Nursing Diagnosis Guide: Complete List & Tutorial

The nursing diagnosis is where you stop describing the disease and start naming what nursing can actually do about it. The physician owns the medical diagnosis. You own the human response to it: the airway you have to keep clear, the skin you have to protect, the anxiety you have to bring down. Get the diagnosis right and the rest of the care plan writes itself. Get it wrong and every intervention downstream is aimed at the wrong target.

This guide covers what a nursing diagnosis is, how it differs from a medical diagnosis and a collaborative problem, the classification system, the four types, and how to write one correctly.

What is a Nursing Diagnosis?

A nursing diagnosis is a clinical judgment about a human response to a health condition or life process, or a vulnerability to that response, in an individual, family, group, or community. It is built from the data you gather during assessment, and it is the basis for selecting the interventions you are accountable for.

Purposes of Nursing Diagnosis

A nursing diagnosis sets priorities and points interventions at them. It identifies how a patient or group responds to actual or potential health problems and surfaces the strengths and resources you can draw on to resolve them. It gives the team a common language, frames the expected outcomes used for quality assurance and third-party payers, and provides a basis for evaluating whether the care worked. For students, writing diagnoses sharpens problem-solving and critical thinking.

Nursing Diagnosis vs Medical Diagnosis vs Collaborative Problem

The same phrase gets used three ways, so pin it down. As a step in the nursing process, "diagnosis" is the D in ADPIE. As a label, a nursing diagnosis is the name you assign once you cluster the data. A patient who is anxious, fearful, and not sleeping gets three labels: Anxiety, Fear, and Disturbed Sleep Pattern. Each one names a response nurses have the autonomy to treat, whether physical, mental, or spiritual. The focus is care.

A medical diagnosis is made by the physician or advanced practitioner and names the disease or pathological state only they can treat: Diabetes Mellitus, Tuberculosis, Hepatitis, Chronic Kidney Disease. It usually does not change, and nurses carry out the prescribed treatments around it.

A collaborative problem sits between the two. It is a potential complication that nurses manage with both independent actions and physician-prescribed interventions, with the nursing piece focused on monitoring the patient and catching the complication before it develops.

So the line is simple: a nursing diagnosis targets the patient's physiological and psychological response, a medical diagnosis targets the illness itself.

Classification of Nursing Diagnoses (Taxonomy II)

Taxonomy II was adopted in 2002, built on the Functional Health Patterns assessment framework of Dr. Marjory Gordon. It has three levels: 13 Domains, 47 Classes, and the nursing diagnoses themselves. Diagnoses are no longer grouped by Gordon's patterns. They are coded across seven axes (diagnostic concept, time, unit of care, age, health status, descriptor, and topology) and listed alphabetically by concept rather than by the first word.

The Nursing Process

The five stages are assessment, diagnosing, planning, implementation, and evaluation. Every stage demands critical thinking. Beyond knowing the diagnoses and their definitions, you have to recognize their defining characteristics, the related factors behind them, and the interventions that fit.

Types of Nursing Diagnoses

There are four types: Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.

Problem-Focused (Actual) Diagnosis

A problem-focused diagnosis is a problem present at the time of assessment, supported by associated signs and symptoms. It is not automatically more important than a risk diagnosis. A risk diagnosis is often the top priority for a given patient.

A problem-focused diagnosis has three components: the diagnostic label, the related factors, and the defining characteristics. Examples:

• Anxiety related to stress as evidenced by increased tension, apprehension, and expressed concern about upcoming surgery
• Acute Pain related to decreased myocardial flow as evidenced by grimacing, expression of pain, and guarding behavior

Risk Diagnosis

A risk diagnosis is a clinical judgment that a problem does not exist yet, but risk factors make it likely to develop unless you intervene. It is based on current health status, past history, and other factors that raise the patient's odds of a problem. Risk diagnoses earn their place by catching problems early enough to prevent them.

Risk diagnoses have no etiological (related) factors. The patient is simply more susceptible than others in a similar situation. An older adult with diabetes and vertigo who has trouble walking and refuses help during ambulation fits Risk for Injury or Risk for Falls.

For a risk diagnosis, "as evidenced by" connects the label to the risk factors, not to defining characteristics. The two components are:

1. Risk diagnostic label, joined by "as evidenced by"
2. Risk factors

Examples:

• Risk for Injury as evidenced by reduced cognitive awareness and use of sedative medications
• Risk for Infection as evidenced by surgical wound, compromised immune system, and prolonged hospitalization
• Risk for Falls as evidenced by muscle weakness, history of previous falls, impaired mobility, and use of assistive devices

Health Promotion Diagnosis

A health promotion (wellness) diagnosis is a clinical judgment about a patient's motivation and readiness to increase wellbeing. When a first-time mother shows interest in learning to breastfeed properly, the diagnosis Readiness for Enhanced Breastfeeding guides interventions that support her. It is about moving an individual, family, or community from one level of wellness to a higher one. It is usually a one-part statement (the label alone), though related factors can be added for clarity. Examples:

• Readiness for Enhanced Knowledge as evidenced by expressed desire to learn, openness to education, and motivation to understand complex concepts
• Readiness for Enhanced Breastfeeding as evidenced by desire to increase breastfeeding frequency, expressed interest in proper latching, and verbalized commitment
• Readiness for Enhanced Comfort as evidenced by expressed desire to explore comfort measures, willingness to try relaxation, and interest in improving pain management

Syndrome Diagnosis

A syndrome diagnosis names a cluster of problem or risk diagnoses predicted to occur because of a certain situation. It is a one-part statement requiring only the label. Examples:

• Chronic Pain Syndrome
• Frail Elderly Syndrome

Possible Nursing Diagnosis

A possible diagnosis is not one of the four types. It flags a suspected problem that needs more data to confirm or rule out, letting you signal to other nurses that a diagnosis may be present pending further assessment. Examples:

• Possible Chronic Low Self-Esteem
• Possible Social Isolation

Components of a Nursing Diagnosis

A nursing diagnosis has three components: the problem and its definition, the etiology, and the defining characteristics or risk factors.

Problem and Definition

The problem statement, or diagnostic label, concisely names the patient's health problem or response. A label usually has two parts: a qualifier and the focus of the diagnosis. Qualifiers (modifiers) add meaning, limit, or specify the statement. One-word diagnoses (Anxiety, Constipation, Diarrhea, Nausea) are the exception, since qualifier and focus are built into the single term.

Etiology

The etiology, or related factors, names the probable causes of the problem and the conditions involved in its development. It directs the nursing therapy and lets you individualize care, since interventions should target the etiology to remove the underlying cause. It is linked to the problem with "related to":

• Activity Intolerance related to generalized weakness
• Decreased Cardiac Output related to abnormality in blood profile

Risk Factors

Risk factors replace etiological factors in a risk diagnosis. They are the forces that make a patient more vulnerable to an unhealthy condition, written after "as evidenced by":

• Risk for Falls as evidenced by old age and use of a walker
• Risk for Infection as evidenced by break in skin integrity

Defining Characteristics

Defining characteristics are the cluster of signs and symptoms that mark a particular label. In an actual diagnosis they are the patient's identified signs and symptoms. In a risk diagnosis no signs and symptoms exist yet, so risk factors take their place. They are written after "as evidenced by" or "as manifested by."

The Diagnostic Process

Diagnosing has three phases: analyzing data, identifying the patient's health problems, risks, and strengths, and formulating the diagnostic statements.

Analyzing Data

Compare patient data against standards, cluster the cues, and identify gaps and inconsistencies.

Identifying Health Problems, Risks, and Strengths

After analysis, you and the patient identify the problems that support tentative actual, risk, and possible diagnoses, and decide whether each is a nursing diagnosis, a medical diagnosis, or a collaborative problem. This is also where you name the patient's strengths, resources, and ability to cope.

Formulating Diagnostic Statements

The final phase is writing the statements, detailed below.

How to Write a Nursing Diagnosis

A diagnostic statement describes the patient's health status and the factors contributing to it. You do not need every diagnostic indicator. How you write it depends on the type.

PES Format

The PES format stands for Problem (diagnostic label), Etiology (related factors), and Signs/Symptoms (defining characteristics). Statements can be one-part, two-part, or three-part.

One-Part Statement

Health promotion diagnoses are usually one-part statements, since the related factor is always the same motivation toward a higher level of wellness. Syndrome diagnoses also carry no related factors. Examples:

• Readiness for Enhanced Coping
• Rape Trauma Syndrome

Two-Part Statement

Risk and possible diagnoses use two parts: the diagnostic label and the validation or risk factors. There is no third part because signs and symptoms do not exist yet. Examples:

• Risk for Infection as evidenced by weakened immune system response
• Risk for Injury as evidenced by unstable hemodynamic profile

Three-Part Statement

An actual diagnosis uses three parts: diagnostic label, contributing factor ("related to"), and signs and symptoms ("as evidenced by" or "as manifested by"). This is the full PES format. Examples:

• Acute Pain related to tissue ischemia as evidenced by the statement "I'm experiencing intense, sharp pain in my chest"
• Impaired Physical Mobility related to muscle weakness as evidenced by difficulty moving independently and the patient stating "I feel too weak to move on my own"
• Activity Intolerance related to decreased cardiac output as evidenced by shortness of breath and the patient stating "I feel exhausted after just a few steps," secondary to pneumonia

Variations on the Basic Formats

• "Secondary to" splits the etiology into two parts for a more descriptive statement. What follows is usually a pathophysiologic or disease process or a medical diagnosis: Risk for Decreased Cardiac Output as evidenced by reduced preload secondary to myocardial infarction.
• "Complex factors" is used when the etiologic factors are too many or too tangled for a brief phrase: Chronic Low Self-Esteem related to complex factors.
• "Unknown etiology" is used when the defining characteristics are present but the cause is not yet known: Ineffective Coping related to unknown etiology.
• A second part can specify the general response to make it precise: Impaired Skin Integrity (Right Anterior Chest) related to disruption of skin surface secondary to burn injury.

Common Nursing Diagnoses for Care Plans

Use these common diagnoses as starting points when you build care plans:

• Activity Intolerance and Generalized Weakness
• Acute Confusion (Delirium) and Altered Mental Status
• Acute Pain
• Anxiety and Fear
• Bowel Incontinence (Fecal Incontinence)
• Caregiver Role Strain and Family Caregiver Support
• Chronic Confusion (Dementia)
• Chronic Pain (Pain Management)
• Constipation
• Decreased Cardiac Output and Cardiac Support
• Diarrhea
• Disturbed Body Image and Self-Esteem
• Fatigue and Lethargy
• Fever (Pyrexia)
• Fluid Volume Deficit (Dehydration and Hypovolemia)
• Fluid Volume Excess (Hypervolemia)
• Grieving and Loss
• Hyperthermia and Heat-Related Illnesses
• Hypothermia and Cold Injuries
• Imbalanced Nutrition
• Impaired Gas Exchange
• Impaired Swallowing (Dysphagia)
• Impaired Thought Processes and Cognitive Impairment
• Impaired Tissue Perfusion and Ischemia
• Impaired Tissue and Skin Integrity (Wound Care)
• Ineffective Airway Clearance and Coughing
• Ineffective Breathing Pattern (Dyspnea)
• Insomnia and Sleep Deprivation
• Knowledge Deficit and Patient Education
• Nausea and Vomiting
• Physical Mobility and Immobility
• Risk for Aspiration (Aspiration Pneumonia)
• Risk for Bleeding (Hemophilia)
• Risk for Falls (Fall Risk and Prevention)
• Risk for Infection and Infection Control
• Risk for Injury and Patient Safety
• Self-Care Deficit and Activities of Daily Living (ADLs)
• Unstable Blood Glucose Levels (Hyperglycemia and Hypoglycemia)
• Urinary Elimination (Urinary Incontinence and Urinary Retention)