Components of Nursing Diagnosis

Components of Nursing Diagnosis

1. Diagnostic Label

a. Problem: 

• Name of the nursing diagnosis as listed in the taxonomy 
• Describes the problem using as few words as possible

Problems to avoid in writing this part

• DO NOT use the medical diagnosis
• Must be a problem the nurse and/or client can change to do something about
• Relating the problem to an unchangeable situation
• Don’t confuse the etiology with the problem
• Focus on the human responses to the problem
• Avoid the use of one piece of assessment data as a NDX (EDEMA)
• Be specific
• Don’t combine NDX
• Don’t relate one NDX to another. There is a different related to factor if this is a valid NDX
• Nursing interventions should not be included in the NDX
• Keep your language non-judgmental
• Don’t make assumptions or statements you can’t prove with assessment data
• Be sure your statement is legally advisable

b. Qualifier:

• Used to give additional meaning to the nursing diagnosis

2. Etiology

• This is the “related to, R/T” portion of the diagnosis.
• What caused the client to have the problem listed?

Problems to avoid in writing this part

• DO NOT use the medical diagnosis
• Must be a problem the nurse and/or client can change to do something about

3. Defining characteristics

• These are the major and minor clinical cues that validate the presents of an actual nursing diagnosis
• Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the nursing diagnosis