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nsgdiagnosis-190712005448.pdf
- 3. Nursing Diagnosing isthe second phase of the nursing process.
- 4. In thisphase, nurses use critical thinking skills to interpret assessment data and identify client strengths and problems.
- 5. This phaseare directed toward formulating the nursing diagnoses.
- 6. The careplanning activities following this phase are based on the nursing diagnosis.
- 7. The identificationand 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 firstnational conference to identify nursing diagnoses was sponsored by the Saint Louis University School of Nursing and Allied Health Professions in 1973.
- 9. International recognitioncame 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, theorganization changed its name to NANDA International to further reflect the worldwide interest in nursing diagnosis.
- 12. The purposeof 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 isa classification system or set of categories arranged based on a single principle or set of principles.
- 14. The membersof NANDA include staff nurses, clinical specialists, faculty, directors of nursing, deans, theorists, and researchers.
- 16. To usethe 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 termdiagnosing refers to the reasoning process, whereas the term diagnosis is a statement or conclusion regarding the nature of a phenomenon.
- 18. The standardizedNANDA names for the diagnoses are called Diagnostic labels;
- 21. The official NANDAdefinition 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: HealthPromotion Domain 2: Nutrition Domain 3: Elimination and Exchange
- 24. Con-- Domain 4: Activity/Rest Domain5: Perception/Cognition Domain 6: Self-Perception
- 25. Con--- Domain7: 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 CLASS1. HEALTH AWARENESS CLASS 2. HEALTH MANAGEMENT
- 28. Class 1. Healthawareness Class 2. Health management Deficient community Risk-prone health behavior Ineffective health maintenance
- 29. Con------ Ineffective healthmanagement Ineffective family health management Ineffective protection
- 30. DOMAIN 2: NUTRITION CLASS1. 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 infantfeeding 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 fordeficient fluid volume Excess fluid volume Risk for imbalanced fluid volume
- 37. CLASS 1. URINARYFUNCTION CLASS 2. GASTROINTESTINAL FUNCTION CLASS 3. INTEGUMENTARY FUNCTION CLASS 4. RESPIRATORY FUNCTION
- 38. Class 1. Urinaryfunction Impaired urinary elimination Readiness for enhanced urinary elimination Functional urinary incontinence Overflow urinary incontinence
- 39. Con--- Reflex urinaryincontinence 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. Integumentaryfunction Class 4. Respiratory function Impaired gas exchange
- 43. DOMAIN 4: ACTIVITY/REST CLASS1. 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 Impairedtransfer ability Impaired walking
- 47. Class 3. Energybalance Fatigue Wandering
- 48. Class 4. Cardiovascular/pulmonary responses Activity intolerance Risk for activity intolerance Ineffective breathing pattern Decreased cardiac output
- 49. Con-- Risk fordecreased cardiac output Risk for impaired cardiovascular function Risk for ineffective gastrointestinal perfusion
- 50. Risk forineffective renal perfusion Impaired spontaneous ventilation Risk for decreased cardiac tissue perfusion
- 51. Risk for ineffective cerebraltissue perfusion Ineffective peripheral tissue perfusion
- 52. Con-- Risk for ineffectiveperipheral 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 Readinessfor enhanced self- care Self-neglect
- 55. CLASS 1. ATTENTION CLASS2. 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 CLASS1. 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 personalidentity 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. Bodyimage Disturbed body image
- 65. DOMAIN 7: ROLE RELATIONSHIPS CLASS1. CAREGIVING ROLES CLASS 2. FAMILY RELATIONSHIPS CLASS 3. ROLE PERFORMANCE
- 66. Class 1. Caregivingroles Caregiver role strain Risk for caregiver role strain Impaired parenting Readiness for enhanced parenting Risk for impaired parenting
- 67. DOMAIN 8: SEXUALITY CLASS1. 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. Roleperformance Ineffective relationship Readiness for enhanced relationship Risk for ineffective relationship
- 70. Con-- Parental roleconflict Ineffective role performance Impaired social interaction
- 71. DOMAIN 8: SEXUALITY CLASS1. 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 CLASS1. 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. Copingresponses 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 familycoping Disabled family coping Readiness for enhanced family coping Death anxiety
- 79. Con--- Ineffective denial Fear Grieving Complicated grieving Risk for complicated grieving
- 80. Impaired moodregulation 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 infantbehavior Readiness for enhanced organized infant behavior Risk for disorganized infant behavior
- 84. DOMAIN 10: LIFEPRINCIPLES CLASS 1. VALUES CLASS 2. BELIEFS CLASS 3. VALUE/BELIEF/ACTION CONGRUENCE
- 85. Class 1. Values Class2. 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 forenhanced emancipated Decision-making Risk for impaired emancipated decision-making Moral distress Impaired religiosity
- 88. Readiness forenhanced 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 Riskfor injury Risk for corneal injury Risk for perioperative positioning injury
- 92. Con-- Risk forthermal injury Risk for urinary tract injury Impaired dentition Impaired oral mucous membrane
- 93. Risk forimpaired oral mucous membrane Risk for peripheral neurovascular dysfunction Risk for pressure ulcer
- 94. Con-- Risk forshock Impaired skin integrity Risk for impaired skin integrity Risk for sudden infant death syndrome Risk for suffocation Delayed surgical recovery
- 95. Risk fordelayed 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 CLASS1. PHYSICAL COMFORT CLASS 2. ENVIRONMENTAL COMFORT CLASS 3. SOCIAL COMFORT
- 101. Class 1. Physicalcomfort •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. Socialcomfort 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