Nanda Nursing diagnoses definitions and classifaications, Eleventh Editions. 100% proven pass rate.

Document Content and Description Below

The foci of the nursing diagnoses in NANDA-I Taxonomy II, and their associated diasgnoses, start on the following pages: Activity planning 322–323 Activity tolerance 228–229 Acute substance wi... thdrawal syndrome 351–352 Adaptive capacity 357 Adverse reaction to iodinated contrast media 429 Airway clearance 384 Allergy reaction 430 Anxiety 324 Aspiration 385 Attachment 289 Autonomic dysreflexia 353, 355 Balanced energy field 225 Balanced fluid volume 183 Balanced nutrition 157 Bathing self-care 243 Bleeding 386 Blood glucose level 177 Body image 276 Breast milk production 159 Breastfeeding 160–162 Breathing pattern 230 Cardiac output 231, 233 Childbearing process 307, 309–310 Chronic pain syndrome 448 Comfort 442–443, 450–453 Communication 262 Confusion 254–256 Constipation 197, 199–200 Contamination 424, 426 Coping 326–331, 333–334 Death anxiety 335 Decision-making 366Decisional conflict 367 Denial 336 Dentition 387 Development 459 Diarrhea 204 Disuse syndrome 217 Diversional activity engagement 142 Dressing self-care 244 Dry eye 388 Dry mouth 389 Eating dynamics 163–164 Electrolyte balance 182 Elimination 189 Emancipated decision-making 368–370 Emotional control 257 Falls 390 Family processes 290, 293–294 Fatigue 226 Fear 337 Feeding dynamics 166 Feeding pattern 168 Feeding self-care 245 Female genital mutilation 415 Fluid volume 184–186 Frail elderly syndrome 145, 147 Functional constipation 201, 203 Gas exchange 209 Gastrointestinal motility 205–206 Grieving 339–341 Health 148 Health behavior 149 Health literacy 143 Health maintenance 150 Health management 151–153 Home maintenance 242 Hope 266–267Human dignity 268 Hyperbilirubinemia 178 Hyperthermia 434 Hypothermia 435, 437 Immigration transition 315 Impulse control 258 Incontinence 190–195, 207 Infection 382 Injury 392–394 Insomnia 213 Knowledge 259–260 Labor pain 449 Latex allergy reaction 431, 433 Lifestyle 144 Liver function 180 Loneliness 454 Maternal-fetal dyad 311 Memory 261 Metabolic imbalance syndrome 181 Mobility 218–220 Mood regulation 342 Moral distress 371 Mucous membrane integrity 397, 399 Nausea 444 Neonatal abstinence syndrome 358 Neurovascular function 400 Nutrition 158 Obesity 169 Occupational injury 427 Organized behavior 359, 361–362 Other-directed violence 416 Overweight 170, 172 Pain 445–446 Parenting 283, 286, 288 Perioperative hypothermia 438 Perioperative positioning injury 395Personal identity 269–270 Physical trauma 401 Poisoning 428 Post-trauma syndrome 316, 318 Power 343–345 Pressure ulcer 404 Protection 154 Rape-trauma syndrome 319 Relationship 295–297 Religiosity 372–374 Relocation stress syndrome 320–321 Resilience 346–348 Retention 196 Role conflict 298 Role performance 299 Role strain 278, 281 Self-care 247 Self-concept 271 Self-directed violence 417 Self-esteem 272–275 Self-mutilation 418, 420 Self-neglect 248 Sexual function 305 Sexuality pattern 306 Shock 405 Sitting 221 Skin integrity 406–407 Sleep 214–215 Sleep pattern 216 Social interaction 301 Social isolation 455 Sorrow 349 Spiritual distress 375, 377 Spiritual well-being 365 Spontaneous ventilation 234 stable blood pressure 235standing 222 stress 350 sudden death 408 suffocation 409 suicide 422 surgical recovery 410–411 surgical site infection 383 swallowing 173 Thermal injury 396 thermoregulation 439–440 tissue integrity 412–413 tissue perfusion 236–239 toileting self-care 246 transfer ability 223 trauma 403 unilateral neglect 251 venous thromboembolism 414 ventilatory weaning response 240 verbal communication 263 walking 224 wandering 227Read about relevant literature online at MediaCenter.Thieme.com! Simply visit MediaCenter.Thieme.com and, when prompted during the registration process, enter the code below to get started today. XZ88-D7XB-SJK6-QE85NANDA International, Inc. Nursing Diagnoses Definitions and Classification 2018–2020 Eleventh Edition Edited by T. Heather Herdman, PhD, RN, FNI and Shigemi Kamitsuru, PhD, RN, FNI Thieme New York • Stuttgart • Delhi • Rio de JaneiroInternational Rights Manager: Heike Schwabenthan Editorial Services Manager: Mary Jo Casey Editorial Director: Sue Hodgson Managing Editor: Kenneth Schubach Production Editor: Sean Woznicki Editorial Assistant: Mary Wilson Director, Clinical Solutions: Michael Wachinger Book Production Manager, Stuttgart: Sophia Hengst International Production Editor: Andreas Schabert International Marketing Director: Fiona Henderson Director of Sales, North America: Mike Roseman International Sales Director: Louisa Turrell Senior Vice President and Chief Operating Officer: Sarah Vanderbilt President: Brian D. Scanlan Library of Congress Cataloging-in-Publication Data Copyright information for this volume has been filed with the Library of Congress and is available by request from the publisher. For information on licensing the NANDA International (NANDA-I) nursing diagnostic system or permission to use it in other works, please e-mail: nanda-i@thieme.com; additional product information can be found by visiting: www.thieme.com/nanda-i. Copyright © 2018 NANDA International Thieme Publishers New York 333 Seventh Avenue, New York, NY 10001 USA +1 800 782 3488, customerservice@thieme.com Thieme Publishers Stuttgart Rüdigerstrasse 14, 70469 Stuttgart, Germany +49 [0]711 8931 421, customerservice@thieme.de Thieme Publishers Delhi A-12, Second Floor, Sector-2, NOIDA-201301 Uttar Pradesh, India +91 120 45 566 00, customerservice@thieme.in Thieme Publishers Rio de Janeiro Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, CEP 20270-135 RJ, Brazil, +55 21 2563 9700, cliente@thieme.com Printed in Canada by Marquis ISBN 978-1-62623-929-6 ISSN 1943-0728 Also available as an e-book: eISBN 978-1-62623-930-2Cover image: Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2016-17 Edition, Physicians and Surgeons, on the Internet at https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm (visited May 17, 2017) Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher's consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.The editors of this edition would like to dedicate this book to the memory of our founder, Dr. Marjory GordonPart 1 1 2 3 3 .1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 4 4 .1 4.2 4.3 Part 2 C 5 ontents The NANDA International Terminology – Organization and General Information Introduction What's New in the 2018–2020 Edition of Diagnoses and Classification Changes and Revisions Processes and Procedures for Diagnosis Submission and Review Changes to Definitions of Health Promotion Diagnoses New Nursing Diagnoses Revised Nursing Diagnoses Retired Nursing Diagnosis Revisions to Nursing Diagnosis Labels Standardization of Diagnostic Indicator Terms Introduction of At-Risk Populations and Associated Conditions Governance and Organization International Considerations on the Use of the NANDA-I Nursing Diagnoses NANDA International Position Statements An Invitation to Join NANDA International The Theory Behind NANDA International Nursing Diagnoses Nursing Diagnosis Basics5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 6 6 .1 6.2 6.3 6.4 6.5 6.6 6.7 7 7 .1 7.2 7.3 7.4 7.5 7.6 7.7 8 8 .1 8.2 Introduction How Does a Nurse (or Nursing Student) Diagnose? Understanding Nursing Concepts Assessment Nursing Diagnosis Planning/Intervention Evaluation Use of Nursing Diagnosis Brief Chapter Summary References Clinical Reasoning: From Assessment to Diagnosis Introduction The Nursing Process Data Analysis Identifying Potential Nursing Diagnoses (Diagnostic Hypotheses) In-Depth Assessment Summary References Introduction to the NANDA International Taxonomy of Nursing Diagnoses Introduction Classification in Nursing Using the NANDA-I Taxonomy Structuring Nursing Curricula Identifying a Nursing Diagnosis Outside Your Area of Expertise The NANDA-I Nursing Diagnosis Taxonomy: A Short History References Specifications and Definitions Within the NANDA International Taxonomy of Nursing Diagnoses Structure of Taxonomy II A Multiaxial System for Constructing Diagnostic Concepts8.3 8.4 8.5 8.6 8.7 9 9 .1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10 9.11 9.12 9.13 9.14 9.15 10 10.1 10.2 10.3 10.4 10.5 Part 3 Domain 1. Definitions of the Axes Developing and Submitting a Nursing Diagnosis Further Development Recommended Reading References Frequently Asked Questions Introduction When Do We Need Nursing Diagnoses? Basic Questions about Standardized Nursing Languages Basic Questions about NANDA-I Basic Questions about Nursing Diagnoses Questions about Defining Characteristics Questions about Related Factors Questions about Risk Factors Differentiating between Similar Nursing Diagnoses Questions Regarding the Development of a Treatment Plan Questions about Teaching/Learning Nursing Diagnoses Questions about Using NANDA-I in Electronic Health Records Questions about Diagnosis Development and Review Questions about the NANDA-I Definitions and Classification Text References Glossary of Terms Nursing Diagnosis Diagnostic Axes Components of a Nursing Diagnosis Definitions for Classification of Nursing Diagnoses References The NANDA International Nursing Diagnoses Health promotionClass 1. Class 2. Domain 2. Class 1. Class 2. Health awareness Decreased diversional activity engagement Readiness for enhanced health literacy Sedentary lifestyle 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 Nutrition Ingestion Imbalanced nutrition: less than body requirements Readiness for enhanced nutrition Insufficient breast milk production Ineffective breastfeeding Interrupted breastfeeding Readiness for enhanced breastfeeding Ineffective adolescent eating dynamics Ineffective child eating dynamics Ineffective infant feeding dynamics Ineffective infant feeding pattern Obesity Overweight Risk for overweight Impaired swallowing Digestion This class does not currently contain any diagnosesClass 3. Class 4. Class 5. Domain 3. Class 1. Class 2. Absorption This class does not currently contain any diagnoses Metabolism Risk for unstable blood glucose level Neonatal hyperbilirubinemia Risk for neonatal hyperbilirubinemia Risk for impaired liver function Risk for metabolic imbalance syndrome Hydration Risk for electrolyte imbalance Risk for imbalanced fluid volume Deficient fluid volume Risk for deficient fluid volume Excess fluid volume Elimination and exchange 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 Gastrointestinal function Constipation Risk for constipation Perceived constipation Chronic functional constipation Risk for chronic functional constipation Diarrhea Dysfunctional gastrointestinal motilityClass 3. Class 4. Domain 4. Class 1. Class 2. Class 3. Class 4. Risk for dysfunctional gastrointestinal motility Bowel incontinence Integumentary function This class does not currently contain any diagnoses Respiratory function Impaired gas exchange Activity/rest Sleep/rest Insomnia Sleep deprivation Readiness for enhanced sleep Disturbed sleep pattern Activity/exercise Risk for disuse syndrome Impaired bed mobility Impaired physical mobility Impaired wheelchair mobility Impaired sitting Impaired standing Impaired transfer ability Impaired walking Energy balance Imbalanced energy field Fatigue Wandering Cardiovascular/pulmonary responses Activity intolerance Risk for activity intolerance Ineffective breathing pattern Decreased cardiac output Risk for decreased cardiac outputClass 5. Domain 5. Class 1. Class 2. Class 3. Class 4. Impaired spontaneous ventilation Risk for unstable blood pressure Risk for decreased cardiac tissue perfusion Risk for ineffective cerebral tissue perfusion Ineffective peripheral tissue perfusion Risk for ineffective peripheral tissue perfusion Dysfunctional ventilatory weaning response 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 Perception/cognition Attention Unilateral neglect Orientation This class does not currently contain any diagnoses Sensation/perception This class does not currently contain any diagnoses Cognition Acute confusion Risk for acute confusion Chronic confusion Labile emotional control Ineffective impulse control Deficient knowledge Readiness for enhanced knowledge Impaired memoryClass 5. Domain 6. Class 1. Class 2. Class 3. Domain 7. Class 1. Class 2. Communication Readiness for enhanced communication Impaired verbal communication Self-perception 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 Self-esteem Chronic low self-esteem Risk for chronic low self-esteem Situational low self-esteem Risk for situational low self-esteem Body image Disturbed body image Role relationship Caregiving roles Caregiver role strain Risk for caregiver role strain Impaired parenting Risk for impaired parenting Readiness for enhanced parenting Family relationships Risk for impaired attachment Dysfunctional family processes Interrupted family processes Readiness for enhanced family processesClass 3. Domain 8. Class 1. Class 2. Class 3. Domain 9. Class 1. Class 2. Role performance Ineffective relationship Risk for ineffective relationship Readiness for enhanced relationship Parental role conflict Ineffective role performance Impaired social interaction Sexuality Sexual identity This class does not currently contain any diagnoses Sexual function Sexual dysfunction Ineffective sexuality pattern Reproduction Ineffective childbearing process Risk for ineffective childbearing process Readiness for enhanced childbearing process Risk for disturbed maternal-fetal dyad Coping/stress tolerance 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 Coping responses Ineffective activity planning Risk for ineffective activity planning Anxiety Defensive copingClass 3. Domain 10. Class 1. Ineffective coping Readiness for enhanced coping Ineffective community coping Readiness for enhanced community coping Compromised family coping Disabled family coping Readiness for enhanced family coping Death anxiety Ineffective denial Fear Grieving Complicated grieving Risk for complicated grieving Impaired mood regulation Powerlessness Risk for powerlessness Readiness for enhanced power Impaired resilience Risk for impaired resilience Readiness for enhanced resilience Chronic sorrow Stress overload 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 Life principles ValuesClass 2. Class 3. Domain 11. Class 1. Class 2. This class does not currently contain any diagnoses Beliefs Readiness for enhanced spiritual well-being Value/belief/action congruence Readiness for enhanced decision-making Decisional conflict Impaired emancipated decision-making Risk for impaired emancipated decision-making Readiness for enhanced emancipated decision-making Moral distress Impaired religiosity Risk for impaired religiosity Readiness for enhanced religiosity Spiritual distress Risk for spiritual distress Safety/protection Infection Risk for infection Risk for surgical site infection Physical injury Ineffective airway clearance Risk for aspiration Risk for bleeding Impaired dentition Risk for dry eye Risk for dry mouth Risk for falls Risk for corneal injury Risk for injury Risk for urinary tract injury Risk for perioperative positioning injury Risk for thermal injuryClass 3. Class 4. Class 5. Impaired oral mucous membrane integrity Risk for impaired oral mucous membrane integrity Risk for peripheral neurovascular dysfunction Risk for physical trauma Risk for vascular trauma Risk for pressure ulcer Risk for shock Impaired skin integrity Risk for impaired skin integrity Risk for sudden infant death Risk for suffocation Delayed surgical recovery Risk for delayed surgical recovery Impaired tissue integrity Risk for impaired tissue integrity Risk for venous thromboembolism 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 Environmental hazards Contamination Risk for contamination Risk for occupational injury Risk for poisoning Defensive processes Risk for adverse reaction to iodinated contrast media Risk for allergy reaction Latex allergy reaction Risk for latex allergy reactionClass 6. Domain 12. Class 1. Class 2. Class 3. Domain 13. Class 1. Class 2. Thermoregulation Hyperthermia Hypothermia Risk for hypothermia Risk for perioperative hypothermia Ineffective thermoregulation Risk for ineffective thermoregulation Comfort Physical comfort Impaired comfort Readiness for enhanced comfort Nausea Acute pain Chronic pain Chronic pain syndrome Labor pain Environmental comfort Impaired comfort Readiness for enhanced comfort Social comfort Impaired comfort Readiness for enhanced comfort Risk for loneliness Social isolation Growth/development Growth This class does not currently contain any diagnoses Development Risk for delayed development IndexConceptsPreface In the early 1970s, nurses and educators in the United States uncovered the fact that nurses independently diagnosed and treated “something” related to patients and their families, which was different from medical diagnoses. Their great insight opened the new door to the taxonomy of nursing diagnoses, and the establishment of the professional organization that is now known as NANDA International (NANDA-I). As is usual with medical diagnoses for physicians, nurses should have “something” to document a holistic scope of practice to help students acquire our unique body of knowledge, and to enable nurses to collect and analyze data to advance the discipline of nursing. More than 40 years have passed, and the idea of “nursing diagnosis” has inspired and encouraged nurses around the world who seek independent practice based upon professional knowledge. Initially, nurses living outside North America may have been simply the end users of the NANDA-I taxonomy. 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. Who could have imagined that a non-native English speaker from a small Asian country would become the president of NANDA-I in 2016? In this 2018–2020 version, the Eleventh Edition, the taxonomy provides 244 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. Each new diagnosis has been debated and refined by our Diagnosis Development Committee (DDC) members, before finally being submitted to NANDA-I members for a vote of approval. Membership approval does not mean the diagnosis is “completed” or “ready to be used” across all countries or practice areas. We all know that practice and regulation of nursing varies from country to country. It is our hope that publication of these new diagnoses will facilitate further validation studies in different parts of the world, 1to achieve a higher level of evidence. 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 2002, when the LOE criteria were introduced. In addition, to treat the problems described in each nursing diagnosis effectively, related or risk factors are required. However, after sorting some of these factors into “At-Risk Populations” and “Associated Conditions” (things that are not independently treatable by nurses), there are several diagnoses that now have no related or risk factors. NANDA-I is translated into nearly 20 distinct languages. 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. We have directly partnered with GrupoA for our Portuguese translation, and IgakuShoin for much of our Asian market. 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. T. Heather Herdman, for its efforts and support. 2My special thanks to the members of the DDC for their outstanding and timely efforts to review and edit the terminology represented within this book, and especially for the leadership of the DDC Chair, Professor Dickon WeirHughes, since 2014. This remarkable committee, with representation from North and South America and Europe, is the true “powerhouse” of the NANDA-I knowledge content. I am deeply impressed and pleased by the astonishing, comprehensive work of these volunteers over the years Shigemi Kamitsuru, PhD, RN, FNI President, NANDA International, Inc. 3Acknowledgments It goes without saying that the dedication of several individuals to the work of NANDA International, Inc. (NANDA-I) is evident in their donation of time and work to the improvement of the NANDA-I terminology and taxonomy. 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. Camila Takao Lopes of the College of Nursing of the Universidade Federal de São Paulo in Brazil, who worked to organize, update, and maintain the NANDAI terminology database, and supported the work on standardization of the terminology. Additionally, we would like to take the opportunity to acknowledge and personally thank Susan Gallagher-Lepak, PhD, RN, Dean of the College of Health, Education & Social Welfare, at the University of Wisconsin–Green Bay, for her contribution to this particular edition of the NANDA-I text, as the author of the revised Nursing Diagnosis Basics chapter. Please contact us at execdir@nanda.org if you have questions on any of the content, or if you find errors, so that these may be corrected for future publication and translation. T. Heather Herdman, PhD, RN, FNI Shigemi Kamitsuru, PhD, RN, FNI NANDA International, Inc. 41 2 3 4 Part 1 The NANDA International Terminology – Organization and General Information Introduction What's New in the 2018–2020 Edition of Diagnoses and Classification Changes and Revisions Governance and Organization 51 Introduction Part 1 presents introductory information on the new edition of the NANDA International Taxonomy, 2018–2020. This includes an overview of major changes to this edition: new and revised diagnoses, retired diagnoses, label changes, continued revision to standardize diagnostic indicator terms, and the introduction of associated conditions and at risk populations. 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. 62 What's New in the 2018–2020 Edition of Diagnoses and Classification Changes have been made in this edition based on feedback from users, to address the needs of both students and clinicians, as well as to provide additional support to educators. 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. 73 3. 1 3.1.1 3.1.2 Changes and Revisions Processes and Procedures for Diagnosis Submission and Review NANDA-I Diagnosis Submission: 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.g., label and definition; label, definition, defining characteristics, or risk factors; theoretical level for development, and clinical validation; or, label, definition, defining characteristics, and related factors). 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. As new rules are developed, these will be available on the NANDA-I website (www.nanda.org). 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. NANDA-I Diagnosis Submission: Level of Evidence (LOE) Criteria The NANDA-I Education and Research Committee has been tasked to review and revise, as appropriate, these criteria to better reflect the state of the science related to evidence-based nursing. Individuals interested in submitting a diagnosis are advised to refer to the NANDA-I website for updates, as they 8become available (www.nanda.org). LOE 1: Received for Development (Consultation from NANDA-I) LOE 1.1: 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. At this stage, the label is categorized as “Received for Development” and identified as such on the NANDA-I website. LOE 1.2: Label and Definition The label is clear and stated at a basic level. The definition is consistent with the label. The label and definition are distinct from other NANDA-I diagnoses and definitions. The definition differs from the defining characteristics and label. These components are not included in the definition. At this stage, the diagnosis must be consistent with the current NANDA-I definition of nursing diagnosis (see the “Glossary of Terms”). The label and definition are supported by literature references, which are identified. At this stage, the label and its definition are categorized as “Received for Development” and identified as such on the NANDA-I website. LOE 1.3: 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. At this stage, the label and its component parts are categorized as “Received for Development and Clinical Validation,” and identified as such on the NANDA-I website and in a separate section in this book. LOE 2: Accepted for Publication and Inclusion in the NANDA-I Taxonomy LOE 2.1: 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.g., Nursing 9Outcomes Classification [NOC], Nursing Interventions Classification [NIC]) are provided for each diagnosis. LOE 2.2: Concept Analysis The criteria in LOE 2.1 are met. 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. The literature review/concept analysis supports the label and definition, and includes discussion and support of the defining characteristics and related factors (for problem-focused diagnoses), risk factors (for risk diagnoses), or defining characteristics (for health promotion diagnoses). LOE 2.3: Consensus Studies Related to Diagnosis Using Experts The criteria in LOE 2.1 are met. Studies include those soliciting expert opinion, Delphi, and similar studies of diagnostic components in which nurses are the subjects. LOE 3: Clinically Supported (Validation and Testing) LOE 3.1: Literature Synthesis The criteria in LOE 2.2 are met. The synthesis is in the form of an integrated review of the literature. Search terms/MeSH (Medical Subject Headings) terms used in the review are provided to assist future researchers. LOE 3.2: Clinical Studies Related to Diagnosis, but Not Generalizable to the Population The criteria in LOE 2.2 are met. 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. LOE 3.3: Well-Designed Clinical Studies with Small Sample Sizes The criteria in LOE 2.2 are met. The narrative includes a description of studies related to the diagnosis, which includes defining characteristics and related factors, or risk factors. Random sampling is used in these studies, but the sample size is limited. LOE 3.4: Well-Designed Clinical Studies with Random Sample of Sufficient Size to Allow for Generalizability to the Overall Population 103.2 3.3 The criteria in LOE 2.2 are met. The narrative includes a description of studies related to the diagnosis, which includes defining characteristics and related factors, or risk factors. Random sampling is used in these studies, and the sample size is sufficient to allow for generalizability of results to the overall population. Changes to Definitions of Health Promotion Diagnoses The overall definition for a health promotion nursing diagnosis was changed during this cycle. 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.g., neonatal patients, those with conditions preventing verbalization of desire, etc.). 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. In individuals who are unable to express their own readiness to enhance health behaviors, the nurse may determine that a condition for health promotion exists and act on the client’ s behalf. Health promotion responses may exist in an individual, family, group, or community. New Nursing Diagnoses A significant body of work representing new and revised nursing diagnoses was submitted to the NANDA-I Diagnosis Development Committee, with a significant number of those diagnoses being presented to the NANDA-I membership for consideration during this review cycle. NANDA-I would like to take this opportunity to congratulate those submitters who successfully met the level of evidence criteria with their submissions and/or revisions. Seventeen new diagnoses were approved by the Diagnosis Development Committee, the NANDA-I Board of Directors, and the NANDA-I membership ( Table 3.1). 113.4 3.5 Revised Nursing Diagnoses Seventy-two diagnoses were revised during this cycle. Table 3.2 shows those diagnoses, highlights the revisions that were made for each of them, and identifies the submitters/revisers. Retired Nursing Diagnosis Eight diagnoses were removed from the terminology during this edition. 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 (00113), 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. Table 3.1 New NANDA-I Nursing Diagnoses, 2018–2020 Approved diagnosis (new) Submitter(s) Domain 1: Health Promotion Readiness for enhanced health literacy Class 1: Health awareness B. Flores, PhD, RN, WHNP-BC Domain 2: Nutrition Ineffective adolescent eating dynamics Class 1: Ingestion S. Mlynarczyk, PhD, RN; M. Dewys, PhD, RN; G. Lyte, PhD, RN Ineffective child eating dynamics Class 1: Ingestion S. Mlynarczyk, PhD, RN; M. Dewys, PhD, RN; G. Lyte, PhD, RN Ineffective infant eating dynamics Class 1: Ingestion S. Mlynarczyk, PhD, RN; M. Dewys, PhD, RN; G. Lyte, PhD, RN Risk for metabolic imbalance syndrome Class 4: Metabolism V.E. Fernández-Ruiz, PhM; M.M. Lopez-Santos, PhM; D. Armero-Barranco, PhD; J.M. XandriGraupera, PhM; J.A. Paniagua-Urban, PhM; M. Solé-Agusti, PhM; M.D. Arrillo-Izquierdo, PhM; A. Ruiz-Sanchez, PhM Domain 4: Activity/Rest Imbalanced energy field N. Frisch, PhD, RN, FAAN; H. Butcher, PhD, RN; 12Class 3: Energy balance D. Shields, PhD, RN, CCRN, AHN-BC, QTTT Risk for unstable blood pressure Class 4: Cardiovascular/pulmonary responses C. Amoin, DSN, MN, RN Domain 9: Coping/stress Tolerance Risk for complicated immigration transition Class 1: Posttrauma responses R. Rifa, RN, PhD Neonatal abstinence syndrome Class 3: Neurobehavioral stress L. M. Cleveland, PhD, RN, PNP-BC Acute substance withdrawal syndrome Class 3: Neurobehavioral stress L. Clapp, RN, MS, CACIII; K. Mahler, RN, BSN Risk for acute substance withdrawal syndrome Class 3: Neurobehavioral stress L. Clapp, RN, MS, CACIII; K. Mahler, RN, BSN Domain 11: Safety/Protection Risk for surgical site infection Class 1: Infection F. F. Ercole, PhD, RN; T.C.M. Chianca, PhD, RN; C. Campos, MSN, RN; T.G.R. Macieira, BSN, RN; L.M.C. Franco, MSN Risk for dry mouth Class 2: Physical injury I. Eser, PhD, RN (1); N. Duruk, PhD, RN (2) Risk for venous thromboembolism Class 2: Physical injury G. Meyer, PhD, RN, CNL Risk for female genital mutilation I.J. Ruiz, RN Class 3: Violence Risk for occupational injury Class 4: Environmental hazards F. Sanchez-Ayllon, PhD, RN Risk for ineffective thermoregulation Class 6: Thermoregulation Diagnosis Development Committee Noncompliance (00079), Domain 1, Class 2. This diagnosis was quite old, with a last revision in 1998. 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 (00160), Domain 2, Class 5. Readiness for enhanced urinary elimination (00166), Domain 3, Class 1. These diagnoses lacked sufficient evidence to support their continuation within the terminology. Risk for impaired cardiovascular function (00239), Domain 4, Class 4. This diagnosis lacked sufficient differentiation from other cardiovascular diagnoses within the terminology. Risk for ineffective gastrointestinal perfusion (00202), Domain 4, Class 4. Risk for ineffective renal perfusion (00203), Domain 4, Class 4. 133.6 These diagnoses were not found to be independently modifiable by nursing practice. Risk for imbalanced body temperature (00005), Domain 11, Class 6 – replaced by new diagnosis, Risk for ineffective thermoregulation (00274). 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 (00008). Therefore, the label and definition were changed, leading to the need to retire the current code and assign a new code. Revisions to Nursing Diagnosis Labels Changes were made to 11 nursing diagnosis labels. 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 3.3. 141516173.7 Table 3.3 Revisions to nursing diagnosis labels of NANDA-I nursing diagnoses, 2018–2020 Domain Previous diagnostic label New diagnostic label 1. Health promotion Deficient diversional activity (00097) Decreased diversional activity engagement 2. Nutrition Insufficient breast milk (00216) Insufficient breast milk production 2. Nutrition Neonatal jaundice (00194) Neonatal hyperbilirubinemia 2. Nutrition Risk for neonatal jaundice (00230) Risk for hyperbilirubinemia 11. Safety/Protection Impaired oral mucous membrane (00045) Impaired oral mucous membrane integrity 11. Safety/Protection Risk for impaired oral mucous membrane (00247) Risk for impaired oral mucous membrane integrity 11. Safety/Protection Risk for sudden infant death syndrome (00156) Risk for sudden infant death 11. Safety/Protection Risk for trauma (00038) Risk for physical trauma 11. Safety/Protection Risk for allergy response (00217) Risk for allergic reaction 11. Safety/Protection Latex allergy response (00041) Latex allergic reaction 11. Safety/Protection Risk for latex allergy response (00042) Risk for latex allergic reaction Standardization of Diagnostic Indicator Terms For the past three cycles of this book, work has been underway to decrease variation in terms used for defining characteristics, related factors, and risk factors. 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. This involved many hours of 18review, literature searches, discussion, and consultation with clinical experts in different fields. 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. For example, every term with the stem “pulmo-” was searched, to ensure that consistency was maintained. Common phrases, such as verbalizes, reports, states, lack of, insufficient, inadequate, excess, etc., were also used to filter. 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: – Translations should be improved. There have been multiple questions regarding previous editions that were difficult to answer. Some examples are the following: – When you say lack in English, does that mean absence of or insufficient? The answer is often, “Both!” Although the duality of this word is well accepted in English, the lack of clarity creates confusion for clinicians who are non-native English speakers, and it makes it very difficult to translate into languages in which a different word would be used depending on the intended meaning. – Is there a reason why some defining characteristics are noted in singular form and yet in another diagnosis, the same characteristic is noted in plural form (e.g., absence of significant other(s), absence of significant other, absence of significant others)? – There are many terms that are similar or that are examples of other terms used in the terminology. For example, what is the difference between abnormal skin color (e.g., pale, dusky), color changes, cyanosis, pale, skin color changes, and slight cyanosis? Are the differences significant? Could 193.8 these terms be combined into one? 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 truly important that translators “struggle” to ensure conceptual clarity when translating the terms—there is a difference between the terms “dusky skin color” and “cyanotic skin color,” and this can impact one's clinical judgment. Decreasing the variation in these terms should simplify the translation process, as one term/phrase will be used throughout the terminology for similar diagnostic indicators. – Clarity for clinicians should be improved. It is confusing to students and practicing nurses alike when they see similar but slightly different terms in different diagnoses. Are they the same? Is there some subtle difference they do not understand? Why cannot NANDA-I be more clear? And what about all of those “e.g.’s” in the terminology? Are they there to teach, to clarify, to list every potential example? There seems to be a mixture of possible reasons for their appearance in the terminology. You will notice that many of the “e.g.’s” have been removed, unless it was felt that they were truly needed to clarify intent. “Teaching tips” that were present in some parentheses are gone, too—the terminology is not the place for these. We have also done our best to condense terms and standardize them, whenever possible. – This work facilitates the coding of the diagnostic indicators, which should allow their use for populating assessment databases within electronic health records (EHR), and increase the availability of decision-support tools regarding accuracy in diagnosis and linking diagnosis to appropriate treatment plans. 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 Associated Conditions Users of this book will notice the use of the following new terms as they review the diagnostic indicators for most diagnoses: at-risk populations and associated conditions. One of the issues we have often struggled with in the terminology is a “laundry list” of related factors, many of which are not amenable to 20independent nursing intervention. 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 atrisk populations or associated conditions. The phrases were moved “as is,” meaning that no new conceptual work was completed on these phrases; this work will need to be undertaken in the future. At-risk populations are groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences. 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. 214 4. 1 Governance and Organization International Considerations on the Use of the NANDA-I Nursing Diagnoses T. Heather Herdman As we noted earlier, NANDA International, Inc. initially began as a North American organization and, therefore, the earliest nursing diagnoses were primarily developed by nurses from the United States and Canada. 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. now includes nurses from nearly 40 countries, with nearly two-thirds of its members coming from countries outside North America. 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 2002, 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 2002—it simply does not reflect our international scope, and it is not the legal name of the organization. We retained “NANDA” within our name because of its status in the nursing profession, so think of it more as a trademark or brand name than as an acronym, since it no longer “stands for” the original name of the association. As NANDA-I experiences increased worldwide adoption, issues related to differences in the scope of nursing practice, diversity of nurse practice models, divergent laws and regulations, nurse competency, and educational differences 22must be addressed. In 2009, NANDA-I held an International Think Tank Meeting, which included 86 individuals representing 16 countries. 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. Nurses in other nations are facing regulations aimed to ensure that everything done within nursing practice can be demonstrated to be evidence-based, and therefore face difficulties with some of the older nursing diagnoses and/or those linked interventions that are not supported by a strong level of research literature. 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. Every nurse should be aware of, and work within, the standards and scope of practice and any laws or regulations within which he/she is licensed to practice. 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. Conversely, these individuals may be able to provide evidence that would support the 234.2 4.2.1 removal of diagnoses from the current taxonomy, which, if they were not shown in their translations, would be unlikely to occur. 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. I have met nurse authors who indicate that operating room nurses “cannot diagnose because they don't assess,” or that intensive care unit nurses “have to practice under strict physician protocol that doesn't include nursing diagnosis.” Neither of these statements is factual, but rather represents the personal opinions of those nurses. 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. NANDA International Position Statements From time to time, the NANDA International Board of Directors provides position statements as a result of requests from members or users of the NANDA-I taxonomy. Currently, there are two position statements: one addresses the use of the NANDA-I taxonomy as an assessment framework, and the other addresses the structure of the nursing diagnosis statement when included in a care plan. NANDA-I publishes these statements in an attempt to prevent others from interpreting NANDA-I's stance on important issues, and to prevent misunderstandings or misinterpretations. NANDA INTERNATIONAL Position 244.2.2 Statement Number 1 The Use of Taxonomy II as an Assessment Framework Nursing assessments provide the starting point for determining nursing diagnoses. It is vital that a recognized nursing assessment framework is used in practice to identify the patient's* problems, risks, and outcomes for enhancing health. NANDA International does not endorse one single assessment method or tool. 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. * NANDA International defines patient as “individual, family, group or community.” NANDA INTERNATIONAL Position Statement Number 2 The Structure of the Nursing Diagnosis Statement When Included in a Care Plan NANDA International believes that the structure of a nursing diagnosis as a statement, including the diagnosis label and the related factors as exhibited by defining characteristics, is the best clinical practice, and may be an effective teaching strategy. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors, and/or risk factors found within the patient's* assessment. While this is recognized as best practice, it may be that some information systems do not provide this opportunity. Nurse leaders and nurse informaticists must work together to ensure that vendor solutions are available which allow the nurse to validate accurate diagnoses through clear identification of the 254.3 4.3.1 diagnostic statement, related and/or risk factors, and defining characteristics. * NANDA International defines patient as “individual, family, group or community.” An Invitation to Join NANDA International Words are powerful. 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 International: A Member-Driven Organization Our Vision NANDA International, Inc. (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. – We provide the world's leading evidence-based nursing diagnoses for use in practice and to determine interventions and outcomes. – We fund research through the NANDA-I Foundation. – We are a supportive and energetic global network of nurses who are committed to improving the quality of nursing care through evidence-based practice. Our Purpose Implementation of nursing diagnosis enhances every aspect of nursing practice, from garnering professional respect to assuring accurate documentation for reimbursement. NANDA International exists to develop, refine, and promote terminology that 26accurately reflects nurses’ clinical judgments. This unique, evidence-based perspective includes social, psychological, and spiritual dimensions of care. Our History NANDA International was originally named the North American Nursing Diagnosis Association (NANDA) and was founded in 1982. The organization grew out of the National Conference Group, a task force established at the First National Conference on the Classification of Nursing Diagnoses, held in St. Louis, MO, United States, in 1973. This conference and the ensuing task force ignited interest in the concept of standardizing nursing terminology. In 2002, NANDA was relaunched as NANDA International to reflect increasing worldwide interest in the field of nursing terminology development. Although we no longer use the name “North American Nursing Diagnosis Association,” and it is not appropriate to refer to the organization by this name (nor is North American Nursing Diagnosis Association, International correct to use), unless quoting it prior to 2002, we did maintain “NANDA” as a brand name or trademark within our name, because of its international recognition as the leader in nursing diagnostic terminology. As of this edition, NANDA-I has approved 244 diagnoses for clinical use, testing, and refinement. A dynamic, international process of diagnosis review and classification approves and updates terms and definitions for identified human responses. NANDA-I has international networks in Brazil, Colombia, Ecuador, Italy, Mexico, Nigeria–Ghana, Peru, and Portugal, as well as a German-language group; other country, specialty, and/or language groups interested in forming a NANDA-I Network should contact the CEO/Executive Director of NANDA-I at execdir@nanda.org. NANDA-I also has collaborative links with nursing terminology societies around the world such as the Japanese Society of Nursing Diagnosis (JSND), the Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACENDIO), the Asociacíon Española de Nomenclatura, Taxonomia y Diagnóstico de Enfermeria (AENTDE), the Association Francophone Européenne des Diagnostics Interventions Résultats Infirmiers (AFEDI), the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC). NANDA International's Commitment NANDA-I is a member-driven, grassroots organization committed to the development of nursing diagnostic terminology. The desired outcome of the association's work is to provide nurses at all levels and in all areas of practice 274.3.2 with a standardized nursing terminology with which to: – Name actual or potential human responses to health problems, and life processes. – Develop, refine, and disseminate evidence-based terminology representing clinical judgments made by professional nurses. – Facilitate study of the phenomena of concern to nurses for the purpose of improving patient care, patient safety, and patient outcomes for which nurses have accountability. – Document care for reimbursement of nursing services. – Contribute to the development of informatics and information standards, ensuring the inclusion of nursing terminology in electronic health care records. 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. Involvement Opportunities The participation of NANDA-I members is critical to the growth and development of nursing terminology. 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. Why Join NANDA-I? 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. – NANDA-I Membership Network Groups connect colleagues within a specific country, region, language, or nursing specialty. – Professional contribution and achievement are recognized through our Founders, Mentors, Unique Contribution, and Editor's Awards. Research grant awards are offered through the NANDA-I Foundation. – Fellows are identified by NANDA-I as nursing leaders with standardized nursing language expertise in the areas of education, administration, clinical practice, informatics, and research. 284.3.3 Resources – Members receive a complimentary subscription to our online scientific journal, the International Journal of Nursing Knowledge (IJNK). IJNK communicates efforts to develop and implement standardized nursing language across the globe. – The NANDA-I website offers resources for nursing diagnosis development, refinement, and submission, NANDA-I taxonomy updates, and an Online Membership Directory. Member Benefits – Members receive discounts on English-language NANDA-I taxonomy publications, including print and electronic versions of NANDA-I Nursing Diagnoses and Classification. – We partner with organizations offering products/services of interest to the nursing community, with a price advantage for members. Member discounts apply to our biennial conference and NANDA-I products, such as our T-shirts and tote bags. – Our Regular Membership fees are based on the World Health Organization's classification of countries. 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.nanda.org for more information and instructions for membership registration. Who Is Using the NANDA International Taxonomy? – International Standards Organization compatible – Health Level 7 International registered – SNOMED-CT available – Unified Medical Language System compatible – American Nurses’ Association recognized terminology The NANDA-I taxonomy is currently available in Bahasa Indonesian, Basque, Chinese, Czech, Dutch, English, Estonian, French, German, Italian, Japanese, Portuguese, Spanish (European and Hispanoamerican editions), and Swedish. For more information, and to apply for membership online, please visit: 29www.nanda.org. 305 6 7 8 9 1 0 Part 2 The Theory Behind NANDA International Nursing Diagnoses Nursing Diagnosis Basics Clinical Reasoning: From Assessment to Diagnosis Introduction to the NANDA International Taxonomy of Nursing Diagnoses Specifications and Definitions Within the NANDA International Taxonomy of Nursing Diagnoses Frequently Asked Questions Glossary of Terms 315 5. 1 Nursing Diagnosis Basics Susan Gallagher-Lepak Introduction Health care is delivered by various types of health care professionals, including nurses, physicians, and physical therapists, to name just a few. This is true in hospitals as well as other settings across the continuum of care (e.g., clinics, homecare, long-term care, churches, prisons). 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. 5.1). 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. Each health profession has a way to describe “what” the profession knows and “how” it acts on what it knows. This chapter is primarily focused on the “what.” A profession may have a common language that is used to describe and code its knowledge. Physicians treat 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). Nurses treat human responses to health problems and/or life processes and use the NANDA International, Inc. (NANDA-I) nursing diagnosis taxonomy. The nursing diagnosis taxonomy, and the process of diagnosing using this taxonomy, will be described further. 32Fig. 5.1 Example of a collaborative health care team. The NANDA-I taxonomy provides a way to classify and categorize areas of concern to the nursing professional (i.e., diagnostic foci). It contains 244 nursing diagnoses grouped into 13 domains and 47 classes. According to the Cambridge Dictionary On-Line (2017), a domain is “an area of interest;” examples of domains in the NANDA-I taxonomy include activity/rest, coping/stress tolerance, elimination/exchange, and nutrition. Domains are divided into classes, which are groupings that share common attributes. Nurses deal with responses to health problems/life processes among individuals, families, groups, and communities. Such responses are the central concern of nursing care and fill the circle ascribed to nursing in Fig. 5.1. A nursing diagnosis can be problem-focused, a state of health promotion, or a potential risk. – Problem-focused diagnosis—a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, group, or community – Risk diagnosis—a clinical judgment concerning the susceptibility of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes – Health promotion diagnosis—a clinical judgment concerning motivation and desire to increase well-being and to actualize health potential. These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any health state. In cases where individuals are unable to express their 335.2 own readiness to enhance health behaviors, the nurse may determine that a condition for health promotion exists and then act on the client's behalf. Health promotion responses may exist in an individual, family, group, or community. Although limited in number in the NANDA-I taxonomy, a syndrome can be present. A syndrome is a clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are therefore best addressed together and through similar interventions. An example of a syndrome diagnosis is chronic pain syndrome (00255). 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 (00198), fatigue (00093), impaired physical mobility (00085), or social isolation (00053). How Does a Nurse (or Nursing Student) Diagnose? The nursing process includes assessment, nursing diagnosis, planning, outcome setting, intervention, and evaluation ( Fig. 5.2). Nurses use assessment and clinical judgment to formulate hypotheses or explanations about presenting problems, risks, and/or health promotion opportunities. 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. 345.3 Fig. 5.2 The modified nursing process. Adapted from Herdman 2013. Understanding Nursing Concepts Knowledge of key concepts, or nursing diagnostic foci, is necessary before beginning an assessment. Examples of critical concepts important to nursing practice include breathing, elimination, thermoregulation, physical comfort, selfcare, 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. In looking at problems that can occur with 355.4 regard to ventilation, the nurse will be faced with the diagnoses of impaired spontaneous ventilation (00033) and dysfunctional ventilatory weaning response (00034); concerns with gas exchange may lead the nurse to the diagnosis of impaired gas exchange (00030), while issues related to breathing pattern might lead to a diagnosis of ineffective breathing pattern (00032). 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. Assessment Assessment involves the collection of subjective and objective data (e.g., vital signs, patient/family interview, physical exam) and review of historical information provided by the patient/family, or found within the patient chart. Nurses also collect data on patient/family strengths (to identify health promotion opportunities) and risks (to prevent or postpone potential problems). Assessments can be based on a specific nursing theory, such as one developed by Florence Nightingale, Wanda Horta, or Sr. Callista Roy, or on a standardized assessment framework such as Marjory Gordon's Functional Health Patterns. These frameworks provide a way of categorizing large amounts of data into a manageable number of related patterns or categories of data. The foundation of nursing diagnosis is clinical reasoning. Clinical reasoning 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 2010). Clinical judgment is “an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not)” (Tanner 2006, p. 204). Key issues, or diagnostic foci, may be evident early in the assessment (e.g., altered skin integrity, loneliness) and allow the nurse to begin the diagnostic process. For example, a patient may report pain and/or show agitation while holding a body part. The nurse will recognize the client's discomfort based on client report and/or pain behaviors. Expert nurses can quickly identify clusters of clinical cues from assessment data and seamlessly progress to nursing diagnoses. Novice nurses take a more sequential process in determining appropriate nursing diagnoses. 365.5 Practice Reflection from a Nurse in the United States: As I went through nursing school, we created numerous care plans that were built around nursing diagnoses … On Day 1 of the clinical rotation, we reviewed our patient's chart, met with, and assessed the patient, and then developed a care plan that we would then initiate and/or continue on Day 2. Nursing Diagnosis A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community (NANDA-I 2013). A nursing diagnosis typically contains two parts: (1) descriptor or modifier and (2) focus of the diagnosis or the key concept of the diagnosis ( Table 5.1). There are some exceptions in which a nursing diagnosis is only one word, such as anxiety (00146), constipation (00011), fatigue (00093), and nausea (00134). 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 (00092), impaired memory (00131), readiness for enhanced health management (00162), and risk for falls (00155), 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.g., poor vision, difficulty with gait, history of falls, anxiety with relocation). Table 5.1 Parts of a nursing diagnosis label Modifier Focus of the diagnosis Ineffective Breathing pattern Risk for Constipation Deficient Fluid volume Impaired Skin integrity Readiness for enhanced Resilience 37Each nursing diagnosis has a label and a clear definition. 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. In addition, they need to know the “diagnostic indicators”—the information that is used to diagnose and differentiate one diagnosis from another. These diagnostic indicators include defining characteristics and related factors or risk factors ( Table 5.2). Defining characteristics are observable cues/inferences that cluster as manifestations of a diagnosis (e.g., signs or symptoms). 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.g., cause, contributed factor). 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.g., environmental, psychological, genetic). Table 5.2 Key terms at a glance Term Brief description Nursing diagnosis Problem, strength, or risk identified for a patient, family, group, or community Defining characteristic Sign or symptom (objective or subjective cues) Related factor Causes or contributing factors (etiological factors) Risk factor Determinant (increase risk) At-risk populations Groups of people who share a characteristic that causes each member to be susceptible to a particular human response. 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 5.2). At-risk populations are groups of individuals who share characteristics that cause each member to be susceptible to a particular human response. For example, individuals at extremes of age are 38an at-risk population that share a greater susceptibility to deficient fluid volume. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmaceutical agents. 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. 109) and the information contained in the Changes and Revisions section (p. 4) of this book. A nursing diagnosis does not need to contain all types of diagnostic indicators (i.e., defining characteristics, related factors, and/or risk factors). Problemfocused 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. A common format used when learning nursing diagnosis includes _____ [nursing diagnosis] related to ______ [cause/related factors] as evidenced by ____________ [symptoms/defining characteristics]. 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. Depending on the electronic health record in a particular health care institution, the “related to” and “as evidenced by” components may not be included within the electronic system. This information, however, should be recognized in the assessment data 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. 395.6 There are additional boxes that are blank for nurses to input other diagnoses. 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. Every shift the nurse responsible has the option to click on “continue plan of care,” “revise plan of care,” or “resolved.” Planning/Intervention Once diagnoses are identified, prioritizing of selected nursing diagnoses must occur to determine care priorities. High-priority nursing diagnoses need to be identified (i.e., urgent need, diagnoses with high level of congruence with defining characteristics, related factors, or risk factors) so that care can be directed to resolve these problems or lessen the severity or risk of occurrence (in the case of risk diagnoses). Nursing diagnoses are used to identify intended outcomes of care and plan nursing-specific interventions sequentially. A nursing outcome refers to a measurable behavior or perception demonstrated by an individual, a family, a group, or a community that is responsive to nursing intervention (Center for Nursing Classification & Clinical Effectiveness [CNC], n.d.). 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. An intervention is defined as “any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes” (CNC, n.d.). The Nursing Interventions Classification (NIC) is 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.g., physicians, respiratory and physical therapists). For example, blood glucose management is a concept important to nurses, risk for 405.7 unstable blood glucose (00179) is a nursing diagnosis, and nurses implement nursing interventions to treat this condition. 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. Refer to Kamitsuru's Tripartite Model of Nursing Practice (p.109). 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 secondarylevel university hospital. An electronic medical record system with NANDANIC-NOC linkages is used to document the nursing process. 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: bathing; ineffective tissue perfusion: cardiopulmonary; impaired gas exchange; risk for unstable blood glucose level; decreased cardiac output; and risk for infection. Next, the system generates possible NOC outcomes for each diagnosis and the nurse chooses the one that is most representative of his/her aims. 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. Evaluation A nursing diagnosis “provides the basis for selection of nursing interventions to achieve outcomes for which nursing has accountability” (NANDA-I 2013). 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: “What data might I have missed? Am I making an inappropriate judgment? How confident am I in this diagnosis? Do I need to 415.8 consult with someone with more experience? Have I confirmed the diagnosis with the patient/family/group/community? 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.g., “what we always do”)? Use of Nursing Diagnosis This description of nursing diagnosis basics, although aimed primarily at nursing students and beginning nurses learning nursing diagnosis, can benefit many nurses in that it highlights critical steps in using nursing diagnosis and provides examples of areas in which inaccurate diagnosing can occur. An area that needs continued emphasis, for example, includes the process of linking knowledge of underlying nursing concepts to assessment, and ultimately nursing diagnosis. The nurse's understanding of key concepts (or diagnostic foci) directs the 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. Using the NANDA-I terminology (the diagnoses themselves), nurses can communicate with each other as well as professionals from other health care disciplines about “what” nursing is uniquely. The use of nursing diagnosis in our patient/family interactions can help them to understand the issues on which nurses will be focusing, and can engage them in their own care. The terminology provides a shared language for nurses to address health problems, risk states, and readiness for health promotion. NANDA-I's nursing diagnoses are used internationally, with translation into nearly 20 languages. 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. Nursing diagnoses are peer reviewed, and submitted for acceptance/revision to NANDA-I by practicing nurses, nurse educators, and nurse researchers around the world. Submissions of new diagnoses and/or revisions to existing diagnoses have continued to grow in number over the more than 40 years of the NANDA-I 425.9 5.10 nursing diagnosis terminology. Continued submissions (and revisions) to NANDA-I will further strengthen the scope, extent, and supporting evidence of the terminology. Brief Chapter Summary This chapter describes types of nursing diagnoses (i.e., problem-focused, risk, health promotion, syndrome) and steps in the nursing process. The nursing process begins with an understanding of underlying concepts of nursing science. Assessment follows and involves collection and clustering of data into meaningful patterns. Nursing diagnosis, a subsequent step in the nursing process, involves clinical judgment about a human response to a health condition or life process, or vulnerability for that response by an individual, a family, a group, or a community. The nursing diagnosis components were reviewed in this chapter, including the label, definition, and diagnostic indicators (i.e., related factors, risk factors, at risk populations, and associated conditions). 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. References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. Available at: dsm.psychiatryonline.org Cambridge University Press. Cambridge Dictionary On-Line. Cambridge, UK: Cambridge University Press; 2017. Available at: http://dictionary.cambridge.org/dictionary/english/ Center for Nursing Classification & Clinical Effectiveness (CNC), University of Iowa College of Nursing. N.d. Overview: Nursing Interventions Classification (NIC). Available at: www.nursing.uiowa.edu/cncce/nursinginterventions-classification-overview Center for Nursing Classification & Clinical Effectiveness (CNC), University of Iowa College of Nursing. N.d. Overview: Nursing Outcome Classification 43(NOC). Available at: www.nursing.uiowa.edu/cncce/nursing-outcomesclassification-overview Herdman TH. Manejo de casos empleando diagnósticos de enfermería de la NANDA Internacional [Case management using NANDA International nursing diagnoses]. XXX Congreso FEMAFEE 2013. Monterrey, Mexico Levett-Jones T, Hoffman K, Dempsey J, et al. The “five rights” of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically “at risk” patients.. Nurse Educ Today. 2010; 30(6):515–520 NANDA International (NANDA-I). Nursing diagnosis definition. In: Herdman TH, Kamitsuru S, eds. NANDA International Nursing Diagnoses: Definitions and Classification, 2012–2014. Oxford: Wiley; 2013:464 Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing.. J Nurs Educ. 2006; 45(6):204–211 446 6. 1 Clinical Reasoning: From Assessment to Diagnosis T. Heather Herdman Introduction Clinical reasoning has been defined in a variety of ways within health disciplines. Koharchik et al (2015) indicate that it requires the application of ideas and experience to arrive at a valid conclusion; in nursing, it describes the way a nurse “analyzes and understands a patient's situation and forms conclusions” (p. 58). Tanner (2006) sees it as the process by which nurses make clinical judgments by selecting from alternatives, weighing evidence, using intuition and pattern recognition. Similarly, Banning (2008) conducted a concept analysis of clinical reasoning, using 71 publications dating from 1964 to 2005. 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. Rather, it occurs over time, often across multiple patient/family encounters. 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. Some 45of these individuals occasionally nod their heads or comment in what seems to be an encouraging manner, some seem concerned, and others appear to be as confused by what they are watching as you are. 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. Although you may not know anything about Mahjong, you can understand the concept “game.” With this understanding, you might begin to look at the scene unfolding before you in a different way. 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 goodnatured taunting of one another, rather than angry shouting. Once you understand the concept of “game,” you can begin to paint a picture in your mind as to what is happening in this scene, and you can begin to interpret the data you are collecting (cues) in a way that makes sense within the context of a game. Without the “game” concept, though, you might continue the struggle to make sense of your observations. 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. 46Now, let us look at the idea of nursing concepts using a clinical scenario. Stacy is on her first clinical placement as a nursing student, working with David, a registered nurse in an independent/assisted elderly living facility. 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. When David asks her why she is worried about her heart, she says, “Well, I'm old and that's what tends to go bad.” David asks her how much exercise she has been getting, and if she has been feeling at all stressed lately. Mrs. 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. Finally, he talks with her about connecting with the director of resident life to find out how she might be able to visit her friend, or have her friend come to the facility to see her new apartment. 476.2 6.2.1 Stacy is amazed that David almost immediately identified a potential problem with Mrs. Randall. David draws Stacy's attention to the nursing diagnosis insomnia (00095), and she realizes that his assessment data are defining characteristics and related factors of this diagnosis. David talks with Stacy about the concept of sleep and the things that can impact it, such as stress (Mrs. Randall's recent move; lack of connection with her friend; being in a new apartment) and external factors (a new environment that is too warm), as well as the impact that physical exercise can have on improving sleep. He quickly considered this nursing diagnosis because he understands normal sleep patterns and could identify factors that contribute to a disturbance in a normal pattern. Further, because he understands that insomnia is caused by external factors, he identified probable etiological (related) factors. Stacy, as a nursing student, did not have the conceptual knowledge yet from which to draw; for her, this diagnosis did not seem obvious. This is the reason why studying concepts underlying diagnoses is so important. We cannot diagnose problems or risk situations if we do not first understand normal patterns of human response, nor can we consider health promotion opportunities. The Nursing Process Assessment is perhaps the most critical step in the nursing process. If this step is not completed in a patient-centric manner, nurses will lose control over the subsequent steps of the nursing process. Without proper nursing assessment, there can be no patient-centered nursing diagnosis, and without an appropriate nursing diagnosis, there can be no evidence-based, patient-centered, independent nursing interventions. Assessment should not be performed to merely fill in the blank spaces on a form or computer screen. If this form of rote assessment rings a bell for you, it is time to take a new look at the purpose of assessment! Assessment During the assessment and diagnosis steps of the nursing process, nurses collect data from a patient (or family/group/community), process data into information, and organize that information into meaningful categories of knowledge that represent the nursing discipline, also known as nursing diagnoses. Assessment provides the best opportunity for nurses to establish an effective therapeutic relationship with the patient. In other words, assessment is 486.2.2 both an intellectual and an interpersonal activity. What is the purpose of a nursing assessment? As you can see in Fig. 6.1, assessment involves multiple steps, with the goal being to develop diagnostic hypotheses, validate/refute these hypotheses to determine diagnoses, and prioritize these diagnoses, which then become the basis for nursing treatment. This probably sounds like a long, involved process and, frankly, who has time for all of that? In the real world, however, these steps can happen in the blink of an eye, especially for expert nurses. For instance, if a nurse sees a neonate who is irritable, showing signs of respiratory distress, and is unable to maintain sucking, he/she might immediately check a temperature and, upon finding it is 36 ° C/96.8 ° F, he/she would then conclude that the neonate is experiencing hypothermia. Thus, the movement from data collection (observation of the neonate's behavior) to determining potential diagnoses (e.g., hypothermia) occurs in a matter of minutes. However, this quickly determined diagnosis might not be the right one—or it may not be the highest priority for your patient. So, how do you accurately diagnose? Only by starting with accurate assessment—and the proper use of the data collected during that assessment—can you ensure accuracy in diagnosis. This chapter provides foundational knowledge for what to do with all the data you have collected. After all, why bother collecting them if you are not going to use them? In the next section, we will go through each of the steps in the process that takes us from assessment to diagnosis. But first, let us spend a few minutes discussing the purpose, because assessment is not simply a task that nurses complete. We need to understand its purpose so we can understand how it applies to our professional role as nurses Why Do Nurses Assess? Nurses need to assess patients from the viewpoint of the nursing discipline to diagnose accurately and to provide effective care. What is the “nursing discipline”? Simply put, it is the body of knowledge that comprises the science of nursing. Nursing diagnoses provide standardized terms, with clear definitions and assessment criteria, that represent that knowledge—just as medical diagnoses represent the knowledge of the medical profession. Diagnosing a patient based on his/her medical diagnosis or medical information, however, is neither a recommended nor safe diagnostic process. Such an overly 49simplified conclusion could lead to inappropriate interventions, prolonged length of stay, and unnecessary readmissions. Remember that nurses diagnose a human response to health conditions/life processes, or a vulnerability for that response, and that diagnosis then provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse has accountability—the focus here is “human response.” Human beings are complicated—every human being does not respond to the same situation in the same way. Our responses are based on a lot of factors—genetics, physiology, health condition, past experiences with illness/injury. However, responses are also influenced by the patient's culture, ethnicity, religion/spiritual beliefs, gender, and family upbringing. This means that human responses are not so easily identified. If we simply assume that every patient with a medical diagnosis will respond in a certain way, we may treat conditions (and therefore use the nurse's time and other resources) that do not exist, while missing others that truly need our attention. Fig. 6.1 Steps in moving from assessment to diagnosis. It is possible that there may be close relationships between some nursing diagnoses and medical conditions; however, to date we do not have sufficient scientific evidence to definitively link all nursing diagnoses to medical 50diagnoses. For instance, there is no way to know whether a patient has deficient knowledge (00126), based solely on a new medical diagnosis or procedure. The individual might have another family member with that same diagnosis, or who previously underwent the same procedure. One can also not assume that every patient with a medical diagnosis will respond in the same way; every patient who is undergoing a surgical procedure is not necessarily experiencing anxiety (00146), for example. Therefore, nursing assessment and diagnosis should be approached from the viewpoint of the nursing discipline, and should only be made when based on a patient-centric assessment. What is wrong with this diagnostic process? Unfortunately, in your practice, you will probably observe nurses who assign, or “pick,” a diagnosis before they have assessed the patient. For example, a nurse may begin to complete a plan of care based on the nursing diagnosis of anxiety (00146) for a patient coming into an obstetrical unit for childbirth, before the patient has even arrived on the unit or been evaluated. Nurses working in obstetrics encounter many laboring patients, and those patients are often very anxious. Those nurses may know that labor coaching and deep breathing are effective interventions for reducing anxiety. Therefore, assuming a relationship between labor and anxiety could be useful in practice. However, the statement “laboring patients have anxiety” may not apply to every patient (it is a hypothesis), and so it must be validated with each patient. This is especially true because anxiety is a subjective experience— although we may think the patient seems anxious, or we may expect her to be anxious, only she can tell us if she feels anxious. In other words, the nurse can understand how the patient feels only if the patient tells the nurse about her feelings; so, anxiety is a problem-focused nursing diagnosis that requires subjective data from the patient. What appears to be anxiety may actually be labor pain (00256) or ineffective childbearing process (00221); we simply cannot know until we assess and validate our findings. Thus, before nurses diagnose a patient, a thorough assessment is absolutely necessary. An understanding of potential, high-frequency diagnoses (those that often occur in a particular setting or with a particular patient population), however, is very helpful, as the knowledge of the diagnostic criteria related to those diagnoses can help focus the nurse's assessment as he/she tries to rule out or confirm various diagnostic hypotheses. 516.2.3 The Screening Assessment There are two types of assessment: screening and in-depth assessment. Both require data collection; however, they serve different purposes. The screening assessment is the initial data collection step and is probably the easiest to complete. Not Simply a Matter of Filling in the Blanks Most schools and health care organizations provide nurses with a standardized form—on paper or in the electronic health record—that must be completed for each patient, within a specified amount of time. For example, patients who are admitted to the hospital may need to have this assessment completed within 24 hours of admission. Patients seen in an ambulatory clinic may have a required assessment prior to being seen by the primary care provider (e.g., a physician or nurse practitioner). This initial assessment may include standardized screening tools, such as the Subjective Global Assessment (SGA) and/or the MiniNutritional Assessment (MNA) for assessing existing malnutrition and risk for malnutrition, respectively (Young et al 2013), or the Clinically Useful Depression Outcome Scale (CUDOS) for adult depression screening (Zimmerman et al 2008). There may be open-ended screening questions, such as: “Who can you talk to if you have a difficult situation to handle?” And there will be tools that enable completion of an assessment based on a specific nursing theory or model (e.g., Gordon's functional health patterns [FHP]), body system review, or some other method of organizing the data to be collected. The performance of a screening assessment requires specific competencies for the accurate completion of various procedures to obtain data, and it requires a high level of skill in interpersonal communication. Patients must feel safe and trust the nurse before they will feel comfortable answering personal questions or providing answers, especially if they feel their responses might not be received as culturally/spiritually “normal” or “accepted.” We indicated that the initial screening assessment may be the easiest step because, in some ways, it is initially a process of “filling in the blanks.” The screening form might require information about the patient's vital signs, so the nurse obtains these and inputs those data into the assessment form. The form requires that information is collected about the patient's various physiologic systems, and the nurse fills in all the blank spaces on the form that deal with these systems (heart rhythm, presence of a murmur, pedal pulses, lung sounds, bowel sounds, etc.), along with basic psychosocial and spiritual data. However, good nursing assessment requires far more than this initial 526.2.4 screening. Obviously, when the nurse reviews data collected during his/her assessment and starts to recognize potential diagnoses, he/she will need to collect further data that can help him/her determine if there are other human responses occurring that are of concern, that indicate risks for the patient, or that suggest health promotion opportunities. The nurse will also want to identify the etiology or precipitating factors of areas of concern. It is quite possible that these in-depth questions are not included in the organization's assessment form, because there is simply no way to include every possible question that might need to be asked for every possible human response! Knowledge of the concepts underlying the nursing discipline should drive these more in-depth questions, based on the responses of the patient/family that were obtained during the screening assessment. For example, if a patient indicated that she was experiencing difficulty with her breathing when she walked up her steps, the nurse would rely on his knowledge of various concepts to further obtain data to confirm or refute potential diagnoses. If the nurse did not understand the concepts of activity tolerance, gas exchange, or energy balance, for example, he might not know what questions to ask to continue the assessment and identify an appropriate diagnosis. Where Do Nurses Assess and Diagnose? A brief point should be made about the role of professional nurses and assessment. Nurses work in a variety of settings—from primary care to hospitals, from maternity units to operating rooms. Regardless of setting or unit, professional nurses should always be assessing patients, considering diagnoses related to their needs, identifying relevant outcomes, and implementing interventions. Nursing diagnoses are used in operating rooms, ambulatory clinics, psychiatric facilities, home health, and hospice organizations, as well as in public health, school nursing, occupational health, and, of course, in hospitals. As diverse as nursing practice is, there are core diagnoses that seem to cross them all: acute pain (00132), anxiety (00146), deficient knowledge (00126), readiness for enhanced health management (00162), for example, can probably be found anywhere a nurse might practice. For example, nurses in the operating room assess anxiety levels in patients, as well as their skin condition. As patients are being prepared for surgery, those diagnosed with anxiety (00146) may be gently touched, eye contact may be established, soft music might be played, questions they have can be answered, and breathing techniques can be encouraged to help them relax. As a patient's skin is being prepped for the incision, turgor, edema, pressure points, and positioning will be considered to 536.2.5 decrease risk for impaired skin integrity (00047) and risk for perioperative positioning injury (00087). Sometimes nurses suggest that nursing diagnosis is irrelevant in critical care units, because much of their practice is directed at medical diagnoses. This statement basically suggests that nurses do not practice nursing in critical care— yet, we certainly know that is not the case. There is no question that critical care nurses have a strong focus on interventions related to medical conditions, and often intervene with patients using “standing protocols” (standing medical orders) that require critical thinking to correctly implement. But, let us be clear —nurses in critical care units need to practice nursing! Patients in critical condition are at risk for many complications that can be prevented by independent, professional nursing practice: ventilator-related pneumonias (risk for infection, 00004), pressure ulcers (risk for pressure ulcer, 00249), corneal injury (risk for corneal injury, 00245). They are often scared (fear, 00148), and families are stressed, but they need to know how to care for their loved one when he/she comes home: deficient knowledge (00126), stress overload (00177), risk for caregiver role strain (00162). If nurses only attend to the obvious medical condition, they, as the adage says, may win the battle, but still lose the war! These patients may develop sequelae that could have been avoided, the length of stay may be prolonged, or discharge home could result in untoward events, and increased readmission rates. Do critical care nurses attend to medical conditions? Certainly! Should they also focus on the human responses? Absolutely! Assessment Framework Let us take a moment to consider the type of framework that supports a thorough nursing assessment. An evidence-based assessment framework should be used for accurate nursing diagnosis, as well as safe patient care. It should also represent the discipline of the professional using it: in this case, the assessment form should represent knowledge from the nursing discipline. Should we use the NANDA-I taxonomy as an assessment framework? There is sometimes confusion over the difference between the NANDA International, Inc. (NANDA-I) Taxonomy II of nursing diagnoses and the functional health pattern (FHP) assessment framework (Gordon 1994). The NANDA-I taxonomy was developed based on Gordon's work; that is why the two frameworks look similar. However, their purposes and functions are entirely 546.3 different. The NANDA-I taxonomy serves its intended purpose of sorting/categorizing nursing diagnoses. Each domain and class is defined, so the framework helps nurses to locate a nursing diagnosis within the taxonomy. On the other hand, the FHP framework was scientifically developed to standardize the structure for nursing assessment (Gordon 1994). It guides the history-taking and physical examination by nurses, providing items to assess, and a structure for organizing assessment data. In addition, the sequence of 11 patterns provides an efficient and effective flow for the nursing assessment. See Chapters 7 and 8 for more specific information on the NANDA-I taxonomy. As stated in the NANDA-I Position Statement (2011), use of an evidence-based assessment framework, such as Gordon's FHP, is highly recommended for accurate nursing diagnosis and safe patient care. It is not intended that the NANDA-I taxonomy should be used as an assessment framework. Data Analysis The second step in the nursing process is the conversion of data to information. Its purpose is to help us to consider what the data we collected in the screening assessment might mean, or to help us identify additional data that need to be collected. The terms “information” and “data” are sometimes used interchangeably; however, the actual characteristics of data and information are quite different. In order to have a better understanding of assessment and nursing diagnosis, it is useful to take a moment to differentiate data from information. Data are the raw facts collected by nurses through their observations, and from subjective information provided by patients/families. Nurses collect data from a patient (or family/group/community), and then, using their nursing knowledge, they transform those data into information. Information can be considered data with an assigned judgment or meaning, such as “high” or “low,” “normal” or “abnormal,” and “important” or “unimportant.” Fig. 6.2 provides an example of how objective and subjective data can be converted into information through the application of nursing knowledge in the case study of Mrs. E, a 79-year-old woman with acute abdominal pain. We will follow her case from the initial screening assessment until we have 55determined which nursing diagnoses are the most appropriate on which to base her care. Fig. 6.2 Converting data to information: The case of Mrs. E, a 79-year-old woman with severe abdominal pain. It is important to note that the same data can be interpreted differently depending on the context, or the gathering of new data. For example, let us suppose that a nurse in a school setting is examining Roxanne, a 9-year-old, after her fall off her bicycle on the way to school. During the exam, the nurse realizes that the scrapes and cuts suffered are superficial, and Roxanne rates her pain at a 3 on a scale of 1 to 10, with 10 being the worst pain imaginable. However, the nurse is concerned by her breathing, which is rapid (rate of 40), shallow, and punctuated with occasional audible wheezes. The nurse listens to Roxanne's lungs and notices diminished breath sounds to her right lower lobe, and crackles in her upper lobes. He/she takes Roxanne's temperature via the oral route, and 566.3.1 finds that it is elevated, at 37.7 ° C/99.9 ° F. These facts are given meaning by comparing them to accepted normal findings, as the nurse processes data into information. The nurse realizes that Roxanne has a slight fever, and potentially a respiratory infection. After asking Roxanne how she has been feeling, Roxanne tells the nurse that she had been away from school for three days earlier in the week with a “bad lung thing,” and was on some medication that had made her feel a lot better. With this new piece of data, the nurse may conclude that Roxanne's condition is improving, but requires surveillance over the next few days. The nurse may want to check with Roxanne's parent(s) to obtain the medical diagnosis and prescription information, so that more data are available when considering appropriate nursing diagnoses. It is therefore important to include both data and information when documenting assessment. Information cannot be validated by others if original data are not provided. For example, simply indicating “Roxanne had a fever and respiratory wheezes” is not clinically useful. How severe was the fever? How were data gathered (oral, axillary, core temperature)? What were her lung sounds, and were they the same bilaterally? Documentation that shows that Roxanne had a fever of 37.7 °C/99.9 °F, via the oral route, with diminished breath sounds to her right lower lobe and crackles in her upper right lobe, enables another nurse to compare new data collected against the previous data, to identify if the patient is improving. Subjective versus Objective Data What is the difference between subjective and objective data? Nurses collect and document two types of data related to a patient: subjective and objective data. While physicians value objective over subjective data for medical diagnoses, nurses value both types of data for nursing diagnoses (Gordon 2008). The Cambridge Dictionary On-Line (2017) defines subjective as “influenced by or based on personal beliefs or feelings, rather than based on facts”; objective means “not influenced by personal beliefs or feelings; fair or real.” One thing you should be careful of here is that, when these terms are used in the context of nursing assessment, they have a slightly different meaning from this general dictionary definition. Although the basic idea remains the same, “subjective” does not mean the nurse’ s beliefs or feelings, but that of the subject of nursing care: the patient/family/group/community. Moreover, “objective” signifies those facts observed by the nurse or other health care professionals. 576.3.2 In other words, the subjective data come from verbal reports from the patient regarding perceptions and thoughts on his/her health, daily life, comfort, relationship, and so on. For instance, a patient may report, “I need to manage my health better,” or “My partner never talks about anything important with me.” Family members/close friends can also provide this type of data, although data from the patient should be obtained whenever possible, because it is the patient's data. Sometimes, however, the patient is unable to provide subjective data, so we must rely on these other sources. For example, in a patient with significant dementia who is no longer verbal, family members may provide subjective information, based on their knowledge of the individual's behavior. An example might be an adult child of the patient telling the nurse, “She always likes to listen to soft music when she eats; it seems to calm her.” Nurses collect these subjective data through the process of history-taking or interview. History-taking is not merely asking the patient one question after another, using a routine format. To obtain accurate data from a patient, nurses must incorporate active listening skills, and use open-ended questions as much as possible, especially as follow-up questions when potentially abnormal data are identified. The objective data are those things that nurses observe about the patient. Objective data are collected through physical examinations and diagnostic test results. Here, “to observe” does not only mean the use of eyesight: it requires the use of all senses. For example, nurses look at the patient's general appearance, listen to his/her lung sounds, they may smell foul wound drainage, and feel the skin temperature using touch. Additionally, nurses use various instruments and tools to collect numerical data (e.g., body weight, blood pressure, oxygen saturation, pain level). To obtain reliable and accurate objective data, nurses must have appropriate knowledge and skills to perform physical assessment and to use standardized tools or monitoring devices. Ask yourself… does this data signify a: – Problem? – Strength? – Vulnerability? Clustering of Information/Seeing a Pattern Once the nurse has collected data and transformed it into information, the next step is to begin to answer the question: what are my patient's human 586.4 responses (nursing diagnoses)? This requires the knowledge of a variety of theories and models from nursing, as well as several related disciplines. And, as previously noted, it requires knowledge about the concepts that underlie the nursing diagnoses themselves. Do you remember the modified nursing process diagram introduced in Chapter 1 ( Fig. 5.2)? In this diagram, Herdman (2013) identifies the importance of theory/nursing science underlying nursing concepts. Think, too, about our discussion of the men playing Mahjong, and the difficulty in understanding that scenario unless you knew you were observing a type of game (a concept) ( Fig. 6.3). In other words, assessment techniques are meaningless if we do not know how to use the data! If the nurse who assessed Mrs. E, ( Fig. 6.2) did not know the normal body mass index (BMI) ranges in that age group, she would not have been able to interpret that patient's weight as being underweight. If the nurse did not understand theories related to nutrition, bowel pattern, and pain, then she might not have identified other vulnerabilities or problem responses exhibited by this elderly woman. Fig. 6.3 The modified nursing process. (Adapted from Herdman 2013.) Identifying Potential Nursing Diagnoses 59(Diagnostic Hypotheses) At this step in the process, the nurse looks at the information that is coming together to form a pattern; it provides the nurse with a way to see what human responses the patient may be experiencing. Initially, the nurse considers all potential diagnoses that may come to mind. Expert nurses can do this in seconds —novice or student nurses may ask for support from more expert nurses or faculty members to guide their thinking. Now that I’ve collected my assessment data and converted it into information, how do I know what’s important and what’s irrelevant for this particular patient? Seeing patterns in the data requires an understanding of the concept that supports each diagnosis. For example, you might find yourself working with a family that includes a married couple in their mid-40 s, both of whom are employed full time outside the home, who are caring for a parent (Mr. W) with dementia, as well as their own three children (ages 9, 14, and 17 years). On your visit to Mr. W, you notice an increase in his need for assistance for care since your last visit 28 days ago. His son, John, tells you that he has begun to wander, and become physically aggressive. He also needs more assistance with daily activities, such as hygiene and feeding. The family lost its daytime caregiver 20 days ago because Mr. W had become physically resistant to her care and had struck her twice. Although she realized he did not intend to cause harm, Mr. W is much stronger than the caregiver and she felt unsafe in this environment. John had to take a leave of absence from his work until a new caregiver can be found to care for him. He also tells you that he has begun to realize that Mr. W becomes highly agitated if he is left alone at all, so he finds it difficult to leave his room to do anything, and has been sleeping on a cot in his room. Previously, Mr. W had required minimal assistance with reorienting, reminding him to eat and perform hygiene tasks; he is now requiring nearly around-the-clock monitoring and care. John is clearly tired, and admits he has not been able to get much sleep because he is afraid his father will get up and hurt himself in the night. Throughout your conversation with John, you observe that he seems frustrated and nervous, and he frequently refers to not being sure if he is doing the right thing for Mr. W. He is clearly very concerned about his father, but also mentions that he feels he has left his wife to be a “single mother” to their children, and that he has been unable to attend any of their extracurricular 60activities, and even had to miss parent–teacher conferences. He notes that this has been especially hard on his youngest daughter. He also mentions that he is not sure how long he can reasonably stay away from work before it becomes an issue with his employer. What does all of this tell you? Unless you have a good understanding of family dynamics, stress, coping, role strain, and grief theories, it may not tell you very much at all! You may know that Mr. W has increasing care needs. But would you know to also focus on the family, and look for a cause (related factors) or other data (defining characteristics) to determine an accurate diagnosis for John? Although you might be assigned to Mr. W, if you are not attentive to what is happening in the family, are you truly attending to Mr. W's needs? Such a situation can lead to the nurse simply focusing on the patient of record, rather than considering the family and its impact on patient outcomes. Or, if you did realize the need to address what is happening with John, but did not have good baseline knowledge of the theories noted previously, you might simply “pick a diagnosis” from a list to describe his response. Conceptual knowledge of each nursing diagnosis allows the nurse to give accurate meanings to the data collected from the patient, and prepares him/her to perform the in-depth assessment. When you have this conceptual knowledge, you will begin to look at the data you collected in a different way. You will turn that data into information, and start to observe how that information starts to group together to form patterns, or to “paint a picture” of what might be happening with your patient. Take another look at Fig. 6.2. With conceptual nursing knowledge of nutrition, pain, and bowel function, you might begin to see the information as possible nursing diagnoses, such as the following: – Imbalanced nutrition, less than body requirements (00002) – Constipation (00011) – Dysfunctional gastrointestinal motility (00196) – Acute pain (00132) Unfortunately, this step is often where nurses stop—they develop a list of diagnoses and either launch directly into action (determining interventions) or simply “pick” one of the diagnoses that sound most appropriate, based on the diagnosis label, and then move on to selecting interventions for those diagnoses. Others may determine that they wish to obtain a certain outcome, and simply aim interventions at that outcome. The problem with this approach is that, unless we know the problem and its cause, the interventions selected may be 616.5 completely inappropriate for this particular patient. Quite simply, these approaches are both ineffective and inappropriate courses of action! For diagnoses to be accurate, they must be validated—and that requires additional, in-depth assessment to confirm, refute, or “rule out” a diagnosis. By combining nursing knowledge and nursing diagnosis knowledge, the nurse can now move from identifying potential diagnoses based on the screening assessment to an in-depth assessment, and then to determining the accurate nursing diagnosis(es). In-Depth Assessment At this stage in your patient's assessment, you should have reviewed the information resulting from the screening assessment, to determine which items were normal, abnormal, or represented a risk (susceptibility) or a strength. Those items that were not considered normal, or were seen as a susceptibility, should have been considered in relation to a problem-focused or risk diagnosis. Areas in which the patient indicated a desire to improve something (e.g., to enhance nutrition) should be considered as a potential health promotion diagnosis. If some data are interpreted as abnormal, further in-depth assessment is crucial to accurately diagnose the patient. However, if nurses simply collect data without paying much attention to them, critical data may be overlooked. Take another look at Fig. 6.2. The nurse could have stopped her assessment here and simply moved on to the diagnoses of acute pain and constipation—perhaps the two most “obvious” diagnoses for this patient. She could have provided education about fiber and fluid intake, as well as the importance of exercise to maintain normal bowel movements, and could have addressed the acute pain by use of heat or cold packs, for example. However, while all those things might be appropriate, she would have neglected to identify some major issues that are probably significant and that, if not addressed, will lead to continued issues with Mrs. E's status. Mrs. E's nurse, however, understood the need for an in-depth assessment and was therefore able to identify the recent loss of her spouse, grief, and social isolation ( Fig. 6.4). The nurse learned that Mrs. E had vulnerabilities consistent with a stressful new living environment (recent move to the independent living facility, lack of transportation, lack of established relationships), and her fear of an acute illness and dying. However, she also identified that Mrs. E had a strength in the support she received from her church 62community, and her verbalized desire to improve the way she was responding to this situation—very important things to build in to any plan of care! So, with this additional in-depth assessment, the nurse could now revise her potential diagnoses: 636.5.1 Fig. 6.4 In-depth assessment: The case of Mrs. E, a 79-year-old woman with severe abdominal pain. – Acute pain (00132) – Imbalanced nutrition, less than body requirements (00002) – Deficient fluid volume (00027) – Constipation (00011) – Dysfunctional gastrointestinal motility (00196) – Grieving (00136) – Relocation stress syndrome (00114) – Ineffective coping (00069) – Death anxiety (00147) – Readiness for enhanced resilience (00212) Confirming/Refuting Potential Nursing Diagnoses Whenever new data are collected and processed into information, it is time to reconsider previous potential or determined diagnoses. In this step, there are three primary things to consider: – Did the in-depth assessment provide new data that would rule out or eliminate one or more of your potential diagnoses? – Did the in-depth assessment point toward new diagnoses that you had not 646.5.2 previously considered? – How can you differentiate between similar diagnoses? It is also important to remember that other nurses will need to be able to continue to validate the diagnosis you make, and to understand how you arrived at your diagnosis. It is for this reason that it is important to use standardized terms, such as the NANDA-I nursing diagnoses, which provide not only a label (e.g., readiness for enhanced resilience), but also a definition and assessment criteria (defining characteristics and related factors, or risk factors) so that other nursing professionals can continue to validate—or perhaps refute—the diagnosis as new data become available for the patient. Terms that are simply constructed by nurses at the bedside, without these validated definitions and assessment criteria, have no consistent meaning and cannot be clinically validated or confirmed. When a NANDA-I nursing diagnosis does not exist that fits a pattern you identify in a patient, it is safer to describe the condition in detail rather than to “make up” a term that will have different meanings to different nurses. Remember that patient safety depends on good communication—so use only standardized terms that have clear definitions and assessment criteria so that they can be easily validated! Eliminating Possible Diagnoses One of the goals of in-depth assessment is to eliminate, or “rule out,” one or more of the potential diagnoses you were considering. You do this by reviewing the information you've obtained and comparing it to what you know about the diagnoses. It is critical that the assessment data support the diagnosis (es). When I look at the patient information – Is it consistent with the definition of the potential diagnosis? – Are the objective/subjective data identified in the patient defining characteristics of the diagnosis? – Does it include causes (related factors) of the potential diagnosis? Diagnoses that are not well supported through the assessment criteria provided by NANDA-I (defining characteristics, related factors, or risk factors) and/or are not supported by etiological factors (causes or contributors to the diagnoses) are not appropriate for a patient. 656.5.3 As we look at Fig. 6.4 and consider the potential diagnoses that Mrs. E's nurse identified, we can begin to eliminate some of these as valid diagnoses. Sometimes it is helpful to do a side-by-side comparison of the diagnoses, focusing on those defining characteristics and related factors that were identified throughout the assessment and patient history ( Table 6.1). For example, after reflection, Mrs. E's nurse quickly eliminates the diagnosis, death anxiety, from consideration. Although Mrs. E does indicate that she is afraid that what happened to her husband might happen to her, the nurse considers that this is more related to her grieving than to actual dread of a real or imagined threat to her life. Further, Mrs. E does not have related factors for the diagnosis, death anxiety, and in fact portrays strengths that are quite contrary to it! Potential New Diagnoses It is very possible, such as in the case of Mrs. E ( Fig. 6.4), that new data will lead to new information, and in turn, to new diagnoses. The same questions that you used to eliminate potential diagnoses should be used as you consider these new diagnoses. 666.5.4 Differentiating between Similar Diagnoses It is helpful to narrow down your potential diagnoses by considering those that are very similar, but that have a distinctive feature that makes one more relevant to the patient than the other. Let us take another look at our patient, Mrs. E. After the in-depth assessment, the nurse had ten potential 67diagnoses; one diagnosis was eliminated, leaving nine potential diagnoses. One way to start the process of differentiation is to look at where the diagnoses are located within the NANDA-I taxonomy. This gives you a clue about how the diagnoses are grouped together into the broad area of nursing knowledge (domain) and the subcategories, or group of diagnoses with similar attributes (class). After eliminating the one diagnosis for which Mrs. E had no related factors, a quick look at Table 6.1 shows her nurse is considering the following: two diagnoses in the nutrition domain (imbalanced nutrition, less than body requirements and deficient fluid volume); two in the elimination and exchange domain (constipation and dysfunctional gastrointestinal motility); four in the coping/stress domain (grieving, relocation stress syndrome, ineffective coping and readiness for enhanced resilience); and one in the comfort domain (acute pain). When I look at the patient information in light of similar nursing diagnoses: – Do the diagnoses share a similar focus, or is it different? – If the diagnoses share a similar focus, is one more focused/specific than the other? – Does one diagnosis potentially lead to another that I have identified? That is, could it be the causative factor of that other diagnosis? As the nurse considers what she knows about Mrs. E, she can look at the responses identified as potential diagnoses in light of these questions. Mrs. E is clearly dehydrated; however, it appears that her decrease in nutrition (imbalanced nutrition, less than body requirements) and hydration (deficient fluid volume) and her subsequent constipation are actually consequences of her grieving and relocation stress syndrome responses, rather than being specific to a lack of food/fluid or a gastrointestinal motility issue (dysfunctional gastrointestinal motility). Therefore, although the nurse is concerned about Mrs. E's fluid and food intake, and will need to treat the symptom of constipation, she believes that these issues can be best addressed in the long term by addressing her grieving and relocation stress syndrome, which the nurse believes are the underlying causes of her current health status. After talking with Mrs. E, the nurse also believes that using the health promotion diagnosis readiness for enhanced resilience, will best support her in 68setting goals around her nutrition and fluid status, physical activity, and bowel elimination, while reinforcing her ability to regain control over her life and improving her resilience. Of those diagnoses located in the coping/stress domain, all are within the same class (coping responses) except relocation stress syndrome (post-trauma responses). Although Mrs. E does have related factors for ineffective coping, the nurse recognizes that Mrs. E has verbalized a desire to improve her resilience, and feels that working with her on this issue from a health promotion perspective (readiness for enhanced resilience) could be more positive for her. This, coupled with the previously mentioned belief that goal setting could be used within this diagnosis to address the nutrition, fluid, and constipation issue, may make this diagnosis more appropriate for Mrs. E. Mrs. E is clearly grieving the loss of her husband of nearly 60 years. While this is a normal process, the nurse is concerned that she has not been attending to her own basic needs. She feels it is imperative for Mrs. E to acknowledge her grief, and to work with her on this response. This diagnosis may be more critical because Mrs. E is also dealing with relocation stress syndrome after moving into an independent living facility. Finally, it is important to manage the acute pain that Mrs. E is experiencing. Because one of the goals is to get her more active to support normal bowel elimination and to assist with overall well-being, it is important to increase her comfort so that her pain does not prohibit her from increasing her level of activity. A thinking tool ( Fig. 6.5) used by our colleagues in medicine can be useful as a review prior to determining your final diagnosis (es): it uses the acronym, SEA TOW (Rencic 2011). This tool can easily be adapted for nursing diagnosis, too ( ). It is always a good idea to ask a colleague, or an expert, for a second opinion if you are unsure of the appropriate diagnosis. Is the diagnosis you are considering the result of a “Eureka” moment? Did you recognize a pattern in the data from your assessment and patient interview? Did you confirm this pattern by reviewing the diagnostic indicators (defining characteristics, related factors)? Did you collect anti-evidence: data that seem to refute this diagnosis? Can you justify the diagnosis even with these data, or do these data suggest you need to look deeper? Think about your thinking—was it logical, reasoned, and built on your knowledge of nursing science and the human response that you are diagnosing? Do you need additional information about the response before you are ready to confirm it? Are you overconfident? This can happen when you are 696.5.5 accustomed to patients presenting with particular diagnoses, and so you “jump” to a diagnosis, rather than truly applying clinical reasoning skills. Finally, what else could be missing? Are there other data you need to collect or review in order to validate, confirm, or rule out a potential nursing diagnosis? Use of the SEA TOW acronym can help you validate your clinical reasoning process and increase the likelihood of accurate diagnosis. Fig. 6.5 SEA TOW: A thinking tool for diagnostic decision-making. (Adapted from Rencic 2011.) Making a Diagnosis/Prioritizing The final step is to determine the diagnosis (es) that will drive nursing intervention for your patient. After reviewing everything the nurse learned about her patient, Mrs. E, the nurse may have determined four key diagnoses: – Acute pain (00132) – Grieving (00136) – Relocation stress syndrome (00114) – Readiness for enhanced resilience (00212) Remember that the nursing process, which includes evaluation of the diagnosis, is an ongoing process and as more data become available, or as the patient's condition changes, the diagnosis (es) may also change—or the prioritization may change. Think back for a moment to the initial screening assessment the nurse performed on Mrs. E. Do you see that, without further follow-up, she would 706.6 6.7 have missed the very important diagnosis of grieving and relocation stress syndrome, along with the health promotion opportunity for Mrs. E (readiness for enhanced resilience), and might have designed a plan to address issues that would not have resolved her underlying issues? Can you see why the idea of just “picking” a nursing diagnosis to go along with the medical diagnosis simply isn't the way to go? The in-depth, ongoing assessment provided so much more information about Mrs. E that can be used to determine not only the appropriate diagnoses, but also realistic outcomes and interventions that will best meet her individual needs. Summary Assessment plays a critical role in professional nursing and requires an understanding of nursing concepts based on which nursing diagnoses are developed. Collecting data for the sake of completing some mandatory form or computer screen is a waste of time, and it certainly does not support individualized care for our patients. Collecting data with the intent of identifying critical information, considering nursing diagnoses, and then driving in-depth assessment to validate and prioritize diagnoses: this is the hallmark of professional nursing. So, although it might seem simple, standardizing nursing diagnoses without assessment can, and often does, lead to inaccurate diagnoses, inappropriate outcomes, and ineffective and/or unnecessary interventions for diagnoses that are not relevant to the patient, and may lead to completely missing the most important nursing diagnosis for your patient! References Banning M. Clinical reasoning and its application to nursing: concepts and research studies.. Nurse Educ Pract. 2008; 8(3):177–183 Bellinger G, Casstro D, Mills A. Date, Information, Knowledge, and Wisdom. Available at: otec.uoregon.edu/data-wisdom.htm. Accessed February 27, 2017. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk.. Nurs Res. 1987; 36(4):205–210 Cambridge University Press. Cambridge Dictionary On-Line. Cambridge, UK: 71Cambridge University Press; 2017. Available at: http://dictionary.cambridge.org/us/dictionary/english/subjective Centers for Disease Control & Prevention. About adult BMI. 2015. Available at: www.cdc.gov/healthyweight/assessing/bmi/adult_bmi Gordon M. Nursing Diagnosis: Process and Application. 3rd ed. St. Louis, MO: Mosby; 1994 Gordon M. Assess Notes: Nursing Assessment and Diagnostic Reasoning. Philadelphia, PA: FA Davis; 2008 Herdman, T.H. Manejo de casos empleando diagnósticos de enfermería de la NANDA Internacional [Case management using NANDA International nursing diagnoses]. XXX CONGRESO FEMAFEE 2013. Monterrey, Mexico Koharchik L, Caputi L, Robb M, Culleiton AL. Fostering clinical reasoning in nursing: how can instructors in practice settings impart this essential skill?. Am J Nurs. 2015; 115(1):58–61 Merriam-Webster.com. Subjective. Merriam-Webster; n.d. Available at: www.merriam-webster.com/dictionary/subjective Oliver D, Britton M, Seed P, Martin FC, Hopper AH. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies.. BMJ. 1997; 315(7115):1049–1053 Rencic J. Twelve tips for teaching expertise in clinical reasoning.. Med Teach. 2011; 33 (11):887–892 Simmons B. Clinical reasoning: concept analysis.. J Adv Nurs. 2010; 66(5):1151–1158 Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing.. J Nurs Educ. 2006; 45(6):204–211 Young AM, Kidston S, Banks MD, Mudge AM, Isenring EA. Malnutrition screening tools: comparison against two validated nutrition assessment methods in older medical inpatients.. Nutrition. 2013; 29(1):101–106 Zimmerman M, Chelminski I, McGlinchey JB, Posternak MA. A clinically useful depression outcome scale.. Compr Psychiatry. 2008; 49(2):131–140 727 7. 1 Introduction to the NANDA International Taxonomy of Nursing Diagnoses T. Heather Herdman Introduction NANDA International, Inc. provides a standardized terminology of nursing diagnoses, and it presents its diagnoses in a classifications scheme, more specifically a taxonomy. It is important to understand a little bit about a taxonomy, and how taxonomy differs from terminology. So, let us take a moment to talk about what taxonomy actually represents. A terminology is a system of specialized terms, whereas taxonomy is the science or technique that is used to create a system by which to classify those terms. With regard to nursing, the NANDA-I nursing diagnosis terminology includes the defined terms (labels) that are used to describe clinical judgments made by professional nurses: the diagnoses themselves. A definition of the NANDA-I taxonomy might be “a systematic ordering of phenomena/clinical judgments that define the knowledge of the nursing discipline.” More simply put, the NANDA – I taxonomy of nursing diagnoses is a classification schema to help us organize the concepts of concern (nursing judgments or nursing diagnoses) for nursing practice. A taxonomy is a way of classifying or ordering things into categories; it is a hierarchical classification scheme of main groups, subgroups, and items. A taxonomy can be compared to a filing cabinet—in a drawer (domain) you may file all information you have related to your bills/debts. Within that drawer, you may have individual file folders (classes) for different types of bills/debt: household, automobile, health care, child care, animal care, etc. Within each file folder (class), you would then have individual bills representing each type of debt (nursing diagnoses). The current biological taxonomy originated with Carl Linnaeus in 1735. He originally identified three kingdoms (animal, plant, and mineral), which were then divided into classes, orders, families, genera, and 73species (Quammen 2007). You probably learned about the revised biological taxonomy in a basic science class in your high school or university setting. Terminology, on the other hand, is the language that is used to describe a specific thing; it is the language used in a particular discipline to describe its knowledge. Therefore, the nursing diagnoses form a discipline-specific language, so when we want to talk about the diagnoses themselves, we are talking about the terminology of nursing knowledge. When we want to talk about the way that we structure or categorize the NANDA-I diagnoses, then we are talking about the taxonomy. Let us think about taxonomy as it relates to something we all deal with in our daily lives. When you need to buy food, you go to the grocery store. Suppose that there is a new store in your neighborhood, Classified Groceries, Inc., so you decide to go there to do your shopping. When you enter the store, you notice that the layout seems very different from your regular store, but the person greeting you at the door hands you a diagram to help you learn your way around ( Fig. 7.1). You can see that this store has organized the grocery items into eight main categories or grocery store aisles: proteins, grain products, vegetables, fruits, processed foods, snack foods, deli foods, and beverages. These categories/aisles could also be called “domains”—they are broad levels of classification that divide phenomena into main groups. In this case, the phenomena represent “groceries.” You may also have noticed that the diagram does not just show the eight aisles; each aisle has a few key phrases identified that further help us to understand what types of foods would be found in each aisle. For example, in the aisle (domain) entitled “Beverages,” we see six subcategories: “Coffee,” “Tea,” “Soda,” “Water,” “Beer/hard cider,” and “Wine/sake.” Another way of saying this would be that these subcategories are “Classes” of products that are found under the “Domain” of beverages. One of the rules people try to follow when they develop a taxonomy is that the classes should be mutually exclusive—in other words, one type of grocery product should not be found in multiple classes. This is not always possible, but this should still be the goal, because it makes it much clearer for people who want to use the structure. If you find cheddar cheese in the protein aisle, but find cheddar cheese spread in the snack foods aisle, it makes it hard for people to understand the classification system that is being used. Looking back at our store diagram, there is additional information to be added ( Fig. 7.2). Each of the grocery aisles is further explained, providing a more 74detailed level of information about the groceries that are found in the various aisles. As an example, Fig. 7.2 shows the detailed information provided on the “Beverages” aisle. You will note the six “classes” along with additional detail for each of those classes. These represent various types (or concepts) of beverage products, all of which share similar properties that cluster them together into one group. Fig. 7.1 Domains and classes of Classified Groceries, Inc. 75Fig. 7.2 Classes and types (concepts) of beverages at Classified Groceries, Inc. Given the information with which we have been provided, we could easily manage our shopping list. If we wanted to find some herbal soda, we would quickly be able to find the aisle marked “Beverages,” the shelf marked “Sodas,” and we could confirm that herbal sodas would be found there. Likewise, if we wanted some loose leaf green tea, we would again look at the aisle marked “Beverages,” find the shelf marked “Tea,” and then we would find “Green loose leaf teas.” The purpose of this grocery taxonomy is to help the shopper quickly determine what section of the store contains the grocery supplies that he/she wants to buy. Without this information, the shopper would have to walk up and down each aisle and try to make sense of what products were in which aisle; depending on the size of the store, this could be a very frustrating and confusing experience! Thus, the diagram being provided by the store personnel provides a “concept map,” or a guide for shoppers to quickly understand how the groceries have been classified into locations within the store, with the goal of improving the shopping experience. By now, you are probably getting a good idea of the difficulty of developing a taxonomy that reflects the concepts it is trying to classify in a clear, concise, and consistent manner. Thinking about our grocery store example, can you imagine 767.2 different ways that items in the store could be grouped together? This example of a grocery taxonomy may not meet the goal of avoiding overlap between concepts and classes in a way that is logical for all shoppers. For example, tomato juice is found in the domain Vegetables (vegetable juices), but not in the domain Beverages. Although one group of individuals might find this categorization logical and clear, others might suggest that all beverages should be together. What is important is that the distinction between the domains is well-defined, i.e., all vegetables and vegetable products are found within the vegetable domain, whereas the beverage domain contains beverages that are not vegetable-based. The problem with this distinction might be that we could then argue that wine and hard cider should be in the fruit aisle, and beer and sake should be in the grains aisle! Taxonomies are works in progress—they continue to grow, evolve, and even dramatically change as more knowledge is developed about the area of study. There is often significant debate about what structure is best for categorizing phenomena of concern to different disciplines. There are many ways of categorizing things, and truly, there is no “absolutely right” way. The goal is to find a logical, consistent way to categorize similar things while avoiding overlap between the concepts and the classes. For users of taxonomies, the goal is to understand how it classifies similar concepts into its domains and classes to quickly identify specific concepts as needed. Classification in Nursing Professions organize their formal knowledge into consistent, logical, conceptualized dimensions so that it reflects the professional domain and makes it relevant for clinical practice. For professionals in health care, the knowledge of diagnosis is a significant part of professional knowledge and is essential for clinical practice. Knowledge of nursing diagnoses must therefore be organized in a way that legitimizes professional nursing practice and consolidates the nursing profession's jurisdiction (Abbott 1988). Within the NANDA-I nursing diagnostic taxonomy, we use a hierarchical graphic to show our domains and classes ( Fig. 7.3). The diagnoses themselves are not depicted in this graphic, although they could be. The primary reason we do not include the diagnoses is that there are 244 of them, and that would make the graphic very large—and very hard to read! Classification is a way of understanding reality by naming and ordering items, 77objects, and phenomena into categories (von Krogh 2011). In health care, classification systems denote disciplinary knowledge and demonstrate how a specific group of professionals perceive what are the significant areas of knowledge of the discipline. Therefore, a classification system in health care has multiple functions, including to – provide a view of the knowledge and practice area of a specific profession. – organize phenomena in a way that refers to changes in health, processes, and mechanisms that are of concern to the professional. – show the logical connection between factors that can be controlled or manipulated by professionals in the discipline (von Krogh 2011). In nursing, it is most important that the diagnoses are classified in a way that makes sense clinically, so that when a nurse is trying to identify a diagnosis that he/she may not see very often in practice, he/she can logically use the taxonomy to find the appropriate information on possible related diagnoses. Although the NANDA-I Taxonomy II ( Fig. 7.3) is not intended to function as a nursing assessment framework, it does provide structure for classifying nursing diagnoses into domains and classes, each of which is clearly defined. To provide an example of what it would look like if we included the nursing diagnoses in the graphic representation of the taxonomy, Fig. 7.4 shows only one domain with its classes and nursing diagnoses. As you can see, this is a lot of information to depict in graphic form. 78Fig. 7.3 NANDA-I Taxonomy II domains and classes. 79Fig. 7.4 NANDA-I Domain 2, Nutrition, with classes and nursing diagnoses. Nursing knowledge includes individual, family, group, and community responses, risks, and strengths. The NANDA-I taxonomy is meant to function in the following ways; it should – provide a model, or cognitive map, of the knowledge of the nursing discipline. – communicate that knowledge, and those perspectives and theories. 807.3 7.4 – provide structure and order for that knowledge. – serve as a support tool for clinical reasoning. – provide a way to organize nursing diagnoses within an electronic health record (adapted from von Krogh 2011). Using the NANDA-I Taxonomy Although the taxonomy provides a way of categorizing nursing phenomena, it can also serve other functions. It can help faculty to develop a nursing curriculum, for example, and it can help a nurse identify a diagnosis, perhaps one that he/she may not use frequently, but that he/she needs for a specific patient. Let us look at both situations. Structuring Nursing Curricula Although the NANDA-I nursing taxonomy is not intended to be a nursing assessment framework, it can support the organization of undergraduate education. For example, curricula can be developed around the domains and classes, allowing courses to be taught that are based on the core concepts of nursing practice, and which are categorized in each of the NANDA-I domains. A course might be built around the Nutrition domain ( Fig. 7.4) with units based on each of the classes. In Unit 1, the focus could be on ingestion, and the concept of balanced nutrition would be explored in depth. What is it? How does it impact individual and family health? What are some of the common nutritionrelated problems that our patients encounter? In what types of patients might we be most likely to identify these conditions? What are the primary etiologies? What are the consequences if these conditions go undiagnosed and/or untreated? How can we prevent, treat, and/or improve these conditions? How can we manage the symptoms? Building a nursing curriculum around these key concepts of nursing knowledge enables students to truly understand and build expertise in the knowledge of nursing science, while also learning about and understanding related medical diagnoses and conditions which they will encounter in everyday practice. Designing nursing courses in this way enables students to learn a lot about the disciplinary knowledge of nursing. Eating patterns, feeding dynamics, 817.5 breastfeeding, balanced nutrition, and effective swallowing are some of the key concepts of Domain 2, Nutrition ( Fig. 7.4)—they are the “neutral states” that we must understand before we can identify potential or actual problems with these responses. Understanding balanced nutrition, for example, as a core concept of nursing practice, requires a strong understanding of anatomy, physiology, pathophysiology (including related medical diagnoses), and responses from other domains that might coincide with problems in balanced nutrition. Once you truly understand the concept of balanced nutrition (the “normal” or neutral state), identifying the abnormal state is much easier because you know what you should be seeing if nutrition were balanced, and if you don't see those data, you start to suspect that there might be a problem (or a risk may exist for a problem to develop). So, developing nursing courses around these core concepts enables nursing faculty to focus on the knowledge of the nursing discipline and then to incorporate related medical diagnoses and/or interdisciplinary concerns in a way that allows nurses to focus first on nursing phenomena and then to bring their specific knowledge to an interdisciplinary view of the patient to improve patient care. This then moves into content on realistic patient outcomes and evidencebased interventions that nurses will utilize (dependent and independent nursing interventions) to provide the best possible care for the patient to achieve outcomes for which nurses have accountability. Identifying a Nursing Diagnosis Outside Your Area of Expertise Nurses gain expertise in those nursing diagnoses that they most commonly see in their clinical practice. If your area of interest is cardiovascular nursing practice, then your expertise may include such key concepts as activity tolerance, breathing pattern, and cardiac output, just to name a few! But you will deal with patients who, despite being primarily in your care because of a cardiac event, will also have other issues that require your attention. The NANDA-I taxonomy can help you to identify potential diagnoses for these patients and support your clinical reasoning skills by clarifying what assessment data/diagnostic indicators are necessary for quickly, but accurately, diagnosing your patients. Perhaps, as you are admitting a 45-year old female patient for an inguinal hernia repair, you discover that she has significant rheumatoid arthritis (RA) and several cardiac risk factors. Your patient tells you her pain is normally between 5 82and 6 on a 10-point scale, and she rates it at a 6 today; she has obvious rheumatoid nodules and edema in her hands and wrists. She is a current smoker, describes her physical activity level as minimal, and her BMI (body mass index) is 27.6. She has a history of hypertension and arrhythmia, although today her blood pressure seems well controlled by her antihypertensive medication, and you detect no arrhythmia. You have not cared for many patients with RA, so you review the implications of RA on cardiovascular risk, and find that it is concerning; RA patients have higher cardiovascular morbidity and mortality than the general public. As you review the research, you realize that the inflammatory burden and antirheumatic medication–related cardiotoxicity are important contributors to cardiovascular risk. You want to reflect her risk, but you are not sure which nursing diagnosis is the most accurate for this patient in this situation. By looking at the taxonomy, you can quickly form a “cognitive map” that can help you to find more information on diagnoses of relevance to this patient ( Fig. 7.5). You are concerned about a cardiovascular response, and a quick review of the taxonomy leads you to Domain 4 (activity/rest), Class 4 (cardiovascular/pulmonary responses). You then see that there are three diagnoses specifically related to cardiovascular responses, and you can review the definitions, etiologies, and diagnostic indicators to clarify the most appropriate diagnosis for this patient. Using the taxonomy in this way supports clinical reasoning and helps you to navigate a large volume of information/knowledge (244 diagnoses!) in an effective and efficient manner. A review of the risk factors or the related factors and defining characteristics of these three diagnoses can: (1) provide you with additional data that you need to obtain in order to make an informed decision and/or (2) enable you to compare your assessment with those diagnostic indicators to accurately diagnose your patient. 83Fig. 7.5 Use of the NANDA-I Taxonomy to identify and validate a nursing diagnosis outside the nurse's area of expertise. Think about a recent patient—did you struggle to diagnose his/her human response? Did you find it difficult to know how to identify potential diagnoses? Using the taxonomy can support you in identifying possible diagnoses because of the way the diagnoses are grouped together in classes and domains that represent specific areas of knowledge. Do not forget, however, that simply looking at the diagnosis label and “picking a diagnosis” is not safe care! You need to review the definition and diagnostic indicators (defining characteristics, related factors, or risk factors) for each of the potential diagnoses you identify, which will help you to identify what additional data you should collect or if you have enough data to accurately diagnose the patient's human response. Let us review the case study of Mr. S to understand how you might use the taxonomy to help you to identify potential diagnoses. Case Study: Mr. S Let us suppose that your patient, Mr. S, an 87-year-old widower, presents with 84complaints of severe, shooting pain in his right hip area. He has been living in an assisted living facility for two years, since his wife died, and the staff members there have noticed that he is very agitated and shows signs of severe pain whenever they try to help him walk. They have brought him in to rule out any possible fracture or need for a hip replacement. They note that he had his other hip replaced three years ago, due to osteoporosis. Apparently, the surgery was very successful. Mr. S has no noticeable edema or bruising to his right hip area, but clearly complains of pain when you palpate the area. He has good lower extremity bilateral peripheral pulses and a lower extremity capillary refill time of 4 seconds. His medical history includes a cerebrovascular attack (stroke) at age 80. According to his medical records, he had initial paralysis on the right side and lost all speech function. He received alteplase IV r-tPA, a tissue plasminogen activator (TPA), and recovered full mobility and speech. He was in an inpatient rehabilitation center for 26 days, received speech, physical and occupational therapy, and cared for himself independently after he was discharged home. He has moderate coronary artery disease, but otherwise no significant medical history. According to the staff member accompanying him, Mr. S has been active until a few weeks ago when he started to complain of pain. He enjoyed ballroom dancing, exercised at the facility on a regular basis, and was frequently seen walking around the complex speaking to people, or taking walks outdoors on the grounds of the complex when the weather was nice. She also indicates he has become less social recently, and has not attended different activities that he normally enjoys. She indicates the staff members have attributed this to his level of discomfort. What you notice most about Mr. S, however, is that he seems withdrawn, he barely speaks, and rarely makes eye contact. He struggles to answer your questions, and the staff member often jumps in to provide answers rather than allowing him to answer for himself. Although his speech does not appear to be impaired, he seems to be struggling to find answers to even basic questions, such as his age or the year that his wife died. After completing your assessment and reviewing his history, you believe that Mr. S may be dealing with an issue related to cognition, but this is an area of nursing in which you have little experience; you need some review of potential diagnoses. Since you are considering a cognition issue, you look at the NANDA-I taxonomy to identify the logical location of these diagnoses. 857.6 You identify that Domain 5, Perception/cognition, deals with the human information processing system including attention, orientation, sensation, perception, cognition, and communication. Because you are considering issues related to cognition, you think this domain will contain diagnoses of relevance to Mr. S. You then quickly identify Class 4, Cognition. A review of this class leads to the identification of three potential diagnoses: acute confusion, chronic confusion, and impaired memory. Questions you should ask yourself include: What other human responses should I rule out or consider? What other signs/symptoms, or etiologies, should I look for to confirm this diagnosis? Once you review the definitions and diagnostic indicators (related factors, defining characteristics, and risk factors), you diagnose Mr. S with chronic confusion (00129). Some final questions should include: Am I missing anything? Am I diagnosing without sufficient evidence? If you believe you are correct in your diagnosis, your questions move on to: What outcomes can I realistically expect to achieve with Mr. S? What are the evidence-based nursing interventions that I should consider? How will I evaluate whether or not they were effective? The NANDA-I Nursing Diagnosis Taxonomy: A Short History In 1987, NANDA-I published Taxonomy I, which was structured to reflect nursing theoretical models from North America. In 2002, Taxonomy II was adopted, which was adapted from the Functional Health Patterns assessment framework of Dr. Marjory Gordon. This assessment framework is probably the most used nursing assessment framework around the world. Over the course of the last three years, NANDA-I members and users considered whether to replace Taxonomy II with a recommendation for Taxonomy III, developed by Dr. Gunn von Krogh (discussed in detail in the 10th edition of this text). In 2016, this taxonomy was brought forward to the membership of NANDA-I to determine if the organization should maintain Taxonomy II or possibly move to this new view and adopt a Taxonomy III. After reflection, study, and discussion, the 86overwhelming decision of the membership was to retain Taxonomy II. Work may continue on Taxonomy III, and it could return to the membership for reconsideration at a later date. Table 7.1 demonstrates the domains, classes, and nursing diagnoses and how they are currently located within the NANDA-I Taxonomy II. Table 7.1 Domains, classes, and nursing diagnoses in the NANDA-I Taxonomy II Code Diagnosis Domain 1. Health promotion The awareness of well-being or normality of function and the strategies used to maintain control of and enhance that well-being or normality of function Class 1. Health awareness Recognition of normal function and well-being 00097 Decreased diversional activity engagement 00262 Readiness for enhanced health literacy 00168 Sedentary lifestyle Class 2. Health management Identifying, controlling, performing, and integrating activities to maintain health and well-being 00230 Frail elderly syndrome 00231 Risk for frail elderly syndrome 00215 Deficient community health 00188 Risk-prone health behavior 00099 Ineffective health maintenance 00078 Ineffective health management 00162 Readiness for enhanced health management 00080 Ineffective family health management 00043 Ineffective protection Domain 2. Nutrition The activities of taking in, assimilating, and using nutrients for the purposes of tissue maintenance, tissue repair, and the production of energy Class 1. Ingestion Taking food or nutrients into the body 00002 Imbalanced nutrition: less than body requirements 00163 Readiness for enhanced nutritiona 00216 Insufficient breast milk production 00104 Ineffective breastfeeding 00105 Interrupted breastfeeding 00106 Readiness for enhanced breastfeeding 00269 Ineffective adolescent eating dynamics 8700270 Ineffective child eating dynamics 00271 Ineffective infant eating dynamics 00107 Ineffective infant feeding pattern 00232 Obesity 00233 Overweight 00234 Risk for overweight 00103 Impaired swallowing Class 2. Digestion The physical and chemical activities that convert foodstuffs into substances suitable for absorption and assimilation None at present time Class 3. Absorption The act of taking up nutrients through body tissues None at present time Class 4. Metabolism The chemical and physical processes occurring in living organisms and cells for the development and use of protoplasm, the production of waste and energy, with the release of energy for all vital processes 00179 Risk for unstable blood glucose level 00194 Neonatal hyperbilirubinemia 00230 Risk for neonatal hyperbilirubinemia 00178 Risk for impaired liver function 00263 Risk for metabolic imbalance syndrome Class 5. Hydration The taking in and absorption of fluids and electrolytes 00195 Risk for electrolyte imbalance 00025 Risk for imbalanced fluid volumeb 00027 Deficient fluid volume 00028 Risk for deficient fluid volume 00026 Excess fluid volume Domain 3. Elimination and exchange Secretion and excretion of waste products from the body Class 1. Urinary function The process of secretion, reabsorption, and excretion of urine 00016 Impaired urinary elimination 00020 Functional urinary incontinence 00176 Overflow urinary incontinence 00018 Reflex urinary incontinence 00017 Stress urinary incontinence 00019 Urge urinary incontinence 8800022 Risk for urge urinary incontinence 00023 Urinary retention Class 2. Gastrointestinal function The process of absorption and excretion of the end products of digestion 00011 Constipation 00015 Risk for constipation 00012 Perceived constipation 00235 Chronic functional constipation 00236 Risk for chronic functional constipation 00013 Diarrhea 00196 Dysfunctional gastrointestinal motility 00197 Risk for dysfunctional gastrointestinal motility 00014 Bowel incontinence Class 3. Integumentary function The process of secretion and excretion through the skin None at present time Class 4. Respiratory function The process of exchange of gases and removal of the end products of metabolism 00030 Impaired gas exchange Domain 4. Activity/rest The production, conservation, expenditure, or balance of energy resources Class 1. Sleep/rest Slumber, repose, ease, relaxation, or inactivity 00095 Insomnia 00096 Sleep deprivation 00165 Readiness for enhanced sleep 00198 Disturbed sleep pattern Class 2. Activity/exercise Moving parts of the body (mobility), doing work, or performing actions often (but not always) against resistance 00040 Risk for disuse syndrome 00091 Impaired bed mobility 00085 Impaired physical mobility 00089 Impaired wheelchair mobility 00237 Impaired sitting 00238 Impaired standing 00090 Impaired transfer ability 00088 Impaired walking 89Class 3. Energy balance A dynamic state of harmony between intake and expenditure of resources 00273 Imbalanced energy field 00093 Fatigue 00154 Wandering Class 4. Cardiovascular/pulmonary responses Cardiopulmonary mechanisms that support activity/rest 00092 Activity intolerance 00094 Risk for activity intolerance 00032 Ineffective breathing pattern 00029 Decreased cardiac output 00240 Risk for decreased cardiac output 00033 Impaired spontaneous ventilation 00267 Risk for unstable blood pressure 00200 Risk for decreased cardiac tissue perfusion 00201 Risk for ineffective cerebral tissue perfusion 00204 Ineffective peripheral tissue perfusion 00228 Risk for ineffective peripheral tissue perfusion 00034 Dysfunctional ventilatory weaning response Class 5. Self-care Ability to perform activities to care for one’s body and bodily functions 00098 Impaired home maintenance 00108 Bathing self-care deficit 00109 Dressing self-care deficit 00102 Feeding self-care deficit 00110 Toileting self-care deficit 00182 Readiness for enhanced self-care 00193 Self-neglect Domain 5. Perception/cognition The human processing system including attention, orientation, sensation, perception, cognition, and communication Class 1. Attention Mental readiness to notice or observe 00123 Unilateral neglect Class 2. Orientation Awareness of time, place, and person None at present time Class 3. Sensation/perception Receiving information through the senses of touch, taste, smell, vision, hearing, and kinesthesia, and the 90comprehension of sensory data resulting in naming, associating, and/or pattern recognition None at present time Class 4. Cognition Use of memory, learning, thinking, problem-solving, abstraction, judgment, insight, intellectual capacity, calculation, and language 00128 Acute confusion 00173 Risk for acute confusion 00129 Chronic confusion 00251 Labile emotional control 00222 Ineffective impulse control 00126 Deficient knowledge 00161 Readiness for enhanced knowledge 00131 Impaired memory Class 5. Communication Sending and receiving verbal and nonverbal information 00157 Readiness for enhanced communication 00051 Impaired verbal communication Domain 6. Self-perception Awareness about the self Class 1. Self-concept The perception(s) about the total self 00124 Hope lessness 00185 Readiness for enhanced hope 00174 Risk for compromised human dignity 00121 Disturbed personal identity 00225 Risk for disturbed personal identity 00167 Readiness for enhanced self-concept Class 2. Self-esteem Assessment of one’s own worth, capability, significance, and success 00119 Chronic low self-esteem 00224 Risk for chronic low self-esteem 00120 Situational low self-esteem 00153 Risk for situational low self-esteem Class 3. Body image A mental image of one’s own body 00118 Disturbed body image Domain 7. Role relationship The positive and negative connections or associations between people or groups of people and the means by which those connections are demonstrated 91Class 1. Caregiving roles Socially expected behavior patterns by people providing care who are not health care professionals 00061 Caregiver role strain 00062 Risk for caregiver role strain 00056 Impaired parenting 00057 Risk for impaired parenting 00164 Readiness for enhanced parenting Class 2. Family relationships Associations of people who are biologically related or related by choice 00058 Risk for impaired attachment 00063 Dysfunctional family processes 00060 Interrupted family processes 00159 Readiness for enhanced family processes Class 3. Role performance Quality of functioning in socially expected behavior patterns 00223 Ineffective relationship 00229 Risk for ineffective relationship 00207 Readiness for enhanced relationship 00064 Parental role conflict 00055 Ineffective role performance 00052 Impaired social interaction Domain 8. Sexuality Sexual identity, sexual function, and reproduction Class 1. Sexual identity The state of being a specific person in regard to sexuality and/or gender None at present time Class 2. Sexual function The capacity or ability to participate in sexual activities 00059 Sexual dysfunction 00065 Ineffective sexuality pattern Clas 3. Reproduction Any process by which human beings are produced 00221 Ineffective childbearing process 00227 Risk for ineffective childbearing process 00208 Readiness for enhanced childbearing process 00209 Risk for disturbed maternal-fetal dyad Domain 9. Coping/stress tolerance Contending with life events/life processes 92Class 1. Post-trauma responses Reactions occurring after physical or psychological trauma 00260 Risk for complicated immigration transition 00141 Post-trauma syndrome 00145 Risk for post-trauma syndrome 00142 Rape-trauma syndrome 00114 Relocation stress syndrome 00149 Risk for relocation stress syndrome Class 2. Coping responses The process of managing environmental stress 00199 Ineffective activity planning 00226 Risk for ineffective activity planning 00146 Anxiety 00071 Defensive coping 00069 Ineffective coping 00158 Readiness for enhanced coping 00077 Ineffective community coping 00076 Readiness for enhanced community coping 00074 Compromised family coping 00073 Disabled family coping 00075 Readiness for enhanced family coping 00147 Death anxiety 00072 Ineffective denial 00148 Fear 00136 Grieving 00135 Complicated grieving 00172 Risk for complicated grieving 00241 Impaired mood regulation 00125 Power lessness 00152 Risk for power lessness 00187 Readiness for enhanced power 00210 Impaired resilience 00211 Risk for impaired resilience 00212 Readiness for enhanced resilience 00137 Chronic sorrow 00177 Stress overload Class 3. Behavioral responses reflecting nerve and brain function 93Neurobehavioral stress 00258 Acute substance withdrawal syndrome 00259 Risk for acute substance withdrawal syndrome 00009 Autonomic dysreflexia 00010 Risk for autonomic dysreflexia 00049 Decreased intracranial adaptive capacity 00264 Neonatal abstinence syndrome 00116 Disorganized infant behavior 00115 Risk for disorganized infant behavior 00117 Readiness for enhanced organized infant behavior Domain 10. Life principles Principles underlying conduct, thought, and behavior about acts, customs, or institutions viewed as being true or having intrinsic worth Class 1. Values The identification and ranking of preferred modes of conduct or end states None at present time Class 2. Beliefs Opinions, expectations, or judgments about acts, customs, or institutions viewed as being true or having intrinsic worth 00068 Readiness for enhanced spiritual well-being Class 3. Value/belief/action congruence The correspondence or balance achieved among values, beliefs, and actions 00184 Readiness for enhanced decision-making 00083 Decisional conflict 00242 Impaired emancipated decision-making 00244 Risk for impaired emancipated decision-making 00243 Readiness for enhanced emancipated decision-making 00175 Moral distress 00169 Impaired religiosity 00170 Risk for impaired religiosity 00171 Readiness for enhanced religiosity 00066 Spiritual distress 00067 Risk for spiritual distress Domain 11. Safety/protection Freedom from danger, physical injury, or immune system damage; preservation from loss; and protection of safety and security Class 1. Infection Host responses following pathogenic invasion 00004 Risk for infection 9400266 Risk for surgical site infection Class 2. Physical injury Bodily harm or hurt 00031 Ineffective airway clearance 00009 Risk for aspiration 00206 Risk for bleeding 00048 Impaired dentition 00219 Risk for dry eye 00261 Risk for dry mouth 00155 Risk for falls 00245 Risk for corneal injuryc 00035 Risk for injury 00250 Risk for urinary tract injury 00087 Risk for perioperative positioning injuryc 00220 Risk for thermal injuryc 00045 Impaired oral mucous membrane integrity 00247 Risk for impaired oral mucous membrane integrity 00086 Risk for peripheral neurovascular dysfunction 00038 Risk for physical trauma 00213 Risk for vascular trauma 00249 Risk for pressure ulcer 00205 Risk for shock 00046 Impaired skin integrity 00047 Risk for impaired skin integrity 00156 Risk for sudden infant death 00036 Risk for suffocation 00100 Delayed surgical recovery 00246 Risk for delayed surgical recovery 00044 Impaired tissue integrity 00248 Risk for impaired tissue integrity 00268 Risk for venous thromboembolism Class 3. Violence The exertion of excessive force or power to cause injury or abuse 00272 Risk for female genital mutilation 00138 Risk for other-directed violence 00140 Risk for self-directed violence 00151 Self-mutilation 9500139 Risk for self-mutilation 00150 Risk for suicide Class 4. Environmental hazards Sources of danger in the surroundings 00181 Contamination 00180 Risk for contamination 00265 Risk for occupational injury 00037 Risk for poisoning Class 5. Defensive processes The processes by which the self protects itself from the nonself 00218 Risk for adverse reaction to iodinated contrast media 00217 Risk for allergic reaction 00041 Latex allergic reaction 00042 Risk for latex allergic reaction Class 6. Thermoregulation The physiological process of regulating heat and energy within the body for purposes of protecting the organism 00007 Hyperthermia 00006 Hypothermia 00253 Risk for hypothermia 00254 Risk for perioperative hypothermia 00008 Ineffective thermoregulation 00274 Risk for ineffective thermoregulation Domain 12. Comfort Sense of mental, physical, or social well-being or ease Class 1. Physical comfort Sense of well-being or ease and/or freedom from pain 00214 Impaired comfort 00183 Readiness for enhanced comfort 00134 Nausea 00132 Acute pain 00133 Chronic pain 00255 Chronic pain syndromed 00256 Labor paind Class 2. Environmental comfort Sense of well-being or ease in/with one’s environment 00214 Impaired comfort 00183 Readiness for enhanced comfort 967.7 Class 3. Social comfort Sense of well-being or ease with one’s social situation 00214 Impaired comfort 00183 Readiness for enhanced comfort 00054 Risk for loneliness 00053 Social isolation Domain 13. Growth/development Age-appropriate increases in physical dimensions, maturation of organ systems, and/or progression through the developmental milestones Class 1. Growth Increase in physical dimensions or maturity of organ systems None at present time Class 2. Development Progress or regression through a sequence of recognized milestones in life 00112 Risk for delayed development aThe editors acknowledge this concept is not in alphabetical order; a decision was made to maintain all “nutrition” diagnoses in sequential order. b The editors acknowledge this concept is not in alphabetical order; a decision was made to maintain all “fluid volume” diagnoses in sequential order. cThe editors acknowledge this concept is not in alphabetical order; a decision was made to maintain all “injury” diagnoses in sequential order. d The editors acknowledge this concept is not in alphabetical order; a decision was made to maintain all “pain” diagnoses in sequential order. References Abbott A. The Systems of Professions. Chicago, IL: The University of Chicago Press; 1988 Quammen D. A passion for order. National Geographic Magazine. 2007. Available at: ngm.nationalgeographic.com/print/2007/06/Linnaeus-namegiver/david-quammen-text (retrieved November 1, 2013) Von Krogh G. Taxonomy III Proposal. NANDA International Latin American Symposium. Sao Paulo, Brazil. May, 2011 978 8. 1 Specifications and Definitions Within the NANDA International Taxonomy of Nursing Diagnoses T. Heather Herdman Structure of Taxonomy II Taxonomy is defined as the “system for naming and organizing things … into groups that share similar qualities” (Cambridge Dictionary On-Line, 2017). Within the taxonomy, the domains are “an area of interest or an area over which one has control”; and the classes are “a group … with similar structure” (Cambridge Dictionary On-Line, 2017). We can adapt the definition for a nursing diagnosis taxonomy; specifically, we are concerned with the orderly classification of diagnostic foci of concern to nursing, according to their presumed natural relationships. Taxonomy II has three levels: domains, classes, and nursing diagnoses. Fig. 7.3 depicts the organization of domains and classes in Taxonomy II; Table 7.1 shows Taxonomy II with its 13 domains, 47 classes, and 244 current diagnoses. The Taxonomy II code structure is a 32-bit integer (or if the user's database uses another notation, the code structure is a five-digit code). This structure provides for the stability, or growth and development, of the classification structure by avoiding the need to change codes when new diagnoses, refinements, and revisions are added. New codes are assigned to newly approved diagnoses. Taxonomy II has a code structure that is compliant with recommendations from the National Library of Medicine (NLM) concerning health care terminology codes. The NLM recommends that codes do not contain information about the classified concept, as did the Taxonomy I code structure, which included information about the location and the level of the diagnosis. The NANDA-I terminology is a recognized nursing language that meets the criteria established by the Committee for Nursing Practice Information 988.2 Infrastructure (CNPII) of the American Nurses Association (ANA) (Lundberg et al 2008). The benefit of a recognized nursing language is the indication that the classification system is accepted as supporting nursing practice by providing clinically useful terminology. The terminology is also registered with Health Level Seven International (HL7), a health care informatics standard, as a terminology to be used in identifying nursing diagnoses in electronic messages among clinical information systems (www.HL7.org). A Multiaxial System for Constructing Diagnostic Concepts The NANDA-I diagnoses are concepts constructed by means of a multiaxial system. An axis, for the purpose of the NANDA-I Taxonomy II, is operationally defined as a dimension of the human response that is considered in the diagnostic process. There are seven axes. The NANDA-I Model of a Nursing Diagnosis displays the seven axes and their relationship to each other. – Axis 1: the focus of the diagnosis – Axis 2: subject of the diagnosis (individual, family, group, caregiver, community, etc.) – Axis 3: judgment (impaired, ineffective, etc.) – Axis 4: location (oral, peripheral, cerebral, etc.) – Axis 5: age (neonate, infant, child, adult, etc.) – Axis 6: time (chronic, acute, intermittent) – Axis 7: status of the diagnosis (problem-focused, risk, health promotion) The axes are represented in the labels of the nursing diagnoses through their values. In some cases they are named explicitly, such as with the diagnoses ineffective community coping and dysfunctional family processes, in which the subject of the diagnosis is named using the two values “community” and “family” taken from Axis 2 (subject of the diagnosis). “Ineffective” and “dysfunctional” are two of the values contained in Axis 3 (judgment). In some cases, the axis is implicit, as is the case with the diagnosis ineffective sexuality pattern, in which the subject of the diagnosis (Axis 2) is always the patient. In some instances, an axis may not be pertinent to a diagnosis, and therefore is not part of the nursing diagnostic label. For example, the time axis may not be relevant to every diagnosis. In the case of diagnoses without explicit identification of the subject of the diagnosis, it may be helpful to remember that 998.3 8.3.1 NANDA-I defines a patient as “an individual, a family, a group, or a community.” Axis 1 (the focus of the diagnosis) and Axis 3 (judgment) are essential components of a nursing diagnosis. In some cases, however, the focus of the diagnosis contains the judgment (e.g., fear); in these cases, the judgment is not explicitly separated from the focus of the diagnosis in the diagnostic label. Axis 2 (subject of the diagnosis) is also essential, although, as described earlier, it may be implied and therefore not included in the label. The Diagnosis Development Committee requires these axes for submission; the other axes may be used where relevant for clarity. Definitions of the Axes Axis 1: The Focus of the Diagnosis The focus of the diagnosis is the principal element or the fundamental and essential part, the root, of the diagnostic concept. It describes the “human response” that is the core of the diagnosis. The focus of the diagnosis may consist of one or more nouns. When more than one noun is used (e.g., sexual dysfunction), each one contributes a unique meaning to the focus of the diagnosis, as if the two were a single noun; the meaning of the combined term, however, is different from when the nouns are stated separately. Frequently, a noun (parenting) may be used with an adjective (impaired) to denote the focus of the diagnosis impaired parenting. In some cases, the focus of the diagnosis and the diagnostic concept are one and the same, as is seen with the diagnosis of fear. This occurs when the nursing diagnosis is stated at its most clini [Show More]

Last updated: 2 years ago

Preview 1 out of 567 pages