In 1990, the North American Nursing Diagnosis Association (NANDA) defined nursing diagnosis as "a clinical judgement about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable."
The first conference on nursing diagnosis was held in 1973 to identify nursing knowledge and establish a classification system to be used for computerization. At this conference, the National Group for Classification of Nursing Diagnosis was founded; this group was later renamed the North American Nursing Diagnosis Association (NANDA). In 1984, NANDA established a Diagnosis Review Committee (DRC) to develop a process for reviewing and approving proposed changes to the list of nursing diagnoses. The American Nurses Association (ANA) officially sanctioned NANDA as the organization to govern the development of a classification system for nursing diagnosis in 1987. However, the ANA also recognizes the Omaha system and the Home Health Classification system as two additional nursing diagnosis systems currently in use.
The purpose of the NANDA diagnosis list is three fold. First, it provides nurses with a common frame of reference and standardizes language that improves communication among nurses, helps organize research, and is useful in educating new practitioners. Second, nursing diagnoses provide a classification system to describe the scientific foundation of nursing practices—a major criterion necessary for nursing to be recognized as a separate profession, differentiated from medicine and other health care professions. Third, the NANDA diagnosis system has the potential for computer use and may, in the future, provide nomenclature for the reimbursement of nursing activities, not unlike DRGs and ICDs do for medicine.
It is important to distinguish nursing diagnoses from medical diagnoses. The two are similar because they are both designed to plan care for a patient. However, nursing diagnoses focus on human response to stimuli, while medical diagnoses focus on the disease process. An example of this difference is the different diagnoses given by a nurse and a doctor to a patient who exhibits difficulty breathing, a productive cough, and crackles throughout lung fields. This patient might be medically diagnosed as having pneumonia . Some nursing diagnoses that might be made for this particular patient, however, include activity intolerance, impaired gas exchange , and fatigue.
Another feature that is unique to nursing diagnoses is the identification of potential problems. The diagnosis of "at risk for aspiration" is an example of a diagnosis that recognizes the potential for a given problem to occur. In order for a risk diagnosis to be made, risk factors must be present and identified upon assessment. In the above example, the absence of the gag reflex, and the presence of facial droop or paralysis may be among the risk factors for impaired swallowing that would lead a nurse to make the diagnosis of "at risk for aspiration." These diagnoses are important because they allow nursing to take a preventive approach to patient care.
Expected outcome —A measurable individual, family, or community state, behavior, or perception that is measured along a continuum and is responsive to nursing interventions.
Medical diagnosis —A medical determination of disease or syndrome performed by a physician. The focus is on the disease process and the physical, genetic, or environmental cause of that process.
NANDA, North American Nursing Diagnosis Association —Formed in 1973, this group is responsible for developing a classification system of nursing diagnoses.
NIC, Nursing Interventions Classification — Developed by the Iowa Intervention Project, this is a collection of nursing interventions linked to the NANDA diagnoses. The 2000 publication includes approximately 500 interventions.
NOC, Nursing Outcomes Classification — Developed by the Iowa Outcome Project, this is a comprehensive, standardized classification of patient outcomes developed to evaluate the effects of nursing interventions. The outcomes may be linked to the NANDA diagnoses and other diagnoses systems. The 2000 publication includes 260 outcomes.
Nursing assessment —The way in which a nurse gathers and evaluates data about a client (individual, family, or community). The assessment includes a physical examination, interviewing, and observations. Assessment is also the first step in the nursing process.
Nursing diagnostic statement —The formal, written documentation of a nursing diagnosis. It includes the label or diagnosis, the etiology, and the indicators. In the statement, the etiology is preceeded by the phrase "related to." The indicators are the assessment data that led to the diagnosis. They are preceeded by the phrase, "as evidenced by."
Nursing intervention —Any treatment that a nurse performs on a patient in response to a nursing diagnosis to reach a projected outcome.
Risk diagnosis —A nursing diagnosis that recognizes a potential problem not an existing problem. The indicators for risk diagnoses are risk factors that are identified through assessment.
The term "nursing diagnosis" refers to items on the NANDA list of approved diagnoses, such as anxiety . The term "nursing diagnostic statement" refers to the approved or accepted way in which a nursing diagnosis is written in practice. Gordon identifies three structural components of a nursing diagnostic statement: the problem, the etiology (cause), and the signs and symptoms. An example of a nursing diagnostic statement would read, "Anxiety related to hospitalization as evidenced by verbal comments, and increased heart rate." When writing an "at-risk" nursing diagnostic statement, the signs and symptoms are replaced by the list of risk factors present for a particular response.
Nursing diagnoses may be made for an individual, a family, or a community. An example of a family nursing diagnosis is "risk for altered parent-infant attachment." The nursing diagnostic statement in this case might read, "risk for altered parent-infant attachment related to maternal distancing as evidenced by lack of eye contact between mother and infant." "Management of therapeutic regimen, ineffective: community," is an example of a nursing diagnosis for a community. The nursing diagnostic statement in this case may read, "Management of therapeutic regimen related to prevention of teen pregnancy , ineffective in the community, as evidenced by higher rate of teen pregnancy than surrounding communities."
In order to make an appropriate nursing diagnosis, the practitioner must conduct an in-depth interview, physical assessment, and critical observation of the individual, family, or community for which the diagnosis is being made. A complete nursing assessment includes: the patient's current health status, signs and symptoms, strengths, and problem areas. The patient (who can be an individual, a family, or a group) should be the primary source of assessment data.
After compiling data through assessment, the data are grouped or organized into categories that will assist the nurse in identifying appropriate diagnoses. A variety of organizing frameworks exist to assist the nurse in organizing the data, including Maslow's hierarchy of needs , NANDA's human response patterns, and Gordon's functional health patterns.
Diagnosis is the second step in the nursing process, following assessment. Once an in-depth assessment has been completed and the appropriate nursing diagnoses are made, the steps of planning and implementing nursing interventions and subsequently evaluating the outcomes based on treatment goals must be undertaken. In planning nursing intervention, priorities must be set and expected measurable outcomes or objectives must be specifically stated.
In 1987, a program begun at the University of Iowa for treatment goals became known as the Iowa Intervention Project. This was a large research project from which the Nursing Interventions Classification system (NIC) was produced. In 2000, the third edition of NIC was published. It included almost 500 nursing interventions. NIC provides a link to the NANDA diagnoses. Using NIC, nurses may look up a NANDA diagnosis and be directed to appropriate nursing interventions for that diagnosis.
Research for the development of the Nursing Outcomes Classification (NOC) began in 1991. The second edition of NOC was completed by the Iowa Outcomes Project in 2000 and contains 260 outcomes. Each outcome has a definition, list of indicators, and a five-point Likert scale to assess patient status. NOC has been linked to the NANDA diagnoses, the NIC interventions, Gordon's functional patterns, the Omaha system of problems, resident admission protocols (RAPs) used in nursing homes , and to the OASIS system used in home care .
Nursing diagnoses are made to identify current and potential problems for individuals, families, and communities, and to communicate these problems to other practitioners in a standard form. Once a nursing diagnosis is made, it is anticipated that the appropriate nursing interventions will be implemented to either correct or prevent the problem.
Health care team roles
Although nursing diagnoses are almost exclusively generated and used by nurses, members of the nursing profession hope these diagnoses will become more widely recognized and adopted by other health care professions. Using the standardized language that NANDA provides facilitates communication between health care professionals.
Carpenito, L.J. Nursing Diagnosis Application to Clinical Practice. 7th ed. Philadelphia: Lippincott, 1997.
Cox, H.C., et al. Clinical Applications of Nursing Diagnosis: Adult, Child, Women's, Psychiatric, Gerontic, and Home Health Considerations. 3rd ed. Philadelphia: F.A. Davis Company, 1997.
Laduke, Sharon. "Spotlight What You Really Do With This Powerful Documentation Tool." Nursing (June 2000).
American Nurses Association, 600 Maryland Avenue, SW, Suite 100 West, Washington, DC 20024. (800) 274-4ANA. <http://www.nursingworld.org>.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), One Renaissance Boulevard, Oakbrook Terrace, IL 60181. 630-792-5000. Fax: 630-792-5005. <http://www.jcaho.org>.
The University of Iowa College of Nursing, 101 Nursing Building, Iowa City, IA 52242. (319) 335-8960. <http//coninfo.nursing.uiowa.edu/index.htm>.
Jennifer Lee Losey, R.N.