Every care plan you write hangs on one line: the nursing diagnosis. Get it right and your goals, interventions, and monitoring fall into place. Get it wrong and the whole plan drifts. This lesson shows you what NANDA-I is, how to write a diagnosis the right way, and how to pick the priority one.
What is NANDA-I?
NANDA International (NANDA-I) is the organization that develops and maintains the standardized language of nursing diagnoses. Instead of every nurse describing a problem in their own words, NANDA-I gives us a shared list of approved diagnosis labels, each with a definition and supporting criteria.
A nursing diagnosis is a clinical judgment about a person's (or family's or community's) response to a health problem or life process. It names what nurses can assess, treat, and monitor within our own scope of practice.
A medical diagnosis names the disease or injury. The provider treats the disease. The nurse treats the human response to it.
Nursing diagnosis vs. medical diagnosis
| Medical diagnosis | Nursing diagnosis | |
|---|---|---|
| Focus | The disease, injury, or condition | The person's response to the condition |
| Who makes it | Provider (MD, DO, NP, PA) | Registered nurse |
| How long it lasts | Usually stays the same while the disease is present | Changes as the patient's response changes, sometimes shift to shift |
| Treatment | Medical and surgical orders | Nursing interventions, independent and collaborative |
| Example | Pneumonia | Impaired gas exchange, Ineffective airway clearance |
| Example | Heart failure | Decreased cardiac output, Excess fluid volume, Activity intolerance |
| Example | Hip fracture | Acute pain, Impaired physical mobility, Risk for falls |
| Example | Type 2 diabetes | Risk for unstable blood glucose level, Deficient knowledge |
Notice that one medical diagnosis can lead to several nursing diagnoses. That is the point: nursing looks at the whole person, not only the disease.
The official book
Editors: T. Heather Herdman, Shigemi Kamitsuru, and Camila Takáo Lopes
ISBN: 978-1-68420-601-8
This is the official source for NANDA-I diagnosis labels, definitions, defining characteristics, related factors, and risk factors. Many nursing programs require it, so check your syllabus.
Diagnoses are added, revised, and retired with each edition. Always check the current edition before you write a care plan. If your instructor or clinical site uses a specific edition, use that one. This lesson teaches you how to use the diagnoses. For the exact definitions and criteria, go to the book.
Why nursing diagnoses matter
- Shared language. When every nurse on every shift uses the same label, the plan carries over at handoff. "Impaired gas exchange" means the same thing on days, nights, and the next unit.
- It drives the care plan. In ADPIE, the diagnosis is the D. Assessment data leads to the diagnosis, and the diagnosis leads to your goals, interventions, and evaluation.
- It justifies nursing interventions. Every intervention should trace back to a diagnosis. If you cannot explain which problem an action treats, question why you are doing it.
- It makes outcomes measurable. A clear diagnosis tells you what "better" looks like, so you can write SMART goals.
- It tells you what to monitor. This is the one students miss. The diagnosis tells you what to watch and how you will know if the patient is getting better or worse. See the table below.
- Documentation. Charting that links your assessment, diagnosis, actions, and results shows your clinical reasoning clearly.
- Legal and quality of care. A documented plan shows the nurse identified the problem, acted on it, and followed up. It also supports quality measures, staffing decisions, and continuity of care.
- NCLEX clinical judgment. The NCSBN Clinical Judgment Measurement Model (NCJMM) asks you to recognize cues, analyze cues, and prioritize hypotheses. That is the same thinking you use to choose a nursing diagnosis.
The diagnosis tells you what to watch
| Diagnosis | What to monitor | Getting worse looks like |
|---|---|---|
| Impaired gas exchange | SpO2 trend, ABGs (PaO2, PaCO2, pH), RR and work of breathing, level of consciousness, skin color | Falling SpO2, rising PaCO2, accessory muscle use, new restlessness or confusion |
| Decreased cardiac output | BP and MAP, HR and rhythm, urine output, capillary refill, peripheral pulses, mentation | MAP under 65, urine output under 30 mL/hr, cap refill over 3 seconds, new confusion |
| Risk for infection | Temperature, WBC, IV and incision site checks, wound drainage, lung sounds, urine character | Fever, rising WBC, redness, warmth, swelling, or purulent drainage at a site |
| Deficient fluid volume | Intake and output, daily weight, HR, BP (including orthostatics), mucous membranes, urine specific gravity | Rising HR, falling BP, dropping urine output, concentrated urine |
| Acute pain | Pain score before and after interventions, HR, BP, guarding, ability to move and rest | Rising scores, pain not relieved by the plan, pain that changes in character |
The four types of nursing diagnoses
A problem that is happening now, supported by signs and symptoms you can see or measure.
Written as: Problem + related to (etiology) + as evidenced by (signs and symptoms). Example label: Acute pain.
A problem that has not happened yet, but the patient is vulnerable to it.
Written as: "Risk for" + the problem + the risk factors. There is no "as evidenced by", because there are no signs or symptoms yet. Example label: Risk for falls.
The patient wants to improve their health or well-being, even if nothing is wrong right now.
Written as: "Readiness for enhanced" + the area, supported by what the patient says or shows about wanting to improve. Example label: Readiness for enhanced nutrition.
A cluster of nursing diagnoses that tend to happen together and are best treated together with similar interventions.
Written as: the syndrome label, with its related factors or risk factors as listed in the current edition. These are less common in student care plans. Check the book for the exact format.
How to write it: PES format
For problem-focused diagnoses, use PES:
- P = Problem: the NANDA-I label.
- E = Etiology: the cause, written after "related to" (r/t). This should be something nursing can work on.
- S = Signs and symptoms: your evidence, written after "as evidenced by" (AEB). Use real, specific assessment data.
Worked examples
Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by SpO2 86% on room air, RR 30, PaO2 58 mmHg, and new restlessness.
Acute pain related to tissue injury from surgical incision as evidenced by pain rated 7/10, guarding of the abdomen, HR 104, and refusal to ambulate.
Deficient fluid volume related to active fluid loss from vomiting and diarrhea as evidenced by dry mucous membranes, urine output 20 mL/hr, BP 92/58, and HR 116.
Writing a risk diagnosis
Risk diagnoses have only two parts: the label and the risk factors. No AEB.
Risk for falls related to unsteady gait, use of opioid pain medication, and age over 65.
Risk for infection related to an indwelling urinary catheter, a fresh surgical incision, and elevated blood glucose.
Some programs write risk statements as "as evidenced by risk factors of..." instead of "related to." Both list risk factors, not symptoms. Follow your program's format.
Common mistakes
| Mistake | Wrong | Better |
|---|---|---|
| Medical diagnosis as the etiology | Impaired gas exchange related to pneumonia | Impaired gas exchange related to alveolar-capillary membrane changes |
| Symptom written as the problem | Shortness of breath related to fluid overload | Excess fluid volume related to compromised regulatory mechanisms as evidenced by crackles, dyspnea, and 3 kg weight gain |
| Legally problematic wording | Risk for injury related to side rails left down by night shift | Risk for falls related to unsteady gait and nighttime confusion |
| Judgmental wording | Related to patient being noncompliant and difficult | Related to lack of understanding of the medication schedule |
| Vague evidence | As evidenced by abnormal vital signs and patient looks bad | As evidenced by BP 84/50, HR 124, and cool, mottled extremities |
Rule of thumb: never blame staff, the patient, or the facility in a diagnosis. Stick to the patient's condition and your data.
How to pick the priority diagnosis
Your patient will almost always have more than one nursing diagnosis. Walk through these three steps, in this order, every time.
WHAT IS INSTANTLY LIFE-THREATENING? (ABC Hierarchy)
Airway first, then breathing, then circulation. An actual problem beats a risk problem, unless the risk is imminent and deadly, like a fresh post-op thyroidectomy patient at risk for airway swelling. If nothing is threatening the ABCs, move to Maslow: physiological needs come before safety, and safety comes before love, belonging, and esteem. Quick example: a patient with stridor and a patient with 8/10 pain: the airway wins.
WHERE IS THE ACTUAL BREAKDOWN HAPPENING? (Pathophysiological Site)
Find the organ or system where the body is actually failing. Your diagnosis should name that failure, not something that is happening downstream of it. Quick example: a patient has low SpO2 because fluid is filling the alveoli. The breakdown is at the alveolar-capillary membrane, so the problem is gas exchange, not "anxiety," even if the patient is scared and restless.
IS IT A REAL PROBLEM OR JUST A SYMPTOM/COMPENSATION?
The body fights back, and that fight can look like a problem. Tachycardia and tachypnea are often the body compensating for hypovolemia or acidosis, so treat the cause, not the compensation. A symptom like pain or anxiety may be the result of the real problem. Quick example: a GI bleed patient with HR 128 does not need a "fix the heart rate" diagnosis. The heart is compensating for lost volume. The priority is the fluid loss.
Worked case: one patient, all three steps
A 72-year-old admitted with pneumonia. SpO2 86% on room air, RR 30, HR 118, BP 138/82, temp 38.6°C. Crackles in the right lower lobe. ABG: PaO2 58 mmHg. The patient is restless, keeps saying "I can't catch my breath," rates right-sided chest pain 6/10 when coughing, and tried to get out of bed alone twice.
Four candidate diagnoses:
- Anxiety
- Acute pain
- Impaired gas exchange
- Risk for falls
| Step | What you ask | What it rules in or out |
|---|---|---|
| 1. Life-threatening? | Which one threatens airway, breathing, or circulation right now? | Impaired gas exchange is an actual breathing problem with SpO2 86% and PaO2 58. Risk for falls is a risk, not actual, so it drops. Anxiety and pain are not ABC problems. |
| 2. Where is the breakdown? | Which organ or system is failing? | The lungs: inflammation and exudate in the alveoli are blocking oxygen from crossing into the blood. That is gas exchange. |
| 3. Real problem or symptom? | Are any of these caused by something else on the list? | HR 118 and RR 30 are compensation for low oxygen. The restlessness and anxiety are likely caused by hypoxemia. The fall attempts come from that restlessness. Pain is real, but it is not what will kill this patient in the next hour. |
Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by SpO2 86% on room air, PaO2 58 mmHg, RR 30, and restlessness.
Monitor: SpO2 trend, repeat ABGs, RR and work of breathing, and level of consciousness. As oxygenation improves, watch the anxiety, heart rate, and fall attempts settle down too. That is your proof you treated the real problem. Then address pain, fall safety, and anxiety as secondary diagnoses.
Coming soon
NURSYN games for nursing diagnosis are on the way, so you can practice picking and prioritizing diagnoses the fun way.
Put it into practice
See nursing diagnoses in full care plans, from assessment to evaluation.
Browse 58 ADPIE care plansFor learning only. Use the current NANDA-I edition and your program's guidelines.