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The foci of the nursing diagnoses in NANDA-I Taxonomy II, and their associateddiasgnoses,startonthefollowingpages: Activityplanning322–323 Activitytolerance228–229 Acutesubstancewithdrawalsyndrome351–352 Adaptivecapacity357 Adversereactiontoiodinatedcontrastmedia429 Airwayclearance384 Allergyreaction430 Anxiety324 Aspiration385 Attachment289 Autonomicdysreflexia353,355 Balancedenergyfield225 Balancedfluidvolume183 Balancednutrition157 Bathingself-care243 Bleeding386 Bloodglucoselevel177 Bodyimage276 Breastmilkproduction159 Breastfeeding160–162 Breathingpattern230 Cardiacoutput231,233 Childbearingprocess307,309–310 Chronicpainsyndrome448 Comfort442–443,450–453 Communication262 Confusion254–256 Constipation197,199–200 Contamination424,426 Coping326–331,333–334 Deathanxiety335 Decision-making366 Decisionalconflict367 Denial336 Dentition387 Development459 Diarrhea204 Disusesyndrome217 Diversionalactivityengagement142 Dressingself-care244 Dryeye388 Drymouth389 Eatingdynamics163–164 Electrolytebalance182 Elimination189 Emancipateddecision-making368–370 Emotionalcontrol257 Falls390 Familyprocesses290,293–294 Fatigue226 Fear337 Feedingdynamics166 Feedingpattern168 Feedingself-care245 Femalegenitalmutilation415 Fluidvolume184–186 Frailelderlysyndrome145,147 Functionalconstipation201,203 Gasexchange209 Gastrointestinalmotility205–206 Grieving339–341 Health148 Healthbehavior149 Healthliteracy143 Healthmaintenance150 Healthmanagement151–153 Homemaintenance242 Hope266–267 Humandignity268 Hyperbilirubinemia178 Hyperthermia434 Hypothermia435,437 Immigrationtransition315 Impulsecontrol258 Incontinence190–195,207 Infection382 Injury392–394 Insomnia213 Knowledge259–260 Laborpain449 Latexallergyreaction431,433 Lifestyle144 Liverfunction180 Loneliness454 Maternal-fetaldyad311 Memory261 Metabolicimbalancesyndrome181 Mobility218–220 Moodregulation342 Moraldistress371 Mucousmembraneintegrity397,399 Nausea444 Neonatalabstinencesyndrome358 Neurovascularfunction400 Nutrition158 Obesity169 Occupationalinjury427 Organizedbehavior359,361–362 Other-directedviolence416 Overweight170,172 Pain445–446 Parenting283,286,288 Perioperativehypothermia438 Perioperativepositioninginjury395 Personalidentity269–270 Physicaltrauma401 Poisoning428 Post-traumasyndrome316,318 Power343–345 Pressureulcer404 Protection154 Rape-traumasyndrome319 Relationship295–297 Religiosity372–374 Relocationstresssyndrome320–321 Resilience346–348 Retention196 Roleconflict298 Roleperformance299 Rolestrain278,281 Self-care247 Self-concept271 Self-directedviolence417 Self-esteem272–275 Self-mutilation418,420 Self-neglect248 Sexualfunction305 Sexualitypattern306 Shock405 Sitting221 Skinintegrity406–407 Sleep214–215 Sleeppattern216 Socialinteraction301 Socialisolation455 Sorrow349 Spiritualdistress375,377 Spiritualwell-being365 Spontaneousventilation234 stablebloodpressure235 standing222 stress350 suddendeath408 suffocation409 suicide422 surgicalrecovery410–411 surgicalsiteinfection383 swallowing173 Thermalinjury396 thermoregulation439–440 tissueintegrity412–413 tissueperfusion236–239 toiletingself-care246 transferability223 trauma403 unilateralneglect251 venousthromboembolism414 ventilatoryweaningresponse240 verbalcommunication263 walking224 wandering227 Readaboutrelevantliteratureonlineat MediaCenter.Thieme.com! SimplyvisitMediaCenter.Thieme.comand,whenpromptedduringthe registrationprocess,enterthecodebelowtogetstartedtoday. XZ88-D7XB-SJK6-QE85 NANDAInternational,Inc. NursingDiagnoses DefinitionsandClassification 2018–2020 EleventhEdition Editedby T.HeatherHerdman,PhD,RN,FNI and ShigemiKamitsuru,PhD,RN,FNI Thieme NewYork•Stuttgart•Delhi•RiodeJaneiro InternationalRightsManager:HeikeSchwabenthan EditorialServicesManager:MaryJoCasey EditorialDirector:SueHodgson ManagingEditor:KennethSchubach ProductionEditor:SeanWoznicki EditorialAssistant:MaryWilson Director,ClinicalSolutions:MichaelWachinger BookProductionManager,Stuttgart:SophiaHengst InternationalProductionEditor:AndreasSchabert InternationalMarketingDirector:FionaHenderson DirectorofSales,NorthAmerica:MikeRoseman InternationalSalesDirector:LouisaTurrell SeniorVicePresidentandChiefOperatingOfficer:SarahVanderbilt President:BrianD.Scanlan LibraryofCongressCataloging-in-PublicationData Copyright information for this volume has been filed with the Library of Congress and is available by requestfromthepublisher. 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Theeditorsofthiseditionwouldliketo dedicatethisbooktothememoryofourfounder, Dr.MarjoryGordon Contents Part1 TheNANDAInternationalTerminology–Organization andGeneralInformation 1 Introduction 2 What'sNewinthe2018–2020EditionofDiagnosesand Classification 3 ChangesandRevisions 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 ProcessesandProceduresforDiagnosisSubmissionandReview ChangestoDefinitionsofHealthPromotionDiagnoses NewNursingDiagnoses RevisedNursingDiagnoses RetiredNursingDiagnosis RevisionstoNursingDiagnosisLabels StandardizationofDiagnosticIndicatorTerms IntroductionofAt-RiskPopulationsandAssociatedConditions 4 GovernanceandOrganization 4.1 InternationalConsiderationsontheUseoftheNANDA-INursing Diagnoses NANDAInternationalPositionStatements AnInvitationtoJoinNANDAInternational 4.2 4.3 Part2 TheTheoryBehindNANDAInternationalNursing Diagnoses 5 NursingDiagnosisBasics 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 Introduction HowDoesaNurse(orNursingStudent)Diagnose? UnderstandingNursingConcepts Assessment NursingDiagnosis Planning/Intervention Evaluation UseofNursingDiagnosis BriefChapterSummary References 6 ClinicalReasoning:FromAssessmenttoDiagnosis 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Introduction TheNursingProcess DataAnalysis IdentifyingPotentialNursingDiagnoses(DiagnosticHypotheses) In-DepthAssessment Summary References 7 IntroductiontotheNANDAInternationalTaxonomyofNursing Diagnoses 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Introduction ClassificationinNursing UsingtheNANDA-ITaxonomy StructuringNursingCurricula IdentifyingaNursingDiagnosisOutsideYourAreaofExpertise TheNANDA-INursingDiagnosisTaxonomy:AShortHistory References 8 SpecificationsandDefinitionsWithintheNANDAInternational TaxonomyofNursingDiagnoses 8.1 8.2 StructureofTaxonomyII AMultiaxialSystemforConstructingDiagnosticConcepts 8.3 8.4 8.5 8.6 8.7 DefinitionsoftheAxes DevelopingandSubmittingaNursingDiagnosis FurtherDevelopment RecommendedReading References 9 FrequentlyAskedQuestions 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10 9.11 9.12 9.13 9.14 9.15 Introduction WhenDoWeNeedNursingDiagnoses? BasicQuestionsaboutStandardizedNursingLanguages BasicQuestionsaboutNANDA-I BasicQuestionsaboutNursingDiagnoses QuestionsaboutDefiningCharacteristics QuestionsaboutRelatedFactors QuestionsaboutRiskFactors DifferentiatingbetweenSimilarNursingDiagnoses QuestionsRegardingtheDevelopmentofaTreatmentPlan QuestionsaboutTeaching/LearningNursingDiagnoses QuestionsaboutUsingNANDA-IinElectronicHealthRecords QuestionsaboutDiagnosisDevelopmentandReview QuestionsabouttheNANDA-IDefinitionsandClassificationText References 10 GlossaryofTerms 10.1 10.2 10.3 10.4 10.5 NursingDiagnosis DiagnosticAxes ComponentsofaNursingDiagnosis DefinitionsforClassificationofNursingDiagnoses References Part3 TheNANDAInternationalNursingDiagnoses Domain1. Healthpromotion Class1. Healthawareness Decreaseddiversionalactivityengagement Readinessforenhancedhealthliteracy Sedentarylifestyle Class2. Healthmanagement Frailelderlysyndrome Riskforfrailelderlysyndrome Deficientcommunityhealth Risk-pronehealthbehavior Ineffectivehealthmaintenance Ineffectivehealthmanagement Readinessforenhancedhealthmanagement Ineffectivefamilyhealthmanagement Ineffectiveprotection Domain2. Nutrition Class1. Ingestion Imbalancednutrition:lessthanbodyrequirements Readinessforenhancednutrition Insufficientbreastmilkproduction Ineffectivebreastfeeding Interruptedbreastfeeding Readinessforenhancedbreastfeeding Ineffectiveadolescenteatingdynamics Ineffectivechildeatingdynamics Ineffectiveinfantfeedingdynamics Ineffectiveinfantfeedingpattern Obesity Overweight Riskforoverweight Impairedswallowing Class2. Digestion Thisclassdoesnotcurrentlycontainanydiagnoses Class3. Absorption Thisclassdoesnotcurrentlycontainanydiagnoses Class4. Metabolism Riskforunstablebloodglucoselevel Neonatalhyperbilirubinemia Riskforneonatalhyperbilirubinemia Riskforimpairedliverfunction Riskformetabolicimbalancesyndrome Class5. Hydration Riskforelectrolyteimbalance Riskforimbalancedfluidvolume Deficientfluidvolume Riskfordeficientfluidvolume Excessfluidvolume Domain3. Eliminationandexchange Class1. Urinaryfunction Impairedurinaryelimination Functionalurinaryincontinence Overflowurinaryincontinence Reflexurinaryincontinence Stressurinaryincontinence Urgeurinaryincontinence Riskforurgeurinaryincontinence Urinaryretention Class2. Gastrointestinalfunction Constipation Riskforconstipation Perceivedconstipation Chronicfunctionalconstipation Riskforchronicfunctionalconstipation Diarrhea Dysfunctionalgastrointestinalmotility Riskfordysfunctionalgastrointestinalmotility Bowelincontinence Class3. Integumentaryfunction Thisclassdoesnotcurrentlycontainanydiagnoses Class4. Respiratoryfunction Impairedgasexchange Domain4. Activity/rest Class1. Sleep/rest Insomnia Sleepdeprivation Readinessforenhancedsleep Disturbedsleeppattern Class2. Activity/exercise Riskfordisusesyndrome Impairedbedmobility Impairedphysicalmobility Impairedwheelchairmobility Impairedsitting Impairedstanding Impairedtransferability Impairedwalking Class3. Energybalance Imbalancedenergyfield Fatigue Wandering Class4. Cardiovascular/pulmonaryresponses Activityintolerance Riskforactivityintolerance Ineffectivebreathingpattern Decreasedcardiacoutput Riskfordecreasedcardiacoutput Impairedspontaneousventilation Riskforunstablebloodpressure Riskfordecreasedcardiactissueperfusion Riskforineffectivecerebraltissueperfusion Ineffectiveperipheraltissueperfusion Riskforineffectiveperipheraltissueperfusion Dysfunctionalventilatoryweaningresponse Class5. Domain5. Self-care Impairedhomemaintenance Bathingself-caredeficit Dressingself-caredeficit Feedingself-caredeficit Toiletingself-caredeficit Readinessforenhancedself-care Self-neglect Perception/cognition Class1. Attention Unilateralneglect Class2. Orientation Thisclassdoesnotcurrentlycontainanydiagnoses Class3. Sensation/perception Thisclassdoesnotcurrentlycontainanydiagnoses Class4. Cognition Acuteconfusion Riskforacuteconfusion Chronicconfusion Labileemotionalcontrol Ineffectiveimpulsecontrol Deficientknowledge Readinessforenhancedknowledge Impairedmemory Class5. Domain6. Communication Readinessforenhancedcommunication Impairedverbalcommunication Self-perception Class1. Self-concept Hopelessness Readinessforenhancedhope Riskforcompromisedhumandignity Disturbedpersonalidentity Riskfordisturbedpersonalidentity Readinessforenhancedself-concept Class2. Self-esteem Chroniclowself-esteem Riskforchroniclowself-esteem Situationallowself-esteem Riskforsituationallowself-esteem Class3. Bodyimage Disturbedbodyimage Domain7. Rolerelationship Class1. Caregivingroles Caregiverrolestrain Riskforcaregiverrolestrain Impairedparenting Riskforimpairedparenting Readinessforenhancedparenting Class2. Familyrelationships Riskforimpairedattachment Dysfunctionalfamilyprocesses Interruptedfamilyprocesses Readinessforenhancedfamilyprocesses Class3. Domain8. Roleperformance Ineffectiverelationship Riskforineffectiverelationship Readinessforenhancedrelationship Parentalroleconflict Ineffectiveroleperformance Impairedsocialinteraction Sexuality Class1. Sexualidentity Thisclassdoesnotcurrentlycontainanydiagnoses Class2. Sexualfunction Sexualdysfunction Ineffectivesexualitypattern Class3. Reproduction Ineffectivechildbearingprocess Riskforineffectivechildbearingprocess Readinessforenhancedchildbearingprocess Riskfordisturbedmaternal-fetaldyad Domain9. Coping/stresstolerance Class1. Post-traumaresponses Riskforcomplicatedimmigrationtransition Post-traumasyndrome Riskforpost-traumasyndrome Rape-traumasyndrome Relocationstresssyndrome Riskforrelocationstresssyndrome Class2. Copingresponses Ineffectiveactivityplanning Riskforineffectiveactivityplanning Anxiety Defensivecoping Ineffectivecoping Readinessforenhancedcoping Ineffectivecommunitycoping Readinessforenhancedcommunitycoping Compromisedfamilycoping Disabledfamilycoping Readinessforenhancedfamilycoping Deathanxiety Ineffectivedenial Fear Grieving Complicatedgrieving Riskforcomplicatedgrieving Impairedmoodregulation Powerlessness Riskforpowerlessness Readinessforenhancedpower Impairedresilience Riskforimpairedresilience Readinessforenhancedresilience Chronicsorrow Stressoverload Class3. Neurobehavioralstress Acutesubstancewithdrawalsyndrome Riskforacutesubstancewithdrawalsyndrome Autonomicdysreflexia Riskforautonomicdysreflexia Decreasedintracranialadaptivecapacity Neonatalabstinencesyndrome Disorganizedinfantbehavior Riskfordisorganizedinfantbehavior Readinessforenhancedorganizedinfantbehavior Domain10. Class1. Lifeprinciples Values Thisclassdoesnotcurrentlycontainanydiagnoses Class2. Beliefs Readinessforenhancedspiritualwell-being Class3. Value/belief/actioncongruence Readinessforenhanceddecision-making Decisionalconflict Impairedemancipateddecision-making Riskforimpairedemancipateddecision-making Readinessforenhancedemancipateddecision-making Moraldistress Impairedreligiosity Riskforimpairedreligiosity Readinessforenhancedreligiosity Spiritualdistress Riskforspiritualdistress Domain11. Safety/protection Class1. Infection Riskforinfection Riskforsurgicalsiteinfection Class2. Physicalinjury Ineffectiveairwayclearance Riskforaspiration Riskforbleeding Impaireddentition Riskfordryeye Riskfordrymouth Riskforfalls Riskforcornealinjury Riskforinjury Riskforurinarytractinjury Riskforperioperativepositioninginjury Riskforthermalinjury Impairedoralmucousmembraneintegrity Riskforimpairedoralmucousmembraneintegrity Riskforperipheralneurovasculardysfunction Riskforphysicaltrauma Riskforvasculartrauma Riskforpressureulcer Riskforshock Impairedskinintegrity Riskforimpairedskinintegrity Riskforsuddeninfantdeath Riskforsuffocation Delayedsurgicalrecovery Riskfordelayedsurgicalrecovery Impairedtissueintegrity Riskforimpairedtissueintegrity Riskforvenousthromboembolism Class3. Violence Riskforfemalegenitalmutilation Riskforother-directedviolence Riskforself-directedviolence Self-mutilation Riskforself-mutilation Riskforsuicide Class4. Environmentalhazards Contamination Riskforcontamination Riskforoccupationalinjury Riskforpoisoning Class5. Defensiveprocesses Riskforadversereactiontoiodinatedcontrastmedia Riskforallergyreaction Latexallergyreaction Riskforlatexallergyreaction Class6. Thermoregulation Hyperthermia Hypothermia Riskforhypothermia Riskforperioperativehypothermia Ineffectivethermoregulation Riskforineffectivethermoregulation Domain12. Comfort Class1. Physicalcomfort Impairedcomfort Readinessforenhancedcomfort Nausea Acutepain Chronicpain Chronicpainsyndrome Laborpain Class2. Environmentalcomfort Impairedcomfort Readinessforenhancedcomfort Class3. Socialcomfort Impairedcomfort Readinessforenhancedcomfort Riskforloneliness Socialisolation Domain13. Growth/development Class1. Growth Thisclassdoesnotcurrentlycontainanydiagnoses Class2. Development Riskfordelayeddevelopment Index Concepts Preface Intheearly1970s,nursesandeducatorsintheUnitedStatesuncoveredthefact thatnursesindependentlydiagnosedandtreated“something”relatedtopatients and their families, which was different from medical diagnoses. Their great insight opened the new door to the taxonomy of nursing diagnoses, and the establishment of the professional organization that is now known as NANDA International (NANDA-I). As is usual with medical diagnoses for physicians, nursesshouldhave“something”todocumentaholisticscopeofpracticetohelp studentsacquireouruniquebodyofknowledge,andtoenablenursestocollect andanalyzedatatoadvancethedisciplineofnursing.Morethan40yearshave passed,andtheideaof“nursingdiagnosis”hasinspiredandencouragednurses around the world who seek independent practice based upon professional knowledge. Initially,nurseslivingoutsideNorthAmericamayhavebeensimplytheend users of the NANDA-I taxonomy. Today, development and refinement of the taxonomy is heavily based on a global effort. In fact, we received more submissionsofnewdiagnosesandproposalsforrevisionsfromcountriesoutside North America than within it during this publication cycle. Moreover, the organization has become truly international; members from the Americas, Europe, and Asia are actively participating on committees, leading committees aschairs,and managingtheorganizationasdirectorsoftheBoard.Whocould have imagined that a non-native English speaker from a small Asian country wouldbecomethepresidentofNANDA-Iin2016? Inthis2018–2020version,theEleventhEdition,thetaxonomyprovides244 diagnoses, with the addition of 17 new diagnoses. Each nursing diagnosis has been the product of one or more of our many NANDA-I volunteers, and most haveadefinedevidencebase.Eachnewdiagnosishasbeendebatedandrefined byourDiagnosisDevelopmentCommittee(DDC)members,beforefinallybeing submittedtoNANDA-Imembersforavoteofapproval.Membershipapproval does not mean the diagnosis is “completed” or “ready to be used” across all countriesorpracticeareas.Weallknowthatpracticeandregulationofnursing varies from country to country. It is our hope that publication of these new diagnoseswillfacilitatefurthervalidationstudiesindifferentpartsoftheworld, 1 toachieveahigherlevelofevidence. We always welcome submissions for new nursing diagnoses. At the same time, we have a serious need for revision of existing diagnoses to reflect the most recent evidence. While preparing for this edition, we took a bold step highlightingtheunderlyingproblemswithmanyofthecurrentdiagnoses.Please notethatmorethan70diagnoseshavenolevelofevidence(LOE);thatmeans therehasbeennomajorupdateonthesediagnosessinceatleast2002,whenthe LOE criteria were introduced. In addition, to treat the problems described in eachnursingdiagnosiseffectively,relatedorriskfactorsarerequired.However, after sorting some of these factors into “At-Risk Populations” and “Associated Conditions” (things that are not independently treatable by nurses), there are severaldiagnosesthatnowhavenorelatedorriskfactors. NANDA-Iistranslatedintonearly20distinctlanguages.Translatingabstract English terms into other languages can often be frustrating. When I faced difficulties translating from English to Japanese, I remembered the story from theeighteenth-centuryaboutscholarswhotranslatedaDutchanatomytextbook intoJapanesewithoutanydictionary.Theysaythescholarssometimesspentone monthtotranslatejustonepage!Today,wehavedictionariesandevenautomatic translation systems, but translation of diagnostic labels, definitions, and diagnosticindicatorsisstillnotaneasytask.Conceptualtranslation,ratherthan word-for-word translation, requires that the translators clearly understand the intent of the concept. When the terms in English are abstract or very loosely defined, this increases the difficulty in assuring a correct translation of the concepts. Over the years, I have learned that sometimes a very minor modification of the original English term can alleviate a burden on translators. Your comments and feedback will help make our terminology, not only more translatable,butitwillalsoincreasetheclarityofEnglishexpressions. Beginning with this edition, we have three primary publishing partners. We havedirectlypartneredwithGrupoAforourPortuguesetranslation,andIgakuShoinformuchofourAsianmarket.Theremainderoftheworld,includingthe original English version, will be spearheaded by a team from Thieme Medical Publishers,Inc.Weareveryexcitedaboutthesepartnershipsandthepossibilities thatthesefineorganizationsbringtoourassociationandtheavailabilityofour terminologyaroundtheglobe. I want to commend the work of all NANDA-I volunteers, committee members, chairpersons, and members of the Board of Directors for their time, commitment,devotion,andongoingsupport.Iwanttothankourstaff,ledbyour ChiefExecutive,Dr.T.HeatherHerdman,foritseffortsandsupport. 2 My special thanks to the members of the DDC for their outstanding and timely efforts to review and edit the terminology represented within this book, and especially for the leadership of the DDC Chair, Professor Dickon WeirHughes,since2014.Thisremarkablecommittee,withrepresentationfromNorth and South America and Europe, is the true “powerhouse” of the NANDA-I knowledge content. I am deeply impressed and pleased by the astonishing, comprehensiveworkofthesevolunteersovertheyears ShigemiKamitsuru,PhD,RN,FNI President,NANDAInternational,Inc. 3 Acknowledgments Itgoeswithoutsayingthatthededicationofseveralindividualstotheworkof NANDAInternational,Inc.(NANDA-I)isevidentintheirdonationoftimeand worktotheimprovementoftheNANDA-Iterminologyandtaxonomy.Without question, this terminology reflects the dedication of individuals who research anddeveloporrefinediagnoses,andthevolunteersthatmakeuptheDiagnosis DevelopmentCommittee,aswellasitsChair,Prof.DickonWeir-Hughes.This text represents the culmination of tireless volunteer work by a very dedicated, extremely talented group of individuals who have developed, revised, and studiednursingdiagnosesformorethan40years. We would like to offer a particularly significant note of appreciation to Dr. CamilaTakao Lopesof the CollegeofNursingoftheUniversidadeFederal de SãoPauloinBrazil,whoworkedtoorganize,update,andmaintaintheNANDAI terminology database, and supported the work on standardization of the terminology. Additionally, we would like to take the opportunity to acknowledge and personally thank Susan Gallagher-Lepak, PhD, RN, Dean of the College of Health,Education&SocialWelfare,attheUniversityofWisconsin–GreenBay, forhercontributiontothisparticulareditionoftheNANDA-Itext,astheauthor oftherevisedNursingDiagnosisBasicschapter. [email protected] content, or if you find errors, so that these may be corrected for future publicationandtranslation. T.HeatherHerdman,PhD,RN,FNI ShigemiKamitsuru,PhD,RN,FNI NANDAInternational,Inc. 4 Part1 TheNANDAInternationalTerminology– OrganizationandGeneralInformation 1 Introduction 2 What'sNewinthe2018–2020EditionofDiagnosesandClassification 3 ChangesandRevisions 4 GovernanceandOrganization 5 1 Introduction Part 1 presents introductory information on the new edition of the NANDA International Taxonomy, 2018–2020. This includes an overview of major changes to this edition: new and revised diagnoses, retired diagnoses, label changes, continued revision to standardize diagnostic indicator terms, and the introductionofassociatedconditionsandatriskpopulations. Those individuals and groups who submitted new or revised diagnoses that wereapprovedareidentified. Readerswillnotethatnearlyeverydiagnosishassomechanges,aswehave worked to increase the standardization of the terms used within our diagnostic indicators (defining characteristics, related factors, risk factors). Further, the adoption of at-risk populations and associated conditions was a pain-staking process,ledbyDr.ShigemiKamitsuru.Eachdiagnosiswasreviewedforrelated factorsorriskfactorsthatmetthedefinitionsoftheseterms. 6 2 What'sNewinthe2018–2020Editionof DiagnosesandClassification Changes have been made in this edition based on feedback from users, to addresstheneedsofbothstudentsandclinicians,aswellastoprovideadditional supporttoeducators.Newinformationhasbeenaddedonclinicalreasoning;all chapters are revised for this edition. There are corresponding internet-based presentations available for teachers and students that augment the information found within the chapters; icons appear in chapters that have these accompanyingsupporttools. 7 3 3.1 ChangesandRevisions ProcessesandProceduresforDiagnosis SubmissionandReview 3.1.1 NANDA-IDiagnosisSubmission:Review Process Proposed diagnoses and revisions of diagnoses undergo a systematic review to determine consistency with the established criteria for a nursing diagnosis. All submissionsaresubsequentlystagedaccordingtoevidencesupportingeitherthe levelofdevelopmentorvalidation. Diagnosesmaybesubmittedatvariouslevelsofdevelopment(e.g.,labeland definition; label, definition, defining characteristics, or risk factors; theoretical level for development, and clinical validation; or, label, definition, defining characteristics,andrelatedfactors). Thecurrentreviewprocessforacceptingnewandreviseddiagnosesintothe terminology is under review, as the organization strives to move to a stronger, evidence-basedprocess.Asnewrulesaredeveloped,thesewillbeavailableon theNANDA-Iwebsite(www.nanda.org). Information on the full review process and expedited review process for all newandreviseddiagnosissubmissionswillbeavailableoncetheprocessisfully articulatedandapprovedbytheNANDA-IBoardofDirectors. InformationregardingtheproceduretoappealaDDCdecisionondiagnosis review is also available on our website. This process explains the recourse availabletoasubmitterifasubmissionisnotaccepted. 3.1.2 NANDA-IDiagnosisSubmission:Levelof Evidence(LOE)Criteria The NANDA-I Education and Research Committee has been tasked to review andrevise,asappropriate,thesecriteriatobetterreflectthestateofthescience related to evidence-based nursing. Individuals interested in submitting a diagnosis are advised to refer to the NANDA-I website for updates, as they 8 becomeavailable(www.nanda.org). LOE1:ReceivedforDevelopment(ConsultationfromNANDA-I) LOE1.1:LabelOnly Thelabelisclear,statedatabasiclevel,andsupportedbyliteraturereferences, which are identified. NANDA-I will consult with the submitter and provide education related to diagnostic development through printed guidelines and workshops. At this stage, the label is categorized as “Received for Development”andidentifiedassuchontheNANDA-Iwebsite. LOE1.2:LabelandDefinition Thelabelisclearandstatedatabasiclevel.Thedefinitionisconsistentwiththe label.ThelabelanddefinitionaredistinctfromotherNANDA-Idiagnosesand definitions. The definition differs from the defining characteristics and label. Thesecomponentsarenotincludedinthedefinition.Atthisstage,thediagnosis must be consistent with the current NANDA-I definition of nursing diagnosis (see the “Glossary of Terms”). The label and definition are supported by literature references, which are identified. At this stage, the label and its definitionarecategorizedas“ReceivedforDevelopment”andidentifiedassuch ontheNANDA-Iwebsite. LOE1.3:TheoreticalLevel The definition, defining characteristics and related factors, or risk factors, are provided with theoretical references cited, if available. Expert opinion may be usedtosubstantiatetheneedforadiagnosis.Theintentionofdiagnosesreceived atthislevelistoenablediscussionoftheconcept,testingforclinicalusefulness and applicability, and to stimulate research. At this stage, the label and its component parts are categorized as “Received for Development and Clinical Validation,” and identified as such on the NANDA-I website and in a separate sectioninthisbook. LOE2:AcceptedforPublicationandInclusionintheNANDA-I Taxonomy LOE2.1:Label,Definition,DefiningCharacteristicsandRelated Factors,orRiskFactors,andReferences References are cited for the definition, each defining characteristic, and each relatedfactor,orriskfactor.Inaddition,itisrequiredthatnursingoutcomesand nursing interventions from a standardized nursing terminology (e.g., Nursing 9 OutcomesClassification[NOC],NursingInterventionsClassification[NIC])are providedforeachdiagnosis. LOE2.2:ConceptAnalysis The criteria in LOE 2.1 are met. In addition, a narrative review of relevant literature, culminating in a written concept analysis, is required to demonstrate theexistenceofasubstantivebodyofknowledgeunderlyingthediagnosis.The literaturereview/conceptanalysissupportsthelabelanddefinition,andincludes discussion and support of the defining characteristics and related factors (for problem-focused diagnoses), risk factors (for risk diagnoses), or defining characteristics(forhealthpromotiondiagnoses). LOE2.3:ConsensusStudiesRelatedtoDiagnosisUsingExperts ThecriteriainLOE2.1aremet.Studiesincludethosesolicitingexpertopinion, Delphi, and similar studies of diagnostic components in which nurses are the subjects. LOE3:ClinicallySupported(ValidationandTesting) LOE3.1:LiteratureSynthesis The criteria in LOE 2.2 are met. The synthesis is in the form of an integrated reviewoftheliterature.Searchterms/MeSH(MedicalSubjectHeadings)terms usedinthereviewareprovidedtoassistfutureresearchers. LOE3.2:ClinicalStudiesRelatedtoDiagnosis,butNot GeneralizabletothePopulation ThecriteriainLOE2.2aremet.Thenarrativeincludesadescriptionofstudies related to the diagnosis, which includes defining characteristics and related factors,orriskfactors.Studiesmaybequalitativeinnature,orquantitativeusing nonrandomsamples,inwhichpatientsaresubjects. LOE3.3:Well-DesignedClinicalStudieswithSmallSampleSizes ThecriteriainLOE2.2aremet.Thenarrativeincludesadescriptionofstudies related to the diagnosis, which includes defining characteristics and related factors,orriskfactors.Randomsamplingisusedinthesestudies,butthesample sizeislimited. LOE3.4:Well-DesignedClinicalStudieswithRandomSampleof SufficientSizetoAllowforGeneralizabilitytotheOverallPopulation 10 ThecriteriainLOE2.2aremet.Thenarrativeincludesadescriptionofstudies related to the diagnosis, which includes defining characteristics and related factors,orriskfactors.Randomsamplingisusedinthesestudies,andthesample sizeissufficienttoallowforgeneralizabilityofresultstotheoverallpopulation. 3.2 ChangestoDefinitionsofHealthPromotion Diagnoses The overall definition for a health promotion nursing diagnosis was changed duringthiscycle.Thischangereflectstherecognitionthattherearepopulations for whom health may be enhanced, with the nurse acting as an agent for the patients, even if the patients impacted are unable to verbalize intent (e.g., neonatalpatients,thosewithconditionspreventingverbalizationofdesire,etc.). Thereviseddefinitionisasfollows(newwordingitalicized). HealthPromotionDiagnosis A clinical judgment concerning motivation and desire to increase well-being andtoactualizehealthpotential.Theseresponsesareexpressedbyareadiness to enhance specific health behaviors, and can be used in any health state. In individuals who are unable to express their own readiness to enhance health behaviors,thenursemaydeterminethataconditionforhealthpromotionexists and act on the client’ s behalf. Health promotion responses may exist in an individual,family,group,orcommunity. 3.3 NewNursingDiagnoses Asignificantbodyofworkrepresentingnewandrevisednursingdiagnoseswas submitted to the NANDA-I Diagnosis Development Committee, with a significant number of those diagnoses being presented to the NANDA-I membershipforconsiderationduringthisreviewcycle.NANDA-Iwouldliketo takethisopportunitytocongratulatethosesubmitterswhosuccessfullymetthe levelofevidencecriteriawiththeirsubmissionsand/orrevisions.Seventeennew diagnoses were approved by the Diagnosis Development Committee, the NANDA-IBoardofDirectors,andtheNANDA-Imembership( Table3.1). 11 3.4 RevisedNursingDiagnoses Seventy-twodiagnoseswererevisedduringthiscycle. Table3.2showsthose diagnoses, highlights the revisions that were made for each of them, and identifiesthesubmitters/revisers. 3.5 RetiredNursingDiagnosis Eight diagnoses were removed from the terminology during this edition. One diagnosishadbeenslotted,inthe10thedition,toberetiredifitwasnotrevised. No revision occurred, so this diagnosis was therefore removed. We encourage pediatricnursestoconsiderreconceptualizationofthisdiagnosis,andtopresent ittoNANDA-Iasanewdiagnosis. Riskfordisproportionategrowth(00113),Domain13,Class1. Sevenremainingdiagnoseswereretiredfromtheterminology,afterreviewby theDiagnosisDevelopmentCommittee.Thesediagnoseswereinconsistentwith thecurrentliterature,orlackedsufficientevidencetosupporttheircontinuation withintheterminology. Table3.1NewNANDA-INursingDiagnoses,2018–2020 Approveddiagnosis(new) Submitter(s) Domain1:HealthPromotion Readinessforenhancedhealthliteracy Class1:Healthawareness B.Flores,PhD,RN,WHNP-BC Domain2:Nutrition Ineffectiveadolescenteatingdynamics Class1:Ingestion S.Mlynarczyk,PhD,RN;M.Dewys,PhD,RN;G. Lyte,PhD,RN Ineffectivechildeatingdynamics Class1:Ingestion S.Mlynarczyk,PhD,RN;M.Dewys,PhD,RN; G.Lyte,PhD,RN Ineffectiveinfanteatingdynamics Class1:Ingestion S.Mlynarczyk,PhD,RN;M.Dewys,PhD,RN; G.Lyte,PhD,RN Riskformetabolicimbalancesyndrome Class4:Metabolism V.E.Fernández-Ruiz,PhM;M.M.Lopez-Santos, PhM;D.Armero-Barranco,PhD;J.M.XandriGraupera,PhM;J.A.Paniagua-Urban,PhM;M. Solé-Agusti,PhM;M.D.Arrillo-Izquierdo,PhM;A. Ruiz-Sanchez,PhM Domain4:Activity/Rest Imbalancedenergyfield N.Frisch,PhD,RN,FAAN;H.Butcher,PhD,RN; 12 Class3:Energybalance D.Shields,PhD,RN,CCRN,AHN-BC,QTTT Riskforunstablebloodpressure Class4:Cardiovascular/pulmonaryresponses C.Amoin,DSN,MN,RN Domain9:Coping/stressTolerance Riskforcomplicatedimmigrationtransition Class1:Posttraumaresponses R.Rifa,RN,PhD Neonatalabstinencesyndrome Class3:Neurobehavioralstress L.M.Cleveland,PhD,RN,PNP-BC Acutesubstancewithdrawalsyndrome Class3:Neurobehavioralstress L.Clapp,RN,MS,CACIII;K.Mahler,RN,BSN Riskforacutesubstancewithdrawalsyndrome Class3:Neurobehavioralstress L.Clapp,RN,MS,CACIII;K.Mahler,RN,BSN Domain11:Safety/Protection Riskforsurgicalsiteinfection Class1:Infection F.F.Ercole,PhD,RN;T.C.M.Chianca,PhD,RN; C.Campos,MSN,RN;T.G.R.Macieira,BSN,RN; L.M.C.Franco,MSN Riskfordrymouth Class2:Physicalinjury I.Eser,PhD,RN(1);N.Duruk,PhD,RN(2) Riskforvenousthromboembolism Class2:Physicalinjury G.Meyer,PhD,RN,CNL Riskforfemalegenitalmutilation I.J.Ruiz,RN Class3:Violence Riskforoccupationalinjury Class4:Environmentalhazards F.Sanchez-Ayllon,PhD,RN Riskforineffectivethermoregulation Class6:Thermoregulation DiagnosisDevelopmentCommittee Noncompliance (00079), Domain1,Class 2. This diagnosis was quite old, withalastrevisionin1998.Itisnolongerconsistentwiththemajorityofcurrent researchinthearea,whichhasasitsfocustheconceptofadherenceratherthan compliance. Readinessforenhancedfluidbalance(00160),Domain2,Class5. Readinessforenhancedurinaryelimination(00166),Domain3,Class1. These diagnoses lacked sufficient evidence to support their continuation withintheterminology. Risk for impaired cardiovascular function (00239), Domain 4, Class 4. This diagnosis lacked sufficient differentiation from other cardiovascular diagnoseswithintheterminology. Riskforineffectivegastrointestinalperfusion(00202),Domain4,Class4. Riskforineffectiverenalperfusion(00203),Domain4,Class4. 13 These diagnoses were not found to be independently modifiable by nursing practice. Risk for imbalanced body temperature (00005), Domain 11, Class 6 – replaced by new diagnosis, Risk for ineffective thermoregulation (00274). Revisionstothisdiagnosisledtotherecognitionthattheconceptofinterestwas thermoregulation, and the definition and risk factors were consistent with the currentdiagnosis,ineffectivethermoregulation(00008).Therefore,thelabeland definitionwerechanged,leadingtotheneedtoretirethecurrentcodeandassign anewcode. 3.6 RevisionstoNursingDiagnosisLabels Changesweremadeto11nursingdiagnosislabels.Thesechangesweremadeto ensure that the diagnostic label was consistent with current literature, and reflectedahumanresponse.Thediagnosticlabelchangesareshownin Table 3.3. 14 15 16 17 Table3.3RevisionstonursingdiagnosislabelsofNANDA-Inursingdiagnoses,2018–2020 Domain Previousdiagnosticlabel Newdiagnosticlabel 1.Healthpromotion Deficientdiversionalactivity (00097) Decreaseddiversionalactivity engagement 2.Nutrition Insufficientbreastmilk(00216) Insufficientbreastmilkproduction 2.Nutrition Neonataljaundice(00194) Neonatalhyperbilirubinemia 2.Nutrition Riskforneonataljaundice(00230) Riskforhyperbilirubinemia 11.Safety/Protection Impairedoralmucousmembrane (00045) Impairedoralmucousmembrane integrity 11.Safety/Protection Riskforimpairedoralmucous membrane(00247) Riskforimpairedoralmucous membraneintegrity 11.Safety/Protection Riskforsuddeninfantdeath syndrome(00156) Riskforsuddeninfantdeath 11.Safety/Protection Riskfortrauma(00038) Riskforphysicaltrauma 11.Safety/Protection Riskforallergyresponse(00217) Riskforallergicreaction 11.Safety/Protection Latexallergyresponse(00041) Latexallergicreaction 11.Safety/Protection Riskforlatexallergyresponse (00042) Riskforlatexallergicreaction 3.7 StandardizationofDiagnosticIndicatorTerms For the past three cycles of this book, work has been underway to decrease variation in terms used for defining characteristics, related factors, and risk factors. This work was undertaken in earnest during the previous cycle of the book (10th edition), with several months being dedicated for the review, revision,andstandardizationoftermsbeingused.Thisinvolvedmanyhoursof 18 review, literature searches, discussion, and consultation with clinical experts in differentfields. The process used included individual review of assigned domains, followed by a second reviewer independently reviewing the current and newly recommended terms. The two reviewers then met—either in person or via webbased video conferencing—and reviewed each line a third time, together. Once consensus was reached, the third reviewer took the current and recommendedterms,andindependentlyreviewedthem.Anydiscrepancieswere discusseduntilconsensuswasreached.Aftertheentireprocesswas completed for every diagnosis—including new and revised diagnoses—a process of filtering for similar terms began. For example, every term with the stem “pulmo-” was searched, to ensure that consistency was maintained. Common phrases, such as verbalizes, reports, states, lack of, insufficient, inadequate, excess,etc.,werealsousedtofilter.Thisprocesscontinueduntiltheteamwas unabletofindadditionaltermsthathadnotpreviouslybeenreviewed. This work continued during this 11th cycle of the taxonomy. That said, we know the work is not done, it is not perfect, and there may be disagreements withsomeofthechangesthatweremade.However,wedobelievethesechanges continue to improve the diagnostic indicators, making them more clinically useful,andprovidingbetterdiagnosticsupport. Thebenefitsofthisaremany,butthefollowingareperhapsthemostnotable: – Translations should be improved. There have been multiple questions regardingpreviouseditionsthatweredifficulttoanswer.Someexamplesare thefollowing: – When you say lack in English, does that mean absenceof or insufficient? The answer is often, “Both!” Although the duality of this word is well acceptedinEnglish,thelackofclaritycreatesconfusionforclinicianswho are non-native English speakers, and it makes it very difficult to translate into languages in which a different word would be used depending on the intendedmeaning. – Is there a reason why some defining characteristics are noted in singular formandyetinanotherdiagnosis,thesamecharacteristicisnotedinplural form (e.g., absence of significant other(s), absence of significant other, absenceofsignificantothers)? – There are many terms that are similar or that are examples of other terms used in the terminology. For example, what is the difference between abnormalskincolor(e.g.,pale,dusky),colorchanges,cyanosis,pale,skin colorchanges,and slightcyanosis? Are the differences significant? Could 19 thesetermsbecombinedintoone?Someofthetranslationsarealmostthe same—forexample,abnormalskincolor,colorchanges,skincolorchanges —canweuseonesingletermormustwetranslatetheexactEnglishterm?It is truly important that translators “struggle” to ensure conceptual clarity whentranslatingtheterms—thereisadifferencebetweentheterms“dusky skin color” and “cyanotic skin color,” and this can impact one's clinical judgment. Decreasing the variation in these terms should simplify the translation process, as one term/phrase will be used throughout the terminology for similardiagnosticindicators. –Clarity for clinicians should be improved. It is confusing to students and practicing nurses alike when they see similar but slightly different terms in different diagnoses. Are they the same? Is there some subtle difference they donotunderstand?WhycannotNANDA-Ibemoreclear?Andwhataboutall ofthose“e.g.’s”intheterminology?Aretheytheretoteach,toclarify,tolist everypotentialexample?Thereseemstobeamixtureofpossiblereasonsfor theirappearanceintheterminology. Youwillnoticethatmanyofthe“e.g.’s”havebeenremoved,unlessitwasfelt thattheyweretrulyneededtoclarifyintent.“Teachingtips”thatwerepresent insomeparenthesesaregone,too—theterminologyisnottheplaceforthese. We have also done our best to condense terms and standardize them, wheneverpossible. – This work facilitates the coding of the diagnostic indicators, which should allow their use for populating assessment databases within electronic health records (EHR), and increase the availability of decision-support tools regardingaccuracyindiagnosisandlinkingdiagnosistoappropriatetreatment plans.AlltermsarenowcodedforuseinEHRsystems,whichissomething we have been asked to do repeatedly by many organizations and vendors alike. 3.8 IntroductionofAt-RiskPopulationsand AssociatedConditions Usersofthisbookwillnoticetheuseofthefollowingnewtermsastheyreview thediagnosticindicatorsformostdiagnoses:at-riskpopulationsandassociated conditions.Oneoftheissueswehaveoftenstruggledwithintheterminologyis a “laundry list” of related factors, many of which are not amenable to 20 independent nursing intervention. The issue has been that the data are helpful when diagnosing a patient, and it was decided that these data needed to be available to nurses as they considered potential nursing diagnoses. However, because we indicate that interventions should be aimed at related factors, this causedconfusionamongstudentsandpracticingnurses. Therefore, we have added two new terms in this edition to clearly indicate data which are helpful when making a diagnosis, even though they are not amenabletoindependentnursingintervention.Userswillnoticethatmanyofthe formerrelatedfactorsorriskfactorshavenowbeenrecategorizedintoeitheratrisk populations or associated conditions. The phrases were moved “as is,” meaning that no new conceptual work was completed on these phrases; this workwillneedtobeundertakeninthefuture. At-riskpopulationsaregroupsofpeoplewhoshareacharacteristicthatcauses each member to be susceptible to a particular human response, such as demographics,health/familyhistory,stagesofgrowth/development,orexposure tocertainevents/experiences. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmaceutical agents. These conditions are not independently modifiable by the professional nurse, but may support accuracy in nursing diagnosis. 21 4 4.1 GovernanceandOrganization InternationalConsiderationsontheUseofthe NANDA-INursingDiagnoses T.HeatherHerdman As we noted earlier, NANDA International, Inc. initially began as a North American organization and, therefore, the earliest nursing diagnoses were primarily developed by nurses from the United States and Canada. However, overthepast20to30years,therehasbeenanincreasinginvolvementbynurses from around the world, and membership in NANDA International, Inc. now includesnursesfromnearly40countries,withnearlytwo-thirdsofitsmembers coming from countries outside North America. Work is occurring across all continents using NANDA-I nursing diagnoses in curricula, clinical practice, research, and informatics applications. Development and refinement of diagnoses is ongoing across multiple countries, and the majority of research relatedtotheNANDA-InursingdiagnosesisoccurringoutsideNorthAmerica. As a reflection of this increased international activity, contribution, and utilization, the North American Nursing Diagnosis Association changed its scope to an international organization in 2002, changing its name to NANDA International,Inc.So,please,weaskthatyoudonotrefertotheorganization as the North American Nursing Diagnosis Association (or as the North American Nursing Diagnosis Association International), unless referring to something that happened prior to 2002—it simply does not reflect our international scope, and it is not the legal name of the organization. We retained “NANDA” within our name because of its status in the nursing profession,sothinkofitmoreasatrademarkorbrandnamethanasanacronym, sinceitnolonger“standsfor”theoriginalnameoftheassociation. As NANDA-I experiences increased worldwide adoption, issues related to differencesinthescopeofnursingpractice,diversityofnursepracticemodels, divergent laws and regulations, nurse competency, and educational differences 22 must be addressed. In 2009, NANDA-I held an International Think Tank Meeting, which included 86 individuals representing 16 countries. During that meeting, significant discussions occurred as to how best to handle these and otherissues.Nursesinsomecountriesarenotabletoutilizenursingdiagnosesof amorephysiologicnaturebecausetheyareinconflictwiththeircurrentscopeof nursingpractice.Nursesinothernationsarefacingregulationsaimedtoensure that everything done within nursing practice can be demonstrated to be evidence-based, and therefore face difficulties with some of the older nursing diagnoses and/or those linked interventions that are not supported by a strong level of research literature. Discussions were therefore held with international leaders in nursing diagnosis use and research, looking for direction that would meettheneedsoftheworldwidecommunity. Thesediscussionsresultedinaunanimousdecisiontomaintainthetaxonomy asanintactbodyofknowledgeinalllanguages,inordertoenablenursesaround the world to view, discuss, and consider diagnostic concepts being used by nurses within and outside of their countries, and to engage in discussions, research, and debate regarding the appropriateness of all of the diagnoses. A criticalstatementagreeduponinthatSummitisnotedherepriortointroducing thenursingdiagnosesthemselves: NoteverynursingdiagnosiswithintheNANDA-Itaxonomyisappropriatefor every nurse in practice—nor has it ever been. Some of the diagnoses are specialty-specific,andwouldnotnecessarilybeusedbyallnursesinclinical practice….Therearediagnoseswithinthetaxonomythatmaybeoutsidethe scopeorstandardsofnursingpracticegoverningaparticulargeographicarea inwhichanursepractices. Thosediagnoseswould,intheseinstances,notbeappropriateforpractice,and shouldnotbeusediftheylieoutsidethescopeorstandardsofnursingpractice foraparticulargeographicregion.However,itisappropriateforthesediagnoses to remain visible in the taxonomy, because the taxonomy represents clinical judgmentsmadebynursesaroundtheworld,notjustthosemadeinoneregion orcountry.Everynurseshouldbeawareof,andworkwithin,thestandardsand scopeofpracticeandanylawsorregulationswithinwhichhe/sheislicensedto practice.However,itisalsoimportantforallnursestobeawareoftheareasof nursingpracticethatexistglobally,asthisinformsdiscussionandmayovertime support the broadening of nursing practice across other countries. Conversely, these individuals may be able to provide evidence that would support the 23 removalofdiagnosesfromthecurrenttaxonomy,which,iftheywerenotshown intheirtranslations,wouldbeunlikelytooccur. That said, it is important that you are not avoiding the use of a diagnosis because, in the opinion of one local expert or published textbook, it is not appropriate. I have met nurse authors who indicate that operating room nurses “cannot diagnose because they don't assess,” or that intensive care unit nurses “have to practice under strict physician protocol that doesn't include nursing diagnosis.” Neither of these statements is factual, but rather represents the personal opinions of those nurses. It is, therefore, important to truly educate oneself on regulation, law, and professional standards of practice in one's own countryand areaofpractice,ratherthanrelyingonthewordofoneperson,or group of people, who may be inaccurately defining or describing nursing diagnosis. Ultimately,nursesmustidentifythosediagnosesthatareappropriatefortheir area of practice, that fit within their scope of practice or legal regulations, and for which they have competency. Nurse educators, clinical experts, and nurse administratorsarecriticaltoensuringthatnursesareawareofdiagnosesthatare truly outside the scope of nursing practice in a certain geographic region. Multiple textbooks in many languages are available that include the entire NANDA-I taxonomy, so for the NANDA-I text to remove diagnoses from countrytocountrywouldnodoubtleadtoagreatlevelofconfusionworldwide. Publication of the taxonomy in no way requires that a nurse utilize every diagnosis within it, nor does it justify practicing outside the scope of an individual'snursinglicenseorregulationstopractice. 4.2 NANDAInternationalPositionStatements From time to time, the NANDA International Board of Directors provides position statements as a result of requests from members or users of the NANDA-Itaxonomy.Currently,therearetwopositionstatements:oneaddresses theuseoftheNANDA-Itaxonomyasanassessmentframework,andtheother addresses the structure of the nursing diagnosis statement when included in a careplan.NANDA-Ipublishesthesestatementsinanattempttopreventothers from interpreting NANDA-I's stance on important issues, and to prevent misunderstandingsormisinterpretations. 4.2.1 NANDAINTERNATIONALPosition 24 StatementNumber1 TheUseofTaxonomyIIasanAssessmentFramework Nursing assessments provide the starting point for determining nursing diagnoses.Itisvitalthatarecognizednursingassessmentframeworkisusedin practicetoidentifythepatient's*problems,risks,andoutcomesforenhancing health. NANDAInternationaldoesnotendorseonesingleassessmentmethodortool. Theuseofanevidence-basednursingframework,suchasGordon'sfunctional healthpattern(FHP)assessment,shouldguideassessmentthatsupportsnurses indeterminationofNANDA-Inursingdiagnoses. For accurate determination of nursing diagnoses, a useful, evidence-based assessmentframeworkisthebestpractice. * NANDA International defines patient as “individual, family, group or community.” 4.2.2 NANDAINTERNATIONALPosition StatementNumber2 TheStructureoftheNursingDiagnosisStatementWhenIncludedina CarePlan NANDA International believes that the structure of a nursing diagnosis as a statement,includingthediagnosislabelandtherelatedfactorsasexhibitedby defining characteristics, is the best clinical practice, and may be an effective teachingstrategy. The accuracy of the nursing diagnosis is validated when a nurse is able to clearlyidentify andlinkto the definingcharacteristics,relatedfactors,and/or riskfactorsfoundwithinthepatient's*assessment. While this is recognized as best practice, it may be that some information systemsdonotprovidethisopportunity.Nurseleadersandnurseinformaticists mustworktogethertoensurethatvendorsolutionsare availablewhich allow the nurse to validate accurate diagnoses through clear identification of the 25 diagnosticstatement,relatedand/orriskfactors,anddefiningcharacteristics. * NANDA International defines patient as “individual, family, group or community.” 4.3 AnInvitationtoJoinNANDAInternational Words are powerful. They allow us to communicate ideas and experiences to others so that they may share our understanding. Nursing diagnoses are an example of a powerful and precise terminology that highlights and renders visible the unique contribution of nursing to global health. Nursing diagnoses communicate the professional judgments that nurses make every day—to our patients,ourcolleagues,membersofotherdisciplines,andthepublic.Theyare ourwords. 4.3.1 NANDAInternational:AMember-Driven Organization OurVision NANDA International, Inc. (NANDA-I) will be a global force for the development and use of nursing's standardized diagnostic terminology to improvethehealthcareofallpeople. OurMission Tofacilitatethedevelopment,refinement,dissemination,anduseofstandardized nursingdiagnosticterminology. – We provide the world's leading evidence-based nursing diagnoses for use in practiceandtodetermineinterventionsandoutcomes. –WefundresearchthroughtheNANDA-IFoundation. – We are a supportive and energetic global network of nurses who are committed to improving the quality of nursing care through evidence-based practice. OurPurpose Implementationofnursingdiagnosisenhanceseveryaspectofnursingpractice, from garnering professional respect to assuring accurate documentation for reimbursement. NANDAInternationalexiststodevelop,refine,andpromoteterminologythat 26 accurately reflects nurses’ clinical judgments. This unique, evidence-based perspectiveincludessocial,psychological,andspiritualdimensionsofcare. OurHistory NANDA International was originally named the North American Nursing Diagnosis Association (NANDA) and was founded in 1982. The organization grewoutoftheNationalConferenceGroup,ataskforceestablishedattheFirst National Conference on the Classification of Nursing Diagnoses, held in St. Louis,MO,UnitedStates,in1973.Thisconferenceandtheensuingtaskforce ignited interest in the concept of standardizing nursing terminology. In 2002, NANDA was relaunched as NANDA International to reflect increasing worldwide interest in the field of nursing terminology development. Although we no longer use the name “North American Nursing Diagnosis Association,” anditisnotappropriatetorefertotheorganizationbythisname(norisNorth American Nursing Diagnosis Association, International correct to use), unless quoting it prior to 2002, we did maintain “NANDA” as a brand name or trademarkwithinourname,becauseofitsinternationalrecognitionastheleader innursingdiagnosticterminology. As of this edition, NANDA-I has approved 244 diagnoses for clinical use, testing, and refinement. A dynamic, international process of diagnosis review and classification approves and updates terms and definitions for identified humanresponses. NANDA-I has international networks in Brazil, Colombia, Ecuador, Italy, Mexico, Nigeria–Ghana, Peru, and Portugal, as well as a German-language group; other country, specialty, and/or language groups interested in forming a NANDA-INetworkshouldcontacttheCEO/ExecutiveDirectorofNANDA-Iat [email protected]. NANDA-I also has collaborative links with nursing terminologysocietiesaroundtheworldsuchastheJapaneseSocietyofNursing Diagnosis (JSND), the Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACENDIO), the Asociacíon Española de Nomenclatura, Taxonomia y Diagnóstico de Enfermeria (AENTDE), the Association Francophone Européenne des Diagnostics Interventions Résultats Infirmiers (AFEDI), the Nursing Interventions Classification (NIC), and the NursingOutcomesClassification(NOC). NANDAInternational'sCommitment NANDA-I is a member-driven, grassroots organization committed to the development of nursing diagnostic terminology. The desired outcome of the association's work is to provide nurses at all levels and in all areas of practice 27 withastandardizednursingterminologywithwhichto: – Name actual or potential human responses to health problems, and life processes. – Develop, refine, and disseminate evidence-based terminology representing clinicaljudgmentsmadebyprofessionalnurses. – Facilitate study of the phenomena of concern to nurses for the purpose of improvingpatientcare,patientsafety,andpatientoutcomesforwhichnurses haveaccountability. –Documentcareforreimbursementofnursingservices. – Contribute to the development of informatics and information standards, ensuring the inclusion of nursing terminology in electronic health care records. Nursing terminology is the key to defining the future of nursing practice and ensuring the knowledge of nursing is represented in the patient record— NANDA-I is the global leader in this effort. Join us and become a part of this excitingprocess. InvolvementOpportunities The participation of NANDA-I members is critical to the growth and developmentofnursingterminology.Manyopportunitiesexistforparticipation oncommittees,aswellasinthedevelopment,use,andrefinementofdiagnoses, and in research. Opportunities also exist for international liaison work and networkingwithnursingleaders. 4.3.2 WhyJoinNANDA-I? ProfessionalNetworking –Professionalrelationshipsarebuiltthroughservingoncommittees,attending our various conferences, participation in the Nursing Diagnosis Discussion Forum,andreachingoutthroughtheOnlineMembershipDirectory. –NANDA-IMembershipNetworkGroupsconnectcolleagueswithinaspecific country,region,language,ornursingspecialty. – Professional contribution and achievement are recognized through our Founders,Mentors,UniqueContribution,andEditor'sAwards.Researchgrant awardsareofferedthroughtheNANDA-IFoundation. – Fellows are identified by NANDA-I as nursing leaders with standardized nursing language expertise in the areas of education, administration, clinical practice,informatics,andresearch. 28 Resources – Members receive a complimentary subscription to our online scientific journal, the International Journal of Nursing Knowledge (IJNK). IJNK communicates efforts to develop and implement standardized nursing languageacrosstheglobe. – The NANDA-I website offers resources for nursing diagnosis development, refinement, and submission, NANDA-I taxonomy updates, and an Online MembershipDirectory. MemberBenefits – Members receive discounts on English-language NANDA-I taxonomy publications, including print and electronic versions of NANDA-I Nursing DiagnosesandClassification. – We partner with organizations offering products/services of interest to the nursing community, with a price advantage for members. Member discounts applytoourbiennialconferenceandNANDA-Iproducts,suchasourT-shirts andtotebags. –OurRegularMembershipfeesarebasedontheWorldHealthOrganization's classificationofcountries.Itisourhopethiswillenablemoreindividualswith interestintheworkofNANDA-Itoparticipateinsettingthefuturedirection oftheorganization. HowtoJoin Go to www.nanda.org for more information and instructions for membership registration. 4.3.3 WhoIsUsingtheNANDAInternational Taxonomy? –InternationalStandardsOrganizationcompatible –HealthLevel7Internationalregistered –SNOMED-CTavailable –UnifiedMedicalLanguageSystemcompatible –AmericanNurses’Associationrecognizedterminology The NANDA-I taxonomy is currently available in Bahasa Indonesian, Basque, Chinese, Czech, Dutch, English, Estonian, French, German, Italian, Japanese, Portuguese,Spanish(EuropeanandHispanoamericaneditions),andSwedish. For more information, and to apply for membership online, please visit: 29 www.nanda.org. 30 Part2 TheTheoryBehindNANDAInternational NursingDiagnoses 5 NursingDiagnosisBasics 6 ClinicalReasoning:FromAssessmenttoDiagnosis 7 IntroductiontotheNANDAInternationalTaxonomyofNursingDiagnoses 8 SpecificationsandDefinitionsWithintheNANDAInternationalTaxonomyofNursingDiagnoses 9 FrequentlyAskedQuestions 10 GlossaryofTerms 31 5 NursingDiagnosisBasics SusanGallagher-Lepak 5.1 Introduction Healthcareisdeliveredbyvarioustypesofhealthcareprofessionals,including nurses, physicians, and physical therapists, to name just a few. This is true in hospitals as well as other settings across the continuum of care (e.g., clinics, homecare,long-termcare,churches,prisons).Eachhealthcaredisciplinebrings itsuniquebodyofknowledgetothecareoftheclient.Infact,auniquebodyof knowledgeisacriticalcharacteristicofaprofession. Collaboration, and at times overlap, occurs between professionals in providingcare( Fig.5.1).Forexample,aphysicianinahospitalsettingmay writeanorderfortheclienttowalktwiceperday.Physicaltherapyfocuseson coremusclesandmovementsnecessaryforwalking.Respiratorytherapymaybe involvedifoxygentherapyisusedtotreatarespiratorycondition.Nursinghasa holistic view of the patient, including balance and muscle strength related to walking, as well as confidence and motivation. Social work may be involved withinsurancecoveragefornecessaryequipment. Each health profession has a way to describe “what” the profession knows and“how” it acts on what it knows. This chapter is primarily focused on the “what.”Aprofessionmayhaveacommonlanguagethatisusedtodescribeand code its knowledge. Physicians treat diseases and use the International Classification of Disease (ICD) taxonomy to represent and code the medical problems they treat. Psychologists, psychiatrists, and other mental health professionalstreatmentalhealthdisorders,andusetheDiagnosticandStatistical Manual of Mental Disorders (DSM). Nurses treat human responses to health problems and/or life processes and use the NANDA International, Inc. (NANDA-I)nursingdiagnosistaxonomy.Thenursingdiagnosistaxonomy,and theprocessofdiagnosingusingthistaxonomy,willbedescribedfurther. 32 Fig.5.1Exampleofacollaborativehealthcareteam. TheNANDA-Itaxonomyprovidesawaytoclassifyandcategorizeareasof concerntothenursingprofessional(i.e.,diagnosticfoci).Itcontains244nursing diagnosesgroupedinto13domainsand47classes.AccordingtotheCambridge Dictionary On-Line (2017), a domain is “an area of interest;” examples of domains in the NANDA-I taxonomy include activity/rest, coping/stress tolerance,elimination/exchange,andnutrition.Domainsaredividedintoclasses, whicharegroupingsthatsharecommonattributes. Nurses deal with responses to health problems/life processes among individuals, families, groups, and communities. Such responses are the central concern of nursing care and fill the circle ascribed to nursing in Fig.5.1. A nursing diagnosis can be problem-focused, a state of health promotion, or a potentialrisk. –Problem-focuseddiagnosis—aclinicaljudgmentconcerninganundesirable humanresponsetoahealthcondition/lifeprocessthatexistsinanindividual, family,group,orcommunity – Risk diagnosis—a clinical judgment concerning the susceptibility of an individual,family,group,orcommunityfordevelopinganundesirablehuman responsetohealthconditions/lifeprocesses –Healthpromotiondiagnosis—aclinicaljudgmentconcerningmotivationand desiretoincreasewell-beingandtoactualizehealthpotential.Theseresponses areexpressedbyareadinesstoenhancespecifichealthbehaviors,andcanbe usedinanyhealthstate.Incaseswhereindividualsareunabletoexpresstheir 33 own readiness to enhance health behaviors, the nurse may determine that a condition for health promotion exists and then act on the client's behalf. Health promotion responses may exist in an individual, family, group, or community. Although limited in number in the NANDA-I taxonomy, a syndrome can be present. A syndrome is a clinical judgment concerning a specific cluster of nursingdiagnosesthatoccurtogether,andarethereforebestaddressedtogether and through similar interventions. An example of a syndrome diagnosis is chronicpainsyndrome(00255).Chronicpainisrecurrentorpersistentpainthat has lasted at least 3 months and that significantly affects daily functionings or well-being.Chronicpainsyndromeisdifferentiatedfromchronicpaininthat,in additiontothechronicpain,ithassignificantimpactonotherhumanresponses and thus includes other diagnoses, such as disturbed sleep pattern (00198), fatigue(00093),impairedphysicalmobility(00085),orsocialisolation(00053). 5.2 HowDoesaNurse(orNursingStudent) Diagnose? Thenursingprocessincludesassessment,nursingdiagnosis,planning,outcome setting, intervention, and evaluation ( Fig. 5.2). Nurses use assessment and clinical judgment to formulate hypotheses or explanations about presenting problems,risks,and/orhealthpromotionopportunities.Allofthesestepsrequire knowledge of underlying concepts of nursing science before patterns can be identifiedinclinicaldataoraccuratediagnosescanbemade. 34 Fig.5.2Themodifiednursingprocess.AdaptedfromHerdman2013. 5.3 UnderstandingNursingConcepts Knowledge of key concepts, or nursing diagnostic foci, is necessary before beginning an assessment. Examples of critical concepts important to nursing practiceincludebreathing,elimination,thermoregulation,physicalcomfort,selfcare, and skin integrity. Understanding such concepts allows the nurse to see patternsinthedataandaccuratelydiagnose.Keyareastounderstandwithinthe concept of pain, for example, include manifestations of pain, theories of pain, populations at risk, related pathophysiological concepts (fatigue, depression), andmanagementofpain.Fullunderstandingofkeyconceptsisneeded,aswell, to differentiate diagnoses. For example, to understand issues related to respiration, a nurse must first understand the core concepts of ventilation, gas exchange, and breathing pattern. In looking at problems that can occur with 35 regard to ventilation, the nurse will be faced with the diagnoses of impaired spontaneousventilation(00033)anddysfunctionalventilatoryweaningresponse (00034); concerns with gas exchange may lead the nurse to the diagnosis of impairedgasexchange(00030),whileissuesrelatedtobreathingpatternmight lead to a diagnosis of ineffective breathing pattern (00032). As you can see, althougheachofthesediagnosesisrelatedtotherespiratorysystem,theyarenot all concerned with the same core concept. Thus, the nurse may collect a significant amount of data, but without a sufficient understanding of the core conceptsofventilation,gasexchange,andbreathingpattern,thedataneededfor accuratediagnosismayhavebeenomittedandpatternsintheassessmentdatago unrecognized. 5.4 Assessment Assessment involves the collection of subjective and objective data (e.g., vital signs, patient/family interview, physical exam) and review of historical information provided by the patient/family, or found within the patient chart. Nursesalsocollectdataonpatient/familystrengths(toidentifyhealthpromotion opportunities) and risks (to prevent or postpone potential problems). Assessmentscanbebasedonaspecificnursingtheory,suchasonedevelopedby Florence Nightingale, Wanda Horta, or Sr. Callista Roy, or on a standardized assessment framework such as Marjory Gordon's Functional Health Patterns. These frameworks provide a way of categorizing large amounts of data into a manageablenumberofrelatedpatternsorcategoriesofdata. Thefoundationofnursingdiagnosisisclinicalreasoning.Clinicalreasoning involvestheuseofclinicaljudgmenttodecidewhatiswrongwithapatient,and clinical decision-making to decide what needs to be done (Levett-Jones et al 2010). Clinical judgment is “an interpretation or conclusion about a patient's needs,concerns,orhealthproblems,and/orthedecisiontotakeaction(ornot)” (Tanner2006,p.204).Keyissues,ordiagnosticfoci,maybeevidentearlyinthe assessment(e.g.,alteredskinintegrity,loneliness)andallowthenursetobegin the diagnostic process. For example, a patient may report pain and/or show agitation while holding a body part. The nurse will recognize the client's discomfort based on client report and/or pain behaviors. Expert nurses can quickly identify clusters of clinical cues from assessment data and seamlessly progresstonursingdiagnoses.Novicenursestakeamoresequentialprocessin determiningappropriatenursingdiagnoses. 36 Practice Reflection from a Nurse in the United States: As I went through nursingschool,wecreatednumerouscareplansthatwerebuiltaroundnursing diagnoses … On Day 1 of the clinical rotation, we reviewed our patient's chart,metwith,andassessedthepatient,andthendevelopedacareplanthat wewouldtheninitiateand/orcontinueonDay2. 5.5 NursingDiagnosis A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual,family,group,orcommunity(NANDA-I2013).Anursingdiagnosis typically contains two parts: (1) descriptor or modifier and (2) focus of the diagnosis or the key concept of the diagnosis ( Table 5.1). There are some exceptions in which a nursing diagnosis is only one word, such as anxiety (00146), constipation (00011), fatigue (00093), and nausea (00134). In these diagnoses,themodifierandfocusareinherentintheoneterm. Nurses diagnose health problems, risk states, and readiness for health promotion.Problem-focuseddiagnosesshouldnotbeviewedasmoreimportant than risk diagnoses. Sometimes a risk diagnosis can be the diagnosis with the highestpriorityforapatient.Anexamplemaybeapatientwhohasthenursing diagnosesof activityintolerance (00092), impairedmemory(00131),readiness for enhanced health management (00162), and risk for falls (00155), and has beennewlyadmittedtoaskillednursingfacility.Althoughactivityintolerance andimpairedmemory are the problem-focused diagnoses, the patient's riskfor falls may be the number one priority diagnosis, especially as the individual adjusts to a new environment. This may be especially true when related risk factors are identified in the assessment (e.g., poor vision, difficulty with gait, historyoffalls,anxietywithrelocation). Table5.1Partsofanursingdiagnosislabel Modifier Focusofthediagnosis Ineffective Breathingpattern Riskfor Constipation Deficient Fluidvolume Impaired Skinintegrity Readinessforenhanced Resilience 37 Each nursing diagnosis has a label and a clear definition. It is important to statethatmerelyhavingalabeloralistoflabelsisinsufficient.Itiscriticalthat nurses know the definitions of the diagnoses they most commonly use. In addition,theyneedtoknowthe“diagnosticindicators”—theinformationthatis usedtodiagnoseanddifferentiateonediagnosisfromanother.Thesediagnostic indicators include defining characteristics and related factors or risk factors ( Table5.2).Definingcharacteristics areobservable cues/inferencesthatcluster as manifestations of a diagnosis (e.g., signs or symptoms). An assessment that identifies the presence of a number of defining characteristics lends support to theaccuracyofthenursingdiagnosis.Relatedfactorsareanintegralcomponent of all problem-focused nursing diagnoses. Related factors are etiologies, circumstances,facts,orinfluencesthathavesometypeofrelationshipwiththe nursing diagnosis (e.g., cause, contributed factor). A review of client history oftenhelpstoidentifyrelatedfactors.Wheneverpossible,nursinginterventions should be aimed at these etiological factors in order to remove the underlying cause of the nursing diagnosis. Risk factors are influences that increase the vulnerability of an individual, family, group, or community to an unhealthy event(e.g.,environmental,psychological,genetic). Table5.2Keytermsataglance Term Briefdescription Nursingdiagnosis Problem,strength,orriskidentifiedforapatient, family,group,orcommunity Definingcharacteristic Signorsymptom(objectiveorsubjectivecues) Relatedfactor Causesorcontributingfactors(etiologicalfactors) Riskfactor Determinant(increaserisk) At-riskpopulations Groupsofpeoplewhoshareacharacteristicthat causeseachmembertobesusceptibletoaparticular humanresponse.Thesearecharacteristicsthatare notmodifiablebytheprofessionalnurse. Associatedconditions Medicaldiagnoses,injuryprocedures,medical devices,orpharmaceuticalagents.Theseconditions arenotindependentlymodifiablebythe professionalnurse. New to this edition of the Nursing Diagnosis: Definitions and Classifications book are the categories of at-risk populations and associated conditions within relevantnursingdiagnoses(see Table5.2).At-riskpopulationsaregroupsof individualswhosharecharacteristicsthatcauseeachmembertobesusceptible toaparticularhumanresponse.Forexample,individualsatextremesofageare 38 anat-riskpopulationthatshareagreatersusceptibilitytodeficientfluidvolume. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmaceutical agents. These conditions are not independently modifiablebyaprofessionalnurse.Examplesofassociatedconditionsincludea myocardial infarction, pharmaceutical agents, or surgical procedure. Data on both at-risk populations and associated conditions are important, are often collected during an assessment, and can help the nurse to consider potential diagnoses and confirm them. However, at-risk populations and associated conditions do not meet the intent of defining characteristics or related factors, because nurses cannot change or impact these categories independently. For furtherinformationonthis,seetheFrequentlyAskedQuestionssection(p.109) andtheinformationcontainedintheChangesandRevisionssection(p.4)ofthis book. Anursingdiagnosisdoesnotneedtocontainalltypesofdiagnosticindicators (i.e., defining characteristics, related factors, and/or risk factors). Problemfocused nursing diagnoses contain defining characteristics and related factors. Health promotion diagnoses generally have only defining characteristics, althoughrelatedfactorsmaybeusediftheymightimprovetheunderstandingof thediagnosis.Onlyriskdiagnoseshaveriskfactors. A common format used when learning nursing diagnosis includes _____ [nursing diagnosis] related to ______ [cause/related factors] as evidenced by ____________[symptoms/definingcharacteristics].Forexample,caregiverrole strain related to around-the-clock care responsibilities, complexity of care activities, and unstable health condition of the care receiver as evidenced by difficulty performing required tasks, preoccupation with care routine, fatigue, andalterationin sleeppattern. Depending on the electronic health record in a particular health care institution, the “related to” and “as evidenced by” componentsmaynotbeincludedwithintheelectronicsystem.Thisinformation, however,shouldberecognizedintheassessmentdatacollectedandrecordedin thepatientchartinordertoprovidesupportforthenursingdiagnosis.Without this information, it is impossible to verify diagnostic accuracy, which puts the qualityofnursingcareinquestion. PracticeReflectionfromaNurseintheUnitedStates:Nursingdiagnosesare used on the acute rehabilitation floor in a hospital where I work. Computerizedchartinginthenursingplansofcareismandatoryoneveryshift for every nurse. The electronic system contains 31 prepopulated nursing diagnoses available for the nurse to choose based on the patient assessment. 39 Thereareadditionalboxesthatareblankfornursestoinputotherdiagnoses. Examples of the prepopulated diagnoses include risk for falls, risk for infection,excessfluidvolume,andacutepain.Thenursethatinitiatesthecare plan must also fill in what the problem is related to, the goal, time frame, interventions,andoutcomes.Everyshiftthenurseresponsiblehastheoption toclickon“continueplanofcare,”“reviseplanofcare,”or“resolved.” 5.6 Planning/Intervention Once diagnoses are identified, prioritizing of selected nursing diagnoses must occur to determine care priorities. High-priority nursing diagnoses need to be identified (i.e., urgent need, diagnoses with high level of congruence with defining characteristics, related factors, or risk factors) so that care can be directedtoresolvetheseproblemsorlessentheseverityorriskofoccurrence(in thecaseofriskdiagnoses). Nursing diagnoses are used to identify intended outcomes of care and plan nursing-specific interventions sequentially. A nursing outcome refers to a measurable behavior or perception demonstrated by an individual, a family, a group, or a community that is responsive to nursing intervention (Center for Nursing Classification & Clinical Effectiveness [CNC], n.d.). The Nursing OutcomeClassification(NOC)isonesystemthatcanbeusedtoselectoutcome measures related to a nursing diagnosis. Nurses often, and incorrectly, move directlyfromnursingdiagnosistonursinginterventionwithoutconsiderationof desired outcomes. Instead, outcomes need to be identified before interventions are determined. The order of this process is similar to planning a road trip. Simplygettinginacaranddrivingwillgetapersonsomewhere,butthatmay notbetheplacethepersonreallywantedtogo.Itisbettertofirsthaveaclear location (outcome) in mind, and then choose a route (intervention), to get to a desiredlocation. An intervention is defined as “any treatment, based upon clinical judgment andknowledgethatanurseperformstoenhancepatient/clientoutcomes”(CNC, n.d.). The Nursing Interventions Classification (NIC) is one taxonomy of interventions that nurses may use across various care settings. Using nursing knowledge,nursesperformbothindependentandinterdisciplinaryinterventions. Theseinterdisciplinaryinterventionsoverlapwithcareprovidedbyotherhealth care professionals (e.g., physicians, respiratory and physical therapists). For example, blood glucose management is a concept important to nurses, risk for 40 unstable blood glucose (00179) is a nursing diagnosis, and nurses implement nursinginterventionstotreatthiscondition.Diabetesmellitus,incomparison,is a medical diagnosis, yet nurses provide both independent and interdisciplinary interventionstoclientswithdiabeteswhohavevarioustypesofproblemsorrisk states.RefertoKamitsuru'sTripartiteModelofNursingPractice(p.109). PracticeReflectionfromaNurseinBrazil:Nursingdiagnosesareusedinmy clinical setting, which is an adult ICU (intensive care unit) in a secondaryleveluniversityhospital.AnelectronicmedicalrecordsystemwithNANDANIC-NOClinkagesisusedtodocumentthenursingprocess.Theassessment starts with the input of patient data in standardized questionnaires, which generatesprepopulatedNANDA-Idiagnostichypothesesthatwillbevalidated oreliminatedbythenurse.Thereareadditionalboxesthatareblankfornurses to input other diagnoses. Some prepopulated diagnoses include ineffective protection; self-care deficit: bathing; ineffective tissue perfusion: cardiopulmonary; impaired gas exchange; risk for unstable blood glucose level; decreased cardiac output; and risk for infection. Next, the system generates possible NOC outcomes for each diagnosis and the nurse chooses theonethatismostrepresentativeofhis/heraims.Later,thesystemproposes NIC interventions and activities, for selection by the nurse as a care plan. Every shift the nursing diagnoses are re-evaluated as improved, worsened, unchanged,orresolved. 5.7 Evaluation Anursingdiagnosis“providesthebasisforselectionofnursinginterventionsto achieveoutcomesforwhichnursinghasaccountability”(NANDA-I2013).The nursing process is often described as a stepwise process, but in reality a nurse willgobackandforthbetweenstepsintheprocess.Nurseswillmovebetween assessmentandnursingdiagnosis,forexample,asadditionaldataarecollected andclusteredintomeaningfulpatternsandtheaccuracyofnursingdiagnosesis evaluated. Similarly, the effectiveness of interventions and achievement of identified outcomes is continuously evaluated as the client status is assessed. Evaluationshouldultimatelyoccurateachstepinthenursingprocess,aswellas once the plan of care has been implemented. Several questions to consider include the following: “What data might I have missed? Am I making an inappropriate judgment? How confident am I in this diagnosis? Do I need to 41 consult with someone with more experience? Have I confirmed the diagnosis with the patient/family/group/community? Are the outcomes established appropriate for this client in this setting, given the reality of the patient's condition and resources available? Are the interventions based on research evidenceortradition(e.g.,“whatwealwaysdo”)? 5.8 UseofNursingDiagnosis Thisdescriptionofnursingdiagnosisbasics,althoughaimedprimarilyatnursing students and beginning nurses learning nursing diagnosis, can benefit many nursesinthatithighlightscriticalstepsinusingnursingdiagnosisandprovides examplesofareasinwhichinaccuratediagnosingcanoccur.Anareathatneeds continuedemphasis,forexample,includestheprocessoflinkingknowledgeof underlying nursing concepts to assessment, and ultimately nursing diagnosis. The nurse's understanding of key concepts (or diagnostic foci) directs the assessment process and interpretation of assessment data. Relatedly, nurses diagnoseproblems,riskstates,andreadinessforhealthpromotion.Anyofthese types of diagnoses can be the priority diagnosis (or diagnoses), and the nurse makesthisclinicaljudgment. In representing knowledge of nursing science, the taxonomy provides the structure for a standardized language in which to communicate nursing diagnoses.UsingtheNANDA-Iterminology(thediagnosesthemselves),nurses cancommunicatewitheachotheraswellasprofessionalsfromotherhealthcare disciplinesabout“what”nursingisuniquely.Theuseofnursingdiagnosisinour patient/family interactions can help them to understand the issues on which nurseswillbefocusing,andcanengagethemintheirowncare.Theterminology providesasharedlanguagefornursestoaddresshealthproblems,riskstates,and readiness for health promotion. NANDA-I's nursing diagnoses are used internationally, with translation into nearly 20 languages. In an increasingly global and electronic world, NANDA-I also allows nurses involved in scholarship to communicate about phenomena of concern to nursing in manuscripts and at conferences in a standardized way, thus advancing the scienceofnursing. Nursing diagnoses are peer reviewed, and submitted for acceptance/revision toNANDA-Ibypracticingnurses,nurseeducators,andnurseresearchersaround theworld.Submissionsofnewdiagnosesand/orrevisionstoexistingdiagnoses havecontinuedtogrowinnumberoverthemorethan40yearsoftheNANDA-I 42 nursing diagnosis terminology. Continued submissions (and revisions) to NANDA-Iwillfurtherstrengthenthescope,extent,andsupportingevidenceof theterminology. 5.9 BriefChapterSummary This chapter describes types of nursing diagnoses (i.e., problem-focused, risk, health promotion, syndrome) and steps in the nursing process. The nursing processbeginswithanunderstandingofunderlyingconceptsofnursingscience. Assessment follows and involves collection and clustering of data into meaningfulpatterns.Nursingdiagnosis,asubsequentstepinthenursingprocess, involvesclinicaljudgmentaboutahumanresponsetoahealthconditionorlife process,orvulnerabilityforthatresponsebyanindividual,afamily,agroup,or acommunity.Thenursingdiagnosiscomponentswerereviewedinthischapter, includingthelabel,definition,anddiagnosticindicators(i.e.,relatedfactors,risk factors, at risk populations, and associated conditions). Given that a patient assessmentwilltypicallygenerateanumberofnursingdiagnoses,prioritization of nursing diagnoses is needed and this will direct care delivery. Critical next steps in the nursing process include identification of nursing outcomes and nursinginterventions.Evaluationoccursateachstepofthenursingprocessand atitsconclusion. 5.10 References AmericanPsychiatricAssociation.DiagnosticandStatisticalManualofMental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. Availableat:dsm.psychiatryonline.org Cambridge University Press. Cambridge Dictionary On-Line. Cambridge, UK: Cambridge University Press; 2017. Available at: http://dictionary.cambridge.org/dictionary/english/ CenterforNursingClassification&ClinicalEffectiveness(CNC),Universityof Iowa College of Nursing. N.d. Overview: Nursing Interventions Classification (NIC). Available at: www.nursing.uiowa.edu/cncce/nursinginterventions-classification-overview CenterforNursingClassification&ClinicalEffectiveness(CNC),Universityof Iowa College of Nursing. N.d. Overview: Nursing Outcome Classification 43 (NOC). Available at: www.nursing.uiowa.edu/cncce/nursing-outcomesclassification-overview Herdman TH. Manejo de casos empleando diagnósticos de enfermería de la NANDA Internacional [Case management using NANDA International nursingdiagnoses].XXXCongresoFEMAFEE2013.Monterrey,Mexico Levett-Jones T, Hoffman K, Dempsey J, et al. The “five rights” of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically “at risk” patients.. Nurse Educ Today. 2010; 30(6):515–520 NANDA International (NANDA-I). Nursing diagnosis definition. In: Herdman TH,KamitsuruS,eds.NANDAInternationalNursingDiagnoses:Definitions andClassification,2012–2014.Oxford:Wiley;2013:464 TannerCA.Thinkinglikeanurse:aresearch-basedmodelofclinicaljudgment innursing..JNursEduc.2006;45(6):204–211 44 6 ClinicalReasoning:FromAssessmentto Diagnosis T.HeatherHerdman 6.1 Introduction Clinical reasoning has been defined in a variety of ways within health disciplines. Koharchik et al (2015) indicate that it requires the application of ideasandexperiencetoarriveatavalidconclusion;innursing,itdescribesthe way a nurse “analyzes and understands a patient's situation and forms conclusions”(p.58).Tanner(2006)seesitastheprocessbywhichnursesmake clinical judgments by selecting from alternatives, weighing evidence, using intuitionandpatternrecognition.Similarly,Banning(2008)conductedaconcept analysisofclinicalreasoning,using71publicationsdatingfrom1964to2005. This study defined clinical reasoning as the application of knowledge and experience to a clinical situation, and identified the need for tools to measure clinicalreasoninginnursingpractice,sothatitmightbebetterunderstood. Itisimportanttonotethatconsideringclinicalreasoningasaprocessdoesnot signifythatitisastep-by-step,linearprocess.Rather,itoccursovertime,often across multiple patient/family encounters. This is especially true early in our careers, as we have yet to develop insight from enough patient situations to enablerapidpatternformationorproblemidentification. Whatdowemeanbypatternformation?Wearebasicallytalkingabouthow ourmindspulltogetheravarietyofdatapointstoformapictureofwhatweare seeing.Letusfirstlookatanonclinicalscenario. Assumeyouareoutforawalk,andyougopastagroupofmenseatedata picnic bench at a park. You notice that they are doing something with little rectangularobjects,andtheyarespeakinginveryloudvoices—someareeven shouting—astheyslamtheseobjectsonthetablebetweenthem.Themenseem veryintense,anditappearstheyarearguingabouttheseobjects,butyoucannot understandwhattheseobjectsareorwhatexactlythemenaredoingwiththem. Asyouslowdowntowatchthem,younoticeasmallcrowdhasgathered.Some 45 oftheseindividualsoccasionallynodtheirheadsorcommentinwhatseemsto be an encouraging manner, some seem concerned, and others appear to be as confusedbywhattheyarewatchingasyouare. Whatishappeninghere?Whatisitthatyouareobserving?Itmaybehardfor youtoarticulatewhatyouareseeingifitissomethingwithwhichyouhaveno experience. When we do not understand a concept, it is hard to move forward with our thinking process. Suppose that we told you that what you were observingwasmenplayingMahjong,atypeoftile-basedboardgame.Thetiles areusedlikecards,onlytheyaresmall,rectangularobjectstraditionallymadeof boneorbamboo.AlthoughyoumaynotknowanythingaboutMahjong,youcan understand the concept “game.” With this understanding, you might begin to lookatthesceneunfoldingbeforeyouinadifferentway.Youmightbegintosee thefourmenascompetitors,eachhopingtowinthegame,whichmightexplain theirintensity.Youmightbegintoconsidertheirraisedvoicesasaformofgoodnatured taunting of one another, rather than angry shouting. Once you understandtheconceptof“game,”youcanbegintopaintapictureinyourmind astowhatishappeninginthisscene,andyoucanbegintointerpretthedatayou are collecting (cues) in a way that makes sense within the context of a game. Without the “game” concept, though, you might continue the struggle to make senseofyourobservations. Thesameistruewithconceptsofimportanceinnursing.Manyauthorsfocus onthenursingprocess,withouttakingthetimetoensurethatweunderstandthe conceptsofnursingscience;yet,thenursingprocessbeginswith—andrequires —an understanding of these underlying concepts. If we do not understand our basic disciplinary concepts, we will struggle to identify patterns we see in our patients,families,andcommunities.Thus,itiscriticalthatwelearn(andteach) theseconceptssothatnursescanrecognizenormalhumanresponses,aswellas abnormal,risk,andhealthpromotionstatesrelatedtothoseresponses.Itisfairto say that applying the nursing process (assessment, diagnosis, outcome identification, intervention, and evaluation) is meaningless if we do not understandournursingconcepts(diagnoses)wellenoughtoidentifythemfrom thepatternsinthedatawecollectduringassessment. Withoutasolidgroundingintheconceptsofourdiscipline,wewillnotbegin to generate hypotheses regarding what is happening with our patients (their humanresponses,ornursingdiagnoses),norwillwehavedirectionintermsof conductingamorein-depthassessmenttoruleoutorconfirmthosehypotheses. Thus,althoughconceptualknowledgehasnotgenerallybeenincludedwithinthe nursingprocess,applyingthatprocessisimpossiblewithoutit. 46 Now, let us look at the idea of nursing concepts using a clinical scenario. Stacyisonherfirstclinicalplacementasanursingstudent,workingwithDavid, aregisterednurseinanindependent/assistedelderlylivingfacility.Ononeofher placementdays,Mrs.Randallstopsintoseethenurse.Sheis88yearsold,and hasonlylivedinthefacilityfortwoweeks.ShetellsDavidthatsheisfatigued and cannot concentrate. She is very concerned that there is something wrong withherheart.Davidbeginsbytakinghervitalsigns,butasheisdoingthis,he asks Mrs. Randall to tell him what has been happening in her life since she beganlivingatthefacility.Sheindicatesthatshehasnothadanythingunusual occur that she can identify, other than the move itself. She says this was her choicebecauseshedidnotfeelsafeinherhomeanymore.Shedeniesanychest pain,heartpalpitations,orshortnessofbreath.WhenDavidasksherwhysheis worried about her heart, she says, “Well, I'm old and that's what tends to go bad.” Davidasksherhowmuchexerciseshehasbeengetting,andifshehasbeen feelingatallstressedlately.Mrs.Randallindicatesthatshehasnotbeendoing any exercise since she moved here because she does not like group exercise classes,andthereisnoexerciseequipmentthatshecanuseonherown.Shehad previously used an exercise bike in her home at least 30 minutes per day. She notesitwashardtoleaveherneighborhoodbecauseshehadaverygoodfriend who lived near her and they saw each other every day. Now they only talk by phone.Althoughsheisgladshegetstotalkwithher,shesaysthatitisnotthe sameasenjoyingacupofteainthekitchenwithherfriend.Davidasksifher apartment is comfortable for her. She mentions it has large windows that give plentyofnaturalsunlight,whichshelikes,butnotesitisquitewarm;shelives on the third floor, and even when she turns the heat off, it is warmer than she likes. David tells Mrs. Randall that her vital signs are very good, but he suggests thatshemaybesufferingfromachangeinhersleeppattern,andsuggeststhat they try a few adjustments to see if that can impact her sleep and feelings of restfulness. First, he recommends that they speak with the environmental servicesdirectortogetherheatadjustedtoacomfortabletemperature.Healso tellsherthattherearesomeexercisebikesandtreadmillsinthebuilding,located on the assistedliving unit,butthatallresidentsmayusethematany time.He offerstoshowherwherethesearelocatedandtomakesuresheiscomfortable withhowtousethem,forwhichsheisgrateful.Finally,hetalkswithherabout connectingwiththedirectorofresidentlifetofindouthowshemightbeableto visitherfriend,orhaveherfriendcometothefacilitytoseehernewapartment. 47 StacyisamazedthatDavidalmostimmediatelyidentifiedapotentialproblem with Mrs. Randall. David draws Stacy's attention to the nursing diagnosis insomnia (00095), and she realizes that his assessment data are defining characteristicsandrelatedfactorsofthisdiagnosis.DavidtalkswithStacyabout the concept of sleep and the things that can impact it, such as stress (Mrs. Randall's recent move; lack of connection with her friend; being in a new apartment)andexternalfactors(anewenvironmentthatistoowarm),aswellas the impact that physical exercise can have on improving sleep. He quickly consideredthisnursingdiagnosisbecauseheunderstandsnormalsleeppatterns and could identify factors that contribute to a disturbance in a normal pattern. Further,becauseheunderstandsthatinsomniaiscausedbyexternalfactors,he identifiedprobableetiological(related)factors.Stacy,as anursingstudent,did not have the conceptual knowledge yet from which to draw; for her, this diagnosisdidnotseemobvious. This is the reason why studying concepts underlying diagnoses is so important. We cannot diagnose problems or risk situations if we do not first understand normal patterns of human response, nor can we consider health promotionopportunities. 6.2 TheNursingProcess Assessmentisperhapsthemostcriticalstepinthenursingprocess.Ifthisstepis not completed in a patient-centric manner, nurses will lose control over the subsequent steps of the nursing process. Without proper nursing assessment, there can be no patient-centered nursing diagnosis, and without an appropriate nursingdiagnosis,therecanbenoevidence-based,patient-centered,independent nursinginterventions.Assessmentshouldnotbeperformedtomerelyfillinthe blankspacesonaformorcomputerscreen.Ifthisformofroteassessmentrings abellforyou,itistimetotakeanewlookatthepurposeofassessment! 6.2.1 Assessment Duringtheassessmentanddiagnosisstepsofthenursingprocess,nurses collect data from a patient (or family/group/community), process data into information, and organize that information into meaningful categories of knowledge that represent the nursing discipline, also known as nursing diagnoses. Assessment provides the best opportunity for nurses to establish an effectivetherapeuticrelationshipwiththepatient.Inotherwords,assessmentis 48 bothanintellectualandaninterpersonalactivity. Whatisthepurposeofanursingassessment? Asyoucanseein Fig.6.1,assessmentinvolvesmultiplesteps,withthegoal being to develop diagnostic hypotheses, validate/refute these hypotheses to determine diagnoses, and prioritize these diagnoses, which then become the basisfornursingtreatment.Thisprobablysoundslikealong,involvedprocess and,frankly,whohastimeforallofthat?Intherealworld,however,thesesteps canhappenintheblinkofaneye,especiallyforexpertnurses.Forinstance,ifa nurseseesaneonatewhoisirritable,showingsignsofrespiratorydistress,andis unabletomaintainsucking,he/shemightimmediatelycheckatemperatureand, uponfindingitis36°C/96.8°F,he/shewouldthenconcludethattheneonateis experiencing hypothermia. Thus, the movement from data collection (observationoftheneonate'sbehavior)todeterminingpotentialdiagnoses(e.g., hypothermia)occursinamatterofminutes. However,thisquicklydetermineddiagnosismightnotbetherightone—orit may not be the highest priority for your patient. So, how do you accurately diagnose?Onlybystartingwithaccurateassessment—andtheproperuseofthe data collected during that assessment—can you ensure accuracy in diagnosis. This chapter provides foundational knowledge for what to do with all the data youhavecollected.Afterall,whybothercollectingthemifyouarenotgoingto usethem? In the next section, we will go through each of the steps in the process that takes us from assessment to diagnosis. But first, let us spend a few minutes discussing the purpose, because assessment is not simply a task that nurses complete. We need to understand its purpose so we can understand how it appliestoourprofessionalroleasnurses 6.2.2 WhyDoNursesAssess? Nurses need to assess patients from the viewpoint of the nursing discipline to diagnose accurately and to provide effective care. What is the “nursingdiscipline”?Simplyput,itisthebodyofknowledgethatcomprisesthe science of nursing. Nursing diagnoses provide standardized terms, with clear definitions and assessment criteria, that represent that knowledge—just as medical diagnoses represent the knowledge of the medical profession. Diagnosingapatientbasedonhis/hermedicaldiagnosisormedicalinformation, however,isneitherarecommendednorsafediagnosticprocess.Suchanoverly 49 simplifiedconclusioncouldleadtoinappropriateinterventions,prolongedlength ofstay,andunnecessaryreadmissions. Remember that nurses diagnose a human response to health conditions/life processes,oravulnerabilityforthatresponse,andthatdiagnosisthenprovides thebasisfortheselectionofnursinginterventionstoachieveoutcomesforwhich the nurse has accountability—the focus here is “human response.” Human beings are complicated—every human being does not respond to the same situationinthesameway.Ourresponsesarebasedonalotoffactors—genetics, physiology, health condition, past experiences with illness/injury. However, responsesarealsoinfluencedbythepatient'sculture,ethnicity,religion/spiritual beliefs,gender,andfamilyupbringing.Thismeansthathumanresponsesarenot so easily identified. If we simply assume that every patient with a medical diagnosiswillrespondinacertainway,wemaytreatconditions(andtherefore usethenurse'stimeandotherresources)thatdonotexist,whilemissingothers thattrulyneedourattention. Fig.6.1Stepsinmovingfromassessmenttodiagnosis. It is possible that there may be close relationships between some nursing diagnoses and medical conditions; however, to date we do not have sufficient scientific evidence to definitively link all nursing diagnoses to medical 50 diagnoses.Forinstance,thereisnowaytoknowwhetherapatienthasdeficient knowledge(00126),basedsolelyonanewmedicaldiagnosisorprocedure.The individualmighthaveanotherfamilymemberwiththatsamediagnosis,orwho previously underwent the same procedure. One can also not assume that every patient with a medical diagnosis will respond in the same way; every patient who is undergoing a surgical procedure is not necessarily experiencing anxiety (00146), for example. Therefore, nursing assessment and diagnosis should be approached from the viewpoint of the nursing discipline, and should only be madewhenbasedonapatient-centricassessment. Whatiswrongwiththisdiagnosticprocess? Unfortunately,inyourpractice,youwillprobablyobservenurseswhoassign,or “pick,”adiagnosisbeforetheyhaveassessedthepatient.Forexample,anurse maybegintocompleteaplanofcarebasedonthenursingdiagnosisofanxiety (00146) for a patient coming into an obstetrical unit for childbirth, before the patient has even arrived on the unit or been evaluated. Nurses working in obstetrics encounter many laboring patients, and those patients are often very anxious. Those nurses may know that labor coaching and deep breathing are effectiveinterventionsforreducinganxiety. Therefore,assumingarelationshipbetweenlaborandanxietycouldbeuseful in practice. However, the statement “laboring patients have anxiety” may not applytoeverypatient(itisahypothesis),andsoitmustbevalidatedwitheach patient. This is especially true because anxiety is a subjective experience— although we may think the patient seems anxious, or we may expect her to be anxious,onlyshecantellusifshefeelsanxious.Inotherwords,thenursecan understand how the patient feels only if the patient tells the nurse about her feelings; so, anxiety is a problem-focused nursing diagnosis that requires subjective data from the patient. What appears to be anxiety may actually be labor pain (00256) or ineffective childbearing process (00221); we simply cannot know until we assess and validate our findings. Thus, before nurses diagnose a patient, a thorough assessment is absolutely necessary. An understandingofpotential,high-frequencydiagnoses(thosethatoftenoccurina particular setting or with a particular patient population), however, is very helpful,astheknowledgeofthediagnosticcriteriarelatedtothosediagnosescan helpfocusthenurse's assessmentashe/she tries toruleoutorconfirmvarious diagnostichypotheses. 51 6.2.3 TheScreeningAssessment There are two types of assessment: screening and in-depth assessment. Both require data collection; however, they serve different purposes. The screeningassessmentistheinitialdatacollectionstepandisprobablytheeasiest tocomplete. NotSimplyaMatterofFillingintheBlanks Most schools and health care organizations provide nurses with a standardized form—on paperorintheelectronichealthrecord—thatmustbecompletedfor eachpatient,withinaspecifiedamountoftime.Forexample,patientswhoare admittedtothehospitalmayneedtohavethisassessmentcompletedwithin24 hours of admission. Patients seen in an ambulatory clinic may have a required assessmentpriortobeingseenbytheprimarycareprovider(e.g.,aphysicianor nurse practitioner). This initial assessment may include standardized screening tools, such as the Subjective Global Assessment (SGA) and/or the MiniNutritional Assessment (MNA) for assessing existing malnutrition and risk for malnutrition, respectively (Young et al 2013), or the Clinically Useful Depression Outcome Scale (CUDOS) for adult depression screening (Zimmerman et al 2008). There may be open-ended screening questions, such as:“Whocanyoutalktoifyouhaveadifficultsituationtohandle?”Andthere willbetoolsthatenablecompletionofanassessmentbasedonaspecificnursing theoryormodel(e.g.,Gordon'sfunctionalhealthpatterns[FHP]),bodysystem review,orsomeothermethodoforganizingthedatatobecollected. Theperformanceofascreeningassessmentrequiresspecificcompetenciesfor the accurate completion of various procedures to obtain data, and it requires a high level of skill in interpersonal communication. Patients must feel safe and trustthenursebeforetheywillfeelcomfortableansweringpersonalquestionsor providinganswers,especiallyiftheyfeeltheirresponsesmightnotbereceived asculturally/spiritually“normal”or“accepted.” We indicated that the initial screening assessment may be the easiest step because, in some ways, it is initially a process of “filling in the blanks.” The screening form might require information about the patient's vital signs, so the nurse obtains these and inputs those data into the assessment form. The form requires that information is collected about the patient's various physiologic systems, and the nurse fills in all the blank spaces on the form that deal with thesesystems(heartrhythm,presenceof amurmur,pedalpulses,lungsounds, bowelsounds,etc.),alongwithbasicpsychosocialandspiritualdata. However, good nursing assessment requires far more than this initial 52 screening. Obviously, when the nurse reviews data collected during his/her assessment and starts to recognize potential diagnoses, he/she will need to collect further data that can help him/her determine if there are other human responsesoccurringthatareofconcern,thatindicaterisksforthepatient,orthat suggesthealthpromotionopportunities.Thenursewillalsowanttoidentifythe etiologyorprecipitatingfactorsofareasofconcern.Itisquitepossiblethatthese in-depth questions are not included in the organization's assessment form, because there is simply no way to include every possible question that might needtobeaskedforeverypossiblehumanresponse! Knowledge of the concepts underlying the nursing discipline should drive thesemorein-depthquestions,basedontheresponsesofthepatient/familythat were obtained during the screening assessment. For example, if a patient indicated that she was experiencing difficulty with her breathing when she walkeduphersteps,thenursewouldrelyonhisknowledgeofvariousconcepts to further obtain data to confirm or refute potential diagnoses. If the nurse did not understand the concepts of activity tolerance, gas exchange, or energy balance,forexample,hemightnotknowwhatquestionstoasktocontinuethe assessmentandidentifyanappropriatediagnosis. 6.2.4 WhereDoNursesAssessandDiagnose? A brief point should be made about the role of professional nurses and assessment. Nurses work in a variety of settings—from primary care to hospitals,frommaternityunitstooperatingrooms.Regardlessofsettingorunit, professional nurses should always be assessing patients, considering diagnoses related to their needs, identifying relevant outcomes, and implementing interventions. Nursing diagnoses are used in operating rooms, ambulatory clinics, psychiatric facilities, home health, and hospice organizations, as well as in public health, school nursing, occupational health, and, of course, in hospitals. As diverse as nursing practice is, there are core diagnoses that seem to cross them all: acute pain (00132), anxiety (00146), deficient knowledge (00126), readinessforenhancedhealthmanagement(00162),forexample,canprobably befoundanywhereanursemightpractice.Forexample,nursesintheoperating roomassessanxietylevelsinpatients,aswellastheirskincondition.Aspatients are being prepared for surgery, those diagnosed with anxiety (00146) may be gently touched, eye contact may be established, soft music might be played, questions they have can be answered, and breathing techniques can be encouraged to help them relax. As a patient's skin is being prepped for the incision, turgor, edema, pressure points, and positioning will be considered to 53 decrease risk for impaired skin integrity (00047) and risk for perioperative positioninginjury(00087). Sometimesnursessuggestthatnursingdiagnosisisirrelevantincriticalcare units, because much of their practice is directed at medical diagnoses. This statementbasicallysuggeststhatnursesdonotpracticenursingincriticalcare— yet,wecertainlyknowthatisnotthecase.Thereisnoquestionthatcriticalcare nurses have a strong focus on interventions related to medical conditions, and often intervene with patients using “standing protocols” (standing medical orders)thatrequirecriticalthinkingtocorrectlyimplement.But,letusbeclear —nursesincriticalcareunitsneedtopracticenursing! Patients in critical condition are at risk for many complications that can be prevented by independent, professional nursing practice: ventilator-related pneumonias(riskforinfection,00004),pressureulcers(riskforpressureulcer, 00249), corneal injury (risk for corneal injury, 00245). They are often scared (fear,00148),andfamiliesarestressed,buttheyneedtoknowhowtocarefor their loved one when he/she comes home: deficientknowledge (00126), stress overload(00177),riskforcaregiverrolestrain(00162).Ifnursesonlyattendto theobviousmedicalcondition,they,astheadagesays,maywinthebattle,but still lose the war! These patients may develop sequelae that could have been avoided,thelengthofstaymaybeprolonged,ordischargehomecouldresultin untowardevents,andincreasedreadmissionrates.Docriticalcarenursesattend to medical conditions? Certainly! Should they also focus on the human responses?Absolutely! 6.2.5 AssessmentFramework Letustakeamomenttoconsiderthetypeofframeworkthatsupportsa thoroughnursingassessment.Anevidence-basedassessmentframeworkshould beusedforaccuratenursingdiagnosis,aswellassafepatientcare.Itshouldalso representthedisciplineoftheprofessionalusingit:inthiscase,theassessment formshouldrepresentknowledgefromthenursingdiscipline. ShouldweusetheNANDA-Itaxonomyasanassessmentframework? There is sometimes confusion over the difference between the NANDA International, Inc. (NANDA-I) Taxonomy II of nursing diagnoses and the functional health pattern (FHP) assessment framework (Gordon 1994). The NANDA-I taxonomy was developed based on Gordon's work; that is why the twoframeworkslooksimilar.However,theirpurposesandfunctionsareentirely 54 different. TheNANDA-Itaxonomyservesitsintendedpurposeofsorting/categorizing nursing diagnoses. Each domain and class is defined, so the framework helps nursestolocateanursingdiagnosiswithinthetaxonomy.Ontheotherhand,the FHP framework was scientifically developed to standardize the structure for nursing assessment (Gordon 1994). It guides the history-taking and physical examinationbynurses,providingitemstoassess,andastructurefororganizing assessment data. In addition, the sequence of 11 patterns provides an efficient andeffectiveflowforthenursingassessment. See Chapters 7 and 8 for more specific information on the NANDA-I taxonomy. AsstatedintheNANDA-IPositionStatement(2011),useofanevidence-based assessment framework, such as Gordon's FHP, is highly recommended for accurate nursing diagnosis and safe patient care. It is not intended that the NANDA-Itaxonomyshouldbeusedasanassessmentframework. 6.3 DataAnalysis Thesecondstepinthenursingprocessistheconversionofdatatoinformation. Itspurposeistohelpustoconsiderwhatthedatawecollectedinthescreening assessment might mean, or to help us identify additional data that need to be collected. The terms “information” and “data” are sometimes used interchangeably;however,theactualcharacteristicsofdataandinformationare quitedifferent.Inordertohaveabetterunderstandingofassessmentandnursing diagnosis,itisusefultotakeamomenttodifferentiatedatafrominformation. Data are the raw facts collected by nurses through their observations, and from subjective information provided by patients/families. Nurses collect data from a patient (or family/group/community), and then, using their nursing knowledge, they transform those data into information. Information can be considereddatawithanassignedjudgmentormeaning,suchas“high”or“low,” “normal”or“abnormal,”and“important”or“unimportant.” Fig.6.2provides an example of how objective and subjective data can be converted into information through the application of nursing knowledge in the case study of Mrs.E,a79-year-oldwomanwithacuteabdominalpain. We will follow her case from the initial screening assessment until we have 55 determinedwhichnursingdiagnosesarethemostappropriateonwhichtobase hercare. Fig.6.2Convertingdatatoinformation:ThecaseofMrs.E,a79-year-oldwomanwithsevere abdominalpain. It is important to note that the same data can be interpreted differently depending on the context, or the gathering of new data. For example, let us supposethatanurseinaschoolsettingisexaminingRoxanne,a9-year-old,after herfalloffherbicycleonthewaytoschool.Duringtheexam,thenurserealizes thatthescrapesandcutssufferedaresuperficial,andRoxanneratesherpainata 3onascaleof1to10,with10beingtheworstpainimaginable.However,the nurse is concerned by her breathing, which is rapid (rate of 40), shallow, and punctuated with occasional audible wheezes. The nurse listens to Roxanne's lungsandnoticesdiminishedbreathsoundstoherrightlowerlobe,andcrackles in her upper lobes. He/she takes Roxanne's temperature via the oral route, and 56 findsthatitiselevated,at37.7°C/99.9°F.Thesefactsaregivenmeaningby comparing them to accepted normal findings, as the nurse processes data into information.ThenurserealizesthatRoxannehasaslightfever,andpotentiallya respiratoryinfection.AfteraskingRoxannehowshehasbeenfeeling,Roxanne tellsthenursethatshehadbeenawayfromschoolforthreedaysearlierinthe weekwitha“badlungthing,”andwasonsomemedicationthathadmadeher feel a lot better. With this new piece of data, the nurse may conclude that Roxanne's condition is improving, but requires surveillance over the next few days. The nurse may want to check with Roxanne's parent(s) to obtain the medicaldiagnosisandprescriptioninformation,sothatmoredataareavailable whenconsideringappropriatenursingdiagnoses. It is therefore important to include both data and information when documenting assessment. Information cannot be validated by others if original dataarenotprovided.Forexample,simplyindicating“Roxannehadafeverand respiratory wheezes” is not clinically useful. How severe was the fever? How were data gathered (oral, axillary, core temperature)? What were her lung sounds, and were they the same bilaterally? Documentation that shows that Roxanne had a fever of 37.7 °C/99.9 °F, via the oral route, with diminished breath sounds to her right lower lobe and crackles in her upper right lobe, enablesanothernursetocomparenewdatacollectedagainstthepreviousdata, toidentifyifthepatientisimproving. 6.3.1 SubjectiveversusObjectiveData Whatisthedifferencebetweensubjectiveandobjectivedata? Nurses collect and document two types of data related to a patient: subjective and objective data. While physicians value objective over subjective data for medical diagnoses, nurses value both types of data for nursing diagnoses (Gordon2008).TheCambridgeDictionaryOn-Line(2017)definessubjectiveas “influenced by or based on personal beliefs or feelings, rather than based on facts”;objective means “not influenced by personal beliefs or feelings; fair or real.”Onethingyoushouldbecarefulofhereisthat,whenthesetermsareused inthecontextofnursingassessment,theyhaveaslightlydifferentmeaningfrom this general dictionary definition. Although the basic idea remains the same, “subjective”doesnotmeanthenurse’sbeliefsorfeelings,butthatofthesubject of nursing care: the patient/family/group/community. Moreover, “objective” signifiesthosefactsobservedbythenurseorotherhealthcareprofessionals. 57 Inotherwords,thesubjectivedatacomefromverbalreportsfromthepatient regarding perceptions and thoughts on his/her health, daily life, comfort, relationship,andsoon.Forinstance,apatientmayreport,“Ineedtomanagemy health better,” or “My partner never talks about anything important with me.” Familymembers/closefriendscanalsoprovidethistypeofdata,althoughdata fromthepatientshouldbeobtainedwheneverpossible,becauseitisthepatient's data.Sometimes,however,thepatientisunabletoprovidesubjectivedata,sowe must rely on these other sources. For example, in a patient with significant dementia who is no longer verbal, family members may provide subjective information,basedontheirknowledgeoftheindividual'sbehavior.Anexample mightbeanadultchildofthepatienttellingthenurse,“Shealwayslikestolisten tosoftmusicwhensheeats;itseemstocalmher.” Nurses collect these subjective data through the process of history-taking or interview. History-taking is not merely asking the patient one question after another, using a routine format. To obtain accurate data from a patient, nurses mustincorporateactivelisteningskills,anduseopen-endedquestionsasmuch as possible, especially as follow-up questions when potentially abnormal data areidentified. The objective data are those things that nurses observe about the patient. Objective data are collected through physical examinations and diagnostic test results.Here,“toobserve”doesnotonlymeantheuseofeyesight:itrequiresthe use of all senses. For example, nurses look at the patient's general appearance, listentohis/herlungsounds,theymaysmellfoulwounddrainage,andfeelthe skin temperature using touch. Additionally, nurses use various instruments and tools to collect numerical data (e.g., body weight, blood pressure, oxygen saturation, pain level). To obtain reliable and accurate objective data, nurses musthaveappropriateknowledgeandskillstoperformphysicalassessmentand tousestandardizedtoolsormonitoringdevices. Askyourself…doesthisdatasignifya: –Problem? –Strength? –Vulnerability? 6.3.2 ClusteringofInformation/SeeingaPattern Oncethenursehascollecteddataandtransformeditintoinformation,the next step is to begin to answer the question: what are my patient's human 58 responses (nursing diagnoses)? This requires the knowledge of a variety of theoriesandmodelsfromnursing,aswellasseveralrelateddisciplines.And,as previously noted, it requires knowledge about the concepts that underlie the nursing diagnoses themselves. Do you remember the modified nursing process diagramintroducedinChapter1( Fig.5.2)?Inthisdiagram,Herdman(2013) identifiestheimportanceoftheory/nursingscienceunderlyingnursingconcepts. Think,too,aboutourdiscussionofthemenplayingMahjong,andthedifficulty in understanding that scenario unless you knew you were observing a type of game(aconcept)( Fig.6.3). In other words, assessment techniques are meaningless if we do not know howtousethedata!IfthenursewhoassessedMrs.E,( Fig.6.2)didnotknow thenormalbodymassindex(BMI)rangesinthatagegroup,shewouldnothave beenabletointerpretthatpatient'sweightasbeingunderweight.Ifthenursedid not understand theories related to nutrition, bowel pattern, and pain, then she mightnothaveidentifiedothervulnerabilitiesorproblemresponsesexhibitedby thiselderlywoman. Fig.6.3Themodifiednursingprocess.(AdaptedfromHerdman2013.) 6.4 IdentifyingPotentialNursingDiagnoses 59 (DiagnosticHypotheses) At this step in the process, the nurse looks at the information that is coming togethertoformapattern;itprovidesthenursewithawaytoseewhathuman responses the patient may be experiencing. Initially, the nurse considers all potentialdiagnosesthatmaycometomind.Expertnursescandothisinseconds —novice or student nurses may ask for support from more expert nurses or facultymemberstoguidetheirthinking. Now that I’ve collected my assessment data and converted it into information, how do I know what’s important and what’s irrelevant for thisparticularpatient? Seeingpatternsinthedatarequiresanunderstandingoftheconceptthatsupports eachdiagnosis.Forexample,youmightfindyourselfworkingwithafamilythat includes a married couple in their mid-40 s, both of whom are employed full time outside the home, who are caring for a parent (Mr. W) with dementia, as wellastheirownthreechildren(ages9,14,and17years).OnyourvisittoMr. W,younoticeanincreaseinhisneedforassistanceforcaresinceyourlastvisit 28daysago.Hisson,John,tellsyouthathehasbeguntowander,andbecome physicallyaggressive.Healsoneedsmoreassistancewithdailyactivities,such as hygiene and feeding. The family lost its daytime caregiver 20 days ago because Mr. W had become physically resistant to her care and had struck her twice. Although she realized he did not intend to cause harm, Mr. W is much strongerthanthecaregiverandshefeltunsafeinthisenvironment.Johnhadto takealeaveofabsencefromhisworkuntilanewcaregivercanbefoundtocare forhim.HealsotellsyouthathehasbeguntorealizethatMr.Wbecomeshighly agitatedifheisleftaloneatall,sohefindsitdifficulttoleavehisroomtodo anything, and has been sleeping on a cot in his room. Previously, Mr. W had requiredminimalassistancewithreorienting,remindinghimtoeatandperform hygienetasks;heisnowrequiringnearlyaround-the-clockmonitoringandcare. Johnisclearlytired,andadmitshehasnotbeenabletogetmuchsleepbecause heisafraidhisfatherwillgetupandhurthimselfinthenight. Throughout your conversation with John, you observe that he seems frustratedandnervous,andhefrequentlyreferstonotbeingsureifheisdoing therightthingforMr.W.Heisclearlyveryconcernedabouthisfather,butalso mentions that he feels he has left his wife to be a “single mother” to their children, and that he has been unable to attend any of their extracurricular 60 activities, and even had to miss parent–teacher conferences. He notes that this hasbeenespeciallyhardonhisyoungestdaughter.Healsomentionsthatheis notsurehowlonghecanreasonablystayawayfromworkbeforeitbecomesan issuewithhisemployer. What does all of this tell you? Unless you have a good understanding of familydynamics,stress,coping,rolestrain,andgrieftheories,itmaynottellyou very much at all! You may know that Mr. W has increasing care needs. But would you know to also focus on the family, and look for a cause (related factors) or other data (defining characteristics) to determine an accurate diagnosisforJohn? AlthoughyoumightbeassignedtoMr.W,ifyouarenotattentivetowhatis happening in the family, are you truly attending to Mr. W's needs? Such a situation can lead to the nurse simply focusing on the patient of record, rather than considering the family and its impact on patient outcomes. Or, if you did realizetheneedtoaddresswhatishappeningwithJohn,butdidnothavegood baselineknowledgeofthetheoriesnotedpreviously,youmightsimply“picka diagnosis” from a list to describe his response. Conceptual knowledge of each nursing diagnosis allows the nurse to give accurate meanings to the data collected from the patient, and prepares him/her to perform the in-depth assessment. Whenyouhavethisconceptualknowledge,youwillbegintolookatthedata you collected in a different way. You will turn that data into information, and starttoobservehowthatinformationstartstogrouptogethertoformpatterns,or to“paintapicture”ofwhatmightbehappeningwithyourpatient.Takeanother look at Fig. 6.2. With conceptual nursing knowledge of nutrition, pain, and bowel function, you might begin to see the information as possible nursing diagnoses,suchasthefollowing: –Imbalancednutrition,lessthanbodyrequirements(00002) –Constipation(00011) –Dysfunctionalgastrointestinalmotility(00196) –Acutepain(00132) Unfortunately, this step is often where nurses stop—they develop a list of diagnoses and either launch directly into action (determining interventions) or simply “pick” one of the diagnoses that sound most appropriate, based on the diagnosislabel,andthenmoveontoselectinginterventionsforthosediagnoses. Others may determine that they wish to obtain a certain outcome, and simply aiminterventionsatthatoutcome.Theproblemwiththisapproachisthat,unless we know the problem and its cause, the interventions selected may be 61 completely inappropriate for this particular patient. Quite simply, these approaches are both ineffective and inappropriate courses of action! For diagnoses to be accurate, they must be validated—and that requires additional, in-depthassessmenttoconfirm,refute,or“ruleout”adiagnosis. Bycombiningnursingknowledgeandnursingdiagnosisknowledge,thenurse can now move from identifying potential diagnoses based on the screening assessment to an in-depth assessment, and then to determining the accurate nursingdiagnosis(es). 6.5 In-DepthAssessment At this stage in your patient's assessment, you should have reviewed the information resulting from the screening assessment, to determine which items werenormal,abnormal,orrepresentedarisk(susceptibility)orastrength.Those itemsthatwerenotconsiderednormal,orwereseenasasusceptibility,should havebeenconsideredinrelationtoaproblem-focusedorriskdiagnosis.Areasin which the patient indicated a desire to improve something (e.g., to enhance nutrition)shouldbeconsideredasapotentialhealthpromotiondiagnosis. If some data are interpreted as abnormal, further in-depth assessment is crucialtoaccuratelydiagnosethepatient.However,ifnursessimplycollectdata without paying much attention to them, critical data may be overlooked. Take anotherlookat Fig.6.2.Thenursecouldhavestoppedherassessmenthereand simplymovedontothediagnosesofacutepainandconstipation—perhapsthe two most “obvious” diagnoses for this patient. She could have provided educationaboutfiberandfluidintake,aswellastheimportanceofexerciseto maintainnormalbowelmovements,andcouldhaveaddressedtheacutepainby useofheatorcoldpacks,forexample.However,whileallthosethingsmightbe appropriate, she would have neglected to identify some major issues that are probablysignificantandthat,ifnotaddressed,willleadtocontinuedissueswith Mrs.E'sstatus. Mrs.E'snurse,however,understoodtheneedforanin-depthassessmentand was therefore able to identify the recent loss of her spouse, grief, and social isolation ( Fig. 6.4). The nurse learned that Mrs. E had vulnerabilities consistent with a stressful new living environment (recent move to the independent living facility, lack of transportation, lack of established relationships), and her fear of an acute illness and dying. However, she also identifiedthatMrs.Ehadastrengthinthesupportshereceivedfromherchurch 62 community,andherverbalizeddesiretoimprovethewayshewasrespondingto thissituation—veryimportantthingstobuildintoanyplanofcare!So,withthis additional in-depth assessment, the nurse could now revise her potential diagnoses: 63 Fig.6.4In-depthassessment:ThecaseofMrs.E,a79-year-oldwomanwithsevereabdominalpain. –Acutepain(00132) –Imbalancednutrition,lessthanbodyrequirements(00002) –Deficientfluidvolume(00027) –Constipation(00011) –Dysfunctionalgastrointestinalmotility(00196) –Grieving(00136) –Relocationstresssyndrome(00114) –Ineffectivecoping(00069) –Deathanxiety(00147) –Readinessforenhancedresilience(00212) 6.5.1 Confirming/RefutingPotentialNursing Diagnoses Whenever new data are collected and processed into information, it is time to reconsider previous potential or determined diagnoses. In this step, there are threeprimarythingstoconsider: –Didthein-depthassessmentprovidenewdatathatwouldruleoutoreliminate oneormoreofyourpotentialdiagnoses? – Did the in-depth assessment point toward new diagnoses that you had not 64 previouslyconsidered? –Howcanyoudifferentiatebetweensimilardiagnoses? It is also important to remember that other nurses will need to be able to continuetovalidatethediagnosisyoumake,andtounderstandhowyouarrived at your diagnosis. It is for this reason that it is important to use standardized terms,suchastheNANDA-Inursingdiagnoses,whichprovidenotonlyalabel (e.g., readiness for enhanced resilience), but also a definition and assessment criteria(definingcharacteristicsandrelatedfactors,orriskfactors)sothatother nursingprofessionalscancontinuetovalidate—orperhapsrefute—thediagnosis asnewdatabecomeavailableforthepatient.Termsthataresimplyconstructed by nurses at the bedside, without these validated definitions and assessment criteria, have no consistent meaning and cannot be clinically validated or confirmed.WhenaNANDA-Inursingdiagnosisdoesnotexistthatfitsapattern youidentifyinapatient,itissafertodescribetheconditionindetailratherthan to “make up” a term that will have different meanings to different nurses. Remember that patient safety depends on good communication—so use only standardizedtermsthathavecleardefinitionsandassessmentcriteriasothatthey canbeeasilyvalidated! 6.5.2 EliminatingPossibleDiagnoses Oneofthegoalsofin-depthassessmentistoeliminate,or“ruleout,”one or more of the potential diagnoses you were considering. You do this by reviewingtheinformationyou'veobtainedandcomparingittowhatyouknow aboutthediagnoses.Itiscriticalthattheassessmentdatasupportthediagnosis (es). WhenIlookatthepatientinformation –Isitconsistentwiththedefinitionofthepotentialdiagnosis? – Are the objective/subjective data identified in the patient defining characteristicsofthediagnosis? –Doesitincludecauses(relatedfactors)ofthepotentialdiagnosis? Diagnoses thatare not well supported through theassessmentcriteria provided byNANDA-I(definingcharacteristics,relatedfactors,orriskfactors)and/orare notsupportedbyetiologicalfactors(causesorcontributorstothediagnoses)are notappropriateforapatient. 65 As we look at Fig.6.4 and consider the potential diagnoses that Mrs. E's nurse identified, we can begin to eliminate some of these as valid diagnoses. Sometimes it is helpful to do a side-by-side comparison of the diagnoses, focusingonthosedefiningcharacteristicsandrelatedfactorsthatwereidentified throughouttheassessmentandpatienthistory( Table6.1). Forexample,afterreflection,Mrs.E'snursequicklyeliminatesthediagnosis, death anxiety, from consideration. Although Mrs. E does indicate that she is afraid that what happened to her husband might happen to her, the nurse considersthatthisismorerelatedtohergrievingthantoactualdreadofarealor imaginedthreattoherlife.Further,Mrs.Edoesnothaverelatedfactorsforthe diagnosis,deathanxiety,andinfactportraysstrengthsthatarequitecontraryto it! 6.5.3 PotentialNewDiagnoses Itisverypossible,suchasinthecaseofMrs.E( Fig.6.4),thatnewdata willleadtonewinformation,andinturn,tonewdiagnoses.Thesamequestions that you used to eliminate potential diagnoses should be used as you consider thesenewdiagnoses. 66 6.5.4 DifferentiatingbetweenSimilarDiagnoses It is helpful to narrow down your potential diagnoses by considering those that are very similar, but that have a distinctive feature that makes one more relevant to the patient than the other. Let us take another look at our patient, Mrs. E. After the in-depth assessment, the nurse had ten potential 67 diagnoses;onediagnosiswaseliminated,leavingninepotentialdiagnoses.One waytostarttheprocessofdifferentiationistolookatwherethediagnosesare located within the NANDA-I taxonomy. This gives you a clue about how the diagnoses are grouped together into the broad area of nursing knowledge (domain) and the subcategories, or group of diagnoses with similar attributes (class). AftereliminatingtheonediagnosisforwhichMrs.Ehadnorelatedfactors,a quick look at Table 6.1 shows her nurse is considering the following: two diagnoses in the nutrition domain (imbalanced nutrition, less than body requirements and deficient fluid volume); two in the elimination and exchange domain (constipation and dysfunctional gastrointestinal motility); four in the coping/stress domain (grieving, relocation stress syndrome, ineffective coping and readiness for enhanced resilience); and one in the comfort domain (acute pain). When I look at the patient information in light of similar nursing diagnoses: –Dothediagnosesshareasimilarfocus,orisitdifferent? –Ifthediagnosesshareasimilarfocus,isonemorefocused/specificthanthe other? –DoesonediagnosispotentiallyleadtoanotherthatIhaveidentified?That is,coulditbethecausativefactorofthatotherdiagnosis? As the nurse considers what she knows about Mrs. E, she can look at the responsesidentifiedaspotentialdiagnosesinlightofthesequestions.Mrs.Eis clearly dehydrated; however, it appears that her decrease in nutrition (imbalanced nutrition, less than body requirements) and hydration (deficient fluidvolume)andhersubsequentconstipationareactuallyconsequencesofher grievingandrelocationstresssyndromeresponses,ratherthanbeingspecifictoa lack of food/fluid or a gastrointestinal motility issue (dysfunctional gastrointestinalmotility).Therefore,althoughthenurseisconcernedaboutMrs. E'sfluidandfoodintake,andwillneedtotreatthesymptomofconstipation,she believesthattheseissuescanbebestaddressedinthelongtermbyaddressing her grieving and relocation stress syndrome, which the nurse believes are the underlyingcausesofhercurrenthealthstatus. After talking with Mrs. E, the nurse also believes that using the health promotiondiagnosisreadinessfor enhancedresilience, will best support herin 68 setting goals around her nutrition and fluid status, physical activity, and bowel elimination, while reinforcing her ability to regain control over her life and improvingherresilience. Of those diagnoses located in the coping/stress domain, all are within the same class (coping responses) except relocation stress syndrome (post-trauma responses).AlthoughMrs.Edoeshaverelatedfactorsforineffectivecoping,the nurse recognizes that Mrs. E has verbalized a desire to improve her resilience, andfeelsthatworkingwithheronthisissuefromahealthpromotionperspective (readinessforenhancedresilience)couldbemorepositiveforher.This,coupled withthepreviouslymentionedbeliefthatgoalsettingcouldbeusedwithinthis diagnosis to address the nutrition, fluid, and constipation issue, may make this diagnosismoreappropriateforMrs.E. Mrs.Eisclearlygrievingthe lossof herhusband ofnearly 60 years. While thisisanormalprocess,thenurseisconcernedthatshehasnotbeenattendingto her own basic needs. She feels it is imperative for Mrs. E to acknowledge her grief,andtoworkwithheronthisresponse.Thisdiagnosismaybemorecritical becauseMrs.Eisalsodealingwithrelocationstresssyndromeaftermovinginto anindependentlivingfacility. Finally,itisimportanttomanagetheacutepainthatMrs.Eisexperiencing. Because one of the goals is to get her more active to support normal bowel eliminationandtoassistwithoverallwell-being,itisimportanttoincreaseher comfort so that her pain does not prohibit her from increasing her level of activity. Athinkingtool( Fig.6.5)usedbyourcolleaguesinmedicinecanbeuseful asareviewpriortodeterminingyourfinaldiagnosis(es):itusestheacronym, SEATOW(Rencic2011).Thistoolcaneasilybeadaptedfornursingdiagnosis, too( ). Itisalwaysagoodideatoaskacolleague,oranexpert,forasecondopinion if you are unsure of the appropriate diagnosis. Is the diagnosis you are consideringtheresultofa“Eureka”moment?Didyourecognizeapatterninthe data from your assessment and patient interview? Did youconfirm this pattern byreviewingthediagnosticindicators(definingcharacteristics,relatedfactors)? Didyoucollectanti-evidence:datathatseemtorefutethisdiagnosis?Canyou justifythediagnosisevenwiththesedata,ordothesedatasuggestyouneedto lookdeeper?Thinkaboutyourthinking—wasitlogical, reasoned, and builton your knowledge of nursing science and the human response that you are diagnosing?Doyouneedadditionalinformationabouttheresponsebeforeyou arereadytoconfirmit?Areyouoverconfident?Thiscanhappenwhenyouare 69 accustomedtopatientspresentingwithparticulardiagnoses,andsoyou“jump” toadiagnosis,ratherthantrulyapplyingclinicalreasoningskills.Finally,what elsecouldbemissing?Arethereotherdatayouneedtocollectorreviewinorder tovalidate,confirm,orruleoutapotential nursing diagnosis? Use ofthe SEA TOW acronym can help you validate your clinical reasoning process and increasethelikelihoodofaccuratediagnosis. Fig.6.5SEATOW:Athinkingtoolfordiagnosticdecision-making.(AdaptedfromRencic2011.) 6.5.5 MakingaDiagnosis/Prioritizing The final step is to determine the diagnosis (es) that will drive nursing interventionforyourpatient.Afterreviewingeverythingthenurselearnedabout herpatient,Mrs.E,thenursemayhavedeterminedfourkeydiagnoses: –Acutepain(00132) –Grieving(00136) –Relocationstresssyndrome(00114) –Readinessforenhancedresilience(00212) Rememberthatthenursingprocess,whichincludesevaluationofthediagnosis, is an ongoing process and as more data become available, or as the patient's conditionchanges,thediagnosis(es)mayalsochange—ortheprioritizationmay change. Think back for a moment to the initial screening assessment the nurse performed on Mrs. E. Do you see that, without further follow-up, she would 70 have missed the very important diagnosis of grieving and relocation stress syndrome,alongwiththehealthpromotionopportunityforMrs.E(readinessfor enhanced resilience), and might have designed a plan to address issues that wouldnothaveresolvedherunderlyingissues? Can you see why the idea of just “picking” a nursing diagnosis to go along with the medical diagnosis simply isn't the way to go? The in-depth, ongoing assessmentprovidedsomuchmoreinformationaboutMrs.Ethatcanbeusedto determine not only the appropriate diagnoses, but also realistic outcomes and interventionsthatwillbestmeetherindividualneeds. 6.6 Summary Assessment plays a critical role in professional nursing and requires an understanding of nursing concepts based on which nursing diagnoses are developed.Collectingdataforthesakeofcompletingsomemandatoryformor computer screen is a waste of time, and it certainly does not support individualizedcareforourpatients.Collectingdatawiththeintentofidentifying critical information, considering nursing diagnoses, and then driving in-depth assessment to validate and prioritize diagnoses: this is the hallmark of professionalnursing. So, although it might seem simple, standardizing nursing diagnoses without assessment can, and often does, lead to inaccurate diagnoses, inappropriate outcomes, and ineffective and/or unnecessary interventions for diagnoses that are not relevant to the patient, and may lead to completely missing the most importantnursingdiagnosisforyourpatient! 6.7 References Banning M. Clinical reasoning and its application to nursing: concepts and researchstudies..NurseEducPract.2008;8(3):177–183 Bellinger G, Casstro D, Mills A. Date, Information, Knowledge, and Wisdom. Available at: otec.uoregon.edu/data-wisdom.htm. Accessed February 27, 2017. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden scale for predictingpressuresorerisk..NursRes.1987;36(4):205–210 Cambridge University Press. Cambridge Dictionary On-Line. Cambridge, UK: 71 Cambridge University Press; 2017. Available at: http://dictionary.cambridge.org/us/dictionary/english/subjective CentersforDiseaseControl&Prevention.AboutadultBMI.2015.Availableat: www.cdc.gov/healthyweight/assessing/bmi/adult_bmi GordonM.NursingDiagnosis:ProcessandApplication.3rded.St.Louis,MO: Mosby;1994 Gordon M. Assess Notes: Nursing Assessment and Diagnostic Reasoning. Philadelphia,PA:FADavis;2008 Herdman, T.H. Manejo de casos empleando diagnósticos de enfermería de la NANDA Internacional [Case management using NANDA International nursingdiagnoses].XXXCONGRESOFEMAFEE2013.Monterrey,Mexico KoharchikL,CaputiL,RobbM,CulleitonAL.Fosteringclinicalreasoningin nursing: how can instructors in practice settings impart this essential skill?. AmJNurs.2015;115(1):58–61 Merriam-Webster.com. Subjective. Merriam-Webster; n.d. Available at: www.merriam-webster.com/dictionary/subjective Oliver D, Britton M, Seed P, Martin FC, Hopper AH. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies.. BMJ. 1997;315(7115):1049–1053 Rencic J. Twelve tips forteaching expertise inclinical reasoning..Med Teach. 2011;33(11):887–892 Simmons B. Clinical reasoning: concept analysis.. J Adv Nurs. 2010; 66(5):1151–1158 TannerCA.Thinkinglikeanurse:aresearch-basedmodelofclinicaljudgment innursing..JNursEduc.2006;45(6):204–211 Young AM, Kidston S, Banks MD, Mudge AM, Isenring EA. Malnutrition screening tools: comparison against two validated nutrition assessment methodsinoldermedicalinpatients..Nutrition.2013;29(1):101–106 Zimmerman M, Chelminski I, McGlinchey JB, Posternak MA. A clinically usefuldepressionoutcomescale..ComprPsychiatry.2008;49(2):131–140 72 7 IntroductiontotheNANDAInternational TaxonomyofNursingDiagnoses T.HeatherHerdman 7.1 Introduction NANDA International, Inc. provides a standardized terminology of nursing diagnoses, and it presents its diagnoses in a classifications scheme, more specifically a taxonomy. It is important to understand a little bit about a taxonomy, and how taxonomy differs from terminology. So, let us take a momenttotalkaboutwhattaxonomyactuallyrepresents. A terminology is a system of specialized terms, whereas taxonomy is the science or technique that is used to create a system by which to classify those terms. Withregardtonursing,theNANDA-Inursingdiagnosisterminologyincludes thedefinedterms(labels)thatareusedtodescribeclinicaljudgmentsmadeby professional nurses: the diagnoses themselves. A definition of the NANDA-I taxonomymightbe“asystematicorderingofphenomena/clinicaljudgmentsthat definetheknowledgeofthenursingdiscipline.”Moresimplyput,theNANDA– Itaxonomyof nursing diagnosesisaclassificationschematohelpusorganize the concepts of concern (nursing judgments or nursing diagnoses) for nursing practice. Ataxonomyisawayofclassifyingororderingthingsintocategories;itisa hierarchical classification scheme of main groups, subgroups, and items. A taxonomycanbecomparedtoafilingcabinet—inadrawer(domain)youmay fileallinformationyouhaverelatedtoyourbills/debts.Withinthatdrawer,you may have individual file folders (classes) for different types of bills/debt: household,automobile,healthcare,childcare,animalcare,etc.Withineachfile folder (class), you would then have individual bills representing each type of debt(nursingdiagnoses).ThecurrentbiologicaltaxonomyoriginatedwithCarl Linnaeus in 1735. He originally identified three kingdoms (animal, plant, and mineral), which were then divided into classes, orders, families, genera, and 73 species (Quammen 2007). You probably learned about the revised biological taxonomyinabasicscienceclassinyourhighschooloruniversitysetting. Terminology, on the other hand, is the language that is used to describe a specific thing; it is the language used in a particular discipline to describe its knowledge. Therefore, the nursing diagnoses form a discipline-specific language, so when we want to talk about the diagnoses themselves, we are talking about the terminology of nursing knowledge. When we want to talk aboutthewaythatwestructureorcategorizetheNANDA-Idiagnoses,thenwe aretalkingaboutthetaxonomy. Letusthinkabouttaxonomyasitrelatestosomethingwealldealwithinour daily lives. When you need to buy food, you go to the grocery store. Suppose thatthereisanewstoreinyourneighborhood,ClassifiedGroceries,Inc.,soyou decidetogotheretodoyourshopping.Whenyouenterthestore,younoticethat thelayoutseemsverydifferentfromyourregularstore,butthepersongreeting youatthedoorhandsyouadiagramtohelpyoulearnyourwayaround( Fig. 7.1). You can see that this store has organized the grocery items into eight main categories or grocery store aisles: proteins, grain products, vegetables, fruits, processedfoods,snackfoods,delifoods,andbeverages.Thesecategories/aisles could also be called “domains”—they are broad levels of classification that divide phenomena into main groups. In this case, the phenomena represent “groceries.” You may also have noticed that the diagram does not just show the eight aisles; each aisle has a few key phrases identified that further help us to understandwhattypesoffoodswouldbefoundineachaisle.Forexample,inthe aisle(domain)entitled“Beverages,”weseesixsubcategories:“Coffee,”“Tea,” “Soda,” “Water,” “Beer/hard cider,” and “Wine/sake.” Another way of saying thiswouldbethatthesesubcategoriesare“Classes”ofproductsthatarefound underthe“Domain”ofbeverages. Oneoftherulespeople try to follow whentheydevelop ataxonomyisthat the classes should be mutually exclusive—in other words, one type of grocery productshouldnotbefoundinmultipleclasses.Thisisnotalwayspossible,but this should still be the goal, because it makes it much clearer for people who wanttousethestructure.Ifyoufindcheddarcheeseintheproteinaisle,butfind cheddar cheese spread in the snack foods aisle, it makes it hard for people to understandtheclassificationsystemthatisbeingused. Lookingbackatourstorediagram,thereisadditionalinformationtobeadded ( Fig.7.2). Each of the grocery aisles is further explained, providing a more 74 detailed level of information about the groceries that are found in the various aisles.Asanexample, Fig.7.2showsthedetailedinformationprovidedonthe “Beverages”aisle.Youwillnotethesix“classes”alongwithadditionaldetailfor each of those classes. These represent various types (or concepts) of beverage products,allofwhichsharesimilarpropertiesthatclusterthemtogetherintoone group. Fig.7.1DomainsandclassesofClassifiedGroceries,Inc. 75 Fig.7.2Classesandtypes(concepts)ofbeveragesatClassifiedGroceries,Inc. Given the information with which we have been provided, we could easily manage our shopping list. If we wanted to find some herbal soda, we would quicklybeabletofindtheaislemarked“Beverages,”theshelfmarked“Sodas,” andwecould confirmthat herbalsodas wouldbefoundthere.Likewise,ifwe wanted some loose leaf green tea, we would again look at the aisle marked “Beverages,”findtheshelfmarked“Tea,”andthenwewouldfind“Greenloose leafteas.” The purpose of this grocery taxonomy is to help the shopper quickly determine what section of the store contains the grocery supplies that he/she wantstobuy.Withoutthisinformation,theshopperwouldhavetowalkupand down each aisle and try to make sense of what products were in which aisle; dependingonthesizeofthestore,thiscouldbeaveryfrustratingandconfusing experience!Thus,thediagrambeingprovidedbythestorepersonnelprovidesa “conceptmap,”oraguideforshopperstoquicklyunderstandhowthegroceries havebeenclassifiedintolocationswithinthestore,withthegoalofimproving theshoppingexperience. Bynow,youareprobablygettingagoodideaofthedifficultyofdevelopinga taxonomythatreflectstheconceptsitistryingtoclassifyinaclear,concise,and consistentmanner.Thinkingaboutourgrocerystoreexample,canyouimagine 76 differentwaysthatitemsinthestorecouldbegroupedtogether? This example of a grocery taxonomy may not meet the goal of avoiding overlap between concepts and classes in a way that is logical for all shoppers. Forexample,tomatojuiceisfoundinthedomainVegetables(vegetablejuices), butnotinthedomainBeverages.Althoughonegroupofindividualsmightfind this categorization logical and clear, others might suggest that all beverages shouldbetogether.Whatisimportantisthatthedistinctionbetweenthedomains iswell-defined,i.e.,allvegetablesandvegetableproductsarefoundwithinthe vegetabledomain,whereasthebeveragedomaincontainsbeveragesthatarenot vegetable-based.Theproblemwiththisdistinctionmightbethatwecouldthen argue that wine and hard cider should be in the fruit aisle, and beer and sake shouldbeinthegrainsaisle! Taxonomiesareworksinprogress—theycontinuetogrow,evolve,andeven dramatically change as more knowledge is developed about the area of study. There is often significant debate about what structure is best for categorizing phenomena of concern to different disciplines. There are many ways of categorizingthings,andtruly,thereisno“absolutelyright”way.Thegoalisto findalogical,consistentwaytocategorizesimilarthingswhileavoidingoverlap between the concepts and the classes. For users of taxonomies, the goal is to understand how it classifies similar concepts into its domains and classes to quicklyidentifyspecificconceptsasneeded. 7.2 ClassificationinNursing Professions organize their formal knowledge into consistent, logical, conceptualizeddimensionssothatitreflectstheprofessionaldomainandmakes itrelevantforclinicalpractice.Forprofessionalsinhealthcare,theknowledge ofdiagnosisisasignificantpartofprofessionalknowledgeandisessentialfor clinicalpractice.Knowledgeofnursingdiagnosesmustthereforebeorganizedin awaythatlegitimizesprofessionalnursingpracticeandconsolidatesthenursing profession'sjurisdiction(Abbott1988). Within the NANDA-I nursing diagnostic taxonomy, we use a hierarchical graphictoshowourdomainsandclasses( Fig.7.3).Thediagnosesthemselves arenotdepictedinthisgraphic,althoughtheycouldbe.Theprimaryreasonwe donotincludethediagnosesisthatthereare244ofthem,andthatwouldmake thegraphicverylarge—andveryhardtoread! Classificationisawayofunderstandingrealitybynamingandorderingitems, 77 objects, and phenomena into categories (von Krogh 2011). In health care, classification systems denote disciplinary knowledge and demonstrate how a specific group of professionals perceive what are the significant areas of knowledgeofthediscipline.Therefore,aclassificationsysteminhealthcarehas multiplefunctions,includingto –provideaviewoftheknowledgeandpracticeareaofaspecificprofession. –organizephenomenainawaythatreferstochangesinhealth,processes,and mechanismsthatareofconcerntotheprofessional. – show the logical connection between factors that can be controlled or manipulatedbyprofessionalsinthediscipline(vonKrogh2011). In nursing, it is most important that the diagnoses are classified in a way that makessenseclinically,sothatwhenanurseistryingtoidentifyadiagnosisthat he/shemaynotseeveryofteninpractice,he/shecanlogicallyusethetaxonomy tofindtheappropriateinformationonpossiblerelateddiagnoses.Althoughthe NANDA-I Taxonomy II ( Fig. 7.3) is not intended to function as a nursing assessment framework, it does provide structure for classifying nursing diagnosesintodomainsandclasses,eachofwhichisclearlydefined. Toprovideanexampleofwhatitwouldlooklikeifweincludedthenursing diagnosesinthegraphicrepresentationofthetaxonomy, Fig. 7.4showsonly onedomainwithitsclassesandnursingdiagnoses.Asyoucansee,thisisalot ofinformationtodepictingraphicform. 78 Fig.7.3NANDA-ITaxonomyIIdomainsandclasses. 79 Fig.7.4NANDA-IDomain2,Nutrition,withclassesandnursingdiagnoses. Nursing knowledge includes individual, family, group, and community responses,risks,andstrengths.TheNANDA-Itaxonomyismeanttofunctionin thefollowingways;itshould –provideamodel,orcognitivemap,oftheknowledgeofthenursingdiscipline. –communicatethatknowledge,andthoseperspectivesandtheories. 80 –providestructureandorderforthatknowledge. –serveasasupporttoolforclinicalreasoning. –provideawaytoorganizenursingdiagnoseswithinanelectronichealthrecord (adaptedfromvonKrogh2011). 7.3 UsingtheNANDA-ITaxonomy Although the taxonomy provides a way of categorizing nursing phenomena, it can also serve other functions. It can help faculty to develop a nursing curriculum, for example, and it can help a nurse identify a diagnosis, perhaps one that he/she may not use frequently, but that he/she needs for a specific patient.Letuslookatbothsituations. 7.4 StructuringNursingCurricula Although the NANDA-I nursing taxonomy is not intended to be a nursing assessment framework, it can support the organization of undergraduate education. For example, curricula can be developed around the domains and classes, allowing courses to be taught that are based on the core concepts of nursingpractice,andwhicharecategorizedineachoftheNANDA-Idomains. AcoursemightbebuiltaroundtheNutritiondomain( Fig.7.4)withunits basedoneachoftheclasses.InUnit1,thefocuscouldbeoningestion,andthe conceptofbalancednutritionwouldbeexploredindepth.Whatisit?Howdoes itimpactindividualandfamilyhealth?Whataresomeofthecommonnutritionrelatedproblemsthatourpatientsencounter?Inwhattypesofpatientsmightwe be most likely to identify these conditions? What are the primary etiologies? Whataretheconsequencesiftheseconditionsgoundiagnosedand/oruntreated? How can we prevent, treat, and/or improve these conditions? How can we managethesymptoms? Building a nursing curriculum around these key concepts of nursing knowledge enables students to truly understand and build expertise in the knowledge of nursing science, while also learning about and understanding relatedmedicaldiagnosesandconditionswhichtheywillencounterineveryday practice. Designingnursingcoursesinthiswayenablesstudentstolearnalotaboutthe disciplinary knowledge of nursing. Eating patterns, feeding dynamics, 81 breastfeeding,balancednutrition,andeffectiveswallowingaresomeofthekey conceptsofDomain2,Nutrition( Fig.7.4)—theyarethe“neutralstates”that we must understand before we can identify potential or actual problems with theseresponses. Understandingbalancednutrition,forexample,asacoreconceptofnursing practice, requires a strong understanding of anatomy, physiology, pathophysiology (including related medical diagnoses), and responses from other domains that might coincide with problems in balanced nutrition. Once youtrulyunderstandtheconceptofbalancednutrition(the“normal”orneutral state),identifyingtheabnormalstateismucheasierbecauseyouknowwhatyou shouldbeseeingifnutritionwerebalanced,andifyoudon'tseethosedata,you starttosuspectthattheremightbeaproblem(orariskmayexistforaproblem todevelop).So,developingnursingcoursesaroundthesecoreconceptsenables nursingfacultytofocusontheknowledgeofthenursingdisciplineandthento incorporaterelatedmedicaldiagnosesand/orinterdisciplinaryconcernsinaway that allows nurses to focus first on nursing phenomena and then to bring their specificknowledgetoaninterdisciplinaryviewofthepatienttoimprovepatient care. This then moves into content on realistic patient outcomes and evidencebasedinterventionsthatnurseswillutilize(dependentandindependentnursing interventions) to provide the best possible care for the patient to achieve outcomesforwhichnurseshaveaccountability. 7.5 IdentifyingaNursingDiagnosisOutsideYour AreaofExpertise Nursesgainexpertiseinthosenursingdiagnosesthattheymostcommonlyseein theirclinicalpractice.Ifyourareaofinterestiscardiovascularnursingpractice, then your expertise may include such key concepts as activity tolerance, breathingpattern,andcardiacoutput,justtonameafew!Butyouwilldealwith patients who, despite being primarily in your care because of a cardiac event, willalsohaveotherissuesthatrequireyourattention.TheNANDA-Itaxonomy canhelpyoutoidentifypotentialdiagnosesforthesepatientsandsupportyour clinicalreasoningskillsbyclarifyingwhatassessmentdata/diagnosticindicators arenecessaryforquickly,butaccurately,diagnosingyourpatients. Perhaps, as you are admitting a 45-year old female patient for an inguinal herniarepair,youdiscoverthatshehassignificantrheumatoidarthritis(RA)and severalcardiacriskfactors.Yourpatienttellsyouherpainisnormallybetween5 82 and 6 on a 10-point scale, and she rates it at a 6 today; she has obvious rheumatoidnodulesandedemainherhandsandwrists.Sheisacurrentsmoker, describesherphysicalactivitylevelasminimal,andherBMI(bodymassindex) is 27.6. She has a history of hypertension and arrhythmia, although today her blood pressure seems well controlled by her antihypertensive medication, and youdetectnoarrhythmia. YouhavenotcaredformanypatientswithRA,soyoureviewtheimplications of RA on cardiovascular risk, and find that it is concerning; RA patients have higher cardiovascular morbidity and mortality than the general public. As you reviewtheresearch,yourealizethattheinflammatoryburdenandantirheumatic medication–related cardiotoxicity are important contributors to cardiovascular risk.Youwanttoreflectherrisk,butyouarenotsurewhichnursingdiagnosisis themostaccurateforthispatientinthissituation.Bylookingatthetaxonomy, you can quickly form a “cognitive map” that can help you to find more informationondiagnosesofrelevancetothispatient( Fig.7.5). Youareconcernedaboutacardiovascularresponse,andaquickreviewofthe taxonomy leads you to Domain 4 (activity/rest), Class 4 (cardiovascular/pulmonary responses). You then see that there are three diagnoses specifically related to cardiovascular responses, and you can review the definitions, etiologies, and diagnostic indicators to clarify the most appropriatediagnosisforthispatient.Usingthetaxonomyinthiswaysupports clinical reasoning and helps you to navigate a large volume of information/knowledge(244diagnoses!)inaneffectiveandefficientmanner.A review of the risk factors or the related factors and defining characteristics of thesethreediagnosescan:(1)provideyouwithadditionaldatathatyouneedto obtaininordertomakeaninformeddecisionand/or(2)enableyoutocompare your assessment with those diagnostic indicators to accurately diagnose your patient. 83 Fig.7.5UseoftheNANDA-ITaxonomytoidentifyandvalidateanursingdiagnosisoutsidethe nurse'sareaofexpertise. Think about a recent patient—did you struggle to diagnose his/her human response?Didyoufinditdifficulttoknowhowtoidentifypotentialdiagnoses? Usingthetaxonomycansupportyouinidentifyingpossiblediagnosesbecause of the way the diagnoses are grouped together in classes and domains that represent specific areas of knowledge. Do not forget, however, that simply lookingatthediagnosislabeland“pickingadiagnosis”isnotsafecare!You needtoreviewthedefinitionanddiagnosticindicators(definingcharacteristics, relatedfactors,orriskfactors)foreachofthepotentialdiagnosesyouidentify, whichwillhelpyoutoidentifywhatadditionaldatayoushouldcollectorifyou haveenoughdatatoaccuratelydiagnosethepatient'shumanresponse. LetusreviewthecasestudyofMr.Stounderstandhowyoumightusethe taxonomytohelpyoutoidentifypotentialdiagnoses. CaseStudy:Mr.S Letussupposethatyourpatient,Mr.S,an87-year-oldwidower,presentswith 84 complaintsofsevere,shootingpaininhisrighthiparea.Hehasbeenlivingin an assisted living facility for two years, since his wife died, and the staff memberstherehavenoticedthatheisveryagitatedandshowssignsofsevere painwhenevertheytrytohelphimwalk.Theyhavebroughthimintoruleout anypossiblefractureorneedforahipreplacement.Theynotethathehadhis other hip replaced three years ago, due to osteoporosis. Apparently, the surgerywasverysuccessful. Mr. S has no noticeable edema or bruising to his right hip area, but clearly complains of pain when you palpate the area. He has good lower extremity bilateral peripheral pulses and a lower extremity capillary refill time of 4 seconds.Hismedicalhistoryincludesacerebrovascularattack(stroke)atage 80.Accordingtohismedicalrecords,hehadinitialparalysisontherightside and lost all speech function. He received alteplase IV r-tPA, a tissue plasminogenactivator(TPA),andrecoveredfullmobilityandspeech.Hewas inaninpatientrehabilitationcenterfor26days,receivedspeech,physicaland occupational therapy, and cared for himself independently after he was dischargedhome.Hehasmoderatecoronaryarterydisease,butotherwiseno significantmedicalhistory.Accordingtothestaffmemberaccompanyinghim, Mr.Shasbeenactiveuntilafewweeksagowhenhestartedtocomplainof pain.Heenjoyedballroomdancing,exercisedatthefacilityonaregularbasis, andwasfrequentlyseenwalkingaroundthecomplexspeakingtopeople,or takingwalksoutdoorsonthegroundsofthecomplexwhentheweatherwas nice. She also indicates he has become less social recently, and has not attended different activities that he normally enjoys. She indicates the staff membershaveattributedthistohislevelofdiscomfort. WhatyounoticemostaboutMr.S,however,isthatheseemswithdrawn,he barely speaks, and rarely makes eye contact. He struggles to answer your questions,andthestaffmemberoftenjumpsintoprovideanswersratherthan allowinghimtoanswerforhimself.Althoughhisspeechdoesnotappeartobe impaired,heseemstobestrugglingtofindanswerstoevenbasicquestions, suchashisageortheyearthathiswifedied. Aftercompletingyourassessmentandreviewinghishistory,youbelievethat Mr.Smaybedealingwithanissuerelatedtocognition,butthisisanareaof nursing in which you have little experience; you need some review of potentialdiagnoses.Sinceyouareconsideringacognitionissue,youlookat the NANDA-I taxonomy to identify the logical location of these diagnoses. 85 You identify that Domain 5, Perception/cognition, deals with the human information processing system including attention, orientation, sensation, perception, cognition, and communication. Because you are considering issues related to cognition, you think this domain will contain diagnoses of relevancetoMr.S.YouthenquicklyidentifyClass4,Cognition.Areviewof this class leads to the identification of three potential diagnoses: acute confusion,chronicconfusion,andimpairedmemory. Questions you should ask yourself include: What other human responses should I rule out or consider? What other signs/symptoms, or etiologies, shouldIlookfortoconfirmthisdiagnosis? Once you review the definitions and diagnostic indicators (related factors, defining characteristics, and risk factors), you diagnose Mr. S with chronic confusion(00129). Some final questions should include: Am I missing anything? Am I diagnosingwithoutsufficientevidence?Ifyoubelieveyouarecorrectinyour diagnosis, your questions move on to: What outcomes can I realistically expect to achieve with Mr. S? What are the evidence-based nursing interventionsthatIshouldconsider?HowwillIevaluatewhetherornotthey wereeffective? 7.6 TheNANDA-INursingDiagnosisTaxonomy:A ShortHistory In 1987, NANDA-I published Taxonomy I, which was structured to reflect nursing theoretical models from North America. In 2002, Taxonomy II was adopted, which was adapted from the Functional Health Patterns assessment frameworkofDr.MarjoryGordon.Thisassessmentframeworkisprobablythe mostusednursingassessmentframeworkaroundtheworld.Overthecourseof thelastthreeyears,NANDA-Imembersandusersconsideredwhethertoreplace TaxonomyIIwitharecommendationforTaxonomyIII,developedbyDr.Gunn von Krogh (discussed in detail in the 10th edition of this text). In 2016, this taxonomywasbroughtforwardtothemembershipofNANDA-Itodetermineif the organization should maintain Taxonomy II or possibly move to this new view and adopt a Taxonomy III. After reflection, study, and discussion, the 86 overwhelming decision of the membership was to retain Taxonomy II. Work may continue on Taxonomy III, and it could return to the membership for reconsiderationatalaterdate. Table 7.1 demonstrates the domains, classes, and nursing diagnoses and howtheyarecurrentlylocatedwithintheNANDA-ITaxonomyII. Table7.1Domains,classes,andnursingdiagnosesintheNANDA-ITaxonomyII Code Diagnosis Domain1. Healthpromotion Theawarenessofwell-beingornormalityoffunctionand thestrategiesusedtomaintaincontrolofandenhancethat well-beingornormalityoffunction Class1. Healthawareness Recognitionofnormalfunctionandwell-being 00097 Decreaseddiversionalactivityengagement 00262 Readinessforenhancedhealthliteracy 00168 Sedentarylifestyle Class2. Healthmanagement Identifying,controlling,performing,andintegrating activitiestomaintainhealthandwell-being 00230 Frailelderlysyndrome 00231 Riskforfrailelderlysyndrome 00215 Deficientcommunityhealth 00188 Risk-pronehealthbehavior 00099 Ineffectivehealthmaintenance 00078 Ineffectivehealthmanagement 00162 Readinessforenhancedhealthmanagement 00080 Ineffectivefamilyhealthmanagement 00043 Ineffectiveprotection Domain2. Nutrition Theactivitiesoftakingin,assimilating,andusingnutrients forthepurposesoftissuemaintenance,tissuerepair,and theproductionofenergy Class1. Ingestion Takingfoodornutrientsintothebody 00002 Imbalancednutrition:lessthanbodyrequirements 00163 Readinessforenhancednutritiona 00216 Insufficientbreastmilkproduction 00104 Ineffectivebreastfeeding 00105 Interruptedbreastfeeding 00106 Readinessforenhancedbreastfeeding 00269 Ineffectiveadolescenteatingdynamics 87 00270 Ineffectivechildeatingdynamics 00271 Ineffectiveinfanteatingdynamics 00107 Ineffectiveinfantfeedingpattern 00232 Obesity 00233 Overweight 00234 Riskforoverweight 00103 Impairedswallowing Class2. Digestion Thephysicalandchemicalactivitiesthatconvertfoodstuffs intosubstancessuitableforabsorptionandassimilation Noneatpresenttime Class3. Absorption Theactoftakingupnutrientsthroughbodytissues Noneatpresenttime Class4. Metabolism Thechemicalandphysicalprocessesoccurringinliving organismsandcellsforthedevelopmentanduseof protoplasm,theproductionofwasteandenergy,withthe releaseofenergyforallvitalprocesses 00179 Riskforunstablebloodglucoselevel 00194 Neonatalhyperbilirubinemia 00230 Riskforneonatalhyperbilirubinemia 00178 Riskforimpairedliverfunction 00263 Riskformetabolicimbalancesyndrome Class5. Hydration Thetakinginandabsorptionoffluidsandelectrolytes 00195 Riskforelectrolyteimbalance 00025 Riskforimbalancedfluidvolumeb 00027 Deficientfluidvolume 00028 Riskfordeficientfluidvolume 00026 Excessfluidvolume Domain3. Eliminationandexchange Secretionandexcretionofwasteproductsfromthebody Class1. Urinaryfunction Theprocessofsecretion,reabsorption,andexcretionof urine 00016 Impairedurinaryelimination 00020 Functionalurinaryincontinence 00176 Overflowurinaryincontinence 00018 Reflexurinaryincontinence 00017 Stressurinaryincontinence 00019 Urgeurinaryincontinence 88 00022 Riskforurgeurinaryincontinence 00023 Urinaryretention Class2. Gastrointestinalfunction Theprocessofabsorptionandexcretionoftheend productsofdigestion 00011 Constipation 00015 Riskforconstipation 00012 Perceivedconstipation 00235 Chronicfunctionalconstipation 00236 Riskforchronicfunctionalconstipation 00013 Diarrhea 00196 Dysfunctionalgastrointestinalmotility 00197 Riskfordysfunctionalgastrointestinalmotility 00014 Bowelincontinence Class3. Integumentaryfunction Theprocessofsecretionandexcretionthroughtheskin Noneatpresenttime Class4. Respiratoryfunction Theprocessofexchangeofgasesandremovaloftheend productsofmetabolism 00030 Impairedgasexchange Domain4. Activity/rest Theproduction,conservation,expenditure,orbalanceof energyresources Class1. Sleep/rest Slumber,repose,ease,relaxation,orinactivity 00095 Insomnia 00096 Sleepdeprivation 00165 Readinessforenhancedsleep 00198 Disturbedsleeppattern Class2. Activity/exercise Movingpartsofthebody(mobility),doingwork,or performingactionsoften(butnotalways)against resistance 00040 Riskfordisusesyndrome 00091 Impairedbedmobility 00085 Impairedphysicalmobility 00089 Impairedwheelchairmobility 00237 Impairedsitting 00238 Impairedstanding 00090 Impairedtransferability 00088 Impairedwalking 89 Class3. Energybalance Adynamicstateofharmonybetweenintakeand expenditureofresources 00273 Imbalancedenergyfield 00093 Fatigue 00154 Wandering Class4. Cardiovascular/pulmonaryresponses Cardiopulmonarymechanismsthatsupportactivity/rest 00092 Activityintolerance 00094 Riskforactivityintolerance 00032 Ineffectivebreathingpattern 00029 Decreasedcardiacoutput 00240 Riskfordecreasedcardiacoutput 00033 Impairedspontaneousventilation 00267 Riskforunstablebloodpressure 00200 Riskfordecreasedcardiactissueperfusion 00201 Riskforineffectivecerebraltissueperfusion 00204 Ineffectiveperipheraltissueperfusion 00228 Riskforineffectiveperipheraltissueperfusion 00034 Dysfunctionalventilatoryweaningresponse Class5. Self-care Abilitytoperformactivitiestocareforone’sbodyand bodilyfunctions 00098 Impairedhomemaintenance 00108 Bathingself-caredeficit 00109 Dressingself-caredeficit 00102 Feedingself-caredeficit 00110 Toiletingself-caredeficit 00182 Readinessforenhancedself-care 00193 Self-neglect Domain5. Perception/cognition Thehumanprocessingsystemincludingattention, orientation,sensation,perception,cognition,and communication Class1. Attention Mentalreadinesstonoticeorobserve 00123 Unilateralneglect Class2. Orientation Awarenessoftime,place,andperson Noneatpresenttime Class3. Sensation/perception Receivinginformationthroughthesensesoftouch,taste, smell,vision,hearing,andkinesthesia,andthe 90 comprehensionofsensorydataresultinginnaming, associating,and/orpatternrecognition Noneatpresenttime Class4. Cognition Useofmemory,learning,thinking,problem-solving, abstraction,judgment,insight,intellectualcapacity, calculation,andlanguage 00128 Acuteconfusion 00173 Riskforacuteconfusion 00129 Chronicconfusion 00251 Labileemotionalcontrol 00222 Ineffectiveimpulsecontrol 00126 Deficientknowledge 00161 Readinessforenhancedknowledge 00131 Impairedmemory Class5. Communication Sendingandreceivingverbalandnonverbalinformation 00157 Readinessforenhancedcommunication 00051 Impairedverbalcommunication Domain6. Self-perception Awarenessabouttheself Class1. Self-concept Theperception(s)aboutthetotalself 00124 Hopelessness 00185 Readinessforenhancedhope 00174 Riskforcompromisedhumandignity 00121 Disturbedpersonalidentity 00225 Riskfordisturbedpersonalidentity 00167 Readinessforenhancedself-concept Class 2.Self-esteem Assessmentofone’sownworth,capability,significance, andsuccess 00119 Chroniclowself-esteem 00224 Riskforchroniclowself-esteem 00120 Situationallowself-esteem 00153 Riskforsituationallowself-esteem Class3. Bodyimage Amentalimageofone’sownbody 00118 Disturbedbodyimage Domain7. Rolerelationship Thepositiveandnegativeconnectionsorassociations betweenpeopleorgroupsofpeopleandthemeansby whichthoseconnectionsaredemonstrated 91 Class1. Caregivingroles Sociallyexpectedbehaviorpatternsbypeopleproviding carewhoarenothealthcareprofessionals 00061 Caregiverrolestrain 00062 Riskforcaregiverrolestrain 00056 Impairedparenting 00057 Riskforimpairedparenting 00164 Readinessforenhancedparenting Class2. Familyrelationships Associationsofpeoplewhoarebiologicallyrelatedor relatedbychoice 00058 Riskforimpairedattachment 00063 Dysfunctionalfamilyprocesses 00060 Interruptedfamilyprocesses 00159 Readinessforenhancedfamilyprocesses Class3. Roleperformance Qualityoffunctioninginsociallyexpectedbehavior patterns 00223 Ineffectiverelationship 00229 Riskforineffectiverelationship 00207 Readinessforenhancedrelationship 00064 Parentalroleconflict 00055 Ineffectiveroleperformance 00052 Impairedsocialinteraction Domain8. Sexuality Sexualidentity,sexualfunction,andreproduction Class1. Sexualidentity Thestateofbeingaspecificpersoninregardtosexuality and/orgender Noneatpresenttime Class2. Sexualfunction Thecapacityorabilitytoparticipateinsexualactivities 00059 Sexualdysfunction 00065 Ineffectivesexualitypattern Clas3. Reproduction Anyprocessbywhichhumanbeingsareproduced 00221 Ineffectivechildbearingprocess 00227 Riskforineffectivechildbearingprocess 00208 Readinessforenhancedchildbearingprocess 00209 Riskfordisturbedmaternal-fetaldyad Domain9. Coping/stresstolerance Contendingwithlifeevents/lifeprocesses 92 Class1. Post-traumaresponses Reactionsoccurringafterphysicalorpsychologicaltrauma 00260 Riskforcomplicatedimmigrationtransition 00141 Post-traumasyndrome 00145 Riskforpost-traumasyndrome 00142 Rape-traumasyndrome 00114 Relocationstresssyndrome 00149 Riskforrelocationstresssyndrome Class2. Copingresponses Theprocessofmanagingenvironmentalstress 00199 Ineffectiveactivityplanning 00226 Riskforineffectiveactivityplanning 00146 Anxiety 00071 Defensivecoping 00069 Ineffectivecoping 00158 Readinessforenhancedcoping 00077 Ineffectivecommunitycoping 00076 Readinessforenhancedcommunitycoping 00074 Compromisedfamilycoping 00073 Disabledfamilycoping 00075 Readinessforenhancedfamilycoping 00147 Deathanxiety 00072 Ineffectivedenial 00148 Fear 00136 Grieving 00135 Complicatedgrieving 00172 Riskforcomplicatedgrieving 00241 Impairedmoodregulation 00125 Powerlessness 00152 Riskforpowerlessness 00187 Readinessforenhancedpower 00210 Impairedresilience 00211 Riskforimpairedresilience 00212 Readinessforenhancedresilience 00137 Chronicsorrow 00177 Stressoverload Class3. Behavioralresponsesreflectingnerveandbrainfunction 93 Neurobehavioralstress 00258 Acutesubstancewithdrawalsyndrome 00259 Riskforacutesubstancewithdrawalsyndrome 00009 Autonomicdysreflexia 00010 Riskforautonomicdysreflexia 00049 Decreasedintracranialadaptivecapacity 00264 Neonatalabstinencesyndrome 00116 Disorganizedinfantbehavior 00115 Riskfordisorganizedinfantbehavior 00117 Readinessforenhancedorganizedinfantbehavior Domain10. Lifeprinciples Principlesunderlyingconduct,thought,andbehavior aboutacts,customs,orinstitutionsviewedasbeingtrueor havingintrinsicworth Class1. Values Theidentificationandrankingofpreferredmodesof conductorendstates Noneatpresenttime Class2. Beliefs Opinions,expectations,orjudgmentsaboutacts,customs, orinstitutionsviewedasbeingtrueorhavingintrinsic worth 00068 Readinessforenhancedspiritualwell-being Class3. Value/belief/actioncongruence Thecorrespondenceorbalanceachievedamongvalues, beliefs,andactions 00184 Readinessforenhanceddecision-making 00083 Decisionalconflict 00242 Impairedemancipateddecision-making 00244 Riskforimpairedemancipateddecision-making 00243 Readinessforenhancedemancipateddecision-making 00175 Moraldistress 00169 Impairedreligiosity 00170 Riskforimpairedreligiosity 00171 Readinessforenhancedreligiosity 00066 Spiritualdistress 00067 Riskforspiritualdistress Domain11. Safety/protection Freedomfromdanger,physicalinjury,orimmunesystem damage;preservationfromloss;andprotectionofsafety andsecurity Class1. Infection Hostresponsesfollowingpathogenicinvasion 00004 Riskforinfection 94 00266 Riskforsurgicalsiteinfection Class2. Physicalinjury Bodilyharmorhurt 00031 Ineffectiveairwayclearance 00009 Riskforaspiration 00206 Riskforbleeding 00048 Impaireddentition 00219 Riskfordryeye 00261 Riskfordrymouth 00155 Riskforfalls 00245 Riskforcornealinjuryc 00035 Riskforinjury 00250 Riskforurinarytractinjury 00087 Riskforperioperativepositioninginjuryc 00220 Riskforthermalinjuryc 00045 Impairedoralmucousmembraneintegrity 00247 Riskforimpairedoralmucousmembraneintegrity 00086 Riskforperipheralneurovasculardysfunction 00038 Riskforphysicaltrauma 00213 Riskforvasculartrauma 00249 Riskforpressureulcer 00205 Riskforshock 00046 Impairedskinintegrity 00047 Riskforimpairedskinintegrity 00156 Riskforsuddeninfantdeath 00036 Riskforsuffocation 00100 Delayedsurgicalrecovery 00246 Riskfordelayedsurgicalrecovery 00044 Impairedtissueintegrity 00248 Riskforimpairedtissueintegrity 00268 Riskforvenousthromboembolism Class3. Violence Theexertionofexcessiveforceorpowertocauseinjuryor abuse 00272 Riskforfemalegenitalmutilation 00138 Riskforother-directedviolence 00140 Riskforself-directedviolence 00151 Self-mutilation 95 00139 Riskforself-mutilation 00150 Riskforsuicide Class4. Environmentalhazards Sourcesofdangerinthesurroundings 00181 Contamination 00180 Riskforcontamination 00265 Riskforoccupationalinjury 00037 Riskforpoisoning Class5. Defensiveprocesses Theprocessesbywhichtheselfprotectsitselffromthe nonself 00218 Riskforadversereactiontoiodinatedcontrastmedia 00217 Riskforallergicreaction 00041 Latexallergicreaction 00042 Riskforlatexallergicreaction Class6. Thermoregulation Thephysiologicalprocessofregulatingheatandenergy withinthebodyforpurposesofprotectingtheorganism 00007 Hyperthermia 00006 Hypothermia 00253 Riskforhypothermia 00254 Riskforperioperativehypothermia 00008 Ineffectivethermoregulation 00274 Riskforineffectivethermoregulation Domain12. Comfort Senseofmental,physical,orsocialwell-beingorease Class1. Physicalcomfort Senseofwell-beingoreaseand/orfreedomfrompain 00214 Impairedcomfort 00183 Readinessforenhancedcomfort 00134 Nausea 00132 Acutepain 00133 Chronicpain 00255 Chronicpainsyndromed 00256 Laborpaind Class2. Environmentalcomfort Senseofwell-beingoreasein/withone’senvironment 00214 Impairedcomfort 00183 Readinessforenhancedcomfort 96 Class3. Socialcomfort Senseofwell-beingoreasewithone’ssocialsituation 00214 Impairedcomfort 00183 Readinessforenhancedcomfort 00054 Riskforloneliness 00053 Socialisolation Domain13. Growth/development Age-appropriateincreasesinphysicaldimensions, maturationoforgansystems,and/orprogressionthrough thedevelopmentalmilestones Class1. Growth Increaseinphysicaldimensionsormaturityoforgan systems Noneatpresenttime Class2. Development Progressorregressionthroughasequenceofrecognized milestonesinlife 00112 Riskfordelayeddevelopment aThe editors acknowledge this concept is not in alphabetical order; a decision was made to maintain all “nutrition”diagnosesinsequentialorder. bThe editors acknowledge this conceptisnotin alphabetical order; a decision was made to maintain all “fluidvolume”diagnosesinsequentialorder. cThe editors acknowledge this concept is not in alphabetical order; a decision was made to maintain all “injury”diagnosesinsequentialorder. dThe editors acknowledge this conceptisnotin alphabetical order; a decision was made to maintain all “pain”diagnosesinsequentialorder. 7.7 References AbbottA.TheSystemsofProfessions.Chicago,IL:TheUniversityofChicago Press;1988 Quammen D. A passion for order. National Geographic Magazine. 2007. Available at: ngm.nationalgeographic.com/print/2007/06/Linnaeus-namegiver/david-quammen-text(retrievedNovember1,2013) Von Krogh G. Taxonomy III Proposal. NANDA International Latin American Symposium.SaoPaulo,Brazil.May,2011 97 8 SpecificationsandDefinitionsWithinthe NANDAInternationalTaxonomyof NursingDiagnoses T.HeatherHerdman 8.1 StructureofTaxonomyII Taxonomy is defined as the “system for naming and organizing things … into groups that share similar qualities” (Cambridge Dictionary On-Line, 2017). Withinthetaxonomy,thedomainsare“anareaofinterestoranareaoverwhich one has control”; and the classes are “a group … with similar structure” (CambridgeDictionaryOn-Line,2017). Wecanadaptthedefinitionforanursingdiagnosistaxonomy;specifically,we are concerned with the orderly classification of diagnostic foci of concern to nursing, according to their presumed natural relationships. Taxonomy II has three levels: domains, classes, and nursing diagnoses. Fig. 7.3 depicts the organization of domains and classes in Taxonomy II; Table 7.1 shows TaxonomyIIwithits13domains,47classes,and244currentdiagnoses. The Taxonomy II codestructureisa32-bitinteger(oriftheuser'sdatabase uses another notation, the code structure is a five-digit code). This structure provides for the stability, or growth and development, of the classification structure by avoiding the need to change codes when new diagnoses, refinements,andrevisionsareadded.Newcodesareassignedtonewlyapproved diagnoses. Taxonomy II has a code structure that is compliant with recommendations from the National Library of Medicine (NLM) concerning health care terminology codes. The NLM recommends that codes do not contain informationabouttheclassifiedconcept,asdidtheTaxonomyIcodestructure, whichincludedinformationaboutthelocationandthelevelofthediagnosis. The NANDA-I terminologyisarecognizednursinglanguagethatmeetsthe criteria established by the Committee for Nursing Practice Information 98 Infrastructure(CNPII)oftheAmericanNursesAssociation(ANA)(Lundberget al2008).Thebenefitofarecognizednursinglanguageistheindicationthatthe classification system is accepted as supporting nursing practice by providing clinically useful terminology. The terminology is also registered with Health Level Seven International (HL7), a health care informatics standard, as a terminologytobeusedinidentifyingnursingdiagnosesinelectronicmessages amongclinicalinformationsystems(www.HL7.org). 8.2 AMultiaxialSystemforConstructing DiagnosticConcepts The NANDA-I diagnoses are concepts constructed by means of a multiaxial system.Anaxis,forthepurposeoftheNANDA-ITaxonomyII,isoperationally defined as a dimension of the human response that is considered in the diagnostic process. There are seven axes. The NANDA-I Model of a Nursing Diagnosisdisplaysthesevenaxesandtheirrelationshiptoeachother. –Axis1:thefocusofthediagnosis – Axis 2: subject of the diagnosis (individual, family, group, caregiver, community,etc.) –Axis3:judgment(impaired,ineffective,etc.) –Axis4:location(oral,peripheral,cerebral,etc.) –Axis5:age(neonate,infant,child,adult,etc.) –Axis6:time(chronic,acute,intermittent) –Axis7:statusofthediagnosis(problem-focused,risk,healthpromotion) The axes are represented in the labels of the nursing diagnoses through their values. In some cases they are named explicitly, such as with the diagnoses ineffective community coping and dysfunctional family processes, in which the subject of the diagnosis is named using the two values “community” and “family” taken from Axis 2 (subject of the diagnosis). “Ineffective” and “dysfunctional”aretwoofthevaluescontainedinAxis3(judgment). Insomecases,theaxisisimplicit,asisthecasewiththediagnosisineffective sexualitypattern, in which the subject of the diagnosis (Axis 2) is always the patient. In some instances, an axis may not be pertinent to a diagnosis, and thereforeisnotpartofthenursingdiagnosticlabel.Forexample,thetimeaxis maynotberelevanttoeverydiagnosis.Inthecaseofdiagnoseswithoutexplicit identificationofthesubjectofthediagnosis,itmaybehelpfultorememberthat 99 NANDA-I defines a patient as “an individual, a family, a group, or a community.” Axis 1 (the focus of the diagnosis) and Axis 3 (judgment) are essential components of a nursing diagnosis. In some cases, however, the focus of the diagnosiscontainsthejudgment(e.g.,fear);inthesecases,thejudgmentisnot explicitlyseparatedfromthefocusofthediagnosisinthediagnosticlabel.Axis 2(subjectofthediagnosis)isalsoessential,although,asdescribedearlier,itmay beimpliedandthereforenotincludedinthelabel.TheDiagnosisDevelopment Committeerequirestheseaxesforsubmission;theotheraxesmaybeusedwhere relevantforclarity. 8.3 DefinitionsoftheAxes 8.3.1 Axis1:TheFocusoftheDiagnosis Thefocusofthediagnosisistheprincipalelementorthefundamentaland essential part, the root, of the diagnostic concept. It describes the “human response”thatisthecoreofthediagnosis. The focus of the diagnosis may consist of one or more nouns. When more thanonenounisused(e.g.,sexualdysfunction),eachonecontributes aunique meaning to the focus of the diagnosis, as if the two were a single noun; the meaning of the combined term, however, is different from when the nouns are statedseparately.Frequently,anoun(parenting)maybeusedwithanadjective (impaired)todenotethefocusofthediagnosisimpairedparenting. Insomecases,thefocusofthediagnosisandthediagnosticconceptareone andthesame,asisseenwiththediagnosisoffear.Thisoccurswhenthenursing diagnosis is stated at its most clinically useful level and the separation of the focus of the diagnosis adds no meaningful level of abstraction. It can be very difficult to determine exactly what should be considered the focus of the diagnosis.Forexample,usingthediagnosesofbowelincontinence(00014)and stress urinary incontinence (00017), the question becomes: Is the focus of the diagnosis incontinence alone, or are there two foci—bowel incontinence and urinaryincontinence?Inthisinstance,incontinenceisthefocusandthelocation terms(Axis4)ofbowelandurinaryprovidemoreclarificationaboutthefocus. However,incontinenceinandofitselfisajudgmenttermthatcanstandalone, andsoitbecomesthefocusofthediagnosisregardlessoflocation. Insomecases,however,removingthelocation(Axis4)fromthediagnostic 100 focuswouldpreventitfromprovidingmeaningtonursingpractice.Forexample, ifwelookatthefocusofthediagnosisriskforimbalancedbodytemperature,is the focus of the diagnosis bodytemperature or simply temperature? Or if you lookatthediagnosisdisturbedpersonalidentity,isthefocusidentityorpersonal identity? Decisions about what constitutes the essence of the focus of the diagnosis, then, are made on the basis of what helps to identify the nursing practice implication and whether or not the term indicates a human response. Temperature could mean environmental temperature, which is not a human response—so it is important to identify body temperature as the diagnostic concept.Similarly,identitycanmeannothingmorethanone'sgender,eyecolor, height, or age—again, these are characteristics but not human responses; personal identity, however, indicates one's self-perception and is a human response.Insomecases,thefocusmayseemsimilar,butisinfactquitedistinct: violence and self-directed violence are two different human responses, and therefore must be identified separately in terms of diagnostic foci within TaxonomyII.ThediagnosticfocioftheNANDA-Inursingdiagnosesareshown in Table8.1. Table8.1DiagnosticfocioftheNANDA-Inursingdiagnoses –Activityplanning –Activitytolerance –Acutesubstancewithdrawal syndrome –Adaptivecapacity –Adversereactionto iodinatedcontrastmedia –Airwayclearance –Allergicreaction –Anxiety –Aspiration –Attachment –Autonomicdysreflexia –Balancedenergyfield –Balancedfluidvolume –Balancednutrition –Bathingself-care –Bleeding –Bloodglucoselevel –Bodyimage –Breastmilkproduction –Breastfeeding –Breathingpattern –Feedingself-care –Femalegenitalmutilation –Fluidvolume –Frailelderlysyndrome –Funtionalconstipation –Gasexchange –Gastrointestinalmotility –Grieving –Healthbehavior –Healthliteracy –Healthmaintenance –Healthmanagement –Health –Homemaintenance –Hope –Humandignity –Hyperbilirubinemia –Hyperthermia –Hypothermia –Immigrationtransition –Impulsecontrol –Incontinence –Infection 101 –Post-traumasyndrome –Power –Pressureulcer –Protection –Rape-traumasyndrome –Relationship –Religiosity –Relocationstresssyndrome –Resilience –Retention –Roleconflict –Roleperformance –Rolestrain –Self-care –Self-concept –Self-directedviolence –Self-esteem –Self-mutilation –Self-neglect –Sexualfunction –Sexualitypattern –Shock –Sitting –Cardiacoutput –Childbearingprocess –Chronicpainsyndrome –Comfort –Communication –Confusion –Constipation –Contamination –Coping –Deathanxiety –Decisionalconflict –Decisionmaking –Denial –Dentition –Development –Diarrhea –Disusesyndrome –Diversionalactivity engagement –Dressingself-care –Dryeye –Drymouth –Eatingdynamics –Electrolytebalance –Elimination –Emancipateddecisionmaking –Emotionalcontrol –Falls –Familyprocesses –Fatigue –Fear –Feedingpattern –Injury –Insomnia –Knowledge –Laborpain –Latexallergicreaction –Lifestyle –Liverfunction –Loneliness –Maternal–fetaldyad –Memory –Metabolicimbalancesyndrome –Mobility –Moodregulation –Moraldistress –Mucousmembraneintegrity –Nausea –Neonatalabstinencesyndrome –Neurovascularfunction –Nutrition –Obesity –Occupationalinjury –Organizedbehavior –Other-directedviolence –Overweight –Pain –Parenting –Perioperativehypothermia –Perioperativepositioninginjury –Personalidentity –Physicaltrauma –Poisoning –Skinintegrity –Sleeppattern –Sleep –Socialinteraction –Socialisolation –Sorrow –Spiritualdistress –Spiritualwell-being –Spontaneousventilation –Standing –Stress –Suddeninfantdeath –Suffocation –Suicide –Surgicalrecovery –Surgicalsiteinfection –Swallowing –Thermalinjury –Thermoregulation –Tissueintegrity –Tissueperfusion –Toiletingself-care –Transferability –Unilateralneglect –Stablebloodpressure –Venousthromboembolism –Ventilatoryweaningresponse –Verbalcommunication –Walking –Wandering 8.3.2 Axis2:SubjectoftheDiagnosis The subject of the diagnosis is defined as the person(s) for whom a nursingdiagnosisisdetermined.ThevaluesinAxis2areindividual,caregiver, family, group, and community, representing the NANDA-I definition of “patient”: –Individual:Asinglehumanbeingdistinctfromothers,aperson. –Caregiver:Afamilymemberorhelperwhoregularlylooksafterachildora sick,elderly,ordisabledperson. – Family: Two or more people having continuous or sustained relationships, 102 perceiving reciprocal obligations, sensing common meaning, and sharing certainobligationstowardothers;relatedbybloodand/orchoice. –Group:Anumberofpeoplewithsharedcharacteristics. – Community: A group of people living in the same locale under the same governance.Examplesincludeneighborhoodsandcities. When the subject of the diagnosis is not explicitly stated, it becomes the individual by default. However, it is perfectly appropriate to consider such diagnosesfortheothersubjectsofthediagnosisaswell.Thediagnosisimpaired comfort (00214) could be applied to an individual who has insufficient situational control, insufficient privacy, and insufficient resources, which is evidencedbydiscontentwiththeindividual'ssituation,aninabilitytorelax,and alteration in the individual's sleep pattern. It could also be appropriate for a community that has experienced noxious environmental stimuli (e.g., environmentaldisaster),andwhichhasinsufficientcontroloveritsenvironment and insufficient resources to combat the problem it is facing, and whose residentsareexperiencingdistressingsymptoms,fear,anxiety,etc. 8.3.3 Axis3:Judgment Ajudgmentisadescriptorormodifierthatlimitsorspecifiesthemeaning of the focus of the diagnosis. The focus of the diagnosis, together with the nurse'sjudgmentaboutit,formsthediagnosis.Allthedefinitionsusedarefound intheOxfordEnglishLivingDictionaryOn-Line(2017).ThevaluesinAxis3 arefoundin Table8.2. Table8.2DefinitionsofjudgmenttermsforAxis3,NANDA-ITaxonomyII Judgment Definition Complicated Consistingofmanyinterconnectingpartsor elements;intricate;involvingmanydifferentand confusingaspects Compromised Madevulnerableortofunctionlesseffectively Decreased Smallerorfewerinsize,amount,intensity,or degree Defensive Usedorintendedtodefendorprotect Deficient/deficit Nothavingenoughofaspecifiedqualityor ingredient;insufficientorinadequate Delayed Late,slow,orpostponed Deprivation Lackordenialofsomethingconsideredtobea necessity Disabled Limitedinmovements,senses,oractivities 103 Disorganized Notproperlyplannedorcontrolled;scatteredor inefficient Disproportionate Toolargeortoosmallincomparisonwith somethingelse(norm) Disturbed Havinghadanormalpatternorfunctiondisrupted Dysfunctional Notoperatingnormallyorproperly;unabletodeal adequatelywithsocialnorms Emancipated Freefromlegal,social,orpoliticalrestrictions; liberated Effective Successfulinproducingadesiredorintendedresult Enhanced Intensify,increase,orfurtherimprovethequality, value,orextent Excess Anamountofsomethingthatismorethan necessary,permitted,ordesirable Failure Theactionorstateofnotfunctioning;lackof success Frail Weakanddelicate;physicallyormentallyinfirm througholdage Functional Relatingtothewayinwhichsomethingworksor operates;oforhavingaspecificactivity,purpose,or task Imbalanced Lackofproportionorrelationbetween correspondingthings Impaired Weakenedordamaged(something,especiallya facultyorfunction) Ineffective Notproducinganysignificantordesiredeffect Insufficient Notenough,inadequate;incapable,incompetent Interrupted Astopincontinuousprogress(ofanactivityor process);tobreakthecontinuityofsomething Labile Liabletochange;easilyaltered;oforcharacterized byemotionswhichareeasilyaroused,freely expressed,andtendtoalterquicklyand spontaneously Low Belowaverageinamount,extent,orintensity;small Non- Expressingnegationorabsence Organized Arrangedorstructuredinasystematicway; efficient Overload Toogreataburden Perceived Becomeawareorconscious(ofsomething);come torealizeorunderstand Readinessfor Willingnesstodosomething;stateofbeingfully preparedforsomething Riskfor Situationinvolvingexposuretodanger;possibility 104 thatsomethingunpleasantorunwelcomewill happen Risk-prone Likelyorliabletosufferfrom,do,orexperience somethingunpleasantorregrettable Sedentary (Awayoflife)characterizedbymuchsittingand littlephysicalexercise Situational Relatedtoordependentonasetofcircumstancesor stateofaffairs;relatingtothelocationand surroundingsofaplace Unstable Pronetochange,fail;notfirmlyestablished;likely togiveway;notstable 8.3.4 Axis4:Location Location describes the parts/regions of the body and/or their related functions—alltissues,organs,anatomicalsites,orstructures.Allthedefinitions used are found in the Oxford English Living Dictionary On-Line (2017). The valuesinAxis4areshownin Table8.3. Table8.3LocationsandtheirdefinitionsinAxis4,NANDA-ITaxonomyII Term Definition Auditory Relatingtothesenseofhearing Bladder Muscularmembranoussacintheabdomenwhich receivesurinefromthekidneysandstoresitfor excretion Body Physicalstructure,includingthebones,flesh,and organs,ofaperson Bowel Partofthealimentarycanalbelowthestomach;the intestine Breast Tissueoverlyingthechest(pectoral)muscles. Women'sbreastsaremadeofspecializedtissuethat producesmilk(glandulartissue)aswellasfatty tissue Cardiac Relatingtotheheart Cardiopulmonary Relatingtotheheartandlungs Cardiovascular Relatingtotheheartandbloodvessels Cerebral Ofthecerebrumofthebrain Dentition Arrangementorconditionoftheteeth Eye Oneofapairofglobularorgansofsightinthe humanhead Gastrointestinal Relatingtothestomachandtheintestines Genital Relatingtothehumanreproductiveorgans Gustatory Concernedwithtastingorthesenseoftaste 105 Intracranial Withintheskull Kinesthetic Awarenessofthepositionandmovementofthe partsofthebodybymeansofsensoryorgans (proprioceptors)inthemusclesandjoints Liver Largelobedglandularorganintheabdomen, involvedinmanymetabolicprocesses Mouth Openingandcavityinthelowerpartofthehuman face,surroundedbythelips,throughwhichfoodis takeninandvocalsoundsareemitted Mucousmembranes Epithelialtissueswhichsecretemucusandline manybodycavitiesandtubularorgansincludingthe gutandrespiratorypassages Neurovascular Containingneuralandvascularstructures;ofor relatingtothenervousandvascularsystems,or theirinteractions Olfactory Relatingtothesenseofsmell Oral Cavityofthemouth Peripheral Oforrelatingtothesurfaceorouterpartofabody ororgan;external Peripheralvascular Systemofveinsandarteriesnotinthechestor abdomen Renal Relatingtothekidneys Skin Thethinlayeroftissueformingthenaturalouter coveringofthebody Tactile Oforconnectedwiththesenseoftouch Tissue Anyofthedistincttypesofmaterialofwhich humansaremade,consistingofspecializedcells andtheirproducts Vascular Relatingto,affecting,orconsistingofavesselor vessels,especiallythosewhichcarryblood Venous Relatingtoaveinortheveins Visual Relatingtoseeingorsight Urinary Relatingtourine Urinarytract Relatingtoordenotingthesystemoforgans, structures,andductsbywhichurineisproduced anddischarged,comprisingthekidneys,ureters, bladder,andurethra 8.3.5 Axis5:Age Age refers to the age of the person who is the subject of the diagnosis (Axis2).ThevaluesinAxis5arenotedbelow,withalldefinitions,except that ofolderadult,beingdrawnfromtheWorldHealthOrganization(2013). –Fetus:unbornhumanmorethan8weeksafterconception,untilbirth 106 –Neonate:person<28daysofage –Infant:person≥28daysand<1yearofage –Child:personaged1to9years,inclusive –Adolescent:personaged10to19years,inclusive –Adult:personolderthan19yearsofageunlessnationallawdefinesaperson asbeinganadultatanearlierage –Olderadult:person≥65yearsofage 8.3.6 Axis6:Time Time describes the duration of the focus of the diagnosis (Axis 1). The valuesinAxis6are: –Acute:lasting<3months –Chronic:lasting≥3months –Intermittent:stoppingorstartingagainatintervals,periodic,cyclic –Continuous:uninterrupted,goingonwithoutstop 8.3.7 Axis7:StatusoftheDiagnosis The status of the diagnosis refers to the actuality or potentiality of the problem/health promotion opportunity/syndrome or to the categorization of the diagnosisasahealthpromotiondiagnosis.ThevaluesinAxis7are: – Problem-focused: undesirable human response to a health condition/life processthatexistsinthecurrentmoment(includessyndromediagnoses) – Health promotion: motivation and desire to increase well-being and to actualizehumanhealthpotentialthatexistsinthecurrentmoment(Penderet al2006) – Risk: susceptibility for developing, in the future, an undesirable human responsetohealthconditions/lifeprocesses(includessyndromediagnoses) 8.4 DevelopingandSubmittingaNursingDiagnosis A nursing diagnosis is constructed by combining the values from Axis 1 (the focusofthediagnosis),Axis2(subjectofthediagnosis),andAxis3(judgment), and adding values from the other axes for relevant clarity. Researchers or interestedprofessionalnurseswouldbeginwiththefocusofthediagnosis(Axis 1) and add the appropriate judgment term (Axis 3). Remember that these two axes are sometimes combined into a single diagnostic concept, as can be seen withthenursingdiagnosisfear(00148).Next,theywouldspecifythesubjectof the diagnosis (Axis 2). If the subject is an “individual,” they need not make it 107 explicit.Finally,theycanusetheremainingaxes,iftheyareappropriate,toadd moredetail. NANDA-I does not support the randomconstructionofdiagnosticconcepts thatwouldoccurbysimplymatchingtermsfromoneaxistoanothertocreatea diagnosis label to represent judgments based on a patient assessment. Clinical problems/areas of nursing foci that are identified and which do not have a NANDA-I label should be carefully described in documentation to ensure accuracyofothernurses’/healthcareprofessionals’interpretationoftheclinical judgment. Creatingadiagnosistobeusedinclinicalpracticeand/ordocumentationby matching terms from different axes, without development of the definition and other component parts of a diagnosis (defining characteristics, related factors, riskfactors,associatedconditions,andat-riskpopulations,asappropriate)inan evidence-based manner, negates the purpose of a standardized language as a methodtotrulyrepresent,inform,anddirectclinicaljudgmentandpractice. Thisisaseriousconcernwithregardtopatientsafety,becausethelackofthe knowledgeinherentwithinthecomponentdiagnosticpartsmakesitimpossible to ensure diagnostic accuracy. Nursing terms arbitrarily created at the point of carecouldresultinmisinterpretationoftheclinicalproblem/areaoffocus,and subsequently lead to inappropriate outcome setting and intervention choice. It alsomakesitimpossibletoaccuratelyresearchincidenceofnursingdiagnosesor to conduct outcome or intervention studies related to diagnoses since, without clear component parts of a diagnosis (definitions, defining characteristics, related factors, or risk factors), it is impossible to know if the concept being studiedtrulyrepresentsthesamephenomena. Therefore, when discussing construction of diagnostic concepts in this chapter, the intent is to inform clinicians as to how diagnostic concepts are developedandtoprovideclarityforindividualswhoaredevelopingdiagnoses, forsubmissionintotheNANDA-ITaxonomy;itshouldnotbemisinterpreted to suggest that NANDA-I supports the creation of diagnosis labels by cliniciansatthepointofpatientcare. 8.5 FurtherDevelopment NANDA International will be focusing on revision of diagnoses that are currently included in the terminology, but which were “grandfathered” in after the level of evidence criteria was adopted in 2002. There are over 50 such 108 diagnoses,whichwillberemovedfromtheterminologyduringthenextedition should this revision not occur. Therefore, we strongly discourage the development of new diagnoses at this time, with the focus instead on bringing diagnoses to a minimum level of evidence of 2.1, and raising the level of evidence of other diagnoses. The other focus for the organization will be to strengthen the clinical usefulness of diagnostic indicators (defining characteristicsandrelatedfactors).Ourdesireistobeabletoidentify,through clinicalresearchandmeta-analysis/meta-synthesis,thosedefiningcharacteristics thatarerequiredforadiagnosistobemade(“criticaldefiningcharacteristics”) andtoremovethosethatarenotclinicallyuseful.Thiswillstrengthenourability toprovidedecisionsupportfornursesatthebedside. 8.6 RecommendedReading Matos FGOA, Cruz DALM. Development of an instrument to evaluate diagnosisaccuracy..RevEscEnfermUSP.2009;43(Spe):1087–1095 PaansW,NiewegRMB,vanderSchansCP,SermeusW.Whatfactorsinfluence theprevalenceandaccuracyofnursingdiagnosesdocumentationinclinical practice?Asystematicliteraturereview..JClinNurs.2011;20(17–18):2386– 2403 8.7 References LundbergC,WarrenJ,BrokelJ,etal.Selectingastandardizedterminologyfor theelectronichealthrecordthatrevealstheimpactofnursingonpatientcare. Online J Nurs Inform 2008; 12(2). Available at: http://ojni.org/12_2/lundberg.pdf Oxford University Press. Oxford English Living Dictionary On-Line. Oxford UniversityPress;2017.Availableat:https://en.oxforddictionaries.com PenderNJ,MurdaughCL,ParsonsMA.HealthPromotioninNursingPractice. 5thed.UpperSaddleRiver,NJ:PearsonPrentice-Hall;2006 WorldHealthOrganization.Healthtopics:Infant,newborn.2013.Availableat: http://www.who.int/topics/infant_newborn/en/ World Health Organization. Definition of key terms. 2013. Available at: http://www.who.int/hiv/pub/guidelines/arv2013/intro/keyterms/en/ 109 9 9.1 FrequentlyAskedQuestions Introduction Weroutinelyreceivequestionsviaourwebsiteandemail,andwhenmembersof the NANDA-I Board of Directors or the CEO/Executive Director travel and present at a variety of conferences. We include some of the most common questions here, along with their answers, with the hope that it will help others whomayhavethesamequestions. 9.2 WhenDoWeNeedNursingDiagnoses? Nurses often work withapatientwhohasmedicalproblems.However,from a legalpointofview,physiciansareresponsibleforthediagnosisandtreatmentof thesemedicalproblems.Likewise,nursesareresponsibleforthediagnosisand treatmentofnursingproblems.Theimportantpointisthatnursingproblemsare differentfrommedicalproblems.Tomakethispointclear,letusexaminehow nursingpracticeexistswithinhealthcare,usingawiderperspectivebasedonthe Three Pillar Model of Nursing Practice (Kamitsuru 2008). This model shows threemainpartsofnursingpractice,whicharedistinctbutinterrelated. In clinical practice, nurses are expected to perform many actions. First, we havepractices/interventionsthataredrivenbymedicaldiagnoses.Thesenursing actions are related to medical treatments, patient surveillance and monitoring, and interdisciplinary collaboration. Nurses take these actions in response to medical diagnoses, and use medical standards of care as the basis for these nursingactions. Second, we have practice that is driven by nursing diagnoses. These independent nursing interventions do not require physician approval or permission.Theseactionsarebasedonnursingstandardsofcare. Finally,wehavepracticethatisdrivenbyorganizationalprotocols.Thesecan beactionsrelatedtobasiccare,suchaschanginglinen,providinghygiene,and dailycare.Theseactionsarenotspecificallyrelatedtoeithermedicaldiagnoses 110 ornursingdiagnoses,buttheyarebasedonorganizationalstandardsofcare. Allthreeactionscombinedformthepracticeofnursing.Eachhasadifferent knowledge base and different responsibilities. The three parts are equally important for nurses to understand, but only one of them relates to our unique disciplinaryknowledge—andthatistheareaweknowasnursingdiagnosis.This modelalsoshowswhywedonotneedtorenamemedicaldiagnosesasnursing diagnoses.Medicaldiagnosesalreadyexistinthemedicaldomain.But,medical diagnoses do not always explain everything that nurses understand about patients, judgments we make about their human response, or interventions we implement for patients. So, we use nursing diagnoses to explain independent clinical judgments nurses make about our patients. Thus, nursing diagnoses providetheunderpinningofindependentnursinginterventions. 9.3 BasicQuestionsaboutStandardizedNursing Languages Whatisstandardizednursinglanguage? Standardized nursing language (SNL) is a commonly understood set of terms used to describe the clinical judgments involved in assessments (nursing diagnoses), along with the interventions and outcomes related to the documentation of nursing care. Standardization requires terms, definitions, and indicators(eitherdiagnosticoroutcomeindicators)tobeclinicallyuseful. Howmanystandardizednursinglanguagesarethere? The American Nurses Association recognizes 12 languages for nursing. NANDA-I is the only diagnostic language that uses a peer-review system for inclusioninitstaxonomy.Itisalsotheonlyterminologytoprovidethecritical diagnostic indicators (defining characteristics, related factors, risk factors, associated conditions, and at-risk populations) to support a nurse's clinical reasoningatthebedside. Whatarethedifferencesamongstandardizednursinglanguages? Many nursing languages claim to be standardized; some are simply a list of terms, others provide definitions of those terms. NANDA-I maintains that a standardized language that represents any profession should provide, at a minimum, an evidence-based definition, list of defining characteristics (signs/symptoms), and related factors (etiologic factors), along with additional 111 data that support diagnosis, such as at-risk populations and associated conditions.Riskdiagnosesshouldincludeanevidence-baseddefinitionandalist ofriskfactors,whichareamenabletoindependentnursingintervention.Without these,anyonecandefineanyterminhis/herownway,whichobviouslyviolates thepurposeofstandardization.Italsoprohibitsanyelectronicdecision-support withlinkagedirectlytonursingassessments. Iseepeopleuseterms,suchas“selectadiagnosis,”“choosea diagnosis,”and“pickadiagnosis”—itsoundsasthoughthereis aneasywaytoknowwhatdiagnosistouse.Isthatcorrect? Whenwespeakaboutdiagnosing,wereallyarenottalkingaboutsomethingas simplistic as picking a term from a list or choosing something that “sounds right” for our patient. We are speaking about the diagnostic decision-making process, in which nurses diagnose. So, rather than using these simplistic terms (selecting, choosing, picking), we should really describe the process of diagnosing! Rather than saying “choose a diagnosis,” we should be saying “diagnosethepatient/family”;ratherthansaying“pickingadiagnosis,”wecould use “ensure accuracy in your diagnosis,” or again, simply “diagnose the patient/family.” Words are powerful—so when we say things such as choose, pick,andselect,itdoessoundsimple,asifweneedtosimplyreadthroughalist oftermsandpickone.Usingdiagnosticreasoning,however,ismuchmorethan that—and diagnosing is what we are doing, which goes far beyond “picking” something! 9.4 BasicQuestionsaboutNANDA-I WhatisNANDAInternational? Implementationofnursingdiagnosisenhanceseveryaspectofnursingpractice, from garnering professional respect to assuring consistent documentation representingnurses’professionalclinicaljudgmentandaccuratedocumentation to enable reimbursement. NANDA-I exists to develop, refine, and promote terminologythataccuratelyreflectsnurses’clinicaljudgments. WhydoesNANDA-Ichargeafeeforaccesstoitsnursing diagnoses? In any field, development and maintenance of a research-based body of work requiresaninvestmentoftimeandexpertise,anddisseminationofthatworkis 112 an additional expense. As a volunteer organization, we sponsor committee meetings for review of submitted diagnoses, to ensure they meet the level of evidence (LOE) criteria. We also provide educational courses and offerings in English, Spanish, and Portuguese due to the high demand of this content. We have committee members from all over the world, and the cost of videoconferencingandtheoccasionalface-to-facemeetingisanexpense—asare our conferences and educational events. Our fees support this work on a breakeven basis, and are quite modest in comparison to fees charged for a licensetomanyotheravailablehealthcaredatabasesandelectroniclicenses. Ifwebuyabookandtypethecontentsintosoftwareourselves,do westillhavetopay? NANDAInternational,Inc.dependsonthefundsreceivedfromthesaleofour textbooks and electronic licensing to maintain and improve the state of the science within our terminology. The NANDA-I terminology is a copyrighted terminology; therefore, no part of the NANDA-I publication, NANDA International Nursing Diagnoses: Definitions and Classification, can be reproduced, stored in a retrieval system, or transmitted by any means, electronic, mechanical, photocopying, recording, or otherwise without the priorpermissionofthepublisher.Thisincludespublicationinonlineblogs, websites,etc. Thisistrueregardlessofthelanguageinwhichyouintendtousethework. Forusageotherthanreadingorconsultingthebook,alicenseisrequiredfrom ThiemeMedicalPublishers,Inc., orthe approvedpublisherofthebookinany otherlanguage.Theofficialtranslationrightsholdersforourworkinlanguages otherthanEnglishcanbefoundatthelinkbelow.Useofthiscontentrequires that you apply for and receive permission from the publisher to reproduce our work in any format. Further information is available on our website (www.nanda.org) or you can contact Thieme Medical Publishers at [email protected]. ShouldthestructureofTaxonomyIIbeusedasanursing assessmentframework? Thepurposeofthetaxonomyistoprovideorganizationtotheterms(diagnoses) withinNANDA-I.Itwasneverintendedtoserveasan assessmentframework. Please see our Position Statement on the use of taxonomy as a nursing assessmentframework(p.48). WhatisPES,howwasitdeveloped,andwhatareitsorigins?Does 113 NANDA-Irequirethe“PESformat/scheme”? “PES”isanacronymthatstandsforproblem,etiology(relatedfactors),ands igns/symptoms(definingcharacteristics).ThePESformatwasfirstpublishedby Dr. Marjory Gordon, a founder and former President of NANDA-I. The componentpartsofNANDA-Idiagnosesarenowreferredtoasrelatedfactors anddefiningcharacteristics,andthereforethewording“PESformat”isnotused in current NANDA-I books. It is still used in several countries and in many publications. Formulating accurate diagnoses relies on assessing and documenting related factors and defining characteristics, and the PES format supportsthis,whichiscriticalforaccuracyinnursingdiagnoses,afocuswhich NANDA-Istronglysupports. However,NANDA-IdoesnotrequirethePESformat,oranyotherformat,to document nursing diagnoses. We are aware of the wide variety of electronic documentation systems in use and in development around the world, and it seemsthatthereareasmanywaysofprovidingnursingdocumentationasthere aresystems!Manycomputersystemsdonotallowtheuseofthe“relatedto…as evidenced by” model. However, it is important that nurses communicate the assessment data that support the diagnosis they make, so that others caring for the patient know why a diagnosis was selected. Please see the NANDA-I PositionStatementNumber2:TheStructureoftheNursingDiagnosisStatement WhenIncludedinaCarePlan(p.28). ThePESformatremainsastrongmethodforteachingclinicalreasoningand supporting students and nurses as they learn the skill of diagnosis. Because patientsusuallyhavemorethanonerelatedfactorand/ordefiningcharacteristic, many sites replaced the wording “as manifested/as evidenced by” and “related to” with a list of the defining characteristics and related factors following the diagnosticstatement.Thislistisbasedontheindividualpatientsituationandby usingstandardizedNANDA-Iterms. Regardless of the requirements for documentation, it is important to remember that for safe patient care in clinical areas, it is crucial to survey or assess defining characteristics (manifestations of diagnoses) and related factors (or causes) of nursing diagnoses. Choosing effective interventions is based on relatedfactorsanddefiningcharacteristics. HowdoIwritethediagnosticstatementforrisk,problemfocused,andhealthpromotiondiagnoses? Documentationsystemsdifferbyorganization,soinsomecasesyoumaywrite (orselectfromacomputerizedlist)thediagnosticlabelthatcorrespondstothe 114 human response you have diagnosed. Assessment data may be found in a different section (or “screen”) of the computer system, and you would select your related factors and defining characteristics, or your risk factors, in that location.ExamplesofPESchartingareshownbelow. Problem-FocusedDiagnosis. To use the PES format, start with the diagnosis itself, followed by the etiologic factors (related factors in a problem-focused diagnosis). Finally, you identify the major signs/symptoms (defining characteristics). Impaired parenting related to insufficient cognitive readiness for parenting and young parental age (related factors) as evidenced by deficient parent – childinteraction,perceivedroleinadequacy,andinappropriatecare-taking skills(definingcharacteristics). Risk Diagnosis. For risk diagnoses, there are no related factors (etiological factors), since you are identifying a vulnerability in a patient for a potential problem;theproblemisnotyetpresent.Differentexpertsrecommenddifferent phrasing (some use “related to,” others use “as evidenced by” for risk diagnoses).Becausetheterm“relatedto”isusedtosuggestanetiology,inthe caseofaproblem-focuseddiagnosis,andbecausethereisonlyavulnerabilityto aproblemwhenariskdiagnosisisused,NANDA-Ihasdecidedtorecommend the use of the phrase “as evidenced by” to refer to the evidence of risk that exists,ifthePESformatisused. Risk for caregiver role strain as evidenced by unpredictability of illness trajectoryandcaregivingtaskcomplexity(riskfactors). Health Promotion Diagnosis. Because health promotion diagnoses do not require a related factor, there may be no “related to” in the writing of this diagnosis.Instead,thedefiningcharacteristic(s)is(are)providedasevidenceof thedesireonthepartofthepatienttoimprovehis/hercurrenthealthstate(orthe recognition by the professional nurse that an opportunity exists for health promotion,andactionistakentopromotehealthonbehalfofthepatientwhois unabletodosoforhimself/herself). Readiness for enhanced sleep as evidenced by expressed desire to enhance sleep. DoesNANDA-Iprovidealistofitsdiagnoses? There is no real use for simply providing a list of terms—doing so defeats the purpose of a standardized language. Unless the definition, defining 115 characteristics, and related and/or risk factors are known, the label itself is meaningless.Therefore,wedonotbelieveitisintheinterestofpatientsafetyto produce simple lists of terms that could be misunderstood or used inappropriatelyinaclinicalcontext. Itisessentialtohavethedefinitionofthediagnosisand,moreimportantly,the diagnosticindicators(assessmentdata/patienthistorydata)requiredtomakethe diagnosis—for example, the signs/symptoms that you collect through your assessment (“defining characteristics”) and the cause of the diagnosis (“related factors”) or those things that place a patient at significant risk for a diagnosis (“risk factors”). As you assess the patient, you will rely on both your clinical knowledge and “book knowledge” to see patterns in the data—diagnostic indicatorsthatclustertogether,whichmayrelatetoadiagnosis.Questionstoask toidentifyandvalidatethecorrectdiagnosisinclude: 1. Are the majority of the defining characteristics/risk factors present in the patient? 2. Are there etiological factors (“related factors”) for the diagnosis evident in yourpatient? 3.Haveyouvalidatedthediagnosiswiththepatient/familyorwithanothernurse peer(whenpossible)? 9.5 BasicQuestionsaboutNursingDiagnoses WhatarethetypesofnursingdiagnosesinNANDA-I classification? NANDA-I identifies three categories of nursing diagnosis: problem-focused, health promotion, and risk diagnoses. Within the problem-focused and risk categories,youcanalsofindtheuseofsyndromes.Definitionsforeachofthese categories,andsyndromes,canbefoundintheGlossaryofTerms(p.133). Whatarenursingdiagnoses,andwhyshouldIusethem? A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a susceptibility for that response, by an individual, family, group, or community. It requires a nursing assessment to correctly diagnose your patient—you cannot safely standardize nursing diagnoses by using a medical diagnosis. Although it is true that there are common nursing diagnoses that frequently occur in patients with various medicaldiagnoses,thefactisthatyouwillnotknowifthenursingdiagnosisis 116 accurate unless you assess for defining characteristics and establish that key relatedfactorsexist. Anursing diagnosisprovidesthebasisforselectionofnursinginterventions to achieve outcomes for which the nurse has accountability. This means that nursing diagnoses are used to determine the appropriate plan of care for the patient, driving patient outcomes and interventions. You cannot standardize a nursing diagnosis; however, it is possible to standardize nursing interventions once you have selected the appropriate outcome for the nursing diagnosis, as interventionsshouldbeevidence-basedwheneverpossible! NursingdiagnosesalsoprovideastandardlanguageforuseintheElectronic HealthRecord(EHR),enablingclearcommunicationamongcareteammembers and the collection of data for continuous improvement in patient care. Using a diagnostic terminology that provides clinical decision support through the articulation of diagnostic indicators (signs/symptoms/etiologies) can enable linkages to nursing assessment tools, thus improving diagnostic accuracy and nurses’clinicalreasoningskills. Whatisthedifferencebetweenamedicaldiagnosisandanursing diagnosis? A medical diagnosis deals with a disease or medical condition. A nursing diagnosisdealswithactualorpotentialhumanresponsestohealthproblemsand lifeprocesses.Forexample,amedicaldiagnosisofcerebrovascularattack(CVA or stroke) provides information about the patient's pathology. The nursing diagnoses of impaired verbal communication, risk for falls, interrupted family processes, chronic pain, and powerlessness provide a more holistic understandingoftheimpactofthatstrokeonthispatientandhisfamily—they also direct nursing interventions to obtain patient-specific outcomes. If nurses onlyfocusonthestroke,theymightmissthechronicpainthepatientsuffers,his senseofpowerlessness,andeventheinterruptedfamilyprocesses.Theseissues will impact his potential discharge home, his ability to manage his new therapeutic regimen, and his overall quality of life. It is also important to remember that, while a medical diagnosis belongs only to the patient, nursing treatsthepatientandhisfamily,sodiagnosesregardingthefamilyarecritical because they have the potential to impact—positively or negatively—the outcomesyouaretryingtoachievewiththepatient. Whatarethecomponentpartsofadiagnosis,andwhatdothey meanfornursesinpractice? 117 Thereareseveral“parts”ofanursingdiagnosis:thediagnosticlabel,definition, theassessmentcriteriausedtodiagnose,thedefiningcharacteristics,andrelated factorsorriskfactors.AswenotedinChapter8,NANDA-Ihasstrongconcerns about the safety of using terms (diagnosis labels) that have no standardized meaningandnoassessmentcriteria.Pickingadiagnosisfromalist,ormaking up a term at a patient's bedside, is a dangerous practice for a couple of very important reasons. First, communication between health care team members mustbeclear,concise,andconsistent.Ifeverypersondefinesa“diagnosis”ina different way, there is no clarity. Second, how can we assess the validity of a diagnosis,orthediagnosticabilityofanurse,ifwehavenodatatosupportthe diagnosis? Itisalsohelpfultoreviewtheat-riskpopulationsandassociatedconditionsto consider nursing diagnoses that might be higher frequency in certain populations,forexample. LetuslookattheexampleofMrs.Minthecasestudybelow.Thisexample shows the problem with “picking” a diagnosis from a list of terms, without knowledge of the definition or the assessment data needed to diagnose the response. CaseStudy Mrs. M is a 72-year-old woman admitted for a mastectomy due to invasive carcinoma.Shearrivedinthepreoperativeunitwithherdaughter,at6:00am asscheduled.Herintravenousaccesswasstartedbythenightshiftnurse,and her vitals and part of her admission assessment were completed. You notice that the nurse caring for Mrs. M previously documented three nursing diagnoses in the chart: anxiety (00146), disturbed body image (00118), and deficient knowledge (00126). Based on that communication, you form a picture in your mind of this patient and how you will want to approach her. Theanxietyalertsyouthatyouwillwanttobecalmingandreassuringinyour approach,whilethedisturbedbodyimagediagnosisspeakstoherimpending surgicalprocedurewhichwillimpactapartofthebodythatisassociatedwith femalesexuality.Thediagnosisofdeficientknowledgeconcernsyoubecause you must be sure that she understands why she is here, the purpose of the surgery today, and potential complications prior to releasing her to the operatingroom. A little while later, you complete your assessment and find that you have identified some differences compared to the previous nurse's assessment. 118 Althoughyouunderstandwhyyourcolleaguemayhaveselectedthediagnosis of anxiety, you know that fear (00148) is clearly more accurate—although Mrs. M states she is anxious, she tells you that she is concerned about the outcomeofthesurgery,andisworriedthatthesurgeonmightnotbeableto “get all of the cancer.” Because fear is a response to a threat that is consciously recognized as a danger, but anxiety is related to an unknown or nonspecificthreat,youmakethemoreaccuratediagnosisoffear. Your assessment did not confirm any of the defining characteristics of deficientknowledge,nordidyouidentifyanyrelatedfactors.Infact,youlearn that this is the patient's second mastectomy (her previous was five years earlier);sheiswellinformedabouthercancertypeandthepotentialtreatment optionsthatmayfollowsurgery,dependingontheoutcomeoftheprocedure. She is easily able to identify for you the type of procedure she is going to have, the expected length of the procedure, and the most common risks and negative outcomes she could experience. She is a former college professor, and you find her highly intelligent, motivated to make good decisions, and wellinformed. Finally,sheshowsnosignsofdisturbedbodyimage. She chose not to have reconstructivesurgerywithherfirstmastectomy,andindicatesshehasmade thesamedecisionforthisprocedure.Sheisawidow,andsaysthatshedoes not feel the additional risks are worth taking. She appears quite comfortable with her body image, even joking that her breast size was “small to begin with,”sothereis“littledifferencethatisnoticeable.” You do notice that Mrs. M seems to be exhibiting some guarding behavior whenshemoves,andsheappearstobeuncomfortable.Whenyouinquire,you learn that she has severe spinal stenosis and usually uses a “narcotic pain patch”almostdailyforpain,whichshehasnotbeenabletouseforthepast24 hoursbecauseofthesurgery.Sheindicatesherpainisa6to7onascaleof1 to10,with10beingthemostexcruciatingpainpossible.Shealsonotesthat she has been lying on the stretcher now for almost two hours, and that she normallytriestomovearoundduringthemorningto“loosenup,”whichshe findshelpseaseherpain.Althoughyouareunabletomedicateher,andsheis abouttogotosurgery,youhelpherchangeherpositionandapplysomeheat totheareaofdiscomfort,whichshenotesissomethingshealsodoestohelp whensheisathome. 119 You amend the nursing record to indicate two diagnoses: fear and chronic pain(00133). Whenyoumentionyourdifferenceinassessmenttoyourcolleaguethenextday, she responds, “I pick knowledgedeficit for every patient—everyone can learn something.Andshewashavingamastectomy,soobviouslysheisgoingtohave bodyimageissues.” Clearly,thisisfaultythinking,andhadyourcolleaguevalidatedthediagnoses by reviewing the definitions, defining characteristics, and related factors—and by speaking with the patient, it would have been obvious that these were not relevantnursingdiagnoses. Focusing on your colleague's “typical diagnoses” for mastectomy patients, deficientknowledgeanddisturbedbodyimage,wasnotappropriateforMrs.M, as she clearly understood her disease, its treatment options, and possible consequences. Further, she exhibited no concerns with body image and had made her own decision regarding reconstructive surgery. Focusing on these “standard”diagnoses,forwhichtherewasnoassessmentsupportnoted,wastes the nurse's time and leads to provision of unnecessary care, while at the same time limiting time spent on care that could impact the patient's outcomes. Likewise, your colleague failed to conduct a complete assessment that would have led to the important diagnosis of chronic pain. This error in clinical reasoningdelayedtheinitiationofnonpharmacologicalinterventionsthatcould havemadehertimeinyourunitmorecomfortable. HowdoIwriteacareplanincludinganursingdiagnosisfor patientswithaspecificmedicalcondition/diagnosis,e.g., congestiveheartfailureorkneereplacement? Nursing diagnoses are individual (family, group, or community) responses to health problems or life processes. This means one cannot standardize nursing diagnoses based on medical diagnoses or procedures. Although many patients with congestive heart failure may exhibit nursing diagnoses such as activity intolerance(00092)or decreasedcardiacoutput (00029), others may not have theseresponsesormayonlybeatriskforthematthispointintheirtrajectory. Patients who are about to undergo a knee replacement may suffer from acute pain (00132), chronic pain (00133), risk for falls (00155), and/or impaired walking(00088);othersmightrespondwithanxiety(00146)orfatigue(00093). Without a nursing assessment, it is simply impossible to determine the correct diagnosis,andthusdoingsodoesnotcontributetosafe,qualitypatientcare. 120 The care plan for each individual patient is based on assessment data. The assessment data and patient preferences guide the nurse in prioritizing nursing diagnoses and interventions—the medical diagnosis is only one piece of assessmentdataandthereforecannotbeusedastheonlydeterminingfactorfor selectinganursingdiagnosis.Athinkingtoolusedbyourcolleaguesinmedicine canbeusefulasyoudetermineyourdiagnoses:itusestheacronymSEATOW (Rencic2011, Fig.6.5). Itisalwaysagoodideatoaskacolleague,oranexpert,forasecondopinion ifyouareunsureofthediagnosis.Isthediagnosisyouareconsideringtheresult of a “eureka” moment? Did you recognize a pattern in the data from your assessmentandpatientinterview?Canyouconfirmthispatternbyreviewingthe diagnosticindicators?Didyoucollectdatathatseemtoopposethisdiagnosis? Canyoujustifythediagnosisevenwiththedata,ordothedatasuggestyouneed to look deeper? Think about your thinking—was it logical, reasoned, built on your knowledge of nursing science and the human response that you are diagnosing?Doyouneedadditionalinformationabouttheresponsebeforeyou arereadytoconfirmit?Areyouoverconfident?Thiscanhappenwhenyouare accustomedtopatientspresentingwithparticulardiagnoses,andsoyou“jump” toadiagnosis,ratherthantrulyapplyingclinicalreasoningskills.Finally,what otherdatamightyouneedtocollectorreviewinordertovalidate,confirm,or ruleoutapotentialnursingdiagnosis?UseoftheSEATOWacronymcanhelp you validate your clinical reasoning process and increase the likelihood of accuratediagnosis. Howmanydiagnosesshouldmypatienthave? Studentsareoftenencouragedtoidentifyeverydiagnosisthatapatienthas—this is a learning method to improve clinical reasoning and mastery of nursing science.However,inpractice,itisimportanttoprioritizenursingdiagnoses,as theseshouldformthebasisfornursinginterventions.Youshouldconsiderwhich diagnosesarethemostcritical—fromthepatient'sperspectiveaswellasfroma nursing perspective—and the resources and time available for treatment.Other diagnoses may require referral to other health care providers or settings, e.g., home health care, a different hospital unit, skilled nursing facility, etc. In a practicalsense,havingonediagnosisperNANDA-Idomain,oraminimumof5 or10diagnoses,doesnotreflectreality.Althoughitisimportanttoidentifyall diagnoses(problem-focused,risk, andhealthpromotion),nursesmustfocuson high-priority, high-risk diagnoses first; other diagnoses may be added later (moved up on the priority list) to replace those that are resolved or for which interventions are clearly being effective. Also, if the patient's condition 121 deteriorates or additional data are identified that leads to a more urgent diagnosis,prioritizationofthediagnosesmustbereaddressed.Planningcarefor patients is not a “one time thing”—as with all facets of the nursing process, it needstobeconstantlyreevaluatedandadjustedtomeettheneedsofthepatient andhisfamily. CanIchangeanursingdiagnosisafterithasbeendocumentedin apatientrecord? Absolutely! As you continue to assess your patient and collect additional data, you may find that your initial diagnosis was not the most critical—or your patient'sconditionmayhaveresolved,ornewdatabecomeavailablethatrefocus thepriority.Itisveryimportanttocontinuallyevaluateyourpatienttodetermine ifthediagnosisisstillthemostaccurateforthepatientatanyparticularpointin time. CanIdocumentnursingdiagnosesoffamilymembersofapatient inthepatientchart? Documentation rules vary by organization and particular state and country requirements. However, the concept of family-based care is becoming quite standard, and certainly diagnoses that impact the patient, and which can contributetopatientoutcomes,shouldbeconsideredbynurses.Forexample,ifa patient is admitted for exacerbation of a chronic condition, and the nurse recognizesthatthespouseisexhibitingsigns/symptomsofcaregiverrolestrain (00061), it is critical that she confirms or refutes this diagnosis. Taking advantageofthepatient'shospitalization,thenursecanworkwiththespouseto mobilizeresourcesforcaregivingathome,suchastoidentifysourcesofsupport for stress management, respite, and financial concerns. A review of the therapeuticregimen,alongwithrecommendationstosimplifyororganizecare, may be very helpful. Diagnosis and treatment of the spouse's caregiver role strainwillnotonlyimpactthecaregiver,butalsohavesignificantimpactonthe patient'soutcomeswhenhe/shereturnshome. Canallnursingdiagnosesbeusedsafelyandlegallyinevery country? TheNANDA-Iclassificationrepresentsinternationalnursingpractice;therefore, all diagnoses will not be appropriate for every nurse in the world. Please see International Considerations on the Use of the NANDA-I Nursing Diagnoses (p.25). 122 9.6 QuestionsaboutDefiningCharacteristics Whataredefiningcharacteristics? Defining characteristics are observable cues/inferences that cluster as manifestationsofaproblem-focusedorhealth-promotiondiagnosisorsyndrome. Thisimpliesnotonlythingsthatthenursecansee,butalsothingsthatareseen, heard(e.g.,thepatient/familytellsus),touched,orsmelled. Thisbookisusingtheterms“associatedconditions”and“at-risk populations”withmanyofthediagnoses.Thesearenotconditions whichwe,asnurses,canindependentlyimpact.Howcanweuse theminassessment? The intent behind these new categories is to provide information to the professional nurse to support her diagnosis and also to clearly identify those assessment data that she can and cannot directly influence. By separating out theseindicators,itallowsthenursetomorequicklyrecognizerelatedfactorsat which to aim her interventions, or defining characteristics which might require symptom control. These new categories of data are another way of providing decisionsupporttonursesatthepointofcare. Arethedefiningcharacteristicsinthebookarrangedinorderof importance? No! The defining characteristics (and related/risk factors) are listed in alphabetical order, based on the original English language version. Ultimately, thegoalistoidentifycriticaldefiningcharacteristics—thosethatmustbepresent forthediagnosistobemade.Asthatoccurs,wewillreorganizethediagnostic indicatorsintoorderofimportance. HowmanydefiningcharacteristicsdoIneedtoidentifyto diagnoseapatientwithaparticularnursingdiagnosis? That is a difficult question, and it really depends on the diagnosis. For some diagnoses,onedefiningcharacteristicisallthatisnecessary—forexample,with the health promotion diagnoses, a patient's expressed desire to enhance some facet of a human response is all that is required. Other diagnoses require a clusterofsymptoms,probablythreeorfour,tohaveaccuracyindiagnosis.Inthe future, we would like to be able to limit the number of diagnostic indicators provided within NANDA-I, because long lists of signs/symptoms are not necessarilyclinicallyuseful.Asmoreresearchisconductedonnursingconcepts, 123 thisworkwillbefacilitated. 9.7 QuestionsaboutRelatedFactors HowmanyrelatedfactorsdoIneedtoidentifytodiagnosea patientwithaparticularnursingdiagnosis? As with the defining characteristics, this really depends on the diagnosis. One factor is probably not adequate, and this is especially true if you are using a medicaldiagnosisaloneasarelatedfactor.AswesawearlierinthecaseofMrs. M,thiswouldmeanthateverypatientadmittedforamastectomygets“labelled” withdisturbedbodyimage (00118), or every patient with a surgical procedure gets “labelled” with acute pain (00132). This practice is not a diagnostic practice;ittrulyislabellingapatientbasedonanassumptionthatoneperson's responsewillbeexactlythesameasanother's.Thisisanerroneousassumption at best, and can risk misdiagnosis and lead to nurses spending time on unnecessaryinterventions.Intheworstcasescenario,itcanleadtoanerrorof omission in which a significant diagnosis goes unnoticed, and leads to significantproblemswithpatientcareandqualityoutcomes. RelatedfactorswithinNANDA-Idiagnosesarenotalwaysfactors thatanursecaneliminateordecrease.ShouldIincludethemina diagnosisstatement? Afterseparatingoutrelatedfactorsfromthepreviouseditionoftheterminology intothecategoriesat-riskpopulationsandassociatedconditions,therearemany diagnoses with few or no related factors that are modifiable by the nurse. Therefore, during this next cycle, we will be focusing on developing more clinically useful related factors on which you could intervene and for which intervention could lead to a decrease in or cessation of the unfavorable human responseyouhavediagnosed. 9.8 QuestionsaboutRiskFactors HowmanyriskfactorsdoIneedtoidentifytodiagnoseapatient withaparticularrisknursingdiagnosis? As with the defining characteristics and related factors, this really depends on thediagnosis.Forexample,inthenewdiagnosisriskforpressureulcer,havinga 124 BradenQscoreof≤16inachild,oraBradenscalescoreof≤18inanadult,or alowscoreontheRiskAssessmentPressureSore(RAPS)scalemightbeallthat is needed to diagnosis this risk. That is because these standardized tools have been clinically validated as predictors of risk for pressure ulcer. For other diagnoses that do not yet have this level of diagnostic indicator validation, a clustering of risk factors is needed, although probably no more than three or four. Istherearelationshipbetweenrelatedfactorsandriskfactors, suchaswithdiagnosesthathaveaproblem-basedand/orhealth promotiondiagnosis,andariskdiagnosis? Yes! You should notice strong similarities between the related factors for a problem-focuseddiagnosisandtheriskfactorsofariskdiagnosisrelatedtothe sameconcept.Indeed,thelistsoffactorscouldbeidentical.Thesamecondition thatputsyouatriskforanundesirableresponsewouldmostoftenbeanetiology of that response if it were to occur. For example, in the diagnosis risk for disorganizedinfantbehavior(00115),environmentaloverstimulationisnotedas a risk factor. In the problem-focused diagnosis disorganized infant behavior (00116), environmental sensory overstimulation is noted as a related factor. In bothcases,thisissomethingforwhichmanynursinginterventionsareavailable whichcandecreasetheunfavorableresponseormodifyitsriskofoccurrence. 9.9 DifferentiatingbetweenSimilarNursing Diagnoses HowcanIdecidebetweendiagnosesthatareverysimilar—how doIknowwhichoneisthemostaccuratediagnosis? Accuracyindiagnosisiscritical!Avoidreachingaconclusiontooquickly,and use some easy tools to reflect on your decision-making process. SNAPPS (Rencic, 2011), a diagnostic aid that is used in medicine for differentiation between diagnoses, can be easily adapted for nursing. Using this tool, you summarizethedatayoucollectedinyour interviewandassessment,aswellas any other relevant data from the patient record. You then seek to narrow the differential between the diagnoses—eliminate the data that fit for both diagnoses, so you are left with only data that differ. Analyze the data—is a pattern more evident now that you are looking at a narrower cluster of data? Probe a colleague, professor, or expert when you have doubts or unanswered 125 questions—do not ask for the answer; ask them to walk through their thinking with you to help you determine the more appropriate diagnosis. Plan a managementstrategy,whichshouldincludefrequentreassessment,especiallyat the beginning of the plan, to ensure that your diagnosis truly was accurate. Finally, select case-related issues for further investigation and study. Find an article, a case study in a journal, or information from a recent text that can deepen your understanding of the human response you have just diagnosed ( Fig.9.1). Fig.9.1TheSNAPPSdiagnosticaid(Rencic,2011) CanIadd“riskfor”toaproblem-focuseddiagnosistomakeita riskdiagnosis?Orremove“riskfor”fromariskdiagnosisto makeitaproblem-focuseddiagnosis? Simplyput,theanswertothisquestionis“no.”Infact,torandomly“makeup”a label is meaningless and, we believe, could be dangerous. Why? Ask yourself thesequestions:Howisthediagnosisdefined?Whataretheriskfactors(forrisk diagnoses) or the defining characteristics/related factors (for problem-focused diagnoses)thatshouldbeidentifiedduringyournursingassessment?Howwould other people know what you mean if the diagnosis is not clearly defined or provided in a resource format (text, computer system) to review and to enable validationofthediagnosis? 126 If you identify a patient who you feel might be at risk for something, for whichthereisnotanursingdiagnosis,itisbettertodocumentveryclearlywhat itisthatyouareseeinginyourpatientandwhyyoufeelhe/sheisatrisk,sothat otherscaneasilyfollowyourclinicalreasoning.Thisiscriticalforpatientsafety. When considering whether a risk diagnosis should be modified to create an actual diagnosis, the question should be asked: “Is this already identified as a medicaldiagnosis?”Ifso,thereisnoreasontorenameitasanursingdiagnosis, unless there is a distinctive view that nursing would bring to that phenomena, which would be different from that of medicine. For example, “anxiety” is a nursing/medical/psychiatric diagnosis—and all disciplines may approach it differently, from their disciplinary perspectives. On the other hand, when consideringadiagnosissuchas“pneumonia”(infection),whatviewpointwould the nurse bring that would differ from that of medicine? To date, we have not identifiedthattherewouldbeadifferenceintreatmentamongdisciplines,soitis a medical diagnosis for which nurses utilize nursing interventions. Perfectly acceptable! Finally, if you have identified a human response that you believe should be identified as a nursing diagnosis, check out our information on diagnosis development, review the literature, or work with experts to develop it, and submitittoNANDA-I.Itisgenerallynursesinpracticewhoidentifydiagnoses thatweneed,whichallowstheterminologytogrowortoberefinedandtobetter reflecttherealityofpractice. 9.10 QuestionsRegardingtheDevelopmentofa TreatmentPlan HowdoIfindinterventionstobeusedwithnursingdiagnoses? Interventions should be directed at the related or etiologic factors whenever possible. Sometimes, however, that is not possible and so interventions are chosen to control symptoms (defining characteristics). Take a look at two differentsituationsusingthesamediagnosis: –Acutepain(relatedfactors:inappropriateliftingtechniqueandbodyposture; defining characteristics: report of sharp back pain, guarding behavior, and positioningtoavoidpain). – Acute pain (related factors: surgical procedures; defining characteristics: verbal report of sharp incisional pain, guarding behavior, and positioning to avoidpain). 127 Inthefirstexample,thenursecanaiminterventionsatthesymptoms(providing painreliefinterventions)butalsoattheetiology(providingeducationonproper liftingtechniques,properbodymechanics,andexercisestostrengthenthecore musclesandbackmuscles). In the second example, the nurse cannot intervene to remove the causative factor (the surgical procedure), so her interventions are all aimed at symptom control(providingpainreliefinterventions). Choosinginterventionsforaspecificpatientisalsoinfluencedbytheseverity and duration of the nursing diagnosis, effectiveness of interventions, patient preferences, organizational guidelines, and ability to perform the intervention (e.g.,istheinterventionrealistic?). Whendoesanursingcareplanneedrevision? There is not a clear-cut standard for the frequency for revision—it depends on the patient's condition, the severity and complexity of care, and organizational standards.Ingeneral,aminimumguidelinewouldbeonceevery24hours—but in intensive care environments or with complex patient conditions, it is often doneoneormoretimespershift. Whatdoesitmeanto“revise”thecareplan?Thisrequiresareassessmentof thepatient'scurrentconditionstoidentifycurrenthumanresponsesthatrequire nursing intervention—and that means reviewing those conditions that were previouslyidentifiedtodeterminethefollowing: –Aretheystillpresent? –Aretheystillhighpriority? –Aretheyimproving,stayingthesame,orworsening? –Arethecurrentinterventionsbeingeffective? –And,perhapsmostimportantly,didyouidentifythecorrectresponsetotreat (didyoudiagnoseaccurately)? Thesequestionsrequireongoingreassessmentofthepatient.Whenintervention isnotbeingsuccessfulinreachingdeterminedpatientoutcomes,continuingthe same intervention may not be the best policy! Is it possible that there is somethingelsegoingonthatwasnotnotedpreviously?Whatotherdatamight youneedtocollecttoidentifyotherissues?Isthepatientinagreementwithyou about prioritization of care? Are there other interventions that might be more effective? All of this is involved in reviewing and revising the plan of care. Remember that the nursing care plan is a computerized (or written) representationofyourclinicaljudgment—itisnotsomethingyou“do”andthen forgetabout;itshoulddriveeverysinglestepyouundertakeinthepatient'scare 128 —every question you ask, every diagnostic test result, every piece of physical examdataaddmoreinformationtoconsiderwhenlookingatpatientresponses, which means assessment and evaluation should be occurring every time you lookat,talkwith,ortouchapatientandeverytimeyouinteractwiththepatient's familyorenter/reviewdatainthepatient'srecord. Clinical reasoning, diagnosis, and appropriate treatment planning require mindful,reflectivepractice.Itisnotatasktocheckoffsoyoucanmoveonto somethingelse—itisthekeycomponentofprofessionalnursingpractice. 9.11 QuestionsaboutTeaching/LearningNursing Diagnoses IneverlearnedaboutnursingdiagnosiswhileIwasinschool. Whatisthebestwaytostudynursingdiagnosis? Youaregettingagoodstartbyusingthisbook!Butfirst,wereallyrecommend that you spend some time learning/reviewing the concepts that support the diagnoses.Thinkabouthowmuchyouknowaboutventilation,coping,activity tolerance, mobility, feeding patterns, sleep patterns, tissue perfusion, etc. You really need to start with a solid understanding of these “neutral” phenomena; what is normal? What would you expect to see in a healthy patient? What physiological/psychological/sociological factors influence these normal patterns? Once you really understand the concepts, then you can move into deviationsfromthenorm—howwouldyouassessforthese?Whatotherareasof the person's health might be impacted if a deviation occurred? What kinds of things would put someone at risk for developing an undesired response? What arethestrengthsthatpeoplemightdrawontoimprovethisareaoftheirhealth? Whatare nurses sayingaboutthese phenomena—what researchisbeingdone? Arethereclinicalguidelinesforpractice?Alloftheseareasofknowledgewill contribute to your understanding of nursing diagnosis—after all, nursing diagnosesnametheknowledgeofthediscipline.Itsimplyisnotenoughtopick up this book, or any other, and start writing down diagnoses that “sound like” they fit your patient, or that have been linked to a medical diagnosis in some standardizedway.Onceyoutrulyunderstandtheconcepts,youwillstarttosee the patterns in your assessment data that will point you to risk states, problem states,andstrengths—thenyoucanbegintosharpenyourunderstandingofthe diagnoses by reviewing the definitions and diagnostic indicators for the diagnosesthatseemtorepresentthemajorityofpatientresponsesthatyouseein 129 yourpractice.Therearecorediagnosesineveryareaofpractice,andthoseare theonesthatyouwillwanttofocusonsothatyoubuildexpertiseinthemfirst. ShouldIchooseonediagnosisfromeachofthe13domainsand combinethosediagnosesattheendofassessment? Althoughweknowthatsomeprofessorsteachthisway,itisnotamethodthat we support. Arbitrarily assigning a set number of diagnoses to consider is not practical and does not necessarily reflect the patient's reality. Also, as noted previously, the domains are not an assessment format. You should complete a nursingassessment,andasyouareconductingyourassessment,youmaybegin tohypothesizeaboutpotentialdiagnoses.Thatinturnshouldleadyoutomore focusedassessmenttoeitherruleoutorconfirmthosehypotheses.Assessmentis a fluid process—one piece of data may lead you back to previously obtained data, or it may require further in-depth assessment to collect additional information.Werecommendtheuseofanassessmentbasedonanursingmodel, suchasGordon'sfunctionalhealthpatterns.Althoughthetaxonomyiscurrently adapted from these patterns, the assessment framework provides support for nurses in conducting an interview and patient assessment, allowing (and encouraging!) fluid consideration of how data and information obtained from otherpatternsinteractwhileassessmentisoccurring. Myprofessorsdonotallowustouseriskdiagnoses,becausethey saywehavetofocusonthe“real”diagnoses.Arepatientrisk statesnot“real”? Absolutely!Riskdiagnosesareoftenthehighestprioritydiagnosisthatapatient mayhave—apatientwithasignificantvulnerabilitytoinfection,falls,apressure ulcer,orbleedingmayhavenomorecriticaldiagnosisthanthisrisk.Theprior useoftheterm“actual”diagnosismayhaveledtothisconfusion—somepeople interpreted this to mean that the actual (problem-focused) diagnosis was more “real”thantherisk.Thinkabouttheyoungwomanwhohasjustgivenbirthtoa healthy newborn baby—but who developed disseminated intravascular coagulationduringthispregnancyandhasahistoryofpostpartumhemorrhage. She most likely has no higher priority nursing diagnosis than riskforbleeding (00206)!Shemayhaveacutepain(00132)fromherepisiotomy,shemayhave anxiety (00146), and she may have readiness for enhanced breastfeeding (00106)—butanyperinatalnursewilltellyouthatthenumberonefocuswillbe theriskforbleeding! Ourbasicnursingcurriculumisalreadyfull.Whenandwho 130 shouldteachnursingdiagnoses? Nursing, as with other disciplines, is struggling to move from a content-laden educational system to a learner-based, reasoning-focused educational process. For at least the last several decades, the pattern within nursing education has been to try to include more and more information in lectures, readings, and assignments—leading to a pattern of “memorization and regurgitation” of knowledge, often followed by forgetting most of what was “learned” shortly thereafter. It simply does not work! The speed of knowledge development has increased exponentially—we cannot continue to teach every piece of information necessary. Instead, we need to teach core concepts, teach students howtoreason,howtodiscoverknowledgeandknowifitistrustworthy,andto know how to apply it. We have to give them the tools that lead to lifelong learning,andclinicalreasoningisprobablythemostcriticalofthesetools.But criticalreasoningrequiresafieldofknowledge—nursing,inthiscase—andthat requiresmasteryofourdisciplinaryknowledge,whichisrepresentedbynursing diagnoses. Every nursing professor needs to teach nursing diagnoses—in every course, and as the focus of the course. By teaching the concepts, students will learn about related disciplines, their diagnoses, and standard treatments. They will learnabouthumanresponsesandhowtheydifferunderavarietyofsituationsor by age, gender, culture, etc. Restructuring curricula to truly focus on nursing maysoundradical,butitistheonlywaytosolidlyprovidenursingcontenttothe nurses of our future. Teach the core diagnoses that cross all areas of practice first, then as students gain knowledge, teach the core specialty diagnoses. The remaining diagnoses—those that do not occur often or only occur in very specialized conditions—the students will learn as they practice and as they encounterpatientswhoexhibittheseresponses. 9.12 QuestionsaboutUsingNANDA-IinElectronic HealthRecords Isthereanyregulatorymandatethatpatientproblems, interventions,andoutcomesincludedinanelectronichealth recordshouldbestatedusingNANDA-Iterminology?Why shouldweneedtouseNANDA-Inursingdiagnoseswithan electronichealthsystem? 131 There is no regulatory mandate; however, NANDA International nursing diagnoses are strongly suggested by standards organizations for inclusion into the EHR. Several international expert papers and studies promote inclusion of theNANDA-ItaxonomyintotheEHRbasedonseveralreasons: – The safety of patients requires accurate documentation of health problems (e.g.,riskstates,actualdiagnoses,healthpromotiondiagnoses),andNANDAI is the single classification having a broad literature base (with many diagnoses evidence-based including LOE formats). Most importantly, NANDA-I diagnoses are comprehensive concepts including related factors and defining characteristics. This is a major difference from other nursing terminologies. – NANDA-I, NIC, and NOC (NNN) not only are the most frequently used classifications internationally; studies have shown these to be the most evidence-basedandcomprehensiveclassifications. – NANDA-I diagnoses are under continual refinement and development. The classification is not a single-author product—it is based on the work of professionalnursesaroundtheworld,membersandnonmembersofNANDA International (Anderson et al 2009; Bernhart-Just et al 2009; Keenan et al 2008; Lunney 2006; Lunney et al 2005; Müller-Staub 2007; Müller-Staub 2009;Müller-Staubetal2007). 9.13 QuestionsaboutDiagnosisDevelopmentand Review WhodevelopsandrevisesNANDA-Idiagnoses? New and revised diagnoses are submitted to the NANDA-I Diagnosis Development Committee (DDC) by nurses from around the world. Primarily, these nurses come from the areas of practice and education, although we have researchers and theorists who occasionally submit diagnoses, too. The DDC formulatesandconductsreviewprocessesofproposeddiagnoses.Thedutiesof the committee include but are not limited to: the review of newly proposed nursing diagnoses, proposed revisions, or proposed deletions of nursing diagnoses; soliciting and disseminating feedback from experts; implementing processes for review by the membership and voting by the general assembly/membershipondiagnosesdevelopmentmatters. Whyarecertaindiagnosesrevised? 132 Knowledge is constantly evolving within nursing practice, and as research clarifies and refines that knowledge, it is important that the NANDA-I terminologyreflectsthosechanges.Nursesinpractice,aswellaseducatorsand researchers, submit revisions based on their own work or a review of research literature. The purpose is to refine the diagnoses, providing information that enablesaccuracyindiagnosis. 9.14 QuestionsabouttheNANDA-IDefinitionsand ClassificationText HowdoIknowwhichdiagnosesarenew? Thenewandreviseddiagnosesarehighlightedinthesectionofthistextentitled ChangesandRevisions(p.4). WhenIreviewedtheinformaticscodesprovidedinthebook,I noticedthatthereweresomecodesmissing—doesthatmeanthat therearemissingdiagnoses? No,themissingcodesrepresentcodesthatwerenotassigned,ordiagnosesthat have been retired, or removed, from the taxonomy over time. Codes are not reused, but rather are retired along with the diagnosis. Likewise, unassigned codesareneverassignedlater,outofsequence,butsimplyremainpermanently unassigned. Whenadiagnosisisrevised,howdoweknowwhatwaschanged? Inoticedchangestosomediagnoses,buttheyarenotlistedas revisions—why? The section Changes and Revisions (p.4) provides detailed information on changes made in this edition. However, the best way to see each individual changeistocomparethecurrenteditionwiththepreviousone.Wedonotlistall of the edits made as we standardized terms for the diagnostic indicators, however, nor were these changes considered as revisions. There was an emphasis during the last two cycles to continue previous work of refining and standardizing terms of the defining characteristics, related factors, and risk factors.In addition,manyof thecurrentdiagnostic indicatorswereassigned to at-riskpopulationsandassociatedconditions.Thisisaworkinprogress,andit requires slow and meticulous work to ensure that changes do not impact the intendedmeaningoftheterms. 133 Whydonotallofthediagnosesshowalevelofevidence(LOE)? NANDA International did not begin using LOE criteria until 2002. Therefore, diagnoses that were entered into the taxonomy prior to that time do not show LOE criteria because none was identified when the diagnoses were submitted. Alldiagnosesthatexistedinthetaxonomyin2002were“grandfathered”intothe taxonomy, with those clearly not meeting criteria (e.g., no identified related factors, multiple diagnostic foci in the label, etc.) targeted for revision or removal over the next few editions. The last of these diagnoses are slotted for removalinthenextedition.Westronglyencourageworkontheolderdiagnoses tobringthemuptoanLOEconsistentwithaminimumof2.1formaintenancein thetaxonomicstructure. Whathappenedtothereferences?WhydoesnotNANDA-Iprint allofthereferencesusedforallofthediagnoses? NANDA-I began publishing references by asking submitters to identify their threemostimportantreferences.Inthe2009–2011edition,webegantopublish the full list of references, due to the large number of requests received from individuals regarding the literature reviewed for different diagnoses. We have now heard from many individuals that they would prefer to have access to the referencesonline,ratherthaninthebook.Therehavealsobeenconcernsraised about the environmental impact of a larger book, and recommendations to publishinformationspecifictoresearchersandinformaticistselectronically,for thosewhowanttoaccessthisinformation.Afterdiscussion,wedeterminedthat this course of action would be the best one for the purposes of this text. Therefore, all references that we have for all diagnoses will be located on the companion websites for this text (www.thieme.com/nanda-i and http://MediaCenter.thieme.com)toenableeaseofsearchingforandretrieving thisinformation. 9.15 References AndersonCA,KeenanG,JonesJ.Usingbibliometricstosupportyourselection ofanursingterminologyset..ComputInformNurs.2009;27(2):82–90 Bernhart-Just A, Hillewerth K, Holzer-Pruss C, Paprotny M, Zimmermann Heinrich H. Die elektronische Anwendung der NANDA-, NOC- und NICKlassifikationen und Folgerungen für die Pflegepraxis.. Pflege. 2009; 22(6):443–454 134 Kamitsuru S. Kango shindan seminar shiryou [Nursing diagnosis seminar handout].KangoLaboratory(Japanese);2008 KeenanGM,TschannenD,WesleyML.Standardizednursingterminologiescan transformpractice..JNursAdm.2008;38(3):103–106 LunneyM.NANDAdiagnoses,NICinterventions,andNOCoutcomesusedin an electronic health record with elementary school children.. J Sch Nurs. 2006;22(2):94–101 Lunney M. Critical need to address accuracy of nurses’ diagnoses.. OJIN: OnlineJIssuesNurs.2008;13(1) Lunney M, Delaney C, Duffy M, Moorhead S, Welton J. Advocating for standardized nursing languages in electronic health records.. J Nurs Adm. 2005;35(1):1–3 Müller-Staub M. Evaluation of the Implementation of Nursing Diagnostics: A Study on the Use of Nursing Diagnoses, Interventions and Outcomes in NursingDocumentation.Wageningen:Ponsen&Looijen;2007 Müller-Staub M. Preparing nurses to use standardized nursing language in the electronic health record. Studies in health technology and informatics.. ConnectingHealthHumans.2009;146:337–341 Müller-StaubM,LavinMA,NeedhamI,vanAchterbergT.Meetingthecriteria ofanursingdiagnosisclassification:EvaluationofICNP,ICF,NANDAand ZEFP..IntJNursStud.2007;44(5):702–713 Rencic J.Twelve tips for teachingexpertiseinclinicalreasoning..MedTeach. 2011;33(11):887–892 135 10 GlossaryofTerms 10.1 NursingDiagnosis 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,orcommunity.Anursingdiagnosisprovidesthebasis for selection of nursing interventions to achieve outcomes for which the nurse has accountability (approved at the Ninth NANDA Conference; amended in 2009and2013). 10.1.1 Problem-FocusedNursingDiagnosis A clinical judgment concerning an undesirable human response to health conditions/life processes that exists in an individual, family, group, or community. To make a problem-focused diagnosis, the following must be present: defining characteristics (manifestations, signs, and symptoms) that cluster in patterns of related cues or inferences. Related factors (etiological factors) that are related to, contribute to, or antecedent to the diagnostic focus are also required. 10.1.2 HealthPromotionNursingDiagnosis Aclinicaljudgmentconcerningmotivationanddesiretoincreasewellbeingandtoactualizehealthpotential. These responses are expressed by a readiness to enhance specific health behaviors,andcanbeusedinanyhealthstate.Inindividualswhoareunableto express their own readiness to enhance health behaviors, the nurse may determineaconditionforhealthpromotionexistsandactontheclient'sbehalf. Health promotion responses may exist in an individual, family, group, or community. 10.1.3 RiskNursingDiagnosis A clinical judgment concerning the susceptibility of an individual, family, group, or community for developing an undesirable human response to 136 healthconditions/lifeprocesses. To make a risk-focused diagnosis, the following must be present: supported byriskfactorsthatcontributetoincreasedsusceptibility. 10.1.4 Syndrome A clinicaljudgment concerning aspecificcluster ofnursing diagnoses that occur together, and are best addressed together and through similar interventions. To use a syndrome diagnosis, the following must be present: two or more nursingdiagnosesmustbeusedasdefiningcharacteristics.Relatedfactorsmay beusediftheyaddclaritytothedefinition,butarenotrequired. 10.2 DiagnosticAxes 10.2.1 Axis Anaxisisoperationallydefinedasadimensionofthehumanresponse thatisconsideredinthediagnosticprocess.Therearesevenaxesthatparallelthe InternationalStandardsReferenceModelforaNursingDiagnosis. –Axis1:thefocusofthediagnosis – Axis 2: subject of the diagnosis (individual, family, group, caregiver, community) –Axis3:judgment(impaired,ineffective,etc.) –Axis4:location(bladder,auditory,cerebral,etc.) –Axis5:age(neonate,infant,child,adult,etc.) –Axis6:time(chronic,acute,intermittent) –Axis7:statusofthediagnosis(problem-focused,risk,healthpromotion) The axes are represented in the labels of the nursing diagnoses through their values. In some cases, they are named explicitly, such as with the diagnoses ineffective community coping and compromised family coping, in which the subject of the diagnosis (in the first instance “community” and in the second instance “family”) is named using the two values “community” and “family” takenfromAxis2(subjectofthediagnosis).“Ineffective”and“compromised” aretwoofthevaluescontainedinAxis3(judgment). In some cases, the axis is implicit, as is the case with the diagnosis activity intolerance,inwhichthesubjectofthediagnosis(Axis2)isalwaysthepatient. In some instances, an axis may not be pertinent to a particular diagnosis and 137 thereforeisnotpartofthenursingdiagnosticlabel.Forexample,thetimeaxis maynotberelevanttoeverydiagnosis.Inthecaseofdiagnoseswithoutexplicit identificationofthesubjectofthediagnosis,itmaybehelpfultorememberthat NANDA-Idefinespatientas“anindividual,family,group,orcommunity.” Axis 1 (the focus of the diagnosis) and Axis 3 (judgment) are essential components of a nursing diagnosis. In some cases, however, the focus of the diagnosis contains the judgment (e.g., nausea); in these cases, the judgment is not explicitly separated out in the diagnostic label. Axis 2 (subject of the diagnosis)isalsoessential,although,asdescribedabove,itmaybeimpliedand thereforenotincludedinthelabel.TheDDCrequirestheseaxesforsubmission; theotheraxesmaybeusedwhererelevantforclarity. 10.2.2 DefinitionsoftheAxes Axis1:TheFocusoftheDiagnosis The focus of the diagnosis is the principal element or the fundamental and essential part, the root, of the diagnostic concept. It describes the “human response”thatisthecoreofthediagnosis. The focus of the diagnosis may consist of one or more nouns. When more thanonenounisused(e.g.,activityintolerance),eachonecontributesaunique meaning to the focus of the diagnosis, as if the two were a single noun; the meaning of the combined term, however, is different from when the nouns are stated separately. Frequently, an adjective (spiritual) may be used with a noun (distress)todenotethefocusofthediagnosisspiritualdistress(see Table8.1). Axis2:SubjectoftheDiagnosis Theperson(s)forwhomanursingdiagnosisisdetermined.ThevaluesinAxis2 thatrepresenttheNANDA-Idefinitionof“patient”arethefollowing: –Individual:asinglehumanbeingdistinctfromothers,aperson –Caregiver:afamilymemberorhelperwhoregularlylooksafterachildora sick,elderly,ordisabledperson – Family: two or more people having continuous or sustained relationships, perceiving reciprocal obligations, sensing common meaning, and sharing certainobligationstowardothers;relatedbybloodand/orchoice –Group:anumberofpeoplewithsharedcharacteristics – Community: a group of people living in the same locale under the same governance;examplesincludeneighborhoodsandcities Axis3:Judgment 138 Adescriptorormodifierthatlimitsorspecifiesthemeaningofthefocusofthe diagnosis.Thefocusofthediagnosistogetherwiththenurse'sjudgmentaboutit formsthediagnosis.ThevaluesinAxis3arefoundin Table8.2: Axis4:Location Describes the parts/regions of the body and/or their related functions—all tissues,organs,anatomicalsites,orstructures.ForthelocationsinAxis4,see Table8.3. Axis5:Age Referstotheageofthepersonwhoisthesubjectofthediagnosis(Axis2).The valuesinAxis5arenotedbelow,withalldefinitionsexceptthatofolderadult beingdrawnfromtheWorldHealthOrganization(2013): –Fetus:unbornhumanmorethan8weeksafterconception,untilbirth –Neonate:person<28daysofage –Infant:person>28daysand<1yearofage –Child:personaged1to9years,inclusive –Adolescent:personaged10to19years,inclusive –Adult:personolderthan19yearsofageunlessnationallawdefinesaperson asbeinganadultatanearlierage –Olderadult:person>65yearsofage Axis6:Time Describesthedurationofthediagnosticconcept(Axis1).ThevaluesinAxis6 areasfollows: –Acute:lasting<3months –Chronic:lasting>3months –Intermittent:stoppingorstartingagainatintervals,periodic,cyclic –Continuous:uninterrupted,goingonwithoutstop Axis7:StatusoftheDiagnosis Refers to the actuality or potentiality of the problem/syndrome or health promotion opportunity to the categorization of the diagnosis as a health promotion diagnosis. The values in Axis 7 are problem-focused, health promotion,risk. 10.3 ComponentsofaNursingDiagnosis 139 10.3.1 DiagnosisLabel Providesanameforadiagnosisthatreflects,ataminimum,thefocusof the diagnosis (from Axis 1) and the nursing judgment (from Axis 3). It is a concise term or phrase that represents a pattern of related cues. It may include modifiers. 10.3.2 Definition Provides a clear, precise description; delineates its meaning and helps differentiateitfromsimilardiagnoses. 10.3.3 DefiningCharacteristics Observablecues/inferencesthatclusterasmanifestationsofaproblemfocused, health promotion diagnosis or syndrome. This implies not only those things that the nurse can see, but also things that are seen, heard (e.g., the patient/familytellsus),touched,orsmelled. 10.3.4 RiskFactors Environmental factors and physiological, psychological, genetic, or chemicalelementsthatincreasethevulnerabilityofanindividual,family,group, orcommunitytoanunhealthyevent.Onlyriskdiagnoseshaveriskfactors. 10.3.5 RelatedFactors Factorsthatappeartoshowsometypeofpatternedrelationshipwiththe nursing diagnosis. Such factors may be described as antecedent to, associated with, related to, contributing to, or abetting. Only problem-focused nursing diagnosesandsyndromesmusthaverelatedfactors;healthpromotiondiagnoses mayhaverelatedfactors,iftheyhelpclarifythediagnosis. 10.3.6 At-RiskPopulations Groupsofpeoplewhoshareacharacteristicthatcauseseachmemberto besusceptibletoaparticularhumanresponse.Thesearecharacteristicsthatare notmodifiablebytheprofessionalnurse. 10.3.7 AssociatedConditions Medical diagnoses, injury procedures, medical devices, or pharmaceuticalagents;theseconditionsarenotindependentlymodifiablebythe professionalnurse. 140 10.4 DefinitionsforClassificationofNursing Diagnoses 10.4.1 Classification Thearrangementofrelatedphenomenaintaxonomicgroupsaccording to their observed similarities; a category into which something is put (English OxfordLivingDictionaryOn-Line2017). 10.4.2 LevelofAbstraction Describestheconcreteness/abstractnessofaconcept: – Very abstract concepts are theoretical, may not be directly measurable, are defined by concrete concepts, are inclusive of concrete concepts, are disassociated from any specific instance, are independent of time and space, havemoregeneraldescriptors,andmaynotbeclinicallyusefulforplanning treatment. –Concreteconceptsareobservableandmeasurable,limitedbytimeandspace, constituteaspecificcategory,aremoreexclusive,namearealthingorclassof things, are restricted by nature, and may be clinically useful for planning treatment. 10.4.3 Nomenclature Thedevisingorchoosingofnamesforthings,especiallyinascienceor otherdiscipline(EnglishOxfordLivingDictionaryOn-Line2017). 10.4.4 Taxonomy The branch of science concerned with classification, especially of organisms;systematics(EnglishOxfordLivingDictionaryOn-Line2017). 10.5 References OxfordUniversityPress.EnglishOxfordLivingDictionaryOn-Line,Britishand WorldVersion;2017.Availableat:https://en.oxforddictionaries.com PenderNJ,MurdaughCL,ParsonsMA.HealthPromotioninNursingPractice. 5thed.UpperSaddleRiver,NJ:PearsonPrentice-Hall;2006 WorldHealthOrganization.Healthtopics:infant,newborn;2013..Availableat: http://www.who.int/topics/infant_newborn/en/ 141 World Health Organization. Definition of key terms; 2013. Available at: http://www.who.int/hiv/pub/guidelines/arv2013/intro/keyterms/en/ 142 Part3 TheNANDAInternationalNursingDiagnoses Domain1. Healthpromotion Domain2. Nutrition Domain3. Eliminationandexchange Domain4. Activity/rest Domain5. Perception/cognition Domain6. Self-perception Domain7. Rolerelationship Domain8. Sexuality Domain9. Coping/stresstolerance Domain10. Lifeprinciples Domain11. Safety/protection Domain12. Comfort Domain13. Growth/development 143 Domain1. Healthpromotion Class1. Healthawareness Code Diagnosis 00097 Decreaseddiversionalactivityengagement 00262 Readinessforenhancedhealthliteracy 00168 Sedentarylifestyle Class2. Healthmanagement Code Diagnosis 00257 Frailelderlysyndrome 00231 Riskforfrailelderlysyndrome 00215 Deficientcommunityhealth 00188 Risk-pronehealthbehavior 00099 Ineffectivehealthmaintenance 00078 Ineffectivehealthmanagement 00162 Readinessforenhancedhealthmanagement 00080 Ineffectivefamilyhealthmanagement 00043 Ineffectiveprotection NANDAInternational,Inc.NursingDiagnoses:DefinitionsandClassification2018–2020,11thEdition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. ©2017NANDAInternational,Inc.Published2017byThiemeMedicalPublishers,Inc.,NewYork. Companionwebsite:www.thieme.com/nanda-i. 144 Domain1•Class1•DiagnosisCode00097 Decreaseddiversionalactivityengagement Approved1980•Revised2017•LevelofEvidence2.1 Definition Reduced stimulation, interest, or participation in recreational or leisure activities. Definingcharacteristics –Alterationinmood –Boredom –Discontentwithsituation –Flataffect –Frequentnaps –Physicaldeconditioning Relatedfactors –Currentsettingdoesnotallowengagementin activity –Impairedmobility –Environmentalbarrier –Insufficientenergy –Insufficientmotivation –Physicaldiscomfort –Insufficientdiversionalactivity Atriskpopulation –Extremesofage –Prolongedhospitalization –Prolongedinstitutionalization Associatedcondition –Prescribedimmobility –Psychologicaldistress –Therapeuticisolation Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 145 Domain1•Class1•DiagnosisCode00262 Readinessforenhancedhealthliteracy Approved2016•LevelofEvidence2.1 Definition A pattern of using and developing a set of skills and competencies (literacy, knowledge, motivation, culture and language) to find, comprehend, evaluate and use health information and concepts to make daily health decisions to promoteandmaintainhealth,decreasehealthrisksandimproveoverallquality oflife,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhanceabilitytoread,write, speakandinterpretnumbersforeverydayhealth needs –Expressesdesiretoenhanceawarenessofcivic and/orgovernmentprocessesthatimpactpublic health –Expressesdesiretoenhancehealth communicationwithhealthcareproviders –Expressesdesiretoenhanceknowledgeofcurrent determinantsofhealthonsocialandphysical environments –Expressesdesiretoenhancepersonalhealthcare decision-making –Expressesdesiretoenhancesocialsupportfor health –Expressesdesiretoenhanceunderstandingof customsandbeliefstomakehealthcaredecisions –Expressesdesiretoenhanceunderstandingof healthinformationtomakehealthcarechoices –Expressesdesiretoobtainsufficientinformation tonavigatethehealthcaresystem Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 146 Domain1•Class1•DiagnosisCode00168 Sedentarylifestyle Approved2004•LevelofEvidence2.1 Definition Ahabitoflifethatischaracterizedbyalowphysicalactivitylevel. Definingcharacteristics –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Physicaldeconditioning –Preferenceforactivitylowinphysicalactivity Relatedfactors –Insufficientinterestinphysicalactivity –Insufficientknowledgeofhealthbenefits associatedwithphysicalexercise –Insufficientmotivationforphysicalactivity –Insufficientresourcesforphysicalactivity –Insufficienttrainingforphysicalexercise Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 147 Domain1•Class2•DiagnosisCode00257 Frailelderlysyndrome Approved2013•Revised2017•LevelofEvidence2.1 Definition Dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domain of health (physical, functional, psychological, or social) and leads to increased susceptibility to adversehealtheffects,inparticulardisability. Definingcharacteristics –Activityintolerance(00092) –Bathingself-caredeficit(00108) –Decreasedcardiacoutput(00029) –Dressingself-caredeficit(00109) –Fatigue(00093) –Feedingself-caredeficit(00102) –Hopelessness(00124) –Imbalancednutrition:lessthanbody requirements(00002) –Impairedmemory(00131) –Impairedphysicalmobility(00085) –Impairedwalking(00088) –Socialisolation(00053) –Toiletingself-caredeficit(00110) Relatedfactors –Activityintolerance –Anxiety –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Decreaseinenergy –Decreaseinmusclestrength –Depression –Exhaustion –Fearoffalling –Immobility –Impairedbalance –Impairedmobility –Insufficientsocialsupport –Malnutrition –Muscleweakness –Obesity –Sadness –Sedentarylifestyle –Socialisolation Atriskpopulation –Age>70years –Constrictedlivingspace –Historyoffalls –Livingalone 148 –Economicallydisadvantaged –EthnicityotherthanCaucasian –Femalegender –Loweducationallevel –Prolongedhospitalization –Socialvulnerability Associatedcondition –Alterationincognitivefunctioning –Alteredclottingprocess –Anorexia –Chronicillness –Decreaseinserum25-hydroxyvitaminD concentration –Endocrineregulatorydysfunction –Psychiatricdisorder –Sarcopenia –Sarcopenicobesity –Sensorydeficit –Suppressedinflammatoryresponse –Unintentionallossof25%ofbodyweightover oneyear –Unintentionalweightloss>10pounds(>4.5kg) inoneyear –Walking15feetrequires>6seconds(4meters> 5seconds) Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 149 Domain1•Class2•DiagnosisCode00231 Riskforfrailelderlysyndrome Approved2013•Revised2017•LevelofEvidence2.1 Definition Susceptible to a dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domain of health (physical, functional, psychological, or social) and leads to increased susceptibilitytoadversehealtheffects,inparticulardisability. Riskfactors –Activityintolerance –Anxiety –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Decreaseinenergy –Decreaseinmusclestrength –Depression –Exhaustion –Fearoffalling –Immobility –Impairedbalance –Impairedmobility –Insufficientknowledgeofmodifiablefactors –Insufficientsocialsupport –Malnutrition –Muscleweakness –Obesity –Sadness –Sedentarylifestyle –Socialisolation Atriskpopulation –Age>70years –Constrictedlivingspace –Economicallydisadvantaged –EthnicityotherthanCaucasian –Femalegender –Historyoffalls –Livingalone –Loweducationallevel –Prolongedhospitalization –Socialvulnerability Associatedcondition –Alterationincognitivefunctioning –Alteredclottingprocess –Anorexia –Sarcopenicobesity –Sensorydeficit –Suppressedinflammatoryresponse 150 –Chronicillness –Decreaseinserum25-hydroxyvitaminD concentration –Endocrineregulatorydysfunction –Psychiatricdisorder –Sarcopenia –Unintentionallossof25%ofbodyweightover oneyear –Unintentionalweightloss>10pounds(>4.5kg) inoneyear –Walking15feetrequires>6seconds(4meters> 5seconds) Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 151 Domain1•Class2•DiagnosisCode00215 Deficientcommunityhealth Approved2010•LevelofEvidence2.1 Definition Presence of one or more health problems or factors that deter wellness or increasetheriskofhealthproblemsexperiencedbyanaggregate. Definingcharacteristics –Healthproblemexperiencedbygroupsor populations –Programunavailabletoeliminatehealth problem(s)ofagrouporpopulation –Programunavailabletoenhancewellnessofa grouporpopulation –Programunavailabletopreventhealthproblem(s) ofagrouporpopulation –Programunavailabletoreducehealthproblem(s) ofagrouporpopulation –Riskofhospitalizationexperiencedbygroupsor populations –Riskofphysiologicalstatesexperiencedby groupsorpopulations –Riskofpsychologicalstatesexperiencedby groupsorpopulations Relatedfactors –Inadequateconsumersatisfactionwithprogram –Inadequateprogrambudget –Inadequateprogramevaluationplan –Inadequateprogramoutcomedata –Inadequatesocialsupportforprogram –Insufficientaccesstohealthcareprovider –Insufficientcommunityexperts –Insufficientresources –Programincompletelyaddresseshealthproblem Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 152 Domain1•Class2•DiagnosisCode00188 Risk-pronehealthbehavior Approved1986•Revised1998,2006,2008,2017•LevelofEvidence2.1 Definition Impaired ability to modify lifestyle and/or actions in a manner that improves thelevelofwellness. Definingcharacteristics –Failuretoachieveoptimalsenseofcontrol –Failuretotakeactionthatpreventshealth problem –Minimizeshealthstatuschange –Nonacceptanceofhealthstatuschange –Smoking –Substancemisuse Relatedfactors –Inadequatecomprehension –Insufficientsocialsupport –Lowself-efficacy –Negativeperceptionofhealthcareprovider –Negativeperceptionofrecommendedhealthcare strategy –Socialanxiety –Stressors Atriskpopulation –Familyhistoryofalcoholism –Economicallydisadvantaged Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 153 Domain1•Class2•DiagnosisCode00099 Ineffectivehealthmaintenance Approved1982•Revised2017 Definition Inabilitytoidentify,manage,and/orseekouthelptomaintainwell-being. Definingcharacteristics –Absenceofadaptivebehaviorstoenvironmental –Insufficientknowledgeaboutbasichealth changes practices –Absenceofinterestinimprovinghealthbehaviors –Insufficientsocialsupport –Inabilitytotakeresponsibilityformeetingbasic –Patternoflackofhealth-seekingbehavior healthpractices Relatedfactors –Complicatedgrieving –Impaireddecision-making –Ineffectivecommunicationskills –Ineffectivecopingstrategies –Insufficientresources –Spiritualdistress Atriskpopulation –Developmentaldelay Associatedcondition –Alterationincognitivefunctioning –Decreaseinfinemotorskills –Decreaseingrossmotorskills –Perceptualdisorders ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 154 Domain1•Class2•DiagnosisCode00078 Ineffectivehealthmanagement Approved1994•Revised2008,2017•LevelofEvidence2.1 Definition Patternofregulatingandintegratingintodailylivingatherapeuticregimenfor the treatment of illness and its sequelae that is unsatisfactory for meeting specifichealthgoals. Definingcharacteristics –Difficultywithprescribedregimen –Failuretoincludetreatmentregimenindaily living –Failuretotakeactiontoreduceriskfactor –Ineffectivechoicesindailylivingformeeting healthgoal Relatedfactors –Decisionalconflict –Difficultymanagingcomplextreatmentregimen –Difficultynavigatingcomplexhealthcaresystems –Excessivedemands –Familyconflict –Familypatternofhealthcare –Inadequatenumberofcuestoaction –Insufficientknowledgeoftherapeuticregimen –Insufficientsocialsupport –Perceivedbarrier –Perceivedbenefit –Perceivedseriousnessofcondition –Perceivedsusceptibility –Powerlessness Atriskpopulation –Economicallydisadvantaged Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 155 Domain1•Class2•DiagnosisCode00162 Readinessforenhancedhealthmanagement Approved2002•Revised2010,2013•LevelofEvidence2.1 Definition Apatternofregulatingandintegratingintodailylivingatherapeuticregimen forthetreatmentofillnessanditssequelae,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhancechoicesofdaily livingformeetinggoals –Expressesdesiretoenhance immunization/vaccinationstatus –Expressesdesiretoenhancemanagementof illness –Expressesdesiretoenhancemanagementof prescribedregimens –Expressesdesiretoenhancemanagementofrisk factors –Expressesdesiretoenhancemanagementof symptoms Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 156 Domain1•Class2•DiagnosisCode00080 Ineffectivefamilyhealthmanagement Approved1992•Revised2013,2017 Definition Apatternofregulatingandintegratingintofamilyprocessesaprogramforthe treatmentofillnessanditssequelaethatisunsatisfactoryformeetingspecific healthgoalsofthefamilyunit. Definingcharacteristics –Accelerationofillnesssymptomsofafamily member –Decreaseinattentiontoillness –Difficultywithprescribedregimen –Failuretotakeactiontoreduceriskfactor –Inappropriatefamilyactivitiesformeetinghealth goal Relatedfactors –Decisionalconflict –Difficultymanagingcomplextreatmentregimen –Difficultynavigatingcomplexhealthcaresystems –Familyconflict Atriskpopulation –Economicallydisadvantaged ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 157 Domain1•Class2•DiagnosisCode00043 Ineffectiveprotection Approved1990•Revised2017 Definition Decrease in the ability to guard self from internal or external threats such as illnessorinjury. Definingcharacteristics –Alterationinclotting –Alterationinperspiration –Anorexia –Chilling –Coughing –Deficientimmunity –Disorientation –Dyspnea –Fatigue –Immobility –Insomnia –Itching –Maladaptivestressresponse –Neurosensoryimpairment –Pressureulcer –Restlessness –Weakness Relatedfactors –Inadequatenutrition –Substancemisuse Atriskpopulation –Extremesofage Associatedcondition –Abnormalbloodprofile –Cancer –Immunedisorder –Pharmaceuticalagent –Treatmentregimen 158 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 159 Domain2. Nutrition Class1. Ingestion Code Diagnosis 00002 Imbalancednutrition:lessthanbodyrequirements 00163 Readinessforenhancednutrition 00216 Insufficientbreastmilkproduction 00104 Ineffectivebreastfeeding 00105 Interruptedbreastfeeding 00106 Readinessforenhancedbreastfeeding 00269 Ineffectiveadolescenteatingdynamics 00270 Ineffectivechildeatingdynamics 00271 Ineffectiveinfantfeedingdynamics 00107 Ineffectiveinfantfeedingpattern 00232 Obesity 00233 Overweight 00234 Riskforoverweight 00103 Impairedswallowing Class2. Digestion Code Diagnosis Thisclassdoesnotcurrentlycontainanydiagnoses. Class3. Absorption Code Diagnosis Thisclassdoesnotcurrentlycontainanydiagnoses. 160 Class4. Metabolism Code Diagnosis 00179 Riskforunstablebloodglucoselevel 00194 Neonatalhyperbilirubinemia 00230 Riskforneonatalhyperbilirubinemia 00178 Riskforimpairedliverfunction 00263 Riskformetabolicimbalancesyndrome Class5. Hydration Code Diagnosis 00195 Riskforelectrolyteimbalance 00025 Riskforimbalancedfluidvolume 00027 Deficientfluidvolume 00028 Riskfordeficientfluidvolume 00026 Excessfluidvolume NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 161 Domain2•Class1•DiagnosisCode00002 Imbalancednutrition:lessthanbodyrequirements Approved1975•Revised2000,2017 Definition Intakeofnutrientsinsufficienttomeetmetabolicneeds. Definingcharacteristics –Abdominalcramping –Abdominalpain –Alterationintastesensation –Bodyweight20%ormorebelowidealweight range –Capillaryfragility –Diarrhea –Excessivehairloss –Foodaversion –Foodintakelessthanrecommendeddaily allowance(RDA) –Hyperactivebowelsounds –Insufficientinformation –Insufficientinterestinfood –Insufficientmuscletone –Misinformation –Misperception –Palemucousmembranes –Perceivedinabilitytoingestfood –Satietyimmediatelyuponingestingfood –Sorebuccalcavity –Weaknessofmusclesrequiredformastication –Weaknessofmusclesrequiredforswallowing –Weightlosswithadequatefoodintake Relatedfactors –Insufficientdietaryintake Atriskpopulation –Biologicalfactors –Economicallydisadvantaged Associatedcondition –Inabilitytoabsorbnutrients –Inabilitytodigestfood –Inabilitytoingestfood –Psychologicaldisorder 162 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 163 Domain2•Class1•DiagnosisCode00163 Readinessforenhancednutrition Approved2002•Revised2013•LevelofEvidence2.1 Definition Apatternofnutrientintake,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhancenutrition 164 Domain2•Class1•DiagnosisCode00216 Insufficientbreastmilkproduction Approved2010•Revised2017•LevelofEvidence3.1 Definition Inadequate supply of maternal breast milk to support nutritional state of an infantorchild. Definingcharacteristics –Absenceofmilkproductionwithnipple stimulation –Breastmilkexpressedislessthanprescribed volumeforinfant –Delayinmilkproduction –Infantconstipation –Infantfrequentlycrying –Infantfrequentlyseekstosuckleatbreast –Infantrefusestosuckleatbreast –Infantvoidssmallamountsofconcentratedurine –Infantweightgain<500ginamonth –Prolongedbreastfeedingtime –Unsustainedsucklingatbreast Relatedfactors –Ineffectivelatchingontobreast –Ineffectivesuckingreflex –Insufficientopportunityforsucklingatthebreast –Insufficientsucklingtimeatbreast –Maternalalcoholconsumption –Maternalinsufficientfluidvolume –Maternalmalnutrition –Maternalsmoking –Maternaltreatmentregimen –Rejectionofbreast Associatedcondition –Pregnancy Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 165 Domain2•Class1•DiagnosisCode00104 Ineffectivebreastfeeding Approved1988•Revised2010,2013,2017•LevelofEvidence3.1 Definition Difficulty feeding milk from the breasts, which may compromise nutritional statusoftheinfant/child. Definingcharacteristics –Inadequateinfantstooling –Infantarchingatbreast –Infantcryingatthebreast –Infantcryingwithinthefirsthourafter breastfeeding –Infantfussingwithinonehourofbreastfeeding –Infantinabilitytolatchontomaternalbreast correctly –Infantresistinglatchingontobreast –Infantunresponsivetoothercomfortmeasures –Insufficientemptyingofeachbreastperfeeding –Insufficientinfantweightgain –Insufficientsignsofoxytocinrelease –Perceivedinadequatemilksupply –Sorenipplespersistingbeyondfirstweek –Sustainedinfantweightloss –Unsustainedsucklingatthebreast Relatedfactors –DelayedstageIIlactogenesis –Inadequatemilksupply –Insufficientfamilysupport –Insufficientopportunityforsucklingatthebreast –Insufficientparentalknowledgeregarding breastfeedingtechniques –Insufficientparentalknowledgeregarding importanceofbreastfeeding –Interruptedbreastfeeding –Maternalambivalence –Maternalanxiety –Maternalbreastanomaly –Maternalfatigue –Maternalobesity –Maternalpain –Pacifieruse –Poorinfantsuckingreflex –Supplementalfeedingswithartificialnipple Atriskpopulation –Prematurity –Previousbreastsurgery –Previoushistoryofbreastfeedingfailure –Shortmaternityleave 166 Associatedcondition –Oropharyngealdefect Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 167 Domain2•Class1•DiagnosisCode00105 Interruptedbreastfeeding Approved1992•Revised2013,2017•LevelofEvidence2.2 Definition Break in the continuity of feeding milk from the breasts, which may compromisebreastfeedingsuccessand/ornutritionalstatusoftheinfant/child. Definingcharacteristics –Nonexclusivebreastfeeding Relatedfactors –Maternalemployment –Maternal-infantseparation –Needtoabruptlyweaninfant Atriskpopulation –Hospitalizationofchild –Prematurity Associatedcondition –Contraindicationstobreastfeeding –Infantillness –Maternalillness Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 168 Domain2•Class1•DiagnosisCode00106 Readinessforenhancedbreastfeeding Approved1990•Revised2010,2013,2017•LevelofEvidence2.2 Definition Apatternoffeedingmilkfromthebreaststoaninfantorchild,whichmaybe strengthened. Definingcharacteristics –Motherexpressesdesiretoenhanceabilityto exclusivelybreastfeed –Motherexpressesdesiretoenhanceabilityto providebreastmilkforchild'snutritionalneeds Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 169 Domain2•Class1•DiagnosisCode00269 Ineffectiveadolescenteatingdynamics Approved2016•LevelofEvidence2.1 Definition Alteredeatingattitudesandbehaviorsresultinginoverorundereatingpatterns thatcompromisenutritionalhealth Definingcharacteristics –Avoidsparticipationinregularmealtimes –Complainsofhungerbetweenmeals –Foodrefusal –Frequentsnacking –Frequentlyeatingfromfastfoodrestaurants –Frequentlyeatingpoorqualityfood –Frequentlyeatingprocessedfood –Overeating –Poorappetite –Undereating Relatedfactors –Alteredfamilydynamics –Anxiety –Changestoself-esteemuponenteringpuberty –Depression –Eatingdisorder –Eatinginisolation –Excessivefamilymealtimecontrol –Excessivestress –Inadequatechoiceoffood –Irregularmealtime –Mediainfluenceoneatingbehaviorsofhigh caloricunhealthyfoods –Mediainfluenceonknowledgeofhighcaloric unhealthyfoods –Negativeparentalinfluencesoneatingbehaviors –Psychologicalabuse –Psychologicalneglect –Stressfulmealtimes Associatedcondition –Physicalchallengewitheating –Physicalchallengewithfeeding –Physicalhealthissuesofparents –Psychologicalhealthissuesofparents 170 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 171 Domain2•Class1•DiagnosisCode00270 Ineffectivechildeatingdynamics Approved2016•LevelofEvidence2.1 Definition Alteredattitudes,behaviorsandinfluencesonchildeatingpatternsresultingin compromisednutritionalhealth Definingcharacteristics –Avoidsparticipationinregularmealtimes –Complainsofhungerbetweenmeals –Foodrefusal –Frequentsnacking –Frequentlyeatingfromfastfoodrestaurants –Frequentlyeatingpoorqualityfood –Frequentlyeatingprocessedfood –Overeating –Poorappetite –Undereating Relatedfactors EatingHabit –Bribingchildtoeat –Consumptionoflargevolumesoffoodinashort periodoftime –Disorderedeatinghabits –Eatinginisolation –Excessiveparentalcontroloverchild'seating experience –Excessiveparentalcontroloverfamilymealtime –Forcingchildtoeat –Inadequatechoiceoffood –Lackofregularmealtimes –Limitingchild'seating –Rewardingchildtoeat –Stressfulmealtimes –Unpredictableeatingpatterns –Unstructuredeatingofsnacksbetweenmeals FamilyProcess –Abusiverelationship –Anxiousparent-childrelationship –Disengagedparentingstyle –Hostileparent-childrelationship –Insecureparent-childrelationship –Over-involvedparentingstyle –Tenseparent-childrelationship –Under-involvedparentingstyle 172 Parental –Anorexia –Depression –Inabilitytodivideeatingresponsibilitybetween parentandchild –Inabilitytodividefeedingresponsibilitybetween parentandchild –Inabilitytosupporthealthyeatingpatterns –Ineffectivecopingstrategies –Lackofconfidenceinchildtodevelophealthy eatinghabits –Lackofconfidenceinchildtogrowappropriately –Substancemisuse Environmental –Mediainfluenceoneatingbehaviorsofhigh caloricunhealthyfoods –Mediainfluenceonknowledgeofhighcaloric unhealthyfoods Atriskpopulation –Economicallydisadvantaged –Homeless –Involvementwiththefostercaresystem –Lifetransition –Parentalobesity Associatedcondition –Physicalchallengewitheating –Physicalchallengewithfeeding –Physicalhealthissuesofparents –Psychologicalhealthissuesofparents Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 173 Domain2•Class1•DiagnosisCode00271 Ineffectiveinfantfeedingdynamics Approved2016•LevelofEvidence2.1 Definition Alteredparentalfeedingbehaviorsresultinginoverorundereatingpatterns Definingcharacteristics –Foodrefusal –Inappropriatetransitiontosolidfoods –Overeating –Poorappetite –Undereating Relatedfactors –Abusiverelationship –Attachmentissues –Disengagedparentingstyle –Lackofconfidenceinchildtodevelophealthy eatinghabits –Lackofconfidenceinchildtogrowappropriately –Lackofknowledgeofappropriatemethodsof feedinginfantforeachstageofdevelopment –Lackofknowledgeofinfant'sdevelopmental stages –Lackofknowledgeofparent'sresponsibilityin infantfeeding –Mediainfluenceonfeedinginfanthighcaloric, unhealthyfoods –Mediainfluenceonknowledgeofhighcaloric, unhealthyfoods –Multiplecaregivers –Over-involvedparentingstyle –Under-involvedparentingstyle Atriskpopulation –Abandonment –Economicallydisadvantaged –Historyofunsafeeatingandfeedingexperiences –Homeless –Involvementwiththefostercaresystem –Lifetransition –Neonatalintensivecareexperiences –Prematurity –Prolongedhospitalization –Smallforgestationalage Associatedcondition –Chromosomaldisorders –Physicalchallengewitheating 174 –Cleftlip –Cleftpalate –Congenitalheartdisease –Geneticdisorder –Neuraltubedefects –Physicalhealthissuesofparents –Prolongedenteralfeedings –Psychologicalhealthissuesofparents –Sensoryintegrationproblems Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 175 Domain2•Class1•DiagnosisCode00107 Ineffectiveinfantfeedingpattern Approved1992•Revised2006•LevelofEvidence2.1 Definition Impairedabilityofaninfanttosuckorcoordinatethesuck-swallowresponse resultingininadequateoralnutritionformetabolicneeds. Definingcharacteristics –Inabilitytocoordinatesucking,swallowing,and breathing –Inabilitytoinitiateaneffectivesuck –Inabilitytosustainaneffectivesuck Relatedfactors –Oralhypersensitivity –Prolongednilperos(NPO)status Atriskpopulation –Prematurity Associatedcondition –Neurologicaldelay –Neurologicalimpairment –Oralhypersensitivity Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 176 Domain2•Class1•DiagnosisCode00232 Obesity Approved2013•Revised2017•LevelofEvidence3.2 Definition A condition in which an individual accumulates excessive fat for age and genderthatexceedsoverweight. Definingcharacteristics –ADULT:Bodymassindex(BMI)>30kg/m2 –CHILD<2years:Termnotusedwithchildrenat thisage –CHILD2-18years:Bodymassindex(BMI)> 95thpercentileor30kg/m2forageandgender Relatedfactors –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Consumptionofsugar-sweetenedbeverages –Disorderedeatingbehaviors –Disorderedeatingperceptions –Energyexpenditurebelowenergyintakebasedon standardassessment –Excessivealcoholconsumption –Fearregardinglackoffoodsupply –Frequentsnacking –Highfrequencyofrestaurantorfriedfood –Lowdietarycalciumintakeinchildren –Portionsizeslargerthanrecommended –Sedentarybehavioroccurringfor≥2hours/day –Shortenedsleeptime –Sleepdisorder –Solidfoodsasmajorfoodsourceat<5monthsof age Atriskpopulation –Economicallydisadvantaged –Formula-ormixed-fedinfants –Heritabilityofinterrelatedfactors –Highdisinhibitionandrestrainteatingbehavior score –Maternaldiabetesmellitus –Maternalsmoking –Overweightininfancy –Parentalobesity –Prematurepubarche –Rapidweightgainduringchildhood –Rapidweightgainduringinfancy,includingthe firstweek,first4months,andfirstyear 177 Associatedcondition –Geneticdisorder Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 178 Domain2•Class1•DiagnosisCode00233 Overweight Approved2013•Revised2017•LevelofEvidence3.2 Definition A condition in which an individual accumulates excessive fat for age and gender. Definingcharacteristics –ADULT:Bodymassindex(BMI)>25kg/m2 –CHILD<2years:Weight-for-length>95th percentile –CHILD2-18years:Bodymassindex(BMI)> 85thpercentileor25kg/m2but<95thpercentile or30kg/m2forageandgender Relatedfactors –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Consumptionofsugar-sweetenedbeverages –Disorderedeatingbehaviors –Disorderedeatingperceptions –Energyexpenditurebelowenergyintakebasedon standardassessment –Excessivealcoholconsumption –Fearregardinglackoffoodsupply –Frequentsnacking –Highfrequencyofrestaurantorfriedfood –Insufficientknowledgeofmodifiablefactors –Lowdietarycalciumintakeinchildren –Portionsizeslargerthanrecommended –Sedentarybehavioroccurringfor>2hours/day –Shortenedsleeptime –Sleepdisorder –Solidfoodsasmajorfoodsourceat<5monthsof age Atriskpopulation –ADULT:Bodymassindex(BMI)approaching25 –Childrenwithhighbodymassindex(BMI) percentiles kg/m2 –CHILD<2years:Weight-for-lengthapproaching –Economicallydisadvantaged –Formula-ormixed-fedinfants 95thpercentile –Heritabilityofinterrelatedfactors –CHILD2-18years:Bodymassindex(BMI) 2 –Highdisinhibitionandrestrainteatingbehavior approaching85thpercentileor25kg/m score –Childrenwhoarecrossingbodymassindex –Maternaldiabetesmellitus (BMI)percentilesupward 179 –Prematurepubarche –Rapidweightgainduringchildhood –Maternalsmoking –Obesityinchildhood –Parentalobesity –Rapidweightgainduringinfancy,includingthe firstweek,first4months,andfirstyear Associatedcondition –Geneticdisorder Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 180 Domain2•Class1•DiagnosisCode00234 Riskforoverweight Approved2013•Revised2017•LevelofEvidence3.2 Definition Susceptible to excessive fat accumulation for age and gender, which may compromisehealth. Riskfactors –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Consumptionofsugar-sweetenedbeverages –Disorderedeatingbehaviors –Disorderedeatingperceptions –Energyexpenditurebelowenergyintakebasedon standardassessment –Excessivealcoholconsumption –Fearregardinglackoffoodsupply –Frequentsnacking –Highfrequencyofrestaurantorfriedfood –Insufficientknowledgeofmodifiablefactors –Lowdietarycalciumintakeinchildren –Portionsizeslargerthanrecommended –Sedentarybehavioroccurringfor>2hours/day –Shortenedsleeptime –Sleepdisorder –Solidfoodsasmajorfoodsourceat<5monthsof age Atriskpopulation –ADULT:Bodymassindex(BMI)approaching25 –Heritabilityofinterrelatedfactors –Highdisinhibitionandrestrainteatingbehavior kg/m2 score –CHILD<2years:Weight-for-lengthapproaching –Maternaldiabetesmellitus 95thpercentile –Maternalsmoking –CHILD2-18years:Bodymassindex(BMI) –Obesityinchildhood approaching85thpercentileor25kg/m2 –Parentalobesity –Childrenwhoarecrossingbodymassindex –Prematurepubarche (BMI)percentilesupward –Rapidweightgainduringchildhood –Childrenwithhighbodymassindex(BMI) percentiles –Rapidweightgainduringinfancy,includingthe firstweek,first4months,andfirstyear –Economicallydisadvantaged –Formula-ormixed-fedinfants Associatedcondition 181 –Geneticdisorder Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 182 Domain2•Class1•DiagnosisCode00103 Impairedswallowing Approved1986•Revised1998,2017 Definition Abnormalfunctioningoftheswallowingmechanismassociatedwithdeficitsin oral,pharyngeal,oresophagealstructureorfunction. Definingcharacteristics FirstStage:Oral –Abnormaloralphaseofswallowstudy –Chokingpriortoswallowing –Coughingpriortoswallowing –Drooling –Foodfallsfrommouth –Foodpushedoutofmouth –Gaggingpriortoswallowing –Inabilitytoclearoralcavity –Incompletelipclosure –Inefficientnippling –Inefficientsuck –Insufficientchewing –Nasalreflux –Piecemealdeglutition –Poolingofbolusinlateralsulci –Prematureentryofbolus –Prolongedbolusformation –Prolongedmealtimewithinsufficient consumption –Tongueactionineffectiveinformingbolus SecondStage:Pharyngeal –Abnormalpharyngealphaseofswallowstudy –Alterationinheadposition –Choking –Coughing –Delayedswallowing –Feversofunknownetiology –Foodrefusal –Gaggingsensation –Gurglyvoicequality –Inadequatelaryngealelevation –Nasalreflux –Recurrentpulmonaryinfection –Repetitiveswallowing ThirdStage:Esophageal –Abnormalesophagealphaseofswallowstudy –Acidic-smellingbreath –Bruxism –Heartburn –Hematemesis –Hyperextensionofhead 183 –Difficultyswallowing –Epigastricpain –Foodrefusal –Nighttimeawakening –Nighttimecoughing –Odynophagia –Regurgitation –Repetitiveswallowing –Reports“somethingstuck” –Unexplainedirritabilitysurroundingmealtimes –Volumelimiting –Vomiting –Vomitusonpillow Relatedfactors –Behavioralfeedingproblem –Self-injuriousbehavior Atriskpopulation –Behavioralfeedingproblem –Failuretothrive –Historyofenteralfeeding –Self-injuriousbehavior –Developmentaldelay –Prematurity Associatedcondition –Achalasia –Acquiredanatomicdefects –Braininjury –Cerebralpalsy –Conditionswithsignificanthypotonia –Congenitalheartdisease –Cranialnerveinvolvement –Esophagealrefluxdisease –Laryngealabnormality –Laryngealdefect –Mechanicalobstruction –Nasaldefect –Nasopharyngealcavitydefect –Neurologicalproblems –Neuromuscularimpairment –Oropharynxabnormality –Protein-energymalnutrition –Respiratorycondition –Trachealdefect –Trauma –Upperairwayanomaly ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 184 Domain2•Class2 Thisclassdoesnotcurrentlycontainanydiagnoses. 185 Domain2•Class3 Thisclassdoesnotcurrentlycontainanydiagnoses. 186 Domain2•Class4•DiagnosisCode00179 Riskforunstablebloodglucoselevel Approved2006•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to variation in serum levels of glucose from the normal range, whichmaycompromisehealth. Riskfactors –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Doesnotacceptdiagnosis –Excessivestress –Excessiveweightgain –Excessiveweightloss –Inadequatebloodglucosemonitoring –Ineffectivemedicationmanagement –Insufficientdiabetesmanagement –Insufficientdietaryintake –Insufficientknowledgeofdiseasemanagement –Insufficientknowledgeofmodifiablefactors –Nonadherencetodiabetesmanagementplan Atriskpopulation –Alterationinmentalstatus –Delayincognitivedevelopment –Compromisedphysicalhealthstatus –Rapidgrowthperiod Associatedcondition –Pregnancy Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 187 Domain2•Class4•DiagnosisCode00194 Neonatalhyperbilirubinemia Approved2008•Revised2010,2017•LevelofEvidence2.1 Definition The accumulation of unconjugated bilirubin in the circulation (less than 15 ml/dl)thatoccursafter24hoursoflife. Definingcharacteristics –Abnormalbloodprofile –Yellowsclera –Bruisedskin –Yellow-orangeskincolor –Yellowmucousmembranes Relatedfactors –Deficientfeedingpattern –Delayinmeconiumpassage –Infantswithinadequatenutrition Atriskpopulation –ABOincompatibility –Age≤7days –AmericanIndianethnicity –Bloodtypeincompatibilitybetweenmotherand infant –EastAsianethnicity –Infantwhoisbreastfed –Infantwithlowbirthweight –Maternaldiabetesmellitus –Populationslivingathighaltitudes –Prematureinfant –Previoussiblingwithjaundice –Rhesus(Rh)incompatibility –Significantbruisingduringbirth Associatedcondition –Bacterialinfection –Prenatalinfection –Infantwithlivermalfunction –Sepsis –Infantwithenzymedeficiency –Viralinfection –Internalbleeding 188 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 189 Domain2•Class4•DiagnosisCode00230 Riskforneonatalhyperbilirubinemia Approved2010•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to the accumulation of unconjugated bilirubin in the circulation (lessthan15ml/dl)thatoccursafter24hoursoflifewhichmaycompromise health. Riskfactors –Deficientfeedingpattern –Delayinmeconiumpassage –Infantswithinadequatenutrition Atriskpopulation –ABOincompatibility –Age≤7days –AmericanIndianethnicity –Bloodtypeincompatibilitybetweenmotherand infant –EastAsianethnicity –Infantwhoisbreastfed –Infantwithlowbirthweight –Maternaldiabetesmellitus –Populationslivingathighaltitudes –Prematureinfant –Previoussiblingwithjaundice –Rhesus(Rh)incompatibility –Significantbruisingduringbirth Associatedcondition –Bacterialinfection –Prenatalinfection –Infantwithlivermalfunction –Sepsis –Infantwithenzymedeficiency –Viralinfection –Internalbleeding Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 190 Domain2•Class4•DiagnosisCode00178 Riskforimpairedliverfunction Approved2006•Revised2008,2013,2017•LevelofEvidence2.1 Definition Susceptibletoadecreaseinliverfunction,whichmaycompromisehealth. Riskfactors –Substancemisuse Associatedcondition –Humanimmunodeficiencyvirus(HIV)coinfection –Viralinfection –Pharmaceuticalagent This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition if no additional risk factorsaredeveloped. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 191 Domain2•Class4•DiagnosisCode00263 Riskformetabolicimbalancesyndrome Approved2016•LevelofEvidence2.1 Definition Susceptible to a toxic cluster of biochemical and physiological factors associatedwiththedevelopmentofcardiovasculardiseasearisingfromobesity andtype2diabetes,whichmaycompromisehealth. Riskfactors –Ineffectivehealthmaintenance(00099) –Obesity(00232) –Overweight(00233) –Riskforunstablebloodglucoselevel(00179) –Risk-pronehealthbehavior(00188) –Sedentarylifestyle(00168) –Stressoverload(00177) Atriskpopulation –Age>30years –Familyhistoryofhypertension –Familyhistoryofdiabetesmellitus –Familyhistoryofobesity –Familyhistoryofdyslipidemia Associatedcondition –Excessiveendogenousorexogenous glucocorticoids>25g/dl –Microalbuminuria>30mg/dl –Polycysticovarysyndrome –Unstablebloodpressure –Uricacid>7mg/dl Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 192 Domain2•Class5•DiagnosisCode00195 Riskforelectrolyteimbalance Approved2008•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to changes in serum electrolyte levels, which may compromise health. Riskfactors –Diarrhea –Excessivefluidvolume –Insufficientfluidvolume –Insufficientknowledgeofmodifiablefactors –Vomiting Associatedcondition –Compromisedregulatorymechanism –Renaldysfunction –Endocrineregulatorydysfunction –Treatmentregimen Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 193 Domain2•Class5•DiagnosisCode00025 Riskforimbalancedfluidvolume Approved1998•Revised2008,2013,2017•LevelofEvidence2.1 Definition Susceptible to a decrease, increase, or rapid shift from one to the other of intravascular, interstitial and/or intracellular fluid, which may compromise health.Thisreferstobodyfluidloss,gain,orboth. Riskfactors –Tobedeveloped Associatedcondition –Apheresis –Ascites –Burninjury –Intestinalobstruction –Pancreatitis –Sepsis –Trauma –Treatmentregimen This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition if no risk factors are developed. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 194 Domain2•Class5•DiagnosisCode00027 Deficientfluidvolume Approved1978•Revised1996,2017 Definition Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration,waterlossalonewithoutchangeinsodium. Definingcharacteristics –Alterationinmentalstatus –Alterationinskinturgor –Decreaseinbloodpressure –Decreaseinpulsepressure –Decreaseinpulsevolume –Decreaseintongueturgor –Decreaseinurineoutput –Decreaseinvenousfilling –Drymucousmembranes –Dryskin –Increaseinbodytemperature –Increaseinheartrate –Increaseinhematocrit –Increaseinurineconcentration –Suddenweightloss –Thirst –Weakness Relatedfactors –Barriertoaccessingfluid –Insufficientfluidintake –Insufficientknowledgeaboutfluidneeds Atriskpopulation –Extremesofage –Extremesofweight –Factorsinfluencingfluidneeds Associatedcondition –Activefluidvolumeloss –Compromisedregulatorymechanism –Deviationsaffectingfluidabsorption –Deviationsaffectingfluidintake –Excessivefluidlossthroughnormalroute –Fluidlossthroughabnormalroute –Pharmaceuticalagent 195 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 196 Domain2•Class5•DiagnosisCode00028 Riskfordeficientfluidvolume Approved1978•Revised2010,2013,2017 Definition Susceptible to experiencing decreased intravascular, interstitial, and/or intracellularfluidvolumes,whichmaycompromisehealth. Riskfactors –Barriertoaccessingfluid –Insufficientfluidintake –Insufficientknowledgeaboutfluidneeds Atriskpopulation –Extremesofage –Extremesofweight –Factorsinfluencingfluidneeds Associatedcondition –Activefluidvolumeloss –Compromisedregulatorymechanism –Deviationsaffectingfluidabsorption –Deviationsaffectingfluidintake –Excessivefluidlossthroughnormalroute –Fluidlossthroughabnormalroute –Pharmaceuticalagent ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 197 Domain2•Class5•DiagnosisCode00026 Excessfluidvolume Approved1982•Revised1996,2013,2017•LevelofEvidence2.1 Definition Surplusintakeand/orretentionoffluid. Definingcharacteristics –Adventitiousbreathsounds –Alterationinbloodpressure –Alterationinmentalstatus –Alterationinpulmonaryarterypressure(PAP) –Alterationinrespiratorypattern –Alterationinurinespecificgravity –Anasarca –Anxiety –Azotemia –Decreaseinhematocrit –Decreaseinhemoglobin –Dyspnea –Edema –Electrolyteimbalance –Hepatomegaly –Increaseincentralvenouspressure(CVP) –Intakeexceedsoutput –Jugularveindistension –Oliguria –Orthopnea –Paroxysmalnocturnaldyspnea –Pleuraleffusion –Positivehepatojugularreflex –PresenceofS3heartsound –Pulmonarycongestion –Restlessness –Weightgainovershortperiodoftime Relatedfactors –Excessivefluidintake –Excessivesodiumintake Associatedcondition –Compromisedregulatorymechanism Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 198 Domain3. Eliminationandexchange Class1. Urinaryfunction Code Diagnosis 00016 Impairedurinaryelimination 00020 Functionalurinaryincontinence 00176 Overflowurinaryincontinence 00018 Reflexurinaryincontinence 00017 Stressurinaryincontinence 00019 Urgeurinaryincontinence 00022 Riskforurgeurinaryincontinence 00023 Urinaryretention Class2. Gastrointestinalfunction Code Diagnosis 00011 Constipation 00015 Riskforconstipation 00012 Perceivedconstipation 00235 Chronicfunctionalconstipation 00236 Riskforchronicfunctionalconstipation 00013 Diarrhea 00196 Dysfunctionalgastrointestinalmotility 00197 Riskfordysfunctionalgastrointestinalmotility 00014 Bowelincontinence Class3. Integumentaryfunction Code Diagnosis 199 Thisclassdoesnotcurrentlycontainanydiagnoses. Class4. Respiratoryfunction Code Diagnosis 00030 Impairedgasexchange NANDAInternational,Inc.NursingDiagnoses:DefinitionsandClassification2018–2020,11thEdition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 200 Domain3•Class1•DiagnosisCode00016 Impairedurinaryelimination Approved1973•Revised2006,2017•LevelofEvidence2.1 Definition Dysfunctioninurineelimination. Definingcharacteristics –Dysuria –Frequentvoiding –Hesitancy –Nocturia –Urinaryincontinence –Urinaryretention –Urinaryurgency Relatedfactors –Multiplecausality Associatedcondition –Anatomicobstruction –Sensorymotorimpairment –Urinarytractinfection This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition if no specific related factorsaredeveloped. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 201 Domain3•Class1•DiagnosisCode00020 Functionalurinaryincontinence Approved1986•Revised1998,2017 Definition Inability of a usually continent person to reach the toilet in time to avoid unintentionallossofurine. Definingcharacteristics –Completelyemptiesbladder –Earlymorningurinaryincontinence –Sensationofneedtovoid –Timerequiredtoreachtoiletistoolongafter sensationofurge –Voidingpriortoreachingtoilet Relatedfactors –Alterationinenvironmentalfactor –Weakenedsupportingpelvicstructure Associatedcondition –Alterationincognitivefunctioning –Impairedvision –Neuromuscularimpairment –Psychologicaldisorder ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 202 Domain3•Class1•DiagnosisCode00176 Overflowurinaryincontinence Approved2006•Revised2017•LevelofEvidence2.1 Definition Involuntarylossofurineassociatedwithoverdistentionofthebladder. Definingcharacteristics –Bladderdistention –Highpost-voidresidualvolume –Involuntaryleakageofsmallvolumeofurine –Nocturia Relatedfactors –Fecalimpaction Associatedcondition –Bladderoutletobstruction –Detrusorexternalsphincterdyssynergia –Detrusorhypocontractility –Severepelvicorganprolapse –Treatmentregimen –Urethralobstruction Additionalmodifiablerelatedfactorstobedeveloped. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 203 Domain3•Class1•DiagnosisCode00018 Reflexurinaryincontinence Approved1986•Revised1998,2017 Definition Involuntary loss of urine at somewhat predictable intervals when a specific bladdervolumeisreached. Definingcharacteristics –Absenceofvoidingsensation –Absenceofurgetovoid –Inabilitytovoluntarilyinhibitvoiding –Inabilitytovoluntarilyinitiatevoiding –Incompleteemptyingofbladderwithlesion abovepontinemicturitioncenter –Predictablepatternofvoiding –Sensationofurgencytovoidwithoutvoluntary inhibitionofbladdercontraction –Sensationsassociatedwithfullbladder Relatedfactors –Tobedeveloped Associatedcondition –Neurologicalimpairmentabovelevelofpontine micturitioncenter –Neurologicalimpairmentabovelevelofsacral micturitioncenter –Tissuedamage ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 204 Domain3•Class1•DiagnosisCode00017 Stressurinaryincontinence Approved1986•Revised2006,2017•LevelofEvidence2.1 Definition Suddenleakageofurinewithactivitiesthatincreaseintra-abdominalpressure. Definingcharacteristics –Involuntaryleakageofsmallvolumeofurine –Involuntaryleakageofsmallvolumeofurinein theabsenceofdetrusorcontraction –Involuntaryleakageofsmallvolumeofurinein theabsenceofoverdistendedbladder Relatedfactors –Weakpelvicfloormuscles Associatedcondition –Degenerativechangesinpelvicfloormuscles –Increaseinintra-abdominalpressure –Intrinsicurethralsphincterdeficiency Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 205 Domain3•Class1•DiagnosisCode00019 Urgeurinaryincontinence Approved1986•Revised2006,2017•LevelofEvidence2.1 Definition Involuntarypassageofurineoccurringsoonafterastrongsensationorurgency tovoid. Definingcharacteristics –Inabilitytoreachtoiletintimetoavoidurineloss –Involuntarylossofurinewithbladder contractions –Involuntarylossofurinewithbladderspasms –Urinaryurgency Relatedfactors –Alcoholconsumption –Caffeineintake –Fecalimpaction –Ineffectivetoiletinghabits –Involuntarysphincterrelaxation Associatedcondition –Atrophicurethritis –Atrophicvaginitis –Bladderinfection –Decreaseinbladdercapacity –Detrusorhyperactivitywithimpairedbladder contractility –Impairedbladdercontractility –Treatmentregimen Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 206 Domain3•Class1•DiagnosisCode00022 Riskforurgeurinaryincontinence Approved1998•Revised2008,2013,2017•LevelofEvidence2.1 Definition Susceptible to involuntary passage of urine occurring soon after a strong sensationorurgencytovoid,whichmaycompromisehealth. Riskfactors –Alcoholconsumption –Caffeineintake –Fecalimpaction –Ineffectivetoiletinghabits –Involuntarysphincterrelaxation Associatedcondition –Atrophicurethritis –Atrophicvaginitis –Bladderinfection –Decreaseinbladdercapacity –Detrusorhyperactivitywithimpairedbladder contractility –Impairedbladdercontractility –Treatmentregimen Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 207 Domain3•Class1•DiagnosisCode00023 Urinaryretention Approved1986•Revised2017 Definition Inabilitytoemptybladdercompletely. Definingcharacteristics –Absenceofurinaryoutput –Bladderdistention –Dribblingofurine –Dysuria –Frequentvoiding –Overflowincontinence –Residualurine –Sensationofbladderfullness –Smallvoiding Relatedfactors –Tobedeveloped Associatedcondition –Blockageinurinarytract –Highurethralpressure –Reflexarcinhibition –Strongsphincter ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 208 Domain3•Class2•DiagnosisCode00011 Constipation Approved1975•Revised1998,2017 Definition Decrease in normal frequency of defecation accompanied by difficult or incompletepassageofstooland/orpassageofexcessivelyhard,drystool. Definingcharacteristics –Abdominalpain –Abdominaltendernesswithpalpablemuscle resistance –Abdominaltendernesswithoutpalpablemuscle resistance –Anorexia –Atypicalpresentationsinolderadults –Borborygmi –Brightredbloodwithstool –Changeinbowelpattern –Decreaseinstoolfrequency –Decreaseinstoolvolume –Distendedabdomen –Fatigue –Hard,formedstool –Headache –Hyperactivebowelsounds –Hypoactivebowelsounds –Inabilitytodefecate –Increaseinintra-abdominalpressure –Indigestion –Liquidstool –Painwithdefecation –Palpableabdominalmass –Palpablerectalmass –Percussedabdominaldullness –Rectalfullness –Rectalpressure –Severeflatus –Soft,paste-likestoolinrectum –Strainingwithdefecation –Vomiting Relatedfactors –Abdominalmuscleweakness –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Confusion –Decreaseingastrointestinalmotility –Dehydration –Depression –Eatinghabitchange –Habituallysuppressesurgetodefecate –Inadequatedietaryhabits –Inadequateoralhygiene –Inadequatetoiletinghabits –Insufficientfiberintake –Insufficientfluidintake –Irregulardefecationhabits –Laxativeabuse 209 –Emotionaldisturbance –Obesity –Recentenvironmentalchange Associatedcondition –Electrolyteimbalance –Hemorrhoids –Hirschprung'sdisease –Inadequatedentition –Ironsalts –Neurologicalimpairment –Postsurgicalbowelobstruction –Pregnancy –Prostateenlargement –Rectalabscess –Rectalanalfissure –Rectalanalstricture –Rectalprolapse –Rectalulcer –Rectocele –Tumor ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 210 Domain3•Class2•DiagnosisCode00015 Riskforconstipation Approved1998•Revised2013,2017 Definition Susceptible to a decrease in normal frequency of defecation accompanied by difficultorincompletepassageofstool,whichmaycompromisehealth. Riskfactors –Abdominalmuscleweakness –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Confusion –Decreaseingastrointestinalmotility –Dehydration –Depression –Eatinghabitchange –Emotionaldisturbance –Habituallysuppressesurgetodefecate –Inadequatedietaryhabits –Inadequateoralhygiene –Inadequatetoiletinghabits –Insufficientfiberintake –Insufficientfluidintake –Irregulardefecationhabits –Laxativeabuse –Obesity –Recentenvironmentalchange Associatedcondition –Electrolyteimbalance –Hemorrhoids –Hirschprung'sdisease –Inadequatedentition –Ironsalts –Neurologicalimpairment –Postsurgicalbowelobstruction –Pregnancy –Prostateenlargement –Rectalabscess –Rectalanalfissure –Rectalanalstricture –Rectalprolapse –Rectalulcer –Rectocele –Tumor ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 211 Domain3•Class2•DiagnosisCode00012 Perceivedconstipation Approved1988 Definition Self-diagnosis of constipation combined with abuse of laxatives, enemas, and/orsuppositoriestoensureadailybowelmovement. Definingcharacteristics –Enemaabuse –Expectsdailybowelmovement –Expectsdailybowelmovementatsametime everyday –Laxativeabuse –Suppositoryabuse Relatedfactors –Culturalhealthbeliefs –Familyhealthbeliefs –Impairedthoughtprocess ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 212 Domain3•Class2•DiagnosisCode00235 Chronicfunctionalconstipation Approved2013•Revised2017•LevelofEvidence2.2 Definition Infrequentordifficultevacuationoffeces,whichhasbeenpresentforatleast3 oftheprior12months. Definingcharacteristics Adult:Presenceof≥2ofthefollowingsymptomsonRomeIII classificationsystem: –Lumpyorhardstoolsin≥25%defecations –Strainingduring≥25%ofdefecations –Sensationofincompleteevacuationfor≥25%of defecations –Sensationofanorectalobstruction/blockagefor≥ 25%ofdefecations –Manualmaneuverstofacilitate≥25%of defecations(digitalmanipulation,pelvicfloor support) –≤3evacuationsperweek Child>4years:Presenceof≥2criteriaonRomeIIIPediatric classificationsystemfor≥2months: –≤2defecationsperweek –≥1episodeoffecalincontinenceperweek –Stoolretentiveposturing –Painfulorhardbowelmovements –Presenceoflargefecalmassintherectum –Largediameterstoolsthatmayobstructthetoilet Child≤4years:Presenceof≥2criteriaonRomeIIIPediatric classificationsystemfor≥1month: –≤2defecationsperweek –≥1episodeoffecalincontinenceperweek –Stoolretentiveposturing –Painfulorhardbowelmovements –Presenceoflargefecalmassintherectum –Largediameterstoolsthatmayobstructthetoilet 213 General –Distendedabdomen –Fecalimpaction –Leakageofstoolwithdigitalstimulation –Painwithdefecation –Palpableabdominalmass –Positivefecaloccultbloodtest –Prolongedstraining –Type1or2onBristolStoolChart Relatedfactors –Decreaseinfoodintake –Dehydration –Depression –Dietdisproportionallyhighinfat –Dietdisproportionallyhighinprotein –Frailelderlysyndrome –Habituallysuppressesurgetodefecate –Impairedmobility –Insufficientdietaryintake –Insufficientfluidintake –Insufficientknowledgeofmodifiablefactors –Lowcaloricintake –Low-fiberdiet –Sedentarylifestyle Associatedcondition –Amyloidosis –Analfissure –Analstricture –Autonomicneuropathy –Cerebralvascularaccident –Chronicintestinalpseudoobstruction –Chronicrenalinsufficiency –Colorectalcancer –Dementia –Dermatomyositis –Diabetesmellitus –Extraintestinalmass –Hemorrhoids –Hirschprung'sdisease –Hypercalcemia –Hypothyroidism –Inflammatoryboweldisease –Ischemicstenosis –Multiplesclerosis –Myotonicdystrophy –Panhypopituitarism –Paraplegia –Parkinson'sdisease –Pelvicfloordysfunction –Perinealdamage –Pharmaceuticalagent –Polypharmacy –Porphyria –Postinflammatorystenosis –Pregnancy –Proctitis –Scleroderma –Slowcolontransittime –Spinalcordinjury –Surgicalstenosis Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 214 Domain3•Class2•DiagnosisCode00236 Riskforchronicfunctionalconstipation Approved2013•Revised2017•LevelofEvidence2.2 Definition Susceptible to infrequent or difficult evacuation of feces, which has been presentnearly3oftheprior12months,whichmaycompromisehealth. Riskfactors –Decreaseinfoodintake –Dehydration –Depression –Dietdisproportionallyhighinfat –Dietdisproportionallyhighinprotein –Frailelderlysyndrome –Habituallysuppressesurgetodefecate –Impairedmobility –Insufficientdietaryintake –Insufficientfluidintake –Insufficientknowledgeofmodifiablefactors –Lowcaloricintake –Low-fiberdiet –Sedentarylifestyle Associatedcondition –Amyloidosis –Analfissure –Analstricture –Autonomicneuropathy –Cerebralvascularaccident –Chronicintestinalpseudoobstruction –Chronicrenalinsufficiency –Colorectalcancer –Dementia –Dermatomyositis –Diabetesmellitus –Extraintestinalmass –Hemorrhoids –Hirschprung'sdisease –Hypercalcemia –Hypothyroidism –Inflammatoryboweldisease –Ischemicstenosis –Multiplesclerosis –Myotonicdystrophy –Panhypopituitarism –Paraplegia –Parkinson'sdisease –Pelvicfloordysfunction –Perinealdamage –Pharmaceuticalagent –Polypharmacy –Porphyria –Postinflammatorystenosis –Pregnancy –Proctitis –Scleroderma –Slowcolontransittime –Spinalcordinjury –Surgicalstenosis 215 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 216 Domain3•Class2•DiagnosisCode00013 Diarrhea Approved1975•Revised1998,2017 Definition Passageofloose,unformedstools. Definingcharacteristics –Abdominalpain –Bowelurgency –Cramping –Hyperactivebowelsounds –Looseliquidstools,>3in24hours Relatedfactors –Anxiety –Increaseinstresslevel –Laxativeabuse –Substancemisuse Atriskpopulation –Exposuretocontaminant –Exposuretotoxin –Exposuretounsanitaryfoodpreparation Associatedcondition –Enteralfeedings –Gastrointestinalinflammation –Gastrointestinalirritation –Infection –Malabsorption –Parasite –Treatmentregimen ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 217 Domain3•Class2•DiagnosisCode00196 Dysfunctionalgastrointestinalmotility Approved2008•Revised2017•LevelofEvidence2.1 Definition Increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinalsystem. Definingcharacteristics –Abdominalcramping –Abdominalpain –Absenceofflatus –Accelerationofgastricemptying –Bile-coloredgastricresidual –Changeinbowelsounds –Diarrhea –Difficultywithdefecation –Distendedabdomen –Hard,formedstool –Increaseingastricresidual –Nausea –Regurgitation –Vomiting Relatedfactors –Anxiety –Changeinwatersource –Eatinghabitchange –Immobility –Malnutrition –Sedentarylifestyle –Stressors –Unsanitaryfoodpreparation Atriskpopulation –Aging –Ingestionofcontaminatedmaterial –Prematurity Associatedcondition –Decreaseingastrointestinalcirculation –Diabetesmellitus –Enteralfeedings –Foodintolerance –Gastroesophagealrefluxdisease –Infection –Pharmaceuticalagent –Treatmentregimen 218 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 219 Domain3•Class2•DiagnosisCode00197 Riskfordysfunctionalgastrointestinalmotility Approved2008•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to increased, decreased, ineffective, or lack of peristaltic activity withinthegastrointestinalsystem,whichmaycompromisehealth. Riskfactors –Anxiety –Changeinwatersource –Eatinghabitchange –Immobility –Malnutrition –Sedentarylifestyle –Stressors –Unsanitaryfoodpreparation Atriskpopulation –Aging –Ingestionofcontaminatedmaterial –Prematurity Associatedcondition –Decreaseingastrointestinalcirculation –Diabetesmellitus –Enteralfeedings –Foodintolerance –Gastroesophagealrefluxdisease –Infection –Pharmaceuticalagent –Treatmentregimen Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 220 Domain3•Class2•DiagnosisCode00014 Bowelincontinence Approved1975•Revised1998,2017 Definition Involuntarypassageofstool. Definingcharacteristics –Bowelurgency –Constantpassageofsoftstool –Doesnotrecognizeurgetodefecate –Fecalstaining –Inabilitytodelaydefecation –Inabilitytoexpelformedstooldespiterecognition ofrectalfullness –Inabilitytorecognizerectalfullness –Inattentivetourgetodefecate Relatedfactors –Difficultywithtoiletingself-care –Environmentalfactor –Generalizeddeclineinmuscletone –Immobility –Inadequatedietaryhabits –Incompleteemptyingofbowel –Laxativeabuse –Stressors Associatedcondition –Abnormalincreaseinabdominalpressure –Abnormalincreaseinintestinalpressure –Alterationincognitivefunctioning –Chronicdiarrhea –Colorectallesion –Dysfunctionalrectalsphincter –Impaction –Impairedreservoircapacity –Lowermotornervedamage –Pharmaceuticalagent –Rectalsphincterabnormality –Uppermotornervedamage ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 221 Domain3•Class3 Thisclassdoesnotcurrentlycontainanydiagnoses. 222 Domain3•Class4•DiagnosisCode00030 Impairedgasexchange Approved1980•Revised1996,1998,2017 Definition Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillarymembrane. Definingcharacteristics –Abnormalarterialbloodgases –AbnormalarterialpH –Abnormalbreathingpattern –Abnormalskincolor –Confusion –Decreaseincarbondioxide(CO2)level –Diaphoresis –Dyspnea –Headacheuponawakening –Hypercapnia –Hypoxemia –Hypoxia –Irritability –Nasalflaring –Restlessness –Somnolence –Tachycardia –Visualdisturbance Relatedfactors –Tobedeveloped Associatedcondition –Alveolar-capillarymembranechanges –Ventilation-perfusionimbalance ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 223 Domain4. Activity/rest Class1. Sleep/rest Code Diagnosis 00095 Insomnia 00096 Sleepdeprivation 00165 Readinessforenhancedsleep 00198 Disturbedsleeppattern Class2. Activity/exercise Code Diagnosis 00040 Riskfordisusesyndrome 00091 Impairedbedmobility 00085 Impairedphysicalmobility 00089 Impairedwheelchairmobility 00237 Impairedsitting 00238 Impairedstanding 00090 Impairedtransferability 00088 Impairedwalking Class3. Energybalance Code Diagnosis 00273 Imbalancedenergyfield 00093 Fatigue 00154 Wandering Class4. Cardiovascular/pulmonaryresponses 224 Code Diagnosis 00092 Activityintolerance 00094 Riskforactivityintolerance 00032 Ineffectivebreathingpattern 00029 Decreasedcardiacoutput 00240 Riskfordecreasedcardiacoutput 00033 Impairedspontaneousventilation 00267 Riskforunstablebloodpressure 00200 Riskfordecreasedcardiactissueperfusion 00201 Riskforineffectivecerebraltissueperfusion 00204 Ineffectiveperipheraltissueperfusion 00228 Riskforineffectiveperipheraltissueperfusion 00034 Dysfunctionalventilatoryweaningresponse Class5. Self-care Code Diagnosis 00098 Impairedhomemaintenance 00108 Bathingself-caredeficit 00109 Dressingself-caredeficit 00102 Feedingself-caredeficit 00110 Toiletingself-caredeficit 00182 Readinessforenhancedself-care 00193 Self-neglect NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 225 Domain4•Class1•DiagnosisCode00095 Insomnia Approved2006•Revised2017•LevelofEvidence2.1 Definition Adisruptioninamountandqualityofsleepthatimpairsfunctioning. Definingcharacteristics –Alterationinaffect –Alterationinconcentration –Alterationinmood –Alterationinsleeppattern –Compromisedhealthstatus –Decreaseinqualityoflife –Difficultyinitiatingsleep –Difficultymaintainingsleepstate –Dissatisfactionwithsleep –Earlyawakening –Increaseinabsenteeism –Increaseinaccidents –Insufficientenergy –Nonrestorativesleeppattern –Sleepdisturbanceproducingnextday consequences Relatedfactors –Alcoholconsumption –Anxiety –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Depression –Environmentalbarrier –Fear –Frequentnaps –Grieving –Inadequatesleephygiene –Physicaldiscomfort –Stressors Associatedcondition –Hormonalchange –Pharmaceuticalagent Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 226 Domain4•Class1•DiagnosisCode00096 Sleepdeprivation Approved1998•Revised2017 Definition Prolonged periods of time without sustained natural, periodic suspension of relativeconsciousnessthatprovidesrest. Definingcharacteristics –Agitation –Alterationinconcentration –Anxiety –Apathy –Combativeness –Confusion –Decreaseinfunctionalability –Decreaseinreactiontime –Drowsiness –Fatigue –Fleetingnystagmus –Hallucinations –Handtremors –Heightenedsensitivitytopain –Irritability –Lethargy –Malaise –Perceptualdisorders –Restlessness –Transientparanoia Relatedfactors –Age-relatedsleepstageshifts –Averagedailyphysicalactivityislessthan recommendedforgenderandage –Environmentalbarrier –Latedayconfusion –Nonrestorativesleeppattern –Overstimulatingenvironment –Prolongeddiscomfort –Sleepterror –Sleepwalking –Sustainedcircadianasynchrony –Sustainedinadequatesleephygiene Atriskpopulation –Familialsleepparalysis Associatedcondition 227 –Conditionswithperiodiclimbmovement –Dementia –Idiopathiccentralnervoussystem hypersomnolence –Narcolepsy –Nightmares –Sleepapnea –Sleep-relatedenuresis –Sleep-relatedpainfulerections –Treatmentregimen ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 228 Domain4•Class1•DiagnosisCode00165 Readinessforenhancedsleep Approved2002•Revised2013•LevelofEvidence2.1 Definition A pattern of natural, periodic suspension of relative consciousness to provide restandsustainadesiredlifestyle,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhancesleep 229 Domain4•Class1•DiagnosisCode00198 Disturbedsleeppattern Approved1980•Revised1998,2006•LevelofEvidence2.1 Definition Time-limitedawakeningsduetoexternalfactors. Definingcharacteristics –Difficultyindailyfunctioning –Difficultyinitiatingsleep –Difficultymaintainingsleepstate –Dissatisfactionwithsleep –Feelingunrested –Unintentionalawakening Relatedfactors –Disruptioncausedbysleeppartner –Environmentalbarrier –Immobilization –Insufficientprivacy –Nonrestorativesleeppattern 230 Domain4•Class2•DiagnosisCode00040 Riskfordisusesyndrome Approved1988•Revised2013,2017 Definition Susceptible to deterioration of body systems as the result of prescribed or unavoidablemusculoskeletalinactivity,whichmaycompromisehealth. Riskfactors –Pain Associatedcondition –Alterationinlevelofconsciousness –Mechanicalimmobility –Paralysis –Prescribedimmobility ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 231 Domain4•Class2•DiagnosisCode00091 Impairedbedmobility Approved1998•Revised2006,2017•LevelofEvidence2.1 Definition Limitationofindependentmovementfromonebedpositiontoanother. Definingcharacteristics –Impairedabilitytomovebetweenlongsittingand –Impairedabilitytorepositionselfinbed supinepositions –Impairedabilitytoturnfromsidetoside –Impairedabilitytomovebetweenproneand supinepositions –Impairedabilitytomovebetweensittingand supinepositions Relatedfactors –Environmentalbarrier –Insufficientknowledgeofmobilitystrategies –Insufficientmusclestrength –Obesity –Pain –Physicaldeconditioning Associatedcondition –Alterationincognitivefunctioning –Musculoskeletalimpairment –Neuromuscularimpairment –Pharmaceuticalagent This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition unless strongly differentiatedfromImpairedphysicalmobility(00085). Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 232 Domain4•Class2•DiagnosisCode00085 Impairedphysicalmobility Approved1973•Revised1998,2013,2017•LevelofEvidence2.1 Definition Limitationinindependent,purposefulmovementofthebodyorofoneormore extremities. Definingcharacteristics –Alterationingait –Decreaseinfinemotorskills –Decreaseingrossmotorskills –Decreaseinrangeofmotion –Decreaseinreactiontime –Difficultyturning –Discomfort –Engagesinsubstitutionsformovement –Exertionaldyspnea –Movement-inducedtremor –Posturalinstability –Slowedmovement –Spasticmovement –Uncoordinatedmovement Relatedfactors –Activityintolerance –Anxiety –Bodymassindex(BMI)>75thpercentile appropriateforageandgender –Culturalbeliefregardingacceptableactivity –Decreaseinendurance –Decreaseinmusclecontrol –Decreaseinmusclemass –Decreaseinmusclestrength –Depression –Disuse –Insufficientenvironmentalsupport –Insufficientknowledgeofvalueofphysical activity –Jointstiffness –Malnutrition –Pain –Physicaldeconditioning –Reluctancetoinitiatemovement –Sedentarylifestyle Associatedcondition –Alterationinbonestructureintegrity –Alterationincognitivefunctioning –Alterationinmetabolism –Contractures –Musculoskeletalimpairment –Neuromuscularimpairment –Pharmaceuticalagent –Prescribedmovementrestrictions 233 –Developmentaldelay –Sensory-perceptualimpairment Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 234 Domain4•Class2•DiagnosisCode00089 Impairedwheelchairmobility Approved1998•Revised2006,2017•LevelofEvidence2.1 Definition Limitationofindependentoperationofwheelchairwithinenvironment. Definingcharacteristics –Impairedabilitytooperatepowerwheelchairona decline –Impairedabilitytooperatepowerwheelchairon anincline –Impairedabilitytooperatepowerwheelchairon curbs –Impairedabilitytooperatepowerwheelchairon evensurface –Impairedabilitytooperatepowerwheelchairon unevensurface –Impairedabilitytooperatewheelchairona decline –Impairedabilitytooperatewheelchaironan incline –Impairedabilitytooperatewheelchaironcurbs –Impairedabilitytooperatewheelchaironeven surface –Impairedabilitytooperatewheelchaironuneven surface Relatedfactors –Alterationinmood –Decreaseinendurance –Environmentalbarrier –Insufficientknowledgeofwheelchairuse –Insufficientmusclestrength –Obesity –Pain –Physicaldeconditioning Associatedcondition –Alterationincognitivefunctioning –Impairedvision –Musculoskeletalimpairment –Neuromuscularimpairment This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition unless strongly differentiatedfromImpairedphysicalmobility(00085). Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 235 Domain4•Class2•DiagnosisCode00237 Impairedsitting Approved2013•Revised2017•LevelofEvidence2.1 Definition Limitationofabilitytoindependentlyandpurposefullyattainand/ormaintaina restpositionthatissupportedbythebuttocksandthighs,inwhichthetorsois upright. Definingcharacteristics –Impairedabilitytoadjustpositionofoneorboth lowerlimbsonunevensurface –Impairedabilitytoattainabalancedpositionof thetorso –Impairedabilitytoflexormovebothhips –Impairedabilitytoflexormovebothknees –Impairedabilitytomaintainthetorsoinbalanced position –Impairedabilitytostresstorsowithbodyweight Relatedfactors –Insufficientendurance –Insufficientenergy –Insufficientmusclestrength –Malnutrition –Pain –Self-imposedreliefposture Associatedcondition –Alterationincognitivefunctioning –Impairedmetabolicfunctioning –Neurologicaldisorder –Orthopedicsurgery –Prescribedposture –Psychologicaldisorder –Sarcopenia Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 236 Domain4•Class2•DiagnosisCode00238 Impairedstanding Approved2013•Revised2017•LevelofEvidence2.1 Definition Limitationofabilitytoindependentlyandpurposefullyattainand/ormaintain thebodyinanuprightpositionfromfeettohead. Definingcharacteristics –Impairedabilitytoadjustpositionofoneorboth lowerlimbsonunevensurface –Impairedabilitytoattainabalancedpositionof thetorso –Impairedabilitytoextendoneorbothhips –Impairedabilitytoextendoneorbothknees –Impairedabilitytoflexoneorbothhips –Impairedabilitytoflexoneorbothknees –Impairedabilitytomaintainthetorsoinbalanced position –Impairedabilitytostresstorsowithbodyweight Relatedfactors –Emotionaldisturbance –Insufficientendurance –Insufficientenergy –Insufficientmusclestrength –Malnutrition –Obesity –Pain –Self-imposedreliefposture Associatedcondition –Circulatoryperfusiondisorder –Impairedmetabolicfunctioning –Injurytolowerextremity –Neurologicaldisorder –Prescribedposture –Sarcopenia –Surgicalprocedure Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 237 Domain4•Class2•DiagnosisCode00090 Impairedtransferability Approved1998•Revised2006,2017•LevelofEvidence2.1 Definition Limitationofindependentmovementbetweentwonearbysurfaces. Definingcharacteristics –Impairedabilitytotransferbetweenbedandchair –Impairedabilitytotransferbetweenbedand standingposition –Impairedabilitytotransferbetweencarandchair –Impairedabilitytotransferbetweenchairand floor –Impairedabilitytotransferbetweenchairand standingposition –Impairedabilitytotransferbetweenfloorand standingposition –Impairedabilitytotransferbetweenunevenlevels –Impairedabilitytotransferinoroutofbathtub –Impairedabilitytotransferinoroutofshower –Impairedabilitytotransferonoroffacommode –Impairedabilitytotransferonoroffatoilet Relatedfactors –Environmentalbarrier –Impairedbalance –Insufficientknowledgeoftransfertechniques –Insufficientmusclestrength –Obesity –Physicaldeconditioning –Pain Associatedcondition –Alterationincognitivefunctioning –Impairedvision –Musculoskeletalimpairment –Neuromuscularimpairment Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 238 Domain4•Class2•DiagnosisCode00088 Impairedwalking Approved1998•Revised2006,2017•LevelofEvidence2.1 Definition Limitationofindependentmovementwithintheenvironmentonfoot. Definingcharacteristics –Impairedabilitytoclimbstairs –Impairedabilitytonavigatecurbs –Impairedabilitytowalkondecline –Impairedabilitytowalkonincline –Impairedabilitytowalkonunevensurface –Impairedabilitytowalkrequireddistance Relatedfactors –Alterationinmood –Decreaseinendurance –Environmentalbarrier –Fearoffalling –Insufficientknowledgeofmobilitystrategies –Insufficientmusclestrength –Obesity –Pain –Physicaldeconditioning Associatedcondition –Alterationincognitivefunctioning –Impairedbalance –Impairedvision –Musculoskeletalimpairment –Neuromuscularimpairment Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 239 Domain4•Class3•DiagnosisCode00273 Imbalancedenergyfield Approved2016•LevelofEvidence2.1 Definition A disruption in the vital flow of human energy that is normally a continuous wholeandisunique,dynamic,creativeandnonlinear. Definingcharacteristics –Arrhythmicenergyfieldpatterns –Blockageoftheenergyflow –Congestedenergyfieldpatterns –Congestionoftheenergyflow –Dissonantrhythmsoftheenergyfieldpatterns –Energydeficitoftheenergyflow –Expressionoftheneedtoregaintheexperienceof thewhole –Hyperactivityoftheenergyflow –Irregularenergyfieldpatterns –Magneticpulltoanareaoftheenergyfield –Pulsatingtopoundingfrequencyoftheenergy fieldpatterns –Pulsationssensedintheenergyflow –Randomenergyfieldpatterns –Rapidenergyfieldpatterns –Slowenergyfieldpatterns –Strongenergyfieldpatterns –Temperaturedifferentialsofcoldintheenergy flow –Temperaturedifferentialsofheatintheenergy flow –Tinglingsensedintheenergyflow –Tumultuousenergyfieldpatterns –Unsynchronizedrhythmssensedintheenergy flow –Weakenergyfieldpatterns Relatedfactors –Anxiety –Discomfort –Excessivestress –Interventionsthatdisrupttheenergeticpatternor flow –Pain Atriskpopulation –Crisisstates –Lifetransition Associatedcondition 240 –Illness –Injury Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 241 Domain4•Class3•DiagnosisCode00093 Fatigue Approved1988•Revised1998,2017 Definition An overwhelming sustained sense of exhaustion and decreased capacity for physicalandmentalworkattheusuallevel. Definingcharacteristics –Alterationinconcentration –Alterationinlibido –Apathy –Disinterestinsurroundings –Drowsiness –Guiltaboutdifficultymaintainingresponsibilities –Impairedabilitytomaintainusualphysical activity –Impairedabilitytomaintainusualroutines –Increaseinphysicalsymptoms –Increaseinrestrequirement –Ineffectiveroleperformance –Insufficientenergy –Introspection –Lethargy –Nonrestorativesleeppattern –Tiredness Relatedfactors –Anxiety –Depression –Environmentalbarrier –Increaseinphysicalexertion –Malnutrition –Nonstimulatinglifestyle –Demandingoccupation –Physicaldeconditioning –Sleepdeprivation –Stressors Atriskpopulation –Demandingoccupation –Exposuretonegativelifeevent Associatedcondition –Anemia –Pregnancy –Illness 242 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 243 Domain4•Class3•DiagnosisCode00154 Wandering Approved2000•Revised2017 Definition Meandering, aimless, or repetitive locomotion that exposes the individual to harm;frequentlyincongruentwithboundaries,limits,orobstacles. Definingcharacteristics –Continuousmovementfromplacetoplace –Elopingbehavior –Frequentmovementfromplacetoplace –Fretfullocomotion –Haphazardlocomotion –Hyperactivity –Impairedabilitytolocatelandmarksinafamiliar setting –Locomotionintounauthorizedspaces –Locomotionresultingingettinglost –Locomotionthatcannotbeeasilydissuaded –Longperiodsoflocomotionwithoutanapparent destination –Pacing –Periodsoflocomotioninterspersedwithperiods ofnonlocomotion –Persistentlocomotioninsearchofsomething –Scanningbehavior –Searchingbehavior –Shadowingacaregiver'slocomotion –Trespassing Relatedfactors –Alterationinsleep-wakecycle –Desiretogohome –Overstimulatingenvironment –Physiologicalstate –Separationfromfamiliarenvironment Atriskpopulation –Premorbidbehavior Associatedcondition –Alterationincognitivefunctioning –Corticalatrophy –Psychologicaldisorder –Sedation 244 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 245 Domain4•Class4•DiagnosisCode00092 Activityintolerance Approved1982•Revised2017 Definition Insufficient physiological or psychological energy to endure or complete requiredordesireddailyactivities. Definingcharacteristics –Abnormalbloodpressureresponsetoactivity –Abnormalheartrateresponsetoactivity –Electrocardiogram(ECG)change –Exertionaldiscomfort –Exertionaldyspnea –Fatigue –Generalizedweakness Relatedfactors –Imbalancebetweenoxygensupply/demand –Immobility –Inexperiencewithanactivity –Physicaldeconditioning –Sedentarylifestyle Atriskpopulation –Historyofpreviousactivityintolerance Associatedcondition –Circulatoryproblem –Respiratorycondition ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 246 Domain4•Class4•DiagnosisCode00094 Riskforactivityintolerance Approved1982•Revised2013,2017 Definition Susceptibletoexperiencinginsufficientphysiologicalorpsychologicalenergy to endure or complete required or desired daily activities, which may compromisehealth. Riskfactors –Imbalancebetweenoxygensupply/demand –Immobility –Inexperiencewithanactivity –Physicaldeconditioning –Sedentarylifestyle Atriskpopulation –Historyofpreviousactivityintolerance Associatedcondition –Circulatoryproblem –Respiratorycondition ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 247 Domain4•Class4•DiagnosisCode00032 Ineffectivebreathingpattern Approved1980•Revised1996,1998,2010,2017•LevelofEvidence2.1 Definition Inspirationand/orexpirationthatdoesnotprovideadequateventilation. Definingcharacteristics –Abnormalbreathingpattern –Alteredchestexcursion –Bradypnea –Decreaseinexpiratorypressure –Decreaseininspiratorypressure –Decreaseinminuteventilation –Decreaseinvitalcapacity –Dyspnea –Increaseinanterior-posteriorchestdiameter –Nasalflaring –Orthopnea –Prolongedexpirationphase –Pursed-lipbreathing –Tachypnea –Useofaccessorymusclestobreathe –Useofthree-pointposition Relatedfactors –Anxiety –Bodypositionthatinhibitslungexpansion –Fatigue –Hyperventilation –Obesity –Pain –Respiratorymusclefatigue Associatedcondition –Bonydeformity –Chestwalldeformity –Hypoventilationsyndrome –Musculoskeletalimpairment –Neurologicalimmaturity –Neurologicalimpairment –Neuromuscularimpairment –Spinalcordinjury Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 248 Domain4•Class4•DiagnosisCode00029 Decreasedcardiacoutput Approved1975•Revised1996,2000,2017 Definition Inadequate blood pumped by the heart to meet the metabolic demands of the body. Definingcharacteristics AlteredHeartRate/Rhythm –Bradycardia –Electrocardiogram(ECG)change –Heartpalpitations –Tachycardia AlteredPreload –Decreaseincentralvenouspressure(CVP) –Decreaseinpulmonaryarterywedgepressure (PAWP) –Edema –Fatigue –Heartmurmur –Increaseincentralvenouspressure(CVP) –Increaseinpulmonaryarterywedgepressure (PAWP) –Jugularveindistension –Weightgain AlteredAfterload –Abnormalskincolor –Alterationinbloodpressure –Clammyskin –Decreaseinperipheralpulses –Decreaseinpulmonaryvascularresistance(PVR) –Decreaseinsystemicvascularresistance(SVR) –Dyspnea –Increaseinpulmonaryvascularresistance(PVR) –Increaseinsystemicvascularresistance(SVR) –Oliguria –Prolongedcapillaryrefill AlteredContractility –Adventitiousbreathsounds –Coughing –Decreaseinstrokevolumeindex(SVI) –Orthopnea 249 –Decreaseincardiacindex –Decreaseinejectionfraction –Decreaseinleftventricularstrokeworkindex (LVSWI) –Paroxysmalnocturnaldyspnea –PresenceofS3heartsound –PresenceofS4heartsound Behavioral/Emotional –Anxiety –Restlessness Relatedfactors –Tobedeveloped Associatedcondition –Alterationinafterload –Alterationincontractility –Alterationinheartrate –Alterationinheartrhythm –Alterationinpreload –Alterationinstrokevolume ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 250 Domain4•Class4•DiagnosisCode00240 Riskfordecreasedcardiacoutput Approved2013•Revised2017•LevelofEvidence2.1 Definition Susceptible to inadequate blood pumped by the heart to meet metabolic demandsofthebody,whichmaycompromisehealth. Riskfactors –Tobedeveloped Associatedcondition –Alterationinafterload –Alterationincontractility –Alterationinheartrate –Alterationinheartrhythm –Alterationinpreload –Alterationinstrokevolume This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition if no modifiable risk factorsaredeveloped. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 251 Domain4•Class4•DiagnosisCode00033 Impairedspontaneousventilation Approved1992•Revised2017 Definition Inability to initiate and/or maintain independent breathing that is adequate to supportlife. Definingcharacteristics –Apprehensiveness –Decreaseinarterialoxygensaturation(SaO2) –Decreaseincooperation –Decreaseinpartialpressureofoxygen(PO2) –Decreaseintidalvolume –Dyspnea –Increaseinaccessorymuscleuse –Increaseinheartrate –Increaseinmetabolicrate –Increaseinpartialpressureofcarbondioxide (PCO2) –Restlessness Relatedfactors –Respiratorymusclefatigue Associatedcondition –Alterationinmetabolism ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 252 Domain4•Class4•DiagnosisCode00267 Riskforunstablebloodpressure Approved2016•LevelofEvidence2.1 Definition Susceptible to fluctuating forces of blood flowing through arterial vessels, whichmaycompromisehealth. Riskfactors –Inconsistencywithmedicationregimen –Orthostasis Associatedcondition –Adverseeffectsofcocaine –Adverseeffectsofnonsteroidalanti-inflammatory drugs(NSAIDS) –Adverseeffectsofsteroids –Cardiacdysrhythmia –CushingSyndrome –Electrolyteimbalance –Fluidretention –Fluidshifts –Hormonalchange –Hyperosmolarsolutions –Hyperparathyroidism –Hyperthyroidism –Hypothyroidism –Increasedintracranialpressure –Rapidabsorptionanddistributionofantiarrhythmiaagent –Rapidabsorptionanddistributionofdiuretic agent –Rapidabsorptionanddistributionofvasodilator agents –Sympatheticresponses –Useofantidepressantagents Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 253 Domain4•Class4•DiagnosisCode00200 Riskfordecreasedcardiactissueperfusion Approved2008•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to a decrease in cardiac (coronary) circulation, which may compromisehealth. Riskfactors –Insufficientknowledgeofmodifiablefactors –Substancemisuse Atriskpopulation –Familyhistoryofcardiovasculardisease Associatedcondition –Cardiactamponade –Cardiovascularsurgery –Coronaryarteryspasm –Diabetesmellitus –Hyperlipidemia –Hypertension –Hypovolemia –Hypoxemia –Hypoxia –IncreaseinC-reactiveprotein –Pharmaceuticalagent Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 254 Domain4•Class4•DiagnosisCode00201 Riskforineffectivecerebraltissueperfusion Approved2008•Revised2013,2017•LevelofEvidence2.1 Definition Susceptibletoadecreaseincerebraltissuecirculation,whichmaycompromise health. Riskfactors –Substancemisuse Atriskpopulation –Recentmyocardialinfarction Associatedcondition –Abnormalpartialthromboplastintime(PTT) –Abnormalprothrombintime(PT) –Akineticleftventricularwallsegment –Aorticatherosclerosis –Arterialdissection –Atrialfibrillation –Atrialmyxoma –Braininjury –Brainneoplasm –Carotidstenosis –Cerebralaneurysm –Coagulopathy –Dilatedcardiomyopathy –Disseminatedintravascularcoagulopathy –Embolism –Hypercholesterolemia –Hypertension –Infectiveendocarditis –Mechanicalprostheticvalve –Mitralstenosis –Pharmaceuticalagent –Sicksinussyndrome –Treatmentregimen This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition if no additional risk factorsaredeveloped. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 255 Domain4•Class4•DiagnosisCode00204 Ineffectiveperipheraltissueperfusion Approved2008•Revised2010,2017•LevelofEvidence2.1 Definition Decreaseinbloodcirculationtotheperiphery,whichmaycompromisehealth. Definingcharacteristics –Absenceofperipheralpulses –Alterationinmotorfunction –Alterationinskincharacteristic –Ankle-brachialindex<0.90 –Capillaryrefilltime>3seconds –Colordoesnotreturntoloweredlimbafter1 minutelegelevation –Decreaseinbloodpressureinextremities –Decreaseinpain-freedistancesduringa6-minute walktest –Decreaseinperipheralpulses –Delayinperipheralwoundhealing –Distanceinthe6-minutewalktestbelownormal range –Edema –Extremitypain –Femoralbruit –Intermittentclaudication –Paresthesia –Skincolorpaleswithlimbelevation Relatedfactors –Excessivesodiumintake –Insufficientknowledgeofdiseaseprocess –Insufficientknowledgeofmodifiablefactors –Sedentarylifestyle –Smoking Associatedcondition –Diabetesmellitus –Endovascularprocedure –Hypertension –Trauma Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 256 Domain4•Class4•DiagnosisCode00228 Riskforineffectiveperipheraltissueperfusion Approved2010•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to a decrease in blood circulation to the periphery, which may compromisehealth. Riskfactors –Excessivesodiumintake –Insufficientknowledgeofdiseaseprocess –Insufficientknowledgeofmodifiablefactors –Sedentarylifestyle –Smoking Associatedcondition –Diabetesmellitus –Endovascularprocedure –Hypertension –Trauma Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 257 Domain4•Class4•DiagnosisCode00034 Dysfunctionalventilatoryweaningresponse Approved1992•Revised2017 Definition Inability to adjust to lowered levels of mechanical ventilator support that interruptsandprolongstheweaningprocess. Definingcharacteristics Mild –Breathingdiscomfort –Fatigue –Fearofmachinemalfunction –Feelingwarm –Increaseinfocusonbreathing –Mildincreaseinrespiratoryrateoverbaseline –Perceivedneedforincreaseinoxygen –Restlessness Moderate –Abnormalskincolor –Apprehensiveness –Decreaseinairentryonauscultation –Diaphoresis –Facialexpressionoffear –Hyperfocusedonactivities –Impairedabilitytocooperate –Impairedabilitytorespondtocoaching –Increaseinbloodpressurefrombaseline(<20 mmHg) –Increaseinheartratefrombaseline(<20 beats/min) –Minimaluseofrespiratoryaccessorymuscles –Moderateincreaseinrespiratoryrateover baseline Severe –Abnormalskincolor –Adventitiousbreathsounds –Agitation –Asynchronizedbreathingwiththeventilator –Decreaseinlevelofconsciousness –Deteriorationinarterialbloodgasesfrom baseline –Increaseinheartratefrombaseline(≥20 beats/min) –Paradoxicalabdominalbreathing –Profusediaphoresis –Shallowbreathing –Significantincreaseinrespiratoryrateabove baseline 258 –Gaspingbreaths –Increaseinbloodpressurefrombaseline(≥to20 mmHg) –Useofsignificantrespiratoryaccessorymuscles Relatedfactors Physiological –Alterationinsleeppattern –Inadequatenutrition –Ineffectiveairwayclearance –Pain Psychological –Anxiety –Decreaseinmotivation –Fear –Hopelessness –Insufficientknowledgeofweaningprocess –Insufficienttrustinhealthcareprofessional –Lowself-esteem –Powerlessness –Uncertaintyaboutabilitytowean Situational –Environmentalbarrier –Inappropriatepaceofweaningprocess –Insufficientsocialsupport –Uncontrolledepisodicenergydemands Associatedcondition –Historyofunsuccessfulweaningattempt –Historyofventilatordependence>4days ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 259 Domain4•Class5•DiagnosisCode00098 Impairedhomemaintenance Approved1980•Revised2017 Definition Inability to independently maintain a safe growth-promoting immediate environment. Definingcharacteristics –Difficultymaintainingacomfortableenvironment –Excessivefamilyresponsibilities –Impairedabilitytomaintainhome –Insufficientclothing –Insufficientcookingequipment –Insufficientequipmentformaintaininghome –Insufficientlinen –Patternofdiseasecausedbyunhygienic conditions –Patternofinfectioncausedbyunhygienic conditions –Requestforassistancewithhomemaintenance –Unsanitaryenvironment Relatedfactors –Inadequaterolemodel –Insufficientfamilyorganization –Insufficientfamilyplanning –Insufficientknowledgeofhomemaintenance –Insufficientknowledgeofneighborhood resources –Insufficientsupportsystem Atriskpopulation –Financialcrisis Associatedcondition –Alterationincognitivefunctioning 260 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 261 Domain4•Class5•DiagnosisCode00108 Bathingself-caredeficit Approved1980•Revised1998,2008,2017•LevelofEvidence2.1 Definition Inabilitytoindependentlycompletecleansingactivities. Definingcharacteristics –Impairedabilitytoaccessbathroom –Impairedabilitytoaccesswater –Impairedabilitytodrybody –Impairedabilitytogatherbathingsupplies –Impairedabilitytoregulatebathwater –Impairedabilitytowashbody Relatedfactors –Anxiety –Decreaseinmotivation –Environmentalbarrier –Pain –Weakness Associatedcondition –Alterationincognitivefunctioning –Impairedabilitytoperceivebodypart –Impairedabilitytoperceivespatialrelationships –Musculoskeletalimpairment –Neuromuscularimpairment –Perceptualdisorders 262 Domain4•Class5•DiagnosisCode00109 Dressingself-caredeficit Approved1980•Revised1998,2008,2017•LevelofEvidence2.1 Definition Inabilitytoindependentlyputonorremoveclothing. Definingcharacteristics –Impairedabilitytochooseclothing –Impairedabilitytofastenclothing –Impairedabilitytogatherclothing –Impairedabilitytomaintainappearance –Impairedabilitytopickupclothing –Impairedabilitytoputclothingonlowerbody –Impairedabilitytoputclothingonupperbody –Impairedabilitytoputonvariousitemsof clothing –Impairedabilitytoremoveclothingitem –Impairedabilitytouseassistivedevice –Impairedabilitytousezipper Relatedfactors –Anxiety –Decreaseinmotivation –Discomfort –Environmentalbarrier –Fatigue –Pain –Weakness Associatedcondition –Alterationincognitivefunctioning –Musculoskeletalimpairment –Neuromuscularimpairment –Perceptualdisorders 263 Domain4•Class5•DiagnosisCode00102 Feedingself-caredeficit Approved1980•Revised1998,2008,2017•LevelofEvidence2.1 Definition Inabilitytoeatindependently. Definingcharacteristics –Impairedabilitytobringfoodtomouth –Impairedabilitytochewfood –Impairedabilitytogetfoodontoutensil –Impairedabilitytohandleutensils –Impairedabilitytomanipulatefoodinmouth –Impairedabilitytoopencontainers –Impairedabilitytopickupcup –Impairedabilitytopreparefood –Impairedabilitytoself-feedacompletemeal –Impairedabilitytoself-feedinanacceptable manner –Impairedabilitytoswallowfood –Impairedabilitytoswallowsufficientamountof food –Impairedabilitytouseassistivedevice Relatedfactors –Anxiety –Decreaseinmotivation –Discomfort –Environmentalbarrier –Fatigue –Pain –Weakness Associatedcondition –Alterationincognitivefunctioning –Musculoskeletalimpairment –Neuromuscularimpairment –Perceptualdisorders 264 Domain4•Class5•DiagnosisCode00110 Toiletingself-caredeficit Approved1980•Revised1998,2008,2017•LevelofEvidence2.1 Definition Inability to independently perform tasks associated with bowel and bladder elimination. Definingcharacteristics –Impairedabilitytocompletetoilethygiene –Impairedabilitytoflushtoilet –Impairedabilitytomanipulateclothingfor toileting –Impairedabilitytoreachtoilet –Impairedabilitytorisefromtoilet –Impairedabilitytositontoilet Relatedfactors –Anxiety –Decreaseinmotivation –Environmentalbarrier –Fatigue –Impairedabilitytotransfer –Impairedmobility –Pain –Weakness Associatedcondition –Alterationincognitivefunctioning –Musculoskeletalimpairment –Neuromuscularimpairment –Perceptualdisorders 265 Domain4•Class5•DiagnosisCode00182 Readinessforenhancedself-care Approved2006•Revised2013•LevelofEvidence2.1 Definition A pattern of performing activities for oneself to meet health-related goals, whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhanceindependencewith health –Expressesdesiretoenhanceindependencewith life –Expressesdesiretoenhanceindependencewith personaldevelopment –Expressesdesiretoenhanceindependencewith well-being –Expressesdesiretoenhanceknowledgeofselfcarestrategies –Expressesdesiretoenhanceself-care Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 266 Domain4•Class5•DiagnosisCode00193 Self-neglect Approved2008•Revised2017•LevelofEvidence2.1 Definition Aconstellationofculturallyframedbehaviorsinvolvingoneormoreself-care activitiesinwhichthereisafailuretomaintainasociallyacceptedstandardof healthandwell-being(Gibbons,Lauder&Ludwick,2006). Definingcharacteristics –Insufficientenvironmentalhygiene –Insufficientpersonalhygiene –Nonadherencetohealthactivity Relatedfactors –Deficientexecutivefunction –Fearofinstitutionalization –Inabilitytomaintaincontrol –Lifestylechoice –Stressors –Substancemisuse Associatedcondition –Alterationincognitivefunctioning –Capgrassyndrome –Frontallobedysfunction –Functionalimpairment –Learningdisability –Malingering –Psychiatricdisorder –Psychoticdisorder Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 267 Domain5. Perception/cognition Class1. Attention Code Diagnosis 00123 Unilateralneglect Class2. Orientation Code Diagnosis Thisclassdoesnotcurrentlycontainanydiagnoses. Class3. Sensation/perception Code Diagnosis Thisclassdoesnotcurrentlycontainanydiagnoses. Class4. Cognition Code Diagnosis 00128 Acuteconfusion 00173 Riskforacuteconfusion 00129 Chronicconfusion 00251 Labileemotionalcontrol 00222 Ineffectiveimpulsecontrol 00126 Deficientknowledge 00161 Readinessforenhancedknowledge 00131 Impairedmemory Class5. Communication 268 Code Diagnosis 00157 Readinessforenhancedcommunication 00051 Impairedverbalcommunication NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 269 Domain5•Class1•DiagnosisCode00123 Unilateralneglect Approved1986•Revised2006,2017•LevelofEvidence2.1 Definition Impairmentinsensoryandmotorresponse,mentalrepresentation,andspatial attention of the body, and the corresponding environment, characterized by inattentiontoonesideandoverattentiontotheoppositeside.Left-sideneglect ismoresevereandpersistentthanright-sideneglect. Definingcharacteristics –Alterationinsafetybehavioronneglectedside –Disturbanceofsoundlateralization –Failuretodressneglectedside –Failuretoeatfoodfromportionofplateon neglectedside –Failuretogroomneglectedside –Failuretomoveeyesintheneglectedhemisphere –Failuretomoveheadintheneglectedhemisphere –Failuretomovelimbsintheneglected hemisphere –Failuretomovetrunkintheneglected hemisphere –Failuretonoticepeopleapproachingfromthe neglectedside –Hemianopsia –Impairedperformanceonlinecancellation,line bisection,andtargetcancellationtests –Lefthemiplegiafromcerebrovascularaccident –Markeddeviationoftheeyestostimulionthe non-neglectedside –Markeddeviationofthetrunktostimulionthe non-neglectedside –Omissionofdrawingontheneglectedside –Perseveration –Representationalneglect –Substitutionofletterstoformalternativewords whenreading –Transferofpainsensationtothenon-neglected side –Unawareofpositioningofneglectedlimb –Unilateralvisuospatialneglect –Useofverticalhalfofpageonlywhenwriting Relatedfactors –Tobedeveloped Associatedcondition –Braininjury 270 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionifnorelatedfactorsare developed. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 271 Domain5•Class2 Thisclassdoesnotcurrentlycontainanydiagnoses. 272 Domain5•Class3 Thisclassdoesnotcurrentlycontainanydiagnoses. 273 Domain5•Class4•DiagnosisCode00128 Acuteconfusion Approved1994•Revised2006,2017•LevelofEvidence2.1 Definition Reversible disturbances of consciousness, attention, cognition and perception thatdevelopoverashortperiodoftime,andwhichlastlessthan3months. Definingcharacteristics –Agitation –Alterationincognitivefunctioning –Alterationinlevelofconsciousness –Alterationinpsychomotorfunctioning –Hallucinations –Inabilitytoinitiategoal-directedbehavior –Inabilitytoinitiatepurposefulbehavior –Insufficientfollow-throughwithgoal-directed behavior –Insufficientfollow-throughwithpurposeful behavior –Misperception –Restlessness Relatedfactors –Alterationinsleep-wakecycle –Dehydration –Impairedmobility –Inappropriateuseofrestraints –Malnutrition –Pain –Sensorydeprivation –Substancemisuse –Urinaryretention Atriskpopulation –Age≥60years –Historyofcerebralvascularaccident –Malegender Associatedcondition –Alterationincognitivefunctioning –Delirium –Dementia –Impairedmetabolicfunctioning –Infection –Pharmaceuticalagent 274 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 275 Domain5•Class4•DiagnosisCode00173 Riskforacuteconfusion Approved2006•Revised2013,2017•LevelofEvidence2.2 Definition Susceptible to reversible disturbances of consciousness, attention, cognition and perception that develop over a short period of time, which may compromisehealth. Riskfactors –Alterationinsleep-wakecycle –Dehydration –Impairedmobility –Inappropriateuseofrestraints –Malnutrition –Pain –Sensorydeprivation –Substancemisuse –Urinaryretention Atriskpopulation –Age≥60years –Historyofcerebralvascularaccident –Malegender Associatedcondition –Alterationincognitivefunctioning –Delirium –Dementia –Impairedmetabolicfunctioning –Infection –Pharmaceuticalagent Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 276 Domain5•Class4•DiagnosisCode00129 Chronicconfusion Approved1994•Revised2017•LevelofEvidence3.1 Definition Irreversible, progressive, insidious, and long-term alteration of intellect, behavior and personality, manifested by impairment in cognitive functions (memory, speech, language, decision making, and executive function), and dependencyinexecutionofdailyactivities Definingcharacteristics –Adequatealertnesstosurroundings –Alterationinatleastonecognitivefunctionother thanmemory –Alterationinbehavior –Alterationinlong-termmemory –Alterationinpersonality –Alterationinshort-termmemory –Alterationinsocialfunctioning –Inabilitytoperformatleastonedailyactivity –Insidiousandirreversibleonsetincognitive impairment –Long-termcognitiveimpairment –Progressiveimpairmentincognitivefunctioning Associatedcondition –Cerebralvascularaccident –Dementia Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 277 Domain5•Class4•DiagnosisCode00251 Labileemotionalcontrol Approved2013•Revised2017•LevelofEvidence2.1 Definition Uncontrollableoutburstsofexaggeratedandinvoluntaryemotionalexpression. Definingcharacteristics –Absenceofeyecontact –Crying –Difficultyinuseoffacialexpressions –Embarrassmentregardingemotionalexpression –Excessivecryingwithoutfeelingsadness –Excessivelaughingwithoutfeelinghappiness –Expressionofemotionincongruentwith triggeringfactor –Involuntarycrying –Involuntarylaughing –Uncontrollablecrying –Uncontrollablelaughing –Withdrawalfromoccupationalsituation –Withdrawalfromsocialsituation Relatedfactors –Alterationinself-esteem –Emotionaldisturbance –Fatigue –Insufficientknowledgeaboutsymptomcontrol –Insufficientknowledgeofdisease –Insufficientmusclestrength –Socialdistress –Stressors –Substancemisuse Associatedcondition –Braininjury –Functionalimpairment –Mooddisorder –Musculoskeletalimpairment –Pharmaceuticalagent –Physicaldisability –Psychiatricdisorder Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 278 Domain5•Class4•DiagnosisCode00222 Ineffectiveimpulsecontrol Approved2010•Revised2017•LevelofEvidence2.1 Definition A pattern of performing rapid, unplanned reactions to internal or external stimuliwithoutregardforthenegativeconsequencesofthesereactionstothe impulsiveindividualortoothers. Definingcharacteristics –Actingwithoutthinking –Askingpersonalquestionsdespitediscomfortof others –Gamblingaddiction –Inabilitytosavemoneyorregulatefinances –Inappropriatesharingofpersonaldetails –Irritability –Overlyfamiliarwithstrangers –Sensationseeking –Sexualpromiscuity –Temperoutbursts –Violentbehavior Relatedfactors –Hopelessness –Mooddisorder –Smoking –Substancemisuse Associatedcondition –Alterationincognitivefunctioning –Alterationindevelopment –Organicbraindisorder –Personalitydisorder Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 279 Domain5•Class4•DiagnosisCode00126 Deficientknowledge Approved1980•Revised2017 Definition Absenceofcognitiveinformationrelatedtoaspecifictopic,oritsacquisition. Definingcharacteristics –Inaccuratefollow-throughofinstruction –Inaccurateperformanceonatest –Inappropriatebehavior –Insufficientknowledge Relatedfactors –Insufficientinformation –Insufficientinterestinlearning –Insufficientknowledgeofresources –Misinformationpresentedbyothers Associatedcondition –Alterationincognitivefunctioning –Alterationinmemory ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 280 Domain5•Class4•DiagnosisCode00161 Readinessforenhancedknowledge Approved2002•Revised2013•LevelofEvidence2.1 Definition Apatternofcognitiveinformationrelatedtoaspecifictopic,oritsacquisition, whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhancelearning 281 Domain5•Class4•DiagnosisCode00131 Impairedmemory Approved1994•Revised2017•LevelofEvidence3.1 Definition Persistentinabilitytorememberorrecallbitsofinformationorskills Definingcharacteristics –Consistentlyforgetstoperformabehavioratthe scheduledtime –Persistentforgetfulness –Persistentinabilitytolearnanewskill –Persistentinabilitytolearnnewinformation –Persistentinabilitytoperformapreviously learnedskill –Persistentinabilitytorecallfactualinformationor events –Persistentinabilitytorecallfamiliarnames, words,orobjects –Persistentinabilitytorecallifabehaviorwas performed –Persistentinabilitytoretainanewskill –Persistentinabilitytoretainnewinformation –Preservedcapacitytoperformdailyactivities independently Relatedfactors –Alterationinfluidvolume Associatedcondition –Anemia –Braininjury –Decreaseincardiacoutput –Electrolyteimbalance –Hypoxia –Mildcognitiveimpairment –Neurologicalimpairment –Parkinson'sDisease Additionalmodifiablerelatedfactorstobedeveloped. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 282 Domain5•Class5•DiagnosisCode00157 Readinessforenhancedcommunication Approved2002•Revised2013•LevelofEvidence2.1 Definition A pattern of exchanging information and ideas with others, which can be strengthened. Definingcharacteristics –Expressesdesiretoenhancecommunication 283 Domain5•Class5•DiagnosisCode00051 Impairedverbalcommunication Approved1983•Revised1996,1998,2017 Definition Decreased,delayed,orabsentabilitytoreceive,process,transmit,and/orusea systemofsymbols. Definingcharacteristics –Absenceofeyecontact –Difficultycomprehendingcommunication –Difficultyexpressingthoughtsverbally –Difficultyformingsentences –Difficultyformingwords –Difficultyinselectiveattending –Difficultyinuseofbodyexpressions –Difficultyinuseoffacialexpressions –Difficultymaintainingcommunication –Difficultyspeaking –Difficultyverbalizing –Disorientedtoperson –Disorientedtoplace –Disorientedtotime –Dyspnea –Inabilitytospeak –Inabilitytospeaklanguageofcaregiver –Inabilitytousebodyexpressions –Inabilitytousefacialexpressions –Inappropriateverbalization –Partialvisualdeficit –Slurredspeech –Stuttering –Totalvisualdeficit Relatedfactors –Alterationinself-concept –Culturalincongruence –Emotionaldisturbance –Environmentalbarrier –Insufficientinformation –Insufficientstimuli –Lowself-esteem –Vulnerability Atriskpopulation –Absenceofsignificantother Associatedcondition 284 –Alterationindevelopment –Alterationinperception –Centralnervoussystemimpairment –Oropharyngealdefect –Physicalbarrier –Physiologicalcondition –Psychoticdisorder –Treatmentregimen ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 285 Domain6. Self-perception Class1. Self-concept Code Diagnosis 00124 Hopelessness 00185 Readinessforenhancedhope 00174 Riskforcompromisedhumandignity 00121 Disturbedpersonalidentity 00225 Riskfordisturbedpersonalidentity 00167 Readinessforenhancedself-concept Class2. Self-esteem Code Diagnosis 00119 Chroniclowself-esteem 00224 Riskforchroniclowself-esteem 00120 Situationallowself-esteem 00153 Riskforsituationallowself-esteem Class3. Bodyimage Code Diagnosis 00118 Disturbedbodyimage NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 286 Domain6•Class1•DiagnosisCode00124 Hopelessness Approved1986•Revised2017 Definition Subjective state in which an individual sees limited or no alternatives or personalchoicesavailableandisunabletomobilizeenergyonownbehalf. Definingcharacteristics –Alterationinsleeppattern –Decreaseinaffect –Decreaseinappetite –Decreaseininitiative –Decreaseinresponsetostimuli –Decreaseinverbalization –Despondentverbalcues –Inadequateinvolvementincare –Passivity –Pooreyecontact –Shrugginginresponsetospeaker –Turningawayfromspeaker Relatedfactors –Chronicstress –Lossofbeliefinspiritualpower –Lossofbeliefintranscendentvalues –Prolongedactivityrestriction –Socialisolation Atriskpopulation –Historyofabandonment Associatedcondition –Deteriorationinphysiologicalcondition ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 287 Domain6•Class1•DiagnosisCode00185 Readinessforenhancedhope Approved2006•Revised2013•LevelofEvidence2.1 Definition A pattern of expectations and desires for mobilizing energy on one's own behalf,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhanceabilitytoset achievablegoals –Expressesdesiretoenhancebeliefinpossibilities –Expressesdesiretoenhancecongruencyof expectationwithgoal –Expressesdesiretoenhanceconnectednesswith others –Expressesdesiretoenhancehope –Expressesdesiretoenhanceproblem-solvingto meetgoal –Expressesdesiretoenhancesenseofmeaningin life –Expressesdesiretoenhancespirituality Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 288 Domain6•Class1•DiagnosisCode00174 Riskforcompromisedhumandignity Approved2006•Revised2013•LevelofEvidence2.1 Definition Susceptible for perceived loss of respect and honor, which may compromise health. Riskfactors –Culturalincongruence –Dehumanizingtreatment –Disclosureofconfidentialinformation –Exposureofthebody –Humiliation –Insufficientcomprehensionofhealthinformation –Intrusionbyclinician –Invasionofprivacy –Limiteddecision-makingexperience –Lossofcontroloverbodyfunction –Stigmatization Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 289 Domain6•Class1•DiagnosisCode00121 Disturbedpersonalidentity Approved1978•Revised2008,2017•LevelofEvidence2.1 Definition Inabilitytomaintainanintegratedandcompleteperceptionofself. Definingcharacteristics –Alterationinbodyimage –Confusionaboutculturalvalues –Confusionaboutgoals –Confusionaboutideologicalvalues –Delusionaldescriptionofself –Feelingofemptiness –Feelingofstrangeness –Fluctuatingfeelingsaboutself –Genderconfusion –Inabilitytodistinguishbetweeninternaland externalstimuli –Inconsistentbehavior –Ineffectivecopingstrategies –Ineffectiverelationships –Ineffectiveroleperformance Relatedfactors –Alterationinsocialrole –Cultindoctrination –Culturalincongruence –Discrimination –Dysfunctionalfamilyprocesses –Lowself-esteem –Manicstates –Perceivedprejudice –Stagesofgrowth Atriskpopulation –Developmentaltransition –Situationalcrisis –Exposuretotoxicchemical Associatedcondition –Dissociativeidentitydisorder –Organicbraindisorder –Pharmaceuticalagent –Psychiatricdisorder 290 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 291 Domain6•Class1•DiagnosisCode00225 Riskfordisturbedpersonalidentity Approved2010•Revised2013,2017•LevelofEvidence2.1 Definition Susceptibletotheinabilitytomaintainanintegratedandcompleteperception ofself,whichmaycompromisehealth. Riskfactors –Alterationinsocialrole –Cultindoctrination –Culturalincongruence –Discrimination –Dysfunctionalfamilyprocesses –Lowself-esteem –Manicstates –Perceivedprejudice –Stagesofgrowth Atriskpopulation –Developmentaltransition –Exposuretotoxicchemical –Situationalcrisis Associatedcondition –Dissociativeidentitydisorder –Organicbraindisorder –Pharmaceuticalagent –Psychiatricdisorder Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 292 Domain6•Class1•DiagnosisCode00167 Readinessforenhancedself-concept Approved2002•Revised2013•LevelofEvidence2.1 Definition Apatternofperceptionsorideasabouttheself,whichcanbestrengthened. Definingcharacteristics –Acceptanceoflimitations –Acceptanceofstrengths –Actionscongruentwithverbalexpressions –Expressesconfidenceinabilities –Expressesdesiretoenhanceroleperformance –Expressesdesiretoenhanceself-concept –Expressessatisfactionwithbodyimage –Expressessatisfactionwithpersonalidentity –Expressessatisfactionwithsenseofworth –Expressessatisfactionwiththoughtsaboutself 293 Domain6•Class2•DiagnosisCode00119 Chroniclowself-esteem Approved1988•Revised1996,2008,2017•LevelofEvidence2.1 Definition Negative evaluation and/or feelings about one's own capabilities, lasting at leastthreemonths. Definingcharacteristics –Dependentonothers’opinions –Exaggeratesnegativefeedbackaboutself –Excessiveseekingofreassurance –Guilt –Hesitanttotrynewexperiences –Indecisivebehavior –Nonassertivebehavior –Overlyconforming –Passivity –Pooreyecontact –Rejectionofpositivefeedback –Repeatedlyunsuccessfulinlifeevents –Shame –Underestimatesabilitytodealwithsituation Relatedfactors –Culturalincongruence –Inadequateaffectionreceived –Inadequatebelonging –Inadequategroupmembership –Inadequaterespectfromothers –Ineffectivecopingwithloss –Receivinginsufficientapprovalfromothers –Spiritualincongruence Atriskpopulation –Exposuretotraumaticsituation –Patternoffailure –Repeatednegativereinforcement Associatedcondition –Psychiatricdisorder 294 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 295 Domain6•Class2•DiagnosisCode00224 Riskforchroniclowself-esteem Approved2010•Revised2013,2017•LevelofEvidence2.1 Definition Susceptibletolongstandingnegativeself-evaluating/feelingsaboutselforselfcapabilities,whichmaycompromisehealth. Riskfactors –Culturalincongruence –Inadequateaffectionreceived –Inadequatebelonging –Inadequategroupmembership –Inadequaterespectfromothers –Ineffectivecopingwithloss –Receivinginsufficientapprovalfromothers –Spiritualincongruence Atriskpopulation –Exposuretotraumaticsituation –Patternoffailure –Repeatednegativereinforcement Associatedcondition –Psychiatricdisorder Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 296 Domain6•Class2•DiagnosisCode00120 Situationallowself-esteem Approved1988•Revised1996,2000,2017 Definition Development of a negative perception of self-worth in response to a current situation. Definingcharacteristics –Helplessness –Indecisivebehavior –Nonassertivebehavior –Purposelessness –Self-negatingverbalizations –Situationalchallengetoself-worth –Underestimatesabilitytodealwithsituation Relatedfactors –Alterationinbodyimage –Alterationinsocialrole –Behaviorinconsistentwithvalues –Decreaseincontroloverenvironment –Inadequaterecognition –Patternofhelplessness –Unrealisticself-expectations Atriskpopulation –Developmentaltransition –Historyofabandonment –Historyofabuse –Historyofloss –Historyofneglect –Historyofrejection –Patternoffailure Associatedcondition –Functionalimpairment –Physicalillness ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis 297 completedtobringituptoalevelofevidence2.1orhigher. 298 Domain6•Class2•DiagnosisCode00153 Riskforsituationallowself-esteem Approved2000•Revised2013,2017 Definition Susceptibletodevelopinganegativeperceptionofself-worthinresponsetoa currentsituation,whichmaycompromisehealth. Riskfactors –Alterationinbodyimage –Alterationinsocialrole –Behaviorinconsistentwithvalues –Decreaseincontroloverenvironment –Inadequaterecognition –Patternofhelplessness –Unrealisticself-expectations Atriskpopulation –Developmentaltransition –Historyofabandonment –Historyofabuse –Historyofloss –Historyofneglect –Historyofrejection –Patternoffailure Associatedcondition –Functionalimpairment –Physicalillness ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 299 Domain6•Class3•DiagnosisCode00118 Disturbedbodyimage Approved1973•Revised1998,2017 Definition Confusioninmentalpictureofone'sphysicalself. Definingcharacteristics –Absenceofbodypart –Alterationinbodyfunction –Alterationinbodystructure –Alterationinviewofone'sbody –Avoidslookingatone'sbody –Avoidstouchingone'sbody –Behaviorofacknowledgingone'sbody –Behaviorofmonitoringone'sbody –Changeinabilitytoestimatespatialrelationship ofbodytoenvironment –Changeinlifestyle –Changeinsocialinvolvement –Depersonalizationofbodypartbyuseof impersonalpronouns –Depersonalizationoflossbyuseofimpersonal pronouns –Emphasisonremainingstrengths –Extensionofbodyboundary –Fearofreactionbyothers –Focusonpastappearance –Focusonpastfunction –Focusonpreviousstrength –Heightenedachievement –Hidingofbodypart –Negativefeelingaboutbody –Nonverbalresponsetochangeinbody –Nonverbalresponsetoperceivedchangeinbody –Overexposureofbodypart –Perceptionsthatreflectanalteredviewofone's bodyappearance –Personalizationofbodypartbyname –Personalizationoflossbyname –Preoccupationwithchange –Preoccupationwithloss –Refusaltoacknowledgechange –Traumatononfunctioningbodypart Relatedfactors –Alterationinself-perception –Culturalincongruence –Spiritualincongruence Atriskpopulation –Developmentaltransition 300 Associatedcondition –Alterationinbodyfunction –Alterationincognitivefunctioning –Illness –Impairedpsychosocialfunctioning –Injury –Surgicalprocedure –Trauma –Treatmentregimen ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 301 Domain7. Rolerelationship Class1. Caregivingroles Code Diagnosis 00061 Caregiverrolestrain 00062 Riskforcaregiverrolestrain 00056 Impairedparenting 00057 Riskforimpairedparenting 00164 Readinessforenhancedparenting Class2. Familyrelationships Code Diagnosis 00058 Riskforimpairedattachment 00063 Dysfunctionalfamilyprocesses 00060 Interruptedfamilyprocesses 00159 Readinessforenhancedfamilyprocesses Class3. Roleperformance Code Diagnosis 00223 Ineffectiverelationship 00229 Riskforineffectiverelationship 00207 Readinessforenhancedrelationship 00064 Parentalroleconflict 00055 Ineffectiveroleperformance 00052 Impairedsocialinteraction 302 NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 303 Domain7•Class1•DiagnosisCode00061 Caregiverrolestrain Approved1992•Revised1998,2000,2017•LevelofEvidence2.1 Definition Difficulty in fulfilling care responsibilities, expectations and/or behaviors for familyorsignificantothers. Definingcharacteristics CaregivingActivities –Apprehensivenessaboutfutureabilitytoprovide care –Apprehensivenessaboutfuturehealthofcare receiver –Apprehensivenessaboutpotential institutionalizationofcarereceiver –Apprehensivenessaboutwell-beingofcare receiverifunabletoprovidecare –Difficultycompletingrequiredtasks –Difficultyperformingrequiredtasks –Dysfunctionalchangeincaregivingactivities –Preoccupationwithcareroutine CaregiverHealthStatus:Physiological –Fatigue –Gastrointestinaldistress –Headache –Hypertension –Rash –Weightchange CaregiverHealthStatus:Emotional –Alterationinsleeppattern –Anger –Depression –Emotionalvacillation –Frustration –Impatience –Ineffectivecopingstrategies –Insufficienttimetomeetpersonalneeds –Nervousness –Somatization –Stressors CaregiverHealthStatus:Socioeconomic 304 –Changeinleisureactivities –Lowworkproductivity –Refusalofcareeradvancement –Socialisolation Caregiver-CareReceiverRelationship –Difficultywatchingcarereceiverwithillness –Grievingofchangesinrelationshipwithcare receiver –Uncertaintyaboutchangesinrelationshipwith carereceiver FamilyProcesses –Concernaboutfamilymember(s) –Familyconflict Relatedfactors CareReceiver –Conditioninhibitsconversation –Dependency –Dischargedhomewithsignificantneeds –Increaseincareneeds –Problematicbehavior –Substancemisuse –Unpredictabilityofillnesstrajectory –Unstablehealthcondition Caregiver –Physicalconditions –Substancemisuse –Unrealisticself-expectations –Competingrolecommitments –Ineffectivecopingstrategies –Inexperiencewithcaregiving –Insufficientemotionalresilience –Insufficientenergy –Insufficientfulfillmentofothers'expectations –Insufficientfulfillmentofself-expectations –Insufficientknowledgeaboutcommunity resources –Insufficientprivacy –Insufficientrecreation –Isolation –Notdevelopmentallyreadyforcaregiverrole –Stressors Caregiver-CareReceiverRelationship –Abusiverelationship –Codependency –Patternofineffectiverelationships –Presenceofabuse –Unrealisticcarereceiverexpectations –Violentrelationship CaregivingActivities 305 –Around-the-clockcareresponsibilities –Changeinnatureofcareactivities –Complexityofcareactivities –Excessivecaregivingactivities –Extendeddurationofcaregivingrequired –Inadequatephysicalenvironmentforproviding care –Insufficientassistance –Insufficientequipmentforprovidingcare –Insufficientrespiteforcaregiver –Insufficienttime –Unpredictabilityofcaresituation FamilyProcesses –Familyisolation –Ineffectivefamilyadaptation –Patternoffamilydysfunction –Patternoffamilydysfunctionpriortothe caregivingsituation –Patternofineffectivefamilycoping Socioeconomic –Alienation –Difficultyaccessingassistance –Difficultyaccessingcommunityresources –Difficultyaccessingsupport –Insufficientcommunityresources –Insufficientsocialsupport –Insufficienttransportation –Socialisolation Atriskpopulation –Carereceiver'sconditioninhibitsconversation –Developmentaldelayofcarereceiver –Developmentaldelayofcaregiver –Exposuretoviolence –Femalecaregiver –Financialcrisis –Partnerascaregiver –Prematurity Associatedcondition CareReceiver –Alterationincognitivefunctioning –Chronicillness –Congenitaldisorder –Illnessseverity –Psychiatricdisorder –Psychologicaldisorder Caregiver –Alterationincognitivefunctioning –Healthimpairment –Psychologicaldisorder 306 Domain7•Class1•DiagnosisCode00062 Riskforcaregiverrolestrain Approved1992•Revised2010,2013,2017•LevelofEvidence2.1 Definition Susceptible to difficulty in fulfilling care responsibilities, expectations and/or behaviorsforfamilyorsignificantothers,whichmaycompromisehealth. Riskfactors CareReceiver –Dependency –Dischargedhomewithsignificantneeds –Increaseincareneeds –Problematicbehavior –Substancemisuse –Unpredictabilityofillnesstrajectory –Unstablehealthcondition –Unstablehealthcondition Caregiver –Substancemisuse –Unrealisticself-expectations –Competingrolecommitments –Ineffectivecopingstrategies –Inexperiencewithcaregiving –Insufficientemotionalresilience –Insufficientenergy –Insufficientfulfillmentofothers'expectations –Insufficientfulfillmentofself-expectations –Insufficientknowledgeaboutcommunity resources –Insufficientprivacy –Insufficientrecreation –Isolation –Notdevelopmentallyreadyforcaregiverrole –Physicalconditions –Stressors Caregiver-CareReceiverRelationship –Abusiverelationship –Codependency –Patternofineffectiverelationships –Presenceofabuse –Unrealisticcarereceiverexpectations –Violentrelationship CaregivingActivities 307 –Around-the-clockcareresponsibilities –Changeinnatureofcareactivities –Complexityofcareactivities –Inadequatephysicalenvironmentforproviding care –Insufficientassistance –Insufficientequipmentforprovidingcare –Excessivecaregivingactivities –Extendeddurationofcaregivingrequired –Insufficientrespiteforcaregiver –Insufficienttime –Unpredictabilityofcaresituation FamilyProcesses –Familyisolation –Ineffectivefamilyadaptation –Patternoffamilydysfunction –Patternoffamilydysfunctionpriortothe caregivingsituation –Patternofineffectivefamilycoping Socioeconomic –Alienation –Difficultyaccessingassistance –Difficultyaccessingcommunityresources –Difficultyaccessingsupport –Insufficientcommunityresources –Insufficientsocialsupport –Insufficienttransportation –Socialisolation Atriskpopulation –Carereceiver'sconditioninhibitsconversation –Developmentaldelayofcarereceiver –Developmentaldelayofcaregiver –Exposuretoviolence –Femalecaregiver –Financialcrisis –Partnerascaregiver –Prematurity Associatedcondition CareReceiver –Alterationincognitivefunctioning –Chronicillness –Congenitaldisorder –Illnessseverity –Psychologicaldisorder –Psychiatricdisorder Caregiver –Alterationincognitivefunctioning –Healthimpairment –Psychologicaldisorder 308 Domain7•Class1•DiagnosisCode00056 Impairedparenting Approved1978•Revised1998,2017 Definition Inabilityofprimarycaregivertocreate,maintainorregainanenvironmentthat promotestheoptimumgrowthanddevelopmentofthechild. Definingcharacteristics InfantorChild –Behavioraldisorder –Delayincognitivedevelopment –Diminishedseparationanxiety –Failuretothrive –Frequentaccidents –Frequentillness –Historyofabuse –Historyoftrauma –Impairedsocialfunctioning –Insufficientattachmentbehavior –Lowacademicperformance –Runawayfromhome Parental –Abandonmentofchild –Failuretoprovidesafehomeenvironment –Decreaseinabilitytomanagechild –Decreaseincuddling –Deficientparent-childinteraction –Frustrationwithchild –Hostility –Inadequatechildhealthmaintenance –Inappropriatecare-takingskills –Inappropriatechild-carearrangements –Inappropriatestimulation –Inconsistentbehaviormanagement –Inconsistentcare –Inflexibilityinmeetingneedsofchild –Neglectsneedsofchild –Perceivedinabilitytomeetchild'sneeds –Perceivedroleinadequacy –Punitive –Rejectionofchild –Speaksnegativelyaboutchild Relatedfactors InfantorChild –Prolongedseparationfromparent –Temperamentconflictswithparentalexpectations 309 Parental –Alterationinsleeppattern –Conflictbetweenpartners –Depression –Failuretoprovidesafehomeenvironment –Fatherofchilduninvolved –Inabilitytoputchild'sneedsbeforeown –Inadequatechild-carearrangements –Ineffectivecommunicationskills –Ineffectivecopingstrategies –Insufficientaccesstoresources –Insufficientfamilycohesiveness –Insufficientknowledgeaboutchilddevelopment –Insufficientknowledgeaboutchildhealth maintenance –Insufficientknowledgeaboutparentingskills –Insufficientparentalrolemodel –Insufficientprenatalcare –Insufficientproblem-solvingskills –Insufficientresources –Insufficientresponsetoinfantcues –Insufficientsocialsupport –Insufficienttransportation –Insufficientvaluingofparenthood –Late-termprenatalcare –Lowself-esteem –Motherofchilduninvolved –Nonrestorativesleeppattern –Preferenceforphysicalpunishment –Rolestrain –Sleepdeprivation –Socialisolation –Stressors –Unrealisticexpectations Atriskpopulation InfantorChild –Developmentaldelay –Difficulttemperament –Genderotherthandesired –Prematurity Parental –Changeinfamilyunit –Closelyspacedpregnancies –Difficultbirthingprocess –Economicallydisadvantaged –Highnumberofpregnancies –Historyofabuse –Historyofbeingabusive –Historyofmentalillness –Historyofsubstancemisuse –Insufficientcognitivereadinessforparenting –Legaldifficulty –Loweducationallevel –Multiplebirths –Relocation –Singleparent –Unemployment –Unplannedpregnancy –Unwantedpregnancy –Workdifficulty –Youngparentalage Associatedcondition 310 InfantorChild –Alterationinperceptualabilities –Behavioraldisorder –Chronicillness –Disablingcondition Parental –Alterationincognitivefunctioning –Disablingcondition –Physicalillness ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 311 Domain7•Class1•DiagnosisCode00057 Riskforimpairedparenting Approved1978•Revised1998,2013,2017 Definition Susceptibletoprimarycaregiverdifficultyincreating,maintainingorregaining an environment that promotes the optimum growth and development of the child,whichmaycompromisethewell-beingofthechild. Riskfactors InfantorChild –Prolongedseparationfromparent –Temperamentconflictswithparentalexpectations Parental –Alterationinsleeppattern –Conflictbetweenpartners –Depression –Failuretoprovidesafehomeenvironment –Fatherofchilduninvolved –Inabilitytoputchild'sneedsbeforeown –Inadequatechild-carearrangements –Ineffectivecommunicationskills –Ineffectivecopingstrategies –Insufficientaccesstoresources –Insufficientfamilycohesiveness –Insufficientknowledgeaboutchilddevelopment –Insufficientknowledgeaboutchildhealth maintenance –Insufficientknowledgeaboutparentingskills –Insufficientparentalrolemodel –Insufficientprenatalcare –Insufficientproblem-solvingskills –Insufficientresources –Insufficientresponsetoinfantcues –Insufficientsocialsupport –Insufficienttransportation –Insufficientvaluingofparenthood –Late-termprenatalcare –Lowself-esteem –Motherofchilduninvolved –Nonrestorativesleeppattern –Preferenceforphysicalpunishment –Rolestrain –Sleepdeprivation –Socialisolation –Stressors –Unrealisticexpectations Atriskpopulation 312 InfantorChild –Developmentaldelay –Difficulttemperament –Genderotherthandesired –Prematurity Parental –Changeinfamilyunit –Closelyspacedpregnancies –Difficultbirthingprocess –Economicallydisadvantaged –Highnumberofpregnancies –Historyofabuse –Historyofbeingabusive –Historyofmentalillness –Historyofsubstancemisuse –Insufficientcognitivereadinessforparenting –Legaldifficulty –Loweducationallevel –Multiplebirths –Relocation –Singleparent –Unemployment –Unplannedpregnancy –Unwantedpregnancy –Workdifficulty –Youngparentalage Associatedcondition InfantorChild –Alterationinperceptualabilities –Behavioraldisorder –Chronicillness –Disablingcondition Parental –Alterationincognitivefunctioning –Disablingcondition –Physicalillness ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 313 Domain7•Class1•DiagnosisCode00164 Readinessforenhancedparenting Approved2002•Revised2013•LevelofEvidence2.1 Definition A pattern of providing an environment for children to nurture growth and development,whichcanbestrengthened. Definingcharacteristics –Childrenexpressdesiretoenhancehome environment –Parentexpressesdesiretoenhanceparenting –Parentexpressesdesiretoenhanceemotional supportofchildren –Parentexpressesdesiretoenhanceemotional supportofotherdependentperson 314 Domain7•Class2•DiagnosisCode00058 Riskforimpairedattachment Approved1994•Revised2008,2013,2017•LevelofEvidence2.1 Definition Susceptible to disruption of the interactive process between parent or significant other and child that fosters the development of a protective and nurturingreciprocalrelationship. Riskfactors –Anxiety –Child'sillnesspreventseffectiveinitiationof parentalcontact –Disorganizedinfantbehavior –Inabilityofparenttomeetpersonalneeds –Insufficientprivacy –Parentalconflictresultingfromdisorganized infantbehavior –Parent-childseparation –Physicalbarrier –Substancemisuse Atriskpopulation –Prematureinfant 315 Domain7•Class2•DiagnosisCode00063 Dysfunctionalfamilyprocesses Approved1994•Revised2008,2017•LevelofEvidence2.1 Definition Familyfunctioningwhichfailstosupportthewell-beingofitsmembers. Definingcharacteristics Behavioral –Agitation –Alterationinconcentration –Blaming –Brokenpromises –Chaos –Complicatedgrieving –Conflictavoidance –Contradictorycommunicationpattern –Controllingcommunicationpattern –Criticizing –Decreaseinphysicalcontact –Denialofproblems –Dependency –Difficultyhavingfun –Difficultywithintimaterelationship –Difficultywithlife-cycletransition –Disturbanceinacademicperformanceinchildren –Enablingsubstanceusepattern –Escalatingconflict –Failuretoaccomplishdevelopmentaltasks –Harshself-judgment –Immaturity –Inabilitytoacceptawiderangeoffeelings –Inabilitytoaccepthelp –Inabilitytoadapttochange –Inabilitytodealconstructivelywithtraumatic experiences –Unreliablebehavior –Inabilitytoexpressawiderangeoffeelings –Inabilitytomeettheemotionalneedsofits members –Inabilitytomeetthesecurityneedsofits members –Inabilitytomeetthespiritualneedsofits members –Inabilitytoreceivehelpappropriately –Inappropriateangerexpression –Ineffectivecommunicationskills –Insufficientknowledgeaboutsubstancemisuse –Insufficientproblem-solvingskills –Lying –Manipulation –Nicotineaddiction –Orientationfavorstensionreliefratherthangoal attainment –Paradoxicalcommunicationpattern –Powerstruggles –Rationalization –Refusaltogethelp –Seekingofaffirmation –Seekingofapproval –Self-blame –Socialisolation –Specialoccasionscenteredonsubstanceuse –Stress-relatedphysicalillness –Substancemisuse 316 –Verbalabuseofchildren –Verbalabuseofparent –Verbalabuseofpartner Feelings –Abandonment –Anger –Anxiety –Confusesloveandpity –Confusion –Depression –Dissatisfaction –Distress –Embarrassment –Emotionalisolation –Emotionallycontrolledbyothers –Failure –Fear –Feelingdifferentfromothers –Feelingmisunderstood –Feelingunloved –Frustration –Guilt –Hopelessness –Hostility –Hurt –Insecurity –Lingeringresentment –Loneliness –Loss –Lossofidentity –Lowself-esteem –Mistrust –Moodiness –Powerlessness –Rejection –Repressedemotions –Shame –Takingresponsibilityforsubstancemisuser's behavior –Tension –Unhappiness –Vulnerability –Worthlessness RolesandRelationships –Changeinrolefunction –Chronicfamilyproblems –Closedcommunicationsystem –Conflictbetweenpartners –Deteriorationinfamilyrelationships –Diminishedabilityoffamilymemberstorelateto eachotherformutualgrowthandmaturation –Disruptioninfamilyrituals –Disruptioninfamilyroles –Disturbanceinfamilydynamics –Familydenial –Inconsistentparenting –Ineffectivecommunicationwithpartner –Insufficientcohesiveness –Insufficientfamilyrespectforautonomyofits members –Insufficientfamilyrespectforindividualityofits members –Insufficientrelationshipskills –Neglectofobligationtofamilymember –Patternofrejection –Perceivedinsufficientparentalsupport –Triangulatingfamilyrelationships Relatedfactors –Addictivepersonality –Insufficientproblem-solvingskills 317 –Ineffectivecopingstrategies –Substancemisuse Atriskpopulation –Economicallydisadvantaged –Familyhistoryofresistancetotreatment –Familyhistoryofsubstancemisuse –Geneticpredispositiontosubstancemisuse Associatedcondition –Biologicalfactors –Intimacydysfunction –Surgicalprocedure 318 Domain7•Class2•DiagnosisCode00060 Interruptedfamilyprocesses Approved1982•Revised1998,2017 Definition Breakinthecontinuityoffamilyfunctioningwhichfailstosupportthewellbeingofitsmembers. Definingcharacteristics –Changeinavailabilityforaffective responsiveness –Changeinfamilyconflictresolution –Changeinfamilysatisfaction –Changeinintimacy –Changeinparticipationforproblem-solving –Assignedtaskschange –Changeincommunicationpattern –Changeinsomatization –Changeinstress-reductionbehavior –Changesinexpressionsofconflictwith communityresources –Changesinexpressionsofisolationfrom communityresources –Changesinparticipationfordecision-making –Changesinrelationshippattern –Decreaseinavailableemotionalsupport –Decreaseinmutualsupport –Ineffectivetaskcompletion –Poweralliancechange –Ritualchange Relatedfactors –Changesininteractionwithcommunity –Powershiftamongfamilymembers –Shiftinfamilyroles Atriskpopulation –Changeinfamilyfinances –Changeinfamilysocialstatus –Developmentalcrisis –Developmentaltransition –Situationalcrisis –Situationaltransition Associatedcondition –Shiftinhealthstatusofafamilymember 319 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 320 Domain7•Class2•DiagnosisCode00159 Readinessforenhancedfamilyprocesses Approved2002•Revised2013•LevelofEvidence2.1 Definition Apatternoffamilyfunctioningtosupportthewell-beingofitsmembers,which canbestrengthened. Definingcharacteristics –Expressesdesiretoenhancebalancebetween autonomyandcohesiveness –Expressesdesiretoenhancecommunication pattern –Expressesdesiretoenhanceenergylevelof familytosupportactivitiesofdailyliving –Expressesdesiretoenhancefamilyadaptationto change –Expressesdesiretoenhancefamilydynamics –Expressesdesiretoenhancefamilyresilience –Expressesdesiretoenhancegrowthoffamily members –Expressesdesiretoenhanceinterdependencewith community –Expressesdesiretoenhancemaintenanceof boundariesbetweenfamilymembers –Expressesdesiretoenhancerespectforfamily members –Expressesdesiretoenhancesafetyoffamily members 321 Domain7•Class3•DiagnosisCode00223 Ineffectiverelationship Approved2010•Revised2017•LevelofEvidence2.1 Definition Apatternof mutualpartnershipthatisinsufficienttoprovideforeachother's needs. Definingcharacteristics –Delayinmeetingofdevelopmentalgoals appropriateforfamilylife-cyclestage –Dissatisfactionwithcomplementaryrelationship betweenpartners –Dissatisfactionwithemotionalneedfulfillment betweenpartners –Dissatisfactionwithideasharingbetween partners –Dissatisfactionwithinformationsharingbetween partners –Dissatisfactionwithphysicalneedfulfillment betweenpartners –Inadequateunderstandingofpartner's compromisedfunctioning –Insufficientbalanceinautonomybetween partners –Insufficientbalanceincollaborationbetween partners –Insufficientmutualrespectbetweenpartners –Insufficientmutualsupportindailyactivities betweenpartners –Partnernotidentifiedassupportperson –Unsatisfyingcommunicationwithpartner Relatedfactors –Ineffectivecommunicationskills –Stressors –Substancemisuse –Unrealisticexpectations Atriskpopulation –Developmentalcrisis –Historyofdomesticviolence –Incarcerationofonepartner Associatedcondition –Alterationincognitivefunctioninginonepartner 322 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 323 Domain7•Class3•DiagnosisCode00229 Riskforineffectiverelationship Approved2010•Revised2013,2017•LevelofEvidence2.1 Definition Susceptibletodevelopingapatternthatisinsufficientforprovidingamutual partnershiptoprovideforeachother'sneeds. Riskfactors –Ineffectivecommunicationskills –Stressors –Substancemisuse –Unrealisticexpectations Atriskpopulation –Developmentalcrisis –Historyofdomesticviolence –Incarcerationofonepartner Associatedcondition –Alterationincognitivefunctioninginonepartner Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 324 Domain7•Class3•DiagnosisCode00207 Readinessforenhancedrelationship Approved2006•Revised2013•LevelofEvidence2.1 Definition Apatternofmutualpartnershiptoprovideforeachother'sneeds,whichcanbe strengthened. Definingcharacteristics –Expressesdesiretoenhanceautonomybetween partners –Expressesdesiretoenhancecollaboration betweenpartners –Expressesdesiretoenhancecommunication betweenpartners –Expressesdesiretoenhanceemotionalneed fulfillmentforeachpartner –Expressesdesiretoenhancemutualrespect betweenpartners –Expressesdesiretoenhancesatisfactionwith complementaryrelationshipbetweenpartners –Expressesdesiretoenhancesatisfactionwith emotionalneedfulfillmentforeachpartner –Expressesdesiretoenhancesatisfactionwithidea sharingbetweenpartners –Expressesdesiretoenhancesatisfactionwith informationsharingbetweenpartners –Expressesdesiretoenhancesatisfactionwith physicalneedfulfillmentforeachpartner –Expressesdesiretoenhanceunderstandingof partner'sfunctionaldeficit Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 325 Domain7•Class3•DiagnosisCode00064 Parentalroleconflict Approved1988•Revised2017 Definition Parentalexperienceofroleconfusionandconflictinresponsetocrisis. Definingcharacteristics –Anxiety –Concernaboutchangeinparentalrole –Concernaboutfamily –Disruptionincaregiverroutines –Fear –Frustration –Guilt –Perceivedinadequacytoprovideforchild'sneeds –Perceivedlossofcontroloverdecisionsrelating tochild –Reluctancetoparticipateinusualcaregiver activities Relatedfactors –Interruptionsinfamilylifeduetohomecare regimen –Intimidatedbyinvasivemodalities –Intimidatedbyrestrictivemodalities –Parent-childseparation Atriskpopulation –Changeinmaritalstatus –Homecareofachildwithspecialneeds –Livinginnontraditionalsetting ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 326 Domain7•Class3•DiagnosisCode00055 Ineffectiveroleperformance Approved1978•Revised1996,1998,2017 Definition A pattern of behavior and self-expression that does not match the environmentalcontext,norms,andexpectations. Definingcharacteristics –Alterationinroleperception –Anxiety –Changeincapacitytoresumerole –Changeinothers’perceptionofrole –Changeinself-perceptionofrole –Changeinusualpatternofresponsibility –Depression –Discrimination –Domesticviolence –Harassment –Inappropriatedevelopmentalexpectations –Ineffectiveadaptationtochange –Ineffectivecopingstrategies –Ineffectiveroleperformance –Insufficientconfidence –Insufficientexternalsupportforroleenactment –Insufficientknowledgeofrolerequirements –Insufficientmotivation –Insufficientopportunityforroleenactment –Insufficientself-management –Insufficientskills –Pessimism –Powerlessness –Roleambivalence –Roleconflict –Roleconfusion –Roledenial –Roledissatisfaction –Rolestrain –Systemconflict –Uncertainty Relatedfactors –Alterationinbodyimage –Conflict –Depression –Domesticviolence –Fatigue –Inadequaterolemodel –Inappropriatelinkagewiththehealthcaresystem –Insufficientresources –Insufficientrewards –Insufficientrolepreparation –Insufficientrolesocialization –Insufficientsupportsystem –Lowself-esteem –Pain –Stressors –Substancemisuse –Unrealisticroleexpectations 327 Atriskpopulation –Developmentallevelinappropriateforrole expectation –Economicallydisadvantaged –Highdemandsofjobschedule –Loweducationallevel –Youngage Associatedcondition –Neurologicaldefect –Personalitydisorder –Physicalillness –Psychosis ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 328 Domain7•Class3•DiagnosisCode00052 Impairedsocialinteraction Approved1986•Revised2017 Definition Insufficientorexcessivequantityorineffectivequalityofsocialexchange. Definingcharacteristics –Discomfortinsocialsituations –Dissatisfactionwithsocialengagement –Dysfunctionalinteractionwithothers –Familyreportschangeininteraction –Impairedsocialfunctioning Relatedfactors –Communicationbarrier –Disturbanceinself-concept –Disturbanceinthoughtprocesses –Environmentalbarrier –Impairedmobility –Insufficientknowledgeabouthowtoenhance mutuality –Insufficientskillstoenhancemutuality –Socioculturaldissonance Atriskpopulation –Absenceofsignificantother Associatedcondition –Therapeuticisolation ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 329 Domain8. Sexuality Class1. Sexualidentity Code Diagnosis Thisclassdoesnotcurrentlycontainanydiagnoses. Class2. Sexualfunction Code Diagnosis 00059 Sexualdysfunction 00065 Ineffectivesexualitypattern Class3. Reproduction Code Diagnosis 00221 Ineffectivechildbearingprocess 00227 Riskforineffectivechildbearingprocess 00208 Readinessforenhancedchildbearingprocess 00209 Riskfordisturbedmaternal-fetaldyad NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 330 Domain8•Class1 Thisclassdoesnotcurrentlycontainanydiagnoses. 331 Domain8•Class2•DiagnosisCode00059 Sexualdysfunction Approved1980•Revised2006,2017•LevelofEvidence2.1 Definition Astateinwhichanindividualexperiencesachangeinsexualfunctionduring thesexualresponsephasesofdesire,arousal,and/ororgasm,whichisviewed asunsatisfying,unrewarding,orinadequate. Definingcharacteristics –Alterationinsexualactivity –Alterationinsexualexcitation –Alterationinsexualsatisfaction –Changeininteresttowardothers –Changeinself-interest –Changeinsexualrole –Decreaseinsexualdesire –Perceivedsexuallimitation –Seekingconfirmationofdesirability –Undesiredchangeinsexualfunction Relatedfactors –Absenceofprivacy –Inadequaterolemodel –Insufficientknowledgeaboutsexualfunction –Misinformationaboutsexualfunction –Presenceofabuse –Psychosocialabuse –Valueconflict –Vulnerability Atriskpopulation –Absenceofsignificantother Associatedcondition –Alterationinbodyfunction –Alterationinbodystructure 332 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 333 Domain8•Class2•DiagnosisCode00065 Ineffectivesexualitypattern Approved1986•Revised2006,2017•LevelofEvidence2.1 Definition Expressionsofconcernregardingownsexuality. Definingcharacteristics –Alterationinrelationshipwithsignificantother –Alterationinsexualactivity –Alterationinsexualbehavior –Changeinsexualrole –Difficultywithsexualactivity –Difficultywithsexualbehavior –Valueconflict Relatedfactors –Conflictaboutsexualorientation –Conflictaboutvariantpreference –Fearofpregnancy –Fearofsexuallytransmittedinfection –Impairedrelationshipwithasignificantother –Inadequaterolemodel –Insufficientknowledgeaboutalternativesrelated tosexuality –Skilldeficitaboutalternativesrelatedtosexuality –Absenceofprivacy Atriskpopulation –Absenceofsignificantother Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 334 Domain8•Class3•DiagnosisCode00221 Ineffectivechildbearingprocess Approved2010•Revised2017•LevelofEvidence2.1 Definition Inabilitytoprepareforand/ormaintainahealthypregnancy,childbirthprocess andcareofthenewbornforensuringwell-being. Definingcharacteristics DuringPregnancy –Inadequateprenatalcare –Inadequateprenatallifestyle –Inadequatepreparationofnewborncareitems –Inadequatepreparationofthehomeenvironment –Ineffectivemanagementofunpleasantsymptoms inpregnancy –Insufficientaccessofsupportsystem –Insufficientrespectforunbornbaby –Unrealisticbirthplan DuringLaborandDelivery –Decreaseinproactivityduringlaboranddelivery –Inadequatelifestyleforstageoflabor –Inappropriateresponsetoonsetoflabor –Insufficientaccessofsupportsystem –Insufficientattachmentbehavior AfterBirth –Inadequatebabycaretechniques –Inadequatepostpartumlifestyle –Inappropriatebabyfeedingtechniques –Inappropriatebreastcare –Insufficientaccessofsupportsystem –Insufficientattachmentbehavior –Unsafeenvironmentforaninfant Relatedfactors –Domesticviolence –Inadequatematernalnutrition –Inconsistentprenatalhealthvisits –Insufficientcognitivereadinessforparenting –Insufficientknowledgeofchildbearingprocess –Insufficientparentalrolemodel –Insufficientprenatalcare –Insufficientsupportsystem 335 –Lowmaternalconfidence –Maternalpowerlessness –Maternalpsychologicaldistress –Substancemisuse –Unrealisticbirthplan –Unsafeenvironment Atriskpopulation –Unplannedpregnancy –Unwantedpregnancy Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 336 Domain8•Class3•DiagnosisCode00227 Riskforineffectivechildbearingprocess Approved2010•Revised2013,2017•LevelofEvidence2.1 Definition Susceptibletoaninabilitytoprepareforand/ormaintainahealthypregnancy, childbirthprocessandcareofthenewbornforensuringwell-being. Riskfactors –Domesticviolence –Inadequatematernalnutrition –Inconsistentprenatalhealthvisits –Insufficientcognitivereadinessforparenting –Insufficientknowledgeofchildbearingprocess –Insufficientparentalrolemodel –Insufficientprenatalcare –Insufficientsupportsystem –Lowmaternalconfidence –Maternalpowerlessness –Maternalpsychologicaldistress –Substancemisuse –Unrealisticbirthplan –Unsafeenvironment Atriskpopulation –Unplannedpregnancy –Unwantedpregnancy Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 337 Domain8•Class3•DiagnosisCode00208 Readinessforenhancedchildbearingprocess Approved2008•Revised2013•LevelofEvidence2.1 Definition A pattern of preparing for and maintaining a healthy pregnancy, childbirth process and care of the newborn for ensuring well-being which can be strengthened. Definingcharacteristics DuringPregnancy –Expressesdesiretoenhanceknowledgeof childbearingprocess –Expressesdesiretoenhancemanagementof unpleasantpregnancysymptoms –Expressesdesiretoenhanceprenatallifestyle –Expressesdesiretoenhancepreparationfor newborn DuringLaborandDelivery –Expressesdesiretoenhancelifestyleappropriate forstageoflabor –Expressesdesiretoenhanceproactivityduring laboranddelivery AfterBirth –Expressesdesiretoenhanceattachmentbehavior –Expressesdesiretoenhancebabycaretechniques –Expressesdesiretoenhancebabyfeeding techniques –Expressesdesiretoenhancebreastcare –Expressesdesiretoenhanceenvironmentalsafety forthebaby –Expressesdesiretoenhancepostpartumlifestyle –Expressesdesiretoenhanceuseofsupport system Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 338 Domain8•Class3•DiagnosisCode00209 Riskfordisturbedmaternal-fetaldyad Approved2008•Revised2013,2017•LevelofEvidence2.1 Definition Susceptibletoadisruptionofthesymbioticmother-fetalrelationshipasaresult ofcomorbidorpregnancy-relatedconditions,whichmaycompromisehealth. Riskfactors –Inadequateprenatalcare –Presenceofabuse –Substancemisuse Associatedcondition –Alterationinglucosemetabolism –Compromisedfetaloxygentransport –Pregnancycomplication –Treatmentregimen Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 339 Domain9. Coping/stresstolerance Class1. Post-traumaresponses Code Diagnosis 00260 Riskforcomplicatedimmigrationtransition 00141 Post-traumasyndrome 00145 Riskforpost-traumasyndrome 00142 Rape-traumasyndrome 00114 Relocationstresssyndrome 00149 Riskforrelocationstresssyndrome Class2. Copingresponses Code Diagnosis 00199 Ineffectiveactivityplanning 00226 Riskforineffectiveactivityplanning 00146 Anxiety 00071 Defensivecoping 00069 Ineffectivecoping 00158 Readinessforenhancedcoping 00077 Ineffectivecommunitycoping 00076 Readinessforenhancedcommunitycoping 00074 Compromisedfamilycoping 00073 Disabledfamilycoping 00075 Readinessforenhancedfamilycoping 00147 Deathanxiety 00072 Ineffectivedenial 00148 Fear 340 00136 Grieving 00135 Complicatedgrieving 00172 Riskforcomplicatedgrieving 00241 Impairedmoodregulation 00125 Powerlessness 00152 Riskforpowerlessness 00187 Readinessforenhancedpower 00210 Impairedresilience 00211 Riskforimpairedresilience 00212 Readinessforenhancedresilience 00137 Chronicsorrow 00177 Stressoverload Class3. Neurobehavioralstress Code Diagnosis 00258 Acutesubstancewithdrawalsyndrome 00259 Riskforacutesubstancewithdrawalsyndrome 00009 Autonomicdysreflexia 00010 Riskforautonomicdysreflexia 00049 Decreasedintracranialadaptivecapacity 00264 Neonatalabstinencesyndrome 00116 Disorganizedinfantbehavior 00115 Riskfordisorganizedinfantbehavior 00117 Readinessforenhancedorganizedinfantbehavior NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 341 Domain9•Class1•DiagnosisCode00260 Riskforcomplicatedimmigrationtransition Approved2016•LevelofEvidence2.1 Definition Susceptible to experiencing negative feelings (loneliness, fear, anxiety) in response to unsatisfactory consequences and cultural barriers to one's immigrationtransition,whichmaycompromisehealth. Riskfactors –Availableworkbeloweducationalpreparation –Culturalbarriersinhostcountry –Unsanitaryhousing –Insufficientknowledgeabouttheprocessto accessresourcesinthehostcountry –Insufficientsocialsupportinhostcountry –Languagebarriersinhostcountry –Multiplenon-relatedpersonswithinhousehold –Overcrowdedhousing –Overtdiscrimination –Parent-childconflictsrelatedtoenculturationin thehostcountry –Abusivelandlord Atriskpopulation –Forcedmigration –Hazardousworkconditionswithinadequate training –Illegalstatusinhostcountry –Laborexploitation –Precariouseconomicsituation –Separationfromfamilyinhomecountry –Separationfromfriendsinhomecountry –Unfulfilledexpectationsofimmigration Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 342 Domain9•Class1•DiagnosisCode00141 Post-traumasyndrome Approved1986•Revised1998,2010,2017•LevelofEvidence2.1 Definition Sustainedmaladaptiveresponsetoatraumatic,overwhelmingevent. Definingcharacteristics –Aggression –Alienation –Alterationinconcentration –Alterationinmood –Anger –Anxiety(00146) –Avoidancebehaviors –Compulsivebehavior –Denial –Depression –Dissociativeamnesia –Enuresis –Exaggeratedstartleresponse –Fear(00148) –Flashbacks –Gastrointestinalirritation –Grieving(00136) –Guilt –Headache –Heartpalpitations –Historyofdetachment –Hopelessness(00124) –Horror –Hypervigilance –Intrusivedreams –Intrusivethoughts –Irritability –Neurosensoryirritability –Nightmares –Panicattacks –Rage –Reportsfeelingnumb –Repression –Shame –Substancemisuse Relatedfactors –Diminishedegostrength –Environmentnotconducivetoneeds –Exaggeratedsenseofresponsibility –Insufficientsocialsupport –Perceiveseventastraumatic –Self-injuriousbehavior –Survivorrole Atriskpopulation 343 –Destructionofone'shome –Displacementfromhome –Durationoftraumaticevent –Eventoutsidetherangeofusualhuman experience –Exposuretodisaster –Exposuretoepidemic –Exposuretoeventinvolvingmultipledeaths –Exposuretowar –Historyofabuse –Historyofbeingaprisonerofwar –Historyofcriminalvictimization –Historyoftorture –Humanserviceoccupations –Seriousaccident –Seriousinjurytolovedone –Seriousthreattolovedone –Seriousthreattoself –Witnessingmutilation –Witnessingviolentdeath ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtomeetdefinitionofasyndrome. 344 Domain9•Class1•DiagnosisCode00145 Riskforpost-traumasyndrome Approved1998•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to sustained maladaptive response to a traumatic, overwhelming event,whichmaycompromisehealth. Riskfactors –Diminishedegostrength –Environmentnotconducivetoneeds –Exaggeratedsenseofresponsibility –Insufficientsocialsupport –Perceiveseventastraumatic –Self-injuriousbehavior –Survivorrole Atriskpopulation –Destructionofone'shome –Displacementfromhome –Durationoftraumaticevent –Eventoutsidetherangeofusualhuman experience –Exposuretodisaster –Exposuretoepidemic –Exposuretoeventinvolvingmultipledeaths –Exposuretowar –Historyofabuse –Historyofbeingaprisonerofwar –Historyofcriminalvictimization –Historyoftorture –Humanserviceoccupations –Seriousaccident –Seriousinjurytolovedone –Seriousthreattolovedone –Seriousthreattoself –Witnessingmutilation –Witnessingviolentdeath ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalwork alongwithPost-traumasyndrome(00141)iscompleted. 345 Domain9•Class1•DiagnosisCode00142 Rape-traumasyndrome Approved1980•Revised1998,2017 Definition Sustainedmaladaptiveresponsetoaforced,violent,sexualpenetrationagainst thevictim'swillandconsent. Definingcharacteristics –Aggression –Agitation –Alterationinsleeppattern –Anger –Anxiety(00146) –Changeinrelationship(s) –Confusion –Denial –Dependency –Depression –Disorganization –Dissociativeidentitydisorder –Embarrassment –Fear(00148) –Guilt –Helplessness –Historyofsuicideattempt –Humiliation –Hyperalertness –Impaireddecision-making –Lowself-esteem –Moodswings –Musclespasm –Muscletension –Nightmares –Paranoia –Perceivedvulnerability –Phobias –Physicaltrauma –Powerlessness(00125) –Self-blame –Sexualdysfunction(00059) –Shame –Shock –Substancemisuse –Thoughtsofrevenge Relatedfactors –Tobedeveloped Atriskpopulation –Rape 346 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 347 Domain9•Class1•DiagnosisCode00114 Relocationstresssyndrome Approved1992•Revised2000,2017 Definition Physiological and/or psychosocial disturbance following transfer from one environmenttoanother. Definingcharacteristics –Alienation –Aloneness –Alterationinsleeppattern –Anger –Anxiety(00146) –Concernaboutrelocation –Dependency –Depression –Fear(00148) –Frustration –Increaseinillness –Increaseinphysicalsymptoms –Increaseinverbalizationofneeds –Insecurity –Loneliness –Lossofidentity –Lossofself-worth –Lowself-esteem –Pessimism –Preoccupation –Unwillingnesstomove –Withdrawal Relatedfactors –Ineffectivecopingstrategies –Insufficientpredeparturecounseling –Insufficientsupportsystem –Languagebarrier –Movefromoneenvironmenttoanother –Powerlessness –Significantenvironmentalchange –Socialisolation –Unpredictabilityofexperience Atriskpopulation –Historyofloss Associatedcondition 348 –Compromisedhealthstatus –Deficientmentalcompetence –Impairedpsychosocialfunctioning ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 349 Domain9•Class1•DiagnosisCode00149 Riskforrelocationstresssyndrome Approved2000•Revised2013,2017 Definition Susceptibletophysiologicaland/orpsychosocialdisturbancefollowingtransfer fromoneenvironmenttoanother,whichmaycompromisehealth. Riskfactors –Ineffectivecopingstrategies –Insufficientpredeparturecounseling –Insufficientsupportsystem –Languagebarrier –Movefromoneenvironmenttoanother –Powerlessness –Significantenvironmentalchange –Socialisolation –Unpredictabilityofexperience Atriskpopulation –Historyofloss Associatedcondition –Compromisedhealthstatus –Deficientmentalcompetence –Impairedpsychosocialfunctioning ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 350 Domain9•Class2•DiagnosisCode00199 Ineffectiveactivityplanning Approved2008•Revised2017•LevelofEvidence2.1 Definition Inability to prepare for a set of actions fixed in time and under certain conditions. Definingcharacteristics –Absenceofplan –Excessiveanxietyaboutatasktobeundertaken –Fearaboutatasktobeundertaken –Insufficientorganizationalskills –Insufficientresources –Patternoffailure –Patternofprocrastination –Unmetgoalsforchosenactivity –Worriedaboutatasktobeundertaken Relatedfactors –Flightbehaviorwhenfacedwithproposed solution –Hedonism –Insufficientinformationprocessingability –Insufficientsocialsupport –Patternofprocrastination –Unrealisticperceptionofevent –Unrealisticperceptionofpersonalabilities Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 351 Domain9•Class2•DiagnosisCode00226 Riskforineffectiveactivityplanning Approved2010•Revised2013•LevelofEvidence2.1 Definition Susceptibletoaninabilitytoprepareforasetofactionsfixedintimeandunder certainconditions,whichmaycompromisehealth. Riskfactors –Flightbehaviorwhenfacedwithproposed solution –Hedonism –Insufficientinformationprocessingability –Insufficientsocialsupport –Patternofprocrastination –Unrealisticperceptionofevent –Unrealisticperceptionofpersonalabilities Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 352 Domain9•Class2•DiagnosisCode00146 Anxiety Approved1973•Revised1982,1998,2017 Definition Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the individual); a feelingofapprehensioncausedbyanticipationofdanger.Itisanalertingsign thatwarnsofimpendingdangerandenablestheindividualtotakemeasuresto dealwiththatthreat. Definingcharacteristics Behavioral –Decreaseinproductivity –Extraneousmovement –Fidgeting –Glancingabout –Hypervigilance –Insomnia –Pooreyecontact –Restlessness –Scanningbehavior –Worriedaboutchangeinlifeevent Affective –Anguish –Apprehensiveness –Distress –Fear –Feelingofinadequacy –Helplessness –Increaseinwariness –Irritability –Nervousness –Overexcitement –Rattled –Regretful –Self-focused –Uncertainty Physiological –Facialtension –Handtremors –Increaseinperspiration –Increaseintension –Trembling –Tremor –Voicequivering 353 Sympathetic –Alterationinrespiratorypattern –Anorexia –Briskreflexes –Cardiovascularexcitation –Diarrhea –Drymouth –Facialflushing –Heartpalpitations –Increaseinbloodpressure –Increaseinheartrate –Increaseinrespiratoryrate –Pupildilation –Superficialvasoconstriction –Twitching –Weakness Parasympathetic –Abdominalpain –Alterationinsleeppattern –Decreaseinbloodpressure –Decreaseinheartrate –Diarrhea –Faintness –Fatigue –Nausea –Tinglinginextremities –Urinaryfrequency –Urinaryhesitancy –Urinaryurgency Cognitive –Alterationinattention –Alterationinconcentration –Awarenessofphysiologicalsymptoms –Blockingofthoughts –Confusion –Decreaseinperceptualfield –Diminishedabilitytolearn –Diminishedabilitytoproblemsolve –Forgetfulness –Preoccupation –Rumination –Tendencytoblameothers Relatedfactors –Conflictaboutlifegoals –Interpersonalcontagion –Interpersonaltransmission –Stressors –Substancemisuse –Threatofdeath –Threattocurrentstatus –Unmetneeds –Valueconflict Atriskpopulation –Exposuretotoxin –Familyhistoryofanxiety –Heredity –Majorchange –Maturationalcrisis –Situationalcrisis 354 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 355 Domain9•Class2•DiagnosisCode00071 Defensivecoping Approved1988•Revised2008•LevelofEvidence2.1 Definition Repeated projection of falsely positive self-evaluation based on a selfprotectivepatternthatdefendsagainstunderlyingperceivedthreatstopositive selfregard. Definingcharacteristics –Alterationinrealitytesting –Denialofproblems –Denialofweaknesses –Difficultyestablishingrelationships –Difficultymaintainingrelationships –Grandiosity –Hostilelaughter –Hypersensitivitytoadiscourtesy –Hypersensitivitytocriticism –Insufficientfollowthroughwithtreatment –Insufficientparticipationintreatment –Projectionofblame –Projectionofresponsibility –Rationalizationoffailures –Realitydistortion –Ridiculeofothers –Superiorattitudetowardothers Relatedfactors –Conflictbetweenself-perceptionandvalue system –Fearoffailure –Fearofhumiliation –Fearofrepercussions –Insufficientconfidenceinothers –Insufficientresilience –Insufficientself-confidence –Insufficientsupportsystem –Uncertainty –Unrealisticself-expectations Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 356 Domain9•Class2•DiagnosisCode00069 Ineffectivecoping Approved1978•Revised1998 Definition A pattern of invalid appraisal of stressors, with cognitive and/or behavioral efforts,thatfailstomanagedemandsrelatedtowell-being. Definingcharacteristics –Alterationinconcentration –Alterationinsleeppattern –Changeincommunicationpattern –Destructivebehaviortowardothers –Destructivebehaviortowardself –Difficultyorganizinginformation –Fatigue –Frequentillness –Inabilitytoaskforhelp –Inabilitytoattendtoinformation –Inabilitytodealwithasituation –Inabilitytomeetbasicneeds –Inabilitytomeetroleexpectation –Ineffectivecopingstrategies –Insufficientaccessofsocialsupport –Insufficientgoal-directedbehavior –Insufficientproblemresolution –Insufficientproblem-solvingskills –Risk-takingbehavior –Substancemisuse Relatedfactors –Highdegreeofthreat –Inabilitytoconserveadaptiveenergies –Inaccuratethreatappraisal –Inadequateconfidenceinabilitytodealwitha situation –Inadequateopportunitytoprepareforstressor –Inadequateresources –Ineffectivetensionreleasestrategies –Insufficientsenseofcontrol –Insufficientsocialsupport Atriskpopulation –Maturationalcrisis –Situationalcrisis ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 357 Domain9•Class2•DiagnosisCode00158 Readinessforenhancedcoping Approved2002•Revised2013•LevelofEvidence2.1 Definition Apatternofvalidappraisalofstressorswithcognitiveand/orbehavioralefforts tomanagedemandsrelatedtowell-being,whichcanbestrengthened. Definingcharacteristics –Awarenessofpossibleenvironmentalchange –Expressesdesiretoenhanceknowledgeofstress managementstrategies –Expressesdesiretoenhancemanagementof stressors –Expressesdesiretoenhancesocialsupport –Expressesdesiretoenhanceuseofemotionorientedstrategies –Expressesdesiretoenhanceuseofproblemorientedstrategies –Expressesdesiretoenhanceuseofspiritual resource 358 Domain9•Class2•DiagnosisCode00077 Ineffectivecommunitycoping Approved1994•Revised1998,2017 Definition A pattern of community activities for adaptation and problem-solving that is unsatisfactoryformeetingthedemandsorneedsofthecommunity. Definingcharacteristics –Communitydoesnotmeetexpectationsofits members –Deficientcommunityparticipation –Elevatedcommunityillnessrate –Excessivecommunityconflict –Excessivestress –Highincidenceofcommunityproblems –Perceivedcommunitypowerlessness –Perceivedcommunityvulnerability Relatedfactors –Inadequateresourcesforproblem-solving –Insufficientcommunityresources –Nonexistentcommunitysystems Atriskpopulation –Exposuretodisaster –Historyofdisaster ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 359 Domain9•Class2•DiagnosisCode00076 Readinessforenhancedcommunitycoping Approved1994•Revised2013 Definition A pattern of community activities for adaptation and problem-solving for meetingthedemandsorneedsofthecommunity,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhanceavailabilityof communityrecreationprograms –Expressesdesiretoenhanceavailabilityof communityrelaxationprograms –Expressesdesiretoenhancecommunication amongcommunitymembers –Expressesdesiretoenhancecommunication betweengroupsandlargercommunity –Expressesdesiretoenhancecommunityplanning forpredictablestressors –Expressesdesiretoenhancecommunityresources formanagingstressors –Expressesdesiretoenhancecommunity responsibilityforstressmanagement –Expressesdesiretoenhanceproblem-solvingfor identifiedissue ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 360 Domain9•Class2•DiagnosisCode00074 Compromisedfamilycoping Approved1980•Revised1996,2017 Definition An usually supportive primary person (family member, significant other, or close friend) provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that may be needed by the client to manageormasteradaptivetasksrelatedtohisorherhealthchallenge. Definingcharacteristics –Assistivebehaviorsbysupportpersonproduce unsatisfactoryresults –Clientcomplaintaboutsupportperson'sresponse tohealthproblem –Clientconcernaboutsupportperson'sresponseto healthproblem –Limitationincommunicationbetweensupport personandclient –Protectivebehaviorbysupportperson incongruentwithclient'sabilities –Protectivebehaviorbysupportperson incongruentwithclient'sneedforautonomy –Supportpersonreportsinadequateunderstanding thatinterfereswitheffectivebehaviors –Supportpersonreportsinsufficientknowledge thatinterfereswitheffectivebehaviors –Supportpersonreportspreoccupationwithown reactiontoclient'sneed –Supportpersonwithdrawsfromclient Relatedfactors –Coexistingsituationsaffectingthesupportperson –Exhaustionofsupportperson'scapacity –Familydisorganization –Insufficientinformationavailabletosupport person –Insufficientreciprocalsupport –Insufficientsupportgivenbyclienttosupport person –Insufficientunderstandingofinformationby supportperson –Misinformationobtainedbysupportperson –Misunderstandingofinformationbysupport person –Preoccupationbysupportpersonwithconcern outsideoffamily Atriskpopulation –Developmentalcrisisexperiencedbysupport person –Prolongeddiseasethatexhaustscapacityof supportperson 361 –Familyrolechange –Situationalcrisisfacedbysupportperson ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 362 Domain9•Class2•DiagnosisCode00073 Disabledfamilycoping Approved1980•Revised1996,2008•LevelofEvidence2.1 Definition Behaviorofprimaryperson(familymember,significantother,orclosefriend) that disables his or her capacities and the client's capacities to effectively addresstasksessentialtoeitherperson'sadaptationtothehealthchallenge. Definingcharacteristics –Abandonment –Adoptsillnesssymptomsofclient –Aggression –Agitation –Clientdependence –Depression –Desertion –Disregardforclient'sneeds –Distortionofrealityaboutclient'shealthproblem –Familybehaviorsdetrimentaltowell-being –Hostility –Impairedabilitytostructureameaningfullife –Impairedindividualism –Intolerance –Neglectofbasicneedsofclient –Neglectofrelationshipwithfamilymember –Neglectoftreatmentregimen –Performingroutineswithoutregardforclient's needs –Prolongedhyperfocusonclient –Psychosomaticsymptoms –Rejection Relatedfactors –Ambivalentfamilyrelationships –Chronicallyunexpressedfeelingsbysupport person –Differingcopingstylesbetweensupportperson andclient –Differingcopingstylesbetweensupportpersons –Inconsistentmanagementoffamily'sresistanceto treatment 363 Domain9•Class2•DiagnosisCode00075 Readinessforenhancedfamilycoping Approved1980•Revised2013 Definition Apatternofmanagementofadaptivetasksbyprimaryperson(familymember, significant other, or close friend) involved with the client's health challenge, whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoacknowledgegrowthimpact ofcrisis –Expressesdesiretochooseexperiencesthat optimizewellness –Expressesdesiretoenhanceconnectionwith otherswhohaveexperiencedasimilarsituation –Expressesdesiretoenhanceenrichmentof lifestyle –Expressesdesiretoenhancehealthpromotion ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 364 Domain9•Class2•DiagnosisCode00147 Deathanxiety Approved1998•Revised2006,2017•LevelofEvidence2.1 Definition Vague,uneasyfeelingofdiscomfortordreadgeneratedbyperceptionsofareal orimaginedthreattoone'sexistence. Definingcharacteristics –Concernaboutstrainonthecaregiver –Deepsadness –Fearofdevelopingterminalillness –Fearoflossofmentalabilitieswhendying –Fearofpainrelatedtodying –Fearofprematuredeath –Fearofprolongeddyingprocess –Fearofsufferingrelatedtodying –Fearofthedyingprocess –Negativethoughtsrelatedtodeathanddying –Powerlessness –Worriedabouttheimpactofone'sdeathon significantother Relatedfactors –Anticipationofadverseconsequencesof anesthesia –Anticipationofimpactofdeathonothers –Anticipationofpain –Anticipationofsuffering –Discussionsonthetopicofdeath –Nonacceptanceofownmortality –Observationsrelatedtodeath –Perceivedimminenceofdeath –Uncertaintyaboutencounteringahigherpower –Uncertaintyaboutlifeafterdeath –Uncertaintyabouttheexistenceofahigherpower –Uncertaintyofprognosis Atriskpopulation –Discussionsonthetopicofdeath –Experiencingdyingprocess –Near-deathexperience –Observationsrelatedtodyingprocess Associatedcondition 365 –Terminalillness Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 366 Domain9•Class2•DiagnosisCode00072 Ineffectivedenial Approved1988•Revised2006•LevelofEvidence2.1 Definition Consciousorunconsciousattempttodisavowtheknowledgeormeaningofan eventtoreduceanxietyand/orfear,leadingtothedetrimentofhealth. Definingcharacteristics –Delayinseekinghealthcare –Deniesfearofdeath –Deniesfearofinvalidism –Displacesfearofimpactofthecondition –Displacessourceofsymptoms –Doesnotadmitimpactofdiseaseonlife –Doesnotperceiverelevanceofdanger –Doesnotperceiverelevanceofsymptoms –Inappropriateaffect –Minimizessymptoms –Refusalofhealthcare –Useofdismissivecommentswhenspeakingof distressingevent –Useofdismissivegestureswhenspeakingof distressingevent –Useoftreatmentnotadvisedbyhealthcare professional Relatedfactors –Anxiety –Excessivestress –Fearofdeath –Fearoflosingautonomy –Fearofseparation –Ineffectivecopingstrategies –Insufficientemotionalsupport –Insufficientsenseofcontrol –Perceivedinadequacyindealingwithstrong emotions –Threatofunpleasantreality Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 367 Domain9•Class2•DiagnosisCode00148 Fear Approved1980•Revised1996,2000,2017 Definition Responsetoperceivedthreatthatisconsciouslyrecognizedasadanger. Definingcharacteristics –Apprehensiveness –Decreaseinself-assurance –Excitedness –Feelingofalarm –Feelingofdread –Feelingoffear –Feelingofpanic –Feelingofterror –Fidgeting –Increaseinbloodpressure –Increaseintension –Muscletension –Nausea –Pallor –Pupildilation –Vomiting Cognitive –Decreaseinlearningability –Decreaseinproblem-solvingability –Decreaseinproductivity –Identifiesobjectoffear –Stimulusbelievedtobeathreat Behaviors –Attackbehaviors –Avoidancebehaviors –Focusnarrowedtothesourceoffear –Impulsiveness –Increaseinalertness Physiological –Anorexia –Changeinphysiologicalresponse –Diarrhea –Drymouth –Dyspnea –Fatigue –Increaseinperspiration 368 Relatedfactors –Languagebarrier –Learnedresponsetothreat –Responsetophobicstimulus –Separationfromsupportsystem –Unfamiliarsetting Associatedcondition –Sensorydeficit ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 369 Domain9•Class2•DiagnosisCode00136 Grieving Approved1980•Revised1996,2006,2017•LevelofEvidence2.1 Definition Anormal,complexprocessthatincludesemotional,physical,spiritual,social, and intellectual responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their dailylives. Definingcharacteristics –Alterationinactivitylevel –Alterationindreampattern –Alterationinimmunefunctioning –Alterationinneuroendocrinefunctioning –Alterationinsleeppattern –Anger –Blaming –Despair –Detachment –Disorganization –Distress –Findingmeaninginaloss –Guiltaboutfeelingrelieved –Maintainingaconnectiontothedeceased –Pain –Panicbehavior –Personalgrowth –Psychologicaldistress Relatedfactors –Tobedeveloped Atriskpopulation –Anticipatorylossofsignificantobject –Anticipatorylossofsignificantother –Deathofsignificantother –Lossofsignificantobject ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionifnorelatedfactorsare developed. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 370 Domain9•Class2•DiagnosisCode00135 Complicatedgrieving Approved1980•Revised1986,2004,2006,2017•LevelofEvidence2.1 Definition A disorder that occurs after the death of a significant other, in which the experience of distress accompanying bereavement fails to follow normative expectationsandmanifestsinfunctionalimpairment. Definingcharacteristics –Anger –Anxiety –Avoidanceofgrieving –Decreaseinfunctioninginliferoles –Depression –Disbelief –Distressaboutthedeceasedperson –Excessivestress –Experiencingsymptomsthedeceased experienced –Fatigue –Feelingdazed –Feelingofdetachmentfromothers –Feelingofemptiness –Feelingofshock –Feelingstunned –Insufficientsenseofwell-being –Longingforthedeceasedperson –Lowlevelsofintimacy –Mistrust –Nonacceptanceofadeath –Persistentpainfulmemories –Preoccupationwiththoughtsaboutadeceased person –Rumination –Searchingforadeceasedperson –Self-blame –Separationdistress –Traumaticdistress Relatedfactors –Emotionaldisturbance –Insufficientsocialsupport Atriskpopulation –Deathofsignificantother 371 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 372 Domain9•Class2•DiagnosisCode00172 Riskforcomplicatedgrieving Approved2004•Revised2006,2013,2017•LevelofEvidence2.1 Definition Susceptibletoadisorderthatoccursafterdeathofasignificantotherinwhich theexperienceofdistressaccompanyingbereavementfailstofollownormative expectationsand manifests infunctionalimpairment,whichmaycompromise health. Riskfactors –Emotionaldisturbance –Insufficientsocialsupport Atriskpopulation –Deathofsignificantother Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 373 Domain9•Class2•DiagnosisCode00241 Impairedmoodregulation Approved2013•Revised2017•LevelofEvidence2.1 Definition Amentalstatecharacterizedbyshiftsinmoodoraffectandwhichiscomprised of a constellation of affective, cognitive, somatic, and/or physiologic manifestationsvaryingfrommildtosevere. Definingcharacteristics –Changeinverbalbehavior –Disinhibition –Dysphoria –Excessiveguilt –Excessiveself-awareness –Excessiveself-blame –Flightofthoughts –Hopelessness –Impairedconcentration –Influencedself-esteem –Irritability –Psychomotoragitation –Psychomotorretardation –Sadaffect –Withdrawal Relatedfactors –Alterationinsleeppattern –Anxiety –Appetitechange –Hypervigilance –Impairedsocialfunctioning –Loneliness –Pain –Recurrentthoughtsofdeath –Recurrentthoughtsofsuicide –Socialisolation –Substancemisuse –Weightchange Associatedcondition –Chronicillness –Functionalimpairment –Psychosis 374 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 375 Domain9•Class2•DiagnosisCode00125 Powerlessness Approved1982•Revised2010,2017•LevelofEvidence2.1 Definition Thelivedexperienceoflackofcontroloverasituation,includingaperception thatone'sactionsdonotsignificantlyaffectanoutcome. Definingcharacteristics –Alienation –Dependency –Depression –Doubtaboutroleperformance –Frustrationaboutinabilitytoperformprevious activities –Inadequateparticipationincare –Insufficientsenseofcontrol –Shame Relatedfactors –Dysfunctionalinstitutionalenvironment –Insufficientinterpersonalinteractions –Anxiety –Caregiverrole –Ineffectivecopingstrategies –Insufficientknowledgetomanageasituation –Insufficientsocialsupport –Lowself-esteem –Pain –Socialmarginalization –Stigmatization Atriskpopulation –Economicallydisadvantaged Associatedcondition –Complextreatmentregimen –Illness –Progressiveillness –Unpredictabilityofillnesstrajectory 376 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 377 Domain9•Class2•DiagnosisCode00152 Riskforpowerlessness Approved2000•Revised2010,2013,2017•LevelofEvidence2.1 Definition Susceptibletothelivedexperienceoflackofcontroloverasituation,including apperceptionthatone'sactionsdonotsignificantlyaffecttheoutcome,which maycompromisehealth. Riskfactors –Dysfunctionalinstitutionalenvironment –Insufficientinterpersonalinteractions –Anxiety –Caregiverrole –Ineffectivecopingstrategies –Insufficientknowledgetomanageasituation –Insufficientsocialsupport –Lowself-esteem –Pain –Socialmarginalization –Stigmatization Atriskpopulation –Economicallydisadvantaged Associatedcondition –Complextreatmentregimen –Illness –Progressiveillness –Unpredictabilityofillnesstrajectory Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 378 Domain9•Class2•DiagnosisCode00187 Readinessforenhancedpower Approved2006•Revised2013•LevelofEvidence2.1 Definition A pattern of participating knowingly in change for well-being, which can be strengthened. Definingcharacteristics –Expressesdesiretoenhanceawarenessof possiblechanges –Expressesdesiretoenhanceidentificationof choicesthatcanbemadeforchange –Expressesdesiretoenhanceindependencewith actionsforchange –Expressesdesiretoenhanceinvolvementin change –Expressesdesiretoenhanceknowledgefor participationinchange –Expressesdesiretoenhanceparticipationin choicesfordailyliving –Expressesdesiretoenhanceparticipationin choicesforhealth –Expressesdesiretoenhancepower Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 379 Domain9•Class2•DiagnosisCode00210 Impairedresilience Approved2008•Revised2017•LevelofEvidence2.1 Definition Decreased ability to recover from perceived adverse or changing situations, throughadynamicprocessofadaptation. Definingcharacteristics –Decreasedinterestinacademicactivities –Decreasedinterestinvocationalactivities –Depression –Guilt –Impairedhealthstatus –Ineffectivecopingstrategies –Ineffectiveintegration –Ineffectivesenseofcontrol –Lowself-esteem –Renewedelevationofdistress –Shame –Socialisolation Relatedfactors –Communityviolence –Disruptioninfamilyrituals –Disruptioninfamilyroles –Disturbanceinfamilydynamics –Dysfunctionalfamilyprocesses –Inadequateresources –Inconsistentparenting –Ineffectivefamilyadaptation –Insufficientimpulsecontrol –Insufficientresources –Insufficientsocialsupport –Multiplecoexistingadversesituations –Perceivedvulnerability –Substancemisuse Atriskpopulation –Chronicityofexistingcrisis –Demographicsthatincreasechanceof maladjustment –Economicallydisadvantaged –Ethnicminoritystatus –Exposuretoviolence –Femalegender –Largefamilysize –Lowintellectualability –Lowmaternaleducationallevel –Newcrisis –Parentalmentalillness 380 Associatedcondition –Psychologicaldisorder Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 381 Domain9•Class2•DiagnosisCode00211 Riskforimpairedresilience Approved2008•Revised2013,2017•LevelofEvidence2.1 Definition Susceptibletodecreasedabilitytorecoverfromperceivedadverseorchanging situations, through a dynamic process of adaptation, which may compromise health. Riskfactors –Communityviolence –Disruptioninfamilyrituals –Disruptioninfamilyroles –Disturbanceinfamilydynamics –Dysfunctionalfamilyprocesses –Inadequateresources –Inconsistentparenting –Ineffectivefamilyadaptation –Insufficientimpulsecontrol –Insufficientresources –Insufficientsocialsupport –Multiplecoexistingadversesituations –Perceivedvulnerability –Substancemisuse Atriskpopulation –Chronicityofexistingcrisis –Demographicsthatincreasechanceof maladjustment –Economicallydisadvantaged –Ethnicminoritystatus –Exposuretoviolence –Femalegender –Largefamilysize –Lowintellectualability –Lowmaternaleducationallevel –Newcrisis –Parentalmentalillness Associatedcondition –Psychologicaldisorder 382 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 383 Domain9•Class2•DiagnosisCode00212 Readinessforenhancedresilience Approved2008•Revised2013•LevelofEvidence2.1 Definition Apatternofabilitytorecoverfromperceivedadverseorchangingsituations, throughadynamicprocessofadaptation,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhanceavailableresources –Expressesdesiretoenhancecommunicationskills –Expressesdesiretoenhanceenvironmentalsafety –Expressesdesiretoenhancegoalsetting –Expressesdesiretoenhanceinvolvementin activities –Expressesdesiretoenhanceownresponsibility foraction –Expressesdesiretoenhancepositiveoutlook –Expressesdesiretoenhanceprogresstowardgoal –Expressesdesiretoenhancerelationshipswith others –Expressesdesiretoenhanceresilience –Expressesdesiretoenhanceself-esteem –Expressesdesiretoenhancesenseofcontrol –Expressesdesiretoenhancesupportsystem –Expressesdesiretoenhanceuseofconflict managementstrategies –Expressesdesiretoenhanceuseofcopingskills –Expressesdesiretoenhanceuseofresource Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 384 Domain9•Class2•DiagnosisCode00137 Chronicsorrow Approved1998•Revised2017 Definition Cyclical, recurring, and potentially progressive pattern of pervasive sadness experienced (by a parent, caregiver, individual with chronic illness or disability)inresponsetocontinualloss,throughoutthetrajectoryofanillness ordisability. Definingcharacteristics –Feelingthatinterfereswithwell-being –Overwhelmingnegativefeelings –Sadness Relatedfactors –Crisisindisabilitymanagement –Crisisinillnessmanagement –Missedmilestones –Missedopportunities Atriskpopulation –Deathofsignificantother –Developmentalcrisis –Lengthoftimeasacaregiver Associatedcondition –Chronicdisability –Chronicillness ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 385 Domain9•Class2•DiagnosisCode00177 Stressoverload Approved2006•LevelofEvidence3.2 Definition Excessiveamountsandtypesofdemandsthatrequireaction. Definingcharacteristics –Excessivestress –Feelingofpressure –Impaireddecision-making –Impairedfunctioning –Increaseinanger –Increaseinangerbehavior –Increaseinimpatience –Negativeimpactfromstress –Tension Relatedfactors –Insufficientresources –Repeatedstressors –Stressors Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 386 Domain9•Class3•DiagnosisCode00258 Acutesubstancewithdrawalsyndrome Approved2016•LevelofEvidence2.1 Definition Serious, multifactorial sequelae following abrupt cessation of an addictive compound. Definingcharacteristics –Acuteconfusion(00128) –Anxiety(00146) –Disturbedsleeppattern(00198) –Nausea(00134) –Riskforelectrolyteimbalance(00195) –Riskforinjury(00035) Riskfactors –Developeddependencetoalcoholorother addictivesubstance –Heavyuseofanaddictivesubstanceovertime –Malnutrition –Suddencessationofanaddictivesubstance Atriskpopulation –Historyofpreviouswithdrawalsymptoms –Olderadults Associatedcondition –Comorbidmentaldisorder –Comorbidseriousphysicalillness Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 387 Domain9•Class3•DiagnosisCode00259 Riskforacutesubstancewithdrawalsyndrome Approved2016•LevelofEvidence2.1 Definition Susceptibletoserious,multifactorialsequelaefollowingabruptcessationofan addictivecompound,whichmaycompromisehealth. Riskfactors –Developeddependencetoalcoholorother addictivesubstance –Heavyuseofanaddictivesubstanceovertime –Malnutrition –Suddencessationofanaddictivesubstance Atriskpopulation –Historyofpreviouswithdrawalsymptoms –Olderadults Associatedcondition –Comorbidmentaldisorder –Comorbidseriousphysicalillness Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 388 Domain9•Class3•DiagnosisCode00009 Autonomicdysreflexia Approved1988•Revised2017 Definition Life-threatening,uninhibitedsympatheticresponseofthenervoussystemtoa noxiousstimulusafteraspinalcordinjuryatthe7ththoracicvertebra(T7)or above. Definingcharacteristics –Blurredvision –Bradycardia –Chestpain –Chilling –Conjunctivalcongestion –Diaphoresisabovetheinjury –Diffusepainindifferentareasofthehead –Horner'ssyndrome –Metallictasteinmouth –Nasalcongestion –Pallorbelowinjury –Paresthesia –Paroxysmalhypertension –Pilomotorreflex –Redblotchesonskinabovetheinjury –Tachycardia Relatedfactors GastrointestinalStimuli –Constipation –Difficultpassageoffeces –Digitalstimulation –Enemas –Fecalimpaction –Suppositories IntegumentaryStimuli –Cutaneousstimulation –Skinirritation Musculoskeletal-NeurologicalStimuli –Irritatingstimulibelowlevelofinjury –Painfulstimulibelowlevelofinjury –Pressureoverbonyprominence –Pressureovergenitalia –Rangeofmotionexercises –Spasm 389 Regulatory-SituationalStimuli –Constrictiveclothing –Environmentaltemperaturefluctuations –Positioning Reproductive-UrologicalStimuli –Bladderdistention –Bladderspasm –Instrumentation –Sexualintercourse Other –Insufficientcaregiverknowledgeofdisease process –Insufficientknowledgeofdiseaseprocess Atriskpopulation –Ejaculation –Extremesofenvironmentaltemperature –Menstruation Associatedcondition –Boweldistention –Cystitis –Deepveinthrombosis –Detrusorsphincterdyssynergia –Epididymitis –Esophagealrefluxdisease –Fracture –Gallstones –Gastriculcer –Gastrointestinalsystempathology –Hemorrhoids –Heterotopicbone –Laboranddeliveryperiod –Ovariancyst –Pharmaceuticalagent –Pregnancy –Pulmonaryemboli –Renalcalculi –Substancewithdrawal –Sunburn –Surgicalprocedure –Urethritis –Urinarycatheterization –Urinarytractinfection –Wound ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 390 Domain9•Class3•DiagnosisCode00010 Riskforautonomicdysreflexia Approved1998•Revised2000,2013,2017 Definition Susceptibletolife-threatening,uninhibitedresponseofthesympatheticnervous systempost-spinalshock,inanindividualwithspinalcordinjuryorlesionat the6ththoracicvertebra(T6)orabove(hasbeendemonstratedinpatientswith injuries at the 7th thoracic vertebra [T7] and the 8th thoracic vertebra [T8]), whichmaycompromisehealth. Riskfactors GastrointestinalStimuli –Boweldistention –Constipation –Difficultpassageoffeces –Digitalstimulation –Enemas –Fecalimpaction –Suppositories IntegumentaryStimuli –Cutaneousstimulation –Skinirritation –Sunburn –Wound Musculoskeletal-NeurologicalStimuli –Irritatingstimulibelowlevelofinjury –Painfulstimulibelowlevelofinjury –Pressureoverbonyprominence –Pressureovergenitalia –Rangeofmotionexercises –Spasm Regulatory-SituationalStimuli –Constrictiveclothing –Environmentaltemperaturefluctuations –Positioning 391 Reproductive-UrologicalStimuli –Bladderdistention –Bladderspasm –Instrumentation –Sexualintercourse Other –Insufficientcaregiverknowledgeofdisease process –Insufficientknowledgeofdiseaseprocess Atriskpopulation –Ejaculation –Extremesofenvironmentaltemperature –Menstruation Associatedcondition –Boweldistention –Cystitis –Deepveinthrombosis –Detrusorsphincterdyssynergia –Epididymitis –Esophagealrefluxdisease –Fracture –Gallstones –Gastriculcer –Gastrointestinalsystempathology –Hemorrhoids –Heterotopicbone –Laboranddeliveryperiod –Ovariancyst –Pharmaceuticalagent –Pregnancy –Pulmonaryemboli –Renalcalculi –Substancewithdrawal –Sunburn –Surgicalprocedure –Urethritis –Urinarycatheterization –Urinarytractinfection –Wound ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 392 Domain9•Class3•DiagnosisCode00049 Decreasedintracranialadaptivecapacity Approved1994 Definition Compromise in intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial volumes, resulting in repeated disproportionateincreasesinintracranialpressure(ICP)inresponsetoavariety ofnoxiousandnon-noxiousstimuli. Definingcharacteristics –Baselineintracranialpressure(ICP)≥10mmHg –Disproportionateincreaseinintracranialpressure(ICP)followingstimuli –Elevatedtidalwaveintracranialpressure(P2ICP)waveform –Repeatedincreaseinintracranialpressure(ICP)≥10mmHgfor≥5minutes followingexternalstimuli – Volume-pressure response test variation (volume: pressure ratio 2, pressurevolumeindex<10) –Wide-amplitudeintracranialpressure(ICP)waveform Relatedfactors –Tobedeveloped Associatedcondition –Braininjury –Decreaseincerebralperfusion≤50-60mmHg –Sustainedincreaseinintracranialpressure(ICP) of10-15mmHg –Systemichypotensionwithintracranial hypertension 393 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 394 Domain9•Class3•DiagnosisCode00264 Neonatalabstinencesyndrome Approved2016•LevelofEvidence2.1 Definition A constellation of withdrawal symptoms observed in newborns as a result of in-utero exposure to addicting substances, or as a consequence of postnatal pharmacologicalpainmanagement. Definingcharacteristics –Diarrhea(00013) –Disorganizedinfantbehavior(00116) –Disturbedsleeppattern(00198) –Impairedcomfort(00214) –Ineffectiveinfantfeedingpattern(00107) –Neurobehavioralstress –Riskforaspiration(00039) –Riskforimbalancedbodytemperature(00005) –Riskforimpairedattachment(00058) –Riskforimpairedskinintegrity(00047) –Riskforinjury(00035) Relatedfactors –Tobedeveloped Atriskpopulation –Iatrogenicsubstanceexposureforpaincontrol followingacriticalillnessorsurgery –In-uterosubstanceexposuresecondaryto maternalsubstanceuse TheFinneganNeonatalAbstinenceScoringTool(FNAST)isrecommendedforassessmentofwithdrawal symptoms and for making decisions related to the plan of care. An FNAST score of 8 or greater, in combinationwithahistoryofin-uterosubstanceexposure,isoftenusedtomakethediagnosisofNeonatal Abstinence Syndrome. This instrument was developed and is used predominantly in the U.S. and other westerncountries,soitmaynotbeappropriatetorecommendfortheinternationalcommunity.Modifiable relatedfactorstobedeveloped. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 395 Domain9•Class3•DiagnosisCode00116 Disorganizedinfantbehavior Approved1994•Revised1998,2017 Definition Disintegration of the physiological and neurobehavioral systems of functioning. Definingcharacteristics Attention-InteractionSystem –Impairedresponsetosensorystimuli MotorSystem –Alterationinprimitivereflexes –Exaggeratedstartleresponse –Fidgeting –Fingersplaying –Fisting –Handstoface –Hyperextensionofextremities –Impairedmotortone –Tremor –Twitching –Uncoordinatedmovement Physiological –Abnormalskincolor –Arrhythmia –Bradycardia –Feedingintolerance –Oxygendesaturation –Tachycardia –Time-outsignals RegulatoryProblems –Inabilitytoinhibitstartlereflex –Irritability State-OrganizationSystem –Active-awake –Irritablecrying 396 –Diffusealphaelectroencephalogram(EEG) activitywitheyesclosed –Quiet-awake –Stateoscillation Relatedfactors –Caregivercuemisreading –Environmentaloverstimulation –Feedingintolerance –Inadequatephysicalenvironment –Infantmalnutrition –Insufficientcaregiverknowledgeofbehavioral cues –Insufficientcontainmentwithinenvironment –Insufficientenvironmentalsensorystimulation –Pain –Sensorydeprivation –Sensoryoverstimulation Atriskpopulation –Lowpostconceptualage –Prematurity –Prenatalexposuretoteratogen Associatedcondition –Congenitaldisorder –Geneticdisorder –Infantillness –Immatureneurologicalfunctioning –Impairedinfantmotorfunctioning –Invasiveprocedure –Infantoralimpairment ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 397 Domain9•Class3•DiagnosisCode00115 Riskfordisorganizedinfantbehavior Approved1994•Revised2013,2017 Definition Susceptibletodisintegrationinthepatternofmodulationofthephysiological andneurobehavioralsystemsoffunctioning,whichmaycompromisehealth. Riskfactors –Caregivercuemisreading –Environmentaloverstimulation –Feedingintolerance –Inadequatephysicalenvironment –Infantmalnutrition –Insufficientcaregiverknowledgeofbehavioral cues –Insufficientcontainmentwithinenvironment –Insufficientenvironmentalsensorystimulation –Pain –Sensorydeprivation –Sensoryoverstimulation Atriskpopulation –Lowpostconceptualage –Prematurity –Prenatalexposuretoteratogen Associatedcondition –Congenitaldisorder –Geneticdisorder –Infantillness –Immatureneurologicalfunctioning –Impairedinfantmotorfunctioning –Invasiveprocedure –Infantoralimpairment ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 398 Domain9•Class3•DiagnosisCode00117 Readinessforenhancedorganizedinfantbehavior Approved1994•Revised2013 Definition Anintegratedpatternofmodulationofthephysiologicalandneurobehavioral systemsoffunctioning,whichcanbestrengthened. Definingcharacteristics –Parentexpressesdesiretoenhancecue recognition –Parentexpressesdesiretoenhanceenvironmental conditions –Parentexpressesdesiretoenhancerecognitionof infant'sself-regulatorybehaviors ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 399 Domain10. Lifeprinciples Class1. Values Code Diagnosis Thisclassdoesnotcurrentlycontainanydiagnoses. Class2. Beliefs Code Diagnosis 00068 Readinessforenhancedspiritualwell-being Class3. Value/belief/actioncongruence Code Diagnosis 00184 Readinessforenhanceddecision-making 00083 Decisionalconflict 00242 Impairedemancipateddecision-making 00244 Riskforimpairedemancipateddecision-making 00243 Readinessforenhancedemancipateddecisionmaking 00175 Moraldistress 00169 Impairedreligiosity 00170 Riskforimpairedreligiosity 00171 Readinessforenhancedreligiosity 00066 Spiritualdistress 00067 Riskforspiritualdistress 400 NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 401 Domain10•Class1 Thisclassdoesnotcurrentlycontainanydiagnoses. 402 Domain10•Class2•DiagnosisCode00068 Readinessforenhancedspiritualwell-being Approved1994•Revised2002,2013•LevelofEvidence2.1 Definition Apatternofexperiencingandintegratingmeaningandpurposeinlifethrough connectedness with self, others, art, music, literature, nature, and/or a power greaterthanoneself,whichcanbestrengthened. Definingcharacteristics ConnectionstoSelf –Expressesdesiretoenhanceacceptance –Expressesdesiretoenhancecoping –Expressesdesiretoenhancecourage –Expressesdesiretoenhancehope –Expressesdesiretoenhancejoy –Expressesdesiretoenhancelove –Expressesdesiretoenhancemeaninginlife –Expressesdesiretoenhancemeditativepractice –Expressesdesiretoenhancepurposeinlife –Expressesdesiretoenhancesatisfactionwith philosophyoflife –Expressesdesiretoenhanceselfforgiveness –Expressesdesiretoenhanceserenity –Expressesdesiretoenhancesurrender ConnectionswithOthers –Expressesdesiretoenhanceforgivenessfrom others –Expressesdesiretoenhanceinteractionwith significantother –Expressesdesiretoenhanceinteractionwith spiritualleaders –Expressesdesiretoenhanceservicetoothers ConnectionswithArt,Music,Literature,andNature –Expressesdesiretoenhancecreativeenergy –Expressesdesiretoenhancespiritualreading –Expressesdesiretoenhancetimeoutdoors ConnectionswithPowerGreaterthanSelf –Expressesdesiretoenhancemysticalexperiences –Expressesdesiretoenhanceparticipationin religiousactivity –Expressesdesiretoenhanceprayerfulness –Expressesdesiretoenhancereverence 403 Domain10•Class3•DiagnosisCode00184 Readinessforenhanceddecision-making Approved2006•Revised2013•LevelofEvidence2.1 Definition A pattern of choosing a course of action for meeting short- and long-term health-relatedgoals,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhancecongruencyof decisionwithsocioculturalgoal –Expressesdesiretoenhancecongruencyof decisionwithsocioculturalvalues –Expressesdesiretoenhancecongruencyof decisionswithgoal –Expressesdesiretoenhancecongruencyof decisionswithvalues –Expressesdesiretoenhancedecision-making –Expressesdesiretoenhanceriskbenefitanalysis ofdecisions –Expressesdesiretoenhanceunderstandingof choicesfordecision-making –Expressesdesiretoenhanceunderstandingof meaningofchoices –Expressesdesiretoenhanceuseofreliable evidencefordecisions Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 404 Domain10•Class3•DiagnosisCode00083 Decisionalconflict Approved1988•Revised2006•LevelofEvidence2.1 Definition Uncertaintyaboutcourseofactiontobetakenwhenchoiceamongcompeting actionsinvolvesrisk,loss,orchallengetovaluesandbeliefs. Definingcharacteristics –Delayindecision-making –Distresswhileattemptingadecision –Physicalsignofdistress –Physicalsignoftension –Questioningofmoralprinciplewhileattemptinga decision –Questioningofmoralrulewhileattemptinga decision –Questioningofmoralvalueswhileattemptinga decision –Questioningofpersonalbeliefswhileattempting adecision –Questioningofpersonalvalueswhileattempting adecision –Recognizesundesiredconsequencesofactions beingconsidered –Self-focused –Uncertaintyaboutchoices –Vacillatingamongchoices Relatedfactors –Conflictwithmoralobligation –Conflictinginformationsources –Inexperiencewithdecision-making –Insufficientinformation –Insufficientsupportsystem –Interferenceindecision-making –Moralprinciplesupportsmutuallyinconsistent actions –Moralrulesupportsmutuallyinconsistentactions –Moralvaluesupportsmutuallyinconsistent actions –Perceivedthreattovaluesystem –Unclearpersonalbeliefs –Unclearpersonalvalues Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 405 Domain10•Class3•DiagnosisCode00242 Impairedemancipateddecision-making Approved2013•Revised2017•LevelofEvidence2.1 Definition A process of choosing a healthcare decision that does not include personal knowledgeand/orconsiderationofsocialnorms,ordoesnotoccurinaflexible environment,resultingindecisionaldissatisfaction. Definingcharacteristics –Delayinenactingchosenhealthcareoption –Distresswhenlisteningtoother'sopinion –Excessiveconcernaboutwhatothersthinkisthe bestdecision –Excessivefearofwhatothersthinkabouta decision –Feelingconstrainedindescribingownopinion –Inabilitytochooseahealthcareoptionthatbest fitscurrentlifestyle –Inabilitytodescribehowoptionwillfitinto currentlifestyle –Limitedverbalizationabouthealthcareoptionin other'spresence Relatedfactors –Decreaseinunderstandingofallavailable healthcareoptions –Inabilitytoadequatelyverbalizeperceptions abouthealthcareoptions –Inadequatetimetodiscusshealthcareoptions –Insufficientconfidencetoopenlydiscuss healthcareoptions –Insufficientinformationregardinghealthcare options –Insufficientprivacytoopenlydiscusshealthcare options –Insufficientself-confidenceindecision-making Atriskpopulation –Limiteddecision-makingexperience –Traditionalhierarchicalfamily –Traditionalhierarchicalhealthcaresystems Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 406 Domain10•Class3•DiagnosisCode00244 Riskforimpairedemancipateddecision-making Approved2013•Revised2017•LevelofEvidence2.1 Definition Susceptibletoaprocessofchoosingahealthcaredecisionthatdoesnotinclude personalknowledgeand/orconsiderationofsocialnorms,ordoesnotoccurin aflexibleenvironment,resultingindecisionaldissatisfaction. Riskfactors –Decreaseinunderstandingofallavailable healthcareoptions –Inabilitytoadequatelyverbalizeperceptions abouthealthcareoptions –Inadequatetimetodiscusshealthcareoptions –Insufficientconfidencetoopenlydiscuss healthcareoptions –Insufficientinformationregardinghealthcare options –Insufficientprivacytoopenlydiscusshealthcare options –Insufficientself-confidenceindecision-making Atriskpopulation –Limiteddecision-makingexperience –Traditionalhierarchicalfamily –Traditionalhierarchicalhealthcaresystems Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 407 Domain10•Class3•DiagnosisCode00243 Readinessforenhancedemancipateddecision-making Approved2013•LevelofEvidence2.1 Definition Aprocessofchoosingahealthcaredecisionthatincludespersonalknowledge and/orconsiderationofsocialnorms,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhanceabilitytochoose healthcareoptionsthatbestfitcurrentlifestyle –Expressesdesiretoenhanceabilitytoenact chosenhealthcareoption –Expressesdesiretoenhanceabilitytounderstand allavailablehealthcareoptions –Expressesdesiretoenhanceabilitytoverbalize ownopinionwithoutconstraint –Expressesdesiretoenhancecomforttoverbalize healthcareoptionsinthepresenceofothers –Expressesdesiretoenhanceconfidencein decision-making –Expressesdesiretoenhanceconfidencetodiscuss healthcareoptionsopenly –Expressesdesiretoenhancedecision-making –Expressesdesiretoenhanceprivacytodiscuss healthcareoptions Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 408 Domain10•Class3•DiagnosisCode00175 Moraldistress Approved2006•LevelofEvidence2.1 Definition Response to the inability to carry out one's chosen ethical or moral decision and/oraction. Definingcharacteristics –Anguishaboutactingonone'smoralchoice Relatedfactors –Conflictamongdecision-makers –Conflictinginformationavailableforethical decision-making –Conflictinginformationavailableformoral decision-making –Culturalincongruence –Difficultyreachingend-of-lifedecisions –Difficultyreachingtreatmentdecision –Timeconstraintfordecision-making Atriskpopulation –Lossofautonomy –Physicaldistanceofdecision-maker Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 409 Domain10•Class3•DiagnosisCode00169 Impairedreligiosity Approved2004•Revised2017•LevelofEvidence2.1 Definition Impairedabilitytoexerciserelianceonbeliefsand/orparticipateinritualsofa particularfaithtradition. Definingcharacteristics –Desiretoreconnectwithpreviousbeliefpattern –Desiretoreconnectwithpreviouscustoms –Difficultyadheringtoprescribedreligiousbeliefs –Difficultyadheringtoprescribedreligiousrituals –Distressaboutseparationfromfaithcommunity –Questioningofreligiousbeliefpatterns –Questioningofreligiouscustoms Relatedfactors –Anxiety –Culturalbarriertopracticingreligion –Depression –Environmentalbarriertopracticingreligion –Fearofdeath –Ineffectivecaregiving –Ineffectivecopingstrategies –Insecurity –Insufficientsocialsupport –Insufficientsocioculturalinteraction –Insufficienttransportation –Pain –Spiritualdistress Atriskpopulation –Aging –End-stagelifecrisis –Historyofreligiousmanipulation –Hospitalization –Lifetransition –Personalcrisis –Spiritualcrisis Associatedcondition –Illness 410 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 411 Domain10•Class3•DiagnosisCode00170 Riskforimpairedreligiosity Approved2004•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to an impaired ability to exercise reliance on religious beliefs and/or participate in rituals of a particular faith tradition, which may compromisehealth. Riskfactors –Insufficienttransportation –Pain –Anxiety –Depression –Fearofdeath –Ineffectivecaregiving –Ineffectivecopingstrategies –Insecurity –Insufficientsocialsupport –Culturalbarriertopracticingreligion –Environmentalbarriertopracticingreligion –Insufficientsocioculturalinteraction –Spiritualdistress Atriskpopulation –Aging –End-stagelifecrisis –Lifetransition –Historyofreligiousmanipulation –Hospitalization –Personalcrisis –Spiritualcrisis Associatedcondition –Illness Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 412 Domain10•Class3•DiagnosisCode00171 Readinessforenhancedreligiosity Approved2004•Revised2013•LevelofEvidence2.1 Definition A pattern of reliance on religious beliefs and/or participation in rituals of a particularfaithtradition,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhancebeliefpatternsused inthepast –Expressesdesiretoenhanceconnectionwitha religiousleader –Expressesdesiretoenhanceforgiveness –Expressesdesiretoenhanceparticipationin religiousexperiences –Expressesdesiretoenhanceparticipationin religiouspractices –Expressesdesiretoenhancereligiouscustoms usedinthepast –Expressesdesiretoenhancereligiousoptions –Expressesdesiretoenhanceuseofreligious material Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 413 Domain10•Class3•DiagnosisCode00066 Spiritualdistress Approved1978•Revised2002,2013,2017•LevelofEvidence2.1 Definition Astateofsufferingrelatedtotheimpairedabilitytoexperiencemeaninginlife throughconnectionswithself,others,theworld,orasuperiorbeing. Definingcharacteristics –Anxiety –Crying –Fatigue –Fear –Insomnia –Questioningidentity –Questioningmeaningoflife –Questioningmeaningofsuffering ConnectionstoSelf –Anger –Decreaseinserenity –Feelingunloved –Guilt –Inadequateacceptance –Ineffectivecopingstrategies –Insufficientcourage –Perceivedinsufficientmeaninginlife ConnectionswithOthers –Alienation –Refusestointeractwithspiritualleader –Refusestointeractwithsignificantother –Separationfromsupportsystem ConnectionswithArt,Music,Literature,andNature –Decreaseinexpressionofpreviouspatternof creativity –Disinterestinnature –Disinterestinreadingspiritualliterature ConnectionswithPowerGreaterthanSelf –Angertowardpowergreaterthanself –Inabilitytopray 414 –Feelingabandoned –Hopelessness –Inabilityforintrospection –Inabilitytoexperiencethetranscendent –Inabilitytoparticipateinreligiousactivities –Perceivedsuffering –Requestforaspiritualleader –Suddenchangeinspiritualpractice Relatedfactors –Anxiety –Barriertoexperiencinglove –Changeinreligiousritual –Changeinspiritualpractice –Culturalconflict –Depression –Environmentalchange –Inabilitytoforgive –Increasingdependenceonanother –Ineffectiverelationships –Loneliness –Lowself-esteem –Pain –Perceptionofhavingunfinishedbusiness –Self-alienation –Separationfromsupportsystem –Socialalienation –Socioculturaldeprivation –Stressors –Substancemisuse Atriskpopulation –Aging –Birthofachild –Deathofsignificantother –Exposuretodeath –Lifetransition –Loss –Exposuretonaturaldisaster –Racialconflict –Receivingbadnews –Unexpectedlifeevent Associatedcondition –Activelydying –Chronicillness –Illness –Imminentdeath –Lossofabodypart –Lossoffunctionofabodypart –Physicalillness –Treatmentregimen Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 415 Domain10•Class3•DiagnosisCode00067 Riskforspiritualdistress Approved1998•Revised2004,2013,2017•LevelofEvidence2.1 Definition Susceptible to an impaired ability to experience and integrate meaning and purpose in life through connectedness within self, literature, nature, and/or a powergreaterthanoneself,whichmaycompromisehealth. Riskfactors –Anxiety –Barriertoexperiencinglove –Changeinreligiousritual –Changeinspiritualpractice –Culturalconflict –Depression –Environmentalchange –Inabilitytoforgive –Increasingdependenceonanother –Ineffectiverelationships –Loneliness –Lowself-esteem –Pain –Perceptionofhavingunfinishedbusiness –Self-alienation –Separationfromsupportsystem –Socialalienation –Socioculturaldeprivation –Stressors –Substancemisuse Atriskpopulation –Aging –Birthofachild –Deathofsignificantother –Exposuretodeath –Lifetransition –Loss –Exposuretonaturaldisaster –Racialconflict –Receivingbadnews –Unexpectedlifeevent Associatedcondition –Activelydying –Chronicillness –Illness –Imminentdeath –Lossofabodypart –Lossoffunctionofabodypart –Physicalillness –Treatmentregimen 416 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 417 Domain11. Safety/protection Class1. Infection Code Diagnosis 00004 Riskforinfection 00266 Riskforsurgicalsiteinfection Class2. Physicalinjury Code Diagnosis 00031 Ineffectiveairwayclearance 00039 Riskforaspiration 00206 Riskforbleeding 00048 Impaireddentition 00219 Riskfordryeye 00261 Riskfordrymouth 00155 Riskforfalls 00245 Riskforcornealinjury 00035 Riskforinjury 00250 Riskforurinarytractinjury 00087 Riskforperioperativepositioninginjury 00220 Riskforthermalinjury 00045 Impairedoralmucousmembraneintegrity 00247 Riskforimpairedoralmucousmembrane integrity 00086 Riskforperipheralneurovasculardysfunction 00038 Riskforphysicaltrauma 00213 Riskforvasculartrauma 418 00249 Riskforpressureulcer 00205 Riskforshock 00046 Impairedskinintegrity 00047 Riskforimpairedskinintegrity 00156 Riskforsuddeninfantdeath 00036 Riskforsuffocation 00100 Delayedsurgicalrecovery 00246 Riskfordelayedsurgicalrecovery 00044 Impairedtissueintegrity 00248 Riskforimpairedtissueintegrity 00268 Riskforvenousthromboembolism Class3. Violence Code Diagnosis 00272 Riskforfemalegenitalmutilation 00138 Riskforother-directedviolence 00140 Riskforself-directedviolence 00151 Self-mutilation 00139 Riskforself-mutilation 00150 Riskforsuicide Class4. Environmentalhazards Code Diagnosis 00181 Contamination 00180 Riskforcontamination 00265 Riskforoccupationalinjury 00037 Riskforpoisoning Class5. Defensiveprocesses Code Diagnosis 00218 Riskforadversereactiontoiodinatedcontrast media 00217 Riskforallergyreaction 00041 Latexallergyreaction 00042 Riskforlatexallergyreaction Class6. Thermoregulation 419 Code Diagnosis 00007 Hyperthermia 00006 Hypothermia 00253 Riskforhypothermia 00254 Riskforperioperativehypothermia 00008 Ineffectivethermoregulation 00274 Riskforineffectivethermoregulation NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 420 Domain11•Class1•DiagnosisCode00004 Riskforinfection Approved1986•Revised2010,2013,2017•LevelofEvidence2.1 Definition Susceptibletoinvasionandmultiplicationofpathogenicorganisms,whichmay compromisehealth. Riskfactors –Alterationinperistalsis –Alterationinskinintegrity –Inadequatevaccination –Insufficientknowledgetoavoidexposureto pathogens –Malnutrition –Obesity –Smoking –Stasisofbodyfluid Atriskpopulation –Exposuretodiseaseoutbreak Associatedcondition –AlterationinpHofsecretion –Chronicillness –Decreaseinciliaryaction –Decreaseinhemoglobin –Immunosuppression –Invasiveprocedure –Leukopenia –Prematureruptureofamnioticmembrane –Prolongedruptureofamnioticmembrane –Suppressedinflammatoryresponse Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 421 Domain11•Class1•DiagnosisCode00266 Riskforsurgicalsiteinfection Approved2016•LevelofEvidence2.1 Definition Susceptible to invasion of pathogenic organisms at surgical site, which may compromisehealth. Riskfactors –Alcoholism –Obesity –Smoking Atriskpopulation –Coldtemperatureofoperatingroom –Increasedenvironmentalexposuretopathogens –Excessivenumberofpersonnelpresentduringthe –Sub-optimalAmericanSocietyof surgicalprocedure Anaesthesiologists(ASA)physicalhealthstatus score –Surgicalwoundcontamination Associatedcondition –Comorbidity –Diabetesmellitus –Durationofsurgery –Hypertension –Immunosuppression –Inadequateantibioticprophylaxis –Ineffectiveantibioticprophylaxis –Infectionsatothersurgicalsites –Invasiveprocedure –Post-traumaticosteoarthritis –Rheumatoidarthritis –Typeofanesthesia –Typeofsurgicalprocedure –Useofimplantsand/orprostheses Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 422 Domain11•Class2•DiagnosisCode00031 Ineffectiveairwayclearance Approved1980•Revised1996,1998,2017 Definition Inability to clear secretions or obstructions from the respiratory tract to maintainaclearairway. Definingcharacteristics –Absenceofcough –Adventitiousbreathsounds –Alterationinrespiratorypattern –Alterationinrespiratoryrate –Cyanosis –Difficultyverbalizing –Diminishedbreathsounds –Dyspnea –Excessivesputum –Ineffectivecough –Orthopnea –Restlessness –Wide-eyedlook Relatedfactors –Excessivemucus –Exposuretosmoke –Foreignbodyinairway –Retainedsecretions –Second-handsmoke –Smoking Associatedcondition –Airwayspasm –Allergicairway –Asthma –Chronicobstructivepulmonarydisease –Exudateinthealveoli –Hyperplasiaofthebronchialwalls –Infection –Neuromuscularimpairment –Presenceofartificialairway ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 423 Domain11•Class2•DiagnosisCode00039 Riskforaspiration Approved1988•Revised2013,2017 Definition Susceptible to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids to the tracheobronchial passages, which may compromise health. Riskfactors –Barriertoelevatingupperbody –Decreaseingastrointestinalmotility –Ineffectivecough –Insufficientknowledgeofmodifiablefactors Associatedcondition –Decreaseinlevelofconsciousness –Delayedgastricemptying –Depressedgagreflex –Enteralfeedings –Facialsurgery –Facialtrauma –Impairedabilitytoswallow –Incompetentloweresophagealsphincter –Increaseingastricresidual –Increaseinintragastricpressure –Necksurgery –Necktrauma –Oralsurgery –Oraltrauma –Presenceoforal/nasaltube –Treatmentregimen –Wiredjaw ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 424 Domain11•Class2•DiagnosisCode00206 Riskforbleeding Approved2008•Revised2013,2017•LevelofEvidence2.1 Definition Susceptibletoadecreaseinbloodvolume,whichmaycompromisehealth. Riskfactors –Insufficientknowledgeofbleedingprecautions Atriskpopulation –Historyoffalls Associatedcondition –Aneurysm –Circumcision –Disseminatedintravascularcoagulopathy –Gastrointestinalcondition –Impairedliverfunction –Inherentcoagulopathy –Postpartumcomplication –Pregnancycomplication –Trauma –Treatmentregimen Additionalriskfactorstobedeveloped. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 425 Domain11•Class2•DiagnosisCode00048 Impaireddentition Approved1998•Revised2017 Definition Disruption in tooth development/eruption pattern or structural integrity of individualteeth. Definingcharacteristics –Absenceofteeth –Abradedteeth –Dentalcaries –Enameldiscoloration –Erosionofenamel –Excessiveoralcalculus –Excessiveoralplaque –Facialasymmetry –Halitosis –Incompletetootheruptionforage –Loosetooth –Malocclusion –Prematurelossofprimaryteeth –Rootcaries –Toothfracture –Toothmisalignment –Toothache Relatedfactors –Barriertoself-care –Difficultyaccessingdentalcare –Excessiveintakeoffluoride –Excessiveuseofabrasiveoralcleaningagents –Habitualuseofstainingsubstance –Inadequatedietaryhabits –Inadequateoralhygiene –Insufficientknowledgeofdentalhealth –Malnutrition Atriskpopulation –Economicallydisadvantaged –Geneticpredisposition Associatedcondition –Bruxism –Chronicvomiting –Oraltemperaturesensitivity –Pharmaceuticalagent 426 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 427 Domain11•Class2•DiagnosisCode00219 Riskfordryeye Approved2010•Revised2013,2017•LevelofEvidence2.1 Definition Susceptibletoeyediscomfortordamagetothecorneaandconjunctivadueto reducedquantityorqualityoftearstomoistentheeye,whichmaycompromise health. Riskfactors –Airconditioning –Airpollution –Caffeineintake –Excessivewind –Insufficientknowledgeofmodifiablefactors –Lowhumidity –Prolongedreading –Smoking –Sunlightexposure –VitaminAdeficiency Atriskpopulation –Aging –Contactlenswearer –Femalegender –Historyofallergy Associatedcondition –Autoimmunedisease –Hormonalchange –Mechanicalventilation –Neurologicallesionwithsensoryormotorreflex loss –Ocularsurfacedamage –Treatmentregimen Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 428 Domain11•Class2•DiagnosisCode00261 Riskfordrymouth Approved2016•LevelofEvidence2.1 Definition Susceptible to discomfort or damage to the oral mucosa due to reduced quantity or quality of saliva to moisten the mucosa, which may compromise health. Riskfactors –Dehydration –Depression –Excessivestress –Excitement –Smoking Associatedcondition –Chemotherapy –Fluidrestriction –Inabilitytofeedorally –Oxygentherapy –Pharmaceuticalagent –Pregnancy –Radiationtherapytotheheadandneck –Systemicdiseases Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 429 Domain11•Class2•DiagnosisCode00155 Riskforfalls Approved2000•Revised2013,2017 Definition Susceptible to increased susceptibility to falling, which may cause physical harmandcompromisehealth. Riskfactors Children –Absenceofstairwaygate –Absenceofwindowguard –Inadequatesupervision –Insufficientautomobilerestraints Environment –Clutteredenvironment –Exposuretounsafeweatherrelatedcondition –Insufficientanti-slipmaterialinbathroom –Insufficientlighting –Unfamiliarsetting –Useofrestraints –Useofthrowrugs Physiological –Alterationinbloodglucoselevel –Decreaseinlowerextremitystrength –Diarrhea –Difficultywithgait –Faintnesswhenextendingneck –Faintnesswhenturningneck –Impairedmobility –Incontinence –Sleeplessness –Urinaryurgency Other –Alcoholconsumption –Insufficientknowledgeofmodifiablefactors Atriskpopulation –Age≥65years –Livingalone 430 –Age≤2years –Historyoffalls –Malegenderwhen<1yearofage Associatedcondition –Acuteillness –Alterationincognitivefunctioning –Anemia –Arthritis –Conditionaffectingthefoot –Hearingimpairment –Impairedbalance –Impairedvision –Lowerlimbprosthesis –Neoplasm –Neuropathy –Orthostatichypotension –Pharmaceuticalagent –Postoperativerecoveryperiod –Proprioceptivedeficit –Useofassistivedevice –Vasculardisease ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 431 Domain11•Class2•DiagnosisCode00245 Riskforcornealinjury Approved2013•Revised2017•LevelofEvidence2.1 Definition Susceptible to infection or inflammatory lesion in the corneal tissue that can affectsuperficialordeeplayers,whichmaycompromisehealth. Riskfactors –Exposureoftheeyeball –Insufficientknowledgeofmodifiablefactors Atriskpopulation –Prolongedhospitalization Associatedcondition –Blinking<5timesperminute –GlasgowComaScalescore<6 –Intubation –Mechanicalventilation –Oxygentherapy –Periorbitaledema –Pharmaceuticalagent –Tracheostomy Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 432 Domain11•Class2•DiagnosisCode00035 Riskforinjury Approved1978•Revised2013,2017 Definition Susceptible to physical damage due to environmental conditions interacting withtheindividual'sadaptiveanddefensiveresources,whichmaycompromise health. Riskfactors –Compromisednutritionalsource –Exposuretopathogen –Exposuretotoxicchemical –Immunizationlevelwithincommunity –Insufficientknowledgeofmodifiablefactors –Malnutrition –Nosocomialagent –Physicalbarrier –Unsafemodeoftransport Atriskpopulation –Extremesofage –Impairedprimarydefensemechanisms Associatedcondition –Abnormalbloodprofile –Alterationincognitivefunctioning –Alterationinpsychomotorfunctioning –Alterationinsensation –Autoimmunedysfunction –Biochemicaldysfunction –Effectordysfunction –Immunedysfunction –Sensoryintegrationdysfunction –Tissuehypoxia ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 433 Domain11•Class2•DiagnosisCode00250 Riskforurinarytractinjury Approved2013•Revised2017•LevelofEvidence2.1 Definition Susceptible to damage of the urinary tract structures from use of catheters, whichmaycompromisehealth. Riskfactors –Confusion –Deficientpatientorcaregiverknowledge regardingcareofurinarycatheter –Obesity Atriskpopulation –Extremesofage Associatedcondition –Anatomicalvariationinthepelvicorgans –Conditionpreventingabilitytosecurecatheter –Detrusorsphincterdyssynergia –Impairedcognition –Latexallergy –Longtermuseofurinarycatheter –Medullaryinjury –Multiplecatheterizations –Retentionballooninflatedto≥30ml –Useoflargecaliberurinarycatheter Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 434 Domain11•Class2•DiagnosisCode00087 Riskforperioperativepositioninginjury Approved1994•Revised2006,2013,2017•LevelofEvidence2.1 Definition Susceptible to inadvertent anatomical and physical changes as a result of posture or positioning equipment used during an invasive/surgical procedure, whichmaycompromisehealth. Riskfactors –Immobilization Associatedcondition –Disorientation –Edema –Emaciation –Muscleweakness –Obesity –Sensoriperceptualdisturbancefromanesthesia Duetolimitedamountofthepatientcontactpreoperatively,nursesmaynotbeabletointerveneonmanyof theseassociatedconditions. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 435 Domain11•Class2•DiagnosisCode00220 Riskforthermalinjury Approved2010•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to extreme temperature damage to skin and mucous membranes, whichmaycompromisehealth. Riskfactors –Fatigue –Inadequateprotectiveclothing –Inadequatesupervision –Inattentiveness –Insufficientcaregiverknowledgeofsafety precautions –Insufficientknowledgeofsafetyprecautions –Smoking –Unsafeenvironment Atriskpopulation –Extremesofage –Extremesofenvironmentaltemperature Associatedcondition –Alcoholintoxication –Drugintoxication –Alterationincognitivefunctioning –Neuromuscularimpairment –Neuropathy –Treatmentregimen Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 436 Domain11•Class2•DiagnosisCode00045 Impairedoralmucousmembraneintegrity Approved1982•Revised1998,2013,2017•LevelofEvidence2.1 Definition Injurytothelips,softtissue,buccalcavity,and/ororopharynx. Definingcharacteristics –Badtasteinmouth –Bleeding –Cheilitis –Coatedtongue –Decreaseintastesensation –Desquamation –Difficultyeating –Difficultyspeaking –Enlargedtonsils –Exposuretopathogen –Geographictongue –Gingivalhyperplasia –Gingivalpallor –Gingivalpocketingdeeperthan4mm –Gingivalrecession –Halitosis –Hyperemia –Impairedabilitytoswallow –Macroplasia –Mucosaldenudation –Oraldiscomfort –Oraledema –Oralfissure –Orallesion –Oralmucosalpallor –Oralnodule –Oralpain –Oralpapule –Oralulcer –Oralvesicles –Presenceofmass –Purulentoral-nasaldrainage –Purulentoral-nasalexudates –Smoothatrophictongue –Spongypatchesinmouth –Stomatitis –Whitepatchesinmouth –Whiteplaqueinmouth –White,curd-likeoralexudate –Xerostomia Relatedfactors –Alcoholconsumption –Barriertodentalcare –Barriertooralself-care –Chemicalinjuryagent –Decreaseinsalivation –Dehydration –Inadequateoralhygiene –Insufficientknowledgeoforalhygiene –Malnutrition –Mouthbreathing –Smoking –Stressors 437 –Depression –Inadequatenutrition Atriskpopulation –Economicallydisadvantaged Associatedcondition –Allergy –Alterationincognitivefunctioning –Autoimmunedisease –Autosomaldisorder –Behavioraldisorder –Chemotherapy –Cleftlip –Cleftpalate –Decreaseinhormonelevelinwomen –Decreaseinplatelets –Immunodeficiency –Immunosuppression –Infection –Lossoforalsupportstructure –Mechanicalfactor –Nilperos(NPO)>24hours –Oraltrauma –Radiationtherapy –Sjögren'sSyndrome –Surgicalprocedure –Trauma –Treatmentregimen Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 438 Domain11•Class2•DiagnosisCode00247 Riskforimpairedoralmucousmembraneintegrity Approved2013•Revised2017•LevelofEvidence2.1 Definition Susceptibletoinjurytothelips,softtissues,buccalcavity,and/ororopharynx, whichmaycompromisehealth. Riskfactors –Alcoholconsumption –Barriertodentalcare –Barriertooralself-care –Chemicalinjuryagent –Decreaseinsalivation –Dehydration –Depression –Inadequatenutrition –Inadequateoralhygiene –Insufficientknowledgeoforalhygiene –Malnutrition –Mouthbreathing –Smoking –Stressors Atriskpopulation –Economicallydisadvantaged Associatedcondition –Allergy –Alterationincognitivefunctioning –Autoimmunedisease –Autosomaldisorder –Behavioraldisorder –Chemotherapy –Cleftlip –Cleftpalate –Decreaseinhormonelevelinwomen –Decreaseinplatelets –Immunodeficiency –Immunosuppression –Infection –Lossoforalsupportstructure –Mechanicalfactor –Nilperos(NPO)>24hours –Oraltrauma –Radiationtherapy –Surgicalprocedure –Sjögren'sSyndrome –Trauma –Treatmentregimen 439 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 440 Domain11•Class2•DiagnosisCode00086 Riskforperipheralneurovasculardysfunction Approved1992•Revised2013,2017 Definition Susceptible to disruption in the circulation, sensation, and motion of an extremity,whichmaycompromisehealth. Riskfactors –Tobedeveloped Associatedcondition –Burninjury –Fracture –Immobilization –Mechanicalcompression –Orthopedicsurgery –Trauma –Vascularobstruction ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 441 Domain11•Class2•DiagnosisCode00038 Riskforphysicaltrauma Approved1980•Revised2013,2017 Definition Susceptible to physical injury of sudden onset and severity which require immediateattention. Riskfactors External –Absenceofcall-for-aiddevice –Absenceofstairwaygate –Absenceofwindowguard –Accesstoweapon –Bathinginveryhotwater –Bedinhighposition –Childrenridinginfrontseatofcar –Defectiveappliance –Delayinignitionofgasappliance –Dysfunctionalcall-for-aiddevice –Electricalhazard –Exposuretocorrosiveproduct –Exposuretodangerousmachinery –Exposuretoradiation –Exposuretotoxicchemical –Flammableobject –Greaseonstove –Icicleshangingfromroof –Inadequatestairrails –Inadequatelystoredcombustible –Inadequatelystoredcorrosive –Insufficientanti-slipmaterialinbathroom –Insufficientlighting –Insufficientprotectionfromheatsource –Misuseofheadgear –Misuseofseatrestraint –Nonuseofseatrestraints –Obstructedpassageway –Playingwithdangerousobject –Playingwithexplosive –Pothandlefacingfrontofstove –Proximitytovehiclepathway –Slipperyfloor –Smokinginbed –Smokingnearoxygen –Strugglingwithrestraints –Unanchoredelectricwires –Unsafeoperationofheavyequipment –Unsaferoad –Unsafewalkway –Useofcrackeddishware –Useofthrowrugs –Useofunstablechair –Useofunstableladder –Wearinglooseclothingaroundopenflame Internal 442 –Emotionaldisturbance –Impairedbalance –Insufficientknowledgeofsafetyprecautions –Insufficientvision –Weakness Atriskpopulation –Economicallydisadvantaged –Extremesofenvironmentaltemperature –Gasleak –Highcrimeneighborhood –Historyoftrauma Associatedcondition –Alterationincognitivefunctioning –Alterationinsensation –Decreaseineye-handcoordination –Decreaseinmusclecoordination ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 443 Domain11•Class2•DiagnosisCode00213 Riskforvasculartrauma Approved2008•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to damage to vein and its surrounding tissues related to the presenceofacatheterand/orinfusedsolutions,whichmaycompromisehealth. Riskfactors –Inadequateavailableinsertionsite –Prolongedperiodoftimecatheterisinplace Associatedcondition –Irritatingsolution –Rapidinfusionrate Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 444 Domain11•Class2•DiagnosisCode00249 Riskforpressureulcer Approved2013•Revised2017•LevelofEvidence2.2 Definition Susceptibletolocalizedinjurytotheskinand/orunderlyingtissueusuallyover a bony prominence as a result of pressure, or pressure in combination with shear(NPUAP,2007). Riskfactors –Decreaseinmobility –Dehydration –Dryskin –Extendedperiodofimmobilityonhardsurface –Hyperthermia –Inadequatenutrition –Incontinence –Insufficientcaregiverknowledgeofpressure ulcerprevention –Insufficientknowledgeofmodifiablefactors –Pressureoverbonyprominence –Scalyskin –Self-caredeficit –Shearingforces –Skinmoisture –Smoking –Surfacefriction –Useoflinenwithinsufficientmoisturewicking property Atriskpopulation –ADULT:BradenScalescoreof<17 –AmericanSocietyofAnesthesiologists(ASA) PhysicalStatusclassificationscore≥1 –CHILD:BradenQScaleof≤15 –Extremesofage –Extremesofweight –Femalegender –Historyofcerebralvascularaccident –Historyofpressureulcer –Historyoftrauma –LowscoreonRiskAssessmentPressureSore (RAPS)scale –NewYorkHeartAssociation(NYHA)Functional Classification≥1 Associatedcondition –Alterationincognitivefunctioning –Alterationinsensation –Anemia –Elevatedskintemperatureby1-2°C –Hipfracture –Impairedcirculation 445 –Cardiovasculardisease –Decreaseinserumalbuminlevel –Decreaseintissueoxygenation –Decreaseintissueperfusion –Edema –Lymphopenia –Pharmaceuticalagent –Physicalimmobilization –Reducedtricepsskinfoldthickness Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 446 Domain11•Class2•DiagnosisCode00205 Riskforshock Approved2008•Revised2013,2017•LevelofEvidence2.1 Definition Susceptibletoaninadequatebloodflowtothebody'stissuesthatmayleadto life-threateningcellulardysfunction,whichmaycompromisehealth. Riskfactors –Tobedeveloped Associatedcondition –Hypotension –Hypovolemia –Hypoxemia –Hypoxia –Infection –Sepsis –Systemicinflammatoryresponsesyndrome (SIRS) This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition if no risk factors are developed. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 447 Domain11•Class2•DiagnosisCode00046 Impairedskinintegrity Approved1975•Revised1998.2017•LevelofEvidence2.1 Definition Alteredepidermisand/ordermis. Definingcharacteristics –Acutepain –Alterationinskinintegrity –Bleeding –Foreignmatterpiercingskin –Hematoma –Localizedareahottotouch –Redness Relatedfactors External –Chemicalinjuryagent –Excretions –Humidity –Hyperthermia –Hypothermia –Moisture –Pressureoverbonyprominence –Secretions Internal –Alterationinfluidvolume –Inadequatenutrition –Psychogenicfactor Atriskpopulation –Extremesofage Associatedcondition –Alterationinmetabolism –Alterationinpigmentation –Immunodeficiency –Impairedcirculation 448 –Alterationinsensation –Alterationinskinturgor –Arterialpuncture –Hormonalchange –Pharmaceuticalagent –Radiationtherapy –Vasculartrauma 449 Domain11•Class2•DiagnosisCode00047 Riskforimpairedskinintegrity Approved1975•Revised1998,2010,2013,2017•LevelofEvidence2.1 Definition Susceptible to alteration in epidermis and/or dermis, which may compromise health. Riskfactors External –Chemicalinjuryagent –Excretions –Humidity –Hyperthermia –Hypothermia –Moisture –Secretions Internal –Alterationinfluidvolume –Inadequatenutrition –Pressureoverbonyprominence –Psychogenicfactor Atriskpopulation –Extremesofage Associatedcondition –Alterationinmetabolism –Alterationinpigmentation –Alterationinsensation –Alterationinskinturgor –Arterialpuncture –Hormonalchange –Immunodeficiency –Impairedcirculation –Pharmaceuticalagent –Radiationtherapy –Vasculartrauma 450 Domain11•Class2•DiagnosisCode00156 Riskforsuddeninfantdeath Approved2002•Revised2013,2017•LevelofEvidence3.2 Definition Susceptibletounpredicteddeathofaninfant. Riskfactors –Delayinprenatalcare –Exposuretosecondhandsmoke –Infantoverheating –Infantoverwrapping –Infantplacedinpronepositiontosleep –Infantplacedinside-lyingpositiontosleep –Insufficientprenatalcare –Softsleepsurface –Soft,looseobjectsplacednearinfant –Infantlessthan4months,placedinsitting devicesforroutinesleep Atriskpopulation –AfricanAmericanEthnicity –Age2-4months –Infantnotbreastfedexclusivelyorfedwith expressedbreastmilk –Lowbirthweight –Malegender –Maternalsmokingduringpregnancy –NativeAmericanEthnicity –Postnatalexposuretoalcohol –Postnatalexposuretoelicitdrug –Prematurity –Prenatalexposuretoalcohol –Prenatalexposuretoelicitdrug –Youngparentalage Associatedcondition –Coldweather 451 Domain11•Class2•DiagnosisCode00036 Riskforsuffocation Approved1980•Revised2013,2017 Definition Susceptible to inadequate air availability for inhalation, which may compromisehealth. Riskfactors –Accesstoemptyrefrigerator/freezer –Eatinglargemouthfulsoffood –Emotionaldisturbance –Gasleak –Insufficientknowledgeofsafetyprecautions –Low-strungclothesline –Pacifieraroundinfant'sneck –Playingwithplasticbag –Proppedbottleininfant'scrib –Smallobjectinairway –Smokinginbed –Softunderlayment –Unattendedinwater –Unventedfuel-burningheater –Vehiclerunninginclosedgarage Associatedcondition –Alterationincognitivefunctioning –Alterationinolfactoryfunction –Face/neckdisease –Face/neckinjury –Impairedmotorfunctioning ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 452 Domain11•Class2•DiagnosisCode00100 Delayedsurgicalrecovery Approved1998•Revised2006,2013,2017•LevelofEvidence2.1 Definition Extensionofthenumberofpostoperativedaysrequiredtoinitiateandperform activitiesthatmaintainlife,health,andwell-being. Definingcharacteristics –Discomfort –Evidenceofinterruptedhealingofsurgicalarea –Excessivetimerequiredforrecuperation –Impairedmobility –Inabilitytoresumeemployment –Lossofappetite –Postponesresumptionofwork –Requiresassistanceforself-care Relatedfactors –Malnutrition –Obesity –Pain –Postoperativeemotionalresponse Atriskpopulation –Extremesofage –Historyofdelayedwoundhealing Associatedcondition –AmericanSocietyofAnesthesiologists(ASA) PhysicalStatusclassificationscore≥2 –Diabetesmellitus –Edemaatsurgicalsite –Extensivesurgicalprocedure –Impairedmobility –Perioperativesurgicalsiteinfection –Persistentnausea –Persistentvomiting –Pharmaceuticalagent –Prolongedsurgicalprocedure –Psychologicaldisorderinpostoperativeperiod –Surgicalsitecontamination –Traumaatsurgicalsite 453 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 454 Domain11•Class2•DiagnosisCode00246 Riskfordelayedsurgicalrecovery Approved2013•Revised2017•LevelofEvidence2.1 Definition Susceptible to an extension of the number of postoperative days required to initiateandperformactivitiesthatmaintainlife,health,andwell-being,which maycompromisehealth. Riskfactors –Malnutrition –Obesity –Pain –Postoperativeemotionalresponse Atriskpopulation –Extremesofage –Historyofdelayedwoundhealing Associatedcondition –AmericanSocietyofAnesthesiologists(ASA) PhysicalStatusclassificationscore≥2 –Diabetesmellitus –Edemaatsurgicalsite –Extensivesurgicalprocedure –Impairedmobility –Perioperativesurgicalsiteinfection –Persistentnausea –Persistentvomiting –Pharmaceuticalagent –Prolongedsurgicalprocedure –Psychologicaldisorderinpostoperativeperiod –Surgicalsitecontamination –Traumaatsurgicalsite Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 455 Domain11•Class2•DiagnosisCode00044 Impairedtissueintegrity Approved1986•Revised1998,2013,2017•LevelofEvidence2.1 Definition Damage to the mucous membrane, cornea, integumentary system, muscular fascia,muscle,tendon,bone,cartilage,jointcapsule,and/orligament. Definingcharacteristics –Acutepain –Bleeding –Destroyedtissue –Hematoma –Localizedareahottotouch –Redness –Tissuedamage Relatedfactors –Chemicalinjuryagent –Excessivefluidvolume –Humidity –Imbalancednutritionalstate –Insufficientfluidvolume –Insufficientknowledgeaboutmaintainingtissue integrity –Insufficientknowledgeaboutprotectingtissue integrity Atriskpopulation –Extremesofage –Extremesofenvironmentaltemperature –Exposuretohigh-voltagepowersupply Associatedcondition –Alterationinmetabolism –Alterationinsensation –Arterialpuncture –Impairedcirculation –Impairedmobility –Peripheralneuropathy –Pharmaceuticalagent –Radiationtherapy –Surgicalprocedure –Vasculartrauma 456 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 457 Domain11•Class2•DiagnosisCode00248 Riskforimpairedtissueintegrity Approved2013•Revised2017•LevelofEvidence2.1 Definition Susceptible to damage to the mucous membrane, cornea, integumentary system,muscularfascia,muscle,tendon,bone,cartilage,jointcapsule,and/or ligament,whichmaycompromisehealth. Riskfactors –Chemicalinjuryagent –Excessivefluidvolume –Humidity –Imbalancednutritionalstate –Insufficientfluidvolume –Insufficientknowledgeaboutmaintainingtissue integrity –Insufficientknowledgeaboutprotectingtissue integrity Atriskpopulation –Extremesofage –Extremesofenvironmentaltemperature –Exposuretohigh-voltagepowersupply Associatedcondition –Alterationinmetabolism –Alterationinsensation –Arterialpuncture –Impairedcirculation –Impairedmobility –Peripheralneuropathy –Pharmaceuticalagent –Radiationtherapy –Surgicalprocedure –Vasculartrauma Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 458 Domain11•Class2•DiagnosisCode00268 Riskforvenousthromboembolism Approved2016•LevelofEvidence2.1 Definition Susceptibletothedevelopmentofabloodclotinadeepvein,commonlyinthe thigh,calforupperextremity,whichcanbreakoffandlodgeinanothervessel, whichmaycompromisehealth. Riskfactors –Dehydration –Impairedmobility –Obesity Atriskpopulation –Age>60years –Criticalcareadmission –Currentsmoker –Firstdegreerelativewithhistoryofvenous thromboembolism –Historyofcerebralvascularaccident(CVA) –Historyofpreviousvenousthromboembolism –Lessthan6weekspostpartum Associatedcondition –Cerebralvascularaccident(CVA) –Currentcancerdiagnosis –Traumabelowthewaist –Significantmedicalcomorbidity –Postoperativeformajorsurgery –Postoperativefororthopedicsurgery –Surgeryandtotalanesthesiatime>90minutes –Thrombophilia –Traumaofupperextremity –Useofestrogen-containingcontraceptives –Useofhormonereplacementtherapy –Varicoseveins 459 Domain11•Class3•DiagnosisCode00272 Riskforfemalegenitalmutilation Approved2016•LevelofEvidence2.1 Definition Susceptibletofullorpartialablationofthefemaleexternalgenitaliaandother lesions of the genitalia, whether for cultural, religious or any other nontherapeuticreasons,whichmaycompromisehealth. Riskfactors –Lackoffamilyknowledgeaboutimpactof practiceonphysicalhealth –Lackoffamilyknowledgeaboutimpactof practiceonreproductivehealth –Lackoffamilyknowledgeaboutimpactof practiceonpsychosocialhealth Atriskpopulation –Residingincountrywherepracticeisaccepted –Familyleadersbelongtoethnicgroupinwhich practiceisaccepted –Belongingtofamilyinwhichanyfemalemember hasbeensubjectedtopractice –Favorableattitudeoffamilytowardspractice –Femalegender –Belongingtoethnicgroupinwhichpracticeis accepted –Planningtovisitfamily'scountryoforigin Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 460 Domain11•Class3•DiagnosisCode00138 Riskforother-directedviolence Approved1980•Revised1996,2013,2017 Definition Susceptibletobehaviorsinwhichanindividualdemonstratesthatheorshecan bephysically,emotionally,and/orsexuallyharmfultoothers. Riskfactors –Accesstoweapon –Impulsiveness –Negativebodylanguage –Patternofindirectviolence –Patternofother-directedviolence –Patternofthreateningviolence –Patternofviolentanti-socialbehavior –Suicidalbehavior Atriskpopulation –Historyofchildhoodabuse –Historyofcrueltytoanimals –Historyoffire-setting –Historyofmotorvehicleoffense –Historyofsubstancemisuse –Historyofwitnessingfamilyviolence Associatedcondition –Alterationincognitivefunctioning –Neurologicalimpairment –Pathologicalintoxication –Perinatalcomplications –Prenatalcomplications –Psychoticdisorder ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 461 Domain11•Class3•DiagnosisCode00140 Riskforself-directedviolence Approved1994•Revised2013,2017 Definition Susceptibletobehaviorsinwhichanindividualdemonstratesthatheorshecan bephysically,emotionally,and/orsexuallyharmfultoself. Riskfactors –Behavioralcuesofsuicidalintent –Conflictaboutsexualorientation –Conflictininterpersonalrelationship(s) –Employmentconcern –Engagementinautoeroticsexualacts –Insufficientpersonalresources –Socialisolation –Suicidalideation –Suicidalplan –Verbalcuesofsuicidalintent Atriskpopulation –Age≥45years –Age15-19years –Historyofmultiplesuicideattempts –Maritalstatus –Occupation –Patternofdifficultiesinfamilybackground Associatedcondition –Mentalhealthissue –Physicalhealthissue –Psychologicaldisorder ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 462 Domain11•Class3•DiagnosisCode00151 Self-mutilation Approved2000•Revised2017 Definition Deliberate self-injurious behavior causing tissue damage with the intent of causingnonfatalinjurytoattainreliefoftension. Definingcharacteristics –Abrading –Biting –Constrictingabodypart –Cutsonbody –Hitting –Ingestionofharmfulsubstance –Inhalationofharmfulsubstance –Insertionofobjectintobodyorifice –Pickingatwound –Scratchesonbody –Self-inflictedburn –Severingofabodypart Relatedfactors –Absenceoffamilyconfidant –Alterationinbodyimage –Dissociation –Disturbanceininterpersonalrelationships –Eatingdisorder –Emotionaldisturbance –Feelingthreatenedwithlossofsignificant relationship –Impairedself-esteem –Impulsiveness –Inabilitytoexpresstensionverbally –Ineffectivecommunicationbetweenparentand adolescent –Ineffectivecopingstrategies –Irresistibleurgeforself-directedviolence –Irresistibleurgetocutself –Isolationfrompeers –Labilebehavior –Lossofcontroloverproblem-solvingsituation –Lowself-esteem –Mountingtensionthatisintolerable –Negativefeeling –Patternofinabilitytoplansolutions –Patternofinabilitytoseelong-termconsequences –Perfectionism –Requiresrapidstressreduction –Substancemisuse –Useofmanipulationtoobtainnurturing relationshipwithothers Atriskpopulation –Adolescence –Childhoodsurgery 463 –Batteredchild –Childhoodillness –Developmentaldelay –Familydivorce –Familyhistoryofself-destructivebehavior –Familysubstancemisuse –Historyofchildhoodabuse –Historyofself-directedviolence –Incarceration –Livinginnontraditionalsetting –Peerswhoself-mutilate –Sexualidentitycrisis –Violencebetweenparentalfigures Associatedcondition –Autism –Borderlinepersonalitydisorder –Characterdisorder –Depersonalization –Psychoticdisorder ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 464 Domain11•Class3•DiagnosisCode00139 Riskforself-mutilation Approved1992•Revised2000,2013,2017 Definition Susceptibletodeliberateself-injuriousbehaviorcausingtissuedamagewiththe intentofcausingnonfatalinjurytoattainreliefoftension. Riskfactors –Absenceoffamilyconfidant –Alterationinbodyimage –Dissociation –Disturbanceininterpersonalrelationships –Eatingdisorder –Emotionaldisturbance –Feelingthreatenedwithlossofsignificant relationship –Impairedself-esteem –Impulsiveness –Inabilitytoexpresstensionverbally –Ineffectivecommunicationbetweenparentand adolescent –Ineffectivecopingstrategies –Irresistibleurgeforself-directedviolence –Irresistibleurgetocutself –Isolationfrompeers –Labilebehavior –Lossofcontroloverproblem-solvingsituation –Lowself-esteem –Mountingtensionthatisintolerable –Negativefeeling –Patternofinabilitytoplansolutions –Patternofinabilitytoseelong-termconsequences –Perfectionism –Requiresrapidstressreduction –Substancemisuse –Useofmanipulationtoobtainnurturing relationshipwithothers Atriskpopulation –Adolescence –Batteredchild –Childhoodillness –Childhoodsurgery –Developmentaldelay –Familydivorce –Familyhistoryofself-destructivebehavior –Familysubstancemisuse –Historyofchildhoodabuse –Historyofself-directedviolence –Incarceration –Livinginnontraditionalsetting –Lossofsignificantrelationship –Peerswhoself-mutilate –Sexualidentitycrisis –Violencebetweenparentalfigures 465 Associatedcondition –Autism –Borderlinepersonalitydisorder –Characterdisorder –Depersonalization –Psychoticdisorder ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 466 Domain11•Class3•DiagnosisCode00150 Riskforsuicide Approved2000•Revised2013,2017 Definition Susceptibletoself-inflicted,life-threateninginjury. Riskfactors Behavioral –Changingawill –Givingawaypossessions –Impulsiveness –Makingawill –Markedchangeinattitude –Markedchangeinbehavior –Markedchangeinschoolperformance –Purchaseofagun –Stockpilingmedication –Suddeneuphoricrecoveryfrommajordepression Psychological –Guilt –Substancemisuse Situational –Accesstoweapon –Lossofautonomy –Lossofindependence Social –Clustersuicides –Disciplinaryproblems –Disruptivefamilylife –Grieving –Helplessness –Hopelessness –Insufficientsocialsupport –Legaldifficulty –Loneliness –Lossofsignificantrelationship –Socialisolation Verbal 467 –Reportsdesiretodie –Threatofkillingself Other –Chronicpain Atriskpopulation –Adolescence –Adolescentslivinginnontraditionalsettings –Caucasianethnicity –Divorcedstatus –Economicallydisadvantaged –Olderadults –Familyhistoryofsuicide –Historyofchildhoodabuse –Historyofsuicideattempt –Homosexualyouth –Institutionalization –Livingalone –Malegender –NativeAmericanethnicity –Relocation –Retired –Widowed –Youngadultmales Associatedcondition –Physicalillness –Psychiatricdisorder –Terminalillness ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 468 Domain11•Class4•DiagnosisCode00181 Contamination Approved2006•Revised2017•LevelofEvidence2.1 Definition Exposure to environmental contaminants in doses sufficient to cause adverse healtheffects. Definingcharacteristics Pesticides –Dermatologicaleffectsofpesticideexposure –Gastrointestinaleffectsofpesticideexposure –Neurologicaleffectsofpesticideexposure –Pulmonaryeffectsofpesticideexposure –Renaleffectsofpesticideexposure Chemicals –Dermatologicaleffectsofchemicalexposure –Gastrointestinaleffectsofchemicalexposure –Immunologicaleffectsofchemicalexposure –Neurologicaleffectsofchemicalexposure –Pulmonaryeffectsofchemicalexposure –Renaleffectsofchemicalexposure Biologics –Dermatologicaleffectsofbiologicexposure –Gastrointestinaleffectsofbiologicexposure –Neurologicaleffectsofbiologicexposure –Pulmonaryeffectsofbiologicexposure –Renaleffectsofbiologicexposure Pollution –Neurologicaleffectsofpollutionexposure –Pulmonaryeffectsofpollutionexposure Waste –Dermatologicaleffectsofwasteexposure –Gastrointestinaleffectsofwasteexposure –Hepaticeffectsofwasteexposure –Pulmonaryeffectsofwasteexposure 469 Radiation –Geneticeffectsofradiationexposure –Immunologicaleffectsofradiationexposure –Neurologicaleffectsofradiationexposure –Oncologicaleffectsofradiationexposure Relatedfactors External –Carpetedflooring –Chemicalcontaminationoffood –Chemicalcontaminationofwater –Flaking,peelingsurfaceinpresenceofyoung children –Inadequatebreakdownofcontaminant –Inadequatehouseholdhygienepractices –Inadequatemunicipalservices –Inadequatepersonalhygienepractices –Inadequateprotectiveclothing –Inappropriateuseofprotectiveclothing –Ingestionofcontaminatedmaterial –Playingwhereenvironmentalcontaminantsare used –Unprotectedexposuretochemical –Unprotectedexposuretoheavymetal –Unprotectedexposuretoradioactivematerial –Useofenvironmentalcontaminantinthehome –Useofnoxiousmaterialininsufficiently ventilatedarea –Useofnoxiousmaterialwithouteffective protection Internal –Concomitantexposure –Inadequatenutrition –Smoking Atriskpopulation –Children<5years –Economicallydisadvantaged –Exposuretoareaswithhighcontaminantlevel –Exposuretoatmosphericpollutants –Exposuretobioterrorism –Exposuretodisaster –Exposuretoradiation –Femalegender –Gestationalageduringexposure –Olderadults –Previousexposuretocontaminant Associatedcondition –Pre-existingdisease –Pregnancy Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 470 Domain11•Class4•DiagnosisCode00180 Riskforcontamination Approved2006•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to exposure to environmental contaminants, which may compromisehealth. Riskfactors External –Carpetedflooring –Chemicalcontaminationoffood –Chemicalcontaminationofwater –Flaking,peelingsurfaceinpresenceofyoung children –Inadequatebreakdownofcontaminant –Inadequatehouseholdhygienepractices –Inadequatemunicipalservices –Inadequatepersonalhygienepractices –Inadequateprotectiveclothing –Inappropriateuseofprotectiveclothing –Ingestionofcontaminatedmaterial –Playingwhereenvironmentalcontaminantsare used –Unprotectedexposuretochemical –Unprotectedexposuretoheavymetal –Unprotectedexposuretoradioactivematerial –Useofenvironmentalcontaminantinthehome –Useofnoxiousmaterialininsufficiently ventilatedarea –Useofnoxiousmaterialwithouteffective protection Internal –Concomitantexposure –Inadequatenutrition –Smoking Atriskpopulation –Children<5years –Economicallydisadvantaged –Exposuretoareaswithhighcontaminantlevel –Exposuretoatmosphericpollutants –Exposuretobioterrorism –Exposuretodisaster –Exposuretoradiation –Femalegender –Gestationalageduringexposure –Olderadults –Previousexposuretocontaminant 471 Associatedcondition –Pre-existingdisease –Pregnancy Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 472 Domain11•Class4•DiagnosisCode00265 Riskforoccupationalinjury Approved2016•LevelofEvidence2.1 Definition Susceptible to sustain a work-related accident or illness, which may compromisehealth. Riskfactors Individual –Excessivestress –Improperuseofpersonalprotectiveequipment –Inadequateroleperformance –Inadequatetimemanagement –Ineffectivecopingstrategies –Insufficientknowledge –Misinterpretationofinformation –Psychologicaldistress –Unsafeactsofoverconfidence –Unsafeactsofunhealthynegativehabits Environmental –Distractionfromsocialrelationships –Exposuretobiologicalagents –Exposuretochemicalagents –Exposuretoextremesoftemperature –Exposuretonoise –Exposuretoradiation –Exposuretoteratogenicagents –Exposuretovibration –Inadequatephysicalenvironment –Laborrelationships –Lackofpersonalprotectiveequipment –Nightshiftworkrotatingtodayshiftwork –Occupationalburnout –Physicalworkload –Shiftwork Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 473 Domain11•Class4•DiagnosisCode00037 Riskforpoisoning Approved1980•Revised2006,2013,2017•LevelofEvidence2.1 Definition Susceptible to accidental exposure to, or ingestion of, drugs or dangerous productsinsufficientdoses,whichmaycompromisehealth. Riskfactors External –Accesstodangerousproduct –Accesstoillicitdrugspotentiallycontaminated bypoisonousadditives –Accesstopharmaceuticalagent –Occupationalsettingwithoutadequatesafeguards Internal –Emotionaldisturbance –Insufficientknowledgeofpoisoningprevention –Inadequateprecautionsagainstpoisoning –Insufficientvision –Insufficientknowledgeofpharmacologicalagents Associatedcondition –Alterationincognitivefunctioning Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 474 Domain11•Class5•DiagnosisCode00218 Riskforadversereactiontoiodinatedcontrastmedia Approved2010•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to noxious or unintended reaction associated with the use of iodinatedcontrastmediathatcanoccurwithinsevendaysaftercontrastagent injection,whichmaycompromisehealth. Riskfactors –Dehydration –Generalizedweakness Atriskpopulation –Extremesofage –Historyofallergy –Historyofpreviousadverseeffectfromiodinated contrastmedia Associatedcondition –Chronicillness –Concurrentuseofpharmaceuticalagents –Contrastmediaprecipitatesadverseevent –Fragilevein –Unconsciousness Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 475 Domain11•Class5•DiagnosisCode00217 Riskforallergyreaction Approved2010•Revised2013,2017•LevelofEvidence2.1 Definition Susceptible to an exaggerated immune response or reaction to substances, whichmaycompromisehealth. Riskfactors –Exposuretoallergen –Exposuretoenvironmentalallergen –Exposuretotoxicchemical Atriskpopulation –Historyoffoodallergy –Historyofinsectstingallergy –Repeatedexposuretoallergenproducing environmentalsubstance Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 476 Domain11•Class5•DiagnosisCode00041 Latexallergyreaction Approved1998•Revised2006,2017•LevelofEvidence2.1 Definition Ahypersensitivereactiontonaturallatexrubberproducts. Definingcharacteristics Life-ThreateningReactionswithin1HourofExposure –Bronchospasm –Chesttightness –Contacturticariaprogressingtogeneralized symptoms –Dyspnea –Edema –Hypotension –Myocardialinfarction –Respiratoryarrest –Syncope –Wheezing TypeIVReactionsOccurring≥1HourafterExposure –Discomfortreactiontoadditives –Eczema –Skinirritation –Skinredness GeneralizedCharacteristics –Generalizeddiscomfort –Generalizededema –Reportstotalbodywarmth –Restlessness –Skinflushing GastrointestinalCharacteristics –Abdominalpain –Nausea OrofacialCharacteristics –Erythema –Itching –Periorbitaledema –Rhinorrhea 477 –Nasalcongestion –Tearingoftheeyes Relatedfactors –Tobedeveloped Atriskpopulation –Frequentexposuretolatexproduct –Historyofallergy –Historyofasthma –Historyoffoodallergy –Historyoflatexreaction –Historyofpoinsettiaplantallergy –Historyofsurgeryduringinfancy Associatedcondition –Hypersensitivitytonaturallatexrubberprotein –Multiplesurgicalprocedures ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionifnorelatedfactorsare developed. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 478 Domain11•Class5•DiagnosisCode00042 Riskforlatexallergyreaction Approved1998•Revised2006,2013,2017•LevelofEvidence2.1 Definition Susceptibletoahypersensitivereactiontonaturallatexrubberproducts,which maycompromisehealth. Riskfactors –Tobedeveloped Atriskpopulation –Frequentexposuretolatexproduct –Historyofallergy –Historyofasthma –Historyoffoodallergy –Historyoflatexreaction –Historyofpoinsettiaplantallergy –Historyofsurgeryduringinfancy Associatedcondition –Hypersensitivitytonaturallatexrubberprotein –Multiplesurgicalprocedures This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition if no risk factors are developed. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 479 Domain11•Class6•DiagnosisCode00007 Hyperthermia Approved1986•Revised2013,2017•LevelofEvidence2.2 Definition Core body temperature above the normal diurnal range due to failure of thermoregulation. Definingcharacteristics –Abnormalposturing –Apnea –Coma –Flushedskin –Hypotension –Infantdoesnotmaintainsuck –Irritability –Lethargy –Seizure –Skinwarmtotouch –Stupor –Tachycardia –Tachypnea –Vasodilation Relatedfactors –Dehydration –Inappropriateclothing –Increaseinmetabolicrate –Vigorousactivity Atriskpopulation –Exposuretohighenvironmentaltemperature Associatedcondition –Decreaseinsweatresponse –Illness –Ischemia –Pharmaceuticalagent –Sepsis –Trauma Refertostagingcriteria. 480 Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 481 Domain11•Class6•DiagnosisCode00006 Hypothermia Approved1986•Revised1988,2013,2017•LevelofEvidence2.2 Definition Core body temperature below the normal diurnal range due to failure of thermoregulation. Definingcharacteristics –Acrocyanosis –Bradycardia –Cyanoticnailbeds –Decreaseinbloodglucoselevel –Decreaseinventilation –Hypertension –Hypoglycemia –Hypoxia –Increaseinmetabolicrate –Increaseinoxygenconsumption –Peripheralvasoconstriction –Piloerection –Shivering –Skincooltotouch –Slowcapillaryrefill –Tachycardia Neonates –Infantwithinsufficientenergytomaintain sucking –Infantwithinsufficientweightgain(<30g/day) –Irritability –Jaundice –Metabolicacidosis –Pallor –Respiratorydistress Relatedfactors –Alcoholconsumption –Decreaseinmetabolicrate –Excessiveconductiveheattransfer –Excessiveconvectiveheattransfer –Excessiveevaporativeheattransfer –Excessiveradiativeheattransfer –Inactivity –Insufficientcaregiverknowledgeofhypothermia prevention –Insufficientclothing –Lowenvironmentaltemperature –Malnutrition Neonates 482 –Delayinbreastfeeding –Earlybathingofnewborn –Increaseinoxygendemand Atriskpopulation –Economicallydisadvantaged –Extremesofage –Extremesofweight –High-riskout-of-hospitalbirth –Increasedbodysurfaceareatoweightratio –Insufficientsupplyofsubcutaneousfat –Unplannedout-of-hospitalbirth Associatedcondition –Damagetohypothalamus –Immaturestratumcorneum –Increaseinpulmonaryvascularresistance(PVR) –Ineffectivevascularcontrol –Inefficientnonshiveringthermogenesis –Pharmaceuticalagent –Radiationtherapy –Trauma Refertoappropriateandvalidatedstagingcriteria. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 483 Domain11•Class6•DiagnosisCode00253 Riskforhypothermia Approved2013•Revised2017•LevelofEvidence2.2 Definition Susceptible to a failure of thermoregulation that may result in a core body temperaturebelowthenormaldiurnalrange,whichmaycompromisehealth. Riskfactors –Alcoholconsumption –Excessiveconductiveheattransfer –Excessiveconvectiveheattransfer –Excessiveevaporativeheattransfer –Excessiveradiativeheattransfer –Inactivity –Insufficientcaregiverknowledgeofhypothermia prevention –Insufficientclothing –Lowenvironmentaltemperature –Malnutrition Neonates –Decreaseinmetabolicrate –Delayinbreastfeeding –Earlybathingofnewborn –Increaseinoxygendemand Atriskpopulation –Economicallydisadvantaged –Extremesofage –Extremesofweight –High-riskout-of-hospitalbirth –Increasedbodysurfaceareatoweightratio –Insufficientsupplyofsubcutaneousfat –Unplannedout-of-hospitalbirth Associatedcondition –Damagetohypothalamus –Immaturestratumcorneum –Increaseinpulmonaryvascularresistance(PVR) –Ineffectivevascularcontrol –Inefficientnonshiveringthermogenesis –Pharmaceuticalagent –Radiationtherapy –Trauma 484 Refertoappropriateandvalidatedstagingcriteria. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 485 Domain11•Class6•DiagnosisCode00254 Riskforperioperativehypothermia Approved2013•Revised2017•LevelofEvidence2.1 Definition Susceptibletoaninadvertentdropincorebodytemperaturebelow36°C/96.8 ° F occurring one hour before to 24 hours after surgery, which may compromisehealth. Riskfactors –Excessiveconductiveheattransfer –Excessiveconvectiveheattransfer –Excessiveradiativeheattransfer –Lowenvironmentaltemperature Atriskpopulation –AmericanSocietyofAnesthesiologists(ASA) PhysicalStatusclassificationscore>1 –Lowbodyweight –Lowpreoperativetemperature(<36°C/96.8°F) Associatedcondition –Cardiovascularcomplications –Combinedregionalandgeneralanesthesia –Diabeticneuropathy –Surgicalprocedure Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 486 Domain11•Class6•DiagnosisCode00008 Ineffectivethermoregulation Approved1986•Revised2017•LevelofEvidence2.1 Definition Temperaturefluctuationbetweenhypothermiaandhyperthermia. Definingcharacteristics –Cyanoticnailbeds –Flushedskin –Hypertension –Increaseinbodytemperatureabovenormalrange –Increaseinrespiratoryrate –Mildshivering –Moderatepallor –Piloerection –Reductioninbodytemperaturebelownormal range –Seizure –Skincooltotouch –Skinwarmtotouch –Slowcapillaryrefill –Tachycardia Relatedfactors –Dehydration –Fluctuatingenvironmentaltemperature –Inactivity –Inappropriateclothingforenvironmental temperature –Increaseinoxygendemand –Vigorousactivity Atriskpopulation –Extremesofage –Extremesofweight –Extremesofenvironmentaltemperature –Increasedbodysurfaceareatoweightratio –Insufficientsupplyofsubcutaneousfat Associatedcondition –Alterationinmetabolicrate –Braininjury –Conditionaffectingtemperatureregulation –Decreaseinsweatresponse –Inefficientnonshiveringthermogenesis –Pharmaceuticalagent –Sedation –Sepsis 487 –Illness –Trauma 488 Domain11•Class6•DiagnosisCode00274 Riskforineffectivethermoregulation Approved2016•LevelofEvidence2.1 Definition Susceptibletotemperaturefluctuationbetweenhypothermiaandhyperthermia, whichmaycompromisehealth. Riskfactors –Dehydration –Fluctuatingenvironmentaltemperature –Inactivity –Inappropriateclothingforenvironmental temperature –Increaseinoxygendemand –Vigorousactivity Atriskpopulation –Extremesofage –Extremesofweight –Extremesofenvironmentaltemperature –Increasedbodysurfaceareatoweightratio –Insufficientsupplyofsubcutaneousfat Associatedcondition –Alterationinmetabolicrate –Braininjury –Conditionaffectingtemperatureregulation –Decreaseinsweatresponse –Illness –Inefficientnonshiveringthermogenesis –Pharmaceuticalagent –Sedation –Sepsis –Trauma 489 Domain12. Comfort Class1. Physicalcomfort Code Diagnosis 00214 Impairedcomfort 00183 Readinessforenhancedcomfort 00134 Nausea 00132 Acutepain 00133 Chronicpain 00255 Chronicpainsyndrome 00256 Laborpain Class2. Environmentalcomfort Code Diagnosis 00214 Impairedcomfort 00183 Readinessforenhancedcomfort Class3. Socialcomfort Code Diagnosis 00214 Impairedcomfort 00183 Readinessforenhancedcomfort 00054 Riskforloneliness 00053 Socialisolation NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. 490 EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 491 Domain12•Class1•DiagnosisCode00214 Impairedcomfort Approved2008•Revised2010,2017•LevelofEvidence2.1 Definition Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental,cultural,and/orsocialdimensions. Definingcharacteristics –Alterationinsleeppattern –Anxiety –Crying –Discontentwithsituation –Distressingsymptoms –Fear –Feelingcold –Feelingofdiscomfort –Feelingofhunger –Feelingwarm –Inabilitytorelax –Irritability –Itching –Moaning –Restlessness –Sighing –Uneasyinsituation Relatedfactors –Insufficientenvironmentalcontrol –Insufficientprivacy –Insufficientresources –Insufficientsituationalcontrol –Noxiousenvironmentalstimuli Associatedcondition –Illness-relatedsymptoms –Treatmentregimen ThisdiagnosisisclassifiedunderClass1(Physicalcomfort),Class2(Environmentalcomfort),andClass3 (Socialcomfort). Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 492 Domain12•Class1•DiagnosisCode00183 Readinessforenhancedcomfort Approved2006•Revised2013•LevelofEvidence2.1 Definition A pattern of ease, relief, and transcendence in physical, psychospiritual, environmental,and/orsocialdimensions,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhancecomfort –Expressesdesiretoenhancefeelingof contentment –Expressesdesiretoenhancerelaxation –Expressesdesiretoenhanceresolutionof complaints ThisdiagnosisisclassifiedunderClass1(Physicalcomfort),Class2(Environmentalcomfort),andClass3 (Socialcomfort). Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 493 Domain12•Class1•DiagnosisCode00134 Nausea Approved1998•Revised2002,2010,2017•LevelofEvidence2.1 Definition Asubjectivephenomenonofanunpleasantfeelinginthebackofthethroatand stomach,whichmayormaynotresultinvomiting. Definingcharacteristics –Aversiontowardfood –Gaggingsensation –Increaseinsalivation –Increaseinswallowing –Sourtaste Relatedfactors –Anxiety –Exposuretotoxin –Fear –Noxiousenvironmentalstimuli –Noxioustaste –Unpleasantvisualstimuli Associatedcondition –Biochemicaldysfunction –Esophagealdisease –Gastricdistention –Gastrointestinalirritation –Increaseinintracranialpressure(ICP) –Intra-abdominaltumors –Labyrinthitis –Livercapsulestretch –Localizedtumor –Meniere'sdisease –Meningitis –Motionsickness –Pancreaticdisease –Pregnancy –Psychologicaldisorder –Spleniccapsulestretch –Treatmentregimen Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 494 Domain12•Class1•DiagnosisCode00132 Acutepain Approved1996•Revised2013•LevelofEvidence2.1 Definition Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International AssociationfortheStudyofPain);suddenorslowonsetofanyintensityfrom mild to severe with an anticipated or predictable end, and with a duration of lessthan3months. Definingcharacteristics –Appetitechange –Changeinphysiologicalparameter –Diaphoresis –Distractionbehavior –Evidenceofpainusingstandardizedpain behaviorchecklistforthoseunableto communicateverbally –Expressivebehavior –Facialexpressionofpain –Guardingbehavior –Hopelessness –Narrowedfocus –Positioningtoeasepain –Protectivebehavior –Proxyreportofpainbehavior/activitychanges –Pupildilation –Self-focused –Self-reportofintensityusingstandardizedpain scale –Self-reportofpaincharacteristicsusing standardizedpaininstrument Relatedfactors –Biologicalinjuryagent –Chemicalinjuryagent –Physicalinjuryagent Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 495 Domain12•Class1•DiagnosisCode00133 Chronicpain Approved1986•Revised1996,2013,2017•LevelofEvidence2.1 Definition Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International AssociationfortheStudyofPain);suddenorslowonsetofanyintensityfrom mildtosevere,constantorrecurringwithoutananticipatedorpredictableend, andwithadurationofgreaterthan3months. Definingcharacteristics –Alterationinabilitytocontinueprevious activities –Alterationinsleeppattern –Anorexia –Evidenceofpainusingstandardizedpain behaviorchecklistforthoseunableto communicateverbally –Facialexpressionofpain –Proxyreportofpainbehavior/activitychanges –Self-focused –Self-reportofintensityusingstandardizedpain scale –Self-reportofpaincharacteristicsusing standardizedpaininstrument Relatedfactors –Alterationinsleeppattern –Emotionaldistress –Fatigue –Increaseinbodymassindex –Ineffectivesexualitypattern –Injuryagent –Malnutrition –Nervecompression –Prolongedcomputeruse –Repeatedhandlingofheavyloads –Socialisolation –Whole-bodyvibration Atriskpopulation –Age>50years –Femalegender –Historyofabuse –Historyofgenitalmutilation –Historyofoverindebtedness –Historyofstaticworkpostures –Historyofsubstancemisuse –Historyofvigorousexercise 496 Associatedcondition –Chronicmusculoskeletalcondition –Contusion –Crushinjury –Damagetothenervoussystem –Fracture –Geneticdisorder –Imbalanceofneurotransmitters,neuromodulators andreceptors –Immunedisorder –Impairedmetabolicfunctioning –Ischemiccondition –Muscleinjury –Post-traumarelatedcondition –Prolongedincreaseincortisollevel –Spinalcordinjury –Tumorinfiltration Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 497 Domain12•Class1•DiagnosisCode00255 Chronicpainsyndrome Approved2013•LevelofEvidence2.2 Definition Recurrent or persistent pain that has lasted at least 3 months, and that significantlyaffectsdailyfunctioningorwell-being. Definingcharacteristics –Anxiety(00146) –Constipation(00011) –Deficientknowledge(00126) –Disturbedsleeppattern(00198) –Fatigue(00093) –Fear(00148) –Impairedmoodregulation(00241) –Impairedphysicalmobility(00085) –Insomnia(00095) –Obesity(00232) –Socialisolation(00053) –Stressoverload(00177) Relatedfactors –Tobedeveloped ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionifnorelatedfactorsare developed. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 498 Domain12•Class1•DiagnosisCode00256 Laborpain Approved2013•Revised2017•LevelofEvidence2.2 Definition Sensory and emotional experience that varies from pleasant to unpleasant, associatedwithlaborandchildbirth. Definingcharacteristics –Alterationinbloodpressure –Alterationinheartrate –Alterationinmuscletension –Alterationinneuroendocrinefunctioning –Alterationinrespiratoryrate –Alterationinsleeppattern –Alterationinurinaryfunctioning –Decreaseinappetite –Diaphoresis –Distractionbehavior –Expressivebehavior –Facialexpressionofpain –Increaseinappetite –Narrowedfocus –Nausea –Pain –Perinealpressure –Positioningtoeasepain –Protectivebehavior –Pupildilation –Self-focused –Uterinecontraction –Vomiting Relatedfactors –Tobedeveloped Associatedcondition –Cervicaldilation –Fetalexpulsion ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionifnorelatedfactorsare developed. Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 499 Domain12•Class2•DiagnosisCode00214 Impairedcomfort Approved2008•Revised2010,2017•LevelofEvidence2.1 Definition Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental,cultural,and/orsocialdimensions. Definingcharacteristics –Alterationinsleeppattern –Anxiety –Crying –Discontentwithsituation –Distressingsymptoms –Fear –Feelingcold –Feelingofdiscomfort –Feelingofhunger –Feelingwarm –Inabilitytorelax –Irritability –Itching –Moaning –Restlessness –Sighing –Uneasyinsituation Relatedfactors –Insufficientenvironmentalcontrol –Insufficientprivacy –Insufficientresources –Insufficientsituationalcontrol –Noxiousenvironmentalstimuli Associatedcondition –Illness-relatedsymptoms –Treatmentregimen ThisdiagnosisisclassifiedunderClass1(Physicalcomfort),Class2(Environmentalcomfort),andClass3 (Socialcomfort). Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 500 Domain12•Class2•DiagnosisCode00183 Readinessforenhancedcomfort Approved2006•Revised2013•LevelofEvidence2.1 Definition A pattern of ease, relief, and transcendence in physical, psychospiritual, environmental,and/orsocialdimensions,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhancecomfort –Expressesdesiretoenhancefeelingof contentment –Expressesdesiretoenhancerelaxation –Expressesdesiretoenhanceresolutionof complaints ThisdiagnosisisclassifiedunderClass1(Physicalcomfort),Class2(Environmentalcomfort),andClass3 (Socialcomfort). Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 501 Domain12•Class3•DiagnosisCode00214 Impairedcomfort Approved2008•Revised2010,2017•LevelofEvidence2.1 Definition Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental,cultural,and/orsocialdimensions. Definingcharacteristics –Alterationinsleeppattern –Anxiety –Crying –Discontentwithsituation –Distressingsymptoms –Fear –Feelingcold –Feelingofdiscomfort –Feelingofhunger –Feelingwarm –Inabilitytorelax –Irritability –Itching –Moaning –Restlessness –Sighing –Uneasyinsituation Relatedfactors –Insufficientenvironmentalcontrol –Insufficientprivacy –Insufficientresources –Insufficientsituationalcontrol –Noxiousenvironmentalstimuli Associatedcondition –Illness-relatedsymptoms –Treatmentregimen ThisdiagnosisisclassifiedunderClass1(Physicalcomfort),Class2(Environmentalcomfort),andClass3 (Socialcomfort). Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 502 Domain12•Class3•DiagnosisCode00183 Readinessforenhancedcomfort Approved2006•Revised2013•LevelofEvidence2.1 Definition A pattern of ease, relief, and transcendence in physical, psychospiritual, environmental,and/orsocialdimensions,whichcanbestrengthened. Definingcharacteristics –Expressesdesiretoenhancecomfort –Expressesdesiretoenhancefeelingof contentment –Expressesdesiretoenhancerelaxation –Expressesdesiretoenhanceresolutionof complaints ThisdiagnosisisclassifiedunderClass1(Physicalcomfort),Class2(Environmentalcomfort),andClass3 (Socialcomfort). Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 503 Domain12•Class3•DiagnosisCode00054 Riskforloneliness Approved1994•Revised2006,2013•LevelofEvidence2.1 Definition Susceptible to experiencing discomfort associated with a desire or need for morecontactwithothers,whichmaycompromisehealth. Riskfactors –Affectionaldeprivation –Emotionaldeprivation –Physicalisolation –Socialisolation Originalliteraturesupportavailableathttp://MediaCenter.thieme.com. 504 Domain12•Class3•DiagnosisCode00053 Socialisolation Approved1982•Revised2017 Definition Aloneness experienced by the individual and perceived as imposed by others andasanegativeorthreateningstate. Definingcharacteristics –Absenceofsupportsystem –Alonenessimposedbyothers –Culturalincongruence –Desiretobealone –Developmentaldelay –Disablingcondition –Feelingdifferentfromothers –Flataffect –Historyofrejection –Hostility –Illness –Inabilitytomeetexpectationsofothers –Insecurityinpublic –Meaninglessactions –Memberofasubculture –Pooreyecontact –Preoccupationwithownthoughts –Purposelessness –Repetitiveactions –Sadaffect –Valuesincongruentwithculturalnorms –Withdrawn Relatedfactors –Developmentallyinappropriateinterests –Difficultyestablishingrelationships –Inabilitytoengageinsatisfyingpersonal relationships –Insufficientpersonalresources –Socialbehaviorincongruentwithnorms –Valuesincongruentwithculturalnorms Associatedcondition –Alterationinmentalstatus –Alterationinphysicalappearance –Alterationinwellness 505 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 506 Domain13. Growth/development Class1. Growth Code Diagnosis Thisclassdoesnotcurrentlycontainanydiagnoses. Class2. Development Code Diagnosis 00112 Riskfordelayeddevelopment NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th Edition. EditedbyT.HeatherHerdmanandShigemiKamitsuru. © 2017 NANDA International, Inc. Published 2017 by Thieme Medical Publishers, Inc., New York. Companionwebsite:www.thieme.com/nanda-i. 507 Domain13•Class1 Thisclassdoesnotcurrentlycontainanydiagnoses. 508 Domain13•Class2•DiagnosisCode00112 Riskfordelayeddevelopment Approved1998•Revised2013,2017 Definition Susceptibletodelayof25%ormoreinoneormoreoftheareasofsocialor self-regulatorybehavior,orincognitive,language,gross,orfinemotorskills, whichmaycompromisehealth. Riskfactors –Inadequatenutrition –Presenceofabuse –Substancemisuse –Technologydependence Atriskpopulation –Behavioraldisorder –Economicallydisadvantaged –Exposuretonaturaldisaster –Exposuretoviolence –Historyofadoption –Inadequatematernalnutrition –Insufficientprenatalcare –Involvementwiththefostercaresystem –Late-termprenatalcare –Maternalage≤15years –Maternalage≥35years –Maternalfunctionalilliteracy –Maternalsubstancemisuse –Positivedrugscreen –Prematurity –Unplannedpregnancy –Unwantedpregnancy Associatedcondition –Braininjury –Caregiverlearningdisability –Caregivermentalhealthissue –Chronicillness –Congenitaldisorder –Endocrinedisorder –Failuretothrive –Geneticdisorder –Hearingimpairment –Impairedvision –Leadpoisoning –Prenatalinfection –Recurrentotitismedia –Seizuredisorder –Treatmentregimen 509 ThisdiagnosiswillretirefromtheNANDA-ITaxonomyinthe2021-2023editionunlessadditionalworkis completedtobringituptoalevelofevidence2.1orhigher. 510 Index A abstraction,levelof137 activityintolerance228 activityplanning –ineffectiveactivityplanning322 –riskforineffectiveactivityplanning323 activitytolerance –activityintolerance228 –riskforactivityintolerance229 activity,restdiagnoses,new8 acute136 acuteconfusion254 acutepain66,70,445 acutesubstancewithdrawalsyndrome351 –riskforacutesubstancewithdrawalsyndrome352 adaptivecapacity,decreasedintracranialadaptivecapacity357 adolescent105,136 adult105,136 adversereactiontoiodinatedcontrastmedia,riskforadversereactionto iodinatedcontrastmedia429 Ageaxis105,136 airwayclearance,ineffectiveairwayclearance384 allergyreaction –latexallergyreaction431 –riskforallergyreaction430 –riskforlatexallergyreaction433 anxiety324 –deathanxiety335 applications,useofnursingdiagnosis43 aspiration,riskforaspiration385 assessment –clinicalreasoning48,50 511 –framework54 –in-depth53,62,63 –NANDA-Itaxonomyasframework55 –principles37 –screening52,52,53 –settings53 associatedconditions23,121,137 at-riskpopulations23,121,137 attachment,riskforimpairedattachment289 auditory104 autonomicdysreflexia353 –riskforautonomicdysreflexia355 axesdefinitions100,134 B balancedenergyfield,imbalancedenergyfield225 balancedfluidvolume,riskforimbalancedfluidvolume183 balancednutrition,imbalancednutrition:lessthanbodyrequirements157 bathingself-care,bathingself-caredeficit243 bathingself-caredeficit243 bladder104 bleeding,riskforbleeding386 bloodglucoselevel,riskforunstablebloodglucoselevel177 body104 bodyimage,disturbedbodyimage276 bowel104 bowelincontinence207 breast104 breastmilkproduction,insufficientbreastmilkproduction159 breastfeeding –ineffectivebreastfeeding160 –interruptedbreastfeeding161 –readinessforenhancedbreastfeeding162 breathingpattern,ineffectivebreathingpattern230 C cardiac104 cardiacoutput –decreasedcardiacoutput231 512 –riskfordecreasedcardiacoutput233 cardiopulmonary104 cardiovascular104 careplans118,126–127 caregiver135 caregiverrolestrain278 cerebral104 changingadiagnoses120 child105,136 childbearingprocess –ineffectivechildbearingprocess307 –readinessforenhancedchildbearingprocess310 –riskforineffectivechildbearingprocess309 chronic136 chronicconfusion256 chronicfunctionalconstipation201 chroniclowself-esteem272 chronicpain446 chronicpainsyndrome448 chronicsorrow349 classification79,80,137 clinicaljudgment37 clinicalreasoning –assessmentassessment –clinicalscenario46–47 –confirming,refutingpotentialdiagnoses64 –dataanalysis55,56 –data,subjectivevs.objective57 –differentiatingbetweensimilardiagnoses69 –eliminatingpossiblediagnoses65,66 –errorsin51,61 –in-depthassessment53,62,63 –information,clusteringof59,59 –introduction45 –makingadiagnosis71 –nursingprocess48 –patternformation45,59,59 –potentialdiagnosisidentification60 –potentialnewdiagnoses65 513 –prioritization71 –screeningassessment52,52,53 comfort –impairedcomfort442,450,452 –readinessforenhancedcomfort443,451,453 communication –impairedverbalcommunication263 –readinessforenhancedcommunication262 community135 complicated102 complicatedgrieving340 componentpartsofdiagnosis116,136 compromised102 compromisedfamilycoping331 confirming,refutingpotentialdiagnoses64 confusion –acuteconfusion254 –chronicconfusion256 –riskforacuteconfusion255 constipation66,197 –chronicfunctionalconstipation201 –perceivedconstipation200 –riskforchronicfunctionalconstipation203 –riskforconstipation199 contamination424 –riskforcontamination426 continuous136 coping –compromisedfamilycoping331 –defensivecoping326 –disabledfamilycoping333 –ineffectivecommunitycoping329 –ineffectivecoping327 –readinessforenhancedcommunitycoping330 –readinessforenhancedcoping328 –readinessforenhancedfamilycoping334 coping,stresstolerancediagnoses –new8 –revised10 514 D data –analysis55,56 –information,clusteringof59,59 –subjectivevs.objective57 deathanxiety66,335 decision-making –impairedemancipateddecision-making368 –readinessforenhanceddecision-making366 –readinessforenhancedemancipateddecision-making370 –riskforimpairedemancipateddecision-making369 decisionalconflict367 decreased102 decreasedcardiacoutput231 decreaseddiversionalactivityengagement142 decreasedintracranialadaptivecapacity357 defensive102 defensivecoping326 deficientcommunityhealth148 deficientfluidvolume66,184 deficientknowledge259 deficient,deficit102 definingcharacteristics5,39,121,137 delayed102 delayedsurgicalrecovery410 denial,ineffectivedenial336 dentition104 –impaireddentition387 deprivation102 developing,submittingnursingdiagnosis106,113,118,122,125 development,riskfordelayeddevelopment459 diagnoses –confirming,refutingpotential64 –diagnostichypotheses60 –differentiatingbetweensimilar69 –eliminatingpossible65,66 –potentialdiagnosisidentification60 –potentialnewdiagnoses65 515 diagnosislabel136 diagnostichypotheses60 diarrhea204 differentiatingbetweensimilardiagnoses69,123,124 disabled102 disabledfamilycoping333 disorganized102 disorganizedinfantbehavior359 disproportionate102 disturbed102 disturbedbodyimage276 disturbedpersonalidentity269 disturbedsleeppattern216 disusesyndrome,riskfordisusesyndrome217 diversionalactivityengagement,decreaseddiversionalactivityengagement142 documentation,offamilymembersinpatientchart120 dressingself-care,dressingself-caredeficit244 dressingself-caredeficit244 dryeye,riskfordryeye388 drymouth,riskfordrymouth389 dysfunctional102 dysfunctionalfamilyprocesses290 dysfunctionalgastrointestinalmotility66,205 dysfunctionalventilatoryweaningresponse240 E eatingdynamics –ineffectiveadolescenteatingdynamics163 –ineffectivechildeatingdynamics164 effective102 electrolytebalance,riskforelectrolyteimbalance182 electronichealthrecord(EHR)115,129 eliminatingpossiblediagnoses65,66 elimination,impairedurinaryelimination189 emancipated102 emancipateddecision-making –impairedemancipateddecision-making368 –readinessforenhancedemancipateddecision-making370 –riskforimpairedemancipateddecision-making369 516 emotionalcontrol,labileemotionalcontrol257 energyfield,imbalancedenergyfield225 enhanced102 evaluation42 excess102 excessfluidvolume186 eye104 F failure102 falls,riskforfalls390 family135 familyprocesses –dysfunctionalfamilyprocesses290 –interruptedfamilyprocesses293 –readinessforenhancedfamilyprocesses294 FAQs –associatedconditions121 –at-riskpopulations121 –careplans118,126–127 –changingadiagnoses120 –componentpartsofdiagnosis116 –definingcharacteristics121 –definitions,classificationtext130 –developing,submittingnursingdiagnosis113,122,125 –diagnosisdevelopment,review130 –diagnosislists115 –differentiatingbetweensimilardiagnoses123,124 –documentation,offamilymembersinpatientchart120 –electronichealthrecords129 –healthpromotiondiagnosis114 –internationalconsiderations,nursingdiagnosesusage121 –interventions,finding125–126 –medicalvs.nursingdiagnosis116 –NANDAInternational111 –numberofdiagnoses119 –nursingdiagnoses,basicquestions117 –PESformat112 –problem-focuseddiagnosis113,123–125 517 –references,publishing131 –relatedfactors122 –relatedfactors-riskfactorsrelationship123 –riskdiagnosis114,123–125,128 –riskfactors122 –standardizednursinglanguage110 –structuringnursingcurricula128–129 –teaching,learningnursingdiagnoses127 –typesofnursingdiagnoses115 –whenisnursingdiagnosisneeded109 fatigue226 fear337 feedingdynamics,ineffectiveinfantfeedingdynamics166 feedingpattern,ineffectiveinfantfeedingpattern168 feedingself-care,feedingself-caredeficit245 feedingself-caredeficit245 femalegenitalmutilation,riskforfemalegenitalmutilation415 fetus105,136 fluidvolume –deficientfluidvolume184 –excessfluidvolume186 –riskfordeficientfluidvolume185 –riskforimbalancedfluidvolume183 Focusofthediagnosisaxis100,101,135,135 frail102 frailelderlysyndrome145 –riskforfrailelderlysyndrome147 functional102 functionalconstipation –chronicfunctionalconstipation201 –riskforchronicfunctionalconstipation203 functionalurinaryincontinence190 G gasexchange,impairedgasexchange209 gastrointestinal104 gastrointestinalmotility –dysfunctionalgastrointestinalmotility205 –riskfordysfunctionalgastrointestinalmotility206 518 genital104 grieving66,69–70,339 –complicatedgrieving340 –riskforcomplicatedgrieving341 group135 gustatory104 H health –deficientcommunityhealth148 –ineffectivefamilyhealthmanagement153 –ineffectivehealthmaintenance150 –ineffectivehealthmanagement151 –readinessforenhancedhealthliteracy143 –readinessforenhancedhealthmanagement152 –risk-pronehealthbehavior149 healthbehavior,risk-pronehealthbehavior149 healthliteracy,readinessforenhancedhealthliteracy143 healthmaintenance,ineffectivehealthmaintenance150 healthmanagement –ineffectivefamilyhealthmanagement153 –ineffectivehealthmanagement151 –readinessforenhancedhealthmanagement152 healthpromotiondiagnosis –defined133 –definitions,changesto7 –FAQs114 –new8 –principlesof35 –revised10 healthpromotionvalue106 history-taking58 homemaintenance,impairedhomemaintenance242 hope –hopelessness266 –readinessforenhancedhope267 hopelessness266 humandignity,riskforcompromisedhumandignity268 hyperbilirubinemia,neonatalhyperbilirubinemia178 519 hyperbilirubinemia,riskforneonatalhyperbilirubinemia179 hyperthermia434 hypothermia435 –riskforhypothermia437 –riskforperioperativehypothermia438 I imbalanced102 imbalancedenergyfield225 imbalancednutrition:lessthanbodyrequirements157 immigrationtransition,riskforcomplicatedimmigrationtransition315 impaired102 impairedbedmobility218 impairedcomfort442,450,452 impaireddentition387 impairedemancipateddecision-making368 impairedgasexchange209 impairedhomemaintenance242 impairedmemory261 impairedmoodregulation342 impairedoralmucousmembraneintegrity397 impairedparenting283 impairedphysicalmobility219 impairedreligiosity372 impairedresilience346 impairedsitting221 impairedskinintegrity406 impairedsocialinteraction301 impairedspontaneousventilation234 impairedstanding222 impairedswallowing173 impairedtissueintegrity412 impairedtransferability223 impairedurinaryelimination189 impairedverbalcommunication263 impairedwalking224 impairedwheelchairmobility220 impulsecontrol,ineffectiveimpulsecontrol258 in-depthassessment53,62,63 520 incontinence –bowelincontinence207 –functionalurinaryincontinence190 –overflowurinaryincontinence191 –reflexurinaryincontinence192 –riskforurgeurinaryincontinence195 –stressurinaryincontinence193 –urgeurinaryincontinence194 individual135 ineffective102 ineffectiveactivityplanning322 ineffectiveadolescenteatingdynamics163 ineffectiveairwayclearance384 ineffectivebreastfeeding160 ineffectivebreathingpattern230 ineffectivechildeatingdynamics164 ineffectivechildbearingprocess307 ineffectivecommunitycoping329 ineffectivecoping66,70,327 ineffectivedenial336 ineffectivefamilyhealthmanagement153 ineffectivehealthmaintenance150 ineffectivehealthmanagement151 ineffectiveimpulsecontrol258 ineffectiveinfantfeedingdynamics166 ineffectiveinfantfeedingpattern168 ineffectiveperipheraltissueperfusion238 ineffectiveprotection154 ineffectiverelationship295 ineffectiveroleperformance299 ineffectivesexualitypattern306 ineffectivethermoregulation439 infant105,136 infection –riskforinfection382 –riskforsurgicalsiteinfection383 information,clusteringof59,59 –data injury 521 –riskforcornealinjury392 –riskforinjury393 –riskforoccupationalinjury427 –riskforperioperativepositioninginjury395 –riskforthermalinjury396 –riskforurinarytractinjury394 insomnia213 insufficient102 insufficientbreastmilkproduction159 intermittent136 internationalconsiderations,nursingdiagnosesusage25,121 internationalpositionstatements27 interrupted102 interruptedbreastfeeding161 interruptedfamilyprocesses293 interventions –defined41 –finding125–126 –planning,interventionprinciples41 interview58 intracranial104 J Judgmentaxis102,102,135,135 K kinesthetic104 knowledge –deficientknowledge259 –readinessforenhancedknowledge260 L labile102 labileemotionalcontrol257 laborpain449 latexallergyreaction431 –riskforlatexallergyreaction433 levelofevidence(LOE)criteria –AcceptedforPublicationandInclusion(LOE2)5 –ClinicalStudiesRelatedtoDiagnosis,butNotGeneralizabletothePopulation 522 (LOE3.2)6 –ClinicallySupported(ValidationandTesting)(LOE3)6 –ConceptAnalysis(LOE2.2)5 –ConsensusStudiesRelatedtoDiagnosisUsingExperts(LOE2.3)6 –FAQs131 –LabelandDefinition(LOE1.2)5 –LabelOnly(LOE1.1)4 –Label,Definition,DefiningCharacteristics,RelatedorRiskFactors, References(LOE2.1)5 –LiteratureSynthesis(LOE3.1)6 –ReceivedforDevelopment(LOE1)4 –TheoreticalLevel(LOE1.3)5 –Well-DesignedClinicalStudieswithRandomSampleofSufficientSizeto AllowforGeneralizabilitytotheOverallPopulation(LOE3.4)6 –Well-DesignedClinicalStudieswithSmallSampleSizes(LOE3.3)6 licensing112 lifestyle,sedentarylifestyle144 liver104 liverfunction,riskforimpairedliverfunction180 Locationaxis104,104,136 loneliness,riskforloneliness454 low102 M maternal-fetaldyad,riskfordisturbedmaternal-fetaldyad311 medicalvs.nursingdiagnosis116 memory,impairedmemory261 metabolicimbalancesyndrome,riskformetabolicimbalancesyndrome181 mobility –impairedbedmobility218 –impairedphysicalmobility219 –impairedwheelchairmobility220 moodregulation,impairedmoodregulation342 moraldistress371 mouth104 mucousmembraneintegrity –impairedoralmucousmembraneintegrity397 –riskforimpairedoralmucousmembraneintegrity399 mucousmembranes104 523 N NANDAInternational –commitment30 –FAQs111 –history29 –involvementopportunities30 –joining,howto32,32 –joining,invitationto28 –joining,reasonsto31 –memberbenefits31 –member-drivenorganization29 –mission29 –professionalnetworking31 –purpose29 –resources31 –taxonomy,whoisusing32 –vision29 NANDA-Inursingdiagnoses –associatedconditions23,121 –at-riskpopulations23,121 –basicquestions117 –clinicians,clarityfor22 –defined133 –definitions,classificationtext130 –diagnosisdevelopment,review130 –diagnosticindicatorscoding23 –indicatortermsstandardization21 –labels,revisionsto21 –new8 –revised10 –translations,improved22 NANDA-ITaxonomyII –Ageaxis105,136 –asmultiaxialsystem99 –asrecognizednursinglanguage98 –axesdefinitions100,134 –casestudy85 –codestructure98 524 –diagnosticconceptconstruction99 –domains,classes79,80–81,87 –Focusofthediagnosisaxis100,101,135,135 –historyof86 –identifyingdiagnosisoutsideofexpertise83,84 –Judgmentaxis102,102,135,135 –Locationaxis104,104,136 –purposeof112 –StatusoftheDiagnosisaxis106,136 –structureof80,87,98 –structuringnursingcurricula81,82,128–129 –SubjectoftheDiagnosisaxis102,135 –Timeaxis106,136 –using,functionsof82 NANDA-Iwebsite4 nausea444 neonatalabstinencesyndrome358 neonatalhyperbilirubinemia178 neonate105,136 neurovascular104 neurovascularfunction,riskforperipheralneurovasculardysfunction400 nomenclature138 non-102 numberofdiagnoses119 NursingInterventionsClassification(NIC)41nutrition –imbalancednutrition:lessthanbodyrequirements157 –readinessforenhancednutrition158 nutritiondiagnoses –new8 –revised10 nutrition,imbalanced66 O obesity169 objectivedata57 occupationalinjury,riskforoccupationalinjury427 olderadult105,136 olfactory104 oral104 525 organized102 organizedbehavior –disorganizedinfantbehavior359 –readinessforenhancedorganizedinfantbehavior362 –riskfordisorganizedinfantbehavior361 other-directedviolence,riskforother-directedviolence416 overflowurinaryincontinence191 overload102 overweight170 –riskforoverweight172 P pain –acutepain445 –chronicpain446 –chronicpainsyndrome448 –laborpain449 parentalroleconflict298 parenting –impairedparenting283 –readinessforenhancedparenting288 –riskforimpairedparenting286 patternformation45,59,59 perceived102 perceivedconstipation200 perception,cognitiondiagnosesrevised10 perioperativehypothermia,riskforperioperativehypothermia438 perioperativepositioninginjury,riskforperioperativepositioninginjury395 peripheral104 peripheralvascular104 personalidentity –disturbedpersonalidentity269 –riskfordisturbedpersonalidentity270 PESformat112 physicaltrauma,riskforphysicaltrauma401 planning,intervention41 poisoning,riskforpoisoning428 post-traumasyndrome316 –riskforpost-traumasyndrome318 526 potentialdiagnosisidentification60 potentialnewdiagnoses65 power –powerlessness343 –readinessforenhancedpower345 –riskforpowerlessness344 powerlessness343 pressureulcer,riskforpressureulcer404 principlesofnursingdiagnosis –applications,useof43 –assessmentassessment –clinicaljudgment37 –collaborativehealthcareteam34,34 –componentpartsof116,136 –conceptknowledge37 –definingcharacteristics39,137 –definitions38,38,39,115 –evaluation42 –healthpromotiondiagnosis35 –introduction34 –learning,formatusedto40 –NANDA-Itaxonomy34 –planning,intervention41 –prioritization38 –problem-focuseddiagnosis35,38 –processofdiagnosis36,36 –relatedfactors39 –riskdiagnosis35,38 –riskfactors39 –syndromedefined35,134 problem-focuseddiagnosis –defined133 –FAQs113,123–125 –principlesofnursingdiagnosis35,38 problem-focusedvalue106protection,ineffectiveprotection154 R rape-traumasyndrome319 readinessfor102 527 readinessforenhancedbreastfeeding162 readinessforenhancedchildbearingprocess310 readinessforenhancedcomfort443,451,453 readinessforenhancedcommunication262 readinessforenhancedcommunitycoping330 readinessforenhancedcoping328 readinessforenhanceddecision-making366 readinessforenhancedemancipateddecision-making370 readinessforenhancedfamilycoping334 readinessforenhancedfamilyprocesses294 readinessforenhancedhealthliteracy143 readinessforenhancedhealthmanagement152 readinessforenhancedhope267 readinessforenhancedknowledge260 readinessforenhancednutrition158 readinessforenhancedorganizedinfantbehavior362 readinessforenhancedparenting288 readinessforenhancedpower345 readinessforenhancedrelationship297 readinessforenhancedreligiosity374 readinessforenhancedresilience66,70,348 readinessforenhancedself-care247 readinessforenhancedself-concept271 readinessforenhancedsleep215 readinessforenhancedspiritualwell-being365 references5,131 reflexurinaryincontinence192 relatedfactors137 –FAQs122 –LOE2.15 –principlesofnursingdiagnosis39 –riskfactorsrelationship123 relationship –ineffectiverelationship295 –readinessforenhancedrelationship297 –riskforineffectiverelationship296 religiosity –impairedreligiosity372 –readinessforenhancedreligiosity374 528 –riskforimpairedreligiosity373 relocationstresssyndrome66,69–70,320 –riskforrelocationstresssyndrome321 renal104 resilience –impairedresilience346 –readinessforenhancedresilience348 –riskforimpairedresilience347 retention,urinaryretention196 reviewprocess –expedited4 –full4 –proceduretoappeal4 riskdiagnosis133 –FAQs114,123–125,128 –LOE2.15 –principlesofnursingdiagnosis35,38 riskfactors137 –FAQs122 –principlesofnursingdiagnosis39 riskfor102 riskforactivityintolerance229 riskforacuteconfusion255 riskforacutesubstancewithdrawalsyndrome352 riskforadversereactiontoiodinatedcontrastmedia429 riskforallergyreaction430 riskforaspiration385 riskforautonomicdysreflexia355 riskforbleeding386 riskforcaregiverrolestrain281 riskforchronicfunctionalconstipation203 riskforchroniclowself-esteem273 riskforcomplicatedgrieving341 riskforcomplicatedimmigrationtransition315 riskforcompromisedhumandignity268 riskforconstipation199 riskforcontamination426 riskforcornealinjury392 riskfordecreasedcardiacoutput233 529 riskfordecreasedcardiactissueperfusion236 riskfordeficientfluidvolume185 riskfordelayeddevelopment459 riskfordelayedsurgicalrecovery411 riskfordisorganizedinfantbehavior361 riskfordisproportionategrowth7 riskfordisturbedmaternal-fetaldyad311 riskfordisturbedpersonalidentity270 riskfordisusesyndrome217 riskfordryeye388 riskfordrymouth389 riskfordysfunctionalgastrointestinalmotility206 riskforelectrolyteimbalance182 riskforfalls390 riskforfemalegenitalmutilation415 riskforfrailelderlysyndrome147 riskforhypothermia437 riskforimbalancedfluidvolume183 riskforimpairedattachment289 riskforimpairedemancipateddecision-making369 riskforimpairedliverfunction180 riskforimpairedoralmucousmembraneintegrity399 riskforimpairedparenting286 riskforimpairedreligiosity373 riskforimpairedresilience347 riskforimpairedskinintegrity407 riskforimpairedtissueintegrity413 riskforineffectiveactivityplanning323 riskforineffectivecerebraltissueperfusion237 riskforineffectivechildbearingprocess309 riskforineffectiveperipheraltissueperfusion239 riskforineffectiverelationship296 riskforineffectivethermoregulation440 riskforinfection382 riskforinjury393 riskforlatexallergyreaction433 riskforloneliness454 riskformetabolicimbalancesyndrome181 riskforneonatalhyperbilirubinemia179 530 riskforoccupationalinjury427 riskforother-directedviolence416 riskforoverweight172 riskforperioperativehypothermia438 riskforperioperativepositioninginjury395 riskforperipheralneurovasculardysfunction400 riskforphysicaltrauma401 riskforpoisoning428 riskforpost-traumasyndrome318 riskforpowerlessness344 riskforpressureulcer122,404 riskforrelocationstresssyndrome321 riskforself-directedviolence417 riskforself-mutilation420 riskforshock405 riskforsituationallowself-esteem275 riskforspiritualdistress377 riskforsuddeninfantdeath408 riskforsuffocation409 riskforsuicide422 riskforsurgicalsiteinfection383 riskforthermalinjury396 riskforunstablebloodglucoselevel177 riskforunstablebloodpressure235 riskforurgeurinaryincontinence195 riskforurinarytractinjury394 riskforvasculartrauma403 riskforvenousthromboembolism414 riskvalue106 risk-prone102 risk-pronehealthbehavior149 roleconflict,parentalroleconflict298 roleperformance,ineffectiveroleperformance299 rolestrain –caregiverrolestrain278 –riskforcaregiverrolestrain281 S safety,protectiondiagnoses,new8 531 screeningassessment52,52,53 SEATOWmnemonic70,71,119 secondopinion70 sedentary102 sedentarylifestyle144 self-care –bathingself-caredeficit243 –dressingself-caredeficit244 –feedingself-caredeficit245 –readinessforenhancedself-care247 –toiletingself-caredeficit246 self-concept,readinessforenhancedself-concept271 self-directedviolence,riskforself-directedviolence417 self-esteem –chroniclowself-esteem272 –riskforchroniclowself-esteem273 –riskforsituationallowself-esteem275 –situationallowself-esteem274 self-mutilation418 –riskforself-mutilation420 self-neglect248 sexualdysfunction305 sexualfunction,sexualdysfunction305 sexualitypattern,ineffectivesexualitypattern306 shock,riskforshock405 sitting,impairedsitting221 situational102 situationallowself-esteem274 skin104 skinintegrity –impairedskinintegrity406 –riskforimpairedskinintegrity407 sleep –disturbedsleeppattern216 –readinessforenhancedsleep215 –sleepdeprivation214 sleepdeprivation214 sleeppattern,disturbedsleeppattern216 SNAPPSdiagnosticaid124 532 socialinteraction,impairedsocialinteraction301 socialisolation455 sorrow,chronicsorrow349 spiritualdistress375 –riskforspiritualdistress377 spiritualwell-being,readinessforenhancedspiritualwell-being365 spontaneousventilation,impairedspontaneousventilation234 stablebloodpressure,riskforunstablebloodpressure235 standardizednursinglanguage110 standing,impairedstanding222 StatusoftheDiagnosisaxis106,136 stress,stressoverload350 stressoverload350 stressurinaryincontinence193 StructureoftheNursingDiagnosisStatementWhenIncludedinaCarePlan (NANDAPositionStatement)27 structuringnursingcurricula81,82,128–129 SubjectoftheDiagnosisaxis102,135 subjectivedata57 suddendeath,riskforsuddeninfantdeath408 suffocation,riskforsuffocation409 suicide,riskforsuicide422 surgicalrecovery –delayedsurgicalrecovery410 –riskfordelayedsurgicalrecovery411 surgicalsiteinfection,riskforsurgicalsiteinfection383 swallowing,impairedswallowing173 syndrome35,134 –acutesubstancewithdrawalsyndrome351 –chronicpainsyndrome448 –frailelderlysyndrome145 –neonatalabstinencesyndrome358 –post-traumasyndrome316 –rape-traumasyndrome319 –relocationstresssyndrome320 –riskforacutesubstancewithdrawalsyndrome352 –riskfordisusesyndrome217 –riskforfrailelderlysyndrome147 –riskformetabolicimbalancesyndrome181 533 –riskforpost-traumasyndrome318 –riskforrelocationstresssyndrome321 T tactile104 taxonomyNANDA-ITaxonomyII –classes,typesin77 –classification79,80,137 –defined138 –domains,classesin76,80 –introductionto74,76–77 –terminologyvs.74 teaching,learningnursingdiagnoses127 thermalinjury,riskforthermalinjury396 thermoregulation –ineffectivethermoregulation439 –riskforineffectivethermoregulation440 ThreePillarModelofNursingPractice109 Timeaxis106,136 tissue104 tissueintegrity –impairedtissueintegrity412 –riskforimpairedtissueintegrity413 tissueperfusion –ineffectiveperipheraltissueperfusion238 –riskfordecreasedcardiactissueperfusion236 –riskforineffectivecerebraltissueperfusion237 –riskforineffectiveperipheraltissueperfusion239 toiletingself-care,toiletingself-caredeficit246 toiletingself-caredeficit246 transferability,impairedtransferability223 trauma –riskforphysicaltrauma401 –riskforvasculartrauma403 typesofnursingdiagnoses115 U unilateralneglect251 unstable102 534 urgeurinaryincontinence194 urinary104 urinaryretention196 urinarytract104 UseofTaxonomyIIasanAssessmentFramework(NANDAPositionStatement) 27 V vascular104 venous104 venousthromboembolism,riskforvenousthromboembolism414 ventilatoryweaningresponse,dysfunctionalventilatoryweaningresponse240 verbalcommunication,impairedverbalcommunication263 visual104 W walking,impairedwalking224 wandering227 535 Concepts A activityplanning322–323 activitytolerance228–229 acutesubstancewithdrawalsyndrome351–352 adaptivecapacity357 adversereactiontoiodinatedcontrastmedia429 airwayclearance384 allergyreaction430 anxiety324 aspiration385 attachment289 autonomicdysreflexia353,355 B balancedenergyfield225 balancedfluidvolume183 balancednutrition157 bathingself-care243 bleeding386 bloodglucoselevel177 bodyimage276 breastmilkproduction159 breastfeeding160–162 breathingpattern230 C cardiacoutput231,233 childbearingprocess307,309–310 chronicpainsyndrome448 comfort442–443,450–453 communication262 confusion254–256 536 constipation197,199–200 contamination424,426 coping326–331,333–334 D deathanxiety335 decision-making366 decisionalconflict367 denial336 dentition387 development459 diarrhea204 disusesyndrome217 diversionalactivityengagement142 dressingself-care244 dryeye388 drymouth389 E eatingdynamics163–164 electrolytebalance182 elimination189 emancipateddecision-making368–370 emotionalcontrol257 F falls390 familyprocesses290,293–294 fatigue226 fear337 feedingdynamics166 feedingpattern168 feedingself-care245 femalegenitalmutilation415 fluidvolume184–186 frailelderlysyndrome145,147 functionalconstipation201,203 G gasexchange209 537 gastrointestinalmotility205–206 grieving339–341 H health148 healthbehavior149 healthliteracy143 healthmaintenance150 healthmanagement151–153 homemaintenance242 hope266–267 humandignity268 hyperbilirubinemia178 hyperbilirubinemia179 hyperthermia434 hypothermia435,437 I immigrationtransition315 impulsecontrol258 incontinence190–195,207 infection382 injury392–394 insomnia213 K knowledge259–260 L laborpain449 latexallergyreaction431,433 lifestyle144 liverfunction180 loneliness454 M maternal-fetaldyad311 memory261 metabolicimbalancesyndrome181 mobility218–220 538 moodregulation342 moraldistress371 mucousmembraneintegrity397,399 N nausea444 neonatalabstinencesyndrome358 neurovascularfunction400 nutrition158 O obesity169 occupationalinjury427 organizedbehavior359,361–362 other-directedviolence416 overweight170,172 P pain445–446 parenting283,286,288 perioperativehypothermia438 perioperativepositioninginjury395 personalidentity269–270 physicaltrauma401 poisoning428 post-traumasyndrome316,318 power343–345 pressureulcer404 protection154 R rape-traumasyndrome319 relationship295–297 religiosity372–374 relocationstresssyndrome320–321 resilience346–348 retention196 roleconflict298 roleperformance299 rolestrain278,281 539 S self-care247 self-concept271 self-directedviolence417 self-esteem272–275 self-mutilation418,420 self-neglect248 sexualfunction305 sexualitypattern306 shock405 sitting221 skinintegrity406–407 sleep214–215 sleeppattern216 socialinteraction301 socialisolation455 sorrow349 spiritualdistress375,377 spiritualwell-being365 spontaneousventilation234 stablebloodpressure235 standing222 stress350 suddendeath408 suffocation409 suicide422 surgicalrecovery410–411 surgicalsiteinfection383 swallowing173 T thermalinjury396 thermoregulation439–440 tissueintegrity412–413 tissueperfusion236–239 toiletingself-care246 transferability223 trauma403 540 U unilateralneglect251 V venousthromboembolism414 ventilatoryweaningresponse240 verbalcommunication263 W walking224 wandering227 541 542
