Nursing diagnosis in general terms: actual, risk and health-promotion statements
- Fundamental
A nursing diagnosis is the nurse's judgment about how a person is responding to their health situation.
What it is
Nursing diagnosis is the second phase of the process. From the assessment data, the nurse identifies the person's responses that nursing can address: a problem that already exists, a risk that could develop, or the person's readiness to improve their well-being. It does not name a disease (that is the medical diagnosis) but what the person is living through because of it. A problem statement usually has three parts: the problem, its related factors («related to») and the data that show it («as evidenced by»). Institutions use standardised taxonomies; this page describes them in general terms only.
Key points
- Actual problem: already present and supported by current signs and symptoms.
- Risk: could develop without intervention, because of the person's vulnerabilities (for example, a risk of falls in a dizzy older adult).
- Health promotion: the person wants to and is ready to improve some aspect of their well-being.
- Syndrome: two or more nursing diagnoses that occur together and are best addressed together, with similar interventions.
- The diagnosis must be confirmed with this patient's data, not copied from a list.
Components
- Problem: which human response is altered or at risk.
- Related factors: the cause or contributors to the problem that nursing can treat (not a medical diagnosis).
- Supporting data: subjective and objective findings from the assessment.
What it is for
- It guides the goals and interventions of the care plan: interventions aim at the related factors.
- It shows what the nurse treats on their own judgment: registered nurses make nursing diagnoses independently.
- It individualises care: two people with the same disease can have different nursing diagnoses.
Types of nursing diagnosis, described in general terms
| Type | What it is based on | Example in plain words |
|---|---|---|
| Actual problem | Signs and symptoms present | A problem moving related to wound pain, shown by being unable to sit up alone |
| Risk | Risk factors, no signs yet | A risk of falls because of dizziness on standing and sedative use |
| Health promotion | The person's motivation to improve | Readiness to improve eating habits, expressed by the person |
| Syndrome | Two or more diagnoses that occur together | Several related problems addressed together with the same interventions |
In nursing practice
- The same medical diagnosis produces different responses in each person, and so different nursing diagnoses.
- The nurse formulates nursing diagnoses and acts on them; the medical diagnosis is made by the physician or another authorised provider.
- It is reviewed at every evaluation: a problem may resolve, change or give way to another.
Common mistakes
- Writing a disease («pneumonia») as if it were a nursing diagnosis.
- Giving as a related factor something nursing cannot change, such as the medical diagnosis.
- Listing signs and symptoms in a risk diagnosis, as if the problem already existed.
- Picking a diagnosis from a list with no patient data to support it.
Test yourself
Think of the answer, then tap the question to see it.
What does a nursing diagnosis describe, unlike a medical one?
The person's response to their health situation, which nursing can address; the medical diagnosis names the disease.
What are the three parts of an actual-problem statement?
The problem, the related factors («related to») and the supporting data («as evidenced by»).
What supports a risk diagnosis, if the problem does not exist yet?
The person's risk factors; there are no signs or symptoms of the problem yet.
Which type of diagnosis expresses that the person wants to improve their well-being?
A health-promotion diagnosis.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Nursing Fundamentals (Open RN), 4.4 Diagnosis (Open RN, Chippewa Valley Technical College (LibreTexts), 2022); Nursing Fundamentals (Open RN), 4.6 Planning (Open RN, Chippewa Valley Technical College (LibreTexts), 2022).
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Representative model, for educational purposes only.