Categories or Types of Nursing Diagnosis

Categories or Types of Nursing Diagnosis

The four main categories of nursing diagnoses recognized by the NANDA-I include problem-focuses (actual), risk, health promotion, and syndrome diagnosis.

Problem-Focused or Actual Nursing Diagnosis

An actual or problem-focused nursing diagnosis is a patient/client problem present during a nursing assessment. The diagnosis is based on the presence of associated signs and symptoms, and it contains three components: (a) Nursing diagnosis, (b) related factors, and (c) defining characteristics. Actual diagnoses can be used throughout the course of a patient�s stay in the hospital or can be solved by the end of a given shift. The template for a problem-focused diagnosis is Problem-focused diagnosis related to����. (Related Factors) as evidenced by ��. (defining characteristics). Examples of problem-focused diagnoses include:

• Anxiety (diagnosis) related to stress and situational crises (related factors) as evidenced by anguish, insomnia, restlessness, and anorexia (defining characteristics)
• Acute pain related to decreased myocardial flow as evidenced by expression of pain, guarding behavior, and grimacing.
• Shortness of breathing related to pain as evidenced by pressure-lip breathing, reports of pain when inhaling, and use of accessory muscles to breathe.

Risk Nursing Diagnosis

The risk nursing diagnosis is also technical as the problem-focused nursing diagnosis. It is a clinical judgment that a problem does not exist. However, the presence of risk factors indicates that the problem will likely develop unless nursing interventions are activated. A risk diagnosis is based on the current health status of the patient, their past medical or health history, and other risk factors that make a patient vulnerable to experiencing a specific health problem or a set of health problems. It is an important part of nursing care planning as it allows the identification and treatment or management of problems early enough through mitigation measures. When writing a risk diagnosis, the focus is not on the etiological factors, and instead, it is assumed that an individual or a group is more susceptible to developing a health problem than others in the same situation due to the risk factors. The critical components of a risk nursing diagnosis are the risk diagnostic label and the risk factors. The template for a risk nursing diagnosis is as follows: Risk diagnosis or diagnostic label (Risk for) �.as evidenced by (AEB)�. (Risk factors) Examples of risk nursing diagnoses include:

• Risk for infection as evidenced by immunosuppression and missed vaccinations.
• Risk for falls as evidenced by poor bones, osteoporosis, and improper use of crutches
• Risk for injury as evidenced by altered clotting factors
• Risk for kidney stones as evidenced by vigorous dehydration and not drinking enough water
• Risk for adult falls as evidenced by lack of engineering controls at home
• Risk for pressure ulcers as evidenced by lack of ambulation

Health Promotion Diagnosis

The health promotion diagnosis is also known as a wellness diagnosis. Nurses make a clinical judgment about the client's motivation, desire, and need to achieve well-being. It identifies the readiness of the patients to engage in activities that promote their health and well-being. Such diagnoses help guide independent nursing interventions to support the patients in learning and adhering to health promotion patterns and programs. Health promotion diagnoses go beyond the patient to cover family and community transition to attain higher levels of wellness. The components of health promotion diagnosis include the diagnostic label or a one-part statement. The template for a health promotion diagnosis is as follows: [Health Promotion Label] as evidenced by (defining characteristics) Examples of health promotion diagnoses include:

• Readiness for enhanced nutrition as evidenced by the patient�s verbalization of the desire to adhere to enhanced nutrition
• A sedentary lifestyle ad evidenced by insufficient physical activity.
• Reediness to enhanced family coping as evidenced by verbalization of desire to optimize wellness
• Readiness for enhanced self-care as evidenced by an expressed desire to enhance self-care
• Enthusiasm for exclusive breastfeeding as defined by the passion and knowledge of exclusive breastfeeding

Syndromes Diagnosis

A syndrome diagnosis is a clinical judgment relating to a cluster of problems or risk nursing diagnoses predicted to present due to a certain event or situation. Like the health promotion diagnosis, they are also a one-part statement where the diagnostic label is enough, but you can add the defining characteristics. The template for syndrome diagnosis is: Syndrome diagnosis or diagnostic label Examples of syndrome diagnosis include:

• Disuse syndrome
• Rape-trauma syndrome
• Chronic pain syndrome

Steps for Writing a Nursing Diagnosis

As a nursing student, there are specific steps you need to take when writing a nursing diagnosis. Remember, a nursing diagnosis is a short statement that constantly forms the basis of care planning. You must draft hypothetical nursing care plans based on case studies, vignettes, or patient data to hone your clinical judgment, decision-making, problem-solving, and critical thinking. Here are the steps when formulating a nursing diagnosis

Step 1: Assessment

The first step when assigned to write a nursing diagnosis is to observe the presenting symptoms of the patient. Read the case study or vignette or check the patient information/data to describe the patient's problem based on the signs and symptoms.

Step 2: identify the potential diagnosis

Look at what the patient has done to alleviate the symptoms and how they cope with pain, loss of functioning, or discomfort. Look at both the subjective and objective information. Subjective data is what the patient says about their feelings, whereas objective data comes from measurable and verifiable observations using scientific methods. Examples of objective information include vital signs and diagnostic/lab results/findings. You should also identify the specific problem you will address in the nursing diagnosis. It is a matter of prioritizing care to stabilize the patient. You should also look for the source of the problem the patient is experiencing. For instance, if you diagnose a chronic patient, check for injuries or burns related to it. Check the past medical diagnosis and be open to the fact that the patient can have multiple diagnoses. Your diagnosis should also include the potential problems related to the related factors. To make an effective clinical judgment, look up the official terminology for your observed problem. For this, you can use the NANDA-I nursing diagnosis categories. You should, at this point, confirm and rule out other diagnoses or create new diagnoses.

Step 3: Write the nursing care plan

Nursing diagnosis helps you implement dependent and interdependent nursing care plans for the patient. You can create measurable and achievable goals and come up with evidence-based interventions.

Step 4: Evaluate

After implementing the nursing care plan, the next step is to constantly evaluate the patient's progress to identify if the current interventions are effective or should be altered. A nursing diagnosis is assessed to ensure the care plan works well.

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