Nursing Diagnosis, Planning Nursing Care
Nursing Diagnosis
The nursing diagnosis is the second step in the nursing process and is the clinical judgment about individual, family, or community (aggregate) responses to actual or risk health problems, wellness states, or syndromes. This judgment is based on a critical analysis of the assessment data. The purpose of a nursing diagnosis is to effectively communicate the health care needs of individuals and aggregates among members of the health care team and within the health care delivery system. Society tends to interpret nursing through the use of nursing language.
When a nursing diagnosis is a part of the client’s plan of care, the nurse is able to communicate the client’s needs to other professionals involved in that care. These needs encompass physiologic, role function, self-concept, interdependence, and spiritual dimensions. In order to determine individualized therapeutic nursing interventions, the nurse must first collect and organize assessment data before developing appropriate nursing diagnoses.
This chapter describes the nature of a nursing diagnosis, its purposes, and the components of a nursing diagnostic statement. It also discusses the process involved in developing a nursing diagnosis and methods through which nurses can avoid errors in the formulation of nursing diagnoses. This chapter concludes with strategies for overcoming barriers to the use of a nursing diagnosis in the clinical setting.
What Is A Nursing Diagnosis?
Diagnosis is the science and art of identifying problems or conditions. Although this process has been linked primarily with physicians, it is also used by members of other professions, such as nurses, lawyers, social workers, mechanics, psychologists, and teachers. Though the term nursing diagnosis may convey multiple meanings, “in effect, nursing diagnosis defines nursing practice” (Sparks & Taylor, 1994, p. 32H).
There are many definitions of nursing diagnosis that have evolved over the past decades. At the ninth North American Nursing Diagnosis Association (NANDA) conference, the following definition of nursing diagnosis was approved: A clinical judgment about individual, family or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable (NANDA, 1996, p. 8).
Additional definitions of nursing diagnosis abound in the nursing literature. It is clear that although all definitions are not exactly alike, there are similar attributes among them, such as a focus on client-centered problems; the promotion of nursing accountability; an awareness of the human response to health problems; the formation of clinical judgments about individuals, families, or communities; and the development of nursing interventions that a nurse is licensed to enact.
Following are selected descriptions of nursing diagnoses that reflect the historical evolution of the concept:
• “A creative approach to nursing involves a nursing diagnosis and the design and means for carrying out a plan for the care of an individual person. There are five areas of patients’ needs on which the nursing diagnosis is based . . . treatment and medication, personal hygiene, environmental, guidance and teaching and human or self needs” (Fry, 1953, p. 301).
• “Use of the term diagnosis is gaining acceptance as the logical end product of nursing assessment” (Gebbie & Lavin, 1974, p. 250).
• “A nursing diagnosis is a statement that describes the human response (health state or actual/potential altered interaction pattern) of an individual or group which the nurse can legally identify and for which the nurse can order the definitive interventions to maintain the health state or to reduce, eliminate, or prevent alterations” (Carpenito, 1989, p. 5).
• “Nursing diagnosis is defined in the Roy Adaptation Model as a judgment process resulting in a statement conveying the person’s adaptation status” (Roy & Andrews, 1991, p. 37).
• “Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” (NANDA, 1996, p. 8).
Comparison of Nursing and Medical Diagnoses
It is important to have a clear understanding of the nature of a nursing diagnosis as compared to a medical diagnosis. Clarification of this point is necessary to distinguish between the nursing and medical professions and the potential legal ramifications.
Delineation of “What is the nature of nursing?” versus “What is the nature of medicine?” is critical. In order to practice nursing, nurses need to know what it is that they do. Nursing diagnoses assist nurses in defining their scope of practice just as medical diagnoses assist physicians in defining their scope of practice. In addition, the use of diagnoses iursing and medicine enables clarification of the legal boundaries for practice.
Medicine uses the term medical diagnosis and nursing uses the term nursing diagnosis to identify problems relating to a client’s health status:
• Medical diagnosis is the terminology used for a clinical judgment by the physician that identifies or determines a specific disease, condition, or pathologic state.
• Nursing diagnosis is the terminology used for a clinical judgment by the professional nurse that identifies the client’s or aggregate’s actual, risk, wellness, or syndrome responses to a health state, problem, or condition.
See the accompanying display for a comparison of nursing and medical diagnoses.
It is important to emphasize that the term nursing diagnosis has been used in three contexts: “the process of diagnosis, the product of diagnosis or individual diagnoses, and the taxonomy of diagnoses” (Wooldridge, Brown, & Herman, 1993, p. 51). The process of diagnosis is identified as the second step of the nursing process. In this step, the nurse collects data, validates and critically analyzes the data, clusters the data into groups, and identifies the client, family, or community health problems or conditions. The product of diagnosis is the diagnostic label that is assigned to the identified problem. The taxonomy of diagnosis is a classification system in which nursing diagnoses are organized according to client responses to specific conditions.
There are both similarities and differences between medical and nursing diagnoses. The similarities include (1) using the diagnostic process, with “process” implying purpose, organization, and creativity (Bevis, 1978); (2) using cognitive, interpersonal, and psychomotor skills; (3) collecting and critically analyzing assessment data; (4) evaluating outcomes to ascertain continuation, resolution, or change of identified diagnosis; and (5) performing within legal dimensions and standards of the respective profession. An example of these similarities can be illustrated by considering Alan Brown, a client who has a medical diagnosis of asthma. The physician and nurse would both collect assessment data on respiratory status. The physician would use this information to treat the disease of asthma and the nurse would use this information to focus on Mr. Brown’s response to the disease, which would result in a nursing diagnosis of Ineffective Breathing Pattern.
Nursing diagnoses are different from medical diagnoses in (1) purpose, (2) goals, and (3) therapeutic interventions. The purpose of a nursing diagnosis is to focus on the human response or responses of the individual family or community to identified problems or conditions. Medical diagnoses center on the disease state or pathological condition. For example, if the medical diagnosis for Sheila Barrington is breast cancer, appropriate nursing diagnoses may include Fear, Deficient Knowledge related to treatment measures, Anticipatory Grieving, Body Image Disturbance, Powerlessness, and Ineffective Coping. In addition, the goals (aims, intent, or ends) that accompany these nursing diagnoses differ, as do the specific, individualized therapeutic nursing interventions (nursing actions to promote or restore health and enhance general well-being).
Historical Perspective
The term nursing diagnosis has been in the literature since the early 1950s. Fry (1953) identified that nursing diagnosis is integral to the plan of nursing care and is an important tool for individualizing client care. However, these ideas were slow to gain momentum despite the interests of several nurse theorists and the focus on client-centered problems in the 1960s and the 1970s. In 1973, the First National Conference for the Classification of Nursing Diagnoses convened in
Additional endorsement for nursing diagnosis came from the American Nurses Association (ANA) in
At the 13th conference in 1998, NANDA developed 21 new nursing diagnoses and revised 37 nursing diagnoses by clarifying existing diagnoses and their definitions, defining their characteristics, and related factors.
Following the biennial conference in April 1994, the Taxonomy Committee identified the need to revise the structure of Taxonomy I. During the 14th biennial conference in April 2000, NANDA adopted the taxonomy, Taxonomy II. “Taxonomy II was designed to be multiaxial in its form, thereby substantially improving the flexibility of the nomenclature and allowing for easy additions and modifications” (NANDA, 2001, p. 212). With the publication of these standards, the nurse has both a professional and legal obligation to practice as defined by the professional organization for nurses.
Research
With the inception of the first conference oursing diagnoses, NANDA supported research endeavors on the development of a nursing diagnosis classification system. The first type of research conducted was identification studies, where the clinician repeatedly observed a condition in order to label a nursing diagnoses. At the sixth conference in 1986, Fehring identified the need for two standardized research methodologies for data collection: (1) diagnostic content validity (DCV), retrospective evidence from experts on the characteristics of a given label; and (2) clinical diagnostic validity (CDV), prospective evidence on the characteristics from a clinical perspective (Whitley, 1999). In 1989, NANDA sponsored an invitational conference on research methodologies for generating and validating existing diagnoses and to develop new methodologies to direct future studies.
Although there is an abundance of DCV studies, only a few clinical studies have been conducted because the CDV model is more complicated to execute. Nursing Diagnosis: The Journal of Nursing Language & Classification is the official publication of NANDA. The journal was first published in 1989 to promote the development, refinement, and utilization of nursing language and classification.
Roberts, Madigan, Anthony, and Pabst (1996) conducted a secondary analysis study to examine the congruence betweeursing diagnoses and clinically relevant data of clients being transferred from intensive care to medical-surgical units. The results of this study showed that diagnoses were not made or were made less frequently than indicated by the supporting clinical evidence (see the Research Focus). One of the findings indicated that a system still needs to be developed for determining that clients being observed have the diagnosis being studied and that nurses accurately identify all relevant diagnoses in the clinical setting.
Whitley (1999) suggests the development of a “research agenda” to promote research in a coordinated fashion since interest about nursing diagnoses has spread in the international community, at a time when a common nursing language is needed to strengtheursing’s bases for practice. In 1998, the NANDA Board instituted an ad hoc research committee to coordinate nursing diagnosis research and funding and to develop a “research agenda.”
Purposes of Nursing Diagnosis
Nursing diagnosis is unique in that it focuses on a client’s response to a health problem, rather than on the problem itself, and it provides the structure through which nursing care can be delivered. Although these characteristics have always been in existence withiursing, they were unidentified prior to the mid-20th century. One of the requisites of a profession is a unique body of knowledge or frame of reference (
Nursing diagnosis also provides a means for effective communication. It is generally agreed among nurses, health care practitioners, and other health care professionals that there is a need for a common language within the health care sector. A mutual vocabulary that can be used for describing practice, research, and education benefits both the profession and the consumer. With this language, collaboration and international exchanges regarding nursing and health care are possible and benefit from “common definitions of the phenomena of concern within the discipline” (Fitzpatrick & Zanotti, 1995, p. 42). In addition, communication about nursing diagnoses is possible through computer search.
The Cumulative Index to Nursing and Allied Health Literature (CINAHL) has listed the term nursing diagnosis since 1983 (Dougherty, Jankin, Lunney, & Whitley, 1993).
Holistic client, family, and community-focused care are facilitated with the use of nursing diagnosis. The list of NANDA-approved nursing diagnoses (NANDA, 2001) for clinical use provides assistance for the nurse in individualizing care and developing comprehensive therapeutic nursing interventions. Quality care and continuity of care are enhanced with identified nursing diagnoses as part of the client’s plan of nursing care. The accompanying display illustrates the value of applying nursing diagnosis to a home health care situation.
Nursing diagnoses also have the potential of providing an avenue for theory development and nursing research. Dougherty, Jankin, Lunney, and Whitley (1993) published a listing of theory and research-based articles on accepted nursing diagnoses from 1950 to 1993.
Nursing diagnosis has an important impact on the health care delivery system: “Nursing diagnoses provide a method for synthesizing and communicating nurses’ observations and judgements” and “the ability to communicate the health needs of clients can influence funding of preventive and comprehensive health care services” (Gordon, 1994, p. 12).
In summary, nursing diagnosis allows for empowerment of the profession of nursing, facilitates effective communication, and provides a means to individualize nursing care. Nursing diagnosis is essential to clinical practice and education and pivotal for theory development and research.
Components of A Nursing Diagnosis
There are several formats that have been used to structure nursing diagnosis statements. Two formats that are frequently seen in the nursing literature are the two- and three-part statements. The two-part statement is NANDA approved and is used by most nurses, in large part because of its brief and precise format. The three-part statement is preferred by those nurses desiring to strengthen the diagnostic statement by including specific manifestations, an attribute that is not possible through the use of the two-part format.
The Two-Part Statement
The components of a nursing diagnosis typically consist of two parts. Hence, the nursing diagnosis is often described as a “two-part statement.” The first component is a problem statement or diagnostic label that describes the client’s response to an actual, possible, and risk health problem or a wellness condition.
The second component of a two-part nursing diagnosis is the etiology. The etiology is the related cause or contributor to the problem. The diagnostic label and etiology are linked by the term related to (RT). Examples of nursing diagnoses are Disturbed Body Image RT loss of left lower extremity and Activity Intolerance RT decreased oxygen-carrying capacity of cells. Descriptive words or terms may be added to clarify specific nursing diagnoses. These descriptive words are called qualifiers and include Acute, Chronic, Decreased, Deficient, Depleted, Disturbed, Dysfunctional, Enhanced, Excessive, Impaired, Increased, Ineffective, Intermittent, Potential for, and Risk. These terms specify a degree of qualification for the identified nursing diagnosis and are placed (used) before the problem statement.
The Three-Part Statement
The nursing diagnosis can also be expressed as a threepart statement. As in the two-part statement, the first two components are the diagnostic label and the etiology.
The third component consists of defining characteristics (collected data that are also known as signs and symptoms, subjective and objective data, or clinical manifestations).
In the three-part nursing diagnosis format, the third part is joined to the first two components with the connecting phrase “as evidenced by” (AEB). Defining characteristics list the relevant clinical manifestations, such as signs or symptoms for the identified client problem and the related etiology. Defining characteristics are identified for each NANDA-approved diagnosis. These characteristics continue to evolve as they are reviewed and updated at the biennial conference. It is important to emphasize that defining characteristics may assist the nurse in identifying client goals, measurable client outcome criteria, and relevant nursing interventions.
Some nurses believe that the three-part statement strengthens the diagnostic process. However, other nurses prefer the two-part statement and refer to the defining characteristics as part of the original database. Table 7-2 depicts the components and relationship of the one-, two-, and three-part statements. Although the most commonly used format is the two-part statement, it is beneficial for the nurse to be knowledgeable about the use of the threepart statement for development of a nursing diagnosis.
See Table 7-3 for a comparison of selected approved NANDA diagnoses in the two- and three-part statements.
Categories of Nursing Diagnoses
Nursing diagnoses may be classified into three categories: actual, risk, and wellness. The most commoursing diagnoses used are actual and risk diagnoses.
Wellness diagnoses were adopted by NANDA 1996, and Carpenito (1995) described possible nursing diagnoses.
• Actual diagnoses are those problems identified by the nurse that are already in existence. Actual diagnoses may include Excess Fluid Volume related to (RT) intravenous infusion therapy overload and Anxiety RT unknown results of breast biopsy.
• Risk diagnoses are identified by the nurse in situations in which problems might occur but are not currently in existence. Examples of risk diagnoses may include Risk for Poisoning RT increased mobility of infant and failure to have house childproofed and Risk for Deficient Fluid Volume RT excessive number of stools.
• Wellness diagnoses identify the individual or aggregate condition or state that may be enhanced by healthpromoting activities. These consist of a one-part statement (no “related to” phrase) that uses the label “Potential for Enhanced” followed by the state the nurse desires to enhance. Examples of wellness diagnoses may include Readiness for Enhanced Community Coping and Readiness for Enhanced Spiritual Well-Being.
Taxonomy of Nursing Diagnosis
The taxonomy of nursing diagnoses is the type of classification under which the diagnostic label is grouped based on which human response the client is demonstrating to the actual or perceived stressor. Rather than consult the alphabetical listing of NANDA diagnoses, some nurses might find it more helpful to review the NANDA listing by pattern of human response. This listing is called the NANDA Taxonomy II and organizes the NANDA-approved nursing diagnoses under the corresponding human response category.
The NANDA nursing diagnosis taxonomy is composed of nine patterns of human response:
• Exchanging
• Valuing
• Perceiving
• Communicating
• Choosing
• Knowing
• Relating
• Moving
• Feeling
Although the word taxonomy may be somewhat overwhelming for the beginning practitioner, remember it is only an organizational framework and one should not be intimidated by it. Rather, view this approach as another way to find appropriate nursing diagnoses for clients on the basis of the classification of human response.
Developing a Nursing Diagnosis
The development of a nursing diagnosis is a systematic process in which certain activities need to be executed.
The accompanying display illustrates the steps in the development of nursing diagnoses.
Assessing Database
In the assessment phase, the nurse collects data cues from the client. Cues are small amounts of data that are applied to the decision-making process. Nurses should be attentive to the cues gathered from the interview, health history, symptom analysis, physical examination, and laboratory and diagnostic data since they increase the index of suspicion and stimulate further observation of additional sets of cues. Examples of cues might be poor skin turgor, parched lips, dry skin, decreased urine output, and complaint of thirst. The expert nurse immediately processes these cues and determines a nursing diagnosis, plans client outcomes, and implements therapeutic nursing interventions. The novice nurse must proceed more cautiously and use additional time to process these data cues.
Validating Cues
After reviewing the data cues, the nurse validates that information and examines it carefully (see Figure 7-1).
In the example of Mr. Zachary, the nurse determines if the information is accurate and complete. This process involves verifying subjective and objective data.
Verification can be done by interviewing Mr. Zachary again and reassessing data cues, for example, weighing him and measuring abdominal girth.
Interpreting Cues
Through interpretation of data cues and use of critical-thinking strategies, the nurse assigns a meaning to the data cues.
In order to interpret Mr. Zachary’s subjective and objective data cues, the nurse should ask the following questions:
• What is this information telling me?
• Is there a pattern?
• Can this information be put together?
• Is the information falling into a logical arrangement?
• Is the information forming natural groupings?
Critical Thinking in Nursing Diagnosis
Contemporary nursing practice, with its focus oursing diagnoses, interventions, and outcomes, requires critical thinking (Pesut & Herman, 1999). Interpreting data cues is one example of critical thinking that the nurse must do on a daily basis when working with clients. Specifically, the synthesis of information that takes place when interpreting data cues demonstrates how essential it is for the nurse to think critically. Interpreting Mr. Zachary’s cues is pivotal for correctly diagnosing his actual, or at-risk problem, or wellness state. The accompanying display provides questions that are helpful in developing appropriate diagnoses.
Clustering Cues
Once the cues have been collected, validated, and interpreted, the data are then grouped into clusters. A cluster is a set of data cues in which relationships between and among cues are established to identify a specific health state or condition. Related pieces of information about the client are grouped together. Conclusions are drawn from the data cues. One piece of information by itself can be misleading.
This idea is analogous to the assembly of a jigsaw puzzle.
One puzzle piece by itself does not give an accurate idea of the picture. In the same way, one data cue (or piece of assessment data) does not have much relevance by itself. When more pieces of the puzzle are put together or when more data assessment cues are put together, the nurse may have a beginning idea of what the puzzle picture or the client’s health looks like.
In Mr. Zachary’s situation, data cues that can be clustered together include: Subjective: “I always seem to be hungry and I eat five or six times a day” and “I’ve gained
Consulting NANDA List of Nursing Diagnoses
After the data have been organized into clusters, the nurse needs to consult the NANDA list to ascertain similarities and differences between the clusters and NANDA diagnoses. The clustered data are then matched with a particular NANDA diagnosis. In Mr. Zachary’s case, the NANDA-approved diagnosis is Imbalanced Nutrition: More Than Body Requirements.
Writing the Nursing Diagnosis Statement
The nursing diagnosis selected from the NANDA list becomes the diagnostic label, the first part of the diagnosis statement. Etiologies are also identified from the NANDA list. The appropriate etiology is selected and joined to the first part of the statement with the “related to” phrase. Because the NANDA list of nursing diagnoses is constantly evolving, there may be times wheo etiology is provided. In such cases, the nurse should attempt to describe likely contributing factors to the client’s condition.
In a two-part statement, the nursing diagnosis for Mr. Zachary would be Imbalanced Nutrition: More Than Body Requirements RT excessive food intake. The threepart statement would be Imbalanced Nutrition: More Than Body Requirements AEB weight gain, increased appetite, excess adipose tissue, and increased abdominal girth.
