Types and Components of Nursing Diagnoses
Learning Objectives
After reading the chapter, the following questions should be answered:
What are the differences between problem-focused risk and possible nursing diagnoses?
What is a health-promotion diagnosis?
What are syndrome nursing diagnoses?
When can a non-NANDA-I nursing diagnosis be used?
When should unknown etiology be used?
How can errors be avoided in diagnostic statements?
This chapter will focus on types of nursing diagnoses and writing diagnostic statements. There are five types of nursing diagnoses: problem-focused, risk, possible, health promotion, and syndrome.
Problem-Focused Nursing Diagnoses1
A problem-focused nursing diagnosis “describes human responses to health conditions/life processes that exist in an individual, family, or community. It is supported by defining characteristics (manifestations, signs, and symptoms) that cluster in patterns of related cues or inferences” (NANDA-I, 2009). This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factors.
Label
The label should be in clear, concise terms that convey the meaning of the diagnosis.
Definition
The definition should add clarity to the diagnostic label. It should also help to differentiate a particular diagnosis from similar diagnoses.
Defining Characteristics
For problem-focused nursing diagnoses, defining characteristics are signs and symptoms that, when seen together, represent the nursing diagnosis. If a diagnosis has been researched, defining characteristics can be separated into major and minor designations. Table 3.1 represents major and minor defining characteristics for the researched diagnosis, Defensive Coping (Norris & Kunes-Connell, 1987).
Major. For researched diagnoses, at least one must be present under the 80% to 100% grouping.
Minor. These characteristics provide supporting evidence but may not be present.
Most defining characteristics listed under a nursing diagnosis are not separated into major and minor.
Related Factors
In problem-focused nursing diagnoses, related factors are contributing factors that have influenced the change in health status. Such factors can be grouped into four categories:
Pathophysiologic, Biologic, or Psychological. Examples include compromised oxygen transport and compromised circulation. Inadequate circulation can cause Impaired Skin Integrity.
Table 3.1 FREQUENCY SCORES FOR DEFINING CHARACTERISTICS OF DEFENSIVE COPING
Defining Characteristics
Frequency Scores (%)
Major (80%-100%)
Denial of obvious problems/weaknesses
88
Projection of blame/responsibility
87
Rationalizes failures
86
Hypersensitive to slight criticism
84
Minor (50%-79%)
Grandiosity
79
Superior attitude toward others
76
Difficulty in establishing/maintaining relationships
74
Hostile laughter or ridicule of others
71
Difficulty in testing perceptions against reality
62
Lack of follow-through or participation in treatment or therapy
56
Norris, J., & Kunes-Connell, M. (1987). Self-esteem disturbance: A clinical validation study. In A. McLane (Ed.), Classification of nursing diagnoses: Proceedings of the seventh NANDA national conference. St. Louis, MO: CV Mosby.
Treatment-Related. Examples include medications, therapies, surgery, and diagnostic study. Specifically, medications can cause nausea. Radiation can cause fatigue. Scheduled surgery can cause Anxiety.
Situational. Examples include environmental, home, community, institution, personal, life experiences, and roles. Specifically, a flood in a community can contribute to Risk for Infection; divorce can cause Grieving; obesity can contribute to Activity Intolerance.
Maturational. Examples include age-related influences, such as in children and the elderly. Specifically, the elderly are at risk for Social Isolation; infants are at Risk for Injury; and adolescents are at Risk for Infection.
Carp’s CuesRelated factors or contributing factors are the second part of a nursing diagnosis statement. Some of NANDA-I nursing diagnoses labels have the etiology in label as Death Anxiety, Labor Pain. Thus it becomes problematic when the clinician attempts to write a diagnostic statement as Labor Pain related to labor.
Problem-focused nursing diagnoses are validated by signs and symptoms (or defining characteristics). Some NANDA-I diagnoses represent signs/symptoms of that appear under other nursing diagnoses. For example, Self-Neglect can be associated with substance abuse, grieving, depression, confusion, homelessness and influences socialization, relationships, etc.
Anger is human response to multiple situations. Anger can be constructive or destructive. Anger can be found in the defining characteristics of many nursing diagnoses, for example, Risk for Violence to Others, Dysfunctional Family Processes, Anxiety, Acute Confusion. Should anger be a nursing diagnosis or it more clinically useful when with more assessments yield a more specific nursing diagnosis?
INTERACTIVE EXERCISE 3.1 To determine the presence of a problem-focused diagnosis, ask, “Are major signs and symptoms of the diagnosis in this person?”
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Risk and High-Risk Nursing Diagnoses
NANDA-I defines a risk nursing diagnosis as “human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability” (NANDA-I, 2009).
The concept of “at risk” is useful clinically. Nurses routinely prevent problems in people experiencing similar situations such as surgery or childbirth who are not at high risk. For example, all postoperative individuals are at risk for infection. All women postdelivery are at risk for hemorrhage. Thus, there are expected or predictive diagnoses for all individuals who have undergone surgery while on chemotherapy or with a fractured hip.
Carp’s CuesNurses do not need to include all risk diagnoses on the individual’s care plan in the hospital. In fact, it is unproductive for nurses (not students) to write text of the same predicted care repeatedly. Students are expected to identify the predicted care until they are experienced with that care. Instead, this diagnosis is part of the unit’s standard of care (see Chapter 6 for a discussion of standards).
All persons admitted to the hospital are at Risk for Infection related to increased microorganisms in the environment, risk of person-to-person transmission, and invasive tests and therapies. Refer to Box 3.1 for an illustration of this standard diagnosis and how it is individualized to become a high-risk diagnosis. The high-risk concept is very useful for persons who have additional risk factors that make them more vulnerable for the problem to occur. In the hospital or other health care facilities, individuals should be assessed if they are at high risk for falls, infection, or delayed transition. High-risk individuals need additional preventive measures.
Box 3.1 REVISING A STANDARD SURGICAL CARE PLAN NURSING DIAGNOSIS
Standard Nursing Diagnosis
Risk for Infection related to incision and loss of protective skin barrier
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