What is the most important reason for nurses to use a standardized taxonomic such as Nanda I?
In this ultimate tutorial and nursing diagnosis list, know the concepts behind writing NANDA nursing diagnosis. Learn what a nursing diagnosis is, its history and evolution, the nursing process, the different types and classifications, and how to write NANDA nursing diagnoses correctly. Included also in this guide are tips on how you can formulate better nursing diagnoses, plus guides on how you can use them in creating your nursing care plans. Show
What is a Nursing Diagnosis?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. Purposes of Nursing DiagnosisThe purpose of the nursing diagnosis is as follows:
Differentiating Nursing Diagnoses, Medical Diagnoses, and Collaborative ProblemsThe term nursing diagnosis is associated with three different concepts. It may refer to the distinct second step in the nursing process, diagnosis. Also, nursing diagnosis applies to the label when nurses assign meaning to collected data appropriately labeled with NANDA-I-approved nursing diagnosis. For example, during the assessment, the nurse may recognize that the client feels anxious, fearful, and finds it difficult to sleep. Those problems are labeled with nursing diagnoses: respectively, Anxiety, Fear, and Disturbed Sleep Pattern. Lastly, a nursing diagnosis refers to one of many diagnoses in the classification system established and approved by NANDA. In this context, a nursing diagnosis is based upon the patient’s response to the medical condition. It is called a ‘nursing diagnosis’ because these are matters that hold a distinct and precise action associated with what nurses have the autonomy to take action about with a specific disease or condition. This includes anything that is a physical, mental, and spiritual type of response. Hence, a nursing diagnosis is focused on care. COMPARED. Nursing diagnoses vs medical diagnoses vs collaborative problemsOn the other hand, a medical diagnosis is made by the physician or advanced health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat. Moreover, through experience and know-how, the specific and precise clinical entity that might be the possible cause of the illness will then be undertaken by the doctor, therefore, providing the proper medication that would cure the illness. Examples of medical diagnoses are Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. The medical diagnosis normally does not change. Nurses must follow the physician’s orders and carry out prescribed treatments and therapies. Collaborative problems are potential problems that nurses manage using both independent and physician-prescribed interventions. These are problems or conditions that require both medical and nursing interventions, with the nursing aspect focused on monitoring the client’s condition and preventing the development of the potential complication. As explained above, now it is easier to distinguish a nursing diagnosis from a medical diagnosis. Nursing diagnosis is directed towards the patient and his 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. NANDA International (NANDA-I)NANDA-International, earlier known as the North American Nursing Diagnosis Association (NANDA), is the principal organization for defining, distributing and integrating standardized nursing diagnoses worldwide. The term nursing diagnosis was first mentioned in the nursing literature in the 1950s. Two faculty members of Saint Louis University, Kristine Gebbie and Mary Ann Lavin recognized the need to identify nurses’ roles in an ambulatory care setting. In 1973, NANDA’s first national conference was held to identify, develop, and classify nursing diagnoses formally. Subsequent national conferences occurred in 1975, 1980, and every two years. In recognition of the participation of nurses in the United States and Canada, in 1982, the group accepted the name North American Nursing Diagnosis Association (NANDA). In 2002, NANDA became NANDA International (NANDA-I) in response to its significant growth in membership outside of North America. The acronym NANDA was retained in the name because of its recognition. Review, refinement, and research of diagnostic labels continue as new and modified labels are discussed at each biennial conference. Nurses can submit diagnoses to the Diagnostic Review Committee for review. The NANDA-I board of directors gives the final approval for incorporating the diagnosis into the official list of labels. As of 2021, NANDA-I has approved 267 diagnoses for clinical use, testing, and refinement. History and Evolution of Nursing DiagnosisIn this section, we’ll look at the events that led to the evolution of nursing diagnosis today:
Classification of Nursing Diagnoses (Taxonomy II)How are nursing diagnoses listed, arranged, or classified? In 2002, Taxonomy II was adopted, which was based on the Functional Health Patterns assessment framework of Dr. Mary Joy Gordon. Taxonomy II has three levels: Domains (13), Classes (47), and nursing diagnoses. Nursing diagnoses are no longer grouped by Gordon’s patterns but coded according to seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology. In addition, diagnoses are now listed alphabetically by their concept, not by the first word. NURSING DIAGNOSIS TAXONOMY II. Taxonomy II for nursing diagnosis contains 13 domains and 47 classes. Image via: Wikipedia.com
Nursing ProcessThe 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. The steps, importance, purposes, and characteristics of the nursing process are discussed more in detail here: “The Nursing Process: A Comprehensive Guide“ Types of Nursing DiagnosesThe four types of NANDA-I nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome. Here are the four categories of nursing diagnoses provided by the NANDA-I system. TYPES OF NURSING DIAGNOSES. The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.Problem-Focused Nursing DiagnosisA 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. Problem-focused nursing diagnoses have three components: (1) nursing diagnosis, (2) related factors, and (3) defining characteristics. Examples of actual nursing diagnoses are:
Risk Nursing DiagnosisThe second type of nursing diagnosis is called risk nursing diagnosis. These are clinical judgments that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. 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. Components of a risk nursing diagnosis include (1) risk diagnostic label, and (2) risk factors. Examples of risk nursing diagnosis are:
Health Promotion DiagnosisHealth promotion diagnosis (also known as wellness diagnosis) is a clinical judgment about motivation and desire to increase well-being. 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:
Syndrome DiagnosisA 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:
Possible Nursing DiagnosisA 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:
Components of a Nursing DiagnosisA nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis). BUILDING BLOCKS OF A DIAGNOSTIC STATEMENT. Components of an NDx may include problem, etiology, risk factors, and defining characteristics.Problem and DefinitionThe problem statement, or the diagnostic label, describes the client’s health problem or response to which nursing therapy is given concisely. A diagnostic label usually has two parts: qualifier and focus of the diagnosis. Qualifiers (also called modifiers) are words that have been added to some diagnostic labels to give additional meaning, limit, or specify the diagnostic statement. Exempted in this rule are one-word nursing diagnoses (e.g., Anxiety, Constipation, Diarrhea, Nausea, etc.) where their qualifier and focus are inherent in the one term.
EtiologyThe etiology, or related factors, component of a nursing diagnosis label identifies one or more probable causes of the health problem, are the conditions involved in the development of the problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care. Nursing interventions should be aimed at etiological factors in order to remove the underlying cause of the nursing diagnosis. Etiology is linked with the problem statement with the phrase “related to” such as:
Risk FactorsRisk factors are used instead of etiological factors for risk nursing diagnosis. Risk factors are forces that put an individual (or group) at an increased vulnerability to an unhealthy condition. Risk factors are written following the phrase “as evidenced by” in the diagnostic statement.
Defining CharacteristicsDefining characteristics are the clusters of signs and symptoms that indicate the presence of a particular diagnostic label. In actual nursing diagnoses, the defining characteristics are the identified signs and symptoms of the client. For risk nursing diagnosis, no signs and symptoms are present therefore the factors that cause the client to be more susceptible to the problem form the etiology of a risk nursing diagnosis. Defining characteristics are written following the phrase “as evidenced by” or “as manifested by” in the diagnostic statement. Diagnostic Process: How to DiagnoseThere are three phases during the diagnostic process: (1) data analysis, (2) identification of the client’s health problems, health risks, and strengths, and (3) formulation of diagnostic statements. Analyzing DataAnalysis of data involves comparing patient data against standards, clustering the cues, and identifying gaps and inconsistencies. Identifying Health Problems, Risks, and StrengthsIn this decision-making step, after data analysis, the nurse and the client identify problems that support tentative actual, risk, and possible diagnoses. It involves determining whether a problem is a nursing diagnosis, medical diagnosis, or a collaborative problem. Also, at this stage, the nurse and the client identify the client’s strengths, resources, and abilities to cope. Formulating Diagnostic StatementsFormulation of diagnostic statements is the last step of the diagnostic process wherein the nurse creates diagnostic statements. The process is detailed below. How to Write a Nursing Diagnosis?In writing nursing diagnostic statements, describe an individual’s health status and the factors that have contributed to the status. You do not need to include all types of diagnostic indicators. Writing diagnostic statements vary per type of nursing diagnosis (see below). PES FormatAnother 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. PES FORMAT. Writing nursing diagnoses using the PES format.One-Part Nursing Diagnosis StatementHealth 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:
Two-Part Nursing Diagnosis StatementRisk and possible nursing diagnoses have two-part statements: the first part is the diagnostic label and the second is the validation for a risk nursing diagnosis or the presence of risk factors. It’s not possible to have a third part for risk or possible diagnoses because signs and symptoms do not exist. Examples of two-part nursing diagnosis statements include:
Three-part Nursing Diagnosis StatementAn actual or problem-focus nursing diagnosis has three-part statements: diagnostic label, contributing factor (“related to”), and signs and symptoms (“as evidenced by” or “as manifested by”). The three-part nursing diagnosis statement is also called the PES format which includes the Problem, Etiology, and Signs and Symptoms. Examples of three-part nursing diagnosis statements include:
Variations on Basic Statement Formats Variations in writing nursing diagnosis statement formats include the following:
Nursing Diagnosis for Care PlansThis section is the list or database of the common NANDA nursing diagnosis examples that you can use to develop your nursing care plans.
You can find the complete list of nursing diagnoses and their definitions at NANDA International Nursing Diagnoses: Definitions & Classification 2018-2020 11th Edition. Recommended ResourcesRecommended nursing diagnosis and nursing care plan books and resources. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.
See alsoOther recommended site resources for this nursing care plan:
References and SourcesReferences for this Nursing Diagnosis guide and recommended resources to further your reading.
Why is Nanda important in nursing?NANDA diagnoses help strengthen a nurse's awareness, professional role, and professional abilities. Formed in 1982, NANDA is a professional organization that develops, researches, disseminates, and refines the nursing terminology of nursing diagnosis.
What does Nanda mean in nursing diagnosis?A working definition of nursing diagnosis was adopted by the North American Nursing Diagnosis Association (NANDA) Biennial Business Meeting in March 1990.
Why is it important to develop an accurate nursing diagnosis?Accuracy of nurses' diagnoses is defined as a rater's judgment of the match between a diagnostic statement and patient data. Low accuracy can lead to wasted time and energy, harm to patients, absence of positive outcomes, and patient and family dissatisfaction.
What is Nanda and what is its contribution to the nursing diagnosis process?NANDA-International, earlier known as the North American Nursing Diagnosis Association (NANDA), is the principal organization for defining, distributing and integrating standardized nursing diagnoses worldwide. The term nursing diagnosis was first mentioned in the nursing literature in the 1950s.
|