Introduction

A fundamental part of working as a nurse is formulating a nursing diagnosis, which guides outcomes and corresponding interventions to achieve patient care goals. It is a dynamic method of assessment and data aggregation that encompasses the depth and breadth of the nurses’ scope of practice and, in many situations, serves as a tool to aid in critical thinking. To write and apply an appropriate nursing diagnosis, the nurse must gather patient data incorporating the scientific, physiological, and medical aspects of a patient’s situation. The critical thinking skills necessary for this process enable nurses to make clinical judgments based on evidence and experience.

How do nurses learn to do this? How does a nurse learn to think in a way that leads to the appropriate decisions and conclusions? It is one thing to learn clinical knowledge—facts, figures, anatomy, and physiology—but how do nurses learn to go a step further to think critically and apply clinical judgment? The nurse acquires these key skills by creating a systematic method of gathering data, assessing, forming a hypothesis, creating a plan, putting the plan into action, and reevaluating.

This chapter begins with the evolution of nursing diagnoses and a discussion of the nursing process, which is the basis for developing nursing thought. Then, the chapter goes through the various thinkers and theories that moved the development of nursing diagnoses to the newest process in place, the Clinical Judgment Measurement Model (CJMM) developed by the National Council of State Boards of Nursing (NCSBN). The section ends with a discussion on the role nursing diagnosis plays in clinical decision-making, the different categories of nursing diagnosis, and how to formulate the diagnosis from the tools available. Understanding nursing diagnosis is an important part of nursing.