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1.Classification of Nursing Diagnoses by Functional Health Patterns.
2.Classification of Nursing Diagnoses as Basic Human Needs.
3.Classification of Nursing Diagnoses: Definitions, risk factors and characteristic.
A nursing diagnosis is a professional judgment based on the application of clinical knowledge which determines potential or actual experiences and responses to health problems and life processes. The list of NANDA nursing diagnosis can be applied to individuals, families or communities. Included with the list of NANDA nursing diagnosis is an array of commonly applied interventions from which the caregiver can choose to implement to the given patient. Standardized nursing language is a body of terms used in the profession that is considered to be understood in common. The use of common terms promotes patient safety by allowing nurses to quickly and efficiently understand the aspects of a patient’s needs. The use of standardized terms allows nursing staff to avoid sifting through long narratives in order to determine a particular patient’s needs and planned course of care.
nanda nursing diagnosis list
The North American Nursing Diagnosis Association (NANDA) is a body of professionals that manages an official list of nursing diagnoses. The preliminary group was formed in 1973 after a conference was called for the purpose of classifying a list of nursing diagnoses grouped in alphabetical order. Kristine Gebbie and Mary Ann Lavin invited attendees from the United States and Canada to the meeting in St. Louis, Missouri. There the nurses created three components to begin the launch of an organized set of diagnoses. The National Clearinghouse for Nursing Diagnoses located at St. Louis University, the National Conference Group, and a Nursing Diagnosis Newsletter composed the three structures. NANDA was officially formed in 1982. The organization publishes the NANDA-I Definitions and Classification book that can be purchased by healthcare facilities and individual nurses. The association exists in order to continuously refine the terminology used and to develop and promote the lists in order to foster uniformity among professionals.
The NANDA nursing diagnosis list is an essential and useful tool that promotes patient safety by standardizing evidence-based nursing diagnoses. The process enables nurses to implement interventions with predictable outcomes. The presence of uniform and accurate documentation provided by the utilization of the diagnoses assists in obtaining reimbursement of medical bills. NANDA is comprised of goal-oriented nurses who are committed to continually increasing the quality of patient care while promoting and improving levels of patient safety. The group welcomes suggestions from nurses outside of the association on the creation of new or modification of existing nursing diagnoses. The organization conducts research which is funded by the NANDA Foundation.
Health care facilities keep a standardized NANDA nursing diagnosis list on site at each patient care unit. Commonly, pre-printed forms of diagnoses are kept at the nursing station to enable the nurse to have easy access to a course of care that he/she wishes to implement. The forms become part of the patient’s chart for easy accessibility by other staff members and eventually becomes part of the patient’s permanent record.
You can find All detailed diagnosis in our site, you have also a brief of nursing diagnosis list below:
EXCHANGES | COMMUNICATION | RELATIONS| VALUES | CHOICE | MOVEMENT | PERCEPTIONS | KNOWLEDGE | SENSATIONS AND EMOTIONS
– Excess nutrient:
Nutritional higher metabolic needs
– Nutritional Deficiency:
Nutritional intake below metabolic needs.
– Risk of nutritional excess:
Nutrient intake likely to be higher metabolic needs.
– Risk of infection:
High risk of contamination by pathogens.
– Risk of impaired body temperature:
Risk of inability to maintain body temperature within normal limits.
– Hypothermia:
Reduction in body temperature below the normal limits.
– Hyperthermia:
Elevation of body temperature above the normal limits.
– Ineffective Thermoregulation:
Fluctuations in body temperature between hypothermia and hyperthermia.
– Dysreflexia:
Non-inhibition of influx of the sympathetic nervous system faces a noxious stimuli that threaten the life of a person with a spinal cord up to D7 or above.
– Constipation:
Change in normal bowel habits characterized by a decrease in stool frequency and the emission of hard, dry stools.
– Pseudo-constipation:
Self-diagnosis of constipation and use of laxatives, enemas or suppositories to ensure daily bowel.
– Colic Constipation:
Emission of hard, dry stools due to a slower passage of food residues.
– Diarrhea:
Change in bowel habits characterized by the frequent loose stools, liquid and unformed.
– Fecal incontinence:
Change in bowel habits characterized by fecal accidents.
– Altered urinary elimination:
Disturbance in urinary excretion.
– Urinary Stress Incontinence:
Urine flow of less than 50 mL that occurs when abdominal pressure increases.
– Urinary incontinence reflex:
Involuntary flow of urine occurring at somewhat predictable intervals when the bladder reaches a specified volume.
– Urinary incontinence by reducing the time warning:
Involuntary flow of urine shortly after a strong urge to urinate is felt.
– Functional Incontinence:
Involuntary and unpredictable flow of urine.
– Urinary Incontinence complete (true):
Continuous and unpredictable flow of urine.
– Urinary retention (acute or chronic)
Incomplete bladder evacuation. Strong pressure on the urethra prevents the bladder from emptying
completely inhibits urination or until the increase in abdominal pressure cause involuntary urine flow.
– Decreased tissue perfusion:
(Specify) (cardio-pulmonary, cerebral, gastrointestinal, peripheral, renal)
Decrease in nutrition and cellular oxygenation secondary to decreased blood flow in capillaries.
The blood supply to tissues and cardiac output are normally directly connected. However, tissue perfusion may be insufficient without decreased cardiac output.
– Excess fluid volume:
Increase water retention accompanied by edema.
– Fluid Volume Deficit:
Vascular dehydration, cellular or intracellular secondary to dysfunction of regulatory mechanisms which caused an excessive demand organic or decrease the capacity of replacement.
– Risk of deficit fluid volume:
Vascular risk of dehydration, intracellular or cell loss may result from active or dysfunction of regulatory mechanisms which would cause excessive demand or a drop in replacement capacity.
– Decreased cardiac output:
Amount of blood pumped from the heart insufficient for tissue perfusion.
Note: In case of increase in basal metabolic rate, cardiac output may be normal without adequately meet the needs of the tissues. Cardiac output and blood flow to tissues are normally directly connected: the decrease in cardiac output results in impaired tissue perfusion. However, tissue perfusion may be insufficient without decreased cardiac output.
– Disruption of gas exchange:
Decreased exchange of oxygen and / or carbon dioxide between the alveoli and vasculature.
This reaction can occur only following a medical problem but may also result from an ineffective airway clearance and / or ineffective breathing pattern.
– Ineffective airway clearance:
Inability to clear the airways obstructions that impede the free passage of air.
– Mode of breathing ineffective:
Way to inspire and / or expire does not allow fill or empty the lungs properly.
– Inability to sustain spontaneous breathing:
Depletion of energy reserves making the person unable to maintain respiration sufficient to ensure their basic needs.
– Intolerance cessation of assisted ventilation:
Inability to adapt to a decrease in mechanical ventilation and which interrupts extends the withdrawal process.
– Risk of accident:
Situation in which a person may be injured because the conditions under which it is beyond the capacity of adaptation and defense.
– Risk of choking:
Increased danger of accidental suffocation (lack of air).
– Risk of poisoning:
High risk of accidentally come into contact with harmful substances in sufficient quantities to cause poisoning (adverse effects of a prescription medication or a drug).
– Risk of trauma:
High risk of accidental injury to tissue (wound, burn, fracture …)
– Risk of aspiration [suction]:
Risk of inhaling gastric secretions and / or oropharyngeal, solids or liquids into the trachea and bronchi (because of a malfunction or absence of normal protective mechanisms).
– Risk of immobility syndrome:
Risk of deterioration of organ function due to inactivity musculoskeletal prescribed or inevitable.
Note: According to NANDA complications due to immobility including pressure ulcers, constipation, stasis of pulmonary secretions, thrombosis, urinary tract infection, urinary retention, loss of strength or endurance, postural hypotension, decreased the amplitude of joint movements, disorientation, impaired body image and feelings of helplessness.
– Alteration of protective mechanisms:
Decreased ability to protect themselves from internal and external threats such as illness or accidents.
– Damage to tissue integrity:
Mucosal lesion in the cornea, the integument or subcutaneous tissues.
– Violation of the integrity of the oral mucosa:
Out of the tissue layers of the oral cavity.
– Violation of the integrity of the skin:
Skin lesion; break in the integument, the largest multifunctional organ of the body.
– Risk of injury to the skin:
Risk of skin lesion.
– Decreased intracranial adaptive capacity
– Disruption of the energy field
– Impaired verbal communication:
Difficulty or inability to use or understand language in interpersonal reactions.
– Disruption of social interaction:
Social relations excessive, inadequate or ineffective.
– Social isolation:
Loneliness that the person regards as imposed by others and she perceives as threatening or negative.
– Risk of loneliness:
Subjective state of a person at risk of experiencing a wave dysphoria.
– Disturbance in the performance of the role:
Upheaval in the way a person perceives the exercise of its role
– Disturbance in the exercise of parenting:
Unfitness of a parent or designated person to create an environment that promotes maximum growth and development of another human being.
It is important to add a preamble to this diagnosis that adaptation to parenting is part of the normal evolution towards maturity which leads to the nurse (e) activities in health promotion and prevention issues.
– Risk of disruption in the exercise of parenting:
Risk that a parent or surrogate becomes unable to create an environment that promotes maximum growth and development of another human being.
It is important to add a preamble to this diagnosis that adaptation to parenting is part of the normal evolution towards maturity which leads to the nurse (e) activities in health promotion and prevention issues.
– Sexual Dysfunction:
Change in sexual functioning perceived as unsatisfactory, demeaning or inappropriate.
– Disruption of family dynamics:
Dysfunction within a family that works effectively in most cases.
– Failure in the performance of the role of caregiver:
The caretaker of a sick or disabled has difficulty to perform the role of caregiver.
– Risk of failure in the performance of the role of caregiver:
The caretaker of a sick or disabled is likely to experience difficulty in exercising the role of caregiver.
– Disruption of family dynamics:
Dysfunction or risk of dysfunction within a family that works effectively in most cases.
– Conflict facing parenting:
Situation where a parent or a person with a dependent child changes roles or role appear to change due to intrinsic factors (illness, hospitalization, divorce, separation, for example)
– Disruption of sexuality:
Situation where a person experiences or may experience a change in sexual health.
Sexual health is a positive integration aspects of somatic, emotional, intellectual and social aspects of sexual being, so that it enriches personality, communication and love (WHO, 1975)
– Spiritual distress:
Disruption of the life principle that animates the whole being of a person and that integrates and transcends its biological and psychosocial.
– Spiritual well-being: possible updating
– Ineffective individual coping strategies:
Difficulty in adaptive behaviors and use problem solving techniques to meet the demands of life and fulfill its roles.
– Inability to adapt to a change in health status:
Inability to modify lifestyle or behavior based on a change in health status.
– Coping Strategies defensive:
Defense system against anything that seems to threaten a positive self-image, resulting in a systematic overestimation of oneself.
– Denial not constructive:
Conscious or unconscious attempt to disavow knowledge or meaning of an event to reduce anxiety or fear at the expense of his health.
– Ineffective family coping strategies: lack of support
Deteriorating relationship between the patient and a key person or other that makes it and the patient unable to perform effectively the adaptation work necessary to the problem health.
– Ineffective family coping strategies: support compromise:
Support, comfort, support and encouragement that usually provides a key person, family member or friends, are compromised or ineffective. The patient did not have enough support to support the work required to adapt their health problem.
– Effective family coping strategies: growth potential:
Situation where a family member who looks after the customer has done the work necessary to adapt.
It demonstrates the desire and the desire to improve his health and that of the customer and provide opportunity for personal growth.
– Ineffective family coping strategies: potential for improvement
– Ineffective coping strategies of a community
– Support for ineffective treatment program:
How to organize the treatment program of a disease or consequences of illness and to integrate it into daily life does not allow to achieve certain health goals.
– Non-observance (specify):
Refusal knowingly adhere to recommended treatment.
Note: it is difficult to treat the causes of this problem because of the ambiguity of the term. On the one hand nursing staff perceives the noncompliance negatively. On the other hand, the patient sees the refusal to adhere to treatment as a right. Since the nurse must respect the patient’s choice with him she will seek other ways to achieve the same objectives.
– Support for ineffective treatment program by the family
– Support for ineffective treatment program by a joint collectivity
– Effective management of the treatment program by the individual
– Conflict decision (specify):
Uncertainty about the line of action to take when the choice between acts antagonists involves risk, loss or questioning of personal values.
– Looking for a better standard of health: (specify the behavior)
Wishes of individuals whose health status is stable to change personal habits of health and / or its environment to improve its level of health.
A stable state of health is defined as the person has taken steps to prevent the disease age-appropriate, she said good or excellent health and, where appropriate, the signs and symptoms of disease are stabilized .
– Impaired physical mobility:
Location limiting the ability to move independently.
– Risk of peripheral neuromuscular dysfunction:
Risk of circulatory disorder. sensory or motor in a limb.
– Risk of injury in perioperative
– Intolerance to activity:
Lack of physical or mental energy that prevents a person from continuing or completing the required or desired daily activities.
– Fatigue:
Overwhelming feeling of exhaustion and prolonged reducing the capacity of physical and mental work.
– Risk of activity intolerance:
Situation in which a person might run out of physical or emotional energy to pursue or carry out daily activities required or desired.
– Disruption in sleep patterns:
Disruption of sleep that the patient inconvenient or impossible to have the lifestyle they want.
– Lack of leisure:
Boredom resulting from declining interest in leisure activities or inability to have (because of internal or external factors Relevant or not the will).
– Disability (partial or total) to organize and maintain the home:
Inability to maintain unaided a safe and conducive to personal growth.
– Difficult to stay healthy:
Situation in which a person does not know where to get help to stay healthy, is unable to find or do not know what conduct stand facing support services.
If this nursing diagnosis is the result of an addition problem of nursing (lack of knowledge, impaired verbal communication, impaired thinking processes, coping strategies ineffective individual or family …) and if the same factor encouraging is found, we recommend to integrate interventions for difficulty maintaining health diagnosis priority.
– Disability (partial or total) to eat:
Feeding difficulty: difficulty temporary, permanent or gradually increasing.
Note: the notion of personal care is not limited to pae hygiene, it also encompasses the practices of health promotion, the ability to take charge and thinking.
– Disability (partial or total) to swallow:
Decreased ability to move voluntarily liquids and / or solids from the mouth to the stomach.
– Breastfeeding ineffective:
The mother or baby are struggling to master the process of breastfeeding and do not derive satisfaction.
– Breastfeeding interrupted:
Suspension of the process of breastfeeding because the mother is unable to breastfeed or breast-feeding is not recommended against.
– Breastfeeding efficient (learning need):
The mother and baby proficient enough with the nursing process and derive satisfaction.
– Power Mode ineffective in infants:
Disturbance of sucking reflex of a baby or difficulty coordinating sucking and swallowing.
– Disability (partial or total) to wash / perform its hygiene:
Difficulty bathing and hygiene self-care without assistance; difficulty temporary, permanent or gradually increasing.
Note: the notion of personal care is not limited to personal care, it also encompasses the practices of health promotion, the ability to learn and how to think.
– Disability (partial or total) to dress / appearance of care:
Difficulty dressing and treat its appearance without assistance; difficulty temporary, permanent or gradually increasing.
Note: the notion of personal care is not limited to personal care, it also encompasses the practices of health promotion, the ability to learn and how to think.
– Disability (partial or total) to use the toilet:
Difficulty using the toilet without help; difficulty temporary, permanent or gradually increasing.
Note: the notion of personal care is not limited to personal care, it also encompasses the practices of health promotion, the ability to learn and how to think.
– Disturbance of growth and development:
Deviations from established norms for the age group of person.
– Syndrome of maladjustment to a change of environment:
Physiological disturbances and / or psychosocial resulting from a change of medium.
– Risk of behavioral disorganization in infants
– Behavioral disorganization in infants
– Organization of infant behavior: potential for improvement
– Disturbance of body image:
Change in how a person perceives his body image.
– Disturbance of self-esteem:
Adverse judgment for oneself or abilities that can be expressed directly or indirectly.
– Disturbance of chronic self-esteem:
Depreciation and maintenance of long-standing negative feelings vis-?-vis himself or his abilities.
– Disruption of situational self-esteem:
Adverse judgment for oneself in reaction to a loss or a change in a person who previously had a positive image of itself.
– Disturbance of personal identity:
Inability to distinguish between the self and the outside world.
– Altered sensory perception:
(Specify: auditory, gustatory, kinesthetic, olfactory, tactile, visual)
Reaction diminished, exaggerated or inappropriate to a change in the amount or nature of the stimuli received by the senses.
– The hemibody Negligence:
State in which a person does not see one side of the body or do not pay attention.
The non-perception or inattention extends to the immediate space around half of his body.
– Loss of hope:
Subjective state in which a person sees little or no alternatives or personal choices good and is unable to mobilize its oi-these for its own account.
– Feelings of powerlessness:
Impression that his actions will have no effect. Feeling powerless against a common situation or a sudden event.
– Lack of knowledge (specify the need for learning):
The patient or the key person in his life does not have the accurate information needed to make informed choices about their situation and the available treatment modalities and treatment plan.
– Syndrome of misinterpretation of the environment:
Disorientation to person, places, time and circumstances for more than three to six months, requiring the application of safeguards.
– Acute Confusion:
Sudden and transient appearance of a set of behavioral changes accompanied by disturbance of attention, cognition, psychomotor activity, the level of consciousness and / or sleep-wake cycle.
– Chronic Confusion:
Irreversible damage, long and / or progressive ability to interpret environmental stimuli
and intellectual processes that manifests as impaired memory, orientation and behavior.
– Alteration of operations of thought:
Business disruption and cognitive activities.
– Memory problems:
Forgot flanges information or skills acquired. The memory impairment may be caused by physiological or situational and be temporary or permanent.
– Acute pain:
Distress or malaise experienced and reported by the person.
– Chronic Pain:
Pain lasting for more than six months.
Note: Pain indicates that something is wrong. Chronic pain can also be recurring (eg migraine) as constant. One way or another, it is debilitating.
The chronic pain syndrome often manifests as learned behaviors and it seems that the predisposing factors are psychological order. This is a complex clinical entity, separate and associated elements from other nursing diagnoses: helplessness, lack of leisure, disruption of family dynamics, partially or totally unable to eat, to wash self-care or hygiene, sev?tir or treat its appearance, using the toilet …
– Mourning [grief] dysfunctional:
Delayed or exaggerated reaction to a perceived loss of actual or potential.
– Mourning [grief] in advance:
Reaction to a loss before it happens.
Note: It may be a healthy response requiring only supportive interventions and information.
– Risk of violence against self or to others:
Behavior likely to cause harm to oneself or others. The damage can range from neglect to abuse or even death and the injury may be psychological or physical.
– Risk of self harm:
High risk of injury without intent to kill himself producing tissue damage and a sense of relief.
– Post-traumatic reaction:
Painful and prolonged reaction to unforeseen calamity.
– Rape trauma syndrome:
Violent sexual penetration made under duress and against the will of the victim. Trauma syndrome following a sexual assault or attempted assault includes an acute disruption of lifestyle and a long-term process of reorganization. This syndrome consists of three elements: trauma, and mixed reaction silent reaction.
Note: This section uses the female, but even if the victims are mostly women, men can also be victims.
– Rape trauma syndrome: Mixed reaction. cf: rape trauma syndrome
– Rape trauma syndrome: silent reaction. cf: rape trauma syndrome
– Anxiety:
(Mild, moderate, severe or panic)
Vague sense of unease home generally undetermined or unknown.
– Fear:
Fear related to an identifiable source confirmed that the small person.
NANDA has helped to increase patient safety and continuity of care by the development of its standardized list. Its use has helped to allow better efficiency and more effective patient care using nanda Nursing Diagnosis List.