A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability to that response, by an individual, family, group, or community. A nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse has accountability. Nursing diagnoses are developed based on data obtained during the nursing assessment and enable the nurse to develop the care plan.

As explained above, now it is easier to distinguish a nursing diagnosis from a medical diagnosis. Nursing diagnosis is directed towards the patient and their physiological and psychological response. On the other hand, a medical diagnosis is particular to the disease or medical condition. Its center is on the illness.

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The five stages of the nursing process are assessment, diagnosing, planning, implementation, and evaluation. All steps in the nursing process require critical thinking by the nurse. Apart from understanding nursing diagnoses and their definitions, the nurse promotes awareness of defining characteristics and behaviors of the diagnoses, related factors to the selected nursing diagnoses, and the interventions suited for treating the diagnoses.

A problem-focused diagnosis (also known as actual diagnosis) is a client problem present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms. Actual nursing diagnosis should not be viewed as more important than risk diagnoses. There are many instances where a risk diagnosis can be the diagnosis with the highest priority for a patient.

There are no etiological factors (related factors) for risk diagnoses. The individual (or group) is more susceptible to developing the problem than others in the same or a similar situation because of risk factors. For example, an elderly client with diabetes and vertigo who has difficulty walking refuses to ask for assistance during ambulation may be appropriately diagnosed with risk for injury or risk for falls.

Additionally, health promotion diagnosis is concerned with the individual, family, or community transition from a specific level of wellness to a higher level of wellness. Components of a health promotion diagnosis generally include only the diagnostic label or a one-part statement. Examples of health promotion diagnosis:

A syndrome diagnosis is a clinical judgment concerning a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event. They, too, are written as a one-part statement requiring only the diagnostic label. Examples of a syndrome nursing diagnosis are:

A possible nursing diagnosis is not a type of diagnosis as are actual, risk, health promotion, and syndrome. Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem. It provides the nurse with the ability to communicate with other nurses that a diagnosis may be present but additional data collection is indicated to rule out or confirm the diagnosis. Examples include:

Another way of writing nursing diagnostic statements is by using the PES format, which stands for Problem (diagnostic label), Etiology (related factors), and Signs/Symptoms (defining characteristics). Diagnostic statements can be one-part, two-part, or three-part using the PES format.

Health promotion nursing diagnoses are usually written as one-part statements because related factors are always the same: motivated to achieve a higher level of wellness through related factors may be used to improve the chosen diagnosis. Syndrome diagnoses also have no related factors. Examples of one-part nursing diagnosis statements include:

VERY NICE EXPLANATION .THANK YOU . DEAR MADAM /SIR PLEASE CAN YOU PROVIDE ME LIST OF NURSING DIAGNOSIS ALONG WITH REVISED ONE TILL DATE .

I am Lecturer in college of nursing ,India

Thank You

I am a nurse more than 30 yeras and try to teach my team how to used nursing process but it not success. You make me feel it simple and easy to understand . I will use your concept for my team. Thank you somuch

Each time I research about nursing diagnoses, there is something new to learn. This is a very well written piece giving great insights about nursing. More than ever, I have a better understanding of the unique body of nursing knowledge. Bravo to the Matt and entire Nurseslabs team

I am Mai Ba Hai, from Hue University of Medicine and Pharmacy,faculty of nursing.I found that this content is very useful and helpful to me. I think that this content is really fit to my teaching, so I would like to ask your permission that I can translate this content into my languages (Vietnamese) to teach for my nursing students in Vietnam. I will cite you as author of this document. If you are willing to help in this point I really appreciate about it. I am looking forward to receiving your agreement. Yours sincerely.

So, when I compare defining characteristics among actual and risk diagnosis, there is disagreement.

Accumulation of secretion in the lung is aetiology for ineffective airway clearance.

But you provided it as defining characteristics.

So, please make it clear.

congratulations MATT VERA, for the very nice and usefully presentation in nursing diagnosis. it has been very usefully for patient care and teaching activities.

simple and very nice understandable.

Assessment: The nurse collects subjective and objective data about the patient which may include their physical, emotional, and psychological health as well as lifestyle factors, socioeconomic status, and culture. Information obtained during the assessment phase may include vital signs, pain, medication use, medical history, and more.

Although there are some similarities between medical and nursing diagnoses, such as clinical judgment and shared terminology, they are distinct.2 The most apparent difference between nursing and medical diagnoses is the healthcare practitioner deciding the diagnosis. All nursing designations share nursing diagnoses, while physicians create medical diagnoses. The exception is that nurse practitioners in most states can also determine medical diagnoses and prescribe medication. Therefore, a nurse practitioner could determine both nursing and medical diagnoses.

A patient with a medical diagnosis of cerebrovascular accident (stroke) may lead to the complementary nursing diagnosis of unilateral neglect. Without the medical diagnosis, the nurse would not know what was causing unilateral neglect. The nursing diagnosis is a jumping-off point to create goals to manage the deficit and improve patient safety and quality of life.

With the medical diagnosis of dehydration, the nurse knows that the patient is experiencing deficient fluid volume (nursing diagnosis). Therefore, the nurse may implement interventions such as administering IV fluids and recording intake and output for this patient.

Formulating a nursing diagnosis is the second step of the nursing process after assessment.6 First, the nurse analyzes the assessment data they collect from the patient and through observation or diagnostic testing. The nurse will use that data and create clusters of pertinent information to form hypotheses about the appropriate nursing diagnoses. At this stage, the nurse will either write the nursing diagnosis or decide they need additional information to confirm or update their hypothesized diagnosis.

Characteristics and risk factors are the evidence behind the nursing diagnosis.4 However, they should not be used interchangeably. Defining characteristics are observable characteristics that support a problem-focused health promotion diagnosis or syndrome. Defining characteristics are the signs or symptoms of clinical pathology.

Risk factors are used primarily for risk-focused nursing diagnoses. Risk factors replace the defining characteristics of problem-focused nursing diagnoses. Similarly, they provide supporting evidence for the nursing diagnosis. Unlike defining characteristics, risk factors describe why the patient has an increased chance of acquiring the undesirable health outcome identified by the nurse. Risk factors can be biological, psychological, family, or community-related. Patients may have one or multiple risk factors supporting a risk diagnosis.

A problem-focused nursing diagnosis is a nursing diagnosis that addresses a current health challenge.4 In contrast to other nursing diagnoses that address potential problems or opportunities for health improvement, a problem-focused diagnosis deals with a current, known health challenge. To make this type of diagnosis, the defining characteristics of the diagnosis must be present at the time of evaluation. The defining characteristics include signs, symptoms, and patient health history. Defining characteristics act as clues for the nurse and, when grouped together, form patterns that allow a diagnosis to be assigned. Related factors should also be described as part of a problem-focused nursing diagnosis.

In a risk-based diagnosis, the nurse uses their clinical judgment to determine that the patient is at risk for health consequences if preventative measures are not implemented. Otherwise stated, the problem has not yet manifested for the client/family/community, but there is a vulnerability related to risk factors that the nurse identifies. Care plans will focus on preventing undesirable health outcomes.

Nursing diagnosis syndromes are created when two or more concurrent nursing diagnoses are related and can be treated using similar interventions. Nursing syndrome diagnoses also cluster problem and risk-focused nursing diagnoses that often accompany specific health processes or life events.

Standardized methods of writing nursing diagnoses allow for clear communication of their purpose and driving factors. Writing a complete nursing diagnosis helps the nurse clarify their reasoning for potential interventions and care goals. 152ee80cbc

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