Nursing Diagnosis Guide

A nursing diagnosis is your clinical judgment about a patient's response to a health problem, written in a standardized form so the whole care team reads it the same way. NANDA-I (the North American Nursing Diagnosis Association) built the first official classification system in 1982, and it remains the framework you will use to document the decisions you make at the bedside.

Get the diagnosis right and everything downstream improves: communication, care planning, and outcomes. Here is what a nursing diagnosis is, why it matters, and how to write one.

What a Nursing Diagnosis Is

NANDA-I defines it as the professional judgment nurses make every day about their patients, communicated to colleagues, other disciplines, and the public.

A nursing diagnosis usually has three parts:

• A diagnosis approved by NANDA-I
• A "related to" statement naming the cause
• An "as evidenced by" statement citing the specific patient data that supports it

For a patient who is not yet showing a problem but is vulnerable to one, you use a risk diagnosis: "risk for" plus the risk factors.

The diagnosis is the second step of the five-step nursing process.

Assessment

A thorough, holistic evaluation of the patient. You collect subjective and objective data: vital signs, health history, a head-to-toe physical, and psychological, socioeconomic, and spiritual factors.

Diagnosis

You form the diagnosis from the assessment data. It directs nursing-specific care and leads to goals with measurable outcomes.

Outcomes and Planning

You build a care plan from the diagnosis. The plan is measurable and goal-oriented for the patient and, where relevant, the family.

Implementation

You put the care plan into action and continue it from admission through discharge.

Evaluation

You measure the plan against its goals and outcomes and adjust as the patient's needs change.

Nursing Diagnosis vs. Medical Diagnosis

A nurse initiates a nursing diagnosis, and it focuses on the patient's holistic needs and outcomes. A physician's diagnosis identifies a disease, injury, or condition from the patient's signs and symptoms. In states that grant advanced practice registered nurses (APRNs) full practice authority, APRNs diagnose independently.

Nursing Diagnosis

• Based on the patient's immediate situation
• Aimed at resolving a health problem
• Improves communication across the care team
• Holistic

Example: Ineffective breathing pattern related to impaired inhalation and exhalation as evidenced by use of accessory muscles

Medical Diagnosis

• Initiated by a physician or specialist
• Names a medical condition, disease, or injury
• Explains the signs and symptoms

Example: Asthma

Four Categories of Nursing Diagnoses

NANDA-I sorts nursing diagnoses into four types.

Problem-Focused

Tied to a current patient problem. It may run through the whole hospitalization or resolve by the end of your shift.

Example: Anxiety related to situational crisis and stress, as evidenced by restlessness, insomnia, anguish, and anorexia

Risk

Identifies a vulnerability the patient faces before a problem develops.

Example: Risk for infection as evidenced by inadequate vaccination and immunosuppression

Health Promotion

Identifies a way to improve the patient's health, often involving family or community.

Example: Readiness for enhanced self-care as evidenced by expressed desire to improve self-care

Syndrome

Groups a cluster of diagnoses that are best described together when a patient's problems form a pattern.

Example: Chronic pain syndrome

How Diagnoses Are Classified

After collaborating with the National Library of Medicine, NANDA-I built Taxonomy II, a system for naming, describing, and classifying diagnoses to standardize care. It has three levels: diagnosis, domain, and class. Taxonomy II currently holds more than 200 diagnoses, 47 classes, and 13 domains of nursing practice. The domains are:

1. Health promotion
2. Nutrition
3. Elimination and exchange
4. Activity/rest
5. Perception/cognition
6. Self-perception
7. Role relationships
8. Sexuality
9. Coping/stress tolerance
10. Life principles
11. Safety/protection
12. Comfort
13. Growth/development

Each domain contains its own classes.

How to Write a Nursing Diagnosis

Work through five steps for an accurate diagnosis.

Ground It in Nursing Science

Nursing theory gives you the foundation for holistic, patient-centered care and is the starting point for any diagnosis and care plan.

Assess

Gather medical, surgical, and social history and complete a physical. Then ask: what is the patient's current, priority health problem? That answer feeds the diagnosis.

Identify Potential Diagnoses

Once you have identified the problem or human response, ask which information is relevant and which is not. Use the answer to:

• Determine the diagnosis category
• Confirm or rule out other diagnoses
• Create new ones where needed

Validate every diagnosis with an in-depth assessment before you commit to it.

Build the Care Plan

The diagnosis drives the plan. Set measurable, achievable goals and matching interventions, then act on them.

Evaluate

Reassess constantly. If the diagnosis no longer fits the situation, rework it and adjust the plan.

For the full diagnosis list, you need NANDA-I membership or a copy of the NANDA-I Taxonomy II reference.