Structure of diagnoses
The NANDA-I system of nursing diagnosis provides for four categories.
Actual diagnosis – “A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community”. An example of an actual nursing diagnosis is: Sleep deprivation.
Risk diagnosis – “Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability.” An example of a risk diagnosis is: Risk for shock.
Health promotion diagnosis – “A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state.” An example of a health promotion diagnosis is: Readiness for enhanced nutrition.
Syndrome diagnosis – “A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.” An example of a syndrome diagnosis is: Relocation stress syndrome.
Process of diagnoses
Conduct a nursing assessment – collection of subjective and objective data relevant to the care recipient’s (person, family, group, community) human responses to actual or potential health problems / life processes.
Cluster and interpret cues/patterns – Assessment data must be clustered and interpreted before the nurse can plan, implement or evaluate a plan to support patient care
Generate Hypotheses – possible alternatives that could represent the observed cues/patterns.
Validation & Prioritization of Nursing Diagnoses – taking necessary steps to rule out other hypotheses, to confirm with the patient(s) the validity of the hypotheses, and to prioritize the list of diagnoses. A focused assessment may be needed to obtain data for one or more diagnoses
Planning – Determining appropriate (realistic) patient outcomes and interventions most likely to support attainment of those outcomes through evidence-based practice
Implementation – Putting the plan of care (nursing diagnoses – outcomes – interventions) into place, preferably in collaboration with the care recipient(s)
Evaluation – Movement toward identified outcomes is continually evaluated, with changes made to interventions as necessary. When no positive movement is occurring, reassessment to reevaluate appropriateness of diagnoses and/or achievability of outcomes must occur.