As a nursing student, you must learn how to write a nursing diagnosis paper before you complete your academic program. That is because a nursing diagnosis guides nurses in determining appropriate patient care plans. A nurse writes nursing diagnoses based on the patient’s assessment. It must include the problem and its description, the etiology, and the identified risk factors.

Writing a nursing diagnosis helps students to learn how to prepare for their careers. Mastering this art will help you to communicate your judgment based on the information you gathered after assessment to the physicians, other nurses, patients, families, and the public. A nursing diagnosis is an important part of the nursing process. It’s a fundamental tool for nurses and, even, for a lot of healthcare providers.

In our article, you can read everything you need about nursing diagnosis. Besides learning and being able to answer the question,” What is Nanda’s nursing diagnosis?”  You will understand the different types and differences between various nursing diagnoses, definitions, formats, and comparisons and get nursing diagnosis examples, among others. If you need help writing a nursing diagnosis, contact us.

How to Understand Nursing Diagnosis 

A nursing diagnosis is an integral section of the nursing process that helps nurses assess the patient’s health condition and develop care plans based on their thoughtful consideration and judgment. It determines the possible interventions for the family, patients, and community if it is a community nursing diagnosis.

Nursing diagnosis is usually determined based on the patient’s current situation; hence, interventions are based on evidence-based nursing research. From there, the health care providers, among nurses, consider the kind of care to provide to patients from a holistic point of view.

Nanda Approved Nursing Diagnosis 

Nanda-approved nursing diagnoses include;

Actual/problem-focused diagnosis

This diagnosis focuses on specific signs and symptoms that are observable and present during the assessment stage. A nurse prepares a problem statement based on related stressors, complications, or concerns and explains the patient’s current health problem and the nursing interventions needed to develop the patient care plan.

One example of problem-focused nursing diagnosis is recognizing the symptoms of mental distress. The nurse will note behaviors like the patient’s struggle to concentrate, confused thinking, extreme mood changes, and struggle to sleep. The nurse shares this information with other healthcare providers to assist in making a diagnosis that further guides them in making decisions, such as passing it along to the medical provider to assist in making the diagnosis. The nursing diagnosis guides further decisions.

Risk nursing diagnosis 

The risk nursing diagnosis identifies the nursing interventions needed to lower the risk related to a patient’s developing problem. It mainly requires nursing judgment and clinical reasoning because there are no etiological factors for risk diagnoses. A risk nursing diagnosis includes risk factors and diagnostic risk labels.

An example of a risk diagnosis would be the risk of imbalanced body fluid volume.

Health promotion diagnosis 

This nursing diagnosis aims to improve the well-being of the patient, community, or family. This diagnosis only consists of a diagnostic label. Examples include readiness for enhanced family survival.

Syndrome diagnosis

A syndrome diagnosis refers to a group of nursing diagnoses that can be addressed through the same interventions and occurs in the same pattern. An example of this diagnosis is decreased peripheral tissue perfusion.

How Can I Write My Nursing Diagnosis 

For consistency and safe nursing practices, there are standardized ways that you need to pay attention to as you write your nursing diagnosis. Unlike a medical diagnosis that addresses a specific medical condition, a nursing diagnosis addresses patient needs. That is why a nurse needs to personalize a nursing diagnosis to fit the patient’s status and health situation. Ensure it addresses the problem, linked signs and symptoms, and any other related factor that could affect patient care. You can achieve that by:

Data gathering and analyzing

Take time to observe the patient’s symptoms and note their condition. Come up with a description of the critical problem based on the symptoms observed. You can use non-specialist language to write your observations at this point.

Discuss with the patient and relatives about their feeling

As you formulate a nursing diagnosis, remember that you will be using information from the patient and their loved ones. Ask them about the notable changes in patient behavior and how it has affected them and their relationship.

Evaluate the patient’s response to their condition

Understand what the patient has done to eliminate or cope with their situation. Consider the patient, healthcare provider, and relative attitude toward the symptoms. Also, note the behavioral change and patient attitude when these parties are around.

Distinguish between subjective and objective data

Subjective data is acquired from the patient’s complaints about their condition. This kind of data is unverified. On the other hand, objective data is gathered from measurable and verifiable observations using scientific methods. Objective data is crucial in forming a basis for your nursing diagnosis. Subjective data can be used to create a patient care plan.

Identify the problem 

Check for patterns in the data you collected. Symptoms and signs that may lead you to get a proper diagnosis for the patient. Focus on the patient’s experience. Nursing diagnosis is never the same for patients, even those suffering from the same condition. Each problem identified is diagnosed separately.

Identify related factors

Identify the source of the problem and then figure out why the patient is facing such an issue. Once you have an answer, you can develop nursing interventions that will help eliminate or prevent the problem.

Evaluate the patient’s history and overall health

Assess the patient’s past medical records to learn about the factors that could be associated with their current situation. You can share with other healthcare providers to help you learn about the patient’s overall health.

Find the most appropriate nursing diagnosis

At this point, you must research an appropriate term for your observation. You can use your coursebook or Nanda-approved nursing diagnosis list to help you find a word that best fits the condition and needs of the patient. After developing a nursing diagnosis, find potential outcomes and interventions that will work for the patients. Consider how they apply to a specific patient.

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Bring the related factors together for your diagnosis 

List all the causes of the patient’s problem and the related factors. Search for the standardized terms for these factors in your coursebook or other scholarly materials available. Identifying the associated factors helps the nurse in the second section of their diagnosis.

Summarize the data in an “As Evidenced By” statement

Ensure you separate the collected data from the characteristics that indicate the diagnosed problem. Only include the observed features in your AEB statement. Indicate whether the data is objective or subjective.

Difference between Medical Diagnosis and Nursing Diagnosis 

In the medical field, there are a lot of terminologies that are used for simple illnesses, such as running noses. Understanding these terms and what they mean helps nursing students to be able to appropriately apply them in their careers in the future.

Let’s discuss the diagnosis. Medical diagnosis vs nursing diagnosis.

Differences by Definitions and Purpose

What is a medical diagnosis?

A medical diagnosis focuses on a patient’s medical condition, physiological and psychological response. The physician makes this kind of diagnosis based on the illness itself. The sickness is determined through knowledge, experience, and examination of all other possible causes. The doctor then prescribes proper medication that would help cure the disease.

What is a nursing diagnosis?

This diagnosis is based on the patient’s response to the medical condition. A nursing diagnosis is more focused on patient care. Nurses have the autonomy to provide care and treatment using everything linked to human reaction to a specific illness. That could be a spiritual, mental, or physical kind of reaction.

It is essential to understand how each of these diagnoses works to help the patient and other healthcare providers and relatives know how nursing and medical diagnoses complement each other.

Examples of medical diagnoses include:

• Arthritis
• Congestive Heart Failure
• Diabetes Mellitus
• Meningitis
• Scoliosis

Community Nursing Diagnosis 

You can conduct a community nursing diagnosis after identifying the problem and analyzing the data gathered. Nursing diagnosis for community health may be formulated concerning the following issues

• Heath hazards
• Airborne diseases
• Covid-19 pandemic
• Inaccessible health services
• Community dysfunction
• Morbidity and mortality rates
• Inaccessible and unavailable services
• Mortality and morbidity rates
• Physical or emotional problems for specific demographics
• Health promotion needs for specific demographics

Below are some community health nursing diagnosis examples that will help you develop a successful nursing care plan.

• Reduced Activity Tolerance
• Fear
• Fatigue
• Acute Pain
• Hyperthermia
• Unease
• Chronic Pain
• Bloating
• Risk for electrolyte imbalance
• Bathing/dressing/feeding self-care deficit
• Risk for ineffective childbearing process
• Hypothermia
• Decreased Cardiac activity
• Deficient Body Fluid
• Ineffective Thermoregulation
• Ineffective Breathing Pattern
• Surplus fluid volume
• Diarrhea
• Grieving
• Hopelessness
• Less Nutrient Than Body Requirements
• Impaired Gas Exchange
• Impaired Skin Integrity
• Impaired Urinary Elimination
• Ineffective Airway Clearance
• Ineffective Respiratory Pattern
• Ineffective Tissue Perfusion
• Risk for Falls
• Risk for Impaired Skin Integrity
• Risk for Infection
• Risk for Injury
• Risk for Imbalanced Glucose Level
• Dysfunctional ventilatory weaning response
• Impaired transferability
• Activity intolerance
• Situational low self-esteem
• Risk for disturbed maternal-fetal dyad
• Impaired emancipated decision-making
• Risk for poor skin integrity
• Risk for metabolic imbalance syndrome
• Urge urinary incontinence
• Risk for unstable blood pressure
• Impaired verbal communication
• Acute confusion
• Disturbed body image
• Relocation stress syndrome
• Ineffective role performance
• Readiness for enhanced sleep

Safety Nursing Diagnosis 

Accidents and injuries resulting from burns, motor vehicle accidents, falls, drowning, overdoses and poisoning are some of the common cases in health care. When providing care to the victims of accidents and injuries, you are expected to write a safety nursing diagnosis to guide you in developing a plan.

Some of the risk factors that can increase the chances of patient injury are:

Risk for Falls

Risk for falls may occur due to

• Patients’ cognitive
• Physiological state
• Medication

As evidenced by: Muscle weakness

Risk for Injury

The patient’s vulnerability to injury can result from internal and external causes.

Nursing Diagnosis: Risk for Injury

Related to:

• Side effects of medication
• Vision impairment
• Mobility impairment
• Hearing impairment
• Amputated/loss of limbs

As evidenced by:

There are no ‘evidenced by’ symptoms and signs as the issue has not happened. Prevention is the only aim of nursing intervention.

Expected outcomes:

• The patient will be able to identify possible exposures to risk of injury
• The patient will apply safety tips and measure to prevent injury
• The patient will remain uninjured

Assessment:

• Evaluate emotional and physical factors such as amnesia, grief, and recent traumatic experiences, among others, that could affect patient safety.
• Identify possible socioeconomic factors. Inaccessible resources such as housing and transportation can increase the chances of injuries.
• Evaluate for any abuse.  It is the role of the nurse to report any form of abuse. Whether it is physical, emotional, or verbal abuse.

Interventions:

Refer to resources as necessary

Help to prevent injuries by educating patients in self-care and basic safety measures. Such as putting on safety belts to reduce the chances of injury if a motor vehicle accident occurs. For patients with dementia and developmental delays, a nurse should consider providing care in nursing homes and at home.

Administer medications

Ensure you give the right patient the right medication, in proper dosage and at the right time. Double-check the details to make sure everything is clear.

Educate the patient and family on first-aid strategies

This helps them act immediately after the accident to facilitate swift, professional intervention and reduce the risk of complications after the injury.

Do You Need Help with Your Nursing Diagnosis?

Nursing diagnosis is a valuable tool that helps nurses provide quality, safe and evidence-based patient care. Every nurse must learn how a nursing diagnosis template works and master every aspect of health care provision.

You can contact us to hire a tutor that will help you learn a simple nursing diagnosis format and give you a simple step-by-step guide that will aid in formulating and writing a nursing diagnosis seamlessly. Contact us today!