nursing problem list nanda

3 min read 16-03-2025

The nursing process is a systematic approach to planning and providing patient care. A crucial part of this process involves identifying and documenting nursing diagnoses. The North American Nursing Diagnosis Association International (NANDA-I) provides a standardized language for describing these diagnoses. This article will explore how to create a nursing problem list using the NANDA-I framework, explaining its importance and offering practical examples.

What is a Nursing Problem List?

A nursing problem list is a concise, organized summary of a patient's actual and potential health problems from a nursing perspective. It's not a list of medical diagnoses; instead, it focuses on the patient's responses to illness, injury, or other health challenges. Using NANDA-I diagnoses ensures consistency and clarity in communication among healthcare providers. This standardized language facilitates better patient care and improved outcomes.

The Importance of NANDA-I in Nursing

NANDA-I provides a common language for nurses worldwide. This standardized terminology improves communication, reduces ambiguity, and enhances the quality of nursing documentation. By using NANDA-I diagnoses, nurses can accurately and effectively communicate patient needs and plan appropriate interventions. This leads to better collaboration with other healthcare professionals and more efficient care delivery.

How to Create a Nursing Problem List Using NANDA-I Diagnoses

Creating a comprehensive nursing problem list involves several steps:

1. Assessment: Gathering Patient Data

Thoroughly assess the patient, collecting subjective (patient statements) and objective (observable data) information. This includes reviewing medical records, conducting physical examinations, and interviewing the patient and family members. Detailed assessment is critical to accurate diagnosis.

2. Identifying Nursing Diagnoses

Based on the assessment data, identify relevant NANDA-I nursing diagnoses. These diagnoses describe the patient's actual or potential health problems that nurses can treat independently. Consider both physiological and psychosocial aspects of the patient's condition. Remember to focus on the patient's response to the illness, not the illness itself.

3. Prioritizing Diagnoses

Prioritize the identified diagnoses based on urgency and importance. Maslow's Hierarchy of Needs can provide a useful framework. Life-threatening problems, such as impaired gas exchange, take precedence over less urgent problems. This prioritization ensures that interventions are focused on the most critical needs.

4. Documenting the Nursing Problem List

The nursing problem list should be clearly documented in the patient's chart. This typically includes the NANDA-I diagnosis label, related factors (etiology), and defining characteristics (symptoms). For example:

Example 1 (Actual Diagnosis): Impaired Gas Exchange related to pneumonia as evidenced by shortness of breath, decreased oxygen saturation, and use of accessory muscles for breathing.
Example 2 (Risk Diagnosis): Risk for Falls related to age-related muscle weakness and decreased balance.

5. Developing a Plan of Care

Once the nursing problem list is complete, develop a plan of care addressing each diagnosis. This plan should outline specific nursing interventions, expected outcomes, and evaluation methods.

Common NANDA-I Diagnoses

Several NANDA-I diagnoses are frequently used in clinical practice. Some examples include:

Activity Intolerance: Insufficient physiological or psychological energy to endure or complete required or desired daily activities.
Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage.
Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
Impaired Skin Integrity: Damage to the skin's epidermis and/or dermis.
Risk for Infection: Vulnerable to the invasion and multiplication of pathogenic organisms.
Imbalanced Nutrition: Less Than Body Requirements: Nutritional intake insufficient to meet metabolic demands.
Anxiety: Feeling of apprehension, uneasiness, uncertainty, or dread accompanied by autonomic symptoms.
Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of coping skills, or inability to use available resources.

This is not an exhaustive list, and the specific NANDA-I diagnoses used will vary depending on the patient's individual needs. Always refer to the most up-to-date NANDA-I taxonomy for the complete list of diagnoses.

Conclusion

Utilizing NANDA-I diagnoses in creating a nursing problem list is essential for providing high-quality, standardized patient care. By following the steps outlined in this guide, nurses can effectively identify, prioritize, and address patient needs, resulting in improved patient outcomes and enhanced communication among healthcare professionals. Remember to consult the current NANDA-I taxonomy and relevant resources for the most accurate and up-to-date information. The consistent application of this standardized language is vital for the advancement of the nursing profession and optimal patient care.