Writing a Nursing Diagnosis (Diagnostic Statements)

A nursing diagnosis is a clinical judgment made by a registered nurse (RN) to identify the client’s response to an actual or potential health problem. It involves analyzing and interpreting the data collected during the nursing assessment phase. The nursing diagnosis helps the nurse identify the client’s needs, formulate appropriate nursing interventions, and evaluate the outcomes of nursing care.

• Nursing Diagnoses vs Medical Diagnoses: Nursing diagnoses are different from medical diagnoses, which are made by physicians and focus on identifying diseases or medical conditions. Nursing diagnoses, on the other hand, are specific to nursing practice and address the client’s response to the illness or the potential for developing complications.
• Common Format: Nursing diagnoses are typically formulated using a standardized language known as NANDA International (NANDA-I) nursing diagnoses. NANDA-I provides a comprehensive list of nursing diagnoses along with their definitions and defining characteristics. Some examples of nursing diagnoses include “Impaired Gas Exchange,” “Ineffective Tissue Perfusion,” “Acute Pain,” and “Risk for Infection.”
• Example: “Impaired Gas Exchange related to pulmonary congestion due to heart failure, manifested by shortness of breath, decreased oxygen saturation, and adventitious lung sounds.”

• Nursing diagnoses are an essential component of the nursing process, which includes assessment, diagnosis, planning, implementation, and evaluation.
• By identifying the client’s nursing diagnosis, the nurse can plan and provide individualized care to promote the client’s health and well-being.

Components of a Nursing Diagnosis

A nursing diagnosis consists of three essential components: the problem statement (diagnostic label), the related factors (etiology), and the defining characteristics (clinical cues). These components help to identify the client’s health problem and guide the nurse in formulating appropriate nursing interventions. Here’s a breakdown of each component:

1. Problem Statement (Diagnostic Label): The problem statement describes the health problem or alteration in the client’s condition. It represents the actual or potential response to the illness or the risk for developing complications. The problem statement is derived from a standardized list of nursing diagnoses, such as those provided by NANDA-I. Examples of problem statements include “Impaired Gas Exchange,” “Acute Pain,” or “Risk for Infection.”
2. Related Factors (Etiology): The related factors describe the underlying cause or contributing factors that lead to the client’s health problem. They provide insight into why the problem exists or what factors are influencing the client’s condition. Related factors can be physiological, psychological, sociocultural, or environmental. For example, if the problem statement is “Impaired Gas Exchange,” the related factors could be “pulmonary congestion due to heart failure” or “chronic obstructive pulmonary disease (COPD).”
3. Defining Characteristics (Clinical Cues): Defining characteristics are the clinical signs and symptoms that support the presence of the nursing diagnosis. They are the observable and measurable cues that indicate the client’s response to the health problem. Defining characteristics can include physical signs, laboratory results, behavioral changes, or subjective reports from the client. For instance, if the problem statement is “Acute Pain,” the defining characteristics could include the client’s self-report of pain, facial grimacing, guarding behavior, and increased heart rate.

• It’s important to note that not all nursing diagnoses require all three components. Some nursing diagnoses, particularly risk diagnoses, may not have defining characteristics as they focus on the potential for a problem to develop.
• However, the problem statement and related factors remain essential in all nursing diagnoses to accurately identify and address the client’s health needs.

Types of Nursing Diagnoses

Nursing diagnoses can be categorized into different types based on their purpose and focus. Here are four common types of nursing diagnoses:

1. Actual Nursing Diagnoses: These diagnoses represent health problems that are currently present and have been identified through assessment. Actual nursing diagnoses describe the client’s response to the illness or condition. Examples of actual nursing diagnoses include “Impaired Mobility,” “Acute Pain,” or “Impaired Skin Integrity.”
2. Risk Nursing Diagnoses: Risk nursing diagnoses identify potential health problems or complications that a client is vulnerable to develop. These diagnoses focus on the client’s risk factors, such as physiological, environmental, or situational factors, that increase the likelihood of a problem occurring. Examples of risk nursing diagnoses include “Risk for Falls,” “Risk for Infection,” or “Risk for Impaired Skin Integrity.”
3. Wellness Nursing Diagnoses: Wellness nursing diagnoses focus on promoting and maintaining the client’s health and well-being. These diagnoses highlight the client’s strengths, abilities, and potential for growth. Wellness nursing diagnoses are used when clients are in a state of well-being and seek to enhance their health. Examples of wellness nursing diagnoses include “Readiness for Enhanced Nutrition,” “Readiness for Enhanced Sleep,” or “Readiness for Enhanced Coping.”
4. Syndrome Nursing Diagnoses: Syndrome nursing diagnoses describe a cluster of related nursing diagnoses that frequently occur together. These diagnoses recognize that certain health conditions or circumstances have a common pattern of nursing diagnoses associated with them. Examples of syndrome nursing diagnoses include “Post-Trauma Syndrome” for clients who have experienced a traumatic event or “Disuse Syndrome” for clients who have experienced prolonged immobility.

• It’s important to note that these categories are not mutually exclusive, and a client may have multiple nursing diagnoses of different types.
• Nursing diagnoses are dynamic and can change over time as the client’s condition and needs evolve.

Classifications of Nursing Diagnoses

Nursing diagnoses are classified into different categories based on their nature, purpose, or focus. The two main classification systems for nursing diagnoses are the NANDA International (NANDA-I) taxonomy and the Clinical Care Classification (CCC) System. Here’s an overview of these classification systems:

1. NANDA International (NANDA-I) Taxonomy:

   • NANDA-I provides a standardized language and classification system for nursing diagnoses. The NANDA-I taxonomy consists of several domains, classes, and categories that organize nursing diagnoses into a hierarchical structure.
   • The current version of NANDA-I is NANDA-I Nursing Diagnoses: Definitions & Classification 2021-2023.
   • The NANDA-I taxonomy organizes nursing diagnoses into 13 domains, which represent areas of human health. Each domain is further divided into classes, and each class contains several nursing diagnoses. Some examples of NANDA-I domains include “Health Promotion,” “Nutrition,” “Coping/Stress Tolerance,” and “Safety/Protection.”

2. Clinical Care Classification (CCC) System:

   • The CCC System is another classification system that focuses on nursing diagnoses and interventions.
   • It was developed to support the electronic documentation and communication of nursing data. The CCC System classifies nursing diagnoses into 22 categories, which cover various aspects of nursing care, including physiological, psychological, and social dimensions.
   • The CCC System also incorporates related concepts such as nursing interventions, nursing outcomes, and care settings. It provides a standardized framework for documenting nursing diagnoses and facilitating data analysis for research and quality improvement purposes.

• Both the NANDA-I taxonomy and the CCC System are widely used in clinical practice, research, and electronic health record systems to facilitate consistent communication and documentation of nursing diagnoses.
• It’s important to consult the most up-to-date versions of these classification systems, as they are subject to revisions and updates over time to reflect advancements in nursing practice and research.

Writing Nursing Diagnostic Statements

When writing a nursing diagnosis statement, it is important to use a standardized format to ensure clarity and consistency. The nursing diagnosis statement typically consists of three components: the problem statement (diagnostic label), the related factors (etiology), and the defining characteristics (clinical cues). Below is how to write diagnostic statements for each type of nursing diagnosis, along with examples for each type:

1. Actual Nursing Diagnoses:

   1. Diagnostic Statement Format: [Problem Statement] related to [Related Factors], as evidenced by [Defining Characteristics].
   2. Examples:
      • Impaired Mobility related to musculoskeletal impairment, as evidenced by limited range of motion, difficulty walking independently, and impaired balance.
      • Acute Pain related to surgical incision, as evidenced by the patient’s self-report of severe pain (rated 9/10), guarding behavior, and facial grimacing.
      • Impaired Skin Integrity related to prolonged pressure, as evidenced by the presence of a Stage II pressure ulcer on the sacral area, erythema, and skin breakdown.
      • Activity Intolerance related to decreased oxygen-carrying capacity of the blood, as evidenced by fatigue, shortness of breath on exertion, and decreased exercise tolerance.
      • Risk for Uncontrolled Hypertension related to non-compliance with medication regimen and unhealthy lifestyle choices, as evidenced by consistently elevated blood pressure readings.
      • Impaired Gas Exchange related to alveolar consolidation and inflammation, as evidenced by decreased oxygen saturation, productive cough, and abnormal breath sounds.
      • Ineffective Airway Clearance related to excessive mucus production and bronchospasm, as evidenced by chronic cough, wheezing, and diminished breath sounds.
      • Risk for Urinary Tract Infection related to urinary catheterization and incomplete bladder emptying, as evidenced by cloudy urine, urgency, and elevated white blood cell count.
      • Deficient Knowledge related to diabetes management and self-care practices, as evidenced by incorrect administration of insulin, inconsistent blood glucose monitoring, and lack of dietary understanding.
      • Decreased Cardiac Output related to impaired myocardial contractility and increased afterload, as evidenced by decreased blood pressure, weak peripheral pulses, and fatigue.
      • Impaired Physical Mobility related to left-sided hemiparesis and decreased muscle strength, as evidenced by difficulty with ambulation and inability to perform activities of daily living independently.

2. Risk Nursing Diagnoses:

   1. Diagnostic Statement Format: Risk for [Health Problem] related to [Risk Factors].
   2. Examples:
      • Risk for Falls related to history of previous falls, unsteady gait, and use of assistive devices.
      • Risk for Infection related to compromised immune system, presence of invasive devices (e.g., central venous catheter), and recent surgical procedure.
      • Risk for Impaired Skin Integrity related to immobility, poor nutrition status, and excessive moisture from incontinence.
      • Risk for Infection related to compromised immune system, invasive procedures, and inadequate hand hygiene practices.
      • Risk for Falls related to advanced age, history of falls, and use of medications that cause dizziness.
      • Risk for Aspiration related to dysphagia, decreased level of consciousness, and poor oral hygiene.
      • Risk for Impaired Gas Exchange related to chronic respiratory illness, exposure to environmental pollutants, and smoking history.
      • Risk for Impaired Mobility related to musculoskeletal impairment, prolonged bed rest, and inadequate assistive devices.
      • Risk for Altered Nutrition: Less Than Body Requirements related to reduced appetite, financial constraints limiting access to nutritious food, and chronic illness affecting nutrient absorption.

3. Wellness Nursing Diagnoses:

   1. Diagnostic Statement Format: Readiness for Enhanced [Health Behavior] related to [Factors Supporting Enhancement].
   2. Examples:
      • Readiness for Enhanced Nutrition related to expressed willingness to learn about healthy eating, availability of healthy food options at home, and motivation to improve dietary habits.
      • Readiness for Enhanced Sleep related to implementation of a bedtime routine, creation of a conducive sleep environment, and commitment to practicing relaxation techniques.
      • Readiness for Enhanced Coping related to active participation in stress management education, utilization of effective coping strategies in previous stressful situations, and support from a strong social network.
      • Readiness for Enhanced Exercise related to willingness to engage in regular physical activity, access to exercise facilities, and setting specific exercise goals.
      • Readiness for Enhanced Self-Care related to expressed desire to improve self-care practices, access to necessary resources, and willingness to learn and practice self-care techniques.
      • Readiness for Enhanced Parenting related to desire to develop effective parenting skills, access to parenting education resources, and support from family and community.
      • Readiness for Enhanced Decision-Making related to active involvement in decision-making processes, acquisition of relevant information, and access to supportive decision-making tools.
      • Readiness for Enhanced Stress Management related to interest in stress reduction techniques, engagement in relaxation exercises, and access to stress management resources.

4. Syndrome Nursing Diagnoses:

   1. Diagnostic Statement Format: [Syndrome Name] related to [Contributing Factors], as evidenced by [Defining Characteristics].
   2. Examples:
      • Post-Trauma Syndrome related to exposure to a traumatic event, intrusive memories, avoidance behaviors, and heightened startle response.
      • Disuse Syndrome related to prolonged immobility, muscle atrophy, decreased muscle strength, and decreased endurance.
      • Rape Trauma Syndrome related to sexual assault, intense fear, anxiety, hypervigilance, and changes in sleep patterns.
      • Sudden Infant Death Syndrome (SIDS) related to unknown causes, sudden and unexplained death of an infant less than one year old during sleep.
      • Anticipatory Grieving related to terminal illness diagnosis, anticipation of loss, changes in lifestyle, and emotional distress.
      • Complex Regional Pain Syndrome (CRPS) related to trauma or injury, severe pain that is out of proportion to the initial injury, edema, and changes in skin color and temperature.
      • Asperger Syndrome related to neurodevelopmental disorder, difficulties with social interaction and communication, restricted and repetitive patterns of behavior, and intense interests in specific topics.
      • Fetal Alcohol Syndrome related to maternal alcohol consumption during pregnancy, growth deficiencies, facial abnormalities, intellectual disabilities, and behavioral problems.

5. Psychosocial Nursing Diagnoses:*

   Psychosocial issues are important considerations in nursing care, but they are typically addressed within the defining characteristics or related factors of actual nursing diagnoses. Psychosocial nursing diagnoses address the emotional, social, and psychological aspects of an individual’s well-being. Remember, psychosocial nursing diagnoses should be based on a thorough assessment of the client’s psychosocial factors, behaviors, and expressions, and should be individualized to their unique situation.

   Psychosocial nursing diagnoses are not officially recognized as a distinct type within the NANDA-I classification. The types of nursing diagnoses recognized by NANDA-I include actual nursing diagnoses, risk nursing diagnoses, and wellness nursing diagnoses.

   1. Diagnostic Statement Format: [Psychosocial Nursing Diagnosis] related to [Psychosocial Factors], as evidenced by [Defining Characteristics].
   2. Examples:
      • Ineffective Coping related to recent loss of a loved one, lack of social support, and expression of feelings of hopelessness, as evidenced by frequent tearfulness, withdrawal from social activities, and difficulty performing daily tasks.
      • Impaired Social Interaction related to social anxiety, low self-esteem, and lack of assertiveness skills, as evidenced by avoiding social situations, difficulty initiating conversations, and limited social network.
      • Disturbed Body Image related to changes in physical appearance due to chronic illness, negative self-perception, and social stigma, as evidenced by excessive preoccupation with physical appearance, avoidance of mirrors, and self-deprecating comments.
      • Risk for Loneliness related to relocation to a new community, limited social connections, and lack of opportunities for social engagement, as evidenced by expressed feelings of isolation, frequent expressions of longing for companionship, and limited contact with others.
      • Caregiver Role Strain related to caregiving responsibilities for a family member with chronic illness, lack of support from other family members, and financial strain, as evidenced by reports of feeling overwhelmed, signs of caregiver burnout, and neglecting personal self-care needs

• Remember to adapt the diagnostic statements to the specific client’s condition and use the appropriate NANDA-I nursing diagnoses from the most up-to-date sources.
• By following this format, nursing diagnosis statements can effectively communicate the client’s health problem, its underlying causes, and the supporting clinical cues. It aids in guiding nursing interventions and evaluating the outcomes of care.
• Remember to use the most current version of NANDA-I for standardized nursing diagnoses.

Documenting Nursing Diagnoses: Formats

In documenting nursing diagnoses, several formats can be used to ensure consistency and clarity in communication. Here are three common formats applied in writing nursing diagnoses:

1. PES Format:

   • The PES format stands for Problem, Etiology, and Signs/Symptoms. It is a widely used format for documenting nursing diagnoses.
     1. Problem (Diagnostic Label): Clearly state the problem or nursing diagnosis using a standardized label from NANDA-I.
     2. Etiology (Related Factors): Identify the underlying causes or contributing factors that led to the problem.
     3. Signs/Symptoms (Defining Characteristics): Document the observable signs and symptoms that support the presence of the nursing diagnosis.
   • Example using the PES format:
     1. Problem: Impaired Gas Exchange
     2. Etiology: Pulmonary congestion due to heart failure
     3. Signs/Symptoms: Shortness of breath, decreased oxygen saturation, adventitious lung sounds

2. NANDA-I Format:

   • The NANDA-I format follows the standardized taxonomy provided by NANDA International. It includes the diagnostic label, related factors, and defining characteristics.
     1. Diagnostic Label: Use the standardized nursing diagnosis label from NANDA-I.
     2. Related Factors: Identify the factors contributing to the nursing diagnosis.
     3. Defining Characteristics: List the observable signs and symptoms that support the nursing diagnosis.
   • Example using the NANDA-I format: Impaired Gas Exchange related to pulmonary congestion due to heart failure, as evidenced by shortness of breath, decreased oxygen saturation, and adventitious lung sounds.

3. Problem-Focused Format:

   • The problem-focused format emphasizes the problem or nursing diagnosis itself. It provides a concise statement of the problem without explicitly listing the related factors or defining characteristics.
   • Example using the problem-focused format: Impaired Gas Exchange in the context of heart failure.

• When documenting nursing diagnoses, it’s important to use clear and concise language, provide supporting evidence through defining characteristics, and ensure the diagnosis is consistent with the client’s assessment data.
• Remember to follow the specific documentation guidelines and policies of your healthcare facility, as they may have their own preferred format for documenting nursing diagnoses.

Documenting the Nursing Process – Where do Nursing Diagnoses Fit In?

SOAP notes, PIE notes, DAR, and ADPIE are formats used in documenting the nursing process, including nursing diagnoses. Below is a discussion of each:

1. SOAP Notes: SOAP stands for Subjective, Objective, Assessment, and Plan. This format is widely used in healthcare settings and follows a structured approach. The components include:
   • Subjective: Patient’s reported symptoms, concerns, and observations.
   • Objective: Measurable data such as vital signs, lab results, physical examination findings, etc.
   • Assessment: Analysis and interpretation of the subjective and objective data, including nursing diagnoses.
   • Plan: Proposed interventions, goals, expected outcomes, and evaluation criteria.
2. PIE Notes: PIE stands for Problem, Intervention, and Evaluation. This format focuses on the nursing process components and includes:
   • Problem: Identification and documentation of the nursing problem or diagnosis.
   • Intervention: Description of the nursing interventions or actions to address the problem.
   • Evaluation: Assessment of the patient’s response to the intervention and the effectiveness of the care provided.
3. DAR Notes: DAR stands for Data, Action, and Response. This format emphasizes the chronological flow of care and includes:
   • Data: Objective and subjective data gathered from the patient assessment.
   • Action: Nursing interventions or actions taken to address the identified problem or diagnosis.
   • Response: Evaluation and documentation of the patient’s response to the interventions.
4. Nursing Care Plans (NCPs): NCPs commonly utilize the ADPIE format. ADPIE stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation. It is a comprehensive format that includes all the essential components of the nursing process:
   • Assessment: Gathering and documenting relevant data about the patient’s health status.
   • Diagnosis: Identification and documentation of nursing diagnoses based on the assessment findings.
   • Planning: Establishing goals, outcomes, and interventions to address the diagnoses.
   • Implementation: Carrying out the planned interventions and documenting the care provided.
   • Evaluation: Assessing the patient’s progress and evaluating the effectiveness of the care plan.
5. NANDA-I (Nursing Diagnoses) care plan is widely recognized and used in nursing practice. It follows a standardized structure for documenting nursing diagnoses and care plans. The components of the NANDA care plan format include:
   • Nursing Diagnosis: The specific nursing diagnosis or problem identified based on the patient’s assessment data. NANDA-I provides a comprehensive list of standardized nursing diagnoses that can be used to accurately describe the patient’s condition.
   • Related Factors/Etiology: The underlying factors or conditions contributing to the nursing diagnosis. This helps to understand the cause or contributing factors to the identified problem.
   • Defining Characteristics: Observable signs, symptoms, or evidence that support the nursing diagnosis. These are the clinical cues or objective/subjective data that confirm the presence of the nursing problem.
   • Goals/Expected Outcomes: Specific and measurable goals that describe the desired patient outcomes related to the nursing diagnosis. These goals should be realistic, achievable, and relevant to the patient’s condition.
   • Nursing Interventions: The actions, strategies, or treatments that the nurse will implement to address the nursing diagnosis and achieve the desired outcomes. These interventions should be evidence-based and tailored to the individual patient.
   • Rationale: The scientific or clinical justification for selecting and implementing the nursing interventions. This explains the reasoning behind the chosen interventions and their expected impact on the patient’s condition.
   • Evaluation: Assessment of the patient’s response to the nursing interventions and the achievement of the expected outcomes. This involves evaluating the effectiveness of the care plan and making any necessary modifications based on the patient’s progress.

• These formats provide structure and consistency in documenting the nursing care plan. However, it’s important to note that healthcare facilities may have their own preferred formats or electronic health record systems that determine the specific layout and structure of NCPs.
• Nurses should adhere to the facility’s guidelines and documentation standards while creating care plans.