How to Write a Nursing Diagnosis in 2024

What is a nursing diagnosis?

A nursing diagnosis constitutes a clinical assessment of how an individual, family, group, or community responds to health conditions or life processes and their susceptibility to such responses. It serves as the foundation for determining nursing interventions to achieve outcomes for which the nurse is responsible. Nursing diagnoses are employed to:

• Identify the necessary nursing interventions to prevent the emergence of specific medical conditions or other issues.
• Foster wellness and disease prevention.
• Aid in the restoration of health.
• Assist in coping with changes in functioning.

Types of nursing diagnoses

Nursing diagnoses help nurses identify and address various health concerns in individuals, families, groups, or communities. Each type includes specific components that aid in understanding and addressing health challenges effectively.

Problem-focused nursing diagnosis

Also known as actual diagnosis, it identifies health issues during the nursing assessment based on observed signs and symptoms. It's important to note that actual diagnoses shouldn't always precede risk diagnoses, as potential problems sometimes require immediate attention. These diagnoses consist of three elements: the nursing diagnosis, related factors, and defining characteristics. For example, "Anxiety related to stress" would be an actual diagnosis, supported by signs like increased tension and expression of concern.

Risk nursing diagnosis

The second type anticipates future problems based on identified risk factors, guiding nurses in preventive measures. Unlike actual diagnoses, risk diagnoses lack specific causes and focus on factors predisposing patients to potential issues. For instance, "Risk for falls" may apply to an elderly diabetic with vertigo and mobility challenges.

Health promotion diagnosis

This diagnosis identifies areas where health can be enhanced through nursing interventions. Unlike problem-focused or risk diagnoses, health promotion diagnoses typically don't delve into specific causes or symptoms. Instead, they highlight a patient's readiness or potential for improvement in a particular aspect of health.

Syndrome diagnosis

This diagnosis is used to identify a cluster of current or potential nursing issues that are linked to a specific situation or event. It differs from problem-focused or risk diagnoses in that it considers multiple signs and symptoms occurring together, suggesting a complex interplay of factors related to a particular circumstance.

Possible nursing diagnosis

Indicates suspected issues requiring further data for confirmation. It's a communication tool among nurses, acknowledging potential problems that need clarification. For example, "Possible chronic low self-esteem" suggests a suspicion of the issue pending additional assessment.

How to write a nursing diagnosis

When writing different types of nursing diagnoses, it's essential to follow specific formats:

• Problem-focused nursing diagnosis: This type focuses on current health issues and links them to signs and symptoms. The format is Nursing Diagnosis + Related To + As Evidenced By. For example: "Impaired gas exchange related to decreased lung expansion as evidenced by difficulty breathing."
• Risk-focused diagnosis: This anticipates potential health problems based on identified risk factors. It's a two-part statement: Risk (Diagnostic Label) + Risk Factors. For instance: "Risk for skin issues related to immobility and pressure."
• Health promotion-based diagnosis: This highlights a patient's readiness to improve well-being. Typically, only the diagnostic label is used. For example: "Readiness for enhanced spiritual well-being."
• Syndrome diagnosis: This identifies a cluster of nursing issues expected due to specific situations. For example: "Relocation stress syndrome with symptoms like anxiety and sleep disturbances."

Nursing diagnosis vs. medical diagnosis

Nursing Diagnosis and Medical Diagnosis serve distinct purposes in patient care. Medical diagnosis, typically provided by physicians, focuses on identifying diseases or medical conditions. In contrast, nursing diagnosis, formulated by nurses based on assessment data, centers on understanding a patient's responses to actual or potential health issues and life processes.

While medical diagnoses guide treatment plans for specific illnesses, nursing diagnoses inform nurses' care plans to address patients' physical, emotional, and behavioral responses comprehensively. For example, "Ineffective airway clearance related to bronchial inflammation" illustrates a nursing diagnosis addressing a patient's response, while "Bronchitis" represents a medical diagnosis focusing solely on the disease process.

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