Nursing diagnosis is an essential component of nursing practice that helps nurses identify actual or potential health problems and formulate individualized care plans for their patients.
Definition of Nursing Diagnosis
Nursing diagnosis is a clinical judgment made by nurses based on data collected during a patient assessment. It identifies actual or potential health problems and their related factors, including physical, psychological, social, and environmental factors. Nursing diagnosis is used to guide nursing interventions and evaluate patient outcomes.
List of Nursing Diagnosis
Imbalanced nutrition: less than body requirements
Risk for infection
Hypothermia
Hyperthermia
Ineffective thermoregulation
Autonomic dysreflexia
Risk for autonomic dysreflexia
Constipation
Perceived constipation
Diarrhea
Risk for constipation
Impaired urinary elimination
Stress urinary incontinence
Urge urinary incontinence
Risk for urge urinary incontinence
Urinary retention
Risk for imbalanced fluid volume
Excess fluid volume
Deficient fluid volume
Risk for deficient fluid volume
Decreased cardiac output
Impaired gas exchange
Ineffective airway clearance
Ineffective breathing pattern
Impaired spontaneous ventilation
Dysfunctional ventilatory weaning response
Risk for injury
Risk for suffocation
Risk for poisoning
Risk for physical trauma
Risk for aspiration
Risk for disuse syndrome
Risk for latex allergy reaction
Ineffective protection
Impaired tissue integrity
Impaired oral mucous membrane integrity
Impaired skin integrity
Risk for impaired skin integrity
Impaired dentition
Impaired verbal communication
Impaired social interaction
Social isolation
Risk for loneliness
Ineffective role performance
Impaired parenting
Risk for impaired parenting
Risk for impaired attachment
Sexual dysfunction
Interrupted family processes
Caregiver role strain
Risk for caregiver role strain
Dysfunctional family processes
Parental role conflict
Ineffective sexuality pattern
Spiritual distress
Risk for spiritual distress
Readiness for enhanced spiritual wellbeing
Ineffective coping
Defensive coping
Ineffective denial
Disabled family coping
Compromised family coping
Readiness for enhanced family coping
Readiness for enhanced community coping
Ineffective community coping
Decisional conflict
Impaired physical mobility
Risk for peripheral neurovascular dysfunction
Risk for perioperative positioning injuryc
Impaired walking
Impaired wheelchair mobility
Impaired transfer ability
Impaired bed mobility
Fatigue
Insomnia
Sleep deprivation
Decreased diversional activity engagement
Delayed surgical recovery
Feeding self-care deficit
Impaired swallowing
Ineffective breastfeeding
Interrupted breastfeeding
Readiness for enhanced breastfeeding
Bathing self-care deficit
Dressing self-care deficit
Toileting self-care deficit
Relocation stress syndrome
Risk for disorganized infant behavior
Disorganized infant behavior
Readiness for enhanced organized infant behavior
Disturbed body image
Chronic low self-esteem
Situational low self-esteem
Disturbed personal identity
Unilateral neglect
Hopelessness
Powerlessness
Deficient knowledge
Acute confusion
Chronic confusion
📖 Impaired memory ✍
📖 Nursing diagnosis Acute pain ✍
📖 Nursing diagnosis Chronic pain ✍
📖 Nursing diagnosis Nausea ✍
Chronic sorrow
Risk for other-directed violence
Risk for self-mutilation
Risk for self-directed violence
Post-trauma syndrome
Rape-trauma syndrome
Risk for post-trauma syndrome
Anxiety
Death anxiety
Fear
Risk for relocation stress syndrome
Self-mutilation
Risk for powerlessness
Risk for situational low self-esteem
Wandering
Risk for sudden infant death
Readiness for enhanced communication
Readiness for enhanced coping
Readiness for enhanced family processes
Readiness for enhanced knowledge
Readiness for enhanced nutritiona
Readiness for enhanced parenting
Readiness for enhanced sleep
Readiness for enhanced self-concept
Sedentary lifestyle
Impaired religiosity
Risk for impaired religiosity
Readiness for enhanced religiosity
Risk for acute confusion
Risk for compromised human dignity
Moral distress
Stress overload
Risk for impaired liver function
Risk for unstable blood glucose level
Risk for contamination
Contamination
Readiness for enhanced self-care
Readiness for enhanced comfort
Readiness for enhanced decision-making
Readiness for enhanced hope
Readiness for enhanced power
Risk-prone health behavior
Self-neglect
Neonatal hyperbilirubinemia
Risk for electrolyte imbalance
Dysfunctional gastrointestinal motility
Risk for dysfunctional gastrointestinal motility
Disturbed sleep pattern
Ineffective activity planning
Risk for decreased cardiac tissue perfusion
Risk for ineffective cerebral tissue perfusion
Ineffective peripheral tissue perfusion
Risk for shock
Risk for bleeding
Readiness for enhanced relationship
Readiness for enhanced childbearing process
Risk for disturbed maternal-fetal dyad
Impaired resilience
Risk for impaired resilience
Readiness for enhanced resilience
Risk for vascular trauma
Impaired comfort
Deficient community health
Insufficient breast milk production
Risk for allergy reaction
Risk for adverse reaction to iodinated contrast media
Risk for dry eye
Risk for thermal injuryc
Ineffective childbearing process
Ineffective impulse control
Ineffective relationship
Risk for chronic low self-esteem
Risk for disturbed personal identity
Risk for ineffective activity planning
Risk for ineffective childbearing process
Risk for ineffective peripheral tissue perfusion
Risk for ineffective relationship
Risk for neonatal hyperbilirubinemia
Risk for frail elderly syndrome
Obesity
Overweight
Risk for overweight
Chronic functional constipation
Risk for chronic functional constipation
Impaired sitting
Impaired standing
Risk for decreased cardiac output
Impaired mood regulation
Impaired emancipated decision-making
Readiness for enhanced emancipated decision-making
Risk for impaired emancipated decisionmaking
Risk for corneal injury
Risk for delayed surgical recovery
Risk for impaired oral mucous membrane integrity
Risk for impaired tissue integrity
Risk for urinary tract injury
Labile emotional control
Risk for hypothermia
Risk for perioperative hypothermia
Chronic pain syndromed
Labor paind
Frail elderly syndrome
Acute substance withdrawal syndrome
Risk for acute substance withdrawal syndrome
Risk for complicated immigration transition
Risk for dry mouth
Readiness for enhanced health literacy
Neonatal abstinence syndrome
Risk for occupational injury
Risk for surgical site infection
Risk for unstable blood pressure
Ineffective adolescent eating dynamics
Ineffective child eating dynamics
Ineffective infant feeding dynamics
Risk for female genital mutilation
Imbalanced energy field
Risk for ineffective thermoregulation
Ineffective health self-management
Ineffective dry eye self-management
Ineffective lymphedema self-management
Disturbed thought process
Neonatal hypothermia
Risk for ineffective lymphedema selfmanagement
Risk for neonatal hypothermia
Disturbed family identity syndrome
Risk for disturbed family identity syndrome
Readiness for enhanced grieving
Risk for child pressure injury
Neonatal pressure injury
Risk for neonatal pressure injury
Risk for suicidal behavior
Risk for elopement attempt
Risk for thrombosis
Ineffective health maintenance behaviors
Readiness for enhanced health selfmanagement
Ineffective family health self-management
Ineffective infant suck-swallow response
Risk for metabolic syndrome
Disability-associated urinary incontinence
Decreased activity tolerance
Risk for decreased activity tolerance
Ineffective home maintenance behaviors
Maladaptive grieving
Risk for maladaptive grieving
Risk for adult falls
Risk for adult pressure injury
Risk for delayed child development
Risk for child falls
Readiness for enhanced exercise engagement
Risk for ineffective home maintenance behaviors
Readiness for enhanced home maintenance behaviors
Mixed urinary incontinence
Risk for impaired cardiovascular function
Adult pressure injury
Child pressure injury
Delayed child development
Delayed infant motor development
Risk for delayed infant motor development
Dysfunctional adult ventilatory weaning response
Impaired bowel continence
Nipple-areolar complex injury
Risk for nipple-areolar complex injury
Risk for urinary retention
Types of Nursing Diagnosis
There are three types of nursing diagnosis:
Actual Nursing Diagnosis
An actual nursing diagnosis describes a current problem that is present in the patient. This type of nursing diagnosis is based on clinical signs and symptoms, laboratory results, and other objective data. An example of an actual nursing diagnosis is "Impaired Gas Exchange related to pneumonia as evidenced by shortness of breath and decreased oxygen saturation."
Risk Nursing Diagnosis
A risk nursing diagnosis describes a potential problem that the patient is at risk for developing. This type of nursing diagnosis is based on risk factors identified during the patient assessment. An example of a risk nursing diagnosis is "Risk for Falls related to unsteady gait and history of falls."
Health Promotion Nursing Diagnosis
A health promotion nursing diagnosis describes a patient's motivation and desire to improve their health and wellbeing. This type of nursing diagnosis is based on patient strengths and resources. An example of a health promotion nursing diagnosis is "Readiness for Enhanced Nutrition related to increased knowledge and motivation to improve dietary habits."
Process of Nursing Diagnosis
The nursing diagnosis process involves several steps:
Assessment
The first step in the nursing diagnosis process is to collect data about the patient's physical, psychological, social, and environmental status. This information can be gathered through observation, physical examination, interviews, and medical records review.
Data Analysis
After collecting data, nurses analyze it to identify patterns, problems, and potential health risks. They use critical thinking and clinical judgment to interpret the data and make informed decisions about nursing diagnoses.
Diagnosis
The nursing diagnosis is formulated based on the data analysis. Nurses use standardized nursing language, such as NANDA-I (North American Nursing Diagnosis Association International), to identify the problem and related factors.
Planning
After formulating the nursing diagnosis, nurses develop a comprehensive care plan that addresses the patient's specific needs, goals, and interventions. The plan should be individualized and based on the patient's preferences and values.
Implementation
The care plan is implemented through nursing interventions that aim to achieve the goals and improve the patient's health status. Nurses monitor the patient's response to interventions and modify the plan as needed.
Evaluation
The final step in the nursing diagnosis process is to evaluate the effectiveness of the care plan and interventions. Nurses assess the patient's progress towards achieving goals and modify the plan if necessary.
Importance of Nursing Diagnosis
Nursing diagnosis is essential for several reasons:
Individualized Care
Nursing diagnosis helps nurses identify individual patient needs and develop care plans that are tailored to their specific problems, strengths, and preferences.
Efficient Resource Allocation
Nursing diagnosis helps nurses prioritize care interventions and allocate resources effectively. It ensures that resources are used efficiently and effectively to achieve the best patient outcomes.
Improved Patient Outcomes
Nursing diagnosis improves patient outcomes by providing targeted and individualized care that addresses their specific health problems and needs. It helps prevent complications and promotes faster recovery.
Professional Development
Nursing diagnosis is a critical thinking process that requires nurses to analyze data, interpret findings, and make informed decisions. It enhances their clinical judgment skills and promotes their professional development as competent and skilled healthcare providers.
Collaboration with Interdisciplinary Team
Nursing diagnosis facilitates collaboration with the interdisciplinary healthcare team. It enables nurses to communicate effectively with physicians, pharmacists, and other healthcare providers to ensure that the patient receives comprehensive and coordinated care.
Challenges in Nursing Diagnosis
Despite the benefits of nursing diagnosis, several challenges can hinder its effective implementation. These challenges include:
Lack of Knowledge and Skills
Some nurses may lack the knowledge and skills required to perform an accurate and comprehensive patient assessment, analyze data, and formulate a nursing diagnosis. This can compromise the quality of care and patient outcomes.
Time Constraints
Nurses may face time constraints that limit their ability to collect and analyze data thoroughly, formulate a nursing diagnosis, and develop a comprehensive care plan. This can result in incomplete or inadequate care.
Communication Barriers
Effective nursing diagnosis requires communication and collaboration with the patient and the interdisciplinary healthcare team. Communication barriers, such as language differences, cultural differences, and communication disorders, can hinder effective nursing diagnosis.
Conclusion
In conclusion, nursing diagnosis is an essential component of nursing practice that helps nurses identify actual or potential health problems, develop individualized care plans, and promote better patient outcomes. The nursing diagnosis process involves several steps, including assessment, data analysis, diagnosis, planning, implementation, and evaluation. Although nursing diagnosis has many benefits, several challenges, such as lack of knowledge and skills, time constraints, and communication barriers, can hinder its effective implementation.
FAQs
Who can perform a nursing diagnosis?
- Nurses who have completed a nursing program and obtained a license to practice can perform a nursing diagnosis.
What is the difference between a medical diagnosis and a nursing diagnosis?
- A medical diagnosis identifies a disease or condition, while a nursing diagnosis identifies a patient's response to a disease or condition.
Can a nursing diagnosis change over time?
- Yes, a nursing diagnosis can change over time as the patient's health status and needs change.
How can nurses overcome time constraints when performing a nursing diagnosis?
- Nurses can prioritize data collection and analysis, delegate non-nursing tasks to other healthcare providers, and use technology to streamline the nursing diagnosis process.
Can patients be involved in the nursing diagnosis process?
- Yes, patients can be involved in the nursing diagnosis process by providing information about their health status, preferences, and goals.