A nursing diagnosis is a statement about the potential or actual health problems nurses identify in their patients. Formulating a nursing diagnosis is at the heart of nursing practice and is the second step in the five-step nursing process. The nursing process provides the foundation for nursing practice.
But before we discuss three common nursing diagnosis statements used by nurses, a quick overview of the nursing process is imperative.
Developed by the North American Nursing Diagnosis Association International (NANDA-I), a nursing diagnosis serves as a guide for nursing interventions and creating a care plan for your patient. The nursing process includes the following five steps:
- Assessment
- Diagnosis
- Outcomes/planning
- Implementation
- Evaluation
A nursing diagnosis is made by a nurse using critical thinking and clinical judgment while integrating the objective and subjective data obtained during their nursing assessment. Once an assessment is completed, the next step is a nursing diagnosis. Let’s look at three common nursing diagnosis statements below and when they’re applicable for patients.
3 common types of nursing diagnosis
1. Impaired physical mobility
Definition and importance: Impaired physical mobility is described as a decrease in the ability to move one part of the body (such as a limb) or the entire body. This diagnosis is significant because mobility is essential to maintain optimal health.
When mobility is impaired in one area of the body or the entire body, it can also affect a person’s ability to perform their activities of daily living (ADLs).
When to use: This nursing diagnosis is applicable when a patient experiences a decreased ability to move independently due to various factors, such as:
- Post-surgical recovery
- Musculoskeletal injuries or conditions, such as sprains, strains, fractures
- Trauma, like penetrating and blunt force
- Neurological-based conditions such as a having cerebral vascular accident (CVA/stroke), Parkinson’s disease (PD), Lewy body dementia, muscular dystrophy (MD), and multiple sclerosis (MS).
- Cardiac and respiratory problems — two examples are congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD)
- Arthritis
- Peripheral artery disease (PAD)
- Neuropathy
Assessment: Nurses should assess the following when using this diagnosis:
- Range of motion
- Muscle strength
- Fall risk
- Pain level during movement
- Ability to perform ADLs
- Capability for using assistive devices such as walkers and canes
- Environmental barriers to mobility such as loose throw rugs and stairs
Interventions: Evidence-based interventions for impaired physical mobility include:
- Physical therapy referrals to improve strength and mobility
- Cardiac and pulmonary rehab program referrals as appropriate and if indicated
- Pain management strategies, including prescribed medications and non-pharmacological methods when applicable, such as heat and/or cold therapy
- Encouraging regular movement and exercises tailored to the patient's capabilities and as tolerated
- Educating patients on the safe use of assistive devices
- Modifying the environment to reduce the risk of falls and enhance mobility
2. Risk for infection
Definition and importance: Risk for infection is the increased threat of being infected by pathogenic organisms. This nursing diagnosis is critical to use when relevant for a patient, because infections can lead to severe complications, such as sepsis, prolonged hospital stays, and increased healthcare costs.
When to use: This diagnosis should be used when a patient has experienced an acute event, such as surgery or trauma or has a chronic condition that heightens their risk of infection. Some examples are below:
- Compromised immune system — those who are undergoing chemotherapy or have HIV/AIDS.
- Had invasive procedures performed — surgery, central line or urinary catheter placement
- Has open wounds or surgical incisions
- Chronic conditions that can make the immune system more susceptible to infection — diabetes and chronic kidney disease (CKD)
- Trauma
- Poor nutritional status
Assessment: Nurses should monitor for signs that indicate an elevated risk of, or the actual development and presence of an infection, including:
- Fever
- Elevated white blood cell count
- Signs of localized infection such as erythema, swelling, or discharge
- Monitor wounds and surgical incisions for the presence of seropurulent or purulent drainage
Interventions: Evidence-based interventions for managing the nursing diagnosis of risk for infection include:
- Strict adherence to hand hygiene protocols
- Using aseptic techniques during invasive procedures
- Regularly monitoring wounds and surgical incisions
- Dressing changes and evidence-based wound care as per protocols
- Educating patients and caregivers on infection prevention measures
- Ensuring proper nutrition to support optimum immune system function and wound healing
- Administering antibiotics when appropriate
3. Acute pain
Definition and importance: Acute pain is defined as an “unpleasant physical and emotional experience associated with actual or potential tissue damage,” according to the International Association for the Study of Pain (IASP). Managing acute pain is essential for reducing a patient’s pain level and increasing their level of comfort.
When to use: This diagnosis is relevant when a patient experiences a sudden onset of pain due to:
- Surgical procedures
- Traumatic injuries, such as burns, fractures, gunshot wounds, lacerations, impalements, blunt force trauma
- Musculoskeletal injuries, such as sprains, strains, and herniated discs
- Myocardial infarction (MI)
- Exacerbations of chronic conditions like a sickle cell crisis
Assessment: Nurses should perform comprehensive pain assessments, including:
- Pain intensity (using the pain scale as per your organization’s policy)
- Pain location, duration, and quality
- Factors that exacerbate or relieve the pain
- Impact of the pain on daily activities
- Effect of the pain on one’s mood
- Physiological signs of pain such as an elevated heart rate and increased blood pressure (BP)
Interventions: Effective, evidence-based interventions for acute pain management include:
- Administering analgesics as prescribed, such as acetaminophen, NSAIDs, and opioids as needed
- Employing non-pharmacological pain relief methods such as elevation of an injured limb to reduce swelling, ice and/or heat application as indicated, relaxation techniques such as paced breathing or imagery
- Educating patients on pain management strategies
- Encouraging patients to communicate their pain levels and the effectiveness of pain relief interventions to their care team
- Collaborating with the other specialties to adjust pain management plans as needed
A nursing diagnosis can help nurses identify and address patients' issues in a holistic and individualized way, leading to better quality of care and patient satisfaction. By understanding some of the common types and applying the principles of nursing diagnosis, nurses can enhance their critical thinking and clinical judgment skills and provide optimal care for their patients.
Reviewed by Carole Jakucs, MSN, RN, CDCES, PHN on July 15, 2024