Mastering Nursing Diagnoses

What Is a Nursing Diagnosis?

A nursing diagnosis is a clinical judgment made by a nurse about a patient's response to actual or potential health problems or life processes. It forms the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.

Unlike a medical diagnosis, which focuses on identifying and treating disease, a nursing diagnosis focuses on the patient's holistic needs—physical, emotional, social, and spiritual. It helps nurses prioritize care and evaluate its effectiveness over time.

Nursing Diagnosis vs. Medical Diagnosis

It’s essential to differentiate between nursing and medical diagnoses:

Medical Diagnosis: Identifies a specific illness or disease (e.g., “Pneumonia”).

Nursing Diagnosis: Identifies the patient’s response to the illness (e.g., “Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath and low oxygen saturation”).

Nursing diagnoses are dynamic and can change as the patient’s condition evolves. This approach allows nurses to address issues beyond the scope of medical treatment, including education, coping, and health promotion.

The PES Format: Crafting Effective Nursing Diagnoses

To standardize nursing diagnoses, the North American Nursing Diagnosis Association (NANDA) developed the PES format, which is composed of:

• P (Problem): The NANDA-approved diagnosis (e.g., “Imbalanced Nutrition”).
• E (Etiology): The cause or related factor (e.g., “related to intake less than body requirements”).
• S (Symptoms): The clinical manifestations or evidence (e.g., “as evidenced by weight loss of 8 lbs”).

When combined, it looks like this:

Imbalanced Nutrition related to intake less than body requirements as evidenced by weight loss of 8 lbs.

This structured format ensures clarity and precision in care planning.

Steps to Develop a Nursing Diagnosis

Developing a nursing diagnosis can be one of the more challenging aspects of nursing school or clinical rotations. Here’s how to approach it:

Review Clinical Data
Collect information from your patient’s assessment, lab values, vitals, and statements. Focus on how they’re responding to their condition.

Identify the Problem (NANDA Diagnosis)
Use your nursing textbook or resources like nanda.org to find the correct terminology.

Determine the Etiology
Ask yourself, “What is causing this issue for my patient?” This will form the “related to” portion of your diagnosis.

List Supporting Evidence
This is your “as evidenced by” section. Be specific. Look for measurable data like weight loss, lab results, or patient-reported symptoms.

String it All Together (PES Format)

Example:

Hyperthermia related to increased metabolic rate as evidenced by body temperature of 102°F.

Prioritize Your Diagnoses
Not all problems are equal. Use tools like Maslow’s hierarchy of needs or the ABCs (Airway, Breathing, Circulation) to prioritize.

Common Nursing Diagnoses and Examples

There are over 200 NANDA-approved nursing diagnoses. Below are some common examples you may encounter:

• Impaired Physical Mobility
  Related to musculoskeletal injury as evidenced by decreased range of motion and pain during movement.
• Risk for Infection
  Related to surgical incision as evidenced by elevated WBC count and wound drainage.
• Ineffective Airway Clearance
  Related to excessive mucus production as evidenced by abnormal lung sounds and persistent coughing.
• Anxiety
  Related to unfamiliar hospital environments as evidenced by restlessness and verbalization of concerns.
• Deficient Knowledge
  Related to new diagnosis of diabetes as evidenced by questions about insulin administration.

These examples can serve as a foundation as you begin to construct your own nursing diagnoses in school or clinical practice.