How to identify a nursing diagnosis? A step-by-step guide for healthcare professionals

September 29, 2025 •

3 min read

According to NANDA International, a nursing diagnosis is a clinical judgment that forms the basis for selecting interventions. This guide explains how to identify a nursing diagnosis accurately by following a structured, evidence-based process for improved patient outcomes.

Quick Summary

Identifying a nursing diagnosis involves systematically assessing a patient's condition, analyzing collected data to pinpoint health problems, and documenting them accurately using standardized language, such as the PES format.

Key Points

Systematic Assessment: The process begins with collecting subjective and objective patient data through interviews and physical exams to gather a complete picture.
PES Format: Problem-focused diagnoses are written using the three-part PES format: Problem, Etiology, and Symptoms, to ensure clarity and evidence-based rationale.
NANDA-I Standard: The official list of diagnostic labels is standardized by NANDA International, providing a universal language for nursing diagnoses.
Holistic View: Unlike a medical diagnosis, a nursing diagnosis focuses on the patient's holistic response to health problems, including physical, emotional, and social needs.
Validation is Key: Always validate your diagnosis with the patient and other healthcare team members to confirm its accuracy and relevance.
Prioritization: Diagnoses are prioritized based on urgency and patient safety, often guided by frameworks like Maslow's hierarchy or ABCs.

The Nursing Process: Your Framework for Diagnosis

Identifying a nursing diagnosis is not a single action but a critical step within the broader nursing process, often remembered by the acronym ADPIE: Assessment, Diagnosis, Planning, Implementation, and Evaluation. The diagnosis phase directly follows a thorough assessment, where a nurse collects subjective and objective data about the patient's health status. This systematic approach ensures that the resulting diagnosis is evidence-based and tailored to the individual's specific needs.

Step 1: Data Collection and Assessment

Before you can identify a health problem, you must gather all relevant information. This includes a patient's medical history, current symptoms, physical examination findings, and any psychosocial factors impacting their health. The data collected should cover not just the illness itself, but the patient's response to it, a key distinction from a medical diagnosis.

Data collection methods include:

Patient interview: Gathering subjective data (patient feelings, symptoms).
Physical examination: Collecting objective data (vital signs, physical signs).
Reviewing medical records: Looking at lab results, previous diagnoses.
Collaborating with other healthcare team members.

Step 2: Data Analysis and Identification of Health Problems

Once the assessment is complete, analyze the data to identify patterns or cues that point toward a specific health issue. This stage requires strong clinical judgment to interpret the signs and symptoms. The goal is to identify actual or potential health problems that a nurse is licensed and competent to treat independently.

Step 3: Formulating the Nursing Diagnosis (PES Format)

For most problem-focused diagnoses, the standardized PES format provides a clear structure.

The PES components:

Problem (P): The diagnostic label from the official NANDA-I list (e.g., Impaired Gas Exchange). You can find an updated list of approved diagnoses on the NANDA International website: nanda.org.
Etiology (E): The "related to" factor, which identifies the probable cause or contributing factors of the health problem (e.g., related to chronic bronchitis).
Symptoms (S): The "as evidenced by" characteristics, which are the signs and symptoms observed during the assessment (e.g., as evidenced by O2 saturation level of 88% on 2L oxygen via nasal cannula).

Step 4: Differentiating Diagnosis Types

Beyond problem-focused diagnoses, nurses must also consider other types of diagnoses to provide holistic care.

Comparison of Nursing Diagnosis Types


Type	Description	Example
Problem-Focused	Describes an actual, existing health problem supported by clinical evidence.	Impaired Skin Integrity related to immobility as evidenced by a 2cm coccyx ulcer.
Risk	Identifies potential health problems in vulnerable individuals or groups.	Risk for Infection as evidenced by impaired skin integrity.
Health Promotion	A clinical judgment about a person, family, or community's motivation and desire to increase well-being.	Readiness for Enhanced Nutrition as evidenced by expressing a desire to improve eating patterns.

Step 5: Prioritizing and Validating the Diagnosis

After formulating potential diagnoses, prioritize them based on the urgency and impact on the patient's health, often using frameworks like Maslow's hierarchy of needs or the ABCs (Airway, Breathing, Circulation). Finally, validate the diagnosis with the patient, asking for their perception of the problem to ensure it accurately reflects their reality. This collaboration enhances the care plan's effectiveness.

Conclusion

Effectively identifying a nursing diagnosis is a foundational skill that requires more than just memorizing labels; it demands a comprehensive understanding of the patient's condition and a systematic approach. By meticulously following the assessment, analysis, formulation, and validation steps, nurses can create accurate, individualized care plans. This process not only improves patient outcomes but also empowers the nurse to act as a critical thinker and advocate, ensuring care is focused on the patient's response to their health condition, not just the condition itself.

Frequently Asked Questions

You start by performing a thorough patient assessment, collecting both subjective (what the patient says) and objective (measurable) data. This forms the foundation for all subsequent steps in the nursing process.

A medical diagnosis identifies a specific disease or medical condition (e.g., Pneumonia), while a nursing diagnosis describes a patient's human response to that condition or life process (e.g., Impaired Gas Exchange).

PES stands for Problem, Etiology, and Symptoms. This format is used to construct a clear and evidence-based nursing diagnostic statement for problem-focused diagnoses.

Use a standardized, evidence-based resource such as the official NANDA International list. Select the label that most accurately describes the health problem and is supported by your assessment data.

Yes, a 'Risk for' diagnosis includes only two parts: the diagnostic label and the risk factors. It does not include defining characteristics because the problem is not yet present.

Prioritizing helps ensure the most urgent and critical patient needs are addressed first. You can use frameworks like Maslow's hierarchy of needs or the ABCs (Airway, Breathing, Circulation) to guide your prioritization.

Validate your diagnosis by sharing it with the patient to see if they agree with the assessment. You can also consult with more experienced nurses or review your data to ensure it is supported by evidence.