A nursing diagnosis (ND) represents a nurse’s clinical judgment regarding an individual’s, family’s, or community’s response to current or potential health conditions and life processes. This judgment forms the standardized language that directs professional nursing care, setting the stage for interventions and expected outcomes.
The structure of a nursing diagnosis ensures clarity and consistency across healthcare settings, allowing all members of the team to understand the patient’s needs from a nursing perspective. The “Risk for” diagnosis is a specific category within this framework that shifts the focus from treating an existing problem to proactively managing future vulnerabilities.
Defining the Risk for Nursing Diagnosis
A “Risk for” nursing diagnosis is a formal clinical judgment concerning the vulnerability of an individual, family, group, or community to developing an undesirable human response to health conditions or life processes. This category is officially recognized and defined by NANDA-I (North American Nursing Diagnosis Association International), providing standardized terminology for potential patient issues. Unlike an actual nursing diagnosis, which describes a problem already present and evidenced by signs and symptoms, the risk diagnosis addresses a problem that has not yet occurred.
The purpose of using a risk diagnosis is purely preventative, identifying patients who are susceptible to a complication before it manifests. By labeling a patient with a “Risk for” diagnosis, the nurse communicates the need for monitoring and implements specific interventions to mitigate the potential threat. This proactive approach allows the nurse to prioritize care that prevents deterioration and maintains the patient’s current level of health. The diagnosis is based on the presence of specific risk factors that increase the patient’s susceptibility.
The Two-Part Structure: Formatting the Statement
Writing a “Risk for” diagnosis requires adhering to a mandatory two-part format, which differs significantly from the structure used for an actual or problem-focused diagnosis. The concise statement must include the diagnostic label followed by the specific risk factors that make the patient vulnerable. This format is designed to be highly focused, immediately communicating both the potential problem and its underlying causes.
The first part of the statement is the NANDA-I approved label, which always begins with the phrase “Risk for,” such as Risk for Infection or Risk for Falls. This label identifies the specific potential health problem the patient is susceptible to experiencing.
The second part, which details the causes of this vulnerability, is connected to the first part using the phrase related to. This two-part structure is formally written as: [Risk for Problem] related to [Risk Factors].
The connecting phrase related to establishes the relationship between the potential problem and the factors that increase the patient’s likelihood of developing it. For example, a complete statement might be Risk for Impaired Skin Integrity related to immobility and decreased sensation in lower extremities.
The format for a risk diagnosis intentionally omits the third component often found in actual diagnoses, which is the “as evidenced by” section listing defining characteristics or signs and symptoms. Since the problem has not yet occurred, there are no observable signs or symptoms present to support the diagnosis. The two components are therefore sufficient for the nurse to identify the vulnerability and direct preventative action toward the identified risk factors.
Identifying and Selecting Relevant Risk Factors
The second part of the risk diagnosis statement—the risk factors—requires careful clinical judgment based on a thorough patient assessment. Risk factors are the forces, circumstances, or conditions that increase a patient’s susceptibility to a particular health problem. These factors must be supported by the objective and subjective data collected during the initial assessment, ensuring the diagnosis is patient-specific and evidence-based.
A legitimate risk factor can fall into several broad categories, including physiological, environmental, psychological, or genetic elements. For example, an intrinsic, or internal, risk factor might involve a patient’s age, a compromised immune status due to chronic disease, or a genetic predisposition to a condition. These are characteristics inherent to the patient.
Conversely, extrinsic, or external, risk factors relate to the patient’s surroundings or situation. Examples include environmental hazards like an unlit hallway, lifestyle choices such as smoking, or therapeutic issues like the presence of an invasive medical device such as a urinary catheter. The nurse’s intervention strategy will be directly aimed at mitigating these specific factors.
Selecting the most relevant risk factors is a process of linking the patient’s assessment data to the standardized NANDA-I diagnostic label. The nurse must choose only the factors that, if unaddressed, would most likely lead to the potential problem stated in the first part of the diagnosis. This targeted selection ensures that the planned nursing interventions are focused and effective in preventing the undesirable health outcome.
Applying the Structure: Practical Examples
The application of the two-part structure must be precise to be clinically useful and to direct appropriate care. A correctly formulated statement clearly links the potential problem to its underlying causes, providing a complete picture of the patient’s vulnerability.
For instance, a patient recovering from a complex surgical procedure might have the diagnosis Risk for Infection related to presence of surgical incision and suppressed inflammatory response. Another common example involves patient mobility and safety. An elderly patient with documented muscle weakness and a history of previous falls would be diagnosed as Risk for Falls related to lower extremity weakness and use of multiple psychoactive medications.
A common error in writing a risk diagnosis is the inclusion of defining characteristics, which mistakenly turns the statement into an actual diagnosis. For example, the statement Risk for Impaired Skin Integrity related to immobility as evidenced by red area on coccyx is incorrect because the redness indicates the problem is already present.
The existence of that evidence means the diagnosis should be converted to an actual problem-focused diagnosis: Impaired Skin Integrity related to immobility as evidenced by a red area on the coccyx. An additional error is using a medical diagnosis in the problem statement, which is outside the nurse’s scope of practice. Correctly using the two-part structure ensures the diagnosis is actionable, focusing the nurse on interventions that specifically address and reduce the patient’s individual risk factors.