NANDA Nursing Diagnoses: Importance, Process, and Examples
What is a Nursing diagnosis?
Nursing diagnoses are clinical judgments or conclusions about a patient’s health problems or potential health problems that nurses make based on their assessment of the patient’s current condition. These diagnoses are different from medical diagnoses, which are made by physicians and based on medical tests and procedures.
Nursing diagnoses are important because they help nurses identify the patient’s health problems, determine the underlying causes, and develop appropriate care plans. Nursing diagnoses also provide a common language for nurses to communicate with each other and other healthcare professionals. They help nurses evaluate the effectiveness of their interventions and make adjustments as necessary. Nursing diagnoses are developed through a process that involves collecting and analyzing data about the patient’s health status, identifying any abnormal findings and potential health problems, clustering the abnormal findings into patterns or themes, interpreting the patterns or themes to identify underlying causes, and formulating nursing diagnoses based on the identified health problems and causes.
Nursing diagnoses should be specific, measurable, achievable, relevant, and time-bound (SMART). They should reflect the patient’s actual or potential health problems and provide a basis for developing individualized care plans. Nursing diagnoses are constantly reassessed and revised as the patient’s condition changes or as new information becomes available. In this article, we will discuss the importance of nursing diagnoses, the process of developing nursing diagnoses, and provide some examples of nursing diagnoses.
NANDA’s Nursing Diagnose
The North American Nursing Diagnosis Association (NANDA) is a professional organization that develops, publishes, and promotes nursing diagnoses. NANDA was founded in 1982 and has since become a leading authority on nursing diagnoses.
NANDA develops nursing diagnoses through a process of research and consensus-building. The organization reviews the latest scientific and clinical evidence to identify and validate nursing diagnoses. NANDA also consults with nurses, patients, and other healthcare professionals to ensure that nursing diagnoses reflect the needs and perspectives of all stakeholders.
NANDA’s nursing diagnoses are organized into taxonomies, which provide a standardized language for nurses to communicate about patients’ health problems. The current NANDA International Nursing Diagnoses: Definitions and Classification (NANDA-I) taxonomy includes over 200 nursing diagnoses, which are grouped into 13 domains based on the patient’s functional health patterns.
The domains of the NANDA-I taxonomy include:
- Health promotion
- Elimination and exchange
- Activity and rest
- Perception and cognition
- Self-perception and self-concept
- Role relationships
- Sexuality and reproductive
- Coping and stress tolerance
- Life principles
- Safety and protection
- Growth and development
NANDA Nursing Diagnosis Format and Example
The nursing diagnosis format developed by the North American Nursing Diagnosis Association (NANDA) consists of three components: the diagnostic label, related factors or risk factors, and defining characteristics.
- Diagnostic label: The diagnostic label is a concise statement that describes the patient’s actual or potential health problem. It should be specific, measurable, and focused on the patient’s individual health problems. The diagnostic label should be chosen from the NANDA-approved list of nursing diagnoses.
- Related factors or risk factors: Related factors or risk factors are the underlying conditions, circumstances, or events that contribute to the development or exacerbation of the patient’s health problem. Related factors are used for actual nursing diagnoses, while risk factors are used for risk nursing diagnoses. Related factors and risk factors should be evidence-based and supported by patient data.
- Defining characteristics: Defining characteristics are the signs and symptoms that support the nursing diagnosis. They are used to differentiate one nursing diagnosis from another and to validate the nursing diagnosis. Defining characteristics should be specific to the patient’s health problem and supported by patient data.
Here is an example of a nursing diagnosis using the NANDA format:
Diagnostic label: Acute Pain Related factors: Surgical incision, inflammation, muscle spasm Defining characteristics: Verbal report of pain (rated 8 out of 10), grimacing, guarding behavior, increased heart rate, and blood pressure, diaphoresis
In this example, the diagnostic label is Acute Pain, which is supported by related factors such as the surgical incision, inflammation, and muscle spasm. The defining characteristics include the patient’s verbal report of pain, grimacing, guarding behavior, increased heart rate and blood pressure, and diaphoresis, all of which support the diagnosis of Acute Pain.
Importance of Nursing Diagnoses
Nursing diagnoses are important for several reasons. They play a critical role in nursing practice, patient care, and healthcare outcomes. Here are some of the key reasons why nursing diagnoses are important:
- Identify health problems: Nursing diagnoses help nurses identify actual and potential health problems that patients may be experiencing. By analyzing patient data and making clinical judgments, nurses can identify health problems that may not be immediately apparent. This helps ensure that all patient needs are addressed and that no health problems are overlooked.
- Develop care plans: Nursing diagnoses provide the foundation for developing individualized care plans for patients. By identifying specific health problems, nurses can develop care plans that are tailored to meet the unique needs of each patient. This helps ensure that patients receive appropriate and effective care that is responsive to their individual needs.
- Guide interventions: Nursing diagnoses guide the selection of appropriate interventions that will address patients’ health problems. By selecting evidence-based interventions that are appropriate for the specific nursing diagnosis, nurses can improve patient outcomes and ensure that care is effective.
- Evaluate outcomes: Nursing diagnoses provide a framework for evaluating the effectiveness of nursing interventions. By regularly assessing and re-evaluating the patient’s condition, nurses can determine whether the interventions are achieving the desired outcomes. This helps ensure that patients receive effective care and that nursing interventions are modified as needed.
- Promote communication: Nursing diagnoses provide a common language for nurses to communicate with each other and other healthcare professionals. This helps ensure that all members of the healthcare team are on the same page regarding patient care and that information is shared effectively and efficiently.
- Enhance patient safety: Nursing diagnoses can help identify potential risks to patient safety, such as falls, infections, or medication errors. By identifying these risks and taking appropriate measures to mitigate them, nurses can help ensure that patients are safe while in their care.
Types of Nursing Diagnoses
There are three types of nursing diagnoses:
- Actual nursing diagnosis: An actual nursing diagnosis is based on current signs and symptoms exhibited by the patient. It is a clinical judgment that identifies an existing health problem that requires nursing interventions. Actual nursing diagnoses provide a basis for selecting appropriate nursing interventions and evaluating their effectiveness. Examples of actual nursing diagnoses include acute pain, impaired skin integrity, and ineffective airway clearance.
- Risk nursing diagnosis: A risk nursing diagnosis is a clinical judgment that identifies a potential health problem that may occur in the future if the patient’s current risk factors continue to exist. Risk nursing diagnoses provide a basis for preventive nursing interventions to minimize the risk of developing a health problem. Examples of risk nursing diagnoses include risk for falls, risk for infection, and risk for impaired skin integrity.
- Health promotion nursing diagnosis: A health promotion nursing diagnosis is a clinical judgment that identifies a patient’s potential for enhanced well-being. It focuses on the patient’s readiness and motivation to engage in health-promoting behaviors and activities that can improve their overall health and prevent the development of future health problems. Examples of health promotion nursing diagnoses include readiness for enhanced nutrition, readiness for enhanced coping, and readiness for enhanced spiritual well-being.
It is important to note that nursing diagnoses should be individualized based on each patient’s unique health problems and needs. Nursing diagnoses should be validated through a thorough assessment and analysis of patient data, and they should be regularly reassessed and revised as necessary. Additionally, nursing diagnoses should be evidence-based and supported by the latest clinical practice guidelines and research.
Process of Developing Nursing Diagnoses
Developing nursing diagnoses is a process that involves several steps. Here is an overview of the process:
- Data collection: The first step in developing a nursing diagnosis is to collect data about the patient’s health status. This may include conducting a physical examination, reviewing the patient’s medical history and laboratory results, and interviewing the patient and/or family members. The purpose of data collection is to identify any abnormal findings or potential health problems.
- Data analysis: Once data is collected, the nurse must analyze it to identify patterns or themes that may indicate underlying health problems. This involves clustering abnormal findings together and interpreting the patterns to determine potential health problems.
- Identify actual or potential health problems: Based on the data analysis, the nurse should be able to identify actual or potential health problems that the patient is experiencing. These health problems should be specific and reflect the patient’s current condition.
- Identify related factors: Once the nursing diagnosis is identified, the nurse should identify related factors that may be contributing to the health problem. These factors may be physiological, psychological, environmental, or social in nature.
- Formulate the nursing diagnosis: Based on the data analysis and identification of related factors, the nurse should formulate a nursing diagnosis that accurately reflects the patient’s health problem. The nursing diagnosis should be written in a standardized format that includes a problem statement, related factors, and defining characteristics.
- Validate the nursing diagnosis: The nursing diagnosis should be validated by reviewing it with other members of the healthcare team and by assessing whether it accurately reflects the patient’s condition. If necessary, the nursing diagnosis should be revised based on feedback and additional data.
- Develop a care plan: Once the nursing diagnosis is formulated, the nurse should use it to develop a care plan that addresses the patient’s specific health problems and related factors. The care plan should be individualized to meet the patient’s unique needs and should include evidence-based interventions that are appropriate for the nursing diagnosis.
- Reassess and revise: Nursing diagnoses should be regularly reassessed and revised as the patient’s condition changes or as new information becomes available. The nursing diagnosis should be continually evaluated to ensure that it is accurate and relevant to the patient’s current health status.
Examples of Nursing Diagnose
Here are some examples of nursing diagnoses:
- Risk for infection related to the compromised immune system as evidenced by recent chemotherapy treatment and low white blood cell count.
- Impaired physical mobility related to arthritis and recent hip surgery as evidenced by the limited range of motion and use of a walker.
- Risk for falls related to unsteady gait and medication side effects as evidenced by the history of falls and use of a cane.
- Ineffective airway clearance related to asthma exacerbation as evidenced by wheezing, dyspnea, and decreased oxygen saturation levels.
- Impaired skin integrity related to pressure ulcers as evidenced by redness, swelling, and open sores on the patient’s sacral and heel areas.
- Risk for ineffective coping related to a recent diagnosis of cancer as evidenced by reports of anxiety, difficulty sleeping, and decreased appetite.
- Risk for aspiration related to dysphagia as evidenced by difficulty swallowing and coughing after eating or drinking.
- Imbalanced nutrition: less than body requirements related to inadequate intake and malabsorption syndrome as evidenced by low body weight, muscle wasting, and nutritional deficiencies.
- Ineffective tissue perfusion related to peripheral artery disease as evidenced by decreased peripheral pulses, slow capillary refill, and cold extremities.
- Risk for impaired skin integrity related to incontinence and immobility as evidenced by moisture and redness in the patient’s perineal area.
NANDA Nursing Diagnosis List
Here is a list of nursing diagnoses based on the NANDA International (NANDA-I) Taxonomy II:
- Acute pain
- Activity intolerance
- Chronic pain
- Decreased cardiac output
- Deficient fluid volume
- Deficient knowledge
- Disturbed body image
- Disturbed sleep pattern
- Excess fluid volume
- Impaired gas exchange
- Impaired skin integrity
- Impaired swallowing
- Impaired urinary elimination
- Ineffective airway clearance
- Ineffective breathing pattern
- Ineffective coping
- Ineffective health maintenance
- Ineffective tissue perfusion
- Knowledge deficit
- Risk for aspiration
- Risk for bleeding
- Risk for infection
- Risk for injury
- Risk for falls
- Risk for impaired skin integrity
- Risk for ineffective airway clearance
- Risk for deficient fluid volume
- Risk for impaired gas exchange
- Risk for impaired tissue integrity
- Risk for ineffective thermoregulation
- Self-care deficit
- Social isolation
- Spiritual distress
- Stress overload
- Urinary retention
It’s important to note that this is not an exhaustive list and that nursing diagnoses should be individualized based on each patient’s unique health problems and needs. Additionally, nursing diagnoses should be validated through a thorough assessment and analysis of patient data, and they should be regularly reassessed and revised as necessary.
How to Write Nursing Diagnosis
To write a nursing diagnosis, you should follow a systematic approach that includes the following steps:
- Collect patient data: This involves gathering relevant information about the patient’s health status through a thorough assessment, including a physical exam, patient history, lab tests, and diagnostic imaging. You should look for patterns and trends in the data to identify potential health problems.
- Analyze patient data: Once you have collected patient data, you should analyze it to identify actual or potential health problems. Look for signs and symptoms that suggest a specific health problem or condition, and consider risk factors and predisposing factors that may contribute to the problem.
- Formulate a nursing diagnosis: Based on the patient data analysis, you should formulate a nursing diagnosis that identifies a specific health problem that the nurse can treat or manage. A nursing diagnosis should be specific, measurable, and focused on the patient’s individual health problems. It should also be evidence-based and supported by patient data.
- Prioritize nursing diagnoses: You should prioritize nursing diagnoses based on the patient’s needs, the severity of the health problem, and the potential for complications. Prioritization helps the nurse to focus on the most urgent and important health problems and to develop an effective care plan.
- Document nursing diagnosis: Once you have formulated a nursing diagnosis, you should document it in the patient’s medical record, along with the supporting data. This helps to communicate the patient’s health problems to other members of the healthcare team and ensures that the patient receives appropriate care.
- Revise nursing diagnosis: Nursing diagnoses should be regularly reassessed and revised as necessary based on changes in the patient’s health status or response to treatment. This helps to ensure that the patient receives optimal care and that the nursing diagnosis remains accurate and relevant.
In summary, to write a nursing diagnosis, you should collect and analyze patient data, formulate a specific and measurable nursing diagnosis, prioritize nursing diagnoses based on patient needs, document the nursing diagnosis, and revise it as necessary
FAQ Nursing Diagnosis
How is nursing diagnosis different from medical diagnosis?
Medical diagnosis refers to the identification of a disease or medical condition based on clinical signs and symptoms, laboratory tests, and other diagnostic procedures. Nursing diagnosis, on the other hand, refers to the identification of a patient’s actual or potential health problems that can be addressed through nursing interventions. Nursing diagnosis focuses on the patient’s response to the disease or medical condition and its impact on their overall health.
Who can make a nursing diagnosis?
A nursing diagnosis can be made by a registered nurse or an advanced practice registered nurse (APRN) who has the education, training, and competency to analyze patient data, identify health problems, and develop nursing interventions.
How is a nursing diagnosis used in nursing practice?
Nursing diagnosis is used in nursing practice to guide the selection of appropriate nursing interventions to address patient health problems. It is used to develop a care plan that outlines the nursing interventions, expected outcomes, and evaluation criteria. Nursing diagnosis is also used to communicate patient health problems to other members of the healthcare team.
How often should the nursing diagnosis be reviewed?
Nursing diagnosis should be reviewed regularly based on the patient’s changing health status and response to nursing interventions. It should be reassessed and revised as necessary to ensure that it accurately reflects the patient’s current health problems and needs.
Can a nursing diagnosis change over time?
Yes, a nursing diagnosis can change over time based on the patient’s changing health status and response to nursing interventions. It should be regularly reassessed and revised as necessary to ensure that it accurately reflects the patient’s current health problems and needs.
Are nursing diagnoses evidence-based?
Yes, nursing diagnoses should be evidence-based and supported by the latest clinical practice guidelines and research. Evidence-based nursing diagnoses provide a basis for selecting appropriate nursing interventions and evaluating their effectiveness.
Conclusion: Nursing diagnoses are essential components of nursing practice. They help nurses identify the patients’ health problems, determine the underlying causes, and develop appropriate care plans. Nursing diagnoses provide a common language for nurses to communicate with each other and other healthcare professionals. The process of developing nursing diagnoses involves several steps, including assessment, analysis, clustering, interpretation, and formulation. Nursing diagnoses should be specific, measurable, achievable, relevant, and time-bound (SMART). By understanding the importance of nursing diagnoses and the process of developing them, nurses can provide individualized and effective care to their patients.