A nursing diagnosis is a formal, standardized clinical judgment used by nurses to understand and address a patient’s health challenges. It identifies actual or potential health problems and life processes affecting an individual, family, or community. It serves as the foundation for providing holistic and personalized patient care, moving beyond the mere identification of a disease state. By establishing a nursing diagnosis, practitioners organize observations and develop a targeted strategy to support patient recovery.
What It Is and Why It Matters
A nursing diagnosis is a clinical judgment about a person’s, family’s, or community’s responses to existing or potential health conditions and life events. This judgment is based on a comprehensive assessment of the patient’s physical, psychological, and social data collected by the nurse. Its purpose is to provide the structure for selecting nursing interventions designed to achieve outcomes for which the nurse is professionally accountable.
This process focuses on the human experience of illness rather than the illness itself, covering aspects like pain, anxiety, or impaired mobility. For instance, while a medical team diagnoses a fractured femur, the nursing diagnosis addresses the patient’s resulting “Impaired Physical Mobility” or “Acute Pain.” Utilizing standardized terminology, primarily developed by NANDA International (NANDA-I), ensures that nurses globally can communicate a patient’s needs clearly and consistently. This approach promotes patient safety and ensures that the care provided is evidence-based and tailored to the individual’s unique response.
How It Differs from a Medical Diagnosis
The distinction between a nursing diagnosis and a medical diagnosis lies in their focus and scope of practice. A medical diagnosis identifies a specific disease, pathological condition, or injury, such as Type 2 Diabetes Mellitus or a Myocardial Infarction. This diagnosis is made by a physician and remains relatively constant throughout the illness, guiding the medical treatment of the disease itself.
A nursing diagnosis, conversely, focuses on the patient’s reaction to that disease or condition, which is within the nurse’s scope to manage independently. For the patient with a heart attack, the nurse might identify diagnoses such as “Acute Pain,” “Fear,” or “Decreased Cardiac Output.” The nurse’s interventions aim to alleviate these responses and manage symptoms, whereas the physician’s treatment targets the underlying heart condition.
The dynamic nature of the nursing diagnosis means it can change daily or even hourly as the patient’s responses evolve. Two patients with the same medical diagnosis, like a stroke, may have vastly different nursing diagnoses; one might have “Impaired Verbal Communication” while the other has “Risk for Falls.” Both types of diagnoses are necessary, as they form complementary parts of the overall care plan. The medical diagnosis informs the nurse about the underlying cause, and the nursing diagnosis guides the hands-on, patient-centered care.
Anatomy of a Nursing Diagnosis
Nursing diagnoses are formulated using standardized language established and maintained by NANDA International. This standardization ensures that the diagnostic labels are precise and understood by nurses across different healthcare settings. The most common structure for writing a problem-focused nursing diagnosis is a three-part statement, often referred to by the acronym P.E.S.
The “P” stands for the Problem, which is the actual NANDA-I diagnostic label, such as “Ineffective Airway Clearance.” The “E” represents the Etiology, or the related factors, which are the probable causes or contributing factors linked to the problem, connected by the phrase “related to.” These factors are often physiological, situational, or psychological, and they direct the nurse toward appropriate interventions.
The “S” stands for the Signs and Symptoms, also known as the defining characteristics, which are the objective and subjective data collected during the patient assessment. These observable cues provide evidence that the problem exists and are linked using the phrase “as evidenced by.” A complete P.E.S. statement might read: “Ineffective Airway Clearance related to increased pulmonary secretions as evidenced by ineffective cough and adventitious breath sounds (crackles).”
Using Diagnosis to Guide Care
The nursing diagnosis is an integral step within the established Nursing Process, a framework that includes Assessment, Diagnosis, Planning, Implementation, and Evaluation. Following assessment, the formulated diagnosis acts as a bridge, translating the patient’s needs into actionable steps. It directly dictates the goals and expected outcomes of care.
Once the diagnosis is established, the nurse sets specific, measurable, achievable, relevant, and time-bound goals for the patient. For example, if the diagnosis is “Impaired Physical Mobility,” a goal might be for the patient to ambulate 50 feet with minimal assistance by the end of the shift. This goal directs the selection of specific nursing interventions.
Interventions are the actions a nurse performs to help the patient achieve the desired outcome. For a diagnosis of “Risk for Impaired Skin Integrity,” the nurse’s actions include turning and repositioning the patient every two hours and ensuring adequate nutritional intake. Evaluation assesses whether the interventions successfully resolved the diagnosed problem or if the care plan needs revision, ensuring a continuous cycle of patient-centered improvement.