|
Part 1 The NANOA International Terminology: General Information |
|
|
|
1 What's New in the NANDA-I 2021-2023 Edition |
|
|
24 | (21) |
|
1.1 Overview on Changes and Revisions in the NANDA-I 2021-2023 Edition |
|
|
24 | (1) |
|
1.2 New Nursing Diagnoses |
|
|
24 | (6) |
|
1.3 Revised Nursing Diagnoses |
|
|
30 | (7) |
|
1.4 Changes to Nursing Diagnosis Labels |
|
|
37 | (1) |
|
1.5 Retired Nursing Diagnoses |
|
|
37 | (4) |
|
1.6 NANDA-I Nursing Diagnoses: Indicator Term Standardization |
|
|
41 | (4) |
|
2 International Considerations on the Use of the NANDA-I Nursing Diagnoses |
|
|
45 | (5) |
|
Part 2 Recommendations for Research to Improve the Terminology |
|
|
|
3 Future Improvement of the NANDA-I Terminology |
|
|
50 | (7) |
|
|
50 | (1) |
|
3.2 Refinement and Diagnoses to be Developed |
|
|
51 | (4) |
|
|
55 | (2) |
|
4 Revised Level of Evidence Criteria for Diagnosis Submission |
|
|
57 | (21) |
|
|
57 | (1) |
|
4.2 Relationship Between Clinical Evidence and Validity Theory |
|
|
58 | (1) |
|
4.3 Evidence Levels of Validity for NANDA-I Diagnoses |
|
|
59 | (15) |
|
|
74 | (4) |
|
Part 3 The Use of NANDA International Nursing Diagnoses |
|
|
|
5 Nursing Diagnosis Basics |
|
|
78 | (15) |
|
5.1 Principles of Nursing Diagnosis: Introduction |
|
|
78 | (3) |
|
5.2 Principles of Nursing Diagnosis: Diagnosing |
|
|
81 | (1) |
|
5.3 Principles of Nursing Diagnosis: Knowledge of Nursing Concepts |
|
|
82 | (1) |
|
|
82 | (2) |
|
|
84 | (3) |
|
5.6 Planning/Implementing |
|
|
87 | (1) |
|
5.7 Kamitsuru's Tripartite Model of Nursing Practice |
|
|
88 | (2) |
|
|
90 | (1) |
|
5.9 Principles of Nursing Diagnosis: Clinical Application |
|
|
90 | (1) |
|
5.10 Brief Chapter Summary |
|
|
91 | (1) |
|
|
92 | (1) |
|
6 Nursing Diagnosis: An International Terminology |
|
|
93 | (16) |
|
6.1 Nursing Commonalities Around the Globe |
|
|
93 | (1) |
|
6.2 Nursing Education and Practice |
|
|
93 | (2) |
|
6.3 Professional Associations and Nursing Classifications |
|
|
95 | (1) |
|
6.4 International Implementation |
|
|
96 | (8) |
|
|
104 | (1) |
|
6.6 Acknowledgment of Contributors to This Chapter |
|
|
105 | (1) |
|
|
106 | (3) |
|
7 Clinical Reasoning: From Assessment to Diagnosis |
|
|
109 | (17) |
|
7.1 Clinical Reasoning: Introduction |
|
|
109 | (1) |
|
7.2 Clinical Reasoning within the Nursing Process |
|
|
109 | (4) |
|
|
113 | (10) |
|
|
123 | (3) |
|
8 Clinical Application: Data Analysis to Determine Appropriate Nursing Diagnosis |
|
|
126 | (12) |
|
8.1 Clustering of Information/Seeing a Pattern |
|
|
126 | (1) |
|
8.2 Identifying Potential Nursing Diagnoses (Diagnostic Hypotheses) |
|
|
126 | (3) |
|
8.3 Refining the Diagnosis |
|
|
129 | (2) |
|
8.4 Confirming/Refuting Potential Nursing Diagnoses |
|
|
131 | (1) |
|
8.5 Eliminating Possible Diagnoses |
|
|
132 | (2) |
|
8.6 Potential New Diagnoses |
|
|
134 | (1) |
|
8.7 Differentiating Similar Diagnoses |
|
|
134 | (1) |
|
8.8 Diagnosing/Prioritizing |
|
|
135 | (1) |
|
|
136 | (1) |
|
|
137 | (1) |
|
9 Introduction to the NANDA International Taxonomy of Nursing Diagnoses |
|
|
138 | (26) |
|
9.1 Introduction to Taxonomy |
|
|
138 | (5) |
|
9.2 Organizing Nursing Knowledge |
|
|
143 | (2) |
|
9.3 Using NANDA-I Taxonomy |
|
|
145 | (5) |
|
9.4 The NANDA-I Nursing Diagnosis Taxonomy II: A Short History |
|
|
150 | (13) |
|
|
163 | (1) |
|
10 Specifications and Definitions Within the NANDA International Taxonomy of Nursing Diagnoses |
|
|
164 | (13) |
|
10.1 Structure of Taxonomy II |
|
|
164 | (1) |
|
10.2 NANDA-I Taxonomy II: A Multiaxial System |
|
|
165 | (1) |
|
10.3 Definitions of the Axes |
|
|
166 | (8) |
|
10.4 Developing and Submitting a Nursing Diagnosis |
|
|
174 | (1) |
|
10.5 Further Development: Using Axes |
|
|
175 | (1) |
|
|
176 | (1) |
|
|
177 | (10) |
|
|
177 | (1) |
|
|
178 | (2) |
|
11.3 Components of a Nursing Diagnosis |
|
|
180 | (2) |
|
11.4 Definitions for Terms Associated with Nursing Diagnoses |
|
|
182 | (1) |
|
11.5 Definitions for Classification of Nursing Diagnoses |
|
|
182 | (1) |
|
|
183 | (4) |
|
Part 4 The NANDA International Nursing Diagnoses |
|
|
|
Domain 1 Health promotion |
|
|
187 | (24) |
|
|
|
Decreased diversional activity engagement |
|
|
188 | (1) |
|
Readiness for enhanced health literacy |
|
|
189 | (1) |
|
|
190 | (2) |
|
Class 2 Health management |
|
|
|
Risk for elopement attempt |
|
|
192 | (1) |
|
|
193 | (2) |
|
Risk for frail elderly syndrome |
|
|
195 | (1) |
|
Readiness for enhanced exercise engagement |
|
|
196 | (1) |
|
Deficient community health |
|
|
197 | (1) |
|
Risk-prone health behavior |
|
|
198 | (1) |
|
Ineffective health maintenance behaviors |
|
|
199 | (2) |
|
Ineffective health self-management |
|
|
201 | (2) |
|
Readiness for enhanced health self-management |
|
|
203 | (1) |
|
Ineffective family health self-management |
|
|
204 | (2) |
|
Ineffective home maintenance behaviors |
|
|
206 | (1) |
|
Risk for ineffective home maintenance behaviors |
|
|
207 | (1) |
|
Readiness for enhanced home maintenance behaviors |
|
|
208 | (1) |
|
|
209 | (2) |
|
|
211 | (36) |
|
|
|
Imbalanced nutrition: less than body requirements |
|
|
213 | (2) |
|
Readiness for enhanced nutrition |
|
|
215 | (1) |
|
Insufficient breast milk production |
|
|
216 | (1) |
|
Ineffective breastfeeding |
|
|
217 | (2) |
|
Interrupted breastfeeding |
|
|
219 | (1) |
|
Readiness for enhanced breastfeeding |
|
|
220 | (1) |
|
Ineffective adolescent eating dynamics |
|
|
221 | (1) |
|
Ineffective child eating dynamics |
|
|
222 | (2) |
|
Ineffective infant feeding dynamics |
|
|
224 | (2) |
|
|
226 | (2) |
|
|
228 | (2) |
|
|
230 | (2) |
|
Ineffective infant suck-swallow response |
|
|
232 | (2) |
|
|
234 | (2) |
|
|
|
This class does not currently contain any diagnoses |
|
|
|
|
|
This class does not currently contain any diagnoses |
|
|
|
|
|
Risk for unstable blood glucose level |
|
|
236 | (2) |
|
Neonatal hyperbilirubinemia |
|
|
238 | (1) |
|
Risk for neonatal hyperbilirubinemia |
|
|
239 | (1) |
|
Risk for impaired liver function |
|
|
240 | (1) |
|
Risk for metabolic syndrome |
|
|
241 | (1) |
|
|
|
Risk for electrolyte imbalance |
|
|
242 | (1) |
|
Risk for imbalanced fluid volume |
|
|
243 | (1) |
|
|
244 | (1) |
|
Risk for deficient fluid volume |
|
|
245 | (1) |
|
|
246 | (1) |
|
Domain 3 Elimination and exchange |
|
|
247 | (24) |
|
|
|
Disability-associated urinary incontinence |
|
|
249 | (1) |
|
Impaired urinary elimination |
|
|
250 | (1) |
|
Mixed urinary incontinence |
|
|
251 | (1) |
|
Stress urinary incontinence |
|
|
252 | (1) |
|
Urge urinary incontinence |
|
|
253 | (1) |
|
Risk for urge urinary incontinence |
|
|
254 | (1) |
|
|
255 | (1) |
|
Risk for urinary retention |
|
|
256 | (1) |
|
Class 2 Gastrointestinal function |
|
|
|
|
257 | (2) |
|
|
259 | (1) |
|
|
260 | (1) |
|
Chronic functional constipation |
|
|
261 | (2) |
|
Risk for chronic functional constipation |
|
|
263 | (2) |
|
Impaired bowel continence |
|
|
265 | (2) |
|
|
267 | (1) |
|
Dysfunctional gastrointestinal motility |
|
|
268 | (1) |
|
Risk for dysfunctional gastrointestinal motility |
|
|
269 | (1) |
|
Class 3 Integumentary function |
|
|
|
This class does not currently contain any diagnoses |
|
|
|
Class 4 Respiratory function |
|
|
|
|
270 | (1) |
|
|
271 | (52) |
|
|
|
|
274 | (2) |
|
|
276 | (2) |
|
Readiness for enhanced sleep |
|
|
278 | (1) |
|
|
279 | (1) |
|
Class 2 Activity/exercise |
|
|
|
Decreased activity tolerance |
|
|
280 | (1) |
|
Risk for decreased activity tolerance |
|
|
281 | (1) |
|
|
282 | (1) |
|
|
283 | (1) |
|
Impaired physical mobility |
|
|
284 | (1) |
|
Impaired wheelchair mobility |
|
|
285 | (2) |
|
|
287 | (1) |
|
|
288 | (1) |
|
Impaired transfer ability |
|
|
289 | (1) |
|
|
290 | (1) |
|
|
|
|
291 | (1) |
|
|
292 | (2) |
|
|
294 | (1) |
|
Class 4 Cardiovascular/pulmonary responses |
|
|
|
Ineffective breathing pattern |
|
|
295 | (2) |
|
|
297 | (2) |
|
Risk for decreased cardiac output |
|
|
299 | (1) |
|
Risk for impaired cardiovascular function |
|
|
300 | (1) |
|
Ineffective lymphedema self-management |
|
|
301 | (2) |
|
Risk for ineffective lymphedema self-management |
|
|
303 | (2) |
|
Impaired spontaneous ventilation |
|
|
305 | (1) |
|
Risk for unstable blood pressure |
|
|
306 | (1) |
|
|
307 | (1) |
|
Risk for decreased cardiac tissue perfusion |
|
|
308 | (1) |
|
Risk for ineffective cerebral tissue perfusion |
|
|
309 | (1) |
|
Ineffective peripheral tissue perfusion |
|
|
310 | (1) |
|
Risk for ineffective peripheral tissue perfusion |
|
|
311 | (1) |
|
Dysfunctional ventilatory weaning response |
|
|
312 | (2) |
|
Dysfunctional adult ventilatory weaning response |
|
|
314 | (2) |
|
|
|
Bathing self-care deficit |
|
|
316 | (1) |
|
Dressing self-care deficit |
|
|
317 | (1) |
|
Feeding self-care deficit |
|
|
318 | (1) |
|
Toileting self-care deficit |
|
|
319 | (1) |
|
Readiness for enhanced self-care |
|
|
320 | (1) |
|
|
321 | (2) |
|
Domain 5 Perception/cognition |
|
|
323 | (16) |
|
|
|
|
325 | (1) |
|
|
|
This class does not currently contain any diagnoses |
|
|
|
Class 3 Sensation/perception |
|
|
|
This class does not currently contain any diagnoses |
|
|
|
|
|
|
326 | (1) |
|
|
327 | (1) |
|
|
328 | (1) |
|
|
329 | (1) |
|
Ineffective impulse control |
|
|
330 | (1) |
|
|
331 | (1) |
|
Readiness for enhanced knowledge |
|
|
332 | (1) |
|
|
333 | (1) |
|
Disturbed thought process |
|
|
334 | (1) |
|
|
|
Readiness for enhanced communication |
|
|
335 | (1) |
|
Impaired verbal communication |
|
|
336 | (3) |
|
|
339 | (18) |
|
|
|
|
341 | (2) |
|
Readiness for enhanced hope |
|
|
343 | (1) |
|
Risk for compromised human dignity |
|
|
344 | (1) |
|
Disturbed personal identity |
|
|
345 | (1) |
|
Risk for disturbed personal identity |
|
|
346 | (1) |
|
Readiness for enhanced self-concept |
|
|
347 | (1) |
|
|
|
|
348 | (2) |
|
Risk for chronic low self-esteem |
|
|
350 | (1) |
|
Situational low self-esteem |
|
|
351 | (2) |
|
Risk for situational low self-esteem |
|
|
353 | (2) |
|
|
|
|
355 | (2) |
|
Domain 7 Role relationship |
|
|
357 | (28) |
|
|
|
|
359 | (2) |
|
Risk for impaired parenting |
|
|
361 | (2) |
|
Readiness for enhanced parenting |
|
|
363 | (1) |
|
|
364 | (3) |
|
Risk for caregiver role strain |
|
|
367 | (2) |
|
Class 2 Family relationships |
|
|
|
Risk for impaired attachment |
|
|
369 | (1) |
|
Disturbed family identity syndrome |
|
|
370 | (2) |
|
Risk for disturbed family identity syndrome |
|
|
372 | (1) |
|
Dysfunctional family processes |
|
|
373 | (3) |
|
Interrupted family processes |
|
|
376 | (1) |
|
Readiness for enhanced family processes |
|
|
377 | (1) |
|
|
|
|
378 | (1) |
|
Risk for ineffective relationship |
|
|
379 | (1) |
|
Readiness for enhanced relationship |
|
|
380 | (1) |
|
|
381 | (1) |
|
Ineffective role performance |
|
|
382 | (2) |
|
Impaired social interaction |
|
|
384 | (1) |
|
|
385 | (8) |
|
|
|
This class does not currently contain any diagnoses |
|
|
|
|
|
|
386 | (1) |
|
Ineffective sexuality pattern |
|
|
387 | (1) |
|
|
|
Ineffective childbearing process |
|
|
388 | (2) |
|
Risk for ineffective childbearing process |
|
|
390 | (1) |
|
Readiness for enhanced childbearing process |
|
|
391 | (1) |
|
Risk for disturbed maternal-fetal dyad |
|
|
392 | (1) |
|
Domain 9 Coping/stress tolerance |
|
|
393 | (54) |
|
Class 1 Post-trauma responses |
|
|
|
Risk for complicated immigration transition |
|
|
395 | (1) |
|
|
396 | (2) |
|
Risk for post-trauma syndrome |
|
|
398 | (1) |
|
|
399 | (1) |
|
Relocation stress syndrome |
|
|
400 | (2) |
|
Risk for relocation stress syndrome |
|
|
402 | (1) |
|
|
|
Ineffective activity planning |
|
|
403 | (1) |
|
Risk for ineffective activity planning |
|
|
404 | (1) |
|
|
405 | (2) |
|
|
407 | (1) |
|
|
408 | (1) |
|
Readiness for enhanced coping |
|
|
409 | (1) |
|
Ineffective community coping |
|
|
410 | (1) |
|
Readiness for enhanced community coping |
|
|
411 | (1) |
|
Compromised family coping |
|
|
412 | (2) |
|
|
414 | (1) |
|
Readiness for enhanced family coping |
|
|
415 | (1) |
|
|
416 | (2) |
|
|
418 | (1) |
|
|
419 | (2) |
|
|
421 | (2) |
|
Risk for maladaptive grieving |
|
|
423 | (1) |
|
Readiness for enhanced grieving |
|
|
424 | (1) |
|
|
425 | (1) |
|
|
426 | (2) |
|
|
428 | (1) |
|
Readiness for enhanced power |
|
|
429 | (1) |
|
|
430 | (2) |
|
Risk for impaired resilience |
|
|
432 | (1) |
|
Readiness for enhanced resilience |
|
|
433 | (1) |
|
|
434 | (1) |
|
|
435 | (1) |
|
Class 3 Neurobehavioral stress |
|
|
|
Acute substance withdrawal syndrome |
|
|
436 | (1) |
|
Risk for acute substance withdrawal syndrome |
|
|
437 | (1) |
|
|
438 | (2) |
|
Risk for autonomic dysreflexia |
|
|
440 | (2) |
|
Neonatal abstinence syndrome |
|
|
442 | (1) |
|
Disorganized infant behavior |
|
|
443 | (2) |
|
Risk for disorganized infant behavior |
|
|
445 | (1) |
|
Readiness for enhanced organized infant behavior |
|
|
446 | (1) |
|
Domain 10 Life principles |
|
|
447 | (16) |
|
|
|
This class does not currently contain any diagnoses |
|
|
|
|
|
Readiness for enhanced spiritual well-being |
|
|
449 | (2) |
|
Class 3 Value/belief/action congruence |
|
|
|
Readiness for enhanced decision-making |
|
|
451 | (1) |
|
|
452 | (1) |
|
Impaired emancipated decision-making |
|
|
453 | (1) |
|
Risk for impaired emancipated decision-making |
|
|
454 | (1) |
|
Readiness for enhanced emancipated decision-making |
|
|
455 | (1) |
|
|
456 | (1) |
|
|
457 | (1) |
|
Risk for impaired religiosity |
|
|
458 | (1) |
|
Readiness for enhanced religiosity |
|
|
459 | (1) |
|
|
460 | (2) |
|
Risk for spiritual distress |
|
|
462 | (1) |
|
Domain 11 Safety/protection |
|
|
463 | (86) |
|
|
|
|
466 | (1) |
|
Risk for surgical site infection |
|
|
467 | (1) |
|
|
|
Ineffective airway clearance |
|
|
468 | (1) |
|
|
469 | (1) |
|
|
470 | (1) |
|
|
471 | (1) |
|
|
472 | (1) |
|
Ineffective dry eye self-management |
|
|
473 | (2) |
|
|
475 | (1) |
|
|
476 | (2) |
|
|
478 | (2) |
|
|
480 | (1) |
|
|
481 | (1) |
|
Nipple-areolar complex injury |
|
|
482 | (2) |
|
Risk for nipple-areolar complex injury |
|
|
484 | (1) |
|
Risk for urinary tract injury |
|
|
485 | (1) |
|
Risk for perioperative positioning injury |
|
|
486 | (1) |
|
|
487 | (1) |
|
Impaired oral mucous membrane integrity |
|
|
488 | (2) |
|
Risk for impaired oral mucous membrane integrity |
|
|
490 | (1) |
|
Risk for peripheral neurovascular dysfunction |
|
|
491 | (1) |
|
|
492 | (2) |
|
|
494 | (1) |
|
|
495 | (2) |
|
Risk for adult pressure injury |
|
|
497 | (2) |
|
|
499 | (2) |
|
Risk for child pressure injury |
|
|
501 | (2) |
|
|
503 | (2) |
|
Risk for neonatal pressure injury |
|
|
505 | (2) |
|
|
507 | (1) |
|
|
508 | (2) |
|
Risk for impaired skin integrity |
|
|
510 | (2) |
|
Risk for sudden infant death |
|
|
512 | (1) |
|
|
513 | (1) |
|
Delayed surgical recovery |
|
|
514 | (2) |
|
Risk for delayed surgical recovery |
|
|
516 | (1) |
|
Impaired tissue integrity |
|
|
517 | (2) |
|
Risk for impaired tissue integrity |
|
|
519 | (2) |
|
|
|
Risk for female genital mutilation |
|
|
521 | (1) |
|
Risk for other-directed violence |
|
|
522 | (1) |
|
Risk for self-directed violence |
|
|
523 | (1) |
|
|
524 | (2) |
|
|
526 | (2) |
|
Risk for suicidal behavior |
|
|
528 | (2) |
|
Class 4 Environmental hazards |
|
|
|
|
530 | (2) |
|
|
532 | (2) |
|
Risk for occupational injury |
|
|
534 | (1) |
|
|
535 | (1) |
|
Class 5 Defensive processes |
|
|
|
Risk for adverse reaction to iodinated contrast media |
|
|
536 | (1) |
|
Risk for allergy reaction |
|
|
537 | (1) |
|
Risk for latex allergy reaction |
|
|
538 | (1) |
|
|
|
|
539 | (1) |
|
|
540 | (1) |
|
|
541 | (1) |
|
|
542 | (2) |
|
Risk for neonatal hypothermia |
|
|
544 | (1) |
|
Risk for perioperative hypothermia |
|
|
545 | (1) |
|
Ineffective thermoregulation |
|
|
546 | (1) |
|
Risk for ineffective thermoregulation |
|
|
547 | (2) |
|
|
549 | (18) |
|
|
|
|
551 | (1) |
|
Readiness for enhanced comfort |
|
|
552 | (1) |
|
|
553 | (1) |
|
|
554 | (1) |
|
|
555 | (2) |
|
|
557 | (1) |
|
|
558 | (2) |
|
Class 2 Environmental comfort |
|
|
|
|
560 | (1) |
|
Readiness for enhanced comfort |
|
|
561 | (1) |
|
|
|
|
562 | (1) |
|
Readiness for enhanced comfort |
|
|
563 | (1) |
|
|
564 | (1) |
|
|
565 | (2) |
|
Domain 13 Growth/development |
|
|
567 | (8) |
|
|
|
This class does not currently contain any diagnoses |
|
|
|
|
|
Delayed child development |
|
|
568 | (2) |
|
Risk for delayed child development |
|
|
570 | (1) |
|
Delayed infant motor development |
|
|
571 | (2) |
|
Risk for delayed infant motor development |
|
|
573 | (2) |
Index |
|
575 | |
Foci Inside back cover |
|