Title Details

NANDA International Guidelines for Copyright Permission xvii

Preface xix

Introduction xxii

How to Use This Book xxii

Frequently Asked Questions xxiii

Acknowledgments xxv

Chapter Authors xxv

Chapter Reviewers xxv

New Nursing Diagnoses, 2012–2014 xxvi

Revised Nursing Diagnoses, 2012–2014 xxvii

Retired Nursing Diagnosis, 2012–2014 xxviii

Changes to Slotting of Current Diagnoses within the NANDA International Taxonomy II, 2012–2014 xxviii

Changes to Slotting of Current Diagnoses within the NANDA-I/NIC/NOC Taxonomy xxx

Revisions to Diagnoses within the NANDA International Taxonomy 2009–2011 xxx

PART 1 THE NANDA INTERNATIONAL TAXONOMY 1

Introduction 3
T. Heather Herdman

Contributors to the NANDA-I Nursing Diagnosis Taxonomy 3

Chapter 1 The NANDA International Taxonomy II 2012–2014 49
T. Heather Herdman, Gunn von Krogh

History of the Development of Taxonomy II 49

Structure of Taxonomy II 50

A Multiaxial System for Constructing Diagnostic Concepts 53

Definitions of the Axes 55

Axis 1: The Diagnostic Focus 55

Axis 2: Subject of the Diagnosis 59

Axis 3: Judgment 59

Axis 4: Location 60

Axis 5: Age 61

Axis 6: Time 61

Axis 7: Status of the Diagnosis 61

Construction of a Nursing Diagnostic Concept 62

The NNN Taxonomy of Nursing Practice 63

Further Development of the NANDA-I Taxonomy 64

PART 2 EDUCATION AND IMPLEMENTATION OF NANDA INTERNATIONAL NURSING DIAGNOSES WITHIN PRACTICE, ADMINISTRATION, RESEARCH, INFORMATICS AND EDUCATION 67

Chapter 2 Nursing Assessment, Clinical Judgment, and Nursing Diagnoses: How to Determine Accurate Diagnoses 71
Margaret Lunney

Nurses Are Diagnosticians 72

Intellectual, Interpersonal, and Technical Competencies 73

Intellectual Competencies 73

Interpersonal Competencies 74

Technical Competencies 74

Personal Strengths: Tolerance for Ambiguity and Reflective Practice 75

Tolerance for Ambiguity 75

Reflective Practice 76

Assessment and Nursing Diagnosis 76

Assessment Framework 76

Diagnostic Reasoning Associated with Nursing Assessment 77

Recognizing the Existence of Cues 77

Mentally Generating Possible Diagnoses 77

Comparing Cues to Possible Diagnoses 78

Conducting a Focused Data Collection 78

Validating Diagnoses 79

Case Study Example 79

Analysis of Health Data: Nursing Diagnoses 81

Nursing Outcomes Classification 82

Nursing Interventions Classification 82

Appendix: Functional Health Pattern Assessment Framework 84

Directions 84

Health Perception–Health Management Pattern 85

Nutrition–Metabolic Pattern 85

Elimination Pattern 86

Activity–Exercise Pattern 86

Sleep–Rest Pattern 86

Cognitive–Perceptual Pattern 87

Self-Perception–Self-Concept Pattern 87

Role–Relationship Pattern 87

Sexuality–Reproductive Pattern 88

Coping–Stress Tolerance Pattern 88

Value–Belief Pattern 88

Analysis of Data, Nursing Diagnoses, Outcomes, and Interventions 89

Chapter 3 Nursing Diagnosis in Education 90
Barbara Krainovich-Miller, Fritz Frauenfelder, Maria Müller-Staub

Significance for Nursing Education 90

Teaching the Nursing Process Framework 91

Teaching the Assessment Phase of the Nursing Process 91

Teaching Nursing Diagnoses as a Component of the Nursing Process 93

The Nursing Process. Exemplar – Nursing History/Physical Assessment: Identifying Defining Characteristics and Related Factors 94

The Nursing Process. Exemplar – Accuracy of the Nursing Diagnosis Label 95

Risk Diagnoses 96

Health-Promotion Diagnoses 96

Prioritizing Diagnoses 96

Linking Nursing Diagnoses to Outcomes and Interventions 97

Chapter 4 The Value of Nursing Diagnoses in Electronic Health Records 99
Jane M. Brokel, Kay C. Avant, Matthias Odenbreit

Student Use of the Electronic Health Record (EHR) 99

Electronic Health Record 99

Longitudinal Use 100

Importance of Nursing Diagnoses in EHRs 100

Documenting Nursing Diagnoses in the EHR 101

Differences Between EHRs 102

Documenting Defi ning Characteristics, Related Factors, and Risk Factors in the EHR 103

Relationship of Nursing Diagnoses to Assessments 104

Linking Nursing Diagnoses to Other Documentation 104

An Organizing Framework for Nursing Assessments 105

Link Between Assessment and a Short List of Nursing Diagnoses 105

Link Between Nursing Diagnosis and Patient Outcome, Current State, and Mutual Goal for an Outcome 105

Link Between Nursing Diagnoses and Interventions in the Plan of Care 106

Nursing Informatics Specialist/Graduate Student – Guiding Clinical Decision Support (CDS) within the EHR 106

Role of Nursing Informatics 107

Faculty Guide for Students in the Use of Nursing Diagnoses in the EHR 108

Documentation 109

Using the EHR 109

Guiding Student Learning 109

Learning the EHR, CDS and Health Information Exchange (HIE) 110

Assessment Framework 110

Knowledge Resources (Library) 110

Problem List 111

Interdisciplinary Care Planning 111

Clinical Decision Support 111

Health Information Exchange 111

Personal Health Records 111

Chapter 5 Nursing Diagnosis and Research 114
Margaret Lunney, Maria Müller-Staub

Concept Analyses 114

Content Validation 114

Construct- and Criterion-Related Validity 116

Consensus Validation 116

Sensitivity, Specifi city, and Predictive Value of Clinical Indicators 117

Studies of Accuracy of Nurses’ Diagnoses 117

Implementation Studies 117

Prevalence Studies 118

Summary 118

Chapter 6 Clinical Judgment and Nursing Diagnoses in Nursing Administration 122
T. Heather Herdman, Marcelo Chanes

Nursing Research Priorities of Importance to Nurse Administrators 122

Nursing’s Role in Patient Safety 123

Triple Model for Nursing Administrators 125

Conclusion 130

Chapter 7 Nursing Classifications: Criteria and Evaluation 133
Matthias Odenbreit, Maria Müller-Staub, Jane M. Brokel, Kay C. Avant, Gail Keenan

Characteristics of Classifications 134

Classification Criteria 135

Discussion 136

Conclusion 141

PART 3 NANDA-I NURSING DIAGNOSES 2012–2014 145

International Considerations on the Use of the NANDA-I Taxonomy of Nursing Diagnoses 147
T. Heather Herdman

Domain 1: Health Promotion 149

Class 1: Health Awareness 151

Deficient Diversional Activity (00097) 151

Sedentary Lifestyle (00168) 152

Class 2: Health Management 153

Deficient Community Health (00215) 153

Risk-Prone Health Behavior (00188) 155

Ineffective Health Maintenance (00099) 157

Readiness for Enhanced Immunization Status (00186) 158

Ineffective Protection (00043) 160

Ineffective Self-Health Management (00078) 161

Readiness for Enhanced Self-Health Management (00162) 164

Ineffective Family Therapeutic Regimen Management (00080) 167

Domain 2: Nutrition 169

Class 1: Ingestion 171

Insufficient Breast Milk (00216) 171

Ineffective Infant Feeding Pattern (00107) 173

Imbalanced Nutrition: Less Than Body Requirements (00002) 174

Imbalanced Nutrition: More Than Body Requirements (00001) 175

Readiness for Enhanced Nutrition (00163) 176

Risk for Imbalanced Nutrition: More Than Body Requirements (00003) 177

Impaired Swallowing (00103) 178

Class 2: Digestion

Class 3: Absorption

Class 4: Metabolism 180

Risk for Unstable Blood Glucose Level (00179) 180

Neonatal Jaundice (00194) 181

Risk for Neonatal Jaundice (00230) 182

Risk for Impaired Liver Function (00178) 183

Class 5: Hydration 184

Risk for Electrolyte Imbalance (00195) 184

Readiness for Enhanced Fluid Balance (00160) 185

Deficient Fluid Volume (00027) 186

Excess Fluid Volume (00026) 187

Risk for Deficient Fluid Volume (00028) 188

Risk for Imbalanced Fluid Volume (00025) 189

Domain 3: Elimination and Exchange 191

Class 1: Urinary Function 193

Functional Urinary Incontinence (00020) 193

Overflow Urinary Incontinence (00176) 194

Reflex Urinary Incontinence (00018) 195

Stress Urinary Incontinence (00017) 196

Urge Urinary Incontinence (00019) 198

Risk for Urge Urinary Incontinence (00022) 199

Impaired Urinary Elimination (00016) 200

Readiness for Enhanced Urinary Elimination (00166) 201

Urinary Retention (00023) 202

Class 2: Gastrointestinal Function 203

Constipation (00011) 203

Perceived Constipation (00012) 205

Risk for Constipation (00015) 206

Diarrhea (00013) 208

Dysfunctional Gastrointestinal Motility (00196) 209

Risk For Dysfunctional Gastrointestinal Motility (00197) 211

Bowel Incontinence (00014) 213

Class 3: Integumentary Function

Class 4: Respiratory Function 214

Impaired Gas Exchange (00030) 214

Domain 4: Activity/Rest 215

Class 1: Sleep/Rest 217

Insomnia (00095) 217

Sleep Deprivation (00096) 219

Readiness for Enhanced Sleep (00165) 220

Disturbed Sleep Pattern (00198) 221

Class 2: Activity/Exercise 222

Risk for Disuse Syndrome (00040) 222

Impaired Bed Mobility (00091) 223

Impaired Physical Mobility (00085) 224

Impaired Wheelchair Mobility (00089) 225

Impaired Transfer Ability (00090) 226

Impaired Walking (00088) 227

Class 3: Energy Balance 228

Disturbed Energy Field (00050) 228

Fatigue (00093) 229

Wandering (00154) 230

Class 4: Cardiovascular/Pulmonary Responses 231

Activity Intolerance (00092) 231

Risk for Activity Intolerance (00094) 232

Ineffective Breathing Pattern (00032) 233

Decreased Cardiac Output (00029) 235

Risk for Ineffective Gastrointestinal Perfusion (00202) 237

Risk for Ineffective Renal Perfusion (00203) 238

Impaired Spontaneous Ventilation (00033) 239

Ineffective Peripheral Tissue Perfusion (00204) 240

Risk for Decreased Cardiac Tissue Perfusion (00200) 242

Risk for Ineffective Cerebral Tissue Perfusion (00201) 243

Risk for Ineffective Peripheral Tissue Perfusion (00228) 244

Dysfunctional Ventilatory Weaning Response (00034) 246

Class 5: Self-Care 248

Impaired Home Maintenance (00098) 248

Readiness for Enhanced Self-Care (00182) 249

Bathing Self-Care Deficit (00108) 250

Dressing Self-Care Deficit (00109) 251

Feeding Self-Care Deficit (00102) 252

Toileting Self-Care Deficit (00110) 253

Self-Neglect (00193) 254

Domain 5: Perception/Cognition 257

Class 1: Attention 259

Unilateral Neglect (00123) 259

Class 2: Orientation 261

Impaired Environmental Interpretation Syndrome (00127) 261

Class 3: Sensation/Perception

Class 4: Cognition 262

Acute Confusion (00128) 262

Chronic Confusion (00129) 265

Risk for Acute Confusion (00173) 266

Ineffective Impulse Control (00222) 269

Deficient Knowledge (00126) 271

Readiness for Enhanced Knowledge (00161) 272

Impaired Memory (00131) 273

Class 5: Communication 274

Readiness for Enhanced Communication (00157) 274

Impaired Verbal Communication (00051) 275

Domain 6: Self-Perception 277

Class 1: Self-Concept 279

Hopelessness (00124) 279

Risk for Compromised Human Dignity (00174) 280

Risk for Loneliness (00054) 281

Disturbed Personal Identity (00121) 282

Risk for Disturbed Personal Identity (00225) 283

Readiness for Enhanced Self-Concept (00167) 284

Class 2: Self-Esteem 285

Chronic Low Self-Esteem (00119) 285

Situational Low Self-Esteem (00120) 287

Risk for Chronic Low Self-Esteem (00224) 288

Risk for Situational Low Self-Esteem (00153) 290

Class 3: Body Image 291

Disturbed Body Image (00118) 291

Domain 7: Role Relationships 293

Class 1: Caregiving Roles 295

Ineffective Breastfeeding (00104) 295

Interrupted Breastfeeding (00105) 296

Readiness for Enhanced Breastfeeding (00106) 297

Caregiver Role Strain (00061) 298

Risk for Caregiver Role Strain (00062) 301

Impaired Parenting (00056) 302

Readiness for Enhanced Parenting (00164) 304

Risk for Impaired Parenting (00057) 305

Class 2: Family Relationships 307

Risk for Impaired Attachment (00058) 307

Dysfunctional Family Processes (00063) 308

Interrupted Family Processes (00060) 311

Readiness for Enhanced Family Processes (00159) 312

Class 3: Role Performance 313

Ineffective Relationship (00223) 313

Readiness for Enhanced Relationship (00207) 315

Risk for Ineffective Relationship (00229) 316

Parental Role Confl ict (00064) 317

Ineffective Role Performance (00055) 318

Impaired Social Interaction (00052) 320

Domain 8: Sexuality 321

Class 1: Sexual Identity

Class 2: Sexual Function 323

Sexual Dysfunction (00059) 323

Ineffective Sexuality Pattern (00065) 325

Class 3: Reproduction 326

Ineffective Childbearing Process (00221) 326

Readiness for Enhanced Childbearing Process (00208) 328

Risk for Ineffective Childbearing Process (00227) 330

Risk for Disturbed Maternal–Fetal Dyad (00209) 331

Domain 9: Coping/Stress Tolerance 333

Class 1: Post-Trauma Responses 335

Post-Trauma Syndrome (00141) 335

Risk for Post-Trauma Syndrome (00145) 336

Rape-Trauma Syndrome (00142) 337

Relocation Stress Syndrome (00114) 338

Risk for Relocation Stress Syndrome (00149) 339

Class 2: Coping Responses 340

Ineffective Activity Planning (00199) 340

Risk for Ineffective Activity Planning (00226) 342

Anxiety (00146) 344

Defensive Coping (00071) 346

Ineffective Coping (00069) 348

Readiness for Enhanced Coping (00158) 349

Ineffective Community Coping (00077) 350

Readiness for Enhanced Community Coping (00076) 351

Compromised Family Coping (00074) 352

Disabled Family Coping (00073) 354

Readiness for Enhanced Family Coping (00075) 355

Death Anxiety (00147) 356

Ineffective Denial (00072) 358

Adult Failure to Thrive (00101) 360

Fear (00148) 361

Grieving (00136) 363

Complicated Grieving (00135) 365

Risk for Complicated Grieving (00172) 367

Readiness for Enhanced Power (00187) 368

Powerlessness (00125) 370

Risk for Powerlessness (00152) 372

Impaired Individual Resilience (00210) 374

Readiness for Enhanced Resilience (00212) 376

Risk for Compromised Resilience (00211) 378

Chronic Sorrow (00137) 379

Stress Overload (00177) 380

Class 3: Neurobehavioral Stress 383

Autonomic Dysreflexia (00009) 383

Risk for Autonomic Dysreflexia (00010) 384

Disorganized Infant Behavior (00116) 386

Readiness for Enhanced Organized Infant Behavior (00117) 388

Risk for Disorganized Infant Behavior (00115) 389

Decreased Intracranial Adaptive Capacity (00049) 390

Domain 10: Life Principles 391

Class 1: Values 393

Readiness for Enhanced Hope (00185) 393

Class 2: Beliefs 394

Readiness for Enhanced Spiritual Well-Being (00068) 394

Class 3: Value/Belief/Action Congruence 395

Readiness for Enhanced Decision-Making (00184) 395

Decisional Conflict (00083) 396

Moral Distress (00175) 398

Noncompliance (00079) 400

Impaired Religiosity (00169) 402

Readiness for Enhanced Religiosity (00171) 405

Risk for Impaired Religiosity (00170) 407

Spiritual Distress (00066) 410

Risk for Spiritual Distress (00067) 412

Domain 11: Safety/Protection 415

Class 1: Infection 417

Risk for Infection (00004) 417

Class 2: Physical Injury 421

Ineffective Airway Clearance (00031) 421

Risk for Aspiration (00039) 422

Risk for Bleeding (00206) 423

Impaired Dentition (00048) 425

Risk for Dry Eye (00219) 426

Risk for Falls (00155) 428

Risk for Injury (00035) 430

Impaired Oral Mucous Membrane (00045) 431

Risk for Perioperative Positioning Injury (00087) 433

Risk for Peripheral Neurovascular Dysfunction (00086) 434

Risk for Shock (00205) 435

Impaired Skin Integrity (00046) 436

Risk for Impaired Skin Integrity (00047) 437

Risk for Sudden Infant Death Syndrome (00156) 438

Risk for Suffocation (00036) 439

Delayed Surgical Recovery (00100) 440

Risk for Thermal Injury (00220) 442

Impaired Tissue Integrity (00044) 443

Risk for Trauma (00038) 444

Risk for Vascular Trauma (00213) 446

Class 3: Violence 447

Risk for Other-Directed Violence (00138) 447

Risk for Self-Directed Violence (00140) 448

Self-Mutilation (00151) 449

Risk for Self-Mutilation (00139) 451

Risk for Suicide (00150) 452

Class 4: Environmental Hazards 454

Contamination (00181) 454

Risk for Contamination (00180) 458

Risk for Poisoning (00037) 460

Class 5: Defensive Processes 461

Risk for Adverse Reaction to Iodinated Contrast Media (000218) 461

Latex Allergy Response (00041) 463

Risk for Allergy Response (00217) 465

Risk for Latex Allergy Response (00042) 466

Class 6: Thermoregulation 467

Risk for Imbalanced Body Temperature (00005) 467

Hyperthermia (00007) 468

Hypothermia (00006) 469

Ineffective Thermoregulation (00008) 470

Domain 12: Comfort 471

Class 1: Physical Comfort 473

Class 2: Environmental Comfort 473

Class 3: Social Comfort 473

Impaired Comfort (00214) 473

Readiness for Enhanced Comfort (00183) 475

Nausea (00134) 476

Acute Pain (00132) 478

Chronic Pain (00133) 479

Social Isolation (00053) 480

Domain 13: Growth/Development 481

Class 1: Growth 483

Risk for Disproportionate Growth (00113) 483

Class 2: Development 484

Delayed Growth and Development (00111) 484

Risk for Delayed Development (00112) 485

Nursing Diagnoses Retired from the NANDA-I Taxonomy 2009–2014 487

Health-seeking Behaviors (00084) – Retired 2009–2011 489

Disturbed Sensory Perception (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) (00122) – Retired 2012–2014 490

PART 4 NANDA INTERNATIONAL 2012–2014 493

NANDA International Think Tank Meeting 495

Issues related to the DDC 495

Globalization of the Taxonomy 496

Issues for Future Discussion and Research 497

NANDA International Position Statements 498

NANDA-I Position Statement 1: The Use of Taxonomy II as an Assessment Framework 498

NANDA-I Position Statement 2: The Structure of the Nursing Diagnosis Statement when Included in a Care Plan 498

Chapter 8 The Process for Development of an Approved NANDA International Nursing Diagnosis 499
Leann M. Scroggins

Axis 1: The Diagnostic Focus 499

Axis 2: Subject of the Diagnosis 500

Axis 3: Judgment 500

Axis 4: Location 500

Axis 5: Age 501

Axis 6: Time 501

Axis 7: Status of the Diagnosis 501

Label and Definition 503

Defining Characteristics versus Risk Factors 503

Taxonomy Rules 504

Related Factors 505

Identify Related Factors 505

NANDA International Processes and Procedures 508

Full Review Process 508

Expedited Review Process 509

Submission Process for New Diagnoses 509

Submission Process for Revising a Current Nursing Diagnosis 511

Procedure to Appeal a DDC Decision on Diagnosis Review 512

NANDA-I Diagnosis Submission: Level of Evidence Criteria 513

1. Received for Development (Consultation from DDC) 513

1.1 Label Only 513

1.2 Label and Defi nition 513

2. Accepted for Publication and Inclusion in the NANDA-I Taxonomy 513

2.1 Label, Definition, Defining Characteristics or Risk Factors, Related Factors, and References 513

2.2 Concept Analysis 513

2.3 Consensus Studies Related to Diagnosis Using Experts 513

3. Clinically Supported (Validation and Testing) 514

3.1 Literature Synthesis 514

3.2 Clinical Studies Related to Diagnosis, but Not Generalizable to the Population 514

3.3 Well-designed Clinical Studies with Small Sample Sizes 514

3.4 Well-designed Clinical Studies with Random Sample of Suffi cient Size to Allow for Generalizability to the Overall Population 514

Glossary of Terms 515

Nursing Diagnosis 515

Actual Nursing Diagnosis 515

Health-promotion Nursing Diagnosis 515

Risk Nursing Diagnosis 515

Syndrome 515

Wellness Nursing Diagnosis 516

Components of a Nursing Diagnosis 516

Diagnosis Label 516

Definition 516

Defining Characteristics 516

Risk Factors 516

Related Factors 516

Definitions for Classification of Nursing Diagnoses 517

Classification 517

Level of Abstraction 517

Nomenclature 517

Taxonomy 517

NANDA International 2010–2012 518

NANDA International Board of Directors 518

NANDA International Diagnosis Development Committee 518

NANDA International Education & Research Committee 518

NANDA International Informatics Committee 519

NANDA International Taxonomy Committee 519

An Invitation to Join NANDA International 520

NANDA International: A Member-driven Organization 520

Our Vision 520

Our Mission 520

Our Purpose 520

Our History 520

NANDA International’s Commitment 521

Involvement Opportunities 522

Why Join NANDA-I? 522

Professional Networking 522

Resources 522

Member Benefi ts 522

How to Join 523

Who is Using the NANDA International Taxonomy? 523

Index 525

Visit the supporting companion website for this book: www.wiley.com/go/ nursingdiagnoses