CHAPTER 2THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES
care process and standards for professional performance, pro- viding impetus and support for the development and use of nursing diagnosis in the practice setting. Finally, NANDA In- ternational (formerly North American Nursing Diagnosis As- sociation) initiated research and intensified the work (ongoing for more than 30 years) of identifying client problems and needs for which nurses are accountable.
The linkage of nursing diagnoses to specific nursing interventions and client outcomes led to the development of a number of standardized nursing languages, for instance, the Omaha System, Clinical Care Classification (formerly Home Healthcare Classification), Ozbolt Patient Care Data Set (now retired), and Perioperative Minimum Data Set. The purpose of these languages is to help ensure continuity of appropriate cost-effective nursing care for the client regardless of setting.
This is accomplished in part through enhanced communica- tion, standardization of the process of evaluating the care pro- vided, and facilitation of documentation.
Today, NANDA-I continues the development of nurs- ing diagnosis labels (Table 2.1), which are complemented by the Iowa Intervention Project: Nursing Interventions Classi- fication (NIC) and the Iowa Outcomes Project: Nursing Out- comes Classification (NOC). NIC directs our focus to the content and process of nursing care by identifying and stan- dardizing the care activities nurses perform, and NOC describes client outcomes that are responsive to nursing in- tervention and develops corresponding measurement scales.
Combined, these three standardized languages (NNN) form a single language describing client problems or needs, nurs- ing actions, and outcomes for evaluation of the care provided.
Assessment Nursing
Diagnosis Ev
aluation
Assessment Ev
aluation Inter
vention
Planning Inter
vention
Inter ven Planning tion
Ev aluation
Assessment
Nursing Diagnosis Nu
rsing Diagnosis
NURSE CLIENT
Figure 2.1 Diagram of the nursing process. The steps of the nursing process are interrelated, forming a continuous circle of thought and action that is both dynamic and cyclic.
TABLE 2.1 Nursing Diagnoses Accepted for Use and Research Through 2014
Activity Intolerance [specify level]
Activity Intolerance, risk for Activity Planning, ineffective Activity Planning, risk for ineffective Adverse Reaction to Iodinated
Contrast Media, risk for Airway Clearance, ineffective Allergy Response, risk for Anxiety [specify level]
Aspiration, risk for
Attachment, risk for impaired Autonomic Dysreflexia Autonomic Dysreflexia, risk for Behavior, disorganized infant Behavior, readiness for enhanced
organized infant
Behavior, risk for disorganized infant Bleeding, risk for
Blood Glucose Level, risk for unstable Body Image, disturbed
Body Temperature, risk for imbalanced Breast Milk, insufficient
Breastfeeding, ineffective Breastfeeding, interrupted
Breastfeeding, readiness for enhanced Breathing Pattern, ineffective
Cardiac Output, decreased Caregiver Role Strain Caregiver Role Strain, risk for Childbearing Process, ineffective
Childbearing Process, readiness for enhanced Childbearing Process, risk for ineffective Comfort, impaired
Comfort, readiness for enhanced Communication, impaired verbal Communication, readiness for enhanced Confusion, acute
Confusion, risk for acute Confusion, chronic Constipation
Constipation, perceived Constipation, risk for Contamination Contamination, risk for Coping, compromised family Coping, defensive
Coping, disabled family Coping, ineffective
Coping, ineffective community Coping, readiness for enhanced
Coping, readiness for enhanced community Coping, readiness for enhanced family Death Anxiety
Decision Making, readiness for enhanced Decisional Conflict (specify)
Denial, ineffective Dentition, impaired
Development, risk for delayed Diarrhea
Disuse Syndrome, risk for Diversional Activity, deficient Dry Eye, risk for
Electrolyte Imbalance, risk for Energy Field, disturbed
Environmental Interpretation Syndrome, impaired
Failure to Thrive, adult Falls, risk for
Family Processes, dysfunctional Family Processes, interrupted
(continues on page 6)
[ ] author recommendations
Herdman, T.H. (Ed.). Nursing Diagnoses—Definitions and Classification 2012–2014. Copyright © 2012, 1994–2012 NANDA International. Used by arrangement with John Wiley & Sons Limited. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.
TABLE 2.1 Nursing Diagnoses Accepted for Use and Research Through 2014
(continued) Family Processes, readiness forenhanced Fatigue Fear
Feeding Pattern, ineffective infant Fluid Balance, readiness for enhanced [Fluid Volume, deficient hypertonic/
hypotonic]
Fluid Volume, deficient [isotonic]
Fluid Volume, excess
Fluid Volume, risk for deficient Fluid Volume, risk for imbalanced Gas Exchange, impaired
Gastrointestinal Motility, dysfunctional Gastrointestinal Motility, risk for
dysfunctional
Gastrointestinal Perfusion, risk for ineffective
Grieving
Grieving, complicated Grieving, risk for complicated Growth, risk for disproportionate Growth and Development, delayed Health, deficient community Health Behavior, risk-prone Health Maintenance, ineffective Home Maintenance, impaired Hope, readiness for enhanced Hopelessness
Human Dignity, risk for compromised Hyperthermia
Hypothermia
Immunization Status, readiness for enhanced
Impulse Control, ineffective Incontinence, bowel
Incontinence, functional urinary Incontinence, overflow urinary Incontinence, reflex urinary Incontinence, stress urinary Incontinence, urge urinary Incontinence, risk for urge urinary Infection, risk for
Injury, risk for Insomnia
Intracranial Adaptive Capacity, decreased
Jaundice, neonatal Jaundice, risk for neonatal
Knowledge, deficient [Learning Need]
[specify]
Knowledge [specify], readiness for enhanced
Latex Allergy Response Latex Allergy Response, risk for Lifestyle, sedentary
Liver Function, risk for impaired Loneliness, risk for
Maternal-Fetal Dyad, risk for disturbed Memory, impaired
Mobility, impaired bed Mobility, impaired physical Mobility, impaired wheelchair Moral Distress
Nausea
Noncompliance, [ineffective Adherence]
[specify]
Nutrition: less than body requirements, imbalanced
Nutrition: more than body requirements, imbalanced
Nutrition: more than body requirements, risk for imbalanced
Nutrition, readiness for enhanced Oral Mucous Membrane, impaired Pain, acute
Pain, chronic Parenting, impaired
Parenting, readiness for enhanced Parenting, risk for impaired
Perioperative Positioning Injury, risk for Peripheral Neurovascular Dysfunction,
risk for
Personal Identity, disturbed Personal Identity, risk for disturbed Poisoning, risk for
Post-Trauma Syndrome [specify stage]
Post-Trauma Syndrome, risk for Power, readiness for enhanced Powerlessness [specify level]
Powerlessness, risk for Protection, ineffective Rape-Trauma Syndrome Relationship, ineffective
Relationship, readiness for enhanced Relationship, risk for ineffective Religiosity, impaired
Religiosity, readiness for enhanced Religiosity, risk for impaired Relocation Stress Syndrome Relocation Stress Syndrome, risk for Renal Perfusion, risk for ineffective Resilience, impaired individual Resilience, readiness for enhanced Resilience, risk for compromised Role Conflict, parental
Role Performance, ineffective Self-Care, readiness for enhanced Self-Care Deficit, bathing Self-Care Deficit, dressing Self-Care Deficit, feeding Self-Care Deficit, toileting
Self-Concept, readiness for enhanced Self-Esteem, chronic low
Self-Esteem, situational low Self-Esteem, risk for chronic low Self-Esteem, risk for situational low Self-Health Management, ineffective Self-Health Management, readiness for
enhanced Self-Mutilation Self-Mutilation, risk for Self-Neglect
[Sensory Perception, disturbed (specify:
visual, auditory, kinesthetic, gustatory, tactile, olfactory)]
Sexual Dysfunction
Sexuality Pattern, ineffective Shock, risk for
Skin Integrity, impaired Skin Integrity, risk for impaired Sleep, readiness for enhanced Sleep Deprivation
Sleep Pattern, disturbed Social Interaction, impaired Social Isolation
Sorrow, chronic Spiritual Distress Spiritual Distress, risk for
Spiritual Well-Being, readiness for enhanced Stress Overload
Sudden Infant Death Syndrome, risk for Suffocation, risk for
Suicide, risk for
Surgical Recovery, delayed Swallowing, impaired
Therapeutic Regimen Management, ineffective family
Thermal Injury, risk for Thermoregulation, ineffective Tissue Integrity, impaired
Tissue Perfusion, ineffective peripheral Tissue Perfusion, risk for decreased cardiac Tissue Perfusion, risk for ineffective cerebral Tissue Perfusion, risk for ineffective
peripheral
Transfer Ability, impaired Trauma, risk for
Unilateral Neglect
Urinary Elimination, impaired
Urinary Elimination, readiness for enhanced Urinary Retention [acute/chronic]
Vascular Trauma, risk for
Ventilation, impaired spontaneous Ventilatory Weaning Response,
dysfunctional
Violence, risk for other-directed Violence, risk for self-directed Walking, impaired
Wandering [specify sporadic or continual]
CHAPTER 2THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES