​​​​​Introduc​tion

Nurses regularly recognize, diagnose, and treat conditions as part of practice. When you assess a client, plan care, and intervene, you are making clinical judgments and responding with appropriate nursing actions. 

Examples:

• Diagnosing ​and treating hypoglycemia using your organization's hypoglycemia decision support tool (DST)
  
• Recognizing post-operative hypoxia and initiating oxygen therapy
  
• Identifying acute confusion, checking vital signs, and completing focused assessments
  

​​Nursing diagnosis

A nursing diagnosis is a nurse's clinical judgment about a client's physical or mental condition, based on assessment findings, signs, and symptoms. It focuses on conditions that nursing care can prevent, improve, manage, or resolve within the nurse's autonomous scope of practice.

This means nurses diagnose conditions they can address through nursing care, not diseases or disorders that explain the cause (medical diagnosis) of the client's signs or symptoms.

In addition to diagnosing conditions, certified nurses may diagnose a limited number of specific diseases or disorders, as outlined in their certification programs and decision support tools.

After a nursing diagnosis: what can you ​do next?

A nursing diagnosis helps you identify the client's condition and decide whether treatment is needed. But it does not automatically authorize you to perform every activity autonomously.

Before acting, you must apply the four controls on practice:

1. Legislation and regulation
2. BCCNM standards, limits, and conditions
3. Employer policies and supports
4. Your own competence 

Some activities can be initiated autonomously. Some can be performed only if specific requirements, limits, or conditions are met. Others require a client-specific order. 

Categories of activities after a ​​​​​nursing diagnosis

Activities without an​ order

These are activities you are authorized to perform autonomously, as long as they are within your scope of practice and competence and allowed and supported in your practice setting. 

You:

• ​​Confirm the activity is within your class of licensure and scope of practice
• Confirm employer policy, protocol, or algorithm supports it
• Meet BCCNM standards for acting autonomously

• Act within​​ your competence and monitor outcomes

Example: Treating hypoglycemia with oral glucose, when supported by employer policy.

Activities with limits or conditions

Activities with limits or conditions can still fall within autonomous scope if specific requirements are met.

Requirements may include:

• BCCNM limits and conditions
• Employer training or competency validation
• Following a decision support tool or protocol

• Practice-setti​​ng restrictions, such as privileging

You:

• Check the relevant BCCNM limits and conditions
• Confirm any employer requirements
• Ensure you meet all prerequisites, such as education, certification, or validation
• Follow the decision support tool or protocol as required

• D​​ocument accordingly

Examples:

• Treating hypoglycemia with glucagon or D50W by following a decision support tool

• P​​erforming complex wound care only after completing required education and validation

Activities requiring an order

Some activities cannot be performed autonomously. They require a complete client-specific order from an authorized regulated health professional.

You:

• Rec​ognize when the activity requires an order
• Stabilize and monitor the client within your autonomous scope
• Consult the appropriate authorized health professional
• Obtain an order before proceeding

• C​ontinue to reassess and document while awaiting direction

Examples:

• Administering an antipsychotic medication for acute confusion
• Inserting a urinary catheter, depending on class of licensure, competence, and employer policy
• Initiating high-flow oxygen, depending on class of licensure and employer policy 

Treating conditions within autonomous scope

Nurses may carry out non-restricted and restricted activities without an order to assess and treat conditions they have diagnosed, when the activity is authorized, the required conditions are met, and employer policies support it.

Acting autonomously requires sound clinical judgment. You must be competent to:

• Identify and​ diagnose the client's condition
• Decide whether treatment is needed and appropriate
• Carry out the activity safely and ethically
• Monitor outcomes and respond to unexpected changes

​Your role is to recognize, diagnose, and stabilize the client's condition within nursing scope. Another authorized provider, such as an NP or physician, may diagnose the underlying disease or disorder. Diagnosing medical diseases or disorders is outside nursing scope, except where specific certification authorizes it. 

Key point​​

A nursing diagnosis identifies the client's condition. It does not automatically authorize every activity. Always use the four controls on practice to determine whether you may act autonomously, must meet specific limits or conditions, or need a client-specific order. 

​​​Need help or support?​

For further guidance on understanding and applying the standards of practice, contact our team by completing the Standards Support intake form.​