The purpose of this article is a guide for writing a nursing diagnosis. After reading this article, ideally you will have the confidence you need to write a nursing diagnosis that you, your patients and your clinical instructor are going to love.

Introduction

• Writing care plans and nursing diagnosis may sound daunting and stressful, but the purpose of them is to get you thinking like a nurse. You have probably been in awe of a nurse who can think and act quickly when a patient is deteriorating. The reality is, that nurse thought about a nursing diagnosis and a care plan without even thinking twice and acted on it. This guide will help you take the steps to be that awesome nurse.
• The type of nursing diagnosis you will be writing is the NANDA Nursing Diagnosis. NANDA stands for North American Nursing Diagnosis Association. The purpose of using NANDA’s nursing diagnosis is so that there is a standardization of nursing diagnosis.
• This guide will walk you step-by-step through the art of writing a nursing diagnosis so next time your instructor or professor asks for one, you are ready with the answer!

The Nursing Process

In order to write a nursing diagnosis, we must refresh ourselves on the nursing process as it is an important foundation to writing a nursing diagnosis.

Assessment: This is all the subjective and objective data you collected about your patient during your assessment. Physical assessment, emotional and mental status assessments, lifestyle assessments, social assessments.

Diagnosis: This is where you look at all the information you gathered in your assessment and start to come up with a nursing diagnosis.

Planning: In this step you start coming up with possible interventions for your nursing diagnosis. Think about timeline here, are these interventions for goals we will reach today? Tomorrow?

Implementation: This is where you will carry out those interventions you were brainstorming during your planning phase and start seeing the outcomes of your interventions.

Evaluation: This is where you will evaluate if your interventions worked. Remember we put a timeline on this, so you will evaluate if your interventions worked in the timeframe you set. If the interventions were successful that is great, but if not then do not be afraid to modify them and try again!

What is a Nursing Diagnosis?

• According to NANDA, “Nursing diagnoses communicate the professional judgments that nurses make every day to our patients, colleagues, members of other disciplines and the public. Nursing diagnoses define what we know – they are our words.”
• It is important to note that a nursing diagnosis is not the same as a medical diagnosis. Physicians and advanced practice providers (APP) can create a medical diagnosis nurses cannot. A nursing diagnosis focuses on the persons response to an illness/condition.
• There are different types of nursing diagnosis. First, there are problem focused nursing diagnosis, these are going to be based on signs and symptoms you are seeing on your assessment. Next, there are at-risk nursing diagnosis, these use nursing judgement to determine if a patient is “at-risk” for an adverse outcome. An example of an at-risk nursing diagnosis would be risk of falls. Another type of nursing diagnosis is a health promotion nursing diagnosis. A health promotion nursing diagnosis recognizes when someone is ready to participate in actions that promote a healthy lifestyle. An example of a health promotion nursing diagnosis is readiness for enhanced nutrition. Lastly, we have syndrome nursing diagnosis. Syndrome nursing diagnosis are where several nursing diagnosis fit under one umbrella . Theses nursing diagnoses can be treated with the same interventions.

Writing a Problem/Etiology/Symptom also known as PES diagnosis

I am about to give you the exact formula you are going to want to write on a note card and stick in your pocket during clinical or do what I did during nursing school and write it on the back of your badge… if your facility and school allow it of course.

The formula:

This is how you will write a three part problem focused nursing diagnosis. You will start with the problem (nursing diagnosis), you will give the cause of the problem (etiology) and your evidence is in your assessment (symptoms). Lets look at some examples of this:

Fluid volume deficit related to vomiting and diarrhea as evidenced by tachycardia and dry mucus membranes.

Pain related to abdominal surgery as evidenced by tachycardia, hypertension and patient pain score 9/10

Next we can look at a two part nursing diagnosis, these will likely be your at-risk nursing diagnoses.

This is your two step nursing diagnosis. Lets look at some examples of these.

First we have at-risk nursing diagnoses. For example:

Risk for pressure injury as evidenced by immobility or Risk for infection as evidenced by invasive procedure.

Next, we have health promotion diagnosis. Example:

Readiness for enhanced coping as evidenced by willingness to seek emotional support

A syndrome nursing Diagnosis will be one part it will be something like “Chronic pain syndrome”

Conclusion

Writing an accurate and effective nursing diagnosis is a critical skill that directly impacts patient outcomes. Utilizing standardized language and resources like NANDA helps maintain clarity and consistency, while collaboration with the healthcare team enhances the overall quality of care. By using the information provided on this article, you will impress your professors and instructors in no time.