Contents NANDA International Guidelines for Copyright Permission Preface Introduction xv xvi xxii Part 1 An Introduction to Nursing Diagnoses: Accuracy, Application Across Setting, and Submission of Nursing Diagnoses to NANDA-I 2009 2011 1 Assessment, Clinical Judgment, and Nursing Diagnoses: How to Determine Accurate Diagnoses 3 Margaret Lunney Nurses are Diagnosticians 4 Intellectual, Interpersonal and Technical Competencies 5 Personal Strengths: Tolerance for Ambiguity and Reflective Practice 7 Assessment and Nursing Diagnosis 8 Assessment Framework 9 Validating Diagnoses 12 Case Study Example 12 References 16 Appendix: Functional Health Pattern Assessment Framework 18 Directions 18 Nursing Diagnosis in Education 24 Martha Craft-Rosenberg and Kelly Smith Assessment and Identifying Defining Characteristics 24 History and Identifying Related Factors 24 Selecting the Nursing Diagnosis Label 25 Risk Diagnoses 25 Health-Promotion Diagnoses 25 Wellness Diagnoses 26 Prioritizing Diagnoses 26 Linking Nursing Diagnoses to Outcomes and Interventions 26 References 27 The Value of Nursing Diagnoses in Electronic Health Records 28 Jane Brokel and Crystal Health References 30 COPYRIGHTED MATERIAL Contents v
Nursing Diagnosis and Research 32 Margaret Lunney Concept Analyses 32 Construct and Criterion-Related Validity 33 Consensus Validation 34 Studies of Accuracy of Nurses Diagnoses 34 Summary 35 References 35 Nursing Diagnosis in Administration 37 Dickon Weir-Hughes Why Implement Nursing Diagnosis in a Clinical Environment? 37 Evidence-based Practice: Integrating Theory and Practice 38 Nursing in the Era of Electronic Patient Records 38 Leading the Implementation of Nursing Diagnosis in Clinical Practice 39 Conclusion 40 References 40 The Process for Development of an Approved NANDA-I Nursing Diagnosis 41 Leann M. Scroggins Axis 1: The Diagnostic Concept 41 Axis 2: Subject of the Diagnosis 42 Axis 3: Judgment 43 Axis 4: Location 43 Axis 5: Age 43 Axis 6: Time 44 Axis 7: Status of the Diagnosis 44 Defining Characteristics versus Risk Factors 48 References 51 Part 2 NANDA-I Nursing Diagnoses 2009 2011 53 Domain 1 Health Promotion 55 Ineffective Health Maintenance (00099) 57 Ineffective Self Health Management (00078) 58 Impaired Home Maintenance (00098) 61 Readiness for Enhanced Immunization Status (00186) 62 Self Neglect (00193) 64 Readiness for Enhanced Nutrition (00163) 67 Ineffective Family Therapeutic Regimen Management (00080) 68 Readiness for Enhanced Self Health Management (00162) 69 vi Contents
Domain 2 Nutrition 71 Ineffective Infant Feeding Pattern (00107) 73 Imbalanced Nutrition: Less Than Body Requirements (00002) 74 Imbalanced Nutrition: More Than Body Requirements (00001) 75 Risk for Imbalanced Nutrition: More Than Body Requirements (00003) 76 Impaired Swallowing (00103) 77 Risk for Unstable Blood Glucose Level (00179) 79 Neonatal Jaundice (00194) 80 Risk for Impaired Liver Function (00178) 81 Risk for Electrolyte Imbalance (00195) 82 Readiness for Enhanced Fluid Balance (00160) 83 Deficient Fluid Volume (00027) 84 Excess Fluid Volume (00026) 85 Risk for Deficient Fluid Volume (00028) 86 Risk for Imbalanced Fluid Volume (00025) 87 Domain 3 Elimination and Exchange 89 Functional Urinary Incontinence (00020) 91 Overflow Urinary Incontinence (00176) 92 Reflex Urinary Incontinence (00018) 93 Stress Urinary Incontinence (00017) 94 Urge Urinary Incontinence (00019) 96 Risk for Urge Urinary Incontinence (00022) 97 Impaired Urinary Elimination (00016) 98 Readiness for Enhanced Urinary Elimination (00166) 99 Urinary Retention (00023) 100 Bowel Incontinence (00014) 101 Constipation (00011) 102 Perceived Constipation (00012) 104 Risk for Constipation (00015) 105 Diarrhea (00013) 107 Dysfunctional Gastrointestinal Motility (00196) 108 Risk for Dysfunctional Gastrointestinal Motility (00197) 110 Impaired Gas Exchange (00030) 112 Domain 4 Activity/Rest 113 Insomnia (00095) 115 Disturbed Sleep Pattern (00198) 117 Sleep Deprivation (00096) 118 Readiness for Enhanced Sleep (00165) 119 Contents vii
Risk for Disuse Syndrome (00040) 120 Deficient Diversional Activity (00097) 121 Sedentary Lifestyle (00168) 122 Impaired Bed Mobility (00091) 123 Impaired Physical Mobility (00085) 124 Impaired Wheelchair Mobility (00089) 125 Delayed Surgical Recovery (00100) 127 Impaired Transfer Ability (00090) 129 Impaired Walking (00088) 131 Disturbed Energy Field (00050) 132 Fatigue (00093) 133 Activity Intolerance (00092) 134 Risk for Activity Intolerance (00094) 135 Risk for Bleeding (00206) 136 Ineffective Breathing Pattern (00032) 138 Decreased Cardiac Output (00029) 139 Ineffective Peripheral Tissue Perfusion (00204) 141 Risk for Decreased Cardiac Tissue Perfusion (00200) 142 Risk for Ineffective Cerebral Tissue Perfusion (00201) 143 Risk for Ineffective Gastrointestinal Perfusion (00202) 145 Risk for Ineffective Renal Perfusion (00203) 146 Risk for Shock (00205) 147 Impaired Spontaneous Ventilation (00033) 148 Dysfunctional Ventilatory Weaning Response (00034) 149 Readiness for Enhanced Self-Care (00182) 151 Bathing Self-Care Deficit (00108) 153 Dressing Self-Care Deficit (00109) 154 Feeding Self-Care Deficit (00102) 155 Toileting Self-Care Deficit (00110) 156 Domain 5 Perception/Cognition 157 Unilateral Neglect (00123) 159 Impaired Environmental Interpretation Syndrome (00127) 161 Wandering (00154) 162 Disturbed Sensory Perception (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) (00122) 163 Acute Confusion (00128) 164 Chronic Confusion (00129) 167 Risk for Acute Confusion (00173) 168 Deficient Knowledge (00126) 171 Readiness for Enhanced Knowledge (00161) 172 Impaired Memory (00131) 173 viii Contents
Readiness for Enhanced Decision-Making (00184) 174 Ineffective Activity Planning (00199) 176 Impaired Verbal Communication (00051) 178 Readiness for Enhanced Communication (00157) 180 Domain 6 Self-Perception 181 Risk for Compromised Human Dignity (00174) 183 Hopelessness (00124) 184 Disturbed Personal Identity (00121) 185 Risk for Loneliness (00054) 187 Readiness for Enhanced Power (00187) 188 Powerlessness (00125) 190 Risk for Powerlessness (00152) 191 Readiness for Enhanced Self-Concept (00167) 192 Situational Low Self-Esteem (00120) 193 Chronic Low Self-Esteem (00119) 194 Risk for Situational Low Self-Esteem (00153) 196 Disturbed Body Image (00118) 197 Domain 7 Role Relationships 199 Caregiver Role Strain (00061) 201 Risk for Caregiver Role Strain (00062) 204 Impaired Parenting (00056) 205 Readiness for Enhanced Parenting (00164) 207 Risk for Impaired Parenting (00057) 208 Risk for Impaired Attachment (00058) 210 Dysfunctional Family Processes (00063) 211 Interrupted Family Processes (00060) 214 Readiness for Enhanced Family Processes (00159) 215 Effective Breastfeeding (00106) 216 Ineffective Breastfeeding (00104) 217 Interrupted Breastfeeding (00105) 218 Parental Role Conflict (00064) 219 Readiness for Enhanced Relationship (00207) 220 Ineffective Role Performance (00055) 221 Impaired Social Interaction (00052) 223 Domain 8 Sexuality 225 Sexual Dysfunction (00059) 227 Ineffective Sexuality Pattern (00065) 229 Readiness for Enhanced Childbearing Process (00208) 231 Risk for Disturbed Maternal/Fetal Dyad (00209) 233 Contents ix
Domain 9 Coping/Stress Tolerance 235 Post-Trauma Syndrome (00141) 237 Risk for Post-Trauma Syndrome (00145) 238 Rape-Trauma Syndrome (00142) 239 Relocation Stress Syndrome (00114) 240 Risk for Relocation Stress Syndrome (00149) 241 Anxiety (00146) 242 Death Anxiety (00147) 244 Risk-Prone Health Behavior (00188) 247 Compromised Family Coping (00074) 249 Defensive Coping (00071) 251 Disabled Family Coping (00073) 253 Ineffective Coping (00069) 254 Ineffective Community Coping (00077) 255 Readiness for Enhanced Coping (00158) 256 Readiness for Enhanced Community Coping (00076) 257 Readiness for Enhanced Family Coping (00075) 258 Ineffective Denial (00072) 259 Fear (00148) 261 Grieving (00136) 263 Complicated Grieving (00135) 265 Risk for Complicated Grieving (00172) 267 Impaired Individual Resilience (00210) 269 Readiness for Enhanced Resilience (00212) 271 Risk for Compromised Resilience (00211) 274 Chronic Sorrow (00137) 276 Stress Overload (00177) 277 Autonomic Dysreflexia (00009) 280 Risk for Autonomic Dysreflexia (00010) 281 Disorganized Infant Behavior (00116) 283 Risk for Disorganized Infant Behavior (00115) 285 Readiness for Enhanced Organized Infant Behavior (00117) 286 Decreased Intracranial Adaptive Capacity (00049) 287 Domain 10 Life Principles 289 Readiness for Enhanced Hope (00185) 291 Readiness for Enhanced Spiritual Well-Being (00068) 292 Decisional Conflict (00083) 293 Moral Distress (00175) 295 Noncompliance (00079) 297 Impaired Religiosity (00169) 298 Readiness for Enhanced Religiosity (00171) 299 Risk for Impaired Religiosity (00170) 300 x Contents
Spiritual Distress (00066) 301 Risk for Spiritual Distress (00067) 303 Domain 11 Safety/Protection 305 Risk for Infection (00004) 307 Ineffective Airway Clearance (00031) 308 Risk for Aspiration (00039) 309 Risk for Sudden Infant Death Syndrome (00156) 310 Impaired Dentition (00048) 311 Risk for Falls (00155) 312 Risk for Injury (00035) 314 Risk for Perioperative-Positioning Injury (00087) 315 Impaired Oral Mucous Membrane (00045) 316 Risk for Peripheral Neurovascular Dysfunction (00086) 318 Ineffective Protection (00043) 319 Impaired Skin Integrity (00046) 320 Risk for Impaired Skin Integrity (00047) 321 Risk for Suffocation (00036) 322 Impaired Tissue Integrity (00044) 323 Risk for Trauma (00038) 324 Risk for Vascular Trauma (00213) 326 Self-Mutilation (00151) 327 Risk for Self-Mutilation (00139) 329 Risk for Suicide (00150) 330 Risk for Other-Directed Violence (00138) 332 Risk for Self-Directed Violence (00140) 333 Contamination (00181) 334 Risk for Contamination (00180) 338 Risk for Poisoning (00037) 341 Latex Allergy Response (00041) 342 Risk for Latex Allergy Response (00042) 344 Risk for Imbalanced Body Temperature (00005) 345 Hyperthermia (00007) 346 Hypothermia (00006) 347 Ineffective Thermoregulation (00008) 348 Domain 12 Comfort 349 Readiness for Enhanced Comfort (00183) 351 Impaired Comfort (00214) 352 Nausea (00134) 353 Acute Pain (00132) 354 Chronic Pain (00133) 355 Social Isolation (00053) 356 Contents xi
Domain 13 Growth/Development 357 Adult Failure to Thrive (00101) 359 Delayed Growth and Development (00111) 360 Risk for Disproportionate Growth (00113) 361 Risk for Delayed Development (00112) 362 Part 3 Taxonomy II 2009 2011 363 History of the Development of Taxonomy II 365 Structure of Taxonomy II 366 The Multiaxial System 380 Definitions of the Axes 382 Construction of a Nursing Diagnostic Statement 387 The NNN Taxonomy of Nursing Practice 388 Further Development of the NANDA-I Taxonomy 389 References 400 Part 4 Nursing Diagnoses Retired from the NANDA-I Taxonomy 2009 2011 401 Total Urinary Incontinence 403 Rape-Trauma Syndrome: Compound Reaction 404 Rape-Trauma Syndrome: Silent Reaction 405 Effective Therapeutic Regimen Management 406 Ineffective Community Therapeutic Regimen Management 407 Disturbed Thought Processes 408 Part 5 NANDA International 2009 2011 409 Full Review Process 411 Expedited Review Process 412 Submission Process for New Diagnoses 412 Submission Process for Revising a Current Nursing Diagnosis 414 Procedure to Appeal a DDC Decision on Diagnosis Review 415 NANDA-I Diagnosis Submission: Level of Evidence Criteria 416 Glossary of Terms 419 Nursing Diagnoses 419 Components of a Nursing Diagnosis 420 Definitions for Classification of Nursing Diagnoses 420 References 421 NANDA International 2006 2008 422 NANDA International Board of Directors 422 NANDA International Diagnosis Development Committee 422 NANDA International Taxonomy Committee 422 xii Contents
An Invitation to Join NANDA International 423 NANDA International s Commitment 423 Involvement Opportunities 423 NANDA International: A Member-driven Organization 424 Our Vision 424 Our Mission 424 Our Purpose 424 Our History 425 Nanda International Taxonomy 425 Index 429 Contents xiii