List of Nanda Nursing Diagnosis

Nanda nursing diagnosis list 2011


List of NANDA Nursing diagnosis Accepted for Use and Research Divided into 13 domains and 47 classes, below the full list of 13 Domains and 47 classes NANDA Nursing diagnosis. And complete list of NANDA Nursing diagnosis based on alphabetical order.
  1. Domains Health Promotions
    1. Health awareness
    2. Health management
  2. Domains nutrition’s
    1. ingestion
    2. digestion
    3. Absorption
    4. Metabolism
    5. Hydration
  3. Domains Elimination/exchange
    1. Urinary System
    2. Gastrointestinal System
    3. Integumentary system
    4. Pulmonary System
  4. Domains Activity/Rest
    1. Sleep/Rest
    2. Activity/Exercise
    3. Energy Balance
    4. Cardiovascular-pulmonary Responses
    5. Self-Care
  5. Domains Perception/Cognition
    1. Attention
    2. Orientation
    3. Sensation/Perception Cognition
    4. Communication
  6. Domains Self Perception
    1. Self-Concept
    2. Self-Esteem
    3. Body Image
  7. Domains Role Relationship
    1. Caregiving Roles
    2. Family Relationship
    3. Role Performance
  8. Domains Sexuality
    1. Sexual Identity
    2. Sexual Function
    3. Reproduction
  9. Domains Coping/Stress Tolerance
    1. Post-Trauma Responses
    2. Coping Responses
    3. Neuro-behavioral Stress
  10. Domains Life Principles
    1. Values
    2. Beliefs
    3. Values/Belief/action Congruence
  11. Domains Safety/protection
    1. infection
    2. Physical Injury
    3. Violence
    4. Environmental Hazards
    5. Defensive Processes
    6. Thermo regulation
  12. Domains Comfort
    1. Physical Comfort
    2. Environmental Comfort
    3. social Comfort
  13. Domains Growth/Development
    1. Growth
    2. Development

Source : nandanursingdiagnosislist

Nursing Diagnosis for Risk for Infection

Nursing Diagnosis for Risk for Infection

NANDA Definition: At increased risk for being invaded by pathogenic organisms

Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and exposures that occur throughout the course of living. Infections occur when an organism (e.g., bacterium, virus, fungus, or other parasite) invades a susceptible host. Breaks in the integument, the body’s first line of defense, and/or the mucous membranes allow invasion by pathogens. If the host’s (patient’s) immune system cannot combat the invading organism adequately, an infection occurs. Open wounds, traumatic or surgical, can be sites for infection; soft tissues (cells, fat, muscle) and organs (kidneys, lungs) can also be sites for infection either after trauma, invasive procedures, or by invasion of pathogens carried through the bloodstream or lymphatic system. Infections can be transmitted, either by contact or through airborne transmission, sexual contact, or sharing of intravenous (IV) drug paraphernalia. Being malnourished, having inadequate resources for sanitary living conditions, and lacking knowledge about disease transmission place individuals at risk for infection. Health care workers, to protect themselves and others from disease transmission, must understand how to take precautions to prevent transmission. Because identification of infected individuals is not always apparent, standard precautions recommended by the Centers for Disease Control and Prevention (CDC) are widely practiced. In addition, the Occupational Safety and Health Administration (OSHA) has set forth the Blood Borne Pathogens Standard, developed to protect workers and the public from infection. Ease and increase in world travel has also increased opportunities for transmission of disease from abroad. Infections prolong healing, and can result in death if untreated. Antimicrobials are used to treat infections when susceptibility is present. Organisms may become resistant to antimicrobials, requiring multiple antimicrobial therapy. There are organisms for which no antimicrobial is effective, such as the human immunodeficiency virus (HIV).


NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
  • Immune Status
  • Knowledge: Infection Control

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
  • Infection Control
  • Infection Protection

Nursing Interventions :
  • Observe and report signs of Infection.
  • Assess temperature, Use an electronic or mercury thermometer to assess temperature.
  • Note and report laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures).
  • Assess skin for colour, moisture, texture, and turgor (elasticity).
  • Carefully wash and pat dry skin, including skinfold area. Use hydration and moisturization on all at-risk surfaces.
  • Encourage a balanced diet, emphasizing proteins to feed the immune system.
  • Prevent nosocomial pneumonia.
  • Encourage fluid intake and adequate rest to bolster the immune system.
  • Before and after giving care to client use Proper hand washing techniques.
  • Use goggles, gloves, and gowns when appropriate Follow Standard Precautions and wear gloves during any contact with blood, mucous membranes, nonintact skin, or any body substance.
  • Transmission Based Precautions for
    • Airborne
    • Droplet
    • Contact transmitted
  • Sterile technique on catheterize.
  • Use careful technique when changing and emptying urinary catheter bags; avoid cross contamination.
  • Use careful sterile technique wherever there is a loss of skin integrity.
  • Ensure client's appropriate hygienic care with hand washing; bathing; and hair, nail, and perinea care.
  • Antibiotics.

Nursing Diagnosis for Anal Atresia

Anal atresia: Congenital absence of an opening at the bottom end of the intestinal tract. Also called imperforate anus. Occurs in about 1 in 5,000 births. It is corrected by surgery.

Atresia refers here to the absence of a normal opening.


Nursing Diagnosis for Anal Atresia
  1. Impaired Urinary Elimination related to Dysuria
  2. Risk of infection related to feces into the urethra, the microorganisms enter the urinary tract.
  3. Impaired nutrition: less than body requirements related to nausea, vomiting, anorexia.
  4. Pain related to postoperative tissue trauma.
  5. Risk of infection related to inadequate care, postoperative tissue trauma.
  6. Risk for Impaired Skin Integrity related to defecation pattern changes, not spending.

Nursing Diagnosis for Upper Respiratory Tract Infection

Upper respiratory tract infections (URI or URTI) are the illnesses caused by an acute infection which involves the upper respiratory tract: nose, sinuses, pharynx or larynx. This commonly includes: tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, and the common cold.


Nursing Diagnosis for Upper Respiratory Tract Infection
  1. Ineffective breathing pattern related to the inflammatory process in the respiratory tract, pain.
  2. Ineffective airway clearance related to the mechanics of airway obstruction by secretions, inflammatory processes, increased production of secretions.
  3. Anxiety related to the disease experienced by children, hospitalization in children.

Nursing Diagnosis for Asthma

Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways become sore and swollen. That makes them very sensitive, and they may react strongly to things that you are allergic to or find irritating. When your airways react, they get narrower and your lungs get less air. This can cause wheezing, coughing, chest tightness and trouble breathing, especially early in the morning or at night.

When your asthma symptoms become worse than usual, it's called an asthma attack. In a severe asthma attack, the airways can close so much that your vital organs do not get enough oxygen. People can die from severe asthma attacks.

Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms.

NIH: National Heart, Lung, and Blood Institute


Nursing Diagnosis for Asthma
  1. Ineffective airway clearance related to the accumulation of mucus.
  2. Ineffective breathing pattern related to decreased lung expansion.
  3. Impaired nutrition: less than body requirements related to inadequate intake.
  4. Activity intolerance related to physical weakness.
  5. Deficient Knowledge about the disease process associated with a lack of information.
Nursing Diagnosis for Asthma

Diagnosis for Scabies

Scabies (from Latin: scabere, "to scratch"),known colloquially as the seven-year itch, is a contagious skin infection that occurs among humans and other animals. It is caused by a tiny and usually not directly visible parasite, the mite Sarcoptes scabiei, which burrows under the host's skin, causing intense allergic itching. The infection in animals (caused by different but related mite species) is called sarcoptic mange.

Diagnosis for Scabies

Scabies may be diagnosed clinically in geographical areas where it is common when diffuse itching presents along with either lesions in two typical spots or there is itchiness of another household member. The classical sign of scabies is the burrows made by the mites within the skin. To detect the burrow the suspected area is rubbed with ink from a fountain pen or a topical tetracycline solution, which glows under a special light. The skin is then wiped with an alcohol pad. If the person is infected with scabies, the characteristic zigzag or "S" pattern of the burrow will appear across the skin; however, interpreting this test may be difficult, as the burrows are scarce and may be obscured by scratch marks. A definitive diagnosis is made by finding either the scabies mites or their eggs and fecal pellets. Searches for these signs involve either scraping a suspected area, mounting the sample in potassium hydroxide, and examining it under a microscope, or using dermoscopy to examine the skin directly.

Source : wikipedia

Nursing Diagnosis for Scabies

Scabies is a common skin infection that causes small itchy bumps and blisters due to tiny mites that burrow into the top layer of human skin to lay their eggs.

The burrows sometimes appear as short, wavy, reddish, or darkened lines on the skin's surface, especially around the wrists and between the fingers. A child who has contracted scabies can also develop a bumpy red rash.

Scabies is contagious, and is usually transmitted by skin-to-skin contact or through sexual contact with someone else who is infected with it. The infection spreads more easily in crowded conditions and in situations where there is a lot of close contact — like childcare centers or nursing homes. So if someone in your child's class or childcare group has scabies, it's wise to have your child treated for the infection even before he or she develops symptoms.


Nursing Diagnosis for Scabies
  1. Acute pain related to injury to biological agents
  2. Disturbed sleep pattern related to pain
  3. Disturbed body image related to changes in appearance
  4. Anxiety related to changes in health status
  5. Risk for Infection related to biscuits damaged tissue and invasive procedures
  6. Impaired skin integrity related to edema

Nursing Diagnosis for Rheumatoid Arthritis (RA)

Rheumatoid Arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. The process produces an inflammatory response of the synovium (synovitis) secondary to hyperplasia of synovial cells, excess synovial fluid, and the development of pannus in the synovium. The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions, most common in subcutaneous tissue. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in both its chronicity and progression, and RA is considered a systemic autoimmune disease.


Nursing Diagnosis for Rheumatoid Arthritis (RA)
  1. Acute Pain / Chronic related to distention of tissue by the accumulation of fluid / inflammation, joint destruction.
  2. Impaired physical mobility related to skeletal deformities, pain, decreased muscle strength.
  3. Disturbed body image related to changes in the ability to perform common tasks, increased use of energy, mobility imbalance.
  4. Self-care deficit: bathing / hygiene related musculoskeletal damage, decreased strength, endurance, pain when moving, depression.
  5. The need of learning about the disease, prognosis, and treatment associated with a lack of exposure / recall, misinterpretation of information.

Diagnosis of Bronchiectasis

Bronchiectasis

Bronchiectasis is a disease state defined by localized, irreversible dilation of part of the bronchial tree caused by destruction of the muscle and elastic tissue. It is classified as an obstructive lung disease, along with emphysema, bronchitis and cystic fibrosis. Involved bronchi are dilated, inflamed, and easily collapsible, resulting in airflow obstruction and impaired clearance of secretions. Bronchiectasis is associated with a wide range of disorders, but it usually results from necrotizing bacterial infections, such as infections caused by the Staphylococcus or Klebsiella species or Bordetella pertussis.


Diagnosis of Bronchiectasis

The diagnosis of bronchiectasis is based on the review of clinical history and characteristic patterns in high-resolution CT scan findings. Such patterns include "tree-in-bud" abnormalities and cysts with definable borders. In one small study, CT findings of bronchiectasis and multiple small nodules were reported to have a sensitivity of 80%, specificity of 87%, and accuracy of 80% for the detection of bronchiectasis. Bronchiectasis may also be diagnosed without CT scan confirmation if clinical history clearly demonstrates frequent respiratory infections as well as confirmation of an underlying problem via blood work and sputum culture samples.
wikipedia

Nursing Diagnosis for Bronchiectasis

Bronchiectasis

Bronchiectasis is an uncommon disease that results in the abnormal and permanent distortion of one or more of the conducting bronchi or airways, most often secondary to an infectious process. First described by Laennec in 1819, later detailed by Sir William Osler in the late 1800s, and further defined by Reid in the 1950s, bronchiectasis has undergone significant changes in regard to its prevalence, etiology, presentation, and treatment.

Bronchiectasis can be categorized as a chronic obstructive pulmonary lung disease manifested by airways that are inflamed and easily collapsible, resulting in air flow obstruction with shortness of breath, impaired clearance of secretions often with disabling cough, and occasionally hemoptysis. Severe cases can result in progressive impairment with respiratory failure.


Nursing Diagnosis for Bronchiectasis
  1. Ineffective airway clearance related to increased production of viscous secretions or secretion
  2. Impaired gas exchange related to oxygen supply disruptions and damage to the alveoli
  3. Imbalanced nutrition: less than body requirements related to nausea, vomiting, sputum production, dispneu
  4. Risk of infection related to chronic disease process, malnutrition.
  5. Anxiety related to fear of difficulty breathing during an exacerbation phase, lack of knowledge about the treatment that will be implemented
  6. Activity intolerance related to damage to of gas exchange

Diagnosis of Anemia

How is anemia diagnosed ?

Anemia is usually detected or at least confirmed by a complete blood cell (CBC) count. CBC test may be ordered by a physician as a part of routine general check-up and screening or based on clinical signs and symptoms that may suggest anemia or other blood abnormalities.

What is a complete blood cell (CBC) count ?

A CBC is a test for counting and examining the different types of cells in the blood. Traditionally, CBC analysis was performed by a physician or a laboratory technician by viewing a glass slide prepared from a blood sample under a microscope. Today, much of this work is often automated and done by machines. Six component measurements make up a CBC test:

  1. Red blood cell (RBC) count
  2. Hematocrit
  3. Hemoglobin
  4. White blood cell (WBC) count
  5. Differential blood count (the "diff")
  6. Platelet count
Only the first three of these tests: the red blood cell (RBC) count, the hematocrit, and the hemoglobin, are relevant to the diagnosis of anemia.

Additionally, mean corpuscular volume (MCV) is also often reported in a CBC, which basically measures the average volume of red blood cells in a blood sample. This is important in distinguishing the causes of anemia. Units of MCV are reported in femtoliters, a fraction of one millionth of a liter.

Other useful clues to causes of anemia that are reported in a CBC are the size, shape, and color of red blood cells.

Source : medicinenet.com

Nursing Diagnosis for Anemia

Anemia

Anemia is a condition in which the blood has a lower than normal number of red blood cells.

Anemia also can occur if red blood cells don't contain enough hemoglobin. Hemoglobin is an iron-rich protein that gives blood its red color. This protein helps red blood cells carry oxygen from the lungs to the rest of the body.

Nursing Diagnosis for Anemia
  1. Risk of infection related to an inadequate defense, the secondary (decrease in hemoglobin leucopenia, or a decrease in granulocytes (inflammatory response depressed)).
  2. Imbalanced nutrition: Less than body requirements related to the failure to digest or inability to digest the food / nutrient absorption necessary for the formation of red blood cells.
  3. Activity intolerance related to imbalance between oxygen supply (delivery) and demand.
  4. Ineffective tissue perfusion related to decreased cellular components required for the delivery of oxygen / nutrients to the cells.
  5. Risk for impaired skin integrity related to circulatory and neurological changes.
  6. Constipation or diarrhea related to decreased dietary inputs; changes in the digestive process; the side effects of drug therapy.
  7. Deficient knowledge related to lack of exposure / recall; incorrect interpretation of information; do not know the source of information.

Diagnosis of Gastritis

Diagnosis of Gastritis

Often, a diagnosis can be made based on the patient's description of his or her symptoms, but other methods which may be used to verify gastritis include:
  • Blood tests:
    • Blood cell count
    • Presence of H. pylori
    • Pregnancy
    • Liver, kidney, gallbladder, or pancreas functions
  • Urinalysis
  • Stool sample, to look for blood in the stool
  • X-rays
  • ECGs
  • Endoscopy, to check for stomach lining inflammation and mucous erosion
  • Stomach biopsy, to test for gastritis and other conditions
(wikipedia)

Nursing Diagnosis for Gastritis

Gastritis is an inflammation of the lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in the banding or reconstruction of the digestive tract. Chronic causes are infection with bacteria, primarily Helicobacter pylori, chronic bile reflux, stress and certain autoimmune disorders can cause gastritis as well. The most common symptom is abdominal upset or pain. Other symptoms are indigestion, abdominal bloating, nausea, and vomiting and pernicious anemia. Some may have a feeling of fullness or burning in the upper abdomen.wikipedia

Nursing Diagnosis for Gastritis
  1. Disorders of fluid volume and electrolyte balance is less than body requirements related to inadequate intake, vomiting.
  2. Impaired nutrition needs Less than body requirements related to inadequate intake, anorexia.
  3. Acute Pain related to inflammation of gastric mucosa.
  4. Risk for activity intolerance related to physical weakness.
  5. Deficient knowledge about the diseases related to lack of information.

Nursing Diagnosis for Gastritis

Diagnosis for Bronchial Asthma

Diagnosis for Bronchial Asthma


Because asthma does not always happen at the doctor's visit, it's important for you to describe your asthma signs and symptoms to your doctor. You might also notice when the symptoms occur such as during exercise, with a cold, or after smelling smoke. Asthma tests may include :
  • Spirometry: A lung function test to measure your breathing capacity and how well you breathe. You will breathe into a device called a spirometer.
  • Peak Expiratory Flow (PEF): Using a device called a peak flow meter, you forcefully exhale into the tube to measure the force of air you can expend out of your lungs. Peak flow monitoring can allow you to monitor your how well your asthma is doing at home.
  • Chest X-Ray: Your doctor may do a chest X-ray to rule out any other diseases that may be causing similar symptoms.

Nursing Diagnosis for Anxiety

Anxiety

NANDA Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

Anxiety is probably present at some level in every individual’s life, but the degree and the frequency with which it manifests differs broadly. Each individual’s response to anxiety is different. Some people are able to use the emotional edge that anxiety provokes to stimulate creativity or problem-solving abilities; others can become immobilized to a pathological degree. The feeling is generally categorized into four levels for treatment purposes: mild, moderate, severe, and panic. The nurse can encounter the anxious patient anywhere in the hospital or community. The presence of the nurse may lend support to the anxious patient and provide some strategies for traversing anxious moments or panic attacks.

Nursing Diagnosis for Anxiety

Anxiety related to situational crisis / maturasional, unmet needs, stress, threat of death, change of status roles.

NOC: patients showed anxiety control / coping increased

NIC:
  • Anxiety reduction
  • Presence
  • Calming Technique
  • Emotional Support

Nursing Diagnosis Decreased Cardiac Output

Decreased Cardiac Output

NANDA Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body

Common causes of reduced cardiac output include myocardial infarction, hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, pulmonary disease, arrhythmias, drug effects, fluid overload, decreased fluid volume, and electrolyte imbalance. Geriatric patients are especially at risk because the aging process causes reduced compliance of the ventricles, which further reduces contractility and cardiac output. Patients may have acute, temporary problems or experience chronic, debilitating effects of decreased cardiac output. Patients may be managed in an acute, ambulatory care, or home care setting. This care plan focuses on the acute management.


Nursing Diagnosis Decreased Cardiac Output

Decreased Cardiac Output (the heart can not pump blood adequately required for the metabolism of the body) related to changes in cardiac contractility
(tachycardia , ECG changes, edema, jugular venous distention, fatigue, increased JVP, dypsneu)

NOC: patients show an Effective response to cardiac pump

NIC:
  • Cardiac care
  • Vital sign monitoring
  • Neurological monitoring
  • Medication management
  • Oxygen therapy

Nursing Diagnosis for Pulmonary Tuberculosis

Pulmonary tuberculosis (TB) is a contagious bacterial infection that involves the lungs, but may spread to other organs.

Pulmonary tuberculosis (TB) is caused by the bacteria Mycobacterium tuberculosis (M. tuberculosis). You can get TB by breathing in air droplets from a cough or sneeze of an infected person. This is called primary TB.

In the United States, most people will recover from primary TB infection without further evidence of the disease. The infection may stay asleep or inactive (dormant) for years. However, in some people it can reactivate.

Most people who develop symptoms of a TB infection first became infected in the past. However, in some cases, the disease may become active within weeks after the primary infection.
nlm.nih.gov


Nursing Diagnosis for Pulmonary Tuberculosis

  • Risk for (spread/ reactivation) infection
  • Ineffective airway clearance
  • Risk for impaired gas exchange
  • Imbalanced nutrition, less than body requirements
  • Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs.

Nursing Diagnosis for Pneumonia

Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake.

Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an estimated 1.6 million children under the age of five years, accounting for 18% of all deaths of children under five years old worldwide. Pneumonia affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa. Children can be protected from pneumonia, it can be prevented with simple interventions, and treated with low-cost, low-tech medication and care.www.who.int


Nursing Diagnosis for Pneumonia
  • Ineffective airway clearance
  • Impaired gas exchange
  • Risk for (spread) infection
  • Activity intolerance
  • Acute pain
  • Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs
  • Risk for deficient fluid volume
  • Risk for imbalanced nutrition less than body requirements

Nursing Diagnosis for Myocardial Infarction

Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).


Nursing Diagnosis for Myocardial Infarction
  • Acute pain
  • Activity intolerance
  • Anxiety/ Fear
  • Risk for decreased cardiac output
  • Ineffective tissue perfusion
  • Risk for excess fluid volume
  • Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs

Nursing Diagnosis Excess Fluid Volume

NANDA Definition: Increased isotonic fluid retention

Fluid volume excess, or hypervolemia, occurs from an increase in total body sodium content and an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It may also be caused by excessive intake of sodium from foods, intravenous (IV) solutions, medications, or diagnostic contrast dyes. Hypervolemia may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of fluid and sodium restriction, and the use of diuretics. For acute cases dialysis may be required.

Nursing Diagnosis Excess Fluid Volume

Excess Fluid Volume (Increased isotonic fluid retention) related to weak regulatory mechanism, excess fluid intake, excessive sodium intake. (weight gain, blood pressure changes, CVP increased, edema, Dypsneu, oliguria)

NOC : patients showed a balance of fluid volume

NIC :
  • Fluid Management
  • Nutrition management
  • Respiratory management
  • Medication management

Nursing Diagnosis for Activity Intolerance

NANDA Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g., Beta-blockers), or emotional states such as depression or lack of confidence to exert one's self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.

Nursing Diagnosis for Activity Intolerance

Activity intolerance (a condition where individuals have physiological energy insufficiency) related to immobilization, physical weakness, imbalance of oxygen supply with demand.

NOC: The patient showed tolerance to the activity

NIC:
  • Therapeutic activity
  • Energy management
  • Cardiac care

Nursing Diagnoses 2009-2011: Definitions and Classification (NANDA NURSING DIAGNOSIS)

Nursing Diagnosis Nanda


A nursing diagnosis is defined as a clinical judgement about individual, family or community responses to actual or potential health problems or life processes which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

Accurate and valid nursing diagnoses guide the selection of interventions that are likely to produce the desired treatment effects and determine nurse-sensitive outcomes. Nursing diagnoses are seen as key to the future of evidence-based, professionally-led nursing care – and to more effectively meeting the need of patients and ensuring patient safety. In an era of increasing electronic patient health records standardized nursing terminologies such as NANDA, NIC and NOC provide a means of collecting nursing data that are systematically analyzed within and across healthcare organizations and provide essential data for cost/benefit analysis and clinical audit.

'Nursing Diagnoses: Definitions and Classification' is the definitive guide to nursing diagnoses worldwide. Each nursing diagnoses undergoes a rigorous assessment process by NANDA-I with stringent criteria to indicate the strength of the underlying level of evidence.

Each diagnosis comprises a label or name for the diagnosis and a definition. Actual diagnoses include defining characteristics and related factors. Risk diagnoses include risk factors. Many diagnoses are further qualified by terms such as effective, ineffective, impaired, imbalanced, readiness for, disturbed, decreased etc.

The 2009-2011 edition is arranged by concept according to Taxonomy II domains (i.e. Health promotion, Nutrition, Elimination and Exchange, Activity/Rest, Perception/Cognition, Self-Perception, Role Relationships, Sexuality, Coping/ Stress Tolerance, Life Principles, Safety/Protection, Comfort, Growth/Development). The book contains new chapters on 'Critical judgement and assessment' and 'How to identify appropriate diagnoses' and core references for all nursing diagnoses. A companion website hosts NANDA-I position statements, new PowerPoint slides, and FAQs for students.

* 2009-2011 edition arranged by concepts
* New chapters on 'Critical judgement and assessment' and 'How to identify appropriate diagnoses'
* Core references for new diagnoses and level of evidence for each diagnosis
* Companion website available

Click Here :

Nursing Diagnoses 2009-2011: Definitions and Classification (NANDA NURSING DIAGNOSIS)

Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

Nursing Diagnosis Handbook


Write individualized care plans with ease and confidence!

Use this convenient resource to formulate nursing diagnoses and create individualized care plans! Updated with the most recent NANDA-I approved nursing diagnoses, Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 9th Edition shows you how to build customized care plans using a three-step process: assess, diagnose, and plan care. It includes suggested nursing diagnoses for over 1,300 client symptoms, medical and psychiatric diagnoses, diagnostic procedures, surgical interventions, and clinical states. Authors Elizabeth Ackley and Gail Ladwig use Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC) information to guide you in creating care plans that include desired outcomes, interventions, patient teaching, and evidence-based rationales.

  • Promotes evidence-based interventions and rationales by including recent or classic research that supports the use of each intervention.
  • Unique! Provides care plans for every NANDA-I approved nursing diagnosis.
  • Includes step-by-step instructions on how to use the Guide to Nursing Diagnoses and Guide to Planning Care sections to create a unique, individualized plan of care.
  • Includes pediatric, geriatric, multicultural, and home care interventions as necessary for plans of care.
  • Includes examples of and suggested NIC interventions and NOC outcomes in each care plan.
  • Allows quick access to specific symptoms and nursing diagnoses with alphabetical thumb tabs.
  • Unique! Includes a Care Plan Constructor on the companion Evolve website for hands-on practice in creating customized plans of care.
  • Includes the new 2009-2011 NANDA-I approved nursing diagnoses including 21 new and 8 revised diagnoses.
  • Illustrates the Problem-Etiology-Symptom format with an easy-to-follow, colored-coded box to help you in formulating diagnostic statements.
  • Explains the difference between the three types of nursing diagnoses.
  • Expands information explaining the difference between actual and potential problems in performing an assessment.
  • Adds detailed information on the multidisciplinary and collaborative aspect of nursing and how it affects care planning.
  • Shows how care planning is used in everyday nursing practice to provide effective nursing care.
Click Here :
Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

List Of Nursing Diagnosis 2009-2011 NANDA Approved

NANDA Approved Nursing Diagnosis 2007-2008 contains 188 nursing diagnosis, latest NANDA-I Approved Nursing Diagnosis 2009-2011 contains an additional 21 new nursing diagnosis, 9 revisions diagnosis and some of diagnosis are not used again. Total nursing diagnosis at this time is 205 nursing diagnosis.

Nanda I usually revised every 2 years, but this time NANDA I publish a list of NANDA Nursing Diagnosis for period of three years.

for complete list of NANDA Approved Nursing Diagnosis 2009-2011 :
Nursing Diagnoses 2009-2011: Definitions and Classification (NANDA NURSING DIAGNOSIS)

List of Nursing Diagnosis

Here is a List of Nursing Diagnosis NIC, NOC to help formulate proper nursing care.

1. Activity intolerance
2. Ineffective Airway clearance
3. Latex Allergy response
4. Risk for latex Allergy response
5. Anxiety
6. Risk for Aspiration
7. Risk for impaired parent/infant/child Attachment
8. Disturbed Body image
9. Bowel incontinence
10. Ineffective Breastfeeding
11. Ineffective Breathing pattern
12. Decreased Cardiac output
13. Caregiver role strain
14. Impaired Comfort
15. Impaired verbal Communication
16. Parental role Conflict
17. Acute Confusion
18. Chronic Confusion
19. Constipation
20. Ineffective Coping

21. Compromised family Coping
22. Ineffective Denial
23. Diarrhea
24. Disturbed Energy field
25. Adult Failure to thrive
26. Risk for Falls
27. Dysfunctional Family processes: alcoholism
28. Fatigue
29. Fear
30. Deficient Fluid volume
31. Excess Fluid volume
32. Impaired Gas exchange
33. Grieving
34. Anticipatory Grieving
35. Dysfunctional Grieving
36. Delayed Growth and development
37. Ineffective Health maintenance
38. Hopelessness
39. Hyperthermia
40. Functional urinary Incontinence
41. Total urinary Incontinence
42. Risk for Infection
43. Risk for Injury
44. Deficient Knowledge (specify)
45. Readiness for enhanced Knowledge (specify)
46. Impaired Memory
47. Impaired physical Mobility
48. Nausea
49. Imbalanced Nutrition: less than body requirements
50. Imbalanced Nutrition: more than body requirements
51. Impaired Oral mucous membrane
52. Acute Pain
53. Chronic Pain
54. Impaired Parenting
55. Risk for Peripheral neurovascular dysfunction
56. Post-trauma syndrome
57. Powerlessness
58. Impaired Religiosity
59. Bathing/hygiene Self-care deficit
60. Feeding Self-care deficit
61. Risk for situational low Self-esteem
62. Disturbed Sensory perception specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory
63. Impaired Skin integrity
64. Disturbed Sleep pattern
65. Spiritual distress
66. Risk for Suicide
67. Delayed Surgical recovery
68. Impaired Swallowing
69. Ineffective Therapeutic regimen management
70. Disturbed Thought processes
71. Impaired Tissue integrity
72. Ineffective Tissue perfusion specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral
73. Impaired Urinary elimination
74. Urinary retention
75. Wandering

List of Nursing Diagnosis

Nursing Diagnosis for Congestive Heart Failure

Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body. Congestive heart failure can be caused by:

1. diseases that weaken the heart muscle,

2. diseases that cause stiffening of the heart muscles, or

3. diseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver adequate oxygen-rich blood.


Nursing Diagnosis for Congestive Heart Failure
  • Decreased Cardiac Output related to impaired contractility and increased preload and afterload
  • Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures
  • Excess Fluid Volume related to sodium and water retention
  • Activity Intolerance related to oxygen supply and demand imbalance


Source : medicinenet.com

Diagnosis of Diabetes

Diagnosis

If a diagnosis of diabetes is made, the clinician must feel confident that the diagnosis is fully established since the consequences for the individual are considerable and lifelong. The requirements for diagnostic confirmation for a person presenting with severe symptoms and gross hyperglycaemia differ from those for the asymptomatic person with blood glucose values found to be just above the diagnostic cut-off value. Severe hyperglycaemia detected under conditions of acute infective, traumatic, circulatory or other stress may be transitory and should not in itself be regarded as diagnostic of diabetes. The diagnosis of diabetes in an asymptomatic subject should never be made on the basis of a single abnormal blood glucose value. For the asymptomatic person, at least one additional plasma/blood glucose test result with a value in the diabetic range is essential, either fasting, from a random (casual) sample, or from the oral glucose tolerance test (OGTT). If such samples fail to confirm the diagnosis of diabetes mellitus, it will usually be advisable to maintain surveillance with periodic re-testing until the diagnostic situation becomes clear. In these circumstances, the clinician should take into consideration such additional factors as ethnicity, family history, age, adiposity, and concomitant disorders, before deciding on a diagnostic or therapeutic course of action. An alternative to blood glucose estimation or the OGTT has long been sought to simplify the diagnosis of diabetes. Glycated haemoglobin, reflecting average glycaemia over a period of weeks, was thought to provide such a test. Although in certain cases it gives equal or almost equal sensitivity and specificity to glucose measurement (6), it is not available in many parts of the world and is not well enough standardized for its use to be recommended at this time.


Diabetes in children

Diabetes in children usually presents with severe symptoms, very high blood glucose levels, marked glycosuria, and ketonuria. In most children the diagnosis is confirmed without delay by blood glucose measurements, and treatment (including insulin injection) is initiated immediately, often as a life-saving measure. An OGTT is neither necessary nor appropriate for diagnosis in such circumstances. A small proportion of children and adolescents, however, present with less severe symptoms and may require fasting blood glucose measurement and/or an OGTT for diagnosis.

Source : www.staff.ncl.ac.uk

Nursing Diagnosis for Diabetes Mellitus (DM)

Diabetes Mellitus (DM)

Diabetes mellitus (DM) is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin, an anabolic hormone. Insulin is produced by the beta cells of the islets of Langerhans located in the pancreas, and the absence, destruction, or other loss of these cells results in type 1 diabetes (insulin-dependent diabetes mellitus [IDDM]).

Nursing Diagnosis for Diabetes Mellitus (DM)

1. Imbalanced Nutrition: Less/More than Body Requirements
2. Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral
3. Impaired urinary elimination
4. Disturbed sensory perception: Visual, tactile
5. Activity Intolerance
6. Ineffective Coping
7. Sexual dysfunction
8. Fear
9. Deficient Knowledge
10. Deficient knowledge (diagnosis and treatment)
11. Risk for Impaired Skin Integrity
12. Risk for Injury
13. Risk for infection

Nursing Diagnosis

Filled under:

A nursing diagnosis is part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses are developed based on data obtained during the nursing assessment.

NANDA

The primary organization for defining, dissemination and integration of standardized nursing diagnoses worldwide is NANDA-International formerly known as the North American Nursing Diagnosis Association. For nearly 40 years NANDA-I has worked in this area to ensure that diagnoses are developed through a peer-reviewed process requiring standardized levels of evidence, standardized definitions, defining characteristics, related factors and/or risk factors that enable nurses to identify potential diagnoses in the course of a nursing assessment. NANDA-I believes that it is critical that nurses are required to utilize standardized languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characterisitcs) and the related or etiologic factors upon which nurses intervene. NANDA-I terms are developed and refined for actual (current) health responses and for risk situations , as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities. Contributing diagnostic associations include AENTDE (Spain), AFEDI (French language), and JSND (Japan). NANDA-I also has several regional networks including Brasil, Peru, Honduras, Nigeria-Ghana and a German-language group. The taxonomy is published in multiple countries and has been translated into 18 languages; it is in use worldwide. The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, is HL7 registered, ISO-compatible and available within SNOMED CT with appropriate licensure.

Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the electronic health record and can be linked to nurse-sensitive patient outcomes.

Source : wikipedia

Nursing Diagnosis for Hypertension

Hypertension

Hypertensionis the medical term for high blood pressure. It is known as the "silent killer" since it has no initial symptoms but can lead to long-term disease and complications..
  • Many people have high blood pressure and don't know it.
  • Important complications of uncontrolled or poorly treated high blood pressure include heart attack, congestive heart failure, stroke, kidney failure, peripheral artery disease, and aortic aneurysms (weakening of the wall of the aorta, leading to widening or ballooning of the aorta).
  • Public awareness of these dangers has increased. High blood pressure has become the second most common reason for medical office visits in the United States.


Nursing Diagnosis for Hypertension

  1. Fatigue related to effects of hypertension and stresses of daily life
  2. Imbalanced nutrition: More than body requirements related to excessive food intake
  3. Ineffective health maintenance related to inability to modify lifestyle
  4. Deficient knowledge related to effects of prescribed treatment

EXPECTED OUTCOMES
  • Reduce blood pressure readings to less than 150 systolic and 90 diastolic by return visit next week.
  • Incorporate low-sodium and low-fat foods from a list provided into her diet.
  • Develop a plan for regular exercise.
  • Verbalize understanding of the effects of prescribed drug, dietary restrictions, exercise, and follow-up visits to help control hypertension.

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