NURSING DIAGNOSES 2012–2014: DEFINITIONS & CLASSIFICATIONS

Author: T. Herdman, PhD, RN
Affiliation:
Publisher: Wiley-Blackwell
Publication Date: 2012
ISBN 10: 0470654821
ISBN 13: 9780470654828
Edition: 1st

Description:

A nursing diagnosis is defined as a clinical judgment about individual, family or community responses to actual or potential health problems or life processes which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability (NANDA-I, 2009). Accurate and valid nursing diagnoses guide the selection of interventions that are likely to produce the desired treatment effects and determine nurse-sensitive outcomes. Nursing diagnoses are seen as key to the future of evidence-based, professionally-led nursing care -- and to more effectively meeting the need of patients. In an era of increasing electronic patient health records, standardized nursing terminologies such as NANDA-I, NIC and NOC provide a means of collecting nursing data that are systematically analysed within and across healthcare organizations and provide essential data for cost/benefit analysis and clinical audit. Nursing Diagnoses: Definitions and Classification is the definitive guide to nursing diagnoses, as reviewed and approved by NANDA-I. Each nursing diagnoses undergoes a rigorous assessment process by NANDA-I's Diagnosis Development Committee, with stringent criteria used to indicate the strength of the underlying level of evidence. Each diagnosis comprises a label or name for the diagnosis, a definition, defining characteristics, risk factors and/or related factors. Many diagnoses are further qualified by terms such as risk for, effective, ineffective, impaired, imbalanced, self-care deficit, readiness for, disturbed, decreased, etc. The 2012-2014 edition is arranged by concept according to Taxonomy II domains, i.e. Health promotion, Nutrition, Elimination and exchange, Activity/Rest, Perception/Cognition, Self-perception, Role relationships, Sexuality, Coping/ Stress tolerance, Life principles, Safety/protection, Comfort, and Growth/development. The 2012-2014 edition contains revised chapters on NANDA-I taxon

Table of Contents

Front Matter

  • ABOUT
  • NANDA International Guidelines for Copyright Permission
  • Preface
  • Introduction
  • Acknowledgments

PART 1 The NANDA International Taxonomy

    Introduction

    • Contributors to the NANDA-I Nursing Diagnosis Taxonomy

    The NANDA International Taxonomy II 2012–2014

    • History of the Development of Taxonomy II
    • Structure of Taxonomy II
    • A Multiaxial System for Constructing Diagnostic Concepts
    • Definitions of the Axes
    • Construction of a Nursing Diagnostic Concept
    • The NNN Taxonomy of Nursing Practice
    • Further Development of the NANDA-I Taxonomy
    • References

PART 2 Education and Implementation of NANDA International Nursing Diagnoses within Practice, Administration, Research, Informatics and Education

    Nursing Assessment, Clinical Judgment, and Nursing Diagnoses: How to Determine Accurate Diagnoses

    • Nurses Are Diagnosticians
    • Intellectual, Interpersonal, and Technical Competencies
    • Personal Strengths: Tolerance for Ambiguity and Reflective Practice
    • Assessment and Nursing Diagnosis
    • Assessment Framework
    • Case Study Example
    • References
    • Appendix: Functional Health Pattern Assessment Framework

    Nursing Diagnosis in Education

    • Significance for Nursing Education
    • Teaching the Nursing Process Framework
    • Teaching the Assessment Phase of the Nursing Process
    • Teaching Nursing Diagnoses as a Component of the Nursing Process
    • The Nursing Process. Exemplar – Nursing History/Physical Assessment: Identifying Defining Characteristics and Related Factors
    • The Nursing Process. Exemplar – Accuracy of the Nursing Diagnosis Label
    • Risk Diagnoses
    • Health-Promotion Diagnoses
    • Prioritizing Diagnoses
    • Linking Nursing Diagnoses to Outcomes and Interventions
    • References

    The Value of Nursing Diagnoses in Electronic Health Records

    • Student Use of the Electronic Health Record (EHR)
    • Importance of Nursing Diagnoses in EHRs
    • Documenting Nursing Diagnoses in the EHR
    • Documenting Defining Characteristics, Related Factors, and Risk Factors in the EHR
    • Relationship of Nursing Diagnoses to Assessments
    • Linking Nursing Diagnoses to Other Documentation
    • Nursing Informatics Specialist/Graduate Student – Guiding Clinical Decision Support (CDS) within the EHR
    • Faculty Guide for Students in the Use of Nursing Diagnoses in the EHR
    • Learning the EHR, CDS and Health Information Exchange (HIE)
    • References

    Nursing Diagnosis and Research

    • Concept Analyses
    • Content Validation
    • Construct- and Criterion-Related Validity
    • Consensus Validation
    • Sensitivity, Specificity, and Predictive Value of Clinical Indicators
    • Studies of Accuracy of Nurses’ Diagnoses
    • Summary
    • References

    Clinical Judgment and Nursing Diagnoses in Nursing Administration

    • Nursing Research Priorities of Importance to Nurse Administrators
    • Nursing’s Role in Patient Safety
    • Triple Model for Nursing Administrators
    • Conclusion
    • References

    Nursing Classifications: Criteria and Evaluation

    • Characteristics of Classifications
    • Classification Criteria
    • Discussion
    • Conclusion
    • References

PART 3 NANDA-I Nursing Diagnoses 2012–2014

    International Considerations on the Use of the NANDA-I Taxonomy of Nursing Diagnoses

    • International Considerations on the Use of the NANDA-I Taxonomy of Nursing Diagnoses

    Domain 1: Health Promotion

    • Deficient Diversional Activity (00097)
    • Sedentary Lifestyle (00168)
    • Deficient Community Health (00215)
    • Risk-Prone Health Behavior (00188)
    • Ineffective Health Maintenance (00099)
    • Readiness for Enhanced Immunization Status (00186)
    • Ineffective Protection (00043)
    • Ineffective Self-Health Management (00078)
    • Readiness for Enhanced Self-Health Management (00162)
    • Ineffective Family Therapeutic Regimen Management (00080)

    Domain 2: Nutrition

    • Insufficient Breast Milk (00216)
    • Ineffective Infant Feeding Pattern (00107)
    • Imbalanced Nutrition: Less Than Body Requirements (00002)
    • Imbalanced Nutrition: More Than Body Requirements (00001)
    • Readiness for Enhanced Nutrition (00163)
    • Risk for Imbalanced Nutrition: More Than Body Requirements (00003)
    • Impaired Swallowing (00103)
    • Risk for Unstable Blood Glucose Level (00179)
    • Neonatal Jaundice (00194)
    • Risk for Neonatal Jaundice (00230)
    • Risk for Impaired Liver Function (00178)
    • Risk for Electrolyte Imbalance (00195)
    • Readiness for Enhanced Fluid Balance (00160)
    • Deficient Fluid Volume (00027)
    • Excess Fluid Volume (00026)
    • Risk for Deficient Fluid Volume (00028)
    • Risk for Imbalanced Fluid Volume (00025)

    Domain 3: Elimination and Exchange

    • Functional Urinary Incontinence (00020)
    • Overflow Urinary Incontinence (00176)
    • Reflex Urinary Incontinence (00018)
    • Stress Urinary Incontinence (00017)
    • Urge Urinary Incontinence (00019)
    • Risk for Urge Urinary Incontinence (00022)
    • Impaired Urinary Elimination (00016)
    • Readiness for Enhanced Urinary Elimination (00166)
    • Urinary Retention (00023)
    • Constipation (00011)
    • Perceived Constipation (00012)
    • Risk for Constipation (00015)
    • Diarrhea (00013)
    • Dysfunctional Gastrointestinal Motility (00196)
    • Risk For Dysfunctional Gastrointestinal Motility (00197)
    • Bowel Incontinence (00014)
    • Impaired Gas Exchange (00030)

    Domain 4: Activity/Rest

    • Insomnia (00095)
    • Sleep Deprivation (00096)
    • Readiness for Enhanced Sleep (00165)
    • Disturbed Sleep Pattern (00198)
    • Risk for Disuse Syndrome (00040)
    • Impaired Bed Mobility (00091)
    • Impaired Physical Mobility (00085)
    • Impaired Wheelchair Mobility (00089)
    • Impaired Transfer Ability (00090)
    • Impaired Walking (00088)
    • Disturbed Energy Field (00050)
    • Fatigue (00093)
    • Wandering (00154)
    • Activity Intolerance (00092)
    • Risk for Activity Intolerance (00094)
    • Ineffective Breathing Pattern (00032)
    • Decreased Cardiac Output (00029)
    • Risk for Ineffective Gastrointestinal Perfusion (00202)
    • Risk for Ineffective Renal Perfusion (00203)
    • Impaired Spontaneous Ventilation (00033)
    • Ineffective Peripheral Tissue Perfusion (00204)
    • Risk for Decreased Cardiac Tissue Perfusion (00200)
    • Risk for Ineffective Cerebral Tissue Perfusion (00201)
    • Risk for Ineffective Peripheral Tissue Perfusion (00228)
    • Dysfunctional Ventilatory Weaning Response (00034)
    • Impaired Home Maintenance (00098)
    • Readiness for Enhanced Self-Care (00182)
    • Bathing Self-Care Deficit (00108)
    • Dressing Self-Care Deficit (00109)
    • Feeding Self-Care Deficit (00102)
    • Toileting Self-Care Deficit (00110)
    • Self-Neglect (00193)

    Domain 5: Perception/Cognition

    • Unilateral Neglect (00123)
    • Impaired Environmental Interpretation Syndrome (00127)
    • Acute Confusion (00128)
    • Chronic Confusion (00129)
    • Risk for Acute Confusion (00173)
    • Ineffective Impulse Control (00222)
    • Deficient Knowledge (00126)
    • Readiness for Enhanced Knowledge (00161)
    • Impaired Memory (00131)
    • Readiness for Enhanced Communication (00157)
    • Impaired Verbal Communication (00051)

    Domain 6: Self-Perception

    • Hopelessness (00124)
    • Risk for Compromised Human Dignity (00174)
    • Risk for Loneliness (00054)
    • Disturbed Personal Identity (00121)
    • Risk for Disturbed Personal Identity (00225)
    • Readiness for Enhanced Self-Concept (00167)
    • Chronic Low Self-Esteem (00119)
    • Situational Low Self-Esteem (00120)
    • Risk for Chronic Low Self-Esteem (00224)
    • Risk for Situational Low Self-Esteem (00153)
    • Disturbed Body Image (00118)

    Domain 7: Role Relationships

    • Ineffective Breastfeeding (00104)
    • Interrupted Breastfeeding (00105)
    • Readiness for Enhanced Breastfeeding (00106)
    • Caregiver Role Strain (00061)
    • Risk for Caregiver Role Strain (00062)
    • Impaired Parenting (00056)
    • Readiness for Enhanced Parenting (00164)
    • Risk for Impaired Parenting (00057)
    • Risk for Impaired Attachment (00058)
    • Dysfunctional Family Processes (00063)
    • Interrupted Family Processes (00060)
    • Readiness for Enhanced Family Processes (00159)
    • Ineffective Relationship (00223)
    • Readiness for Enhanced Relationship (00207)
    • Risk for Ineffective Relationship (00229)
    • Parental Role Conflict (00064)
    • Ineffective Role Performance (00055)
    • Impaired Social Interaction (00052)

    Domain 8: Sexuality

    • Sexual Dysfunction (00059)
    • Ineffective Sexuality Pattern (00065)
    • Ineffective Childbearing Process (00221)
    • Readiness for Enhanced Childbearing Process (00208)
    • Risk for Ineffective Childbearing Process (00227)
    • Risk for Disturbed Maternal–Fetal Dyad (00209)

    Domain 9: Coping/Stress Tolerance

    • Post-Trauma Syndrome (00141)
    • Risk for Post-Trauma Syndrome (00145)
    • Rape-Trauma Syndrome (00142)
    • Relocation Stress Syndrome (00114)
    • Risk for Relocation Stress Syndrome (00149)
    • Ineffective Activity Planning (00199)
    • Risk for Ineffective Activity Planning (00226)
    • Anxiety (00146)
    • Defensive Coping (00071)
    • Ineffective Coping (00069)
    • Readiness for Enhanced Coping (00158)
    • Ineffective Community Coping (00077)
    • Readiness for Enhanced Community Coping (00076)
    • Compromised Family Coping (00074)
    • Disabled Family Coping (00073)
    • Readiness for Enhanced Family Coping (00075)
    • Death Anxiety (00147)
    • Ineffective Denial (00072)
    • Adult Failure to Thrive (00101)
    • Fear (00148)
    • Grieving (00136)
    • Complicated Grieving (00135)
    • Risk for Complicated Grieving (00172)
    • Readiness for Enhanced Power (00187)
    • Powerlessness (00125)
    • Risk for Powerlessness (00152)
    • Impaired Individual Resilience (00210)
    • Readiness for Enhanced Resilience (00212)
    • Risk for Compromised Resilience (00211)
    • Chronic Sorrow (00137)
    • Stress Overload (00177)
    • Autonomic Dysreflexia (00009)
    • Risk for Autonomic Dysreflexia (00010)
    • Disorganized Infant Behavior (00116)
    • Readiness for Enhanced Organized Infant Behavior (00117)
    • Risk for Disorganized Infant Behavior (00115)
    • Decreased Intracranial Adaptive Capacity (00049)

    Domain 10: Life Principles

    • Readiness for Enhanced Hope (00185)
    • Readiness for Enhanced Spiritual Well-Being (00068)
    • Readiness for Enhanced Decision-Making (00184)
    • Decisional Conflict (00083)
    • Moral Distress (00175)
    • Noncompliance (00079)
    • Impaired Religiosity (00169)
    • Readiness for Enhanced Religiosity (00171)
    • Risk for Impaired Religiosity (00170)
    • Spiritual Distress (00066)
    • Risk for Spiritual Distress (00067)

    Domain 11: Safety/Protection

    • Risk for Infection (00004)
    • Ineffective Airway Clearance (00031)
    • Risk for Aspiration (00039)
    • Risk for Bleeding (00206)
    • Impaired Dentition (00048)
    • Risk For Dry Eye (00219)
    • Risk for Falls (00155)
    • Risk for Injury (00035)
    • Impaired Oral Mucous Membrane (00045)
    • Risk for Perioperative Positioning Injury (00087)
    • Risk for Peripheral Neurovascular Dysfunction (00086)
    • Risk for Shock (00205)
    • Impaired Skin Integrity (00046)
    • Risk for Impaired Skin Integrity (00047)
    • Risk for Sudden Infant Death Syndrome (00156)
    • Risk for Suffocation (00036)
    • Delayed Surgical Recovery (00100)
    • Risk For Thermal Injury (00220)
    • Impaired Tissue Integrity (00044)
    • Risk for Trauma (00038)
    • Risk for Vascular Trauma (00213)
    • Risk for Other-Directed Violence (00138)
    • Risk for Self-Directed Violence (00140)
    • Self-Mutilation (00151)
    • Risk for Self-Mutilation (00139)
    • Risk for Suicide (00150)
    • Contamination (00181)
    • Risk for Contamination (00180)
    • Risk for Poisoning (00037)
    • Risk For Adverse Reaction to Iodinated Contrast Media (00218)
    • Latex Allergy Response (00041)
    • Risk For Allergy Response (00217)
    • Risk for Latex Allergy Response (00042)
    • Risk for Imbalanced Body Temperature (00005)
    • Hyperthermia (00007)
    • Hypothermia (00006)
    • Ineffective Thermoregulation (00008)

    Domain 12: Comfort

    • Impaired Comfort (00214)
    • Readiness for Enhanced Comfort (00183)
    • Nausea (00134)
    • Acute Pain (00132)
    • Chronic Pain (00133)
    • Social Isolation (00053)

    Domain 13: Growth/Development

    • Risk for Disproportionate Growth (00113)
    • Delayed Growth and Development (00111)
    • Risk for Delayed Development (00112)

    Nursing Diagnoses Retired from the NANDA-I Taxonomy 2009–2014

    • Health-seeking Behaviors (00084) – Retired 2009–2011
    • Disturbed Sensory Perception (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) (00122) – Retired 2012–2014

PART 4 NANDA International 2012–2014

    NANDA International Think Tank Meeting

    • Issues Related to the DDC
    • Globalization of the Taxonomy
    • Issues for Future Discussion and Research

    NANDA International Position Statements

    • NANDA-I Position Statement 1: The Use of Taxonomy II as an Assessment Framework
    • NANDA-I Position Statement 2: The Structure of the Nursing Diagnosis Statement When Included in a Care Plan

    The Process for Development of an Approved NANDA International Nursing Diagnosis

    • Axis 1: The Diagnostic Focus
    • Axis 2: Subject of the Diagnosis
    • Axis 3: Judgment
    • Axis 4: Location
    • Axis 5: Age
    • Axis 6: Time
    • Axis 7: Status of the Diagnosis
    • Label and Definition
    • Defining Characteristics versus Risk Factors
    • Related Factors
    • References

NANDA International Processes and Procedures

Glossary of Terms

NANDA International 2010–2012

An Invitation to Join NANDA International