Nanda - Nursing Diagnosis 2015 - 2017

1. DefinitionsandClassification NURSINGDIAGNOSES 20mm
2. NANDA International, Inc. NURSING DIAGNOSES: DEFINITIONS & CLASSIFICATION 2015–2017
3. NANDA International, Inc. NURSING DIAGNOSES: DEFINITIONS & CLASSIFICATION 2015–2017 Tenth Edition Edited by T. Heather Herdman, PhD, RN, FNI and Shigemi Kamitsuru, PhD, RN, FNI
4. This edition first published 2014 © 2014, 2012, 2009, 2007, 2005, 2003, 2001, 1998, 1996, 1994 by NANDA International, Inc. Registered Office John Wiley & Sons, Ltd., The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Offices 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 1606 Golden Aspen Drive, Suites 103 and 104, Ames, Iowa 50010, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. ISBN 9781118914939 ISSN 1943-0728 A catalogue record for this book is available from the Library of Congress and the British Library. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Cover image: iStockphoto / © alvarez Set in 10/12pt Meridien by SPi Publisher Services, Pondicherry, India 1 2014 Correct citation of this text (APA Format, based on the 6th Edition): Herdman, T.H. & Kamitsuru, S. (Eds.). (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. Oxford: Wiley Blackwell.
5. Contents v Contents NANDA International, Inc. Guidelines for Copyright Permission xix Preface xxii Introduction xxvi About the Companion Website xxviii PART 1 CHANGES TO THE NANDA INTERNATIONAL TERMINOLOGY 1 Introduction 3 T. Heather Herdman, RN, PhD, FNI What’s New in the 2015–2017 Edition of Diagnoses and Classification? Acknowledgments 4 Chapter authors 4 Chapter reviewers 5 Reviewer for standardization of diagnostic terms 5 Changes to health promotion and risk diagnoses 5 New nursing diagnoses, 2015–2017 5 Table 1.1 New NANDA-I Nursing Diagnoses, 2015–2017 6 Revised nursing diagnoses, 2015–2017 7 Table 1.2 Revised NANDA-I Nursing Diagnoses, 2015–2017 8 Changes to slotting of current diagnoses within the NANDA-I Taxonomy II, 2015–2017 11 Table 1.3 Slotting Changes to NANDA-I Nursing Diagnoses, 2015–2017 11 Revisions to nursing diagnosis labels within the NANDA-I Taxonomy II, 2015–2017 11 Nursing diagnoses removed from the NANDA-I Taxonomy II, 2015–2017 11 Table 1.4 Revisions to Nursing Diagnosis Labels of NANDA-I Nursing Diagnoses, 2015–2017 12 Standardization of diagnostic indicator terms 12
6. vi Contents Table 1.5 Nursing Diagnoses Removed from the NANDA-I Taxonomy II, 2015–2017 13 Other changes made in the 2015–2017 edition 15 PART 2 NURSING DIAGNOSIS 17 Chapter 1 Nursing Diagnosis Basics 21 Susan Gallagher-Lepak, RN, PhD Figure 1.1 Example of a Collaborative Healthcare Team 22 How does a nurse (or nursing student) diagnose? 23 Figure 1.2 The Modified Nursing Process 23 Understanding nursing concepts 24 Assessment 24 Nursing diagnosis 25 Table 1.1 Parts of a Nursing Diagnosis Label 25 Table 1.2 Key Terms at a Glance 26 Planning/intervention 27 Evaluation 28 Use of nursing diagnosis 28 Brief chapter summary 29 Questions commonly asked by new learners about nursing diagnosis 29 References 30 Chapter 2 From Assessment to Diagnosis 31 T. Heather Herdman, RN, PhD, FNI and Shigemi Kamitsuru, RN, PhD, FNI What happens during nursing assessment? 31 Figure 2.1 Steps in Moving from Assessment to Diagnosis 32 Why do nurses assess? 32 The screening assessment 33 Not a simple matter of “filling in the blanks” 34 Assessment framework 35 Should we use the NANDA-I taxonomy as an assessment framework? 35 Data analysis 35 Figure 2.2 Converting Data to Information 36 Subjective versus objective data 37 Clustering of information/seeing a pattern 38 Figure 2.3 The Modified Nursing Process 39 Identifying potential nursing diagnoses (diagnostic hypotheses) 39 In-depth assessment 41 Figure 2.4 In-Depth Assessment 42
7. Contents vii Confirming/refuting potential nursing diagnoses 43 Eliminating possible diagnoses 43 Potential new diagnoses 44 Differentiating between similar diagnoses 44 Table 2.1 The Case of Caroline: A Comparison of Identified Defining Characteristics and Related Factors 45 Table 2.2 The Case of Caroline: A Comparison of Domains and Classes of Potential Diagnoses 47 Figure 2.5 SEA TOW: A Thinking Tool for Diagnostic Decision-Making 48 Making a diagnosis/prioritizing 49 Summary 50 References 50 Chapter 3 An Introduction to the NANDA-I Taxonomy 52 T. Heather Herdman, RN, PhD, FNI Taxonomy: Visualizing a taxonomic structure 52 Figure 3.1 Domains and Classes of Classified Groceries, Inc. 54 Figure 3.2 Classes and Concepts of Classified Groceries, Inc. 55 Classification in nursing 56 Figure 3.3 NANDA-I Taxonomy II Domains and Classes 58 Figure 3.4 NANDA-I Domain 1, Health Promotion, with Classes and Nursing Diagnoses 60 Using the NANDA-I taxonomy 60 Structuring nursing curricula 60 Figure 3.5 NANDA-I Taxonomy II Activity/Rest Domain 61 Identifying a nursing diagnosis outside your area of expertise 62 Figure 3.6 Use of the NANDA-I Taxonomy II and Terminology to Identify and Validate a Nursing Diagnosis Outside the Nurse’s Area of Expertise 63 Case Study: Mrs. Lendo 64 Figure 3.7 Diagnosing Mrs. Lendo 65 The NANDA-I nursing diagnosis taxonomy: A short history 65 Table 3.1 Domains, Classes, and Nursing Diagnoses in the NANDA-I Taxonomy II 66
8. viii Contents Figure 3.8 Seven Domains of the Proposed Taxonomy III 79 Figure 3.9 Proposed Taxonomy III Domains and Classes 80 Table 3.2 Proposed Taxonomy III Domains, Classes, and Nursing Diagnoses 81 References 90 Chapter 4 NANDA-I Taxonomy II: Specifications and Definitions 91 T. Heather Herdman, RN, PhD, FNI Structure of Taxonomy II 91 Figure 4.1 The ISO Reference Terminology Model for a Nursing Diagnosis 92 A multiaxial system for constructing diagnostic concepts 92 Figure 4.2 The NANDA-I Model of a Nursing Diagnosis 93 Definitions of the axes 94 Axis 1 The focus of the diagnosis 94 Table 4.1 Foci of the NANDA-I Nursing Diagnoses 95 Axis 2 Subject of the diagnosis 97 Axis 3 Judgment 97 Axis 4 Location 97 Table 4.2 Definitions of Judgment Terms for Axis 3, NANDA-I Taxonomy II 98 Table 4.3 Locations in Axis 4, NANDA-I Taxonomy II 100 Axis 5 Age 100 Axis 6 Time 100 Axis 7 Status of the diagnosis 100 Developing and submitting a nursing diagnosis 101 Figure 4.3 A NANDA-I Nursing Diagnosis Model: (Individual) Impaired Standing 101 Figure 4.4 A NANDA-I Nursing Diagnosis Model: Risk for Disorganized Infant Behavior 102 Figure 4.5 A NANDA-I Nursing Diagnosis Model: Readiness for Enhanced Family Coping 102 Further development 103 References 103 Other recommended reading 104 Chapter 5 Frequently Asked Questions 105 T. Heather Herdman, RN, PhD, FNI and Shigemi Kamitsuru, RN, PhD, FNI Basic questions about standardized nursing languages 105 Basic questions about NANDA-I 106
9. Contents ix Basic questions about nursing diagnoses 110 Questions about defining characteristics 116 Questions about related factors 117 Questions about risk factors 118 Differentiating between similar nursing diagnoses 119 Questions regarding the development of a treatment plan 121 Questions about teaching/learning nursing diagnoses 123 Questions about using NANDA-I in electronic health records 126 Questions about diagnosis development and review 127 Questions about the NANDA-I Definitions and Classification text 127 References 129 PART 3 THE NANDA INTERNATIONAL NURSING DIAGNOSES 131 International Considerations on the use of the NANDA-I Nursing Diagnoses 133 T. Heather Herdman, RN, PhD, FNI Domain 1: Health Promotion 137 Class 1. Health awareness 139 Deficient diversional activity – 00097 139 Sedentary lifestyle – 00168 140 Class 2. Health management 141 Frail elderly syndrome – 00257 141 Risk for frail elderly syndrome – 00231 142 Deficient community health – 00215 144 Risk-prone health behavior – 00188 145 Ineffective health maintenance – 00099 146 Ineffective health management – 00078 147 Readiness for enhanced health management – 00162 148 Ineffective family health management – 00080 149 Noncompliance – 00079 150 Ineffective protection – 00043 152 Domain 2: Nutrition 153 Class 1. Ingestion 155 Insufficient breast milk – 00216 155 Ineffective breastfeeding – 00104 156 Interrupted breastfeeding – 00105 158 Readiness for enhanced breastfeeding – 00106 159
10. x Contents Ineffective infant feeding pattern – 00107 160 Imbalanced nutrition: less than body requirements – 00002 161 Readiness for enhanced nutrition – 00163 162 Obesity – 00232 163 Overweight – 00233 165 Risk for overweight – 00234 167 Impaired swallowing – 00103 169 Class 2. Digestion None at present time Class 3. Absorption None at present time Class 4. Metabolism 171 Risk for unstable blood glucose level – 00179 171 Neonatal jaundice – 00194 172 Risk for neonatal jaundice – 00230 173 Risk for impaired liver function – 00178 174 Class 5. Hydration 175 Risk for electrolyte imbalance – 00195 175 Readiness for enhanced fluid balance – 00160 176 Deficient fluid volume – 00027 177 Risk for deficient fluid volume – 00028 178 Excess fluid volume – 00026 179 Risk for imbalanced fluid volume – 00025 180 Domain 3: Elimination and Exchange 181 Class 1. Urinary function 183 Impaired urinary elimination – 00016 183 Readiness for enhanced urinary elimination – 00166 184 Functional urinary incontinence – 00020 185 Overflow urinary incontinence – 00176 186 Reflex urinary incontinence – 00018 187 Stress urinary incontinence – 00017 188 Urge urinary incontinence – 00019 189 Risk for urge urinary incontinence – 00022 190 Urinary retention – 00023 191 Class 2. Gastrointestinal function 192 Constipation – 00011 192 Risk for constipation – 00015 194 Chronic functional constipation – 00235 196 Risk for chronic functional constipation – 00236 198 Perceived constipation – 00012 199 Diarrhea – 00013 200
11. Contents xi Dysfunctional gastrointestinal motility – 00196 201 Risk for dysfunctional gastrointestinal motility – 00197 202 Bowel incontinence – 00014 203 Class 3. Integumentary function None at this time Class 4. Respiratory function 204 Impaired gas exchange – 00030 204 Domain 4: Activity/Rest 205 Class 1. Sleep/rest 209 Insomnia – 00095 209 Sleep deprivation – 00096 210 Readiness for enhanced sleep – 00165 212 Disturbed sleep pattern – 00198 213 Class 2. Activity/exercise 214 Risk for disuse syndrome – 00040 214 Impaired bed mobility – 00091 215 Impaired physical mobility – 00085 216 Impaired wheelchair mobility – 00089 218 Impaired sitting – 00237 219 Impaired standing – 00238 220 Impaired transfer ability – 00090 221 Impaired walking – 00088 222 Class 3. Energy balance 223 Fatigue – 00093 223 Wandering – 00154 224 Class 4. Cardiovascular/pulmonary responses 225 Activity intolerance – 00092 225 Risk for activity intolerance – 00094 226 Ineffective breathing pattern – 00032 227 Decreased cardiac output – 00029 228 Risk for decreased cardiac output – 00240 230 Risk for impaired cardiovascular function – 00239 231 Risk for ineffective gastrointestinal perfusion – 00202 232 Risk for ineffective renal perfusion – 00203 233 Impaired spontaneous ventilation – 00033 234 Risk for decreased cardiac tissue perfusion – 00200 235 Risk for ineffective cerebral tissue perfusion – 00201 236 Ineffective peripheral tissue perfusion – 00204 237 Risk for ineffective peripheral tissue perfusion – 00228 238
12. xii Contents Dysfunctional ventilatory weaning response – 00034 239 Class 5. Self-care 241 Impaired home maintenance – 00098 241 Bathing self-care deficit – 00108 242 Dressing self-care deficit – 00109 243 Feeding self-care deficit – 00102 244 Toileting self-care deficit – 00110 245 Readiness for enhanced self-care – 00182 246 Self-neglect – 00193 247 Domain 5: Perception/Cognition 249 Class 1. Attention 251 Unilateral neglect – 00123 251 Class 2. Orientation None at this time Class 3. Sensation/perception None at this time Class 4. Cognition 252 Acute confusion – 00128 252 Risk for acute confusion – 00173 253 Chronic confusion – 00129 254 Labile emotional control – 00251 255 Ineffective impulse control – 00222 256 Deficient knowledge – 00126 257 Readiness for enhanced knowledge – 00161 258 Impaired memory – 00131 259 Class 5. Communication 260 Readiness for enhanced communication – 00157 260 Impaired verbal communication – 00051 261 Domain 6: Self-Perception 263 Class 1. Self-concept 265 Readiness for enhanced hope – 00185 265 Hopelessness – 00124 266 Risk for compromised human dignity – 00174 267 Disturbed personal identity – 00121 268 Risk for disturbed personal identity – 00225 269 Readiness for enhanced self-concept – 00167 270 Class 2. Self-esteem 271 Chronic low self-esteem – 00119 271 Risk for chronic low self-esteem – 00224 272 Situational low self-esteem – 00120 273
13. Contents xiii Risk for situational low self-esteem – 00153 274 Class 3. Body image 275 Disturbed body image – 00118 275 Domain 7: Role Relationships 277 Class 1. Caregiving roles 279 Caregiver role strain – 00061 279 Risk for caregiver role strain – 00062 282 Impaired parenting – 00056 283 Readiness for enhanced parenting – 00164 286 Risk for impaired parenting – 00057 287 Class 2. Family relationships 289 Risk for impaired attachment – 00058 289 Dysfunctional family processes – 00063 290 Interrupted family processes – 00060 293 Readiness for enhanced family processes – 00159 294 Class 3. Role performance 295 Ineffective relationship – 00223 295 Readiness for enhanced relationship – 00207 296 Risk for ineffective relationship – 00229 297 Parental role conflict – 00064 298 Ineffective role performance – 00055 299 Impaired social interaction – 00052 301 Domain 8: Sexuality 303 Class 1. Sexual identity None at present time Class 2. Sexual function 305 Sexual dysfunction – 00059 305 Ineffective sexuality pattern – 00065 306 Class 3. Reproduction 307 Ineffective childbearing process – 00221 307 Readiness for enhanced childbearing process – 00208 309 Risk for ineffective childbearing process – 00227 310 Risk for disturbed maternal–fetal dyad – 00209 311 Domain 9: Coping/Stress Tolerance 313 Class 1. Post-trauma responses 315 Post-trauma syndrome – 00141 315 Risk for post-trauma syndrome – 00145 317 Rape-trauma syndrome – 00142 318
14. xiv Contents Relocation stress syndrome – 00114 319 Risk for relocation stress syndrome – 00149 320 Class 2. Coping responses 321 Ineffective activity planning – 00199 321 Risk for ineffective activity planning – 00226 322 Anxiety – 00146 323 Defensive coping – 00071 325 Ineffective coping – 00069 326 Readiness for enhanced coping – 00158 327 Ineffective community coping – 00077 328 Readiness for enhanced community coping – 00076 329 Compromised family coping – 00074 330 Disabled family coping – 00073 332 Readiness for enhanced family coping – 00075 333 Death anxiety – 00147 334 Ineffective denial – 00072 335 Fear – 00148 336 Grieving – 00136 338 Complicated grieving – 00135 339 Risk for complicated grieving – 00172 340 Impaired mood regulation – 00241 341 Readiness for enhanced power – 00187 342 Powerlessness – 00125 343 Risk for powerlessness – 00152 344 Impaired resilience – 00210 345 Readiness for enhanced resilience – 00212 346 Risk for impaired resilience – 00211 347 Chronic sorrow – 00137 348 Stress overload – 00177 349 Class 3. Neurobehavioral stress 350 Decreased intracranial adaptive capacity – 00049 350 Autonomic dysreflexia – 00009 351 Risk for autonomic dysreflexia – 00010 352 Disorganized infant behavior – 00116 354 Readiness for enhanced organized infant behavior – 00117 356 Risk for disorganized infant behavior – 00115 357 Domain 10: Life Principles 359 Class 1. Values None at this time Class 2. Beliefs 361 Readiness for enhanced spiritual well-being – 00068 361
15. Contents xv Class 3. Value/belief/action congruence 363 Readiness for enhanced decision-making – 00184 363 Decisional conflict – 00083 364 Impaired emancipated decision-making – 00242 365 Readiness for enhanced emancipated decision-making – 00243 366 Risk for impaired emancipated decision-making – 00244 367 Moral distress – 00175 368 Impaired religiosity – 00169 369 Readiness for enhanced religiosity – 00171 370 Risk for impaired religiosity – 00170 371 Spiritual distress – 00066 372 Risk for spiritual distress – 00067 374 Domain 11: Safety/Protection 375 Class 1. Infection 379 Risk for infection – 00004 379 Class 2. Physical injury 380 Ineffective airway clearance – 00031 380 Risk for aspiration – 00039 381 Risk for bleeding – 00206 382 Risk for dry eye – 00219 383 Risk for falls – 00155 384 Risk for injury – 00035 386 Risk for corneal injury – 00245 387 Risk for perioperative positioning injury – 00087 388 Risk for thermal injury – 00220 389 Risk for urinary tract injury – 00250 390 Impaired dentition – 00048 391 Impaired oral mucous membrane – 00045 392 Risk for impaired oral mucous membrane – 00247 394 Risk for peripheral neurovascular dysfunction – 00086 395 Risk for pressure ulcer – 00249 396 Risk for shock – 00205 398 Impaired skin integrity – 00046 399 Risk for impaired skin integrity – 00047 400 Risk for sudden infant death syndrome – 00156 401 Risk for suffocation – 00036 402 Delayed surgical recovery – 00100 403
16. xvi Contents Risk for delayed surgical recovery – 00246 404 Impaired tissue integrity – 00044 405 Risk for impaired tissue integrity – 00248 406 Risk for trauma – 00038 407 Risk for vascular trauma – 00213 409 Class 3. Violence 410 Risk for other-directed violence – 00138 410 Risk for self-directed violence – 00140 411 Self-mutilation – 00151 412 Risk for self-mutilation – 00139 414 Risk for suicide – 00150 416 Class 4. Environmental hazards 418 Contamination – 00181 418 Risk for contamination – 00180 420 Risk for poisoning – 00037 421 Class 5. Defensive processes 422 Risk for adverse reaction to iodinated contrast media – 00218 422 Risk for allergy response – 00217 423 Latex allergy response – 00041 424 Risk for latex allergy response – 00042 425 Class 6. Thermoregulation 426 Risk for imbalanced body temperature – 00005 426 Hyperthermia – 00007 427 Hypothermia – 00006 428 Risk for hypothermia – 00253 430 Risk for perioperative hypothermia – 00254 432 Ineffective thermoregulation – 00008 433 Domain 12: Comfort 435 Class 1. Physical comfort 437 Impaired comfort – 00214 437 Readiness for enhanced comfort – 00183 438 Nausea – 00134 439 Acute pain – 00132 440 Chronic pain – 00133 442 Labor pain – 00256 444 Chronic pain syndrome – 00255 445 Class 2. Environmental comfort 437 Impaired comfort – 00214 437 Readiness for enhanced comfort – 00183 438 Class 3. Social comfort 437 Impaired comfort – 00214 437
17. Contents xvii Readiness for enhanced comfort – 00183 438 Risk for loneliness – 00054 446 Social isolation – 00053 447 Domain 13: Growth/Development 449 Class 1. Growth 451 Risk for disproportionate growth – 00113 451 Class 2. Development 452 Risk for delayed development – 00112 452 Nursing Diagnoses Accepted for Development and Clinical Validation 2015–2017 455 Disturbed energy field – 00050 455 PART 4 NANDA INTERNATIONAL, INC. 2015–2017 457 NANDA International Position Statements 459 The use of Taxonomy II as an assessment framework 459 The structure of the Nursing Diagnosis statement when included in a care plan 459 NANDA International Processes and Procedures for Diagnosis Submission and Review 461 NANDA-I Diagnosis Submission: Level of evidence criteria 461 Glossary of Terms 464 Nursing diagnosis 464 Diagnostic axes 465 Components of a nursing diagnosis 467 Definitions for classification of nursing diagnoses 468 References 469 An Invitation to Join NANDA International 470 NANDA International: A Member-Driven Organization 470 Our vision 470 Our mission 470 Our purpose 470 Our history 471
18. xviii Contents NANDA International’s Commitment 471 Involvement Opportunities 472 Why join NANDA-I? 472 Who is using the NANDA International Taxonomy? 473 Index 475 Visit the companion website for this book at www.wiley.com/ go/nursingdiagnoses
19. NANDA International, Inc. Guidelines for Copyright Permission The materials presented in this book are copyrighted and all copyright laws apply. For any usage other than reading or consulting the book in the English language, a licence is required from Wiley. Examples of such reuse include but are not restricted to: ■ A publishing house, other organization, or individual wishing to translate the entire book, or parts thereof. ■ An author or publishing house wishing to use the entire nursing diagnosis taxonomy, or parts thereof, in a commercially available textbook or nursing manual. ■ An author or company wishing to use the nursing diagnosis taxonomy in audio-visual materials. ■ A software developer or computer-based patient record vendor wishing to use the nursing diagnosis taxonomy in English in a software program or application (for example, an electronic health record, an e-learning course, or an electronic application for a smartphone or other electronic device). ■ A nursing school, researcher, professional organization, or health- care organization wishing to use the nursing diagnosis taxonomy in an educational program. ■ A researcher wishing to use the taxonomy for non-commercial academic research purposes. Please be aware that the proposal will be submitted by Wiley to NANDA-I for approval before permission is granted. Researchers are encouraged to submit the outcomes of their research to the International Journal of Nursing Knowledge, and to present the results at a NANDA-I conference, as appropriate. ■ A hospital wishing to integrate the nursing diagnosis taxonomy into their own electronic health records. ■ Any of the usages outlined above in a language other than English. NANDA International, Inc. Guidelines for Copyright Permission xix
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22. Preface The 2015–2017 edition of the classic NANDA International, Inc. text, Nursing Diagnoses: Definitions & Classification, provides more clinically applicable diagnoses as a result of the Diagnostic Development Committee’s attentiveness to the potential translations of the diagnos- tic label, definition, defining characteristics, related factors, and risk factors. In the past, a number of nurses asked about the applicability of our work in their own countries and jurisdiction. Changes within the 2015–2017 edition have been implemented to incorporate the diversity and practice differences across the world. The latest edition is not only considered a language, but, truthfully, it is a body of nursing knowledge. These new and revised diagnoses are based on the state of evidence around the world, and they are submitted by nurses, reviewed and revised by nurses, and approved by expert nurse diagnosticians, researchers, and educators. The latest edition enhances the cultural applicability with 25 new nursing diagnoses and 13 revised diagnoses. Additionally, the text includes changes to the official NANDA-I nursing diagnosis category definitions (problem-focused, risk, health promo- tion), and the overall nursing diagnosis definition. NANDA International, Inc. (NANDA-I) is a not-for-profit member- ship organization. This means that with the exception of our business management and administration functions, all of our work is accom- plished by volunteers. Some of the world’s most talented nurse scientists and scholars are or have been NANDA-I volunteers. Contrary to most business entities, there is not an office somewhere with nurse researchers working on nursing diagnoses. The volunteers are people like you and me who give their time and expertise to NANDA-I, because of their strongly held beliefs about the importance of patient care and the contributions that nursing and nurses can and do make to society. With the publication of each new edition of our work, more transla- tions are added. I am delighted that the work is published in numer- ous languages for this international membership organization. Our relationship with our publishing partner, Wiley Blackwell, has evolved over the past five years. One of the arrangements is to ensure that each and every translation is accurate and exact. Together with our publishers, we now have a robust quality assurance mechanism in place to ensure the accuracy of each translation. The source document for each translation is always this, the American English version. We are deeply committed to ensuring the integrity of our work worldwide xxii Preface
23. Preface xxiii and invite you to support us in this quest in order to improve patient safety and the consistency of high-quality evidence-based care. As a not- for-profit organization, we obviously need an income to run the organiza- tion, facilitate meetings of our committees and Board of Directors, sponsor our website and knowledge base, and support educational offerings and conferences throughout the world, and this comes from the licenses we sell for the publishing and use of our work in electronic form. For the first time this year, we will be offering an electronic application of the NANDA-I terminology, complete with an assessment feature and decision support for some of the most commonly used diagnoses. This type of work, too, requires funding for development and testing. As an international organization, we truly value cultural diversity and practice differences. However, as the provider of the world’s most success- ful standardized nursing diagnostic language and knowledge, we have a duty to provide you with exactly that: standardized nursing diagnostic knowledge. We do not support changing diagnoses at the request of trans- lators or clinical specialists in just one edition in a particular language, when diagnosis lacks applicability in that particular culture. This is because we are deeply committed to realizing the clinical benefits of nursing diag- nostic knowledge content for diverse cultures and specialties. We do not believe that we should be supporting the censorship of clinical informa- tion in this text. As a registered nurse you are accountable for appropriate diagnosis, and the use of appropriate terms, within your practice. Clearly, it would be inappropriate for all of us to use each and every one of the diagnoses in this edition, because none of us could claim competence in every sphere of nursing practice simultaneously. Clinically safe nurses are reflective practitioners; a central component to safe practice is to thor- oughly understand one’s own clinical competence. It is highly likely that there are numerous diagnoses in this edition that you will never use in your own practice; others you may use daily. This also links to the issue of cultural applicability because if, when studying this edition, you find a diagnosis that is not applicable to your practice or culture, it is within your gift simply not to use it. However, based on my own varied clinical experi- ences as a registered nurse, I would implore you to not ignore completely those diagnoses that might at first seem culturally awkward. We live in a transcultural and highly mobile society, and exploring those diagnoses that might initially seem unusual can challenge your thinking and open up new possibilities and understanding. This is all part of being a reflective and life-long learning practitioner. Each diagnosis has been the product of one or more of our NANDA-I volunteers or NANDA-I users, and most have a defined evidence base. Each and every new and revised diagnosis will have been refined and debated by our DDC members before finally being submitted to NANDA-I members for a vote of approval. Only if our members vote positively for the inclusion of a new or refined diagnosis does the work
24. xxiv Preface “make it” into the published edition. However, if you feel that a particular diagnosis is incorrect and requires revision, we welcome your views. You should contact the chair of the DDC through our web- site. Please provide as much evidence as possible to support your views. By working in this way, rather than changing just one translation or edition, we can ensure that our nursing diagnostic knowledge contin- ues to have integrity and consistency, and that all benefit from the wisdom and work of individual scholars. We welcome you to submit new diagnoses, as well as revisions to current diagnoses, by using the submission guidelines found on our website. One of the key membership developments in the past few years has been educational content published by Artmed/Panamericana Editora Ltda. (Porto Alegre, Brazil), which compiles educational modules, published in Portuguese, known as PRONANDA. A similar offering will soon be provided in Spanish. Other developments are the NANDA-I database for researchers and others needing to design electronic content. The Educational and Research Committee is preparing new educational materials to help with the educational process. The aim of this new edition of our book is to support those learning to diagnose, and to enable decision-makers to have access to information about diagnoses that describe the problems, risks, and health promotion needs of persons, families, groups, and communi- ties. I personally was very interested in membership of NANDA-I because the body of nursing knowledge content is essential in the design of clinical decision support logic for electronic health record systems and for data analysis. 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 and enthusiasm, and ongoing support. I want to thank our staff, led by our CEO/Executive Director, Dr. T. Heather Herdman, for its efforts and support. I appreciate the publishing partnership with Wiley-Blackwell as well as our translation and global publishing partners, which support the dissemination of knowledge content and the database developed by NANDA-I. My special thanks to the members of the Diagnosis Development Committee for their outstanding and timely efforts to review and edit the diagnoses that are the core portion of this book, and especially for the leadership of the DDC by our Chair since 2010, Dr. Shigemi Kamitsuru. This wonderful committee, with representation from North and Latin America, Europe, and Asia, is the true “power house” of the NANDA-I knowledge content, and I am deeply impressed and pleased by the aston- ishingly comprehensive work of these volunteers over the years. Finally, when I first learned about and learned to use nursing diagnoses 30 years ago, I never imagined that I would one day be the President of NANDA-I, setting the agenda for this incredible body of
25. Preface xxv nursing knowledge. I welcomed the opportunity to volunteer for NANDA-I, because I found value in supporting the advancement of meaningful and useful knowledge to support nurses and students of nursing. All registered nurses and advanced practice nurses are making clinical decisions within practice, education, administration of critical thinking processes, and informatics clinical decision support system designs. For these reasons, NANDA International, Inc. has had, and continues to have, a role in improving the quality of evidence-based care and the safety of patient care, and remains the core base of knowledge for nursing professionals. Jane M. Brokel, PhD, RN, FNI President, NANDA International, Inc.
26. Introduction This book is divided into four parts: ■ Part 1 provides the introduction to the NANDA International, Inc. (NANDA-I) Taxonomy of Nursing Diagnoses. Taxonomy II organizes the diagnoses into domains and classes. Information is provided on diagnoses that are new to, or were removed from, the taxonomy during the past review cycle. ■ Part 2 provides chapters on the basics of nursing diagnosis, assessment, and clinical judgment. These chapters are primarily written for students, clinicians, and educators. The accompanying website includes educational materials designed to support students and faculty in understanding and teaching this material. Changes to the chapters were made based on incredibly helpful feedback received from readers around the world, and questions that we receive on a daily basis at NANDA International, Inc. ■ Part 3 provides the core contents of the NANDA International Nursing Diagnoses: Definitions & Classification book: the 235 diagnoses them- selves, including definitions, defining characteristics, risk factors, and related factors, as appropriate. The diagnoses are categorized using Taxonomy II, and ordered by Domain first, then Class, and then alphabetically within each class (in the English language) by the focus of each diagnosis. We recommend that all translations maintain this order, (Domain, class, alphabetic order in their own language), to facilitate ease of discussion between inter-language groups. ■ Part 4 includes information that relates specifically to NANDA International. Information on processes and procedures related to review of NANDA-I diagnoses, the submission process, and level of evidence criteria are provided. A glossary of terms is given. Finally, information specific to the organization and the benefits of member- ship are outlined. How to Use This Book As noted above, the nursing diagnoses are listed by Domain first, then by Class, and then alphabetically within each class (in the English language) by the focus of each diagnosis. For example, Impaired standing is listed under Domain 4 (Activity / Rest), Class 2 (Activity / Exercise): xxvi Introduction
27. Introduction xxvii Domain 4: Activity / Rest Class 2: Activity / Exercise Impaired standing (00238) It is our hope that the organization of NANDA-I Nursing Diagnoses: Definitions & Classification, 2015–2017 will make it efficient and effective to use. We welcome your feedback. If you have suggestions, please send them by email to: execdir@nanda.org.
28. xxviii About the Companion Website About the Companion Website This book is accompanied by a companion website: www.wiley.com/go/nursingdiagnoses The website includes: ■ Videos ■ References ■ Weblinks
29. NANDA International, Inc. Nursing Diagnoses: Definitions & Classification 2015–2017, Tenth Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru. © 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/nursingdiagnoses Changes to the NANDA International Terminology Part 1 Introduction 3 What’s New in the 2015–2017 Edition of Diagnoses and Classification? 4 Acknowledgments 4 Changes to Health Promotion and Risk Diagnoses 5 New Nursing Diagnoses, 2015–2017 5 Revised Nursing Diagnoses, 2015–2017 7 Changes to Slotting of Current Diagnoses within the NANDA-I Taxonomy II, 2015–2017 11 Revisions to Nursing Diagnosis Labels within the NANDA-I Taxonomy II, 2015–2017 11 Nursing Diagnoses Removed from the NANDA-I Taxonomy II, 2015–2017 11 Standardization of Diagnostic Indicator Terms 12 Other Changes Made in the 2015–2017 Edition 15
30. Introduction T. Heather Herdman, RN, PhD, FNI In this section, introductory information on the new edition of the NANDA International Taxonomy, 2015–2017 is presented. This includes an overview of major changes to this edition: new and revised diagnoses, changes to slotting within the taxonomy, changes to diagnostic labels, and diagnoses that were removed or retired. Those individuals and groups who submitted new or revised diagnoses for approval are identified. A historical perspective on submitters to the complete NANDA-I terminology, which was devel- oped by Betty Ackley for the previous edition of this book, has been updated to include this information, and is now available on our web- site, at www.nanda.org. A description of editorial changes is also provided; readers will note that nearly every diagnosis has some changes as we have worked to increase the standardization of the terms used within our diagnostic indicators (defining characteristics, related factors, risk factors). I would like to offer a particularly significant note of appreciation to Dr. Susan Gallagher-Lepak, of the University of Wisconsin – Green Bay College of Professional Studies, who worked with me over a period of several months to standardize these terms. Additional thanks go to my co-editor, Dr. Shigemi Kamitsuru, who further reviewed and revised our work, which then came full circle back to us for consensus. This process has been a daunting one, with more than 5,600 individual terms requiring review! However, the standardization of these terms has now enabled the coding of all of the diagnostic indicator terms, facilitating their use as assessment data within electronic health records, leading to the development within those records of critical clinical decision support tools for professional nurses. These codes are now available on the NANDA-I website. NANDA International, Inc. Nursing Diagnoses: Definitions & Classification 2015–2017, Tenth Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru. © 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/nursingdiagnoses
31. NANDA International, Inc. Nursing Diagnoses: Definitions & Classification 2015–2017, Tenth Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru. © 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/nursingdiagnoses What’s New in the 2015–2017 Edition ofDiagnoses and Classification? Changes have been made in this edition based on feedback from users, to address the needs of both students and clinicians, as well as to provide additional support to educators. All of the chapters are new for this edition, with the exception of the chapter NANDA-I Taxonomy: Specifications and Definitions, which provides a revision of that found in the previous edition. There are corresponding web-based presentations available for teachers and students that augment the information found within the chapters; icons appear in chapters that have these accompanying support tools. A new chapter, focusing on Frequently Asked Questions, is included. These questions represent the most common questions we receive through the NANDA-I website, and when we present at conferences around the globe. Acknowledgments It goes without saying that the dedication of several individuals to the work of NANDA International, Inc. (NANDA-I) is evident in their donation of time and effort to the improvement of the NANDA-I terminology and taxonomy. This text represents the culmination of the tireless volunteer work of a group of very dedicated, extremely talented individuals who have developed, revised, and studied nursing diagnoses for more than 40 years. Additionally, we would like to take the opportunity to acknowledge and personally thank the following individuals for their contributions to this particular edition of the NANDA-I text. Chapter Authors ■ The Basics of Nursing Diagnosis – Susan Gallagher-Lepak, PhD, RN
32. Changes to the NANDA International Terminology 5 Chapter Reviewers ■ An introduction to the NANDA-I taxonomy – Kay Avant, PhD, RN, FNI, FAAN; Gunn von Krogh, RN, PhD Reviewer for Standardization of Diagnostic Terms ■ Susan Gallagher-Lepak, PhD, RN Please contact us at execdir@nanda.org if you have questions on any of the content or if you find errors, so that these may be corrected for future publication and translation. T. Heather Herdman, PhD, RN, FNI Shigemi Kamitsuru, PhD, RN, FNI Editors NANDA International, Inc. Changes to Health Promotion and Risk Diagnoses The overall definitions for nursing diagnoses were changed during this cycle. These changes had impacts on the way in which current risk and health promotion diagnoses should be defined, so you will note changes to every definition of these diagnoses. These changes were presented to the NANDA-I membership, and approved via online voting. The risk diagnoses were changed to eliminate “risk” from the definition, which has now been replaced by the use of the word “vulnerable.” The health promotion diagnoses were changed to ensure that the definitions reflected that these diagnoses are appropriate for use at any stage in the health–illness continuum, and that a state of balance or health is not required. Similarly, defining characteristics of these diagnoses needed to change, as in many cases they represented healthy, stable states. All of the defining characteristics now begin with the phrase “Expresses the desire to enhance,” because health promotion requires the willingness of the patient to improve upon his current status, whatever that might be. New Nursing Diagnoses, 2015–2017 A significant body of work representing new and revised nursing diagnoses was submitted to the NANDA-I Diagnosis Development Committee, with a substantial portion of that work being presented to
33. 6 Nursing Diagnoses 2015–2017 the NANDA-I membership for consideration in this review cycle. NANDA-I would like to take this opportunity to congratulate those submitters who successfully met the level of evidence criteria with their submissions and/or revisions. Twenty-five new diagnoses were approved by the Diagnosis Development Committee, the NANDA-I Board of Directors, and the NANDA-I membership (Table I.1). Table I.1 New NANDA-I Nursing Diagnoses, 2015–2017 Approved diagnosis (New) Submitter(s) Domain 1. Health Promotion Frail elderly syndrome Margarita Garrido Abejar; Mª Dolores Serrano Parra; Rosa Mª Fuentes Chacón Risk for frail elderly syndrome Margarita Garrido Abejar; Mª Dolores Serrano Parra; Rosa Mª Fuentes Chacón Domain 2. Nutrition Risk for overweight T. Heather Herdman, PhD, RN, FNI Overweight T. Heather Herdman, PhD, RN, FNI Obesity T. Heather Herdman, PhD, RN, FNI Domain 3. Elimination and Exchange Chronic functional constipation T. Heather Herdman, PhD, RN, FNI Domain 4. Activity / Rest Impaired sitting Christian Heering, EdN, RN Impaired standing Christian Heering, EdN, RN Risk for decreased cardiac output Eduarda Ribeiro dos Santos, PhD, RN; Vera Lúcia Regina Maria, PhD, RN; Mariana Fernandes de Souza, PhD, RN; Maria Gaby Rivero de Gutierrez, PhD, RN; Alba Lúcia Bottura Leite de Barros, PhD, RN Risk for impaired cardiovascular function María Begoña Sánchez Gómez PhD(c), RN; Gonzalo Duarte Clíments PhD(c), RN Domain 9. Coping / Stress Tolerance Impaired mood regulation Heidi Bjørge, MnSc, RN Domain 10. Life Principles Impaired emancipated decision-making Ruth Wittmann-Price, PhD, RN Readiness for enhanced emancipated decision-making Ruth Wittmann-Price, PhD, RN Risk for impaired emancipated decision-making Ruth Wittmann-Price, PhD, RN
34. Changes to the NANDA International Terminology 7 Revised Nursing Diagnoses, 2015–2017 Thirteen diagnoses were revised during this cycle; five were approved by the DDC through the expedited review process and eight were revised through the standard review process. Table I.2 shows those Table I.1 Continued Approved diagnosis (New) Submitter(s) Domain 11. Safety / Protection Risk for corneal injury Andreza Werli-Alvarenga, PhD, RN; Tânia Couto Machado Chianca, PhD, RN; Flávia Falci Ercole, PhD, RN Risk for impaired oral mucous membrane Emilia Campos de Carvalho, PhD, RN; Cristina Mara Zamarioli, RN; Ana Paula Neroni Stina, RN; Vanessa dos Santos Ribeiro, undergraduate student; Sheila Ramalho Coelho Vasconcelos de Morais, MNSc, RN Risk for pressure ulcer T. Heather Herdman, PhD, RN, FNI; Cássia Teixeira dos Santos MSN, RN; Miriam de Abreu Almeida PhD, RN; Amália de Fátima Lucena PhD, RN Risk for delayed surgical recovery Rosimere Ferreira Santana, PhD, RN; Dayana Medeiros do Amaral, BSN; Shimmenes Kamacael Pereira, MSN, RN; Tallita Mello Delphino, MSN, RN; Deborah Marinho da Silva, BSN; Thais da Silva Soares, BSN Risk for impaired tissue integrity Katiucia Martins Barros MS, RN; Daclé Vilma Carvalho, PhD, RN Risk for urinary tract injury Danielle Cristina Garbuio, MS; Elaine Santos, MS, RN; Emília Campos de Carvalho, PhD, RN; Tânia Couto Machado Chianca, PhD, RN; Anamaria Alves Napoleão, PhD, RN Labile emotional control Gülendam Hakverdioğlu Yönt, PhD, RN; Esra Akın Korhan, PhD, RN; Leyla Khorshid, PhD, RN Risk for hypothermia T. Heather Herdman, PhD, RN, FNI Risk for perioperative hypothermia Manuel Schwanda, BSc.,RN; Prof. Marianne Kriegl, Mag.; Maria Müller Staub, PhD, EdN, RN, FEANS Domain 12. Comfort Chronic pain syndrome T. Heather Herdman, PhD, RN, FNI Labor pain Simone Roque Mazoni, PhD, RN; Emilia Campos de Carvalho, PhD, RN
35. 8NursingDiagnoses2015–2017 Table I.2 Revised NANDA-I Nursing Diagnoses, 2015–2017 Approved diagnosis (Revised) Revision Submitter(s) DC removed DC added ReF/RiF removed ReF/RiF added Definition revised Comment Domain 2. Nutrition Ineffective breastfeeding 1 1 1 10 X j Definition reflects change in focus from the attachment/ bonding process to that of nutrition j 2 defining characteristics reassigned to related factors T. Heather Herdman, RN, PhD, FNI Interrupted breastfeeding 6 1 1 X j Definition reflects change in focus from attachment/bonding process to that of nutrition j 1 defining characteristic reassigned to related factor T. Heather Herdman, RN, PhD, FNI Readiness for enhanced breastfeeding 1 2 X j Definition reflects change in focus from attachment/bonding process to that of nutrition T. Heather Herdman, RN, PhD, FNI Excess fluid volume 2 Eneida Rejane Rabelo da Silva ScD, RN; Quenia Camille Soares Martins ScD, RN; Graziella Badin Aliti ScD, RN
36. ChangestotheNANDAInternationalTerminology9 Continued Table 1.2 Continued Approved diagnosis (Revised) Revision Submitter(s) DC removed DC added ReF/RiF removed ReF/RiF added Definition revised Comment Domain 4. Activity / Rest Impaired physical mobility 1 Eneida Rejane Rabelo da Silva ScD, RN; Angelita Paganin MSc, RN Domain 7. Role Relationships Risk for caregiver role strain X j Definition revised to be consistent with the problem-focused definition Domain 10. Life Principles Spiritual distress 4 7 11 X Sílvia Caldeira PhD, RN; Emília Campos de Carvalho PhD, RN; Margarida Vieira PhD, RN Domain 11. Safety / Protection Risk for imbalanced body temperature 10 j Diagnosis revised to incorporate neonatal characteristics T. Heather Herdman, RN, PhD, FNI Hyperthermia 9 1 3 X j Diagnosis revised to incorporate neonatal characteristics T. Heather Herdman, RN, PhD, FNI Hypothermia 24 4 8 X j Diagnosis revised to incorporate neonatal characteristics T. Heather Herdman, RN, PhD, FNI
37. 10NursingDiagnoses2015–2017 Approved diagnosis (Revised) Revision Submitter(s) DC removed DC added ReF/RiF removed ReF/RiF added Definition revised Comment Delayed surgical recovery 6 4 1 8 Rosimere Ferreira Santana, Associate PhD, RN; Shimmenes Kamacael Pereira, MSN, RN; Tallita Mello Delphino, MSN, RN; Dayana Medeiros do Amaral, BSN; Deborah Marinho da Silva, BSN; Thais da Silva Soares, BSN; Marcos Venicius de Oliveira Lopes, PhD, RN Impaired tissue integrity 3 10 X Katiucia Martins Barros MS, RN; Daclé Vilma Carvalho PhD, RN Domain 12. Comfort Acute pain 6 6 1 3 X T. Heather Herdman, RN, PhD, FNI Chronic pain 10 5 2 35 X T. Heather Herdman, RN, PhD, FNI DC, defining characteristic; ReF, related factor; RiF, risk factor. Table 1.2 Continued
38. Changes to the NANDA International Terminology 11 diagnoses, highlights the revisions that were made for each of them, and identifies the submitters. Changes to Slotting of Current Diagnoses within the NANDA-I Taxonomy II, 2015–2017 A review of the current taxonomic structure, and slotting of diagnoses within that structure, led to some changes in the way some diagnoses are now classified within the NANDA-I taxonomy. Five nursing diag- noses were reslotted within the NANDA-I taxonomy; these are noted in Table I.3 with their previous and new places in the taxonomy noted. Revisions to Nursing Diagnosis Labels within the NANDA-I Taxonomy II, 2015–2017 Changes were made in five diagnosis labels. These changes, and their rationale, are shown in Table I.4. Nursing Diagnoses Removed from the NANDA-I Taxonomy II, 2015–2017 Seven nursing diagnoses were removed from the taxonomy, either because they were slotted for removal if they were not updated to bring them to a level of evidence of 2.1, due to a change in the classification Table I.3 Slotting Changes to NANDA-I Nursing Diagnoses, 2015–2017 Nursing diagnosis Previous slotting New slotting Domain Class Domain Class Noncompliance Life Principles Value/Belief/ Action Congruence Health Promotion Health Management Ineffective breastfeeding1 Role Relationship Caregiving Roles Nutrition Ingestion Interrupted breastfeeding1 Role Relationship Caregiving Roles Nutrition Ingestion Readiness for enhanced breastfeeding1 Role Relationship Caregiving Roles Nutrition Ingestion Readiness for enhanced hope Life Principles Values Self- Perception Self- Concept Risk for loneliness Self- Perception Self- Concept Comfort Social Comfort 1 Reslotting due to diagnosis revision, including definition change.
39. 12 Nursing Diagnoses 2015–2017 of level of evidence supporting the diagnosis, or because new diagnoses replaced them. Table I.5 provides information on each of the diagnoses that were removed from the taxonomy. Standardization of Diagnostic Indicator Terms For the past two cycles of this book, work has been slowly underway to decrease variation in the terms used for defining characteristics, related factors, and risk factors. This work was undertaken in earnest during this cycle of the book, with several months being dedicated for the review, revision, and standardization of terms being used. This was no easy task, and it involved many hours of review, literature searches, discussion, and consultation with clinical experts in different fields. The process we used included individual review of assigned domains, followed by a second reviewer independently reviewing the current Table I.4 Revisions to Nursing Diagnosis Labels of NANDA-I Nursing Diagnoses, 2015–2017 Previous diagnostic label New diagnostic label Rationale Ineffective self-health management Ineffective health management There is no need to include the “self” in the diagnostic label, as the focus of the diagnosis is assumed to be the individual unless otherwise stated. Readiness for enhanced self-health management Readiness for enhanced health management There is no need to include the “self” in the diagnostic label, as the focus of the diagnosis is assumed to be the individual unless otherwise stated. Ineffective family therapeutic regimen management Ineffective family health management Definition is consistent with the individual health management diagnoses, therefore the diagnostic label should reflect the same diagnostic focus. Impaired individual resilience Impaired resilience There is no need to include “individual” in the diagnostic label, as the focus of the diagnosis is assumed to be the individual unless otherwise stated. Risk for compromised resilience Risk for impaired resilience The problem-focused diagnosis carries the diagnostic label, Impaired resilience, and the definition of the risk diagnosis is consistent with that diagnosis.
40. Changes to the NANDA International Terminology 13 Table I.5 Nursing Diagnoses Removed from the NANDA-I Taxonomy II, 2015–2017 Retired diagnostic label New diagnostic label Rationale Disturbed energy field (00050) – Removed from taxonomy, but reassigned to level of evidence (LOE) 1.2, Theoretical Level, for Development and Validation (LOE 1.2 is not accepted for publication and inclusion in the taxonomy; all literature support currently provided for this diagnosis is regarding intervention rather than for the nursing diagnosis itself) Adult failure to thrive (00101) Frail elderly syndrome New diagnosis replaced previous diagnosis Readiness for enhanced immunization status (00186) – Diagnosis was indicated for retirement in the 2012–2014 edition. Additionally, this content is currently covered within the diagnosis, Readiness for enhanced health management Imbalanced nutrition: more than body requirements (00001) Overweight Obesity New diagnoses replaced previous diagnosis Risk for imbalanced nutrition: more than body requirements (00003) Risk for overweight New diagnosis replaced previous diagnosis Impaired environmental interpretation syndrome (00127) – Diagnosis was indicated for removal in the 2012–2014 edition unless additional work was completed to bring it into compliance with the definition of syndrome diagnoses. This work was not completed. Delayed growth and development (00111) Diagnosis was indicated for removal in the 2012–2014 edition, unless additional work was completed to separate the foci of (1) growth and (2) development into separate diagnostic concepts. This work was not completed.
41. 14 Nursing Diagnoses 2015–2017 and newly recommended terms. The two reviewers then met together, either in person or via web-based video conferencing, and reviewed each and every line a third time, together. Once consensus was reached, the third reviewer then took the current terms and recommended terms, and independently reviewed these. Any discrepancies were discussed until consensus was reached. After the entire process was completed for every diagnosis, including new and revised diagnoses, a process of filtering for similar terms was begun. For example, every term with the stem “pulmo-” was searched, to ensure that consistency was maintained. Common phrases were also used to filter, such as verbalizes, reports, states; lack of; insufficient; inadequate; excess, etc. This process continued until the team was unable to find additional terms that had not previously been reviewed. That said, we know the work is not done, it is not perfect, and there may be disagreements with some of the changes that were made. We can tell you that there are more than 5,600 diagnostic indicators within the terminology, and we believe that we have made a good first effort at standardization of the terms. The benefits of this are many, but three are perhaps the most notable: 1. Translations should be improved. There have been multiple questions over the last two editions that were difficult to answer. Some examples include: (a) When you say lack in English, does that mean absence of or insuf- ficient? The answer is often “Both!” Although the duality of this word is well accepted in English, the lack of clarity does not support the clinician in any language, and it makes it very dif- ficult to translate into languages in which a different word would be used depending on the intended meaning. (b) Is there a reason why some defining characteristics are noted in the singular and yet in another diagnosis the same characteristic is noted in the plural (e.g., absence of significant other(s), absence of significant other, absence of significant others)? (c) 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: abnormal skin color (e.g., pale, dusky), color changes, cyanosis, pale, skin color changes, slight cyanosis? Are the differences significant? Could these be combined into one term? Some of the translations are almost the same (e.g., abnormal skin color, color changes, skin color changes) can we use the same term or must we translate exactly as in the English? Decreasing the variation in these terms should now facilitate trans- lation, as one term/phrase will be used throughout the terminology for similar diagnostic indicators.
42. Changes to the NANDA International Terminology 15 2. 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 don’t understand? Why can’t NANDA-I be more clear? And what about all of those “e.g.s” in the terminology? Are they there to teach, to clarify, to list every potential example? There seems to be a mixture of all of these appearing within the terminology. You will notice that many of the “e.g.s” have been removed, unless it was felt that they were truly needed to clarify intent. “Teaching tips” that were present in some parentheses are gone, too – the terminology is not the place for these. And we have done our best to condense terms and standardize them, whenever possible. 3. This work has enabled the coding of the diagnostic indicators, which will facilitate their use for populating assessment databases within electronic health records, and increase the availability of decision support tools regarding accuracy in diagnosis and linking diagnosis to appropriate treatment plans. Although we did not include the phrase codes within this edition of the taxonomy, a list of all diagnostic indicators, and their codes, is available at the NANDA-I website. It is strongly recommended that these codes be used in all publications to ensure accuracy in translation. Other Changes Made in the 2015–2017 Edition The list of diagnostic indicators has been shortened in a couple of other ways. First, because defining characteristics are identified as those things that can be observed, which includes what can be seen and heard, we have removed terms such as “observed” and “verbalizes,” so that it is no longer necessary to have two terms that relate to the same data. For example, previously there would have been two separate defining characteristics relate to pain, reports pain and observed evidence of pain; in this edition you will simply see pain, which can either be observed or reported. Secondly, some of the subcategories of terms have been deleted (e.g., objective/subjective) because they are no longer necessary. Other deletions include lists of pharmaceutical agents, categorized under the subcategory of pharmaceutical agents.
43. NANDA International, Inc. Nursing Diagnoses: Definitions & Classification 2015–2017, Tenth Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru. © 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/nursingdiagnoses Part 2 Nursing Diagnosis Chapter 1: Nursing Diagnosis Basics 21 Chapter 2: From Assessment to Diagnosis 31 Chapter 3: An Introduction to the NANDA-I Taxonomy 52 Chapter 4: NANDA-I Taxonomy II: Specifications and Definitions 91 Chapter 5: Frequently Asked Questions 105
44. Nursing Diagnosis 19 In this section, we present chapters that are aimed at the student, educator, and nurse in clinical practice. The accompanying website features presentation materials to supplement the information provided in these chapters. Chapter 1 Nursing Diagnosis Basics Susan Gallagher-Lepak, RN, PhD This chapter provides a brief review of nursing diagnosis terms and the process of diagnosing. It serves as a basic introduction to nursing diagnosis: what it is, its role within the nursing process, an introduction to the link between assessment and diagnosis, and usage of nursing diagnosis. Chapter 2 From Assessment to Diagnosis T. Heather Herdman, RN, PhD, FNI and Shigemi Kamitsuru, RN, PhD, FNI This chapter, relates to the importance of nursing assessment for accurate diagnosis within nursing practice. Chapter 3 An Introduction to the NANDA-I Taxonomy T. Heather Herdman, RN, PhD, FNI Written primarily for students and nurses in practice, this chapter explains the purpose of a taxonomy, and how to use the taxonomy within practice and education. Table 3.1 presents the 235 NANDA-I nursing diagnoses that are found within the NANDA-I Taxonomy II, and their placement within its 13 domains and 47 classes. Table 3.2 provides the nursing diagnoses as they are placed within the proposed Taxonomy III. Chapter 4 NANDA-I Taxonomy II: Specifications and Definitions T. Heather Herdman, RN, PhD, FNI (revised from 2012–2014) This chapter provides more detailed information on the structure of the NANDA-I taxonomy, including the multiaxial system for construc- tion of nursing diagnoses during diagnostic development. Each axis is described and defined. The nursing diagnoses and their foci are provided, and each nursing diagnosis is shown as it is placed (slotted) within the NANDA-I Taxonomy II, and the proposed Taxonomy III. A clear link is made between the use of standardized nursing language that permits diagnostic accuracy and the aspect of patient safety;
45. 20 Nursing Diagnoses 2015–2017 Chapter 5 Frequently Asked Questions T. Heather Herdman, RN, PhD, FNI and Shigemi Kamitsuru, RN, PhD, FNI This chapter provides answers to some of the most frequently asked questions that we receive from students, educators, and nurses in practice around the world through the NANDA-I website, and when members of the Board of Directors travel to present at a variety of conferences internationally. point-of-care “creation” of terms to describe clinical reasoning is strongly discouraged due to the lack of standardization, which can lead to inappropriate plans of care, poor outcomes, and the inability to accurately research or demonstrate the impact of nursing care on human responses.
46. NANDA International, Inc. Nursing Diagnoses: Definitions & Classification 2015–2017, Tenth Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru. © 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/nursingdiagnoses Nursing Diagnosis Basics Susan Gallagher-Lepak, RN, PhD Chapter 1 Healthcare is delivered by various types of healthcare professionals, including nurses, physicians, and physical therapists, to name just a few. This is true in hospitals as well as other settings across the con- tinuum of care (e.g., clinics, home care, long-term care, churches, pris- ons). Each healthcare discipline brings its unique body of knowledge to the care of the client. In fact, a unique body of knowledge is often cited as a defining characteristic of a profession. Collaboration, and at times overlap, occurs between professionals in providing care (Figure 1.1). For example, a physician in a hospital set- ting may write an order for the client to walk twice per day. Physical therapy focuses on core muscles and movements necessary for walk- ing. Nursing has a holistic view of the patient, including balance and muscle strength related to walking, as well as confidence and motiva- tion. Social work may have involvement with insurance coverage for necessary equipment. 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.” A profession may have a common language that is used to describe and code its knowledge. Physicians treat dis- ease and use the International Classification of Disease taxonomy, ICD-10, to represent and code the medical problems they treat. Psychologists, psychiatrists, and other mental health professionals treat mental health disorders and use the Diagnostic and Statistical Manual of Mental Disorders, DSM-V. Nurses treat human responses to health problems and/or life processes and use the NANDA International, Inc. (NANDA-I) nursing diagnosis taxonomy. The nursing diagnosis taxonomy, and the process of diagnosing using this taxonomy, will be further described.
47. 22 Nursing Diagnoses 2015–2017 The NANDA-I taxonomy provides a way to classify and categorize areas of concern to nursing (i.e., foci of the diagnoses). It contains 235 nursing diagnoses grouped into 13 domains and 47 classes. A domain is a “sphere of knowledge; examples of domains in the NANDA-I taxonomy include: Nutrition, Elimination/Exchange, Activity/Rest, or Coping/Stress Tolerance (Merriam-Webster, 2009). Domains are divided into classes (groupings that share common attributes). Nurses deal with responses to health conditions/life responses among individuals, families, groups, and communities. Such responses are the central concern of nursing care and fill the circle ascribed to nursing in Figure 1.1. A nursing diagnosis can be problem-focused, or a state of health promotion or potential risk (Herdman, 2012): ■ Problem-focused diagnosis – a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, group, or community ■ Risk diagnosis – a clinical judgment concerning the vulnerability of an individual, family, group or community for developing an undesirable human response to health conditions/life processes ■ Health promotion diagnosis – a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any heath state. Health promotion responses may exist in an individual, family, group, or community Client/Family Nurse Physician Physical therapist Social worker Figure 1.1 Example of a Collaborative Healthcare Team
48. Nursing Diagnosis 23 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 nursing diagnoses that occur together, and are best addressed together and through similar interventions. An example of a syndrome is chronic pain syndrome (00255). Chronic pain is recurrent or persistent pain that has lasted at least three months and that significantly affects daily functioning or well-being. This syndrome is differentiated from chronic pain in that additionally the chronic pain has a significant impact on other human responses and thus includes other diagnoses, such as disturbed sleep pattern (00198), social isolation (00053), fatigue (00093), or impaired physical mobility (00085). How Does a Nurse (or Nursing Student) Diagnose? The nursing process includes assessment, nursing diagnosis, planning, outcome setting, intervention, and evaluation (Figure 1.2). Nurses use assessment and clinical judgment to formulate hypotheses, or expla- nations, about presenting actual or potential problems, risks, and/or Theory/ nursing science/ underlying nursing concepts Assessment/ Patient history PLANNING s interventions Implementation Continual re-evaluation PATIENT/FAMILY/ GROUP/COMMUNITY Figure 1.2 The Modified Nursing Process From T.H. Herdman (2013). Manejo de casos empleando diagnósticos de enfermería de la NANDA Internacional. [Case Management using NANDA International nursing diagnosis] XXX CONGRESO FEMAFEE 2013. Monterrey, Mexico. (Spanish).
49. 24 Nursing Diagnoses 2015–2017 health promotion opportunities. All of these steps require knowledge of underlying concepts of nursing science before patterns can be identi- fied in clinical data or accurate diagnoses can be made. Understanding Nursing Concepts Knowledge of key concepts, or nursing diagnostic foci, is necessary before beginning an assessment. Examples of critical concepts impor- tant to nursing practice include breathing, elimination, thermoregula- tion, physical comfort, self-care, and skin integrity. Understanding such concepts allows the nurse to identify patterns in the data and diagnose accurately. Key areas to understand with the concept of pain, for example, include manifestations of pain, theories of pain, popula- tions at risk, related pathophysiological concepts (e.g., fatigue, depres- sion), and management of pain. Full understanding of key concepts is needed as well to differentiate diagnoses. For example, in order to understand hypothermia or hyperthermia, a nurse must first under- stand the core concepts of thermal stability and thermoregulation. In looking at problems that can occur with thermoregulation, the nurse will be faced with the diagnoses of hypothermia (00006) (or risk for), hyperther- mia (00007) (or risk for), but also risk for imbalanced body temperature (00005) and ineffective thermoregulation (00008). The nurse may collect a significant amount of data, but without a sufficient understanding of the core concepts of thermal stability and thermoregulation, the data needed for accurate diagnosis may have been omitted and patterns in the assessment data go unrecognized. Assessment Assessment involves the collection of subjective and objective informa- tion (e.g., vital signs, patient/family interview, physical exam) and review of historical information in the patient chart. Nurses also collect information on strengths (to identify health promotion opportunities) and risks (areas that nurses can prevent or potential problems they can postpone). Assessments can be based on a particular nursing theory such as one developed by Sister Callista Roy, Wanda Horta, or Dorothea Orem, 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 manageable number of related patterns or categories of data. The foundation of nursing diagnosis is clinical reasoning. Clinical reasoning is required to distinguish normal from abnormal data, clus- ter related data, recognize missing data, identify inconsistencies in
50. Nursing Diagnosis 25 data, and make inferences (Alfaro-Lefebre, 2004). Clinical judgment is “an interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action (or not)” (Tanner, 2006, p. 204). Key issues, or foci, may be evident early in the assessment (e.g., altered skin integrity, loneliness) and allow the nurse to begin 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 progress to nursing diagnoses. Novice nurses take a more sequential process in determining appro- priate nursing diagnoses. Nursing Diagnosis 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, or community. A nursing diagnosis typically contains two parts: 1) descriptor or modifier, and 2) focus of the diagnosis, or the key concept of the diagnosis (Table 1.1). There are some exceptions in which a nursing diagnosis is only one word such as fatigue (00093), constipation (00011), and anxiety (00146). In these diagnoses, the modifier and focus are inherent in the one term. Nurses diagnose health problems, risk states, and readiness for health promotion. Problem-focused diagnoses should not be viewed as more important than risk diagnoses. Sometimes a risk diagnosis can be the diagnosis with the highest priority for a patient. An example may be a patient who has the nursing diagnoses of chronic pain (00133), overweight (00233), risk for impaired skin integrity (00047), and risk for falls (00155), and who has been newly admitted to a skilled nursing facility. Although chronic pain and overweight are her problem-focused diagnoses, her risk for falls may be her number one priority diag- nosis, especially as she adjusts to a new environment. This may be especially true when related risk factors are identified in the assessment Table 1.1 Parts of a Nursing Diagnosis Label Modifier Diagnostic Focus Ineffective Airway Clearance Risk for Overweight Readiness for Enhanced Knowledge Impaired Memory Ineffective Coping
51. 26 Nursing Diagnoses 2015–2017 (e.g., poor vision, difficulty with gait, history of falls, and heightened anxiety with relocation). Each nursing diagnosis has a label, and a clear definition. It is impor- tant to state that merely having a label or a list of labels is insufficient. It is critical that nurses know the definitions of the diagnoses they most commonly use. In addition, they need to know the “diagnostic indicators” – the data that are used to diagnose and to differentiate one diagnosis from another. These diagnostic indicators include defining characteristics and related factors or risk factors (Table 1.2). Defining characteristics are observable cues/inferences that cluster as manifes- tations of a diagnosis (e.g., signs or symptoms). An assessment that identifies the presence of a number of defining characteristics lends sup- port to the accuracy of the nursing diagnosis. Related factors are an integral component of all problem-focused nursing diagnoses. Related factors are etiologies, circumstances, facts, or influences that have some type of relationship with the nursing diagnosis (e.g., cause, contribut- ing factor). A review of client history is often where related factors are identified. Whenever possible, nursing interventions 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). A nursing diagnosis does not need to contain all types of diagnostic indicators (i.e., defining characteristics, related factors, and/or risk fac- tors). Problem-focused nursing diagnoses contain defining characteris- tics and related factors. Health promotion diagnoses generally have only defining characteristics, although related factors may be used if they might improve the understanding of the diagnosis. It is only risk diagnoses that have risk factors. A common format used when learning nursing diagnosis includes _____ [nursing diagnosis] related to ______ [cause/related factors] as evidenced by ____________ [symptoms/defining characteristics]. For example, ineffective airway clearance related to excessive mucus and asthma Table 1.2 Key Terms at a Glance Term Brief Description Nursing Diagnosis Problem, strength, or risk identified for a client, family, group, or community Defining Characteristic Sign or symptom (objective or subjective cue) Related Factor Cause or contributing factor (etiological factor) Risk Factor Determinant (increase risk)
52. Nursing Diagnosis 27 as evidenced by decreased breath sounds bilaterally, crackles over left lobe and persistent, ineffective coughing. Depending on the electronic health record in a particular healthcare institution, the “related to” and “as evidenced by” components may not be included within the electronic system. This information, however, should be recognized in the assessment data col- lected and recorded in the patient chart in order to provide support for the nursing diagnosis. Without this data, it is impossible to verify diag- nostic accuracy, which puts the quality of nursing care into question. Planning/Intervention Once diagnoses are identified, prioritizing of selected nursing diagnoses must occur to determine care priorities. High-priority nursing diagno- ses need to be identified (i.e., urgent need, diagnoses with a high level of congruence with defining characteristics, related factors, or risk fac- tors) so that care can be directed to resolve these problems, or lessen the severity or risk of occurrence (in the case of risk diagnoses). Nursing diagnoses are used to identify intended outcomes of care and plan nursing-specific interventions sequentially. A nursing out- come refers to a measurable behavior or perception demonstrated by an individual, family, group, or community that is responsive to nurs- ing intervention (Center for Nursing Classification [CNC], n.d.). The Nursing Outcome Classification (NOC) is a system that can be used to select outcome measures related to nursing diagnosis. Nurses often, and incorrectly, move directly from nursing diagnosis to nursing inter- vention without consideration of desired outcomes. Instead, outcomes need to be identified before interventions are determined. The order of this process is similar to planning a road trip. Simply getting in a car and driving will get a person somewhere, but that may not be the place the person really wanted to go. Better is to first have a clear location (outcome) in mind, and then choose a route (intervention) to get to a desired location. An intervention is defined as “any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/ client outcomes” (CNC, n.d.). The Nursing Interventions Classification (NIC) is a comprehensive, evidence-based taxonomy of interventions that nurses perform across various care settings. Using nursing knowl- edge, nurses perform both independent and interdisciplinary inter- ventions. These interdisciplinary interventions overlap with care provided by other healthcare professionals (e.g., physicians, respira- tory and physical therapists). For example, blood glucose manage- ment is a concept important to nurses, risk for unstable blood glucose (00179) is a nursing diagnosis, and nurses implement nursing inter- ventions to treat this condition. Diabetes mellitus, in comparison, is a
53. 28 Nursing Diagnoses 2015–2017 medical diagnosis, yet nurses provide both independent and inter- disciplinary interventions to clients with diabetes who have various types of problems or risk states. Refer to the Kamitsuru’s Tripartite Model of Nursing Practice (Figure 5.2) on p. 121. Evaluation A nursing diagnosis “provides the basis for selection of nursing interven- tions to achieve outcomes for which nursing has accountability” (Herdman, 2012). The nursing process is often described as a stepwise process, but in reality a nurse will go back and forth between steps in the process. Nurses will move between assessment and nursing diagnosis, for example, as additional data is collected and clustered into meaningful patterns, and the accuracy of nursing diagnoses is evaluated. Similarly, theeffectivenessofinterventionsandachievementofidentifiedoutcomes is continuously evaluated as the client status is assessed. Evaluation should ultimately occur at each step in the nursing process, as well as once the plan of care has been implemented. Several questions to consider include: “What data might I have missed? Am I making an inappropriate judgment? How confident am I in this diagnosis? Do I need to consult with someone with more experience? Have I confirmed the diagnosis with the patient/family/group/community? Are the outcomes established appropriate for this patient in this setting, given the reality of the client’s condition and resources available? Are the interventions based on research evidence or tradition (e.g., “what we always do”)? Use of Nursing Diagnosis This description of nursing diagnosis basics, although aimed primarily at nursing students and beginning nurses learning nursing diagnosis, can benefit all nurses in that it highlights critical steps in using nursing diagnosis and provides examples of areas in which inaccurate diagnos- ing can occur. An area that needs continued emphasis, for example, includes the process of linking knowledge of underlying nursing concepts to assessment, and ultimately nursing diagnosis. The nurse’s understanding of key concepts (or diagnostic foci) directs the assess- ment process and interpretation of assessment data. Relatedly, nurses diagnose problems, risk states, and readiness for health promotion. Any of these types of diagnoses can be the priority diagnosis (or diagnoses), and the nurse makes this clinical judgment. In representing knowledge of nursing science, the taxonomy pro- vides the structure for a standardized language in which to communi- cate nursing diagnoses. Using the NANDA-I terminology (the diagnoses
54. Nursing Diagnosis 29 themselves), nurses can communicate with each other as well as pro- fessionals from other healthcare disciplines about “what” nursing is uniquely. The use of nursing diagnoses in our patient/family interac- tions can help them to understand the issues on which nurses will be focusing, and can engage them in their own care. The terminology provides a shared language for nurses to address health problems, risk states, and readiness for health promotion. NANDA International’s nursing diagnoses are used internationally, with translation into 16 languages. In an increasingly global and electronic world, NANDA-I also allows nurses involved in scholarship to communicate about phe- nomena of concern to nursing in manuscripts and at conferences in a standardized way, thus advancing the science of nursing. Nursing diagnoses are peer reviewed, and submitted for acceptance/ revision to NANDA-I by practicing nurses, nurse educators, and nurse researchers around the world. Submissions of new diagnoses and/or revisions to existing diagnoses have continued to grow in number over the 40 plus years of the NANDA-I terminology. Continued submissions (and revisions) to NANDA-I will further strengthen the scope, extent, and supporting evidence of the terminology. Brief Chapter Summary This chapter describes types of nursing diagnoses (i.e., problem-focused, risk, health promotion, syndrome) and steps in the nursing process. The nursing process begins with an understanding of underlying concepts of nursing science. Assessment follows, and involves collection and clustering of data into meaningful patterns. Nursing diagnosis, a subsequent step in the nursing process, involves clinical judgment about a human response to a health condition or life process, or vulnerability for that response by an individual, family, group, or community. The nursing diagnosis compo- nents were reviewed in this chapter, including the label, definition, and diagnostic indicators (i.e., defining characteristics and related factors, or risk factors). Given that a patient assessment will typically generate a number of nursing diagnoses, 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 nursing interventions. Evaluation occurs at each step of the nursing process and at its conclusion. Questions Commonly Asked by New Learners About Nursing Diagnosis* ■ Are nursing diagnoses different than medical diagnoses? (p. 112) ■ How many defining characteristics do I need to make a nursing diagnosis? (p. 117)
55. 30 Nursing Diagnoses 2015–2017 ■ How many related factors do I need to use when diagnosing? (p. 118) ■ How many nursing diagnoses do I need for each patient? (p. 124) ■ How do I know which nursing diagnosis is most accurate? (p. 119) ■ How are nursing diagnoses revised or added within NANDA-I? (p. 461) *For answers to these and other questions, see Chapter 5, Frequently Asked Questions (pp. 105–130). References Alfaro-Lefebre, R. (2004). Critical thinking and clinical judgment: A practical approach to outcome-focused thinking (4th ed.). St. Louis: Saunders Elsevier. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th Ed.). Arlington, VA: American Psychiatric Association, accessed from dsm.psychiatryonline.org Center for Nursing Classification & Clinical Effectiveness (CNC), University of Iowa College of Nursing (n.d.) Overview: Nursing Interventions Classification (NIC). Retri- eved from http://www.nursing.uiowa.edu/cncce/nursing-interventions-classification- overview, accessed March 13, 2014. Center for Nursing Classification & Clinical Effectiveness (CNC), University of Iowa College of Nursing (n.d.). Overview: Nursing Outcome Classification (NOC). Retrieved from http://www.nursing.uiowa.edu/cncce/nursing-outcomes-classification-overview, accessed March 13, 2014. Herdman, T. H. (ed.) (2012) NANDA International. Nursing diagnoses: Definitions and classi- fication, 2012–2014. Ames, IA: Wiley-Blackwell. Herdman, T. H. (2013). Manejo de casos empleando diagnósticos de enfermería de la NANDA Internacional. [Case management using NANDA International nursing diag- noses]. XXX CONGRESO FEMAFEE 2013. Monterrey, Mexico. (Spanish) Merriam-Webster (2009). Merriam-Webster’s collegiate dictionary (11th ed.). Springfield, MA: Merriam-Webster. Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204–211.
56. NANDA International, Inc. Nursing Diagnoses: Definitions & Classification 2015–2017, Tenth Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru. © 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/nursingdiagnoses From Assessment to Diagnosis T. Heather Herdman, RN, PhD, FNI and Shigemi Kamitsuru, RN, PhD, FNI Chapter 2 Assessment is the first and the most critical step in the nursing process. If this step is not handled well, nurses will lose control over the subse- quent steps of the nursing process. Without proper nursing assessment, there can be no nursing diagnosis, and without nursing diagnosis, there can be no independent nursing interventions. Assessment should not be performed merely to fill in the blank spaces on a form or computer screen. If this rings a bell for you, it’s time to take a new look at the purpose of assessment! What Happens during Nursing Assessment? During the assessment and diagnosis steps of the nursing process, nurses collect data from a patient (or family/group/community), process that data into information, and then organize that informa- tion into meaningful categories of knowledge, also known as nursing diagnoses. Assessment provides the best opportunity for nurses to establish an effective therapeutic relationship with the patient. In other words, assessment is both an intellectual and an interpersonal activity. As you can see in Figure 2.1, assessment involves multiple steps, with the goal being to diagnose and prioritize these diagnoses, which then become the basis for nursing treatment. Now, this probably sounds like a long, involved process and, frankly, who has time for all of that? In the real world, however, some of these steps happen in the blink of an eye. For instance, if a nurse sees a patient who is holding her lower abdomen and grimacing, he might immediately suspect that the patient is experiencing acute pain (00132). Thus, the movement from data collection (observation of the patient’s behavior) to determining potential diagnoses (e.g., acute pain) occurs in a split second. However, this
57. 32 Nursing Diagnoses 2015–2017 quickly determined diagnosis might not be the right one – or it may not be the highest priority for your patient. Getting there does take time. So, how do you accurately diagnose? Only by continuing to the further step of in-depth assessment – and the proper use of the data collected during that assessment – can you ensure accuracy in diagnosis. The patient may indeed be experiencing acute pain, but without in-depth assessment, there is no way for the nurse to know that the pain is related to intestinal cramping and diarrhea. This chapter provides foundational knowledge for what to do with all of that data you have collected. After all, why bother collecting it if you aren’t going to use it? 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’s spend a few minutes discussing the purpose – because assessment is not simply a task that nurses complete, we need to really understand its purpose so we can understand how it applies to our professional role as nurses. Why Do Nurses Assess? Nurses need to assess patients from the viewpoint of the nursing disci- pline to diagnose accurately and to provide effective care. What is the “nursing discipline”? Simply put, it is the body of knowledge that com- prises the science of nursing. Diagnosing a patient based on his/her medical diagnosis or medical information is neither a recommended nor a safe diagnostic process. Such an overly simplified conclusion could lead to inappropriate interventions, prolonged length of stay, and unnecessary readmissions. Remember that nurses diagnose actual or potential human responses to health conditions/life processes, or a vulnerability for that response – the focus here is “human responses.” Human beings are complicated – we just don’t all respond to one situation in the same way. Those responses are based on many factors: genetics, physiology, health condition, and past experience with illness/injury. However, they are also influenced by the patient’s culture, ethnicity, religion/spiritual beliefs, gender, and family upbringing. This means that human responses Screening assessment Data collection of information Potential diagnoses possible diagnoses that match information available In-depth assessment collection or diagnoses diagnosis diagnoses Figure 2.1 Steps in Moving from Assessment to Diagnosis
58. Nursing Diagnosis 33 are not so easily identified. If we simply assume that every patient with a particular medical diagnosis will respond in a certain way, we may treat conditions (and therefore use the nurse’s time and other resources) that do not exist while missing others that truly need our attention. 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 particular medical diagnoses. For instance, there is no way to identify the patient’s ability for independent daily living or the availability/quality of family support, based on a medical diagnosis of myocardial infarction or osteoporosis. Nor can one assume that every patient with a medical diagnosis will respond in the same way: every patient who has experienced a mastectomy does not experience disturbed body image (00118), for example. Therefore, nurs- ing assessment and diagnosis should be driven from the viewpoint of the nursing discipline. Unfortunately, in your practice, you will probably observe nurses who assign or “pick” a diagnosis before they have assessed the patient. What is wrong with this pathway to diagnosis? As an example, a nurse may begin to complete a plan of care based on the nursing diagnosis of anxiety (00146) for a patient undergoing surgery, before the patient has even arrived on the unit or been evaluated. Nurses working in surgical units encounter many preoperative patients, and those patients are often very anxious. Those nurses may know that preoperative teaching is an effective intervention in reducing anxiety. So, assuming a relationship between preoperative patients and anxiety could be useful in practice. However, the statement “preoperative patients have anxiety” may not apply to every patient (it is a hypothesis), and so it must be validated with each and every patient. This is especially true because anxiety is a subjective experience – although we may think the patient seems anxious, or we may expect him to be anxious, only he can really tell us if he feels anxious. In other words, the nurse can understand how the patient feels only if the patient tells the nurse about his feelings, so anxiety is a problem-focused nursing diagnosis which requires subjective data from the patient. What appears to be anxiety may actually be fear (00148) or ineffective coping (00069); we simply cannot know until we assess and validate our findings. Thus, before nurses diagnose a patient, a thorough assessment is absolutely necessary. The Screening Assessment There are two types of assessment: screening and in-depth assessment. While both require data collection, they serve different purposes. The screening assessment is the initial data collection step, and is probably

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