Nursing Diagnosis Guide

What a nursing diagnosis is

A nursing diagnosis is the nurse's clinical judgment about a patient's response to an actual or potential health problem. It is the bridge between assessment and planning: the assessment produces cues, the diagnosis interprets them, and the plan acts on that interpretation.

A medical diagnosis names the disease and generally does not change while the disease exists. A nursing diagnosis names the response and can change hour to hour. Pneumonia is a medical diagnosis; ineffective airway clearance, activity intolerance and anxiety are the nursing diagnoses that may accompany it.

Four types

• Problem-focused: a response that is present now, supported by defining characteristics — for example acute pain.
• Risk: no signs yet, but recognized risk factors make the problem likely — for example risk for falls. A risk diagnosis never has 'as evidenced by' signs, only risk factors.
• Health promotion: the patient is motivated to improve wellbeing — for example readiness for enhanced nutrition.
• Syndrome: a cluster of diagnoses that predictably occur together — for example chronic pain syndrome.

Building the statement

Two-part statements are used for risk and health-promotion diagnoses; three-part PES statements are used for problem-focused diagnoses. One-part statements appear with some syndrome and health-promotion labels where the label speaks for itself.

1. 1Problem (P). The diagnostic label plus any qualifier such as impaired, ineffective, decreased, risk for.
2. 2Etiology (E). The related factors — the cause nursing can influence. Joined with 'related to'. Never write a medical diagnosis here if a physiological mechanism can be named instead.
3. 3Signs and symptoms (S). The defining characteristics that prove the problem exists. Joined with 'as evidenced by'. Omitted for risk diagnoses.

Examples

• Ineffective airway clearance related to retained thick secretions as evidenced by coarse crackles, weak cough and SpO2 of 89%.
• Risk for infection as evidenced by — no; correctly: Risk for infection related to a surgical incision and an indwelling urinary catheter.
• Deficient fluid volume related to excessive gastrointestinal losses as evidenced by dry mucous membranes, urine output of 20 mL/hr and heart rate of 118.
• Readiness for enhanced health management as evidenced by the client's expressed desire to manage risk factors after myocardial infarction.

Prioritizing diagnoses

• High priority: anything threatening airway, breathing, circulation, safety or life.
• Medium priority: problems causing significant distress or that will lead to harm if untreated but are not immediately life-threatening.
• Low priority: problems relating to long-term development, learning or lifestyle that can wait for the acute issue to resolve.
• Reassess priority every shift — the ranking is not fixed and the patient's own stated priority matters.

Pitfalls

• Using judgmental or legally risky language such as 'noncompliant' or 'poor hygiene due to laziness'.
• Putting the cause and the problem the wrong way round.
• Writing the medical diagnosis as the related factor when a modifiable mechanism exists.
• Reversing a risk diagnosis into a problem-focused one by adding signs that are not there.
• Choosing a label because it is familiar rather than because the cues support it.