Reference:

Lecturer (Tuiza)

Nursing diagnosis entails problem identification. It is a clinical judgment about the client’s responses to actual and potential health problems or life processes. It is based on critical analysis of assessment data and identified client strengths and problems. In contemporary standards, the North American Nursing Diagnosis Association (NANDA) for nursing diagnoses. A nursing diagnosis can focus on different types of problems:

Type	Description
Actual nursing diagnosis	Problem-based. A problem present at the time of assessment. Ex.: “Altered respiratory status”, “Impaired ability to cope”
Health promotion diagnosis	Client preparedness to improve health condition. Ex.: “Willingness to learn about the health maintenance”, “Willingness to change health practices”
Risk nursing diagnosis	Problem-based, for problems not yet present but whose risk factors are present. Ex.: “Risk for or Potential for impaired breathing patterns”
Syndrome diagnosis	Syndromes are a set of similar nursing diagnoses that occur together, and can be resolved with similar interventions. Ex.: “Chronic Pain Syndrome”
Wellness diagnosis	A state of health that may be further enhanced by health promoting activities. Ex.: “Readiness of enhanced spiritual wellbeing”

vs. Medical Diagnoses

Medical diagnoses name the disease at hand, its pathology, and does not describe human responses. As long as the disease remains, this diagnosis does not change. In contrast, nursing diagnoses describe human responses to the disease process or health problem. These change throughout the disease process and can change frequently.

Components of a Nursing Diagnosis

Problem: the health problem, response, or status of the patient. These are paired with qualifiers that add context to the problem. These are words such as “Deteriorated”, “Vulnerable to threat”, “Incomplete”. These are diagnostic labels that direct the formation of client goals and desired outcomes.
Etiology: one or more probably causes of the health problem, giving direction to required nursing therapy. These specify the health problem to the individual at hand, providing client-centered care.
Signs and Symptoms: clusters of signs and symptoms that indicate the presence of a particular diagnostic label. These are used for actual nursing diagnoses, and are not available for risk nursing diagnoses.

Diagnostic Process

Analyze Data: collect and compare significant assessment cues against standards. Cluster these cues for a tentative hypothesis, and identify gaps and inconsistencies (conflicting or erroneous data).
Identify Health Problems, Risks, or Strengths
Formulate Diagnostic Statement: using the components of the nursing diagnosis to create a one-part, two-part, or three-part diagnosis:
- One-part Statement: only the problem (nursing diagnosis) is stated, with no etiology or signs/symptoms necessary. Ex.: “Readiness for enhanced community coping”.
- Two-part Statement: the problem and its etiology, often used for risk statements, as patients do not yet have signs and symptoms. Ex.: “Non-adherence (diabetic diet) related to denial of having disease”, “Anxiety related to threat to physiologic integrity: possible cancer diagnosis”
- Three-part Statement: a full statement of the three components of a nursing diagnosis. Ex.: “Impaired self-esteem related to feelings of rejection by husband as manifested by hypersensitivity to criticism; states “I don’t know if I can manage by myself” and rejects positive feedback”.

Writing a Nursing Diagnosis

State a problem, not a need: Alteration in fluid rather than Fluid replacement.
Word the statement so that it is legally advisable; avoid “incriminatory” statements that predispose the nurse to complaints: Altered skin integrity related to improper positioning insinuates that the problem is caused by negligent care → Altered skin integrity related to immobility
Use non-judgmental statements: Impaired spirituality related to inability to attend church services secondary to immobility rather than Impaired spirituality related to strict rules necessitating church attendance.
Avoid redundancy between the problem and etiology: Altered skin integrity related to ulceration of sacral area is a self-referencing diagnosis. Instead, write Potential for altered skin integrity related to immobility.
Ensure correctness of the cause-and-effect relationship: Pain related to headache is invalid as the headache does not cause pain; it is pain itself. Instead, Pain: severe headache related to avoidance of narcotics due to fear of addiction provides an appropriate etiological statement.
Word the diagnosis specifically and precisely: Alteration in mucous membrane integrity related to noxious agent identifies the etiology, but does not specify the type of interventions potentially required. Instead, Alteration in mucous membrane integrity related to decreased salivation secondary to radiation of neck can point nurses to the proper interventions to use.
Use nursing terminology rather than medical terminology to describe the client’s response: Potential for pneumonia is medical in nature; Potential for altered respiratory status related to accumulation of secretions in lungs better fits a nurse’s field of knowledge. Similarly, etiologies should also use nursing terminology: …related to accumulation of secretion in lungs rather than …related to pneumonia.

List of the accepted nursing diagnoses for use and research (NANDA Diagnoses, Prioritized Interventions, and Rationales 16th Ed., 2021 - 2023)

Diagnosis Modifiers
Activity Planning Ineffective, Risk for Ineffective
Activity Tolerance Decreased
Acute Substance Withdrawal Syndrome Risk for
Adverse Reaction to Iodinated Contrast Media Risk for
Airway Clearance Ineffective
Allergy Reaction Risk for
Anxiety [specify level], Death
Aspiration Risk for
Attachment Risk for Impaired
Autonomic Dysreflexia (As one-part diagnosis), Risk for
Behavior Disorganized Infant, Readiness for Enhanced Disorganized Infant
Bleeding Risk for
Blood Glucose Level Risk for Unstable
Body Image Disturbed
Breast Milk Production Insufficient
Breastfeeding Ineffective, Interrupted, Readiness for Enhanced
Breathing Pattern Ineffective
Cardiac Output Decreased, Risk for Decreased
Cardiovascular Function Risk for Impaired
Childbearing Process Readiness for Enhanced, Risk for Ineffective
Chronic Pain Syndrome -
Comfort Impaired, Readiness for Enhanced
Communication Impaired Verbal, Readiness for Enhanced
Confusion Acute, Chronic, Risk for Acute
Constipation (As one-part diagnosis), Chronic Functional, Perceived, Risk for, Risk for Chronic Functional
Contamination (As one-part diagnosis), Risk for
Continence Impaired Bowel
Coping Compromised Family, Defensive, Disabled Family, Ineffective, Ineffective Community, Readiness for Enhanced, Readiness for Enhanced Community, Readiness for Enhanced Family
Decision-Making Readiness for Enhanced
Decisional Conflict (As one-part diagnosis)
Denial Ineffective
Dentition Impaired
Development Delayed Child, Risk for Delayed Child
Diarrhea (As one-part diagnosis)
Disuse Syndrome Risk for
Disturbed Family Identity Syndrome (As one-part diagnosis), Risk for
Diversional Activity Engagement Risk for Decreased
Dry Eye Risk for
Dry Eye Self-Management Ineffective
Dry Mouth Risk for
Eating Dynamics Ineffective Adolescent, Ineffective Child, Ineffective Infant
Electrolyte Imbalance Risk for
Elimination Impaired Urinary
Elopement Attempt Risk for
Emancipated Decision-Making Impaired, Readiness for Enhanced, Risk for Impaired
Emotional Control Labile
Energy Field Imbalanced
Exercise Engagement Readiness for Enhanced
Falls Risk for Adult, Risk for Child
Family Processes Dysfunctional, Interrupted, Readiness for Enhanced
Fatigue (As one-part diagnosis)
Fear (As one-part diagnosis)
Female Genital Mutilation Risk for
Fluid Volume Deficient (Hyper-/hypotonic), Deficient (Isotonic), Excess, Risk for Deficient, Risk for Imbalanced
Frail Elderly Syndrome (As one-part diagnosis), Risk For
Gas Exchange Impaired
Gastrointestinal Motility Dysfunctional, Risk for Dysfunctional
Grieving Readiness for Enhanced, Maladaptive, Risk for Maladaptive
Growth Risk for Disproportionate
Health Deficient Community
Health Behavior Risk-prone
Health Literacy Readiness for Enhanced
Health Maintenance Behaviors Ineffective
Health Self-Management Ineffective, Ineffective Family, Readiness for Enhanced
Home Maintenance Behaviors Ineffective, Readiness for Enhanced, Risk for Ineffective
Hope Readiness for Enhanced
Hopelessness (As one-part diagnosis)
Human Dignity Risk for Compromised
Hyperbilirubinemia Neonatal, Risk for Neonatal
Hyperthermia (As one-part diagnosis)
Hypothermia (As one-part diagnosis), Neonatal, Risk for, Risk for Neonatal, Risk for Perioperative
Immigration Transition Risk for Complicated
Impulse Control Ineffective
Incontinence Disability-Associated Urinary, Mixed Urinary, Stress Urinary, Risk for Urge Urinary, Urge Urinery
Infection Risk for
Injury Risk for, Risk for Urinary Tract
Insomnia (As one-part diagnosis)
Knowledge Deficient, Readiness for Enhanced
Latex Allergy Reaction Risk for
Lifestyle Sedentary
Liver Function Risk for Impaired
Loneliness Risk for
Lymphedema Self-Management Ineffective, Risk for Ineffective
Maternal-Fetal Dyad Risk for Disturbed
Memory Impaired
Metabolic Imbalance Syndrome Risk for
Mobility Impaired Bed, Impaired Physical, Impaired Wheelchair
Mood regulation Impaired
Moral Distress (As one-part diagnosis)
Motor Development Delayed Infant
Mucous Membrane Integrity Impaired Oral
Mucous Membrane Risk for Impaired Oral
Nausea (As one-part diagnosis)
Neonatal Abstinence Syndrome (As one-part diagnosis)
Neurovascular Dysfunction Risk for Peripheral
Nipple-Areolar Complex Injury (As one-part diagnosis), Risk for
Nutrition Less than Body Requirements, Imbalanced, Readiness for Enhanced
Obesity (As one-part diagnosis)
Occupational Injury Risk for
Overweight (As one-part diagnosis), Risk for
Pain Acute, Chronic, Labor
Parenting Impaired, Readiness for Enhanced, Risk for Impaired
Perioperative Positioning Injury Risk for
Personal Identity Disturbed, Risk for Disturbed
Poisoning Risk for
Post-Trauma Syndrome (As one-part diagnosis), Risk for
Power Readiness for Enhanced
Powerlessness (As one-part diagnosis), Risk For
Pressure Injury Adult, Risk for Adult, Child, Risk for Child, Neonate, Risk for Neonate
Protection Ineffective
Rape-Trauma Syndrome (As one-part diagnosis)
Relationship Ineffective, Readiness for Enhanced, Risk for Ineffective
Religiosity Impaired, Readiness for Enhanced, Risk for Impaired
Relocation Stress Syndrome (As one-part diagnosis), Risk for
Resilience Impaired, Readiness for Enhanced, Risk for Impaired
Retention Acute Urinary, Chronic Urinary, Risk for Urinary
Role Conflict Parental
Role Performance Ineffective
Role Strain Caregiver, Risk for Caregiver
Self-Care Readiness for Enhanced
Self-Care Deficit Bathing, Dressing, Feeding, Toileting
Self-Esteem Chronic Low, Risk for Chronic Low, Risk for Situational Low, Situational Low
Self-Mutilation (As one-part diagnosis), Risk for
Self-Neglect (As one-part diagnosis)
Sensory Perception Disturbed Auditory, Disturbed Gustatory, Disturbed Kinesthetic, Disturbed Olfactory, Disturbed Tactile, Disturbed Visual
Sexual Dysfunction (As one-part diagnosis)
Sexuality Pattern Ineffective
Shock Risk for
Sitting Impaired
Skin Integrity Impaired, Risk for Impaired
Sleep Readiness for Enhanced
Sleep Deprivation (As one-part diagnosis)
Sleep Pattern Disturbed
Social Interaction Impaired
Social Isolation (As one-part diagnosis)
Sorrow Chronic
Spiritual Distress (As one-part diagnosis), Risk For
Spiritual Well-Being Readiness for Enhanced
Standing Impaired
Stress Overload (As one-part diagnosis)
Suck-Swallow Response Ineffective Infant
Sudden Infant Death Risk for
Suffocation Risk for
Suicidal Behavior Risk for
Surgical Recovery Delayed, Risk for Delayed
Surgical Site Infection Risk for
Swallowing Impaired
Thermal Injury Risk for
Thermoregulation Ineffective, Risk for Ineffective
Thought Process Disturbed
Thromosis Risk for
Tissue Integrity Impaired, Risk for Impaired
Tissue Perfusion Ineffective Peripheral, Risk for Decreased Cardiac, Risk for Ineffective Cerebral, Risk for Ineffective Peripheral
Transfer Ability Impaired
Trauma Risk for Physical, Risk for Vascular
Unilateral Neglect (As one-part diagnosis)
Ventilation Impaired Spontaneous
Ventilatory Weaning Response Dysfunctional, Dysfunctional Adult
Violence Risk for Other-Directed, Risk for Self-Directed
Walking Impaired
Wandering Sporadic, Continuous

Mneme

Explorer

Nursing Process: Diagnosis

Components of a Nursing Diagnosis

Diagnostic Process

Writing a Nursing Diagnosis

Graph View

Table of Contents

Diagnosis	Modifiers
Activity Planning	Ineffective, Risk for Ineffective
Activity Tolerance	Decreased
Acute Substance Withdrawal Syndrome	Risk for
Adverse Reaction to Iodinated Contrast Media	Risk for
Airway Clearance	Ineffective
Allergy Reaction	Risk for
Anxiety	[specify level], Death
Aspiration	Risk for
Attachment	Risk for Impaired
Autonomic Dysreflexia	(As one-part diagnosis), Risk for
Behavior	Disorganized Infant, Readiness for Enhanced Disorganized Infant
Bleeding	Risk for
Blood Glucose Level	Risk for Unstable
Body Image	Disturbed
Breast Milk Production	Insufficient
Breastfeeding	Ineffective, Interrupted, Readiness for Enhanced
Breathing Pattern	Ineffective
Cardiac Output	Decreased, Risk for Decreased
Cardiovascular Function	Risk for Impaired
Childbearing Process	Readiness for Enhanced, Risk for Ineffective
Chronic Pain Syndrome	-
Comfort	Impaired, Readiness for Enhanced
Communication	Impaired Verbal, Readiness for Enhanced
Confusion	Acute, Chronic, Risk for Acute
Constipation	(As one-part diagnosis), Chronic Functional, Perceived, Risk for, Risk for Chronic Functional
Contamination	(As one-part diagnosis), Risk for
Continence	Impaired Bowel
Coping	Compromised Family, Defensive, Disabled Family, Ineffective, Ineffective Community, Readiness for Enhanced, Readiness for Enhanced Community, Readiness for Enhanced Family
Decision-Making	Readiness for Enhanced
Decisional Conflict	(As one-part diagnosis)
Denial	Ineffective
Dentition	Impaired
Development	Delayed Child, Risk for Delayed Child
Diarrhea	(As one-part diagnosis)
Disuse Syndrome	Risk for
Disturbed Family Identity Syndrome	(As one-part diagnosis), Risk for
Diversional Activity Engagement	Risk for Decreased
Dry Eye	Risk for
Dry Eye Self-Management	Ineffective
Dry Mouth	Risk for
Eating Dynamics	Ineffective Adolescent, Ineffective Child, Ineffective Infant
Electrolyte Imbalance	Risk for
Elimination	Impaired Urinary
Elopement Attempt	Risk for
Emancipated Decision-Making	Impaired, Readiness for Enhanced, Risk for Impaired
Emotional Control	Labile
Energy Field	Imbalanced
Exercise Engagement	Readiness for Enhanced
Falls	Risk for Adult, Risk for Child
Family Processes	Dysfunctional, Interrupted, Readiness for Enhanced
Fatigue	(As one-part diagnosis)
Fear	(As one-part diagnosis)
Female Genital Mutilation	Risk for
Fluid Volume	Deficient (Hyper-/hypotonic), Deficient (Isotonic), Excess, Risk for Deficient, Risk for Imbalanced
Frail Elderly Syndrome	(As one-part diagnosis), Risk For
Gas Exchange	Impaired
Gastrointestinal Motility	Dysfunctional, Risk for Dysfunctional
Grieving	Readiness for Enhanced, Maladaptive, Risk for Maladaptive
Growth	Risk for Disproportionate
Health	Deficient Community
Health Behavior	Risk-prone
Health Literacy	Readiness for Enhanced
Health Maintenance Behaviors	Ineffective
Health Self-Management	Ineffective, Ineffective Family, Readiness for Enhanced
Home Maintenance Behaviors	Ineffective, Readiness for Enhanced, Risk for Ineffective
Hope	Readiness for Enhanced
Hopelessness	(As one-part diagnosis)
Human Dignity	Risk for Compromised
Hyperbilirubinemia	Neonatal, Risk for Neonatal
Hyperthermia	(As one-part diagnosis)
Hypothermia	(As one-part diagnosis), Neonatal, Risk for, Risk for Neonatal, Risk for Perioperative
Immigration Transition	Risk for Complicated
Impulse Control	Ineffective
Incontinence	Disability-Associated Urinary, Mixed Urinary, Stress Urinary, Risk for Urge Urinary, Urge Urinery
Infection	Risk for
Injury	Risk for, Risk for Urinary Tract
Insomnia	(As one-part diagnosis)
Knowledge	Deficient, Readiness for Enhanced
Latex Allergy Reaction	Risk for
Lifestyle	Sedentary
Liver Function	Risk for Impaired
Loneliness	Risk for
Lymphedema Self-Management	Ineffective, Risk for Ineffective
Maternal-Fetal Dyad	Risk for Disturbed
Memory	Impaired
Metabolic Imbalance Syndrome	Risk for
Mobility	Impaired Bed, Impaired Physical, Impaired Wheelchair
Mood regulation	Impaired
Moral Distress	(As one-part diagnosis)
Motor Development	Delayed Infant
Mucous Membrane Integrity	Impaired Oral
Mucous Membrane	Risk for Impaired Oral
Nausea	(As one-part diagnosis)
Neonatal Abstinence Syndrome	(As one-part diagnosis)
Neurovascular Dysfunction	Risk for Peripheral
Nipple-Areolar Complex Injury	(As one-part diagnosis), Risk for
Nutrition	Less than Body Requirements, Imbalanced, Readiness for Enhanced
Obesity	(As one-part diagnosis)
Occupational Injury	Risk for
Overweight	(As one-part diagnosis), Risk for
Pain	Acute, Chronic, Labor
Parenting	Impaired, Readiness for Enhanced, Risk for Impaired
Perioperative Positioning Injury	Risk for
Personal Identity	Disturbed, Risk for Disturbed
Poisoning	Risk for
Post-Trauma Syndrome	(As one-part diagnosis), Risk for
Power	Readiness for Enhanced
Powerlessness	(As one-part diagnosis), Risk For
Pressure Injury	Adult, Risk for Adult, Child, Risk for Child, Neonate, Risk for Neonate
Protection	Ineffective
Rape-Trauma Syndrome	(As one-part diagnosis)
Relationship	Ineffective, Readiness for Enhanced, Risk for Ineffective
Religiosity	Impaired, Readiness for Enhanced, Risk for Impaired
Relocation Stress Syndrome	(As one-part diagnosis), Risk for
Resilience	Impaired, Readiness for Enhanced, Risk for Impaired
Retention	Acute Urinary, Chronic Urinary, Risk for Urinary
Role Conflict	Parental
Role Performance	Ineffective
Role Strain	Caregiver, Risk for Caregiver
Self-Care	Readiness for Enhanced
Self-Care Deficit	Bathing, Dressing, Feeding, Toileting
Self-Esteem	Chronic Low, Risk for Chronic Low, Risk for Situational Low, Situational Low
Self-Mutilation	(As one-part diagnosis), Risk for
Self-Neglect	(As one-part diagnosis)
Sensory Perception	Disturbed Auditory, Disturbed Gustatory, Disturbed Kinesthetic, Disturbed Olfactory, Disturbed Tactile, Disturbed Visual
Sexual Dysfunction	(As one-part diagnosis)
Sexuality Pattern	Ineffective
Shock	Risk for
Sitting	Impaired
Skin Integrity	Impaired, Risk for Impaired
Sleep	Readiness for Enhanced
Sleep Deprivation	(As one-part diagnosis)
Sleep Pattern	Disturbed
Social Interaction	Impaired
Social Isolation	(As one-part diagnosis)
Sorrow	Chronic
Spiritual Distress	(As one-part diagnosis), Risk For
Spiritual Well-Being	Readiness for Enhanced
Standing	Impaired
Stress Overload	(As one-part diagnosis)
Suck-Swallow Response	Ineffective Infant
Sudden Infant Death	Risk for
Suffocation	Risk for
Suicidal Behavior	Risk for
Surgical Recovery	Delayed, Risk for Delayed
Surgical Site Infection	Risk for
Swallowing	Impaired
Thermal Injury	Risk for
Thermoregulation	Ineffective, Risk for Ineffective
Thought Process	Disturbed
Thromosis	Risk for
Tissue Integrity	Impaired, Risk for Impaired
Tissue Perfusion	Ineffective Peripheral, Risk for Decreased Cardiac, Risk for Ineffective Cerebral, Risk for Ineffective Peripheral
Transfer Ability	Impaired
Trauma	Risk for Physical, Risk for Vascular
Unilateral Neglect	(As one-part diagnosis)
Ventilation	Impaired Spontaneous
Ventilatory Weaning Response	Dysfunctional, Dysfunctional Adult
Violence	Risk for Other-Directed, Risk for Self-Directed
Walking	Impaired
Wandering	Sporadic, Continuous