A nursing diagnosis names the response, not the disease.

01 / Definition

Nursing diagnosis vs. medical diagnosis.

Open RN's Nursing Fundamentals draws the line clearly. Medical diagnoses focus on diseases and medical problems identified by physicians, physician assistants, or advanced practice nurses. Nursing diagnoses focus on the human response to health conditions and life processes, and registered nurses make them independently.

Medical

Community-acquired pneumonia. Treated with antibiotics prescribed by the provider.

Nursing

Ineffective airway clearance, risk for deficient fluid volume, risk for falls. Addressed through nursing assessment, positioning, coaching, hydration, and safety measures.

The medical diagnosis usually stays the same for the whole stay. Nursing diagnoses change as the patient's responses change, which is why they're reassessed every shift.

02 / Types

The four types of nursing diagnosis.

NANDA International (NANDA-I), which maintains the standardized list, groups nursing diagnoses into four types:

03 / Anatomy

The parts of a nursing diagnosis.

Every NANDA-I diagnosis has a label and a definition, plus the evidence that supports it. Knowing the parts makes it much easier to write a correct statement:

Label

The standardized name, such as "Ineffective airway clearance."

Defining characteristics

Observable signs and symptoms: the "as evidenced by" part of the statement.

Related factors

The underlying causes the nurse can treat: the "related to" part.

Risk factors

For risk diagnoses, the factors that make the patient vulnerable.

At-risk populations

Groups whose shared characteristics make them more susceptible, such as older adults for falls.

Associated conditions

Medical diagnoses, injuries, procedures, devices, or medications linked to the diagnosis. They support accuracy, but the nurse can't independently modify them.

04 / Reasoning

From cues to a diagnosis: cluster first.

Don't start from the list of labels. Start from your data. Group related cues into clusters, then ask which human response each cluster describes. Here are Mr. D.'s assessment findings, from our head-to-toe assessment guide, grouped into clusters:

Only after clustering do you look for the label that fits each cluster's definition. Frameworks such as Gordon's Functional Health Patterns or the body systems can help you organize cues, but the clinical question stays the same: what is this patient's response?

05 / Writing

Write the statement.

Each type has its own sentence structure. Open RN uses these:

Problem-focused (PES)

Problem related to etiology as evidenced by signs and symptoms. Ineffective airway clearance related to retained secretions as evidenced by right lower lobe crackles, productive cough, respirations 24, and SpO₂ 90% on 2 L/min.

Risk

Problem as evidenced by risk factors. Risk for falls as evidenced by dizziness on standing and unsteady gait. (Some programs use "related to" here instead.)

Health promotion

Problem as evidenced by the patient's expressed desire to enhance a behavior. Readiness for enhanced health self-management as evidenced by the patient stating he wants to learn how to use his incentive spirometer at home.

06 / Examples

Common nursing diagnoses and the cues behind them.

These are frequently taught nursing diagnoses, shown with the kinds of cues that typically support them. Check exact labels against your NANDA-I edition.

Ineffective airway clearance

Adventitious breath sounds, ineffective or productive cough, changes in respiratory rate

Impaired gas exchange

Low oxygen saturation, abnormal blood gases, restlessness or confusion, shortness of breath

Acute pain

Patient's pain report and rating, guarding, facial expression, changes in vital signs

Excess fluid volume

Edema, weight gain, crackles, shortness of breath, intake greater than output

Risk for infection

Risk factors such as surgical incisions, invasive lines, or a weakened immune system

Impaired physical mobility

Limited range of motion, difficulty turning or walking, needing help to move

Anxiety

The patient's reported worry or fear, restlessness, difficulty concentrating

Deficient knowledge

Inaccurate statements or questions about the condition, treatment, or self-care

07 / Common errors

Mistakes instructors mark down.

• A medical diagnosis as the problem. "Pneumonia" isn't a nursing diagnosis. Name the patient's response to it.
• A medical diagnosis as the "related to." Open RN is explicit: related factors shouldn't be medical diagnoses. Name the underlying cause the nurse can treat, such as "retained secretions," not "pneumonia."
• No evidence. Every "as evidenced by" needs your actual assessment data, not generic textbook symptoms.
• Picking from a list first. Choosing a label and then hunting for cues produces diagnoses that don't fit the patient.
• Judgmental wording. "Noncompliant because he doesn't care" is a judgment, not a diagnosis. Describe the behavior and its cause.
• Too many diagnoses. Three well-supported, prioritized diagnoses beat ten weak ones.

Keep going with Mr. D.

Diagnosis is the first line of the care plan.