[hen-ui-dynamic-experience placement=”aboveTheFold” /][hen-ui-text variant=”b4″]In 1982, NANDA-I, then known as the North American Nursing Diagnosis Association (NANDA), created official nursing diagnosis classifications to help document the many clinical decisions nurses make on behalf of their patients.[/hen-ui-text][hen-ui-text variant=”b4″]Creating and implementing a nursing diagnosis improves communication and patient care outcomes. Nursing diagnoses and processes help ensure and promote evidence-based, safe practices.[/hen-ui-text][hen-ui-text variant=”b4″]Learn about nursing diagnosis, its importance, and how to write one.[/hen-ui-text][hen-ui-flex gap=”xl” align=”left” direction=”column”][hen-ui-flex gap=”xs” align=”left” direction=”column”][hen-ui-heading variant=”h2″]Popular Online RN-to-BSN Programs[/hen-ui-heading][hen-ui-text variant=”b4″ color=”subtext”]Learn about start dates, transferring credits, availability of financial aid, and more by contacting the universities below.[/hen-ui-text][/hen-ui-flex][hen-ui-dynamic-experience placement=”belowTheFold” /][/hen-ui-flex][hen-ui-heading variant=”h2″]What Is a Nursing Diagnosis?[/hen-ui-heading][hen-ui-text variant=”b4″][hen-ui-link href=”https://nanda.org/who-we-are/our-story/” target=”_blank”]NANDA-I[/hen-ui-link] defines the nursing diagnosis as communicating “the professional judgments that nurses make every day to our patients, colleagues, members of other disciplines and the public.”[/hen-ui-text][hen-ui-text variant=”b4″]A nursing diagnosis generally has three components:[/hen-ui-text][hen-ui-list variant=”unordered” bullet-style=”bullet”] [hen-ui-list-item][hen-ui-text variant=”b4″]A diagnosis approved by NANDA-I[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]A “related to” statement that defines the cause of the NANDA-I diagnosis[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]An “as evidenced by” statement that uses specific patient data to provide a reason for the diagnosis.[/hen-ui-text][/hen-ui-list-item][/hen-ui-list][hen-ui-text variant=”b4″]Risk-related nursing diagnoses are used when patients are at risk for developing certain conditions. In this case, nurses use “risk for” and “as evidenced by” statements.[/hen-ui-text][hen-ui-text variant=”b4″]The nursing diagnosis involves nurses’ clinical decisions and expands the nursing process, which includes five core steps.[/hen-ui-text][hen-ui-list variant=”ordered” bullet-style=”check”] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h3″]Assessment[/hen-ui-heading] [hen-ui-text variant=”b4″]Assessment is a thorough and holistic evaluation of a patient. It includes the collection of both subjective and objective patient data such as vital signs, a health history, head-to-toe physical, and a psychological, socioeconomic, and spiritual evaluation.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h3″]Diagnosis[/hen-ui-heading] [hen-ui-text-stack gap=”xs”] [hen-ui-text variant=”b4″]The nurse forms the diagnosis based on the data collected during the assessment. The nursing diagnosis directs nursing-specific patient care.[/hen-ui-text] [hen-ui-text variant=”b4″]In this step, the nurse forms a diagnosis based on the patient’s specific medical and/or social needs. The diagnosis leads to the creation of goals with measurable outcomes.[/hen-ui-text] [/hen-ui-text-stack] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h3″]Outcomes and Planning[/hen-ui-heading] [hen-ui-text variant=”b4″]Outcome and planning involve developing a [hen-ui-link href=”https://nursejournal.org/articles/nursing-care-plans-explained/”]nursing care plan[/hen-ui-link] based on the nursing diagnosis. Planning should be measurable and goal-oriented for the patient and/or their family.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h3″]Implementation[/hen-ui-heading] [hen-ui-text variant=”b4″]Implementation is when nurses initiate the care plan and put it into action. This step provides the continuation of care during hospitalization until discharge.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h3″]Evaluation[/hen-ui-heading] [hen-ui-text variant=”b4″]Evaluation is the final step of the nursing process. A patient care plan is evaluated based on specific goals and desired outcomes and may be adjusted based on the patient’s needs.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item][/hen-ui-list][hen-ui-heading variant=”h2″]How Does a Nurse’s Diagnosis Differ From a Doctor’s Diagnosis?[/hen-ui-heading][hen-ui-text variant=”b4″]A nurse initiates a nurse’s diagnosis. The nursing diagnosis focuses on the patient’s needs and outcomes holistically.[/hen-ui-text][hen-ui-text variant=”b4″]A nursing diagnosis aims to incorporate every part of the nursing practice and clinical judgment into accurate documentation.[/hen-ui-text][hen-ui-text variant=”b4″]A doctor’s diagnosis focuses on assessing the patient’s signs and symptoms, identifying the condition, and constructing a medical diagnosis. In many states, [hen-ui-link href=”https://nursejournal.org/careers/advanced-practice-nursing/”]advanced practice registered nurses (APRNs)[/hen-ui-link] have [hen-ui-link href=”https://nursejournal.org/nurse-practitioner/np-practice-authority-by-state/”]full practice authority[/hen-ui-link], so they can diagnose patients independently of a physician.[/hen-ui-text][hen-ui-grid columns-md=”2″ gap=”md”] [hen-ui-card variant=”background-white” border=”stroke” padding=”lg”] [hen-ui-card-content] [hen-ui-heading variant=”h3″]Nursing Diagnosis[/hen-ui-heading] [hen-ui-list variant=”unordered” bullet-style=”bullet”] [hen-ui-list-item][hen-ui-text variant=”b4″]Based on the patient’s immediate situation[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Initiated to resolve a health problem[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Improves communication among the healthcare teams[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]A holistic approach to caring for patients[/hen-ui-text][/hen-ui-list-item][/hen-ui-list] [hen-ui-text variant=”b4″]Example: Ineffective breathing pattern related to impaired inhalation and exhalation as evidenced by the use of accessory muscles[/hen-ui-text] [/hen-ui-card-content][/hen-ui-card] [hen-ui-card variant=”background-white” border=”stroke” padding=”lg”] [hen-ui-card-content] [hen-ui-heading variant=”h3″]Medical Diagnosis[/hen-ui-heading] [hen-ui-list variant=”unordered” bullet-style=”bullet”] [hen-ui-list-item][hen-ui-text variant=”b4″]Initiated by a medical doctor or specialist[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Defines a medical condition, disease, or injury[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Explains the signs and symptoms of the disease[/hen-ui-text][/hen-ui-list-item][/hen-ui-list] [hen-ui-text variant=”b4″]Example: Asthma[/hen-ui-text] [/hen-ui-card-content][/hen-ui-card][/hen-ui-grid][hen-ui-heading variant=”h2″]4 Categories of Nursing Diagnoses[/hen-ui-heading][hen-ui-text variant=”b4″]NANDA-I divides nursing diagnosis into four main categories.[/hen-ui-text][hen-ui-heading variant=”h3″]1 | Problem-focused Diagnosis[/hen-ui-heading][hen-ui-text variant=”b4″]A problem-focused nursing diagnosis is related to a patient’s problem. It can be used throughout the patient’s hospitalization or resolved by the shift’s end.[/hen-ui-text][hen-ui-text variant=”b4″]Example: Anxiety related to situational crises and stress (related factors) as evidenced by restlessness, insomnia, anguish, and anorexia (defining characteristics)[/hen-ui-text][hen-ui-heading variant=”h3″]2 | Risk Diagnosis[/hen-ui-heading][hen-ui-text variant=”b4″]A risk nursing diagnosis identifies when the patient is at risk for developing a problem. NANDA-I describes it as a vulnerability the patient has encountered.[/hen-ui-text][hen-ui-text variant=”b4″]Example: Risk for infection as evidenced by inadequate vaccination and immunosuppression (risk factors)[/hen-ui-text][hen-ui-heading variant=”h3″]3 | Health Promotion Diagnosis[/hen-ui-heading][hen-ui-text variant=”b4″]A health promotion diagnosis identifies how to improve a patient’s health. A health promotion diagnosis includes the patient and their family/community members.[/hen-ui-text][hen-ui-text variant=”b4″]Example: Readiness for enhanced self-care as evidenced by expressed desire to enhance self-care[/hen-ui-text][hen-ui-heading variant=”h3″]4 | Syndrome Diagnosis[/hen-ui-heading][hen-ui-text variant=”b4″]A syndrome nursing diagnosis identifies a cluster of diagnoses for a patient. These nursing diagnoses are best described together. The patient may be experiencing several health problems forming a pattern.[/hen-ui-text][hen-ui-text variant=”b4″]Example: Chronic pain syndrome[/hen-ui-text][hen-ui-heading variant=”h2″]Nursing Diagnosis Classification[/hen-ui-heading][hen-ui-text variant=”b4″]NANDA-I created Taxonomy II after collaborating with the National Library of Medicine. Taxonomy, [hen-ui-link href=”https://nanda.org/connect-engage/committees-task-forces/taxonomy-task-force/” target=”_blank”]defined as[/hen-ui-link] “a system of naming, describing, and classifying related things,” was created to standardize care. There are three levels: nursing diagnosis, domains, and classes.[/hen-ui-text][hen-ui-text variant=”b4″]The NANDA-I Taxonomy II currently has over 200 nursing diagnoses, 47 classes, and 13 domains of nursing practice. The domains are:[/hen-ui-text][hen-ui-list variant=”ordered” bullet-style=”number”] [hen-ui-list-item][hen-ui-text variant=”b4″]Health promotion[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Nutrition[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Elimination and exchange[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Activity/rest[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Perception/cognition[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Self-perception[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Role relationships[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Sexuality[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Coping/stress tolerance[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Life principles[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Safety/protection[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Comfort[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Growth/development[/hen-ui-text][/hen-ui-list-item][/hen-ui-list][hen-ui-text variant=”b4″]Each domain is associated with specific classes.[/hen-ui-text][hen-ui-card variant=”background-gray” border=”stroke”] [hen-ui-card-content] [hen-ui-heading variant=”h2″]How to Perform a Nursing Diagnosis[/hen-ui-heading][hen-ui-text variant=”b4″]Nurses complete five steps to carry out a strong, accurate nursing diagnosis. Nurses should follow the five nursing processes:[/hen-ui-text][hen-ui-list variant=”ordered” bullet-style=”check”] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h3″]Nursing Science[/hen-ui-heading] [hen-ui-text variant=”b4″]Understanding nursing science and theory provides a strong foundation for patient care. It is also the first step in initiating a holistic, patient-centered nursing diagnosis and care plan.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h3″]Assessment[/hen-ui-heading] [hen-ui-text variant=”b4″]During the [hen-ui-link href=”https://nursejournal.org/resources/nursing-health-assessment/”]health assessment[/hen-ui-link], nurses gather medical, surgical, and social history and perform a physical on the patient.Nurses then ask themselves: What is the current and priority health problem(s) the patient is experiencing? This information is applied to creating a nursing diagnosis.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h3″]Identifying Potential Diagnoses[/hen-ui-heading] [hen-ui-text-stack gap=”xs”] [hen-ui-text variant=”b4″]Once the health problem or human response(s) is identified, nurses ask another question: What important information is relevant to the health problem and what’s unrelated?[/hen-ui-text] [hen-ui-text variant=”b4″]The answer to this question helps create a potential nursing diagnosis. Nurses will then:[/hen-ui-text] [/hen-ui-text-stack] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Confirm and rule out other diagnoses[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Create new diagnoses[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h3″]Implementing a Care Plan[/hen-ui-heading] [hen-ui-text variant=”b4″]A nursing diagnosis determines the [hen-ui-link href=”https://nursejournal.org/articles/nursing-care-plans-explained/”]care plan[/hen-ui-link]. Nurses create measurable, achievable goals and related interventions. They then take action, administering the planned interventions.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h3″]Evaluate[/hen-ui-heading] [hen-ui-text variant=”b4″]Nurses constantly evaluate their patients. They often evaluate a nursing diagnosis to ensure the care plan works. If the nursing diagnosis doesn’t fit the situation, nurses must consider what else can be done to improve the patient’s health.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item][/hen-ui-list] [/hen-ui-card-content][/hen-ui-card][hen-ui-text variant=”b4″]Nurses and nursing students must become members of NANDA-I or purchase the NANDA-I Taxonomy II book to obtain the complete list of nursing diagnoses.[/hen-ui-text]