Nursing Diagnosis: The Second Phase of the Nursing Process
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This document discusses nursing diagnosis, which is the second phase of the nursing process where nurses use critical thinking to interpret assessment data and identify client strengths and problems in order to formulate nursing diagnoses. It provides details on the history and development of nursing diagnosis through organizations like NANDA International, and outlines the 13 domains and associated classes that make up NANDA's standardized nursing diagnosis terminology.
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Nursing Diagnosis: The Second Phase of the Nursing Process
- 3. Nursing Diagnosing is the second phase of the nursing process.
- 4. In this phase, nurses use critical thinking skills to interpret assessment data and identify client strengths and problems.
- 5. This phase are directed toward formulating the nursing diagnoses.
- 6. The care planning activities following this phase are based on the nursing diagnosis.
- 7. The identification and development of nursing diagnoses began formally in 1973, when two faculty members of Saint Louis University, Kristine Gebbie and Mary Ann Lavin, perceived a need to identify nurses’ roles in an ambulatory care setting.
- 8. The first national conference to identify nursing diagnoses was sponsored by the Saint Louis University School of Nursing and Allied Health Professions in 1973.
- 9. International recognition came with the First Canadian Conference in Toronto in 1977 and the International Nursing Conference in May 1987 in Calgary, Alberta, Canada.
- 10. In 1982, the conference group accepted the name North American Nursing Diagnosis Association (NANDA), recognizing the participation and contributions of nurses in the United States and Canada.
- 11. In 2002, the organization changed its name to NANDA International to further reflect the worldwide interest in nursing diagnosis.
- 12. The purpose of NANDA International is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. N A N D A
- 13. A taxonomy is a classification system or set of categories arranged based on a single principle or set of principles.
- 14. The members of NANDA include staff nurses, clinical specialists, faculty, directors of nursing, deans, theorists, and researchers.
- 16. To use the concept of nursing diagnoses effectively in generating and completing a nursing care plan, the nurse must be familiar with the definitions of terms used and the components of nursing diagnoses.
- 17. The term diagnosing refers to the reasoning process, whereas the term diagnosis is a statement or conclusion regarding the nature of a phenomenon.
- 18. The standardized NANDA names for the diagnoses are called Diagnostic labels;
- 21. The official NANDA definition of a nursing diagnosis is: “. . . a clinical judgment concerning a human response to health conditions/ life processes, or a vulnerability for that response, by an individual, family, group, or community”.
- 23. Domain 1: Health Promotion Domain 2: Nutrition Domain 3: Elimination and Exchange
- 24. Con-- Domain 4: Activity/Rest Domain 5: Perception/Cognition Domain 6: Self-Perception
- 25. Con--- Domain 7: Role Relationships Domain 8: Sexuality Domain 9: Coping/Stress Tolerance Domain 10: Life Principles
- 26. Con--- Domain 11: Safety/Protection Domain 12: Comfort Domain 13: Growth/Development
- 27. DOMAIN 1: HEALTH PROMOTION CLASS 1. HEALTH AWARENESS CLASS 2. HEALTH MANAGEMENT
- 28. Class 1. Health awareness Class 2. Health management Deficient community Risk-prone health behavior Ineffective health maintenance
- 29. Con------ Ineffective health management Ineffective family health management Ineffective protection
- 30. DOMAIN 2: NUTRITION CLASS 1. INGESTION CLASS 2. DIGESTION CLASS 3. ABSORPTION CLASS 4. METABOLISM CLASS 5. HYDRATION
- 31. CLASS 1. INGESTION Insufficient breast milk Ineffective breastfeeding Interrupted breastfeeding Readiness for enhanced breastfeeding
- 32. Con------- Ineffective infant feeding pattern Imbalanced nutrition: less than body requirements Readiness for enhanced nutrition
- 33. Con--- Obesity Overweight Risk for overweight Impaired swallowing
- 34. Class 2. Digestion Class 3. Absorption Class 4. Metabolism Risk for unstable blood glucose level Neonatal jaundice Risk for neonatal jaundice Risk for impaired liver function
- 35. Class 5. Hydration Risk for electrolyte imbalance Readiness for enhanced fluid balance Deficient fluid volume
- 36. Con-- Risk for deficient fluid volume Excess fluid volume Risk for imbalanced fluid volume
- 37. CLASS 1. URINARY FUNCTION CLASS 2. GASTROINTESTINAL FUNCTION CLASS 3. INTEGUMENTARY FUNCTION CLASS 4. RESPIRATORY FUNCTION
- 38. Class 1. Urinary function Impaired urinary elimination Readiness for enhanced urinary elimination Functional urinary incontinence Overflow urinary incontinence
- 39. Con--- Reflex urinary incontinence Stress urinary incontinence Urge urinary incontinence Risk for urge urinary incontinence Urinary retention
- 40. Class 2. Gastrointestinal function Constipation Risk for constipation Chronic functional constipation Risk for chronic functional constipation
- 41. Perceived constipation Diarrhea Dysfunctional gastrointestinal motility Risk for dysfunctional gastrointestinal motility Bowel incontinence
- 42. Class 3. Integumentary function Class 4. Respiratory function Impaired gas exchange
- 43. DOMAIN 4: ACTIVITY/REST CLASS 1. SLEEP/REST CLASS 2. ACTIVITY/EXERCISE CLASS 3. ENERGY BALANCE CLASS 4. CARDIOVASCULAR/PULMONA RY RESPONSES CLASS 5. SELF-CARE
- 44. Class 1. Sleep/rest Insomnia Sleep deprivation Readiness for enhanced sleep Disturbed sleep pattern
- 45. Class 2. Activity/exercise Risk for disuse syndrome Impaired bed mobility Impaired physical mobility Impaired wheelchair mobility
- 46. Con--- Impaired sitting Impaired standing Impaired transfer ability Impaired walking
- 47. Class 3. Energy balance Fatigue Wandering
- 48. Class 4. Cardiovascular/pulmonary responses Activity intolerance Risk for activity intolerance Ineffective breathing pattern Decreased cardiac output
- 49. Con-- Risk for decreased cardiac output Risk for impaired cardiovascular function Risk for ineffective gastrointestinal perfusion
- 50. Risk for ineffective renal perfusion Impaired spontaneous ventilation Risk for decreased cardiac tissue perfusion
- 51. Risk for ineffective cerebral tissue perfusion Ineffective peripheral tissue perfusion
- 52. Con-- Risk for ineffective peripheral tissue perfusion Dysfunctional ventilatory weaning response
- 53. Class 5. Self-care Impaired home maintenance Bathing self-care deficit Dressing self-care deficit Feeding self-care deficit
- 54. Toileting self-care deficit Readiness for enhanced self- care Self-neglect
- 55. CLASS 1. ATTENTION CLASS 2. ORIENTATION CLASS 3. SENSATION/PERCEPTION CLASS 4. COGNITION CLASS 5. COMMUNICATION
- 56. Class 1. Attention Unilateral neglect Class 2. Orientation Class 3. Sensation/perception
- 57. Class 4. Cognition Acute confusion Risk for acute confusion Chronic confusion Labile emotional control Ineffective impulse control
- 58. Con-- Deficient knowledge Readiness for enhanced knowledge Impaired memory
- 59. Class 5. Communication Readiness for enhanced communication Impaired verbal communication
- 60. DOMAIN 6: SELF- PERCEPTION CLASS 1. SELF-CONCEPT CLASS 2. SELF-ESTEEM CLASS 3. BODY IMAGE
- 61. Class 1. Self-concept Readiness for enhanced hope Hopelessness Risk for compromised human dignity
- 62. Con-- Disturbed personal identity Risk for disturbed personal identity Readiness for enhanced self- concept
- 63. Class 2. Self-esteem Chronic low self-esteem Risk for chronic low self- esteem Situational low self-esteem Risk for situational low self- esteem
- 64. Class 3. Body image Disturbed body image
- 65. DOMAIN 7: ROLE RELATIONSHIPS CLASS 1. CAREGIVING ROLES CLASS 2. FAMILY RELATIONSHIPS CLASS 3. ROLE PERFORMANCE
- 66. Class 1. Caregiving roles Caregiver role strain Risk for caregiver role strain Impaired parenting Readiness for enhanced parenting Risk for impaired parenting
- 67. DOMAIN 8: SEXUALITY CLASS 1. SEXUAL IDENTITY CLASS 2. SEXUAL FUNCTION CLASS 3. REPRODUCTION
- 68. Class 2. Family relationships Risk for impaired attachment Dysfunctional family processes Interrupted family processes Readiness for enhanced family processes
- 69. Class 3. Role performance Ineffective relationship Readiness for enhanced relationship Risk for ineffective relationship
- 70. Con-- Parental role conflict Ineffective role performance Impaired social interaction
- 71. DOMAIN 8: SEXUALITY CLASS 1. SEXUAL IDENTITY CLASS 2. SEXUAL FUNCTION SEXUAL DYSFUNCTION INEFFECTIVE SEXUALITY PATTERN
- 72. Class 1. Sexual identity Class 2. Sexual function Sexual dysfunction Ineffective sexuality pattern
- 73. Class 3. Reproduction Ineffective childbearing process Readiness for enhanced childbearing process Risk for ineffective childbearing process Risk for disturbed maternal–fetal dyad
- 74. DOMAIN 9: COPING/STRESS TOLERANCE CLASS 1. POST-TRAUMA RESPONSES POST-TRAUMA SYNDROME CLASS 2. COPING RESPONSES CLASS 3. NEUROBEHAVIORAL STRESS
- 75. Class 1. Post-trauma responses Post-trauma syndrome Risk for post-trauma syndrome Rape-trauma syndrome Relocation stress syndrome Risk for relocation stress syndrome
- 76. Class 2. Coping responses Ineffective activity planning Risk for ineffective activity planning Anxiety Defensive coping
- 77. Con-- Ineffective coping Readiness for enhanced coping Ineffective community coping Readiness for enhanced community coping
- 78. Compromised family coping Disabled family coping Readiness for enhanced family coping Death anxiety
- 79. Con--- Ineffective denial Fear Grieving Complicated grieving Risk for complicated grieving
- 80. Impaired mood regulation Readiness for enhanced power Powerlessness Risk for powerlessness
- 81. Con-- Impaired resilience Readiness for enhanced resilience Risk for impaired resilience Chronic sorrow Stress overload
- 82. Class 3. Neurobehavioral stress Decreased intracranial adaptive capacity Autonomic dysreflexia Risk for autonomic dysreflexia
- 83. Con-- Disorganized infant behavior Readiness for enhanced organized infant behavior Risk for disorganized infant behavior
- 84. DOMAIN 10: LIFE PRINCIPLES CLASS 1. VALUES CLASS 2. BELIEFS CLASS 3. VALUE/BELIEF/ACTION CONGRUENCE
- 85. Class 1. Values Class 2. Beliefs Readiness for enhanced spiritual well-being
- 86. Class 3. Value/belief/action congruence Readiness for enhanced decision-making Decisional conflict Impaired emancipated decision-making
- 87. Con-- Readiness for enhanced emancipated Decision-making Risk for impaired emancipated decision-making Moral distress Impaired religiosity
- 88. Readiness for enhanced religiosity Risk for impaired religiosity Spiritual distress Risk for spiritual distress
- 89. DOMAIN 11: SAFETY/PROTECTION CLASS 1. INFECTION CLASS 2. PHYSICAL INJURY CLASS 3. VIOLENCE CLASS 4. ENVIRONMENTAL HAZARDS CLASS 5. DEFENSIVE PROCESSES CLASS 6. THERMOREGULATION
- 90. Class 1. Infection Risk for infection Class 2. Physical injury Ineffective airway clearance Risk for aspiration Risk for bleeding Risk for dry eye
- 91. Risk for falls Risk for injury Risk for corneal injury Risk for perioperative positioning injury
- 92. Con-- Risk for thermal injury Risk for urinary tract injury Impaired dentition Impaired oral mucous membrane
- 93. Risk for impaired oral mucous membrane Risk for peripheral neurovascular dysfunction Risk for pressure ulcer
- 94. Con-- Risk for shock Impaired skin integrity Risk for impaired skin integrity Risk for sudden infant death syndrome Risk for suffocation Delayed surgical recovery
- 95. Risk for delayed surgical recovery Impaired tissue integrity Risk for impaired tissue integrity Risk for trauma Risk for vascular trauma
- 96. Class 3. Violence Risk for other-directed violence Risk for self-directed violence Self-mutilation Risk for self-mutilation Risk for suicide
- 97. Class 4. Environmental hazards Contamination Risk for contamination Risk for poisoning
- 98. Class 5. Defensive processes Risk for adverse reaction to iodinated contrast media Risk for allergy response Latex allergy response Risk for latex allergy response
- 99. Class 6. Thermoregulation Risk for imbalanced body temperature Hyperthermia Hypothermia Risk for hypothermia Risk for perioperative hypothermia Ineffective thermoregulation
- 100. DOMAIN 12: COMFORT CLASS 1. PHYSICAL COMFORT CLASS 2. ENVIRONMENTAL COMFORT CLASS 3. SOCIAL COMFORT
- 101. Class 1. Physical comfort •Impaired comfort •Readiness for enhanced comfort •Nausea •Acute pain •Chronic pain •Labor pain •Chronic pain syndrome
- 102. Class 2. Environmental comfort Impaired comfort Readiness for enhanced comfort
- 103. Class 3. Social comfort Impaired comfort Readiness for enhanced comfort Risk for loneliness Social isolation
- 104. DOMAIN 13: GROWTH/DEVELOPMENT CLASS 1. GROWTH CLASS 2. DEVELOPMENT
- 105. Class 1. Growth Risk for disproportionate growth Class 2. Development Risk for delayed development