A nursing diagnosis is a standardized statement about the health of an individual, community or family. Based on the nursing diagnosis, a nurse selects a method of intervention to provide necessary care to patients. Nurses are responsible for choosing the correct diagnosis and are accountable for a patient’s outcome after receiving care. Nurses use several types of nursing diagnosis statements.
An actual nursing diagnosis is a clinical judgment about a current patient health problem, which is present at the time of the nursing assessment, verified by presence of the major defining symptoms, signs and characteristics, and would benefit from nursing care. Examples of an actual nursing diagnosis statement are anxiety characterized by fear, panic, apprehension and sleep disturbances, or an ineffective airway clearance characterized by an ineffective cough, abnormal breathing or a fever.
A risk nursing diagnosis is clinical judgment about a health problem which does not yet exist, but with respect to which the individual, family or community has risk factors. These risk factors lead to the conclusion that the patient is at a higher risk for developing the health problem in the near future than others. Examples of a risk nursing diagnosis statement are risk for injury related to disorientation and altered mobility and a risk for infection related to a compromised immune system or diabetes.
A wellness nursing diagnosis statement is a clinical judgment that an individual, family or community is able to transition to a level of higher wellness. Before giving a diagnosis of wellness, two factors must be present. An individual, family or community must possess effective present function or status and show a desire for increased wellness. Examples of a wellness nursing diagnosis statement are readiness for enhanced family coping or readiness for enhanced spiritual well-being.
A syndrome nursing diagnosis statement is a clinical judgment, which is associated with a cluster of predicted high-risk or actual nursing diagnosis, related to a certain situation or event. There are five types of syndrome diagnosis: post-trauma syndrome, rape trauma syndrome, relocation stress syndrome, impaired environmental interpretation syndrome and disuse syndrome. An example of a syndrome nursing diagnosis statement is rape trauma syndrome manifested by sleep pattern disturbance, anger and genitourinary discomfort and related to feeling anxious about possible resulting health problems.