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Obra originalmente publicada sob o título Nanda International nursing diagnoses : Reservados todos os direitos de publicação, em língua portuguesa, à. The foci of the nursing diagnoses in NANDA-I Taxonomy II, and their associated .. We have directly partnered with GrupoA for our Portuguese translation, and. NANDA - Free download as PDF File .pdf), Text File .txt) or view presentation slides online. NANDA.
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The editors of this edition would like to dedicate this book to the memory of our founder, Dr. From Assessment to Diagnosis 6. A Short History 7. Health awareness Decreased diversional activity engagement Readiness for enhanced health literacy Sedentary lifestyle Class 2.
Health management Frail elderly syndrome Risk for frail elderly syndrome Deficient community health Risk-prone health behavior Ineffective health maintenance Ineffective health management Readiness for enhanced health management Ineffective family health management Ineffective protection Domain 2. Nutrition Class 1.
Ingestion Imbalanced nutrition: Absorption This class does not currently contain any diagnoses Class 4.
Metabolism Risk for unstable blood glucose level Neonatal hyperbilirubinemia Risk for neonatal hyperbilirubinemia Risk for impaired liver function Risk for metabolic imbalance syndrome Class 5. Hydration Risk for electrolyte imbalance Risk for imbalanced fluid volume Deficient fluid volume Risk for deficient fluid volume Excess fluid volume Domain 3. Elimination and exchange Class 1. Urinary function Impaired urinary elimination Functional urinary incontinence Overflow urinary incontinence Reflex urinary incontinence Stress urinary incontinence Urge urinary incontinence Risk for urge urinary incontinence Urinary retention Class 2.
Integumentary function This class does not currently contain any diagnoses Class 4. Respiratory function Impaired gas exchange Domain 4. Energy balance Imbalanced energy field Fatigue Wandering Class 4. Self-care Impaired home maintenance Bathing self-care deficit Dressing self-care deficit Feeding self-care deficit Toileting self-care deficit Readiness for enhanced self-care Self-neglect Domain 5.
Attention Unilateral neglect Class 2. Orientation This class does not currently contain any diagnoses Class 3. Communication Readiness for enhanced communication Impaired verbal communication Domain 6.
Self-perception Class 1. Self-concept Hopelessness Readiness for enhanced hope Risk for compromised human dignity Disturbed personal identity Risk for disturbed personal identity Readiness for enhanced self-concept Class 2.
Self-esteem Chronic low self-esteem Risk for chronic low self-esteem Situational low self-esteem Risk for situational low self-esteem Class 3. Body image Disturbed body image Domain 7. Role relationship Class 1. Caregiving roles Caregiver role strain Risk for caregiver role strain Impaired parenting Risk for impaired parenting Readiness for enhanced parenting Class 2.
Role performance Ineffective relationship Risk for ineffective relationship Readiness for enhanced relationship Parental role conflict Ineffective role performance Impaired social interaction Domain 8. Sexuality Class 1. Sexual identity This class does not currently contain any diagnoses Class 2. Sexual function Sexual dysfunction Ineffective sexuality pattern Class 3. Reproduction Ineffective childbearing process Risk for ineffective childbearing process Readiness for enhanced childbearing process Risk for disturbed maternal-fetal dyad Domain 9.
Post-trauma responses Risk for complicated immigration transition Post-trauma syndrome Risk for post-trauma syndrome Rape-trauma syndrome Relocation stress syndrome Risk for relocation stress syndrome Class 2.
Neurobehavioral stress Acute substance withdrawal syndrome Risk for acute substance withdrawal syndrome Autonomic dysreflexia Risk for autonomic dysreflexia Decreased intracranial adaptive capacity Neonatal abstinence syndrome Disorganized infant behavior Risk for disorganized infant behavior Readiness for enhanced organized infant behavior Domain Life principles Class 1. Beliefs Readiness for enhanced spiritual well-being Class 3.
Infection Risk for infection Risk for surgical site infection Class 2. Violence Risk for female genital mutilation Risk for other-directed violence Risk for self-directed violence Self-mutilation Risk for self-mutilation Risk for suicide Class 4. Environmental hazards Contamination Risk for contamination Risk for occupational injury Risk for poisoning Class 5.
Thermoregulation Hyperthermia Hypothermia Risk for hypothermia Risk for perioperative hypothermia Ineffective thermoregulation Risk for ineffective thermoregulation Domain Comfort Class 1.
Environmental comfort Impaired comfort Readiness for enhanced comfort Class 3. Social comfort Impaired comfort Readiness for enhanced comfort Risk for loneliness Social isolation Domain Growth This class does not currently contain any diagnoses Class 2.
Today, development and refinement of the taxonomy is heavily based on a global effort. In fact, we received more submissions of new diagnoses and proposals for revisions from countries outside North America than within it during this publication cycle. Moreover, the organization has become truly international; members from the Americas, Europe, and Asia are actively participating on committees, leading committees as chairs, and managing the organization as directors of the Board.
In this — version, the Eleventh Edition, the taxonomy provides diagnoses, with the addition of 17 new diagnoses.
Each nursing diagnosis has been the product of one or more of our many NANDA-I volunteers, and most have a defined evidence base. We all know that practice and regulation of nursing varies from country to country. We always welcome submissions for new nursing diagnoses.
At the same time, we have a serious need for revision of existing diagnoses to reflect the most recent evidence. While preparing for this edition, we took a bold step highlighting the underlying problems with many of the current diagnoses. Please note that more than 70 diagnoses have no level of evidence LOE ; that means there has been no major update on these diagnoses since at least , when the LOE criteria were introduced.
In addition, to treat the problems described in each nursing diagnosis effectively, related or risk factors are required. Translating abstract English terms into other languages can often be frustrating. When I faced difficulties translating from English to Japanese, I remembered the story from the eighteenth-century about scholars who translated a Dutch anatomy textbook into Japanese without any dictionary.
They say the scholars sometimes spent one month to translate just one page! Today, we have dictionaries and even automatic translation systems, but translation of diagnostic labels, definitions, and diagnostic indicators is still not an easy task.
Conceptual translation, rather than word-for-word translation, requires that the translators clearly understand the intent of the concept. When the terms in English are abstract or very loosely defined, this increases the difficulty in assuring a correct translation of the concepts. Over the years, I have learned that sometimes a very minor modification of the original English term can alleviate a burden on translators.
Your comments and feedback will help make our terminology, not only more translatable, but it will also increase the clarity of English expressions. Beginning with this edition, we have three primary publishing partners. The remainder of the world, including the original English version, will be spearheaded by a team from Thieme Medical Publishers, Inc.
We are very excited about these partnerships and the possibilities that these fine organizations bring to our association and the availability of our terminology around the globe.
I want to commend the work of all NANDA-I volunteers, committee members, chairpersons, and members of the Board of Directors for their time, commitment, devotion, and ongoing support.
I want to thank our staff, led by our Chief Executive, Dr. Heather Herdman, for its efforts and support. Without question, this terminology reflects the dedication of individuals who research and develop or refine diagnoses, and the volunteers that make up the Diagnosis Development Committee, as well as its Chair, Prof.
Dickon Weir-Hughes. This text represents the culmination of tireless volunteer work by a very dedicated, extremely talented group of individuals who have developed, revised, and studied nursing diagnoses for more than 40 years. We would like to offer a particularly significant note of appreciation to Dr.
Please contact us at execdir nanda. This includes an overview of major changes to this edition: Those individuals and groups who submitted new or revised diagnoses that were approved are identified.
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. Further, the adoption of at-risk populations and associated conditions was a pain-staking process, led by Dr.
Shigemi Kamitsuru. Each diagnosis was reviewed for related factors or risk factors that met the definitions of these terms. New information has been added on clinical reasoning; all chapters are revised for this edition. There are corresponding internet-based presentations available for teachers and students that augment the information found within the chapters; icons appear in chapters that have these accompanying support tools.
Review Process Proposed diagnoses and revisions of diagnoses undergo a systematic review to determine consistency with the established criteria for a nursing diagnosis.
All submissions are subsequently staged according to evidence supporting either the level of development or validation. Diagnoses may be submitted at various levels of development e. The current review process for accepting new and revised diagnoses into the terminology is under review, as the organization strives to move to a stronger, evidence-based process.
Information on the full review process and expedited review process for all new and revised diagnosis submissions will be available once the process is fully articulated and approved by the NANDA-I Board of Directors.
Information regarding the procedure to appeal a DDC decision on diagnosis review is also available on our website. This process explains the recourse available to a submitter if a submission is not accepted.
LOE 1: Label Only The label is clear, stated at a basic level, and supported by literature references, which are identified. NANDA-I will consult with the submitter and provide education related to diagnostic development through printed guidelines and workshops. LOE 1. Label and Definition The label is clear and stated at a basic level. The definition is consistent with the label. The definition differs from the defining characteristics and label. These components are not included in the definition.
The label and definition are supported by literature references, which are identified. Theoretical Level The definition, defining characteristics and related factors, or risk factors, are provided with theoretical references cited, if available. Expert opinion may be used to substantiate the need for a diagnosis. The intention of diagnoses received at this level is to enable discussion of the concept, testing for clinical usefulness and applicability, and to stimulate research.
LOE 2: Label, Definition, Defining Characteristics and Related Factors, or Risk Factors, and References References are cited for the definition, each defining characteristic, and each related factor, or risk factor. In addition, it is required that nursing outcomes and nursing interventions from a standardized nursing terminology e. LOE 2. In addition, a narrative review of relevant literature, culminating in a written concept analysis, is required to demonstrate the existence of a substantive body of knowledge underlying the diagnosis.
Studies include those soliciting expert opinion, Delphi, and similar studies of diagnostic components in which nurses are the subjects. LOE 3: The synthesis is in the form of an integrated review of the literature.
LOE 3. The narrative includes a description of studies related to the diagnosis, which includes defining characteristics and related factors, or risk factors. Studies may be qualitative in nature, or quantitative using nonrandom samples, in which patients are subjects. Random sampling is used in these studies, but the sample size is limited. Random sampling is used in these studies, and the sample size is sufficient to allow for generalizability of results to the overall population.
This change reflects the recognition that there are populations for whom health may be enhanced, with the nurse acting as an agent for the patients, even if the patients impacted are unable to verbalize intent e.
The revised definition is as follows new wording italicized. Health Promotion Diagnosis A clinical judgment concerning motivation and desire to increase well-being and to actualize health potential. These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any health state.
Health promotion responses may exist in an individual, family, group, or community. Table 3. One diagnosis had been slotted, in the 10th edition, to be retired if it was not revised.
No revision occurred, so this diagnosis was therefore removed. We encourage pediatric nurses to consider reconceptualization of this diagnosis, and to present it to NANDA-I as a new diagnosis. Risk for disproportionate growth , Domain 13, Class 1.
Seven remaining diagnoses were retired from the terminology, after review by the Diagnosis Development Committee. These diagnoses were inconsistent with the current literature, or lacked sufficient evidence to support their continuation within the terminology. Health Promotion Readiness for enhanced health literacy B.
Health awareness Domain 2: Nutrition Ineffective adolescent eating dynamics S.
Class 1: Ingestion G. Lopez-Santos, Class 4: Metabolism PhM; D. Armero-Barranco, PhD; J. Xandri- Graupera, PhM; J. Paniagua-Urban, PhM; M. Arrillo-Izquierdo, PhM; A. Ruiz-Sanchez, PhM Domain 4: Energy balance D. Posttrauma responses Neonatal abstinence syndrome L. Neurobehavioral stress Acute substance withdrawal syndrome L. Neurobehavioral stress Risk for acute substance withdrawal syndrome L.
Neurobehavioral stress Domain Infection C. Physical injury Risk for venous thromboembolism G. Physical injury Risk for female genital mutilation I. Ruiz, RN Class 3: Violence Risk for occupational injury F.
Thermoregulation Noncompliance , Domain 1, Class 2. This diagnosis was quite old, with a last revision in It is no longer consistent with the majority of current research in the area, which has as its focus the concept of adherence rather than compliance.
Readiness for enhanced fluid balance , Domain 2, Class 5. Readiness for enhanced urinary elimination , Domain 3, Class 1. These diagnoses lacked sufficient evidence to support their continuation within the terminology. Risk for impaired cardiovascular function , Domain 4, Class 4.
This diagnosis lacked sufficient differentiation from other cardiovascular diagnoses within the terminology. Risk for ineffective gastrointestinal perfusion , Domain 4, Class 4. Risk for ineffective renal perfusion , Domain 4, Class 4. Risk for imbalanced body temperature , Domain 11, Class 6 — replaced by new diagnosis, Risk for ineffective thermoregulation Revisions to this diagnosis led to the recognition that the concept of interest was thermoregulation, and the definition and risk factors were consistent with the current diagnosis, ineffective thermoregulation Therefore, the label and definition were changed, leading to the need to retire the current code and assign a new code.
These changes were made to ensure that the diagnostic label was consistent with current literature, and reflected a human response. The diagnostic label changes are shown in Table 3. Health promotion Deficient diversional activity Decreased diversional activity engagement 2. Nutrition Insufficient breast milk Insufficient breast milk production 2. Nutrition Neonatal jaundice Neonatal hyperbilirubinemia 2. Nutrition Risk for neonatal jaundice Risk for hyperbilirubinemia This work was undertaken in earnest during the previous cycle of the book 10th edition , with several months being dedicated for the review, revision, and standardization of terms being used.
The process used included individual review of assigned domains, followed by a second reviewer independently reviewing the current and newly recommended terms. The two reviewers then met—either in person or via webbased video conferencing—and reviewed each line a third time, together. Once consensus was reached, the third reviewer took the current and recommended terms, and independently reviewed them.
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 began. Common phrases, 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. This work continued during this 11th cycle of the taxonomy. That said, we know the work is not done, it is not perfect, and there may be disagreements with some of the changes that were made.
However, we do believe these changes continue to improve the diagnostic indicators, making them more clinically useful, and providing better diagnostic support. The benefits of this are many, but the following are perhaps the most notable: There have been multiple questions regarding previous editions that were difficult to answer.
Some examples are the following: For example, what is the difference between abnormal skin color e. Are the differences significant? Some of the translations are almost the same—for example, abnormal skin color, color changes, skin color changes —can we use one single term or must we translate the exact English term? 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 do not understand?
Are they there to teach, to clarify, to list every potential example? There seems to be a mixture of possible reasons for their appearance in the terminology. We have also done our best to condense terms and standardize them, whenever possible. All terms are now coded for use in EHR systems, which is something we have been asked to do repeatedly by many organizations and vendors alike. Introduction of At-Risk Populations and 3. The issue has been that the data are helpful when diagnosing a patient, and it was decided that these data needed to be available to nurses as they considered potential nursing diagnoses.
However, because we indicate that interventions should be aimed at related factors, this caused confusion among students and practicing nurses. Therefore, we have added two new terms in this edition to clearly indicate data which are helpful when making a diagnosis, even though they are not amenable to independent nursing intervention. Users will notice that many of the former related factors or risk factors have now been recategorized into either at- risk populations or associated conditions.
Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmaceutical agents. These conditions are not independently modifiable by the professional nurse, but may support accuracy in nursing diagnosis. However, over the past 20 to 30 years, there has been an increasing involvement by nurses from around the world, and membership in NANDA International, Inc.
Work is occurring across all continents using NANDA-I nursing diagnoses in curricula, clinical practice, research, and informatics applications. Development and refinement of diagnoses is ongoing across multiple countries, and the majority of research related to the NANDA-I nursing diagnoses is occurring outside North America. As a reflection of this increased international activity, contribution, and utilization, the North American Nursing Diagnosis Association changed its scope to an international organization in , changing its name to NANDA International, Inc.
So, please, we ask that you do not refer to the organization as the North American Nursing Diagnosis Association or as the North American Nursing Diagnosis Association International , unless referring to something that happened prior to —it simply does not reflect our international scope, and it is not the legal name of the organization. During that meeting, significant discussions occurred as to how best to handle these and other issues.
Nurses in some countries are not able to utilize nursing diagnoses of a more physiologic nature because they are in conflict with their current scope of nursing practice.
Discussions were therefore held with international leaders in nursing diagnosis use and research, looking for direction that would meet the needs of the worldwide community. These discussions resulted in a unanimous decision to maintain the taxonomy as an intact body of knowledge in all languages, in order to enable nurses around the world to view, discuss, and consider diagnostic concepts being used by nurses within and outside of their countries, and to engage in discussions, research, and debate regarding the appropriateness of all of the diagnoses.
A critical statement agreed upon in that Summit is noted here prior to introducing the nursing diagnoses themselves: Not every nursing diagnosis within the NANDA-I taxonomy is appropriate for every nurse in practice—nor has it ever been. Some of the diagnoses are specialty-specific, and would not necessarily be used by all nurses in clinical practice …. There are diagnoses within the taxonomy that may be outside the scope or standards of nursing practice governing a particular geographic area in which a nurse practices.
Those diagnoses would, in these instances, not be appropriate for practice, and should not be used if they lie outside the scope or standards of nursing practice for a particular geographic region. However, it is appropriate for these diagnoses to remain visible in the taxonomy, because the taxonomy represents clinical judgments made by nurses around the world, not just those made in one region or country. However, it is also important for all nurses to be aware of the areas of nursing practice that exist globally, as this informs discussion and may over time support the broadening of nursing practice across other countries.
That said, it is important that you are not avoiding the use of a diagnosis because, in the opinion of one local expert or published textbook, it is not appropriate. It is, therefore, important to truly educate oneself on regulation, law, and professional standards of practice in one's own country and area of practice, rather than relying on the word of one person, or group of people, who may be inaccurately defining or describing nursing diagnosis.
Ultimately, nurses must identify those diagnoses that are appropriate for their area of practice, that fit within their scope of practice or legal regulations, and for which they have competency. Nurse educators, clinical experts, and nurse administrators are critical to ensuring that nurses are aware of diagnoses that are truly outside the scope of nursing practice in a certain geographic region.
Multiple textbooks in many languages are available that include the entire NANDA-I taxonomy, so for the NANDA-I text to remove diagnoses from country to country would no doubt lead to a great level of confusion worldwide. Publication of the taxonomy in no way requires that a nurse utilize every diagnosis within it, nor does it justify practicing outside the scope of an individual's nursing license or regulations to practice.
Currently, there are two position statements: The use of an evidence-based nursing framework, such as Gordon's functional health pattern FHP assessment, should guide assessment that supports nurses in determination of NANDA-I nursing diagnoses. For accurate determination of nursing diagnoses, a useful, evidence-based assessment framework is the best practice.
While this is recognized as best practice, it may be that some information systems do not provide this opportunity. They allow us to communicate ideas and experiences to others so that they may share our understanding.
Nursing diagnoses are an example of a powerful and precise terminology that highlights and renders visible the unique contribution of nursing to global health.
Nursing diagnoses communicate the professional judgments that nurses make every day—to our patients, our colleagues, members of other disciplines, and the public. They are our words. NANDA-I will be a global force for the development and use of nursing's standardized diagnostic terminology to improve the health care of all people. Our Mission To facilitate the development, refinement, dissemination, and use of standardized nursing diagnostic terminology.
Our Purpose Implementation of nursing diagnosis enhances every aspect of nursing practice, from garnering professional respect to assuring accurate documentation for reimbursement. This unique, evidence-based perspective includes social, psychological, and spiritual dimensions of care. Louis, MO, United States, in This conference and the ensuing task force ignited interest in the concept of standardizing nursing terminology.
A dynamic, international process of diagnosis review and classification approves and updates terms and definitions for identified human responses. Nursing terminology is the key to defining the future of nursing practice and ensuring the knowledge of nursing is represented in the patient record— NANDA-I is the global leader in this effort. Join us and become a part of this exciting process.
Many opportunities exist for participation on committees, as well as in the development, use, and refinement of diagnoses, and in research. Opportunities also exist for international liaison work and networking with nursing leaders. Professional Networking — Professional relationships are built through serving on committees, attending our various conferences, participation in the Nursing Diagnosis Discussion Forum, and reaching out through the Online Membership Directory.
IJNK communicates efforts to develop and implement standardized nursing language across the globe. It is our hope this will enable more individuals with interest in the work of NANDA-I to participate in setting the future direction of the organization. How to Join Go to www. For more information, and to apply for membership online, please visit: This is true in hospitals as well as other settings across the continuum of care e. Each health care discipline brings its unique body of knowledge to the care of the client.
In fact, a unique body of knowledge is a critical characteristic of a profession. Collaboration, and at times overlap, occurs between professionals in providing care Fig. For example, a physician in a hospital setting may write an order for the client to walk twice per day.
Physical therapy focuses on core muscles and movements necessary for walking. Respiratory therapy may be involved if oxygen therapy is used to treat a respiratory condition. Nursing has a holistic view of the patient, including balance and muscle strength related to walking, as well as confidence and motivation.
Social work may be involved with insurance coverage for necessary equipment. Physicians treat diseases and use the International Classification of Disease ICD taxonomy to represent and code the medical problems they treat.
Psychologists, psychiatrists, and other mental health professionals treat mental health disorders, and use the Diagnostic and Statistical Manual of Mental Disorders DSM. The nursing diagnosis taxonomy, and the process of diagnosing using this taxonomy, will be described further. It contains nursing diagnoses grouped into 13 domains and 47 classes. Domains are divided into classes, which are groupings that share common attributes. Such responses are the central concern of nursing care and fill the circle ascribed to nursing in Fig.
A nursing diagnosis can be problem-focused, a state of health promotion, or a potential risk. A syndrome is a clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are therefore best addressed together and through similar interventions. An example of a syndrome diagnosis is chronic pain syndrome Chronic pain is recurrent or persistent pain that has lasted at least 3 months and that significantly affects daily functionings or well-being.
Chronic pain syndrome is differentiated from chronic pain in that, in addition to the chronic pain, it has significant impact on other human responses and thus includes other diagnoses, such as disturbed sleep pattern , fatigue , impaired physical mobility , or social isolation The nursing process includes assessment, nursing diagnosis, planning, outcome setting, intervention, and evaluation Fig.
All of these steps require knowledge of underlying concepts of nursing science before patterns can be identified in clinical data or accurate diagnoses can be made. Adapted from Herdman Examples of critical concepts important to nursing practice include breathing, elimination, thermoregulation, physical comfort, self- care, and skin integrity.
Understanding such concepts allows the nurse to see patterns in the data and accurately diagnose. Key areas to understand within the concept of pain, for example, include manifestations of pain, theories of pain, populations at risk, related pathophysiological concepts fatigue, depression , and management of pain.
Full understanding of key concepts is needed, as well, to differentiate diagnoses. For example, to understand issues related to respiration, a nurse must first understand the core concepts of ventilation, gas exchange, and breathing pattern. As you can see, although each of these diagnoses is related to the respiratory system, they are not all concerned with the same core concept. Thus, the nurse may collect a significant amount of data, but without a sufficient understanding of the core concepts of ventilation, gas exchange, and breathing pattern, the data needed for accurate diagnosis may have been omitted and patterns in the assessment data go unrecognized.
Assessments can be based on a specific nursing theory, such as one developed by Florence Nightingale, Wanda Horta, or Sr. 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 involves the use of clinical judgment to decide what is wrong with a patient, and clinical decision-making to decide what needs to be done Levett-Jones et al Key issues, or diagnostic foci, may be evident early in the assessment e.
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 appropriate nursing diagnoses. A nursing diagnosis typically contains two parts: There are some exceptions in which a nursing diagnosis is only one word, such as anxiety , constipation , fatigue , and nausea 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 activity intolerance , impaired memory , readiness for enhanced health management , and risk for falls , and has been newly admitted to a skilled nursing facility. Although activity intolerance and impaired memory are the problem-focused diagnoses, the patient's risk for falls may be the number one priority diagnosis, especially as the individual adjusts to a new environment. This may be especially true when related risk factors are identified in the assessment e.
Table 5. It is important 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.
These diagnostic indicators include defining characteristics and related factors or risk factors Table 5.
An assessment that identifies the presence of a number of defining characteristics lends support 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. A review of client history often helps to identify related factors.
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.
These are characteristics that are not modifiable by the professional nurse. Associated conditions Medical diagnoses, injury procedures, medical devices, or pharmaceutical agents. These conditions are not independently modifiable by the professional nurse. New to this edition of the Nursing Diagnosis: Definitions and Classifications book are the categories of at-risk populations and associated conditions within relevant nursing diagnoses see Table 5.
At-risk populations are groups of individuals who share characteristics that cause each member to be susceptible to a particular human response.
These conditions are not independently modifiable by a professional nurse. Examples of associated conditions include a myocardial infarction, pharmaceutical agents, or surgical procedure. Data on both at-risk populations and associated conditions are important, are often collected during an assessment, and can help the nurse to consider potential diagnoses and confirm them. However, at-risk populations and associated conditions do not meet the intent of defining characteristics or related factors, because nurses cannot change or impact these categories independently.
For further information on this, see the Frequently Asked Questions section p. A nursing diagnosis does not need to contain all types of diagnostic indicators i. Problem- focused nursing diagnoses contain defining characteristics 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.
Only risk diagnoses have risk factors. For example, caregiver role strain related to around-the-clock care responsibilities, complexity of care activities, and unstable health condition of the care receiver as evidenced by difficulty performing required tasks, preoccupation with care routine, fatigue, and alteration in sleep pattern.
This information, however, should be recognized in the assessment data collected and recorded in the patient chart in order to provide support for the nursing diagnosis. Without this information, it is impossible to verify diagnostic accuracy, which puts the quality of nursing care in question.
Practice Reflection from a Nurse in the United States: Nursing diagnoses are used on the acute rehabilitation floor in a hospital where I work.
Computerized charting in the nursing plans of care is mandatory on every shift for every nurse. The electronic system contains 31 prepopulated nursing diagnoses available for the nurse to choose based on the patient assessment. Examples of the prepopulated diagnoses include risk for falls, risk for infection, excess fluid volume, and acute pain.
The nurse that initiates the care plan must also fill in what the problem is related to, the goal, time frame, interventions, and outcomes. High-priority nursing diagnoses need to be identified i.
Nursing diagnoses are used to identify intended outcomes of care and plan nursing-specific interventions sequentially. The Nursing Outcome Classification NOC is one system that can be used to select outcome measures related to a nursing diagnosis. Nurses often, and incorrectly, move directly from nursing diagnosis to nursing intervention 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. It is better to first have a clear location outcome in mind, and then choose a route intervention , to get to a desired location.
The Nursing Interventions Classification NIC is one taxonomy of interventions that nurses may use across various care settings. Using nursing knowledge, nurses perform both independent and interdisciplinary interventions. These interdisciplinary interventions overlap with care provided by other health care professionals e. Diabetes mellitus, in comparison, is a medical diagnosis, yet nurses provide both independent and interdisciplinary interventions to clients with diabetes who have various types of problems or risk states.
Practice Reflection from a Nurse in Brazil: Nursing diagnoses are used in my clinical setting, which is an adult ICU intensive care unit in a secondary- level university hospital.
The assessment starts with the input of patient data in standardized questionnaires, which generates prepopulated NANDA-I diagnostic hypotheses that will be validated or eliminated by the nurse.
There are additional boxes that are blank for nurses to input other diagnoses. Some prepopulated diagnoses include ineffective protection; self-care deficit: Later, the system proposes NIC interventions and activities, for selection by the nurse as a care plan.
Every shift the nursing diagnoses are re-evaluated as improved, worsened, unchanged, or resolved. 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 are collected and clustered into meaningful patterns and the accuracy of nursing diagnoses is evaluated. Similarly, the effectiveness of interventions and achievement of identified outcomes 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 the following: Am I making an inappropriate judgment? How confident am I in this diagnosis? Are the outcomes established appropriate for this client in this setting, given the reality of the patient's condition and resources available? Are the interventions based on research evidence or tradition e. 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 assessment 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 provides the structure for a standardized language in which to communicate nursing diagnoses.
The terminology provides a shared language for nurses to address health problems, risk states, and readiness for health promotion. In an increasingly global and electronic world, NANDA-I also allows nurses involved in scholarship to communicate about phenomena of concern to nursing in manuscripts and at conferences in a standardized way, thus advancing the science of nursing.
Continued submissions and revisions to NANDA-I will further strengthen the scope, extent, and supporting evidence of the terminology. 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, a family, a group, or a community. The nursing diagnosis components were reviewed in this chapter, including the label, definition, and diagnostic indicators i. 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. Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: American Psychiatric Association; Available at: Cambridge Dictionary On-Line. Cambridge, UK: Cambridge University Press; Nurse Educ Today. Nursing diagnosis definition.
Herdman TH, Kamitsuru S, eds. Definitions and Classification, — Wiley; Thinking like a nurse: J Nurs Educ. From Assessment to Diagnosis T. Heather Herdman 6. Tanner sees it as the process by which nurses make clinical judgments by selecting from alternatives, weighing evidence, using intuition and pattern recognition.
Similarly, Banning conducted a concept analysis of clinical reasoning, using 71 publications dating from to This study defined clinical reasoning as the application of knowledge and experience to a clinical situation, and identified the need for tools to measure clinical reasoning in nursing practice, so that it might be better understood.
It is important to note that considering clinical reasoning as a process does not signify that it is a step-by-step, linear process. This is especially true early in our careers, as we have yet to develop insight from enough patient situations to enable rapid pattern formation or problem identification.
What do we mean by pattern formation? We are basically talking about how our minds pull together a variety of data points to form a picture of what we are seeing. Let us first look at a nonclinical scenario. Assume you are out for a walk, and you go past a group of men seated at a picnic bench at a park. You notice that they are doing something with little rectangular objects, and they are speaking in very loud voices—some are even shouting—as they slam these objects on the table between them.
The men seem very intense, and it appears they are arguing about these objects, but you cannot understand what these objects are or what exactly the men are doing with them. As you slow down to watch them, you notice a small crowd has gathered. What is happening here? What is it that you are observing? It may be hard for you to articulate what you are seeing if it is something with which you have no experience. When we do not understand a concept, it is hard to move forward with our thinking process.
Suppose that we told you that what you were observing was men playing Mahjong, a type of tile-based board game. The tiles are used like cards, only they are small, rectangular objects traditionally made of bone or bamboo. You might begin to see the four men as competitors, each hoping to win the game, which might explain their intensity. You might begin to consider their raised voices as a form of good- natured taunting of one another, rather than angry shouting.
The same is true with concepts of importance in nursing. Many authors focus on the nursing process, without taking the time to ensure that we understand the concepts of nursing science; yet, the nursing process begins with—and requires —an understanding of these underlying concepts.
If we do not understand our basic disciplinary concepts, we will struggle to identify patterns we see in our patients, families, and communities. Thus, it is critical that we learn and teach these concepts so that nurses can recognize normal human responses, as well as abnormal, risk, and health promotion states related to those responses.
It is fair to say that applying the nursing process assessment, diagnosis, outcome identification, intervention, and evaluation is meaningless if we do not understand our nursing concepts diagnoses well enough to identify them from the patterns in the data we collect during assessment. Without a solid grounding in the concepts of our discipline, we will not begin to generate hypotheses regarding what is happening with our patients their human responses, or nursing diagnoses , nor will we have direction in terms of conducting a more in-depth assessment to rule out or confirm those hypotheses.
Thus, although conceptual knowledge has not generally been included within the nursing process, applying that process is impossible without it. On one of her placement days, Mrs. Randall stops in to see the nurse. She is 88 years old, and has only lived in the facility for two weeks.
She tells David that she is fatigued and cannot concentrate. She is very concerned that there is something wrong with her heart. David begins by taking her vital signs, but as he is doing this, he asks Mrs. Randall to tell him what has been happening in her life since she began living at the facility.
She indicates that she has not had anything unusual occur that she can identify, other than the move itself. She says this was her choice because she did not feel safe in her home anymore. She denies any chest pain, heart palpitations, or shortness of breath. Randall indicates that she has not been doing any exercise since she moved here because she does not like group exercise classes, and there is no exercise equipment that she can use on her own.
She had previously used an exercise bike in her home at least 30 minutes per day. She notes it was hard to leave her neighborhood because she had a very good friend who lived near her and they saw each other every day. Now they only talk by phone. Although she is glad she gets to talk with her, she says that it is not the same as enjoying a cup of tea in the kitchen with her friend. David asks if her apartment is comfortable for her.
She mentions it has large windows that give plenty of natural sunlight, which she likes, but notes it is quite warm; she lives on the third floor, and even when she turns the heat off, it is warmer than she likes.
David tells Mrs. Randall that her vital signs are very good, but he suggests that she may be suffering from a change in her sleep pattern, and suggests that they try a few adjustments to see if that can impact her sleep and feelings of restfulness.
First, he recommends that they speak with the environmental services director to get her heat adjusted to a comfortable temperature. He also tells her that there are some exercise bikes and treadmills in the building, located on the assisted living unit, but that all residents may use them at any time. He offers to show her where these are located and to make sure she is comfortable with how to use them, for which she is grateful. The use of nursing diagnoses in the unit assessed is a relatively new process, just as in the institution where the study was conducted.
The first discussion on the construction of a new model of nursing process started in with studies guided by the several nursing theories.
Nurses of the university hospital and professors of the Nursing Undergraduation formed study groups to discuss and define the theoretical framework that would be adopted to base the use of the nursing process; to prepare instruments for data collection history and physical examination and printed for the important records; to think about strategies to implement the new process.
During and , pilot studies were carried out in the Intensive Care and Orthopedic and Trauma Units, using the new model. In , the use of a new proposal was started in the whole institution, including the nursing diagnoses prepared according to NANDA Taxonomy II 12 , and we have kept the evolvement, prescription, and nursing notes that have been performed since the beginning of the 90's.
All changes require time and preparation to meet new demands, as well as investigations to assess how these occurrences are processed to direct interventions that can contribute to the improvement of the work.
The information on AIDS in the country showed an epidemic of multiple dimensions that, over time, has presented deep changes in their evolvement and distribution. It has been demonstrated the importance of heterosexual transmission and characteristics such as the feminization and ageing and pauperization of sick people The fact was also observed in a prospective study carried out in Iceland 16 and another; retrospective study in a Gynecologic Oncology ward, in the same hospital complex where the present study was carried out In this study, the authors assessed the improvement in the preparation of the process and the nursing diagnoses through the analysis and comparison of records before and after an educational intervention.
The most frequent diagnosis, in both times, was that of "pain" and the diagnosis "risk for infection", observed among the ten most frequently diagnosis, was no longer found after intervention.
We may suggest that the diagnosis was mistaken for "Risk for Infection". The main difficulty observed in the construction of nursing diagnoses referred to the appropriate choice or the identification of the related factors and defining characteristics.
In some diagnoses, there was a confusion and a change between the defining characteristic and the related factor, leading to a constant concern. Corroborating with the results of the present study, a systematic review showed that there is a difficult in the process to prepare nursing diagnoses concerning the capacity to associate them with signs, symptoms and etiology that characterize and determine that diagnosis 9.
The results and the choices of the nursing interventions depend on accurate and valid nursing diagnoses Its use starts by data collection and patients' history. When the information of people, families and communities is investigated and collected, professionals identify "signs and symptoms" or the defining characteristics of the nursing diagnoses concepts.
According to NANDA 19 , "the defining characteristics are those that can be observed and verified in individuals, families and communities. They work as signs and inferences that are grouped as manifestations of a real disease or a real state of well-being or a nursing diagnosis".
The factors or variables that influence the diagnoses are integrated to the history, charts and other evidences. These variables form the context, the "related factors" that are combined with the defining characteristics to prepare nursing diagnoses that are identified as characteristics or history of individuals, families and communities Therefore, to confirm the presence of a diagnosis, according to the nursing problems identified in a patient, the presence of defining characteristics of that diagnosis is necessary according to the taxonomy As for the related factors, discussions have been observed on the possibility of the use of factors that were not listed by NANDA, as long as they are strictly based on scientific evidences to ensure their validity.
It is important to consider that the elements of the names of the potential risk diagnoses change if compared to the actual diagnoses. The defining characteristics are not necessary, because in risk diagnoses the signs and symptoms are not present and the data are incomplete In an actual diagnosis, the identification of the defining characteristics require more accurate skills in the clinical evaluation, and the risk diagnosis can be made based on the characteristics of a situation or the context involving the patient.
In the present study, it was observed that most diagnoses of "risk for infection" had as risk factors the "invasive procedures" and "hospital stay". These factors that put patients at risk make nurses suspect that diagnoses are possible 18 , and therefore, if they are well prepared they are important to design preventive actions.
In a study carried out to assess factors that, according to a group of nurses of a university hospital in the south of Brazil, interfere in the adequate use of nursing diagnoses, the authors found arguments relatively "traditional" with a high frequency of agitated duties, number of patients per nurse and being involved with management tasks. Other parameters involved were the absence of a standardized model, shortcomings in the knowledge on the physical exam, and the terminology of the nursing diagnoses Although we have not carried out a similar inquiry in the present study, some aspects should be highlighted.
First the introduction of the use of the terminology was followed by the institution, as previously described, with all nurses discussing the model that was later standardized according to the construction of this collective. However, this follow-up did not seem enough to overcome the difficulties of the terminology. Because of the difficulties suggested by the findings of the present study, the authors recommend the involvement of all the nurses in the preparation of a standard for the most frequent nursing diagnoses, which will imply the discussion of concepts of nursing diagnoses, and the revision of the adopted practices with the participation of doers.
This will also enable the preparation of more adequate interventions to reach the planned goals. We have identified nursing diagnoses, of which had a different construction, were actual diagnoses and 18 were risk diagnoses.
The most frequent diagnoses were: Rev Latinoam Enferm. Conselho Federal de Enfermagem. Carpenito LJ. Porto Alegre: Horta VA. Processo de enfermagem. Lunney M. Critical thinking and accuracy of nurses' diagnoses: Nursing diagnoses, interventions and outcomes - application and impact on nursing practice: J Adv Nurs.
Relations between nursing data collection, diagnoses and prescriptions for adult patients at an intensive care unit. Rev Bras Enferm.
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