Based on NANDA International (NANDA-I) Taxonomy · Clinical Nursing Reference This presents the most frequently encountered nursing diagnoses in clinical practice, organised by body system and care context. For each diagnosis, the guide includes the standard NANDA-I definition, typical related factors (etiology), defining characteristics (signs and symptoms), and a complete sample care plan with measurable Read More
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Based on NANDA International (NANDA-I) Taxonomy · Clinical Nursing Reference
This presents the most frequently encountered nursing diagnoses in clinical practice, organised by body system and care context. For each diagnosis, the guide includes the standard NANDA-I definition, typical related factors (etiology), defining characteristics (signs and symptoms), and a complete sample care plan with measurable goals, evidence-based interventions, rationale, and evaluation criteria.
Nursing diagnoses are not medical diagnoses. They describe the patient’s response to a health condition and identify problems that fall within nursing’s scope of independent and collaborative practice. All diagnoses in this guide align with NANDA International nomenclature.
| How to Use this
Each nursing diagnosis entry follows a consistent structure: Definition — the NANDA-I approved description of the diagnosis Related Factors (Etiology) — causative or contributing conditions (the ‘related to’ clause) Defining Characteristics — observable signs and symptoms (the ‘as evidenced by’ clause) Sample Care Plan — a complete, formatted care plan ready to adapt for practice or study
The PES format (Problem + Etiology + Signs/Symptoms) structures all diagnostic statements: [Diagnosis] related to [etiology] as evidenced by [defining characteristics] |
| # | Nursing Diagnosis | Category | Priority Level |
| 1 | Acute Pain | Comfort | High |
| 2 | Chronic Pain | Comfort | Moderate–High |
| 3 | Impaired Gas Exchange | Oxygenation | Critical |
| 4 | Ineffective Airway Clearance | Oxygenation | Critical |
| 5 | Excess Fluid Volume | Fluid & Electrolyte | High |
| 6 | Deficient Fluid Volume | Fluid & Electrolyte | High |
| 7 | Imbalanced Nutrition: Less Than Body Req | Nutrition | Moderate |
| 8 | Impaired Skin Integrity | Integumentary | Moderate–High |
| 9 | Risk for Infection | Safety | High |
| 10 | Risk for Falls | Safety | High |
| 11 | Impaired Physical Mobility | Activity | Moderate |
| 12 | Activity Intolerance | Activity | Moderate |
| 13 | Constipation | Elimination | Moderate |
| 14 | Urinary Retention | Elimination | Moderate–High |
| 15 | Anxiety | Psychosocial | Moderate–High |
| 16 | Acute Confusion | Cognition | High |
| 17 | Ineffective Coping | Psychosocial | Moderate |
| 18 | Deficient Knowledge | Education | Moderate |
| 19 | Self-Care Deficit (Bathing/Dressing) | Self-Care | Moderate |
| 20 | Impaired Verbal Communication | Communication | Moderate |
Definition
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, with a sudden or slow onset, of any intensity from mild to severe, with an anticipated or predictable end, and a duration of less than 3–6 months.
Related Factors (Common)
Defining Characteristics
| SAMPLE CARE PLAN | |
| Nursing Diagnosis | Acute Pain |
| Related To (Etiology) | Surgical tissue trauma following right total knee arthroplasty |
| As Evidenced By (AEB) | Patient reports pain 8/10 at rest, guarding right knee, reluctance to move, HR 102, diaphoresis |
| Goals / Expected Outcomes | • Patient will report pain ≤ 3/10 within 60 minutes of pharmacological intervention
• Patient will demonstrate use of at least one non-pharmacological pain management technique within 4 hours • Patient will ambulate to bathroom with physiotherapy support on post-operative Day 1 |
| Nursing Interventions | Rationale |
| Perform comprehensive pain assessment using validated scale (NRS 0–10) every 2 hours and PRN; document character, location, duration, aggravating/relieving factors | Accurate, frequent assessment establishes a baseline and detects inadequate control early; unidimensional NRS is validated for post-operative pain |
| Administer prescribed analgesics (PCA opioid, standing paracetamol, NSAID) on schedule; assess effectiveness 30–60 minutes post-administration | Multimodal analgesia (combining agents with different mechanisms) provides superior pain control with lower opioid doses and reduced side effects |
| Position patient with right leg elevated on pillow; apply ice pack to right knee (20 min on/off) as ordered | Elevation reduces dependent oedema; cold therapy causes local vasoconstriction, reducing inflammation and acute pain |
| Teach and encourage non-pharmacological techniques: deep breathing, distraction, music therapy, relaxation | Non-pharmacological strategies activate descending pain inhibitory pathways and reduce anxiety, which amplifies pain perception |
| Educate patient that reporting pain promptly is essential — uncontrolled pain delays recovery and mobility | Patients who fear addiction or believe pain is inevitable under-report; adequate analgesia is essential for participation in rehabilitation |
| Liaise with physiotherapy and pain team; ensure multimodal analgesia plan is optimised before Day 1 mobilisation | Uncontrolled pain is the primary barrier to early mobilisation, which prevents DVT, pneumonia, and deconditioning |
| Evaluation | • Pain score ≤ 3/10 within 60 minutes of analgesia — document as MET / PARTIALLY MET / NOT MET
• Patient correctly demonstrates deep breathing or distraction technique by 4 hours • Patient ambulates to bathroom on Day 1 with physiotherapy support — revise plan if mobility goal not met |
Definition
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, with a sudden or slow onset, of any intensity from mild to severe, that is recurrent or persistent and lasts longer than 3–6 months.
Related Factors
Defining Characteristics
| SAMPLE CARE PLAN | |
| Nursing Diagnosis | Chronic Pain |
| Related To (Etiology) | Peripheral neuropathy secondary to long-standing Type 2 diabetes mellitus |
| As Evidenced By (AEB) | Patient reports bilateral burning foot pain 6/10 daily for >2 years, disturbed sleep, stopped walking for exercise, mood low |
| Goals / Expected Outcomes | • Patient will report average daily pain ≤ 4/10 within 4 weeks of optimised pain management plan
• Patient will report sleeping ≥ 6 hours uninterrupted by pain within 2 weeks • Patient will identify and demonstrate two self-management strategies for pain flares at discharge |
| Nursing Interventions | Rationale |
| Use a chronic pain assessment tool (Brief Pain Inventory) at each visit to capture pain severity, interference, and mood | Chronic pain is multidimensional; tools that assess function and mood provide more actionable information than NRS alone |
| Collaborate with medical team to optimise pharmacological management (e.g., gabapentinoids, SNRIs, topical agents for neuropathic pain) | Neuropathic pain responds poorly to standard opioids; gabapentinoids and SNRIs are first-line evidence-based agents |
| Refer to multidisciplinary pain management programme: physiotherapy, psychology (CBT for chronic pain), occupational therapy | Multidisciplinary pain management is the gold-standard for chronic pain and produces better outcomes than pharmacology alone |
| Educate patient on the neuroscience of chronic pain — explain central sensitisation; reduce fear-avoidance beliefs | Pain neuroscience education reduces catastrophising, improves self-efficacy, and is associated with better functional outcomes |
| Support self-management: graded activity, sleep hygiene, pacing strategies, relaxation techniques | Pacing prevents ‘boom-bust’ cycles common in chronic pain; improved sleep and activity directly reduce pain perception |
| Screen and address psychological comorbidities (depression, anxiety) which dramatically amplify chronic pain | Depression and anxiety are present in up to 50% of chronic pain patients; untreated, they worsen pain and impair recovery |
| Evaluation | • Brief Pain Inventory score reviewed at 4 weeks target improvement in average pain and functional interference
• Patient reports sleep duration and quality at each visit; refer to sleep specialist if insomnia persists • Patient demonstrates pacing technique and one relaxation method at discharge |
Definition
Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
Related Factors
Defining Characteristics
| SAMPLE CARE PLAN | |
| Nursing Diagnosis | Impaired Gas Exchange |
| Related To (Etiology) | Alveolar fluid accumulation secondary to acute decompensated heart failure |
| As Evidenced By (AEB) | SpO2 89% on room air, RR 26 breaths/min, bilateral basal crackles, accessory muscle use, patient reports dyspnoea 7/10 |
| Goals / Expected Outcomes | • Patient’s SpO2 will be ≥ 94% within 2 hours of oxygen and diuretic therapy
• RR will decrease to 12–20 breaths/min within 4 hours • Patient will report dyspnoea ≤ 2/10 by end of shift |
| Nursing Interventions | Rationale |
| Administer supplemental O2 at prescribed flow rate via nasal cannula; titrate to maintain SpO2 ≥ 94% | Supplemental O2 increases alveolar PO2, improving diffusion across the fluid-congested membrane |
| Position patient in high Fowler’s (60–90°) at all times; assist to tripod position if needed | Upright positioning reduces diaphragmatic pressure from abdominal contents and redistributes pulmonary blood flow |
| Monitor SpO2 continuously; assess RR, accessory muscle use, skin colour, and mental status every 30 minutes | Frequent assessment detects deterioration early, allowing timely escalation before respiratory failure |
| Administer IV diuretics as ordered; monitor hourly urine output; record accurate fluid balance | Diuretics reduce preload and pulmonary congestion, directly addressing the cause of impaired gas exchange |
| Teach pursed-lip breathing and diaphragmatic breathing techniques | Pursed-lip breathing prolongs exhalation, maintains positive airway pressure, and reduces air trapping |
| Prepare for escalation: have BiPAP/CPAP equipment available; notify medical team if SpO2 < 90% despite O2 | Non-invasive ventilation may be required if pharmacological and positional measures are insufficient |
| Evaluation | • SpO2 ≥ 94% on prescribed O2 at 2-hour check — document and adjust O2 if not met
• RR 12–20 at 4-hour check; accessory muscle use resolved • Patient reports dyspnoea ≤ 2/10; breath sounds improving on auscultation |
Definition
Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
Related Factors
Defining Characteristics
| SAMPLE CARE PLAN | |
| Nursing Diagnosis | Ineffective Airway Clearance |
| Related To (Etiology) | Retained secretions and splinting of breathing due to post-thoracotomy pain |
| As Evidenced By (AEB) | Weak, ineffective cough, coarse crackles right lower lobe, SpO2 93%, patient splinting chest with both arms on movement |
| Goals / Expected Outcomes | • Patient will demonstrate effective, productive cough within 2 hours of intervention
• Breath sounds will improve (reduced crackles) within 8 hours • SpO2 will be ≥ 95% on room air by end of shift |
| Nursing Interventions | Rationale |
| Ensure adequate analgesia before physiotherapy coordinate timing of PRN doses with chest physiotherapy sessions | Pain is the primary cause of splinting and ineffective cough after thoracic surgery; adequate analgesia is prerequisite to all airway clearance |
| Teach and supervise splinted (‘huffing’) cough technique: patient uses pillow to support incision while coughing | Splinted cough reduces incisional pain while generating sufficient airflow to mobilise secretions |
| Perform chest physiotherapy (percussion and vibration over affected lung segment) every 4 hours | Chest physiotherapy uses mechanical forces to loosen secretions from airway walls for clearance |
| Encourage incentive spirometry: 10 breaths every hour while awake | Incentive spirometry promotes sustained maximal inspiration, preventing atelectasis and facilitating secretion movement |
| Maintain hydration (oral or IV) to reduce secretion viscosity; consider nebulised saline if ordered | Thin, well-hydrated secretions are significantly easier to expectorate than thick, tenacious mucus |
| Assist patient to sit upright or dangle at bedside; early mobilisation facilitates secretion drainage | Gravity-assisted positioning augments mucociliary clearance; upright posture optimises respiratory mechanics |
| Evaluation | • Patient demonstrates productive cough with splinting technique within 2 hours
• Auscultation shows reduced or resolved crackles at right lower lobe at 8-hour reassessment • SpO2 ≥ 95% on room air by end of shift |
| Category 3: Fluid & Electrolyte Diagnoses |
| 5 | Excess Fluid Volume |
Definition
Surplus intake and/or retention of fluid, resulting in increased total body water.
Related Factors
Defining Characteristics
| SAMPLE CARE PLAN | |
| Nursing Diagnosis | Excess Fluid Volume |
| Related To (Etiology) | Compromised cardiac regulatory mechanisms secondary to NYHA Class III heart failure |
| As Evidenced By (AEB) | 3+ bilateral pitting oedema to mid-calf, weight gain 4 kg in 7 days, crackles bilaterally, BNP 820 pg/mL, urine output 20 mL/hour |
| Goals / Expected Outcomes | • Patient will demonstrate urine output ≥ 0.5 mL/kg/hour within 4 hours of diuretic therapy
• Patient will lose 0.5–1 kg of fluid weight per day over next 3 days • Pitting oedema will reduce by at least one grade within 48 hours • Patient will verbalize fluid restriction plan (1.5 L/day) and daily weight monitoring before discharge |
| Nursing Interventions | Rationale |
| Administer IV/oral diuretics as prescribed; monitor and document urine output hourly via IDC | Loop diuretics (furosemide) inhibit Na+/K+/2Cl- cotransporter in the loop of Henle, promoting water excretion; hourly output monitoring detects response |
| Weigh patient daily at same time, on same scales, in same clothing — document and trend | Daily weight is the most sensitive indicator of fluid balance; 1 kg weight change ≈ 1 litre fluid |
| Enforce prescribed fluid restriction; educate patient and family on what counts as fluid intake | Fluid restriction directly limits further fluid accumulation; family education prevents inadvertent excess intake |
| Restrict dietary sodium as ordered; consult dietitian for low-sodium meal planning | Sodium promotes water retention via osmotic mechanisms; sodium restriction reduces fluid accumulation |
| Elevate oedematous limbs above heart level when resting; avoid prolonged dependent positioning | Elevation promotes venous and lymphatic return, reducing dependent oedema |
| Monitor electrolytes (especially K+, Mg2+) daily — diuretic therapy causes renal electrolyte losses | Hypokalaemia and hypomagnesaemia from diuresis increase risk of dangerous cardiac arrhythmias |
| Assess and document skin integrity over oedematous areas; apply moisture barrier and reposition 2-hourly | Oedematous skin is fragile and at high risk of breakdown; pressure injury prevention is essential |
| Evaluation | • Urine output ≥ 0.5 mL/kg/hour (typically ≥ 30 mL/hour) at 4-hour mark
• Daily weight trending downward by 0.5–1 kg/day over 3 days • Oedema grade reduced at 48-hour assessment; patient correctly states fluid restriction and daily weight plan |
| Category 4: Safety Diagnoses |
Definition
Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health. (A risk diagnosis — no AEB required as the problem has not yet occurred.)
Risk Factors
| SAMPLE CARE PLAN | |
| Nursing Diagnosis | Risk for Infection |
| Related To (Etiology) | Presence of central venous catheter (CVC), surgical wound, urinary catheter, and immunosuppression secondary to chemotherapy |
| As Evidenced By (AEB) | N/A — risk diagnosis (no defining characteristics present; problem has not yet occurred) |
| Goals / Expected Outcomes | • Patient will remain free of signs of infection (fever, erythema, purulent discharge) throughout admission
• All invasive devices will be removed at the earliest clinically appropriate time • Patient will demonstrate correct hand hygiene technique before discharge |
| Nursing Interventions | Rationale |
| Perform meticulous hand hygiene (WHO 5 Moments) before and after all patient contact; ensure family and visitors comply | Hand hygiene is the single most effective measure to prevent healthcare-associated infection; compliance must be actively promoted |
| Assess CVC site daily: inspect for erythema, swelling, discharge, tenderness; perform dressing change per protocol (typically every 7 days or when soiled) | CVCs are a primary source of bloodstream infection; daily assessment and evidence-based dressing protocols minimise CLABSI risk |
| Assess surgical wound at each dressing change using NERDS/STONEES criteria; document healing progress | Early detection of wound infection using validated criteria (NERDS for superficial, STONEES for deep infection) allows timely treatment |
| Maintain closed urinary drainage system; perform urinary catheter care with soap and water twice daily; reassess need for catheter daily and remove as soon as possible | Catheter-associated UTI (CAUTI) is the most common hospital-acquired infection; every unnecessary catheter-day increases risk substantially |
| Monitor temperature, WBC, CRP, and culture results daily; report fever > 38°C or signs of SIRS promptly | Early detection of systemic infection (SIRS, sepsis) enables timely intervention and reduces mortality |
| Maintain patient’s nutritional status — consult dietitian; adequate nutrition supports immune function and wound healing | Protein-calorie malnutrition significantly impairs cellular immunity and wound healing, increasing infection susceptibility |
| Evaluation | • No fever, erythema, purulent discharge, or systemic signs of infection throughout admission — document daily
• All invasive devices removed at earliest clinically appropriate time — document dates and rationale for continued use • Patient demonstrates correct 6-step hand hygiene technique before discharge |
Definition
Susceptible to increased susceptibility to falling that may cause physical harm.
Risk Factors
SAMPLE CARE PLAN |
|
| Nursing Diagnosis | Risk for Falls |
| Related To (Etiology) | Orthostatic hypotension, opioid analgesia, unfamiliar environment, and reduced lower limb strength following total hip replacement |
| As Evidenced By (AEB) | N/A — risk diagnosis. Morse Falls Score 55 (high risk). Previous fall 6 months ago. BP drops 22 mmHg systolic on standing. |
| Goals / Expected Outcomes | • Patient will experience no falls throughout admission
• Patient will correctly verbalize fall prevention strategies before first unsupported ambulation attempt • Patient will demonstrate safe use of walking frame with physiotherapy supervision on Day 1 post-op |
| Nursing Interventions | Rationale |
| Apply falls risk armband and signage; document high-risk status on handover and in care plan | Visual identification of high-risk patients ensures all team members implement consistent precautions |
| Ensure call bell is within reach at all times; educate patient to call before standing | Most falls occur during unsupervised transfer or ambulation; patient call-bell compliance is the primary prevention behaviour |
| Keep bed in lowest position, bed brakes locked; ensure clear pathway to bathroom with adequate lighting | Environmental modification removes physical hazards; low bed reduces fall injury severity |
| Implement 2-hourly intentional rounding — toileting, positioning, comfort — to reduce unsupervised mobilisation | Intentional rounding pre-emptively meets patient needs, reducing unexpected unsupported ambulation attempts |
| Educate patient and family on orthostatic hypotension: sit at edge of bed for 2–3 minutes before standing | Gradual position change allows cardiovascular compensation and prevents syncope from orthostatic hypotension |
| Review medication list with medical team: assess whether opioid dose can be reduced; ensure anti-emetics are prescribed | Opioids cause sedation and orthostatic hypotension; reducing dose where pain allows directly reduces fall risk |
| Ensure non-slip footwear is worn for all mobilisation; refer to physiotherapy for walking aid assessment | Appropriate walking aids and footwear correct gait instability — the leading modifiable physical fall risk factor |
| Evaluation | • No falls documented throughout admission
• Patient correctly states 3 fall prevention strategies before first ambulation attempt • Physiotherapy documents safe walking frame use with correct technique on Day 1 |
Definition
Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.
Related Factors
Defining Characteristics
| SAMPLE CARE PLAN | |
| Nursing Diagnosis | Anxiety |
| Related To (Etiology) | New diagnosis of breast cancer and anticipation of chemotherapy commencing next week |
| As Evidenced By (AEB) | Patient tearful throughout assessment, states ‘I can’t stop thinking about dying’, HR 108, poor sleep for 2 weeks, unable to retain information given in oncology appointments |
| Goals / Expected Outcomes | • Patient will identify and verbalize the primary sources of her anxiety within this shift
• Patient will demonstrate one anxiety-reduction technique (e.g., controlled breathing) correctly before end of shift • Patient will report anxiety ≤ 4/10 on GAD-7 scale at next visit (baseline 16/21) • Patient will have attended one oncology support group session within 2 weeks |
| Nursing Interventions | Rationale |
| Establish therapeutic relationship: introduce yourself, sit at eye level, allow uninterrupted time for the patient to express fears without minimising or rushing | A calm, unhurried presence reduces physiological arousal and communicates that the patient’s fears are valid and worthy of attention |
| Assess anxiety level formally using GAD-7 or Hamilton Anxiety Rating Scale; screen for depression (PHQ-9) concurrently | Validated screening tools quantify anxiety severity, facilitate monitoring over time, and identify when pharmacological management may be warranted |
| Provide accurate, clear, jargon-free information about the chemotherapy process, side effects, and management — give written materials to review at home | Anxiety is often fuelled by uncertainty and misinformation; accurate information restores a sense of control and predictability |
| Teach controlled diaphragmatic breathing (4–7–8 technique) and progressive muscle relaxation as immediate coping tools | Controlled breathing activates the parasympathetic nervous system, reducing heart rate and physiological anxiety symptoms within minutes |
| Refer to oncology social worker and clinical psychologist; ensure patient is aware of cancer support groups and survivorship programmes | Cancer-related anxiety frequently exceeds what nursing alone can address; specialist psychological support is evidence-based and reduces distress significantly |
| Address practical concerns (childcare, finances, work leave) which may be significant sources of anxiety — connect with social work | Practical stressors amplify psychological anxiety; coordinating practical support addresses the whole person |
| Evaluation | • Patient identifies 2–3 specific anxiety sources during therapeutic conversation this shift
• Patient correctly demonstrates diaphragmatic breathing technique before end of shift • GAD-7 score at next visit — target ≥ 4-point reduction from baseline of 16 • Referral to psychologist/support group confirmed; patient verbalizes intent to attend |
Definition
Absence or deficiency of cognitive information related to a specific topic, including skills required to manage a health condition.
Related Factors
Defining Characteristics
| SAMPLE CARE PLAN | |
| Nursing Diagnosis | Deficient Knowledge |
| Related To (Etiology) | Newly prescribed insulin therapy and carbohydrate counting for Type 2 diabetes mellitus |
| As Evidenced By (AEB) | Patient unable to demonstrate insulin injection technique, states ‘I don’t know what carbs to avoid’, HbA1c 88 mmol/mol, last BGL log shows multiple readings > 15 mmol/L |
| Goals / Expected Outcomes | • Patient will correctly demonstrate subcutaneous insulin injection technique on mannequin before discharge
• Patient will correctly identify 5 high-carbohydrate foods to moderate from a meal photograph exercise • Patient will verbalize signs of hypoglycaemia and corrective action before discharge • Patient will state BGL monitoring frequency and target range correctly before discharge |
| Nursing Interventions | Rationale |
| Assess baseline knowledge and readiness to learn before beginning education; identify preferred learning style and barriers (literacy, vision, dexterity) | Adults learn most effectively when education is adapted to their readiness, existing knowledge, and learning preferences; pre-assessment prevents information overload |
| Teach insulin injection technique using demonstrate–return demonstrate method: site selection, rotation, angle, needle disposal | Return demonstration is the gold standard for skill-based teaching; observing patient performance identifies and corrects errors before discharge |
| Use visual aids, carbohydrate exchange charts, and real food models for carbohydrate counting education | Visual and tactile learning aids improve retention compared to verbal instruction alone, particularly for complex dietary concepts |
| Provide written, plain-language resource to take home (include BGL targets, hypoglycaemia management, sick day rules) | Written materials support memory and allow review at home; plain language ensures comprehension across literacy levels |
| Refer to Credentialled Diabetes Educator and dietitian for structured diabetes self-management education programme | Structured diabetes education programmes are associated with significant HbA1c reduction and improved self-management outcomes |
| Arrange follow-up phone call or outpatient appointment within 1 week of discharge to reinforce and troubleshoot | Early follow-up catches problems before they lead to emergency presentations; continuity of support is critical in the early weeks after new diagnosis |
| Evaluation | • Patient performs insulin injection on mannequin correctly at discharge — document steps achieved and any errors corrected
• Patient correctly identifies ≥ 5 high-carbohydrate foods during food photograph exercise • Patient accurately describes ≥ 3 hypoglycaemia symptoms and states corrective action (15 g fast-acting carbohydrate) • Patient states correct BGL monitoring frequency and individualised target range |
Definition
Abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period (hours to days).
Related Factors
Defining Characteristics
| SAMPLE CARE PLAN | |
| Nursing Diagnosis | Acute Confusion (Delirium) |
| Related To (Etiology) | Multifactorial — urinary tract infection, opioid analgesics, sleep deprivation, and unfamiliar hospital environment in an elderly patient with mild cognitive impairment |
| As Evidenced By (AEB) | Patient (82-year-old male) disoriented to time and place, CAM positive (inattention, acute onset, fluctuating course, disorganised thinking), HR 102, temp 38.2°C, agitated, pulling at IV line |
| Goals / Expected Outcomes | • Patient will have CAM score reassessed every shift — target resolution of delirium within 72 hours of treating underlying cause
• Patient will experience no harm (falls, self-removal of IV lines, aspiration) during confused episode • Patient will be correctly oriented to person, place, and time with cues at each nursing contact • Family will verbalize understanding of delirium (temporary, treatable) and their role in supporting orientation |
| Nursing Interventions | Rationale |
| Treat underlying cause: administer prescribed antibiotics for UTI; obtain cultures before first dose; review and rationalise medications — discontinue or reduce opioids and anticholinergics where possible | Delirium is a medical emergency; identifying and treating the precipitant (infection, medication, metabolic cause) is the only definitive treatment |
| Implement ABCDEF delirium prevention bundle: Assess pain, Both SAT/SBT, Choice of sedation, Delirium monitoring (CAM-ICU), Early mobility, Family engagement | The ABCDEF bundle is the evidence-based, multicomponent standard for delirium prevention and management in hospital settings |
| Reorient patient at every contact: use patient’s name, introduce yourself, explain where they are, what day it is, what will happen; provide clock, calendar, familiar photos | Frequent reorientation provides external cues that compensate for the patient’s disrupted internal temporal-spatial orientation |
| Ensure continuous sensory aids: glasses and hearing aids in place at all times; ensure adequate lighting during day, darkness and quiet at night | Sensory deprivation (due to removed glasses/hearing aids) is a major delirium precipitant; restoring sensory function reduces confusion |
| Engage family in care: encourage familiar faces at bedside, familiar voices, reading aloud from patient’s preferred material | Familiar faces and voices significantly reduce agitation and distress; family engagement is an active therapeutic intervention |
| Apply non-pharmacological strategies first for agitation: verbal de-escalation, calm reassurance, meeting comfort needs (pain, thirst, toileting); reserve antipsychotics for severe agitation posing safety risk, as per medical order | Non-pharmacological agitation management avoids medication side effects that may worsen delirium; antipsychotics are second-line for safety emergencies only |
| Implement safety measures: low bed, padded bedrails, bed alarm, 1:1 nursing or sitter if required; minimise restraints | Confused patients who attempt to mobilise unsupported are at extreme fall and injury risk; a safe environment prevents harm while allowing mobility |
| Evaluation | • CAM assessment every shift — document positive/negative, features present, and any change from previous assessment
• No falls, self-extubation, IV removal, or aspiration events during confused episode • Patient correctly oriented with verbal cues at ≥ 3 of 4 nursing contacts by 72 hours • Family able to explain delirium as temporary and treatable; verbalizes their role in reorientation |
Every nursing diagnostic statement should follow the PES format. Use the table below as a quick-reference template when formulating diagnostic statements for documentation and care planning.
| Component | Formula Element | Clinical Example |
| Problem (P) | [NANDA-I Diagnosis Label] | Impaired Gas Exchange |
| Etiology (E) | related to [contributing cause or risk factor] | related to alveolar fluid accumulation from acute heart failure |
| Signs/Sx (S) | as evidenced by [defining characteristics] | as evidenced by SpO2 89%, RR 26, bilateral crackles, and dyspnoea 7/10 |
| Full Statement | P + E + S combined | Impaired Gas Exchange related to alveolar fluid accumulation as evidenced by SpO2 89%, RR 26 breaths/min, bilateral basal crackles, and patient-reported dyspnoea 7/10 |
| Risk Diagnosis | [Risk for Diagnosis] related to [risk factors only — no AEB] | Risk for Falls related to orthostatic hypotension, opioid use, and unfamiliar environment |
Nursing diagnoses are the bridge between what nurses observe and what nurses do. Mastery of NANDA-I diagnostic language, combined with the ability to write accurate PES statements and develop individualised, evidence-based care plans, is one of the most important competencies a nurse builds throughout their career.
The diagnoses and care plans in this guide are starting points, not prescriptions. Every patient is unique, and nursing care must always be adapted to the individual’s clinical presentation, values, preferences, and context. Use these frameworks to sharpen your clinical reasoning, but always let the patient in front of you not the textbook example guide your assessment and planning.
| Key Principle for Practice
A nursing diagnosis is not a label applied to a patient. It is a clinical judgement the conclusion of careful, systematic assessment that drives a specific, purposeful plan of care. The quality of your nursing diagnosis reflects the quality of your thinking as a clinician. |
Evan John