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The North American Nursing Diagnosis Association International (NANDA-I) originated the concept of Nursing Diagnosis and produced the First Classification on Nursing Diagnoses in 1973. I have been a member of NANDA-I since 1975. In addition, I served on the Board of Directors and as chairperson of the Diagnostic Review Committee.

Much has changed in the past 48 years in the NANDA-I classification system. Unfortunately, one aspect of nursing diagnosis has not changed. The primary application of nursing diagnoses is in standardized care plans. This blog will examine the clinical use of nursing diagnoses with or without a care plan.

Most if not all healthcare facilities have an online system of care planning to meet the requirements as mandated by their accreditation agencies. In an earlier blog, I examined the practice of requiring students to “create” a care plan prior to or after providing care. These “Student Care Plans “are often created from information from the instructor or from data the student collected on the clinical unit.

In this blog, I recommend that students during their clinical practicum utilize the agency’s standardized care plan or that one is provided in the course material. Assigning individual students or work groups to create standardized care plans focusing on generic medical and surgical nursing care is time consuming and unnecessary. Fundamental students should focus on using the agency care plan or the one provided in the course materials. Students experience new and unexpected events on the nursing unit. Faculty should emphasize that when a situation is assessed that needs additional nursing attention, the student should confer with their instructor. Graduate nurses utilize the institution’s online standardized care plans, which are indexed under medical conditions, surgical procedures, or a specialty such as maternity.

The clinical application of nursing diagnoses beyond a care plan has not been addressed in the literature and thus not emphasized to students.

Student Care Planning

Limited by the data they have, initially students create care plans that are standardized to a condition. This is expected in the initial clinical course in fundamentals and in the initial adult clinical course.

As the student advances to the other clinical courses, they will be introduced to the reality that additional nursing diagnoses or collaborative problems beyond the standardized plan (student generated or institution generated) may be present that necessitate interventions. Routinely, students can be prompted to add any revisions to the plan after they care for the individual with the question> During caring for your assigned individual did you access information or adapt an intervention that the next nurse would find useful? If confirmed, the student should be directed to where they can record the intervention in the facility’s documentation system.

All specialty nursing courses after the fundamental nursing course, eg Maternal Child /Health, Psych-Mental Health, Community Health, and Pediatrics, should have generic care plans. These plans can be on-line and printable.  This allows students the ability to revise the plan after caring for the individual.

The options for the creation of these plans are varied. The faculty can direct students to online sites. The faculty can provide plans (electronic), or the student can access plans in the institution.

Students can be prompted to add any revisions to the plan after they care for the individual with the question> When providing care for _______ did you acquire information or adapt an intervention that the next nurse would find useful? If confirmed, the student should be directed to confer with a staff nurse so they can record the intervention in the facility’s documentation system.

Addendum Nursing Diagnoses/Collaborative Problems

What differentiates addendum nursing diagnoses/collaborative problems from other nursing diagnoses or collaborative problems identified on the standardized care plan?

Addendum nursing diagnoses or collaborative problems are not predicted to be present because of a certain medical condition or surgical procedure. Thus, they are not included in a standardized care plan.

They are additional problem(s) that if not addressed can negatively affect the well-being of the individual/significant others or the safety of staff. They can be at risk problems or actual problems. For example, an individual admitted for injuries from a car accident due to him driving under the influence (DUI). Two children in another car are critically injured. He is desponded and referring to ending his life. Risk for Suicide is added to his problem list as an addendum nursing diagnosis.

Another example is an individual with insulin-dependent diabetes mellitus with a fractured femur, who reports frequent hypoglycemia episodes. This addendum collaborative problem is added to his problem list as High Risk for Complication of Hypoglycemia with a schedule for blood glucose monitoring.

Addendum Nursing Diagnoses are not always associated with the medical diagnosis or a surgical procedure. They can be associated with family conflicts, unexpected tragedies, job-related issues, insufficient finances, chronic mental illness, unsuccessful suicide attempt, substance abuse, sexual assault, gender conflicts, work -related conflicts or chronic noncompliance.

It is imperative the students know that if they need assistance they must speak up. Regardless of whether a student “should know,” the student request should be seen as responsible. Repetitive incidences may need further evaluation and interventions by faculty involved.

Unfortunately, if from a nursing perspective care for an individual is too complicated for the student nurse then the assignment would be problematic for the student and the individual. A negative experience for all involved can be predicted. If students are not mentored in the management of the above-mentioned complex situations, the student misses the opportunity to learn valuable interventions in difficult situations with the individual and /or family. The appropriate nursing diagnoses for fundamental students are probably on the agency's basic medical or surgical care plans.  However, a student could be paired with a nurse to share the caregiving and to observe the interactions of nurse with the individual. At post conference, this student can share their observations and interventions.

Clearly, there are levels of nursing expertise required for nursing diagnoses. Some require specialty preparation as (OB-GYN) Ineffective Childbearing Process, Ineffective Breastfeeding; Risk for Neonatal Pressure Injury; (Pediatrics) Acute Pain (child)Risk for Suffocation, Ineffective Infant Feeding Patten Delayed Growth and Development, Impaired Parenting; (Psych/Mental Health) Risk for Suicide Behavior, Risk for Other-Directed Violence, Social Isolation.

Some require nurse specialists or advance practice preparation, such as Ineffective Child or Adolescent Eating Dynamics, Post Trauma Syndrome, Disabled Family Coping, Risk for Other-Directed Violence, and Dysfunctional Family Coping. Medical-Surgical units can have a varied population of patients and significant others. If a situation involves an individual or family exhibiting disruptive or abusive behavior, I recommend that the instructor re-consider if the assignment will be beneficial for a student.

High Risk Nursing Diagnoses

All generic care plans or standards of care contain Risk Nursing Diagnoses.

If there is data to support the likelihood that an individual is more vulnerable to a Risk Nursing Diagnosis occurring, the term High Risk should be added to the diagnosis.

For example. If someone has an unstable gait or cognitive impairments that increase their Risk for Falls> it can be noted as an addendum to the standard of care by adding High Risk for Falls to the document utilized for care communication.

Handbook of Nursing Diagnosis 16th Edition

Handbook of Nursing Diagnosis 16th Edition is the ideal quick reference for nursing diagnosis information.

Instructors: Learn More

Managing Confidentiality

It is not uncommon when caring for an individual or interacting with their significant others, that new data reflecting a significant nursing diagnosis is confirmed. Nurses assume that all data they acquire should be reported. Rarely, does one think “Is this confidential?” Apart from mandatory reporting of risk for violence or risk for suicide, does the individual confiding to the nurse expect that information to be shared? Certainly, students must confide with their instructor for assistance. When an individual or family member confides in a unit nurse, should this information be shared? If yes with who? The critical question is, How will sharing this information help this individual or significant others? If it is beneficial, this can be explained to the individual and /or the significant others. The decision is theirs.

One approach to this situation would be for the instructor with the student to approach the problem and advise the individual person of resources available.

 It should be explained that it is in their best interests that their nurse, physician, nurse practitioner or physician assistant are informed. One can offer to communicate this situation to them.

Each clinical course after fundamentals can have designated nursing diagnoses that the student can assess for and intervene. These nursing diagnoses are also addendum nursing diagnoses. Addendum nursing diagnoses or collaborative problems are not included in generic medical, surgical, maternal-child, pediatrics standardized care. These are additional nursing diagnoses or collaborative problems that may or may not be related to the primary condition, bur require nursing interventions.  For example, an individual with Diabetes Mellitus, who has a fractured hip will have an addendum collaborative problem Potential Complication: Hypo/Hyperglycemia. Another situation is an individual and their family post an automobile accident. One family member died in the accident. Thus, a Grieving nursing diagnosis would be an addendum nursing diagnosis.

The clinical application of nursing diagnoses beyond a care plan is usually not presented to students. As graduate nurses, the standardized care plans replace the care plans that they generated as students. The institution’s standardized care plans are indexed under a medical condition, surgical procedures, or a specialty such as maternity.

Students create care plans that are standardized to a condition, even if hand-written. This is expected in the initial clinical course in fundamentals and in the initial adult clinical course.

Specialty Care Plans with Nursing Diagnoses /Collaborative Problems

An alternative to faculty providing or directing students to generic specialty care plans (e.g. Maternal Child Health, Psych Mental Health, Pediatrics, etc.) is to organize student work groups  to generate these care plans. The products of this group work can then be utilized by future students. However, I find this option an unnecessary time-consuming assignment on students.

• In pediatrics, age related interventions can complicate the generic care plan. An option is to separate generic care plans for infants ,12 months, toddlers, elementary age, pre-teen, 13-17 years, Individuals >18.
• In Maternal-Child generic plans for pregnancy, post-partum, neonatal.
• In Psych/Mental, generic in-patient care plan addressing Self-Care Deficits, Risk for Suicidal Behavior, Risk for Other-Directed Violence, Self-Care Deficit (specify), and fear.

The Clinical Importance of Nursing Diagnoses not in the Standardized Care Plan

To date, I have not read or written about the use of Nursing Diagnosis without a care plan. The binding of nursing diagnoses to care planning has reduced or eliminated its most important relevance. In fact, it may have contributed to putting one’s nursing diagnosis book on a shelf gathering dust after graduation. The richness of nursing science and practice is imbedded in every nursing diagnosis. Faculty play an important role in instilling in their nursing students that learning is lifelong. It is a “profound teaching moment when a faculty relates to the student that she or he do not know the interventions for a situation.”

Standardized Care Plans predict the care that is needed related to the individual’s primary medical or surgical condition. As described above, these documents can also have addendum nursing diagnoses or collaborative problems. Online plans with the ability to add and delete are in most institutions.

Most days, while providing care to an individual or their significant others, the nurse or the student may encounter data that is associated with a nursing diagnosis that was previously unknown. The nurse’s or the student’s response may only be an acknowledgement and some generic caring words.

The literature is rich with effective nursing interventions for nursing diagnoses. I am extremely proud of the detailed, concise, and caring interventions in my work. As should my colleagues of their work. These books provide a unique compilation of specific nursing interventions for various clinical situations. They are designed to access this information efficiently.

Unfortunately, as nurses we have been led to believe that we must have a remedy for all situations. Sometimes words do not comfort. When my son died in a car accident, I heard over and over “at least he did not suffer”. Instead,” I am so sorry” would have been more comforting” or” I cannot imagine your sorrow. “

The nursing diagnosis books of today are rich with specific, caring, and effective nursing interventions for many problems that a nurse will encounter. These books are comprehensive and can provide a student or practicing nurse with concrete interventions.

Faculty and students can never predict what someone will say on the clinical unit. It is important that since some moments are uncomfortable and awkward, that the response acknowledges the difficulty of the situation. “I am so sorry,”, “I am glad you shared this with me,”, “How can I help you?” are appropriate responses from a caregiver and Nurse. Students should also consult with their instructor.

Students (and graduate nurses) should have access to their book of nursing diagnoses in the clinical setting for these situations. A five-minute read can result in a positive outcome. Care must be taken that this information is confidential.  The instructor will determine how this information will be managed in the documentation system. Of course, any reference to self-harm or violence to another must immediately be reported.

Practicing nurses too often are sharing private information from an individual or significant others with staff. Is this beneficial or gossip? Faculty must caution students that their communication about an individual or significant others can positively or negatively affect the care they receive. It is a highly valued teaching moment, when the instructor uses a post conference to analyze a problematic situation with an unnamed individual or significant others.

Nursing Diagnosis has provided the nursing profession with the art and science of nursing care since 1973. It is important for the nursing profession that its utilization moves from the care plan to the bedside.

Nursing is a revered profession. For the past 22 years, nurses have been rated as the most trusted profession according to Gallup’s 2023 Honesty and Ethics Poll. Let us all continue this legacy. 

Related Content:

• Mastering Nursing Fundamentals Instruction: A Comprehensive Teacher’s Guide
• A Guide to Teaching Nursing Theories
• Nurses are Burning Out on the Job. Educators Can Help.

About the Author:

Lynda Juall Carpenito, MSN, APN, FNI, is the author of several nursing and health care textbooks on nursing process, nursing diagnosis, care planning and documentation and clinical teaching. She is a family nurse practitioner based in Mt. Laurel, New Jersey, and the president of LJC Consultants.