Learning Objectives
By the end of this section, you will be able to:
- Identify how to determine the category for the nursing diagnosis
- Describe how to validate the nursing diagnosis
- Explain how to refine the nursing diagnosis
To make safe and effective clinical judgments using nursing diagnoses, nurses need to understand how the diagnoses are categorized. The categories also differentiate nursing diagnoses from medical diagnoses.
This section discusses the different nursing diagnosis categories and explains how to identify a valid and appropriate diagnosis for a patient’s condition. The discussion also covers how nurses refine a nursing diagnosis to make it more specific and beneficial, thereby promoting positive outcomes for patients.
Determine the Category
Throughout the evolution of nursing diagnosis and the formation of NANDA-I, the organization of categories has been simplified to accommodate the simultaneous progression to an electronic database.
NANDA-I developed a structure that allowed for the expansion of the classification structure without having to change codes when new diagnoses, refinements, and revisions are added (NANDA-I, 2020). This is accomplished through a five-digit code. The code structure is compliant with recommendations from the National Library of Medicine concerning healthcare terminology codes.
The categories for nursing diagnosis can be broken down into problem-focused, risk, health promotion, and syndrome (Figure 13.4). Knowing in which category a diagnosis belongs helps the nurse direct their thought process when planning care and strengthens their critical thinking skills.
Link to Learning
This tutorial provides NANDA-I -approved nursing diagnosesto help students develop an understanding of grouping nursing diagnoses.
Problem-Focused Diagnosis
An actual problem identified or recognized during the assessment process falls into the problem-focused category of nursing diagnoses. Unwanted responses to a health condition would be a problem-focused diagnosis. They are identified or based on the presence of clinical signs and/or symptoms and are the foundation for nursing diagnosis selection.
A problem-focused nursing diagnosis has four components: label, definition, defining characteristics, and related factors. These components will be discussed further in this section. Examples of problem-focused nursing diagnoses include
- impaired mobility related to musculoskeletal injury as evidenced by limited range of motion and difficulty ambulating;
- ineffective breathing pattern related to chronic obstructive pulmonary disease (COPD) as evidenced by shortness of breath and use of accessory muscles for breathing;
- impaired skin integrity related to pressure ulcer on sacrum as evidenced by erythema and skin breakdown; and
- ineffective coping related to the recent loss of a loved one as evidenced by tearfulness and social withdrawal.
Risk Diagnosis
A risk diagnosis is developed through clinical judgment based on the vulnerability of the patient’s individualized situation. A risk diagnosis is recognized when the nurse identifies a potential problem that can/will develop if no intervention is initiated. This is in direct contrast to a problem-focused diagnosis, which is based on the actual presence of signs and symptoms rather than the potential for a problem’s development. Risk diagnoses are broader and used to cover the “what if” situations that could occur. For example, consider an older adult living alone with vertigo. In this patient’s case, the risk diagnosis would be “risk for falls.” The patient has not yet fallen, but their situation lends itself to putting them at risk for this outcome.
Examples of risk nursing diagnoses include
- risk for falls related to history of falls, impaired mobility, and use of sedative medications;
- risk for infection related to compromised immune system secondary to chemotherapy treatment;
- risk for aspiration related to dysphagia and impaired gag reflex; and
- risk for impaired skin integrity related to immobility and prolonged bed rest.
Health Promotion Diagnosis
A health promotion diagnosis can help promote and improve a patient’s overall well-being and health, as well as their family/support structure/community. The diagnoses are not about identified problems or potential risks but about potential benefits based on the patient’s current situation. This category of nursing diagnosis is more concerned with the patient’s motivation and desire to improve their overall well-being and increased quality of life.
Examples of health promotion nursing diagnoses include
- readiness for regular exercise related to expressed interest in starting a fitness program;
- readiness for health literacy enhancement related to limited understanding of medication management;
- readiness for enhanced nutrition related to expressed desire to improve dietary habits and increase intake of fruits and vegetables; and
- readiness for smoking cessation related to acknowledgment of health risks associated with smoking and expressed willingness to quit.
Syndrome Diagnosis
The last category, according to NANDA-I, is syndrome diagnosis. A syndrome diagnosis occurs when a group or cluster of nursing diagnoses can be utilized based on certain life events or situations. The diagnosis can be actual, risk, or health promotion, but all are commonly used for the patient’s situation.
Evidence-based research shows that most people who experience trauma will go through certain phases of healing and experience many of the same signs and symptoms. A syndrome diagnosis is not a “one-and-done” tactic, meaning that the nurse must ensure a diagnosis still relates to the individual patient. That said, it is a helpful way to identify several potential nursing diagnoses based on a specific life event.
Examples of syndrome nursing diagnoses include
- chronic pain syndrome related to neuropathic pain secondary to diabetic neuropathy as evidenced by reports of persistent pain and altered sleep patterns;
- chronic fatigue syndrome related to chronic illness and sleep disturbances, as evidenced by reports of profound fatigue despite adequate rest;
- post-traumatic stress syndrome related to a traumatic event as evidenced by flashbacks and hypervigilance; and
- disorganized infant feeding syndrome related to maternal anxiety and lack of breastfeeding support.
Validate the Nursing Diagnosis
The validation stage comes after the identification of a nursing diagnosis. To validate means confirming the chosen diagnosis is appropriate for the individual patient using evidence to support it. While NANDA-I has developed a database that transitioned to digital format seamlessly (and it makes the identification of nursing diagnosis easier, based on the data collected and documented in the electronic health record), it is still crucial for the nurse to take the extra step to manually validate the diagnosis. There are several key factors used to prove validity. The following are a few questions the nurse can use to help validate the chosen diagnosis:
- Are the collected assessment data appropriate, accurate, and supported by nursing research?
- Did I use the data to identify the existence of a pattern?
- Is the identified pattern characteristic of the defined health problem?
- Does the nursing diagnosis use scientific nursing knowledge and evidence-based practice standards as the basis for selection?
- Can the nursing diagnosis be reduced or resolved by independent nursing action or interventions?
- Would other qualified clinicians formulate the same nursing diagnosis based on my data?
It is important at this stage to actively encourage, rather than ignore, the patient’s ongoing participation in the process. Ask, “What are the patient’s perceptions of the problem?” “What do they think will help resolve the problem?” “How do these perceptions and thoughts compare with the nursing interventions, plans, and expected outcomes?”
For example, the identified nursing diagnosis of “activity intolerance” can be validated and confirmed by the patient through expressed statements such as, “I am unable to complete the assigned tasks due to weakness.”
Related Factors
Related factors are derived from the etiology or pathophysiology of the disease process or condition. Simply put, a related factor is the reason behind the signs and symptoms the patient is experiencing.
For example, if the chosen nursing diagnosis is “ineffective breathing patterns,” the related factors, expressed as a “related to” statement, could be described as “related to decreased lung expansion.” The identified problem or negative response is ineffective breathing, and the related factor used to explain the presence of the problem is decreased lung expansion.
Some related factors are easily identified, while others may stem from different origins. It is important for the nurse to identify which factors are related to the individual patient being in a specific situation. For example, consider the nursing diagnosis of pain. The related factors for pain could range from sources of physical, psychological, psychosocial, or even spiritual and cultural factors. The nurse needs good clinical judgment to determine the exact cause of the patient’s pain and correctly associate the related factor for the formal nursing diagnosis.
Clinical Judgment Measurement Model
Analyze Cues: Asking Specific Questions
As the nurse enters the room, the patient complains of pain at the surgical site. During inspection of the site, the nurse notices that the patient’s skin is red, swollen, and hot to the touch. The nurse is using clinical signs to begin the process of formulating the hypothesis—the patient has an infection. Upon further data collection, the nurse identifies abnormal vital signs that include elevated heart rate and increased temperature. Using analysis, the nurse determines these cues are not related to the nursing diagnosis of pain but to a possible change in the patient’s condition.
Defining Characteristics
The defining characteristic of a nursing diagnosis are the actual signs and symptoms being exhibited by the problem. The phrase used to write defining characteristics is “as evidenced by.” To continue with the example of “ineffective breathing pattern,” the defining characteristics are the signs and symptoms exhibited or expressed by the patient during data collection. The nurse noticed signs and symptoms such as dyspnea (shortness of breath), coughing, and difficulty breathing.
Putting all of these elements together, the nursing diagnosis would be “ineffective breathing pattern (category) related to decreased lung expansion (related factors) as evidenced by dyspnea, coughing, and difficulty breathing (defining characteristics).”
Refine the Nursing Diagnosis
After validating and applying the nursing diagnosis, the nurse may need to refine it. This can be considered the evaluation phase of formulating a nursing diagnosis. To refine the nursing diagnosis, the nurse may need to select a new diagnosis or narrow it down more specifically to assign new interventions based on outcomes. Think of this as the application of patient care. What worked? What did not work?
Sometimes social or environmental factors and disease progression require that the diagnosis be reassessed and the care plan altered. Take the previous nursing diagnosis of “ineffective breathing patterns related to decreased lung expansion as evidenced by dyspnea, coughing, and difficulty breathing” and assume the following interventions were implemented:
- The nurse will encourage the use of incentive spirometry.
- Respiratory therapy will administer breathing treatments as needed per provider’s orders.
- The nurse will assist the patient into semi-Fowler’s position (head of the bed is elevated at an angle of approximately 30 to 45 degrees) to help increase lung expansion.
Now, let’s assume the patient continued to display signs and symptoms of dyspnea, coughing, and difficulty breathing even after the interventions were implemented. This situation would warrant redefining the nursing diagnosis. Things to consider would be the recommendation of further diagnostic tests to determine a more specific underlying cause of the problem, such as impaired gas exchange or possible lung infection. At this point, the nurse would recommend an order for an ABG (arterial blood gas) to help identify ineffective gas exchange or possible sputum analysis to identify any infections.
Patient Conversations
Refining a Nursing Diagnosis
Scenario: Mrs. Winters is an 80-year-old female diagnosed with heart failure and is now being discharged home with a new prescription of furosemide. Currently, Mrs. Winters’s nursing diagnosis is risk for fluid volume overload. The nurse, Samuel, goes into the room to provide discharge instructions to Mrs. Winters.
Nurse: Okay, Mrs. Winters, do you have any other questions for me?
Patient: Yes, I have questions about that water pill.
Nurse: The new diuretic your provider ordered is called furosemide. This is a diuretic that will help you urinate excess fluid, which will help reduce strain on your heart. What questions do you have?
Patient: Well, I live alone. There are two bathrooms in my house, but the only one that works is downstairs. If I am going to pee more than normal, I’m worried I won’t be able to make it to the bathroom in time.
Nurse: Just to make sure I understand—you have two bathrooms, but the one upstairs located near your bedroom doesn’t work? Only the bathroom on the main floor is functioning. Is that right?
Patient: Yes, that’s right. I really don’t want to pee my pants, but I’m scared about running up and down those stairs at my age!
Nurse: I completely understand, and those are valid concerns. We want to keep you safe, and rushing up and down the stairs at night would be considered a fall risk. Let me talk to the social worker. She may be able to get you a bedside commode for you to use at night, and then when the home health aide comes in the daytime, they can empty and clean it for you.
Patient: That sounds pretty good. Let’s see if we can make that work. Thank you!
Scenario follow-up: Samuel refines the nursing diagnosis to include risk for falls in addition to risk for fluid volume overload.