How to Write a NANDA Nursing Diagnosis
The NANDA nursing diagnosis enables nurses to determine an appropriate plan of
care for their patients. Nurses write nursing diagnoses based on their assessment
of the patient. Nursing diagnoses must include the problem and its definition, the
etiology of the problem, and the defining characteristics or risk factors of the
problem. The problem statement explains the patient’s current health problem
and the nursing interventions needed to care for the patient. The etiology
describes possible causes for the current health problem. The defining
characteristics are the signs and symptoms of the health problem. A medical
diagnosis can be referenced as part of an interdisciplinary assessment of care but
cannot be included in the written nursing diagnosis. Types of nursing diagnoses
include problem-focused diagnoses, risk diagnoses, health promotion diagnoses,
and syndrome diagnoses. When writing a problem-focused diagnosis, the formula
is: (Problem-Focused Diagnosis) related to________(Related Factors) as
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evidenced by _____________ (Defining Characteristics). When writing a risk
diagnosis, the formula is as follows: Risk for_____as evidenced by_____(Risk
Factors).
Nursing Diagnosis
Nurse and Diagnostic-computer
NANDA International standardizes nursing terminology, specifically nursing diagnoses. Nurses use collected patient data to formulate nursing
diagnoses or determine health problems better managed by physicians (medical diagnoses) or collectively with other health care professionals
(collaborative problems). Important to note, depending on your specific nursing curriculum, some schools may educate on slightly different nursing
methods of “thinking like a nurse”. ADPIE and AAPIE are both still taught in nursing schools, with a diagnosis step in ADPIE vs AAPIE which includes
analysis. The emphasis is now more on AAPIE to reflect the current expectations of the NCLEX-RN® assessment and clinical judgment for nursing
practice. This allows for a broader analysis of patient needs and improved patient care overall.
Nursing Diagnosis Components
Problem Statement
Problem-cube with Statement
Nursing diagnoses are made up of three components: the problem statement, the etiology/related factors, and defining characteristics/risk factors. The
problem statement pertains to the patient’s current health problem and needed nursing interventions.
Etiology
E.T. Causing the Problem
Nursing diagnoses are made up of three components: the problem statement, the etiology/related factors, risk factors, and defining characteristics.
The etiology, or related factors, identifies probable causes of the health problem and/or the conditions involved in the development of the problem.
Defining Characteristics or Risk factors
Dictionary and Game of Risk
Defining characteristics are the groups of signs and symptoms that indicate the presence of a particular diagnostic label. An example of a written
nursing diagnosis using all three components is as follows: “Ineffective airway clearance (problem statement) related to bronchial airway inflammation
(etiology/related factor) as evidenced by coarse rhonchi to bilateral apices heard on auscultation (defining characteristics).” Risk factors can be used in
place of defining characteristics and encompass the patient’s vulnerability toward their health problem. An example would be something such as, “Risk
for infection as evidenced impaired skin integrity.”
4 Types of Nursing Diagnoses
Problem-Focused
Problem-cube
A problem-focused diagnosis is the patient's problem that is present at the time of the nursing assessment. This nursing diagnosis is based on the signs
and symptoms present in this assessment. Examples are decreased cardiac output and impaired gas exchange. Problem-focused nursing diagnoses
include three components: (1) nursing diagnosis, (2) related factors, and (3) defining characteristics.
Risk
Risk
This nursing diagnosis identifies interventions needed to decrease the risk related to a patient’s problem. There are no etiological factors (related
factors) for risk diagnoses. The components of a risk nursing diagnosis include (1) risk diagnostic label and (2) risk factors. An example of a risk diagnosis
would be “Risk for infection as evidenced by a suppressed inflammatory response.”
Health Promotion
Health Promoter
The purpose of this kind of nursing diagnosis is to improve individual patient, family, or community health and well-being. Examples include readiness
for enhanced family coping. Components of a health promotion diagnosis generally include only the diagnostic label or a one-part statement. An
example would be something such as Readiness for Enhanced Family Coping.
Syndrome
Syndrome
These diagnoses are used when the patient is experiencing multiple health problems forming a pattern responsive to similar nursing interventions.
Syndrome Diagnoses are written as a one-part statement requiring only the diagnostic label. Examples include decreased cardiac output or decreased
tissue perfusion.
Steps For Writing a Problem-Focused Diagnosis
(Problem-Focused Diagnosis) related to________(Related Factors) as evidenced by _____________ (Defining Characteristics).
Problem-Focused Diagnosis Formula
To write a problem-focused diagnostic statement, use the problem-etiology-symptom (PES) method. Start with the diagnosis itself, followed by the
etiologic factors (related factors in an actual diagnosis), then identify the major signs/symptoms (defining characteristics) that are appearing in the
patient. This method is for an actual diagnosis, not a risk diagnosis. An example would be: (Impaired physical mobility) related to (decreased muscle
control) as evidenced by (the inability to control lower extremities).
Steps For Writing a Risk Diagnosis
Risk for_____as evidenced by_____(Risk Factors).
Risk Diagnosis Formula
For risk diagnoses, there are no related factors (etiological factors) as you are identifying a vulnerability in a patient for a potential problem; the
problem is not yet present. Therefore, you identify the risk factors that predispose the individual to a potential problem. An example would be “Risk for
(infection) as evidenced by (suppressed inflammatory response).”
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