NANDA 2018-2020

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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
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NursingDiagnoses
DefinitionsandClassification
2018–2020
EleventhEdition
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and
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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.
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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
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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:
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Cambridge
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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
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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
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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
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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
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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/
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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
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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
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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
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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?
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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.
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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.
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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
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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).
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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,
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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
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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
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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
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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.
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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
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