nursing Diagnosis
This nursing diagnosis refers to the vulnerability of individuals, families, groups, or communities to develop undesirable human responses to health conditions or life processes. Risk factors contributing to increased vulnerability must be present for nurses to make this type of diagnosis.
4. Syndrome
A syndrome relates to a specific cluster of nursing diagnoses that occur together and can be treated simultaneously through similar interventions, including providing pain control, alleviating chest pain, and caring for patients in a way to help increase blood flow, i.e., via correct positioning—to name a few. 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.
NANDA Nursing Diagnosis List
The following table includes NANDA nursing diagnosis examples by domain, encompassing environmental, physical, psychosocial, and spiritual areas:
How to Write a Nursing Diagnosis
According to NANDA recommendations, a nursing diagnosis is a statement that includes both the diagnosis itself and related factors seen through defining characteristics. Nurses should also try to link the defining characteristics, associated factors, and risk factors discovered during the patient’s assessment.
A nursing diagnosis should include the following components:
- Diagnosis label: This is the name for a diagnosis and reflects the diagnostic focus and the nursing judgment. It is a term or phrase representing a pattern of related signs and symptoms.
- Definition: This clear description helps set the diagnosis apart from other diagnoses.
- Defining characteristics: These are all the observable signs and symptoms that cluster to indicate a problem-focused or health-promotion nursing diagnosis or a syndrome. These signs and symptoms may be perceived through any of the senses (sight, touch, smell, etc.) or communicated by the patient or family members.
- Risk factors: These are only part of risk diagnoses; they increase an individual’s, family’s, group’s, or community’s vulnerability to experiencing an unhealthy event. They may be environmental, physiological, psychological, genetic, or chemical.
- Related factors: These factors appear to be related to the nursing diagnosis. Nurses may describe these factors as being antecedent to, associated with, related to, contributing to, or abetting. Problem-focused nursing diagnoses and syndromes must have related factors, whereas health-promotion diagnoses only include related factors if they help to clarify the diagnosis.
Aren’t sure where to start? First, registered nurses must analyze patients’ subjective and objective data and identify patterns.
Then, nurses develop hypotheses based on how these patterns correlate with defining characteristics of a nursing diagnosis.
Nurses must also include the cause—or related factors—of a patient’s problem. If possible, nursing care plans created based on these diagnoses should modify or remove the associated factors that cause the problem identified in the nursing diagnosis.
As with any part of the nursing process, if a nursing diagnosis was not documented, it didn’t happen. Thankfully with modern charting technology, most of the nursing diagnoses are now digitally created after you document your assessment, and they are automatically added to the plan of care.
Want to brush up on your nurse charting skills? Discover essential principles for nurse documentation and tips.
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