Nursing diagnosis identifies patient needs within nursing practice, not medical diagnoses. There are four types of nursing diagnoses: actual, possible, risk, and syndrome. Nurses prioritize diagnoses and develop a plan to achieve goals.
Nursing diagnosis is a tool used by nurses to identify specific patient needs that fall within the scope of nursing practice. Diagnosis is one of the first steps in developing a plan of care and is based on physician recommendations, evaluation of medical records, and in-person examination of patients. Nurses review all information and determine areas that may cause problems or complications for patients.
To understand what a nursing diagnosis is, it is important to understand what it is not. Nurses do not make medical diagnoses, as these are beyond their scope of practice. Determining the underlying cause of a condition falls to doctors and surgeons, while nurses look at how that disease affects other areas of a patient’s life that can be improved through nursing. For example, a doctor diagnoses a patient with heart disease and recommends a low-salt diet, while a nurse diagnoses the patient with a learning disability related to following a therapeutic diet and develops a plan to educate the patient.
There are several types of nursing diagnoses – four of which identify a problem or potential problem – and a well-being nursing diagnosis which identifies a patient’s strengths. An actual diagnosis is based on a problem that is currently present, such as diarrhea. A possible diagnosis identifies a problem that is probably present, but not yet confirmed. A problem that has the potential to become a problem based on current health status is written as a risk diagnosis. When a patient has actual or at risk for a group of related problems, such as post-traumatic stress, those problems are grouped into a syndrome diagnosis.
In general, a nursing diagnosis consists of at least two parts: the diagnosis itself and the rationale for the diagnosis. For example, if a patient is on full bed rest and unable to move around frequently, a nurse may diagnose a risk of disuse syndrome related to impaired mobility. Actual and potential diagnoses go a step further and add evidence of the condition after the “related to” part. A three-part nursing diagnosis for pain can be read as “pain related to surgery experienced by the patient verbalizing that she is in pain”. It may seem redundant to mention pain twice, but it’s important because it identifies how a nurse determined the diagnosis.
Once a nursing diagnosis has been made, the nurse must follow it up by determining a goal for solving the problem and a plan for achieving that goal. When more than one diagnosis is present, the nurse should prioritize them based on those with the greatest immediate need. Patients’ conditions can change frequently during their stay in a facility, and nurses must be prepared to adjust their diagnoses accordingly.
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