Nursing Diagnoses 2009-2011: Definitions and Classification

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(NANDA NURSING DIAGNOSIS)

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

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

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

APPENDIX 2010-2011 NANDA-Approved Nursing Diagnoses – updated

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APPENDIX 2010-2011 NANDA-Approved Nursing Diagnoses – updated

APPENDIX 2010-2011 NANDA-Approved Nursing Diagnoses – updated

Activity Intolerance, Risk for

Airway Clearance, Ineffective

Anxiety

Anxiety, Death

Aspiration, Risk for

Attachment, Parent/Infant/Child, Risk for

Impaired

Autonomic Dysreflexia

Autonomic Dysreflexia, Risk for

Blood Glucose, Risk for Unstable

Body Image, Disturbed

Body Temperature: Imbalanced, Risk for

Bowel Incontinence

Breastfeeding, Effective

Breastfeeding, Ineffective

Breastfeeding, Interrupted

Breathing Pattern, Ineffective

Cardiac Output, Decreased

Caregiver Role Strain

Caregiver Role Strain, Risk for

Comfort, Readiness for Enhanced

Communication: Impaired, Verbal

Communication, Readiness for Enhanced

Confusion, Acute

Confusion, Acute, Risk for

Confusion, Chronic

Constipation

Constipation, Perceived

Constipation, Risk for

Contamination

Contamination, Risk for

Coping: Community, Ineffective

Coping: Community, Readiness for Enhanced

Coping, Defensive

Coping: Family, Compromised

Coping: Family, Disabled

Coping: Family, Readiness for Enhanced

Coping (Individual), Readiness for Enhanced

Coping, Ineffective

Decisional Conflict

Decision Making, Readiness for Enhanced

Denial, Ineffective

Dentition, Impaired

Development: Delayed, Risk for

Diarrhea

Disuse Syndrome, Risk for

Diversional Activity, Deficient

Energy Field, Disturbed

Environmental Interpretation Syndrome, Impaired

Failure to Thrive, Adult

Falls, Risk for

Family Processes, Dysfunctional: Alcoholism

Family Processes, Interrupted

Family Processes, Readiness for Enhanced

Fatigue

Fear

Fluid Balance, Readiness for Enhanced

Fluid Volume, Deficient

Fluid Volume, Deficient, Risk for

Fluid Volume, Excess

Fluid Volume, Imbalanced, Risk for

Gas Exchange, Impaired

Grieving

Grieving, Complicated

Grieving, Risk for Complicated

Growth, Disproportionate, Risk for

Growth and Development, Delayed

Health Behavior, Risk-Prone

Health Maintenance, Ineffective

Health-Seeking Behaviors (Specify)

Home Maintenance, Impaired

Hope, Readiness for Enhanced

Hopelessness

Human Dignity, Risk for Compromised

Hyperthermia

Hypothermia

Immunization Status, Readiness for Enhanced

Infant Behavior, Disorganized

Infant Behavior: Disorganized, Risk for

Infant Behavior: Organized, Readiness for

Enhanced

Infant Feeding Pattern, Ineffective

Infection, Risk for

Injury, Risk for

Insomnia

Intracranial Adaptive Capacity, Decreased

Knowledge, Deficient (Specify)

Knowledge (Specify), Readiness for Enhanced

Latex Allergy Response

Latex Allergy Response, Risk for

Liver Function, Impaired, Risk for

Loneliness, Risk for

Memory, Impaired

Mobility: Bed, Impaired

Mobility: Physical, Impaired

Mobility: Wheelchair, Impaired

Moral Distress

Nausea

Neurovascular Dysfunction: Peripheral, Risk for

Noncompliance (Specify)

Nutrition, Imbalanced: Less than Body

Requirements

Nutrition, Imbalanced: More than Body

Requirements

Nutrition, Imbalanced: More than Body

Requirements, Risk for

Nutrition, Readiness for Enhanced

Oral Mucous Membrane, Impaired

Pain, Acute

Pain, Chronic

Parenting, Impaired

Parenting, Readiness for Enhanced

Parenting, Risk for Impaired

Perioperative Positioning Injury, Risk for

Personal Identity, Disturbed

Poisoning, Risk for

Post-Trauma Syndrome

Post-Trauma Syndrome, Risk for

Power, Readiness for Enhanced

Powerlessness

Powerlessness, Risk for

Protection, Ineffective

Rape-Trauma Syndrome

Rape-Trauma Syndrome: Compound Reaction

Rape-Trauma Syndrome: Silent Reaction

Religiosity, Impaired

Religiosity, Readiness for Enhanced

Religiosity, Risk for Impaired

Relocation Stress Syndrome

Relocation Stress Syndrome, Risk for

Role Conflict, Parental

Role Performance, Ineffective

Sedentary Lifestyle

Self-Care, Readiness for Enhanced

Self-Care Deficit: Bathing/Hygiene

Self-Care Deficit: Dressing/Grooming

Self-Care Deficit: Feeding

Self-Care Deficit: Toileting

Self-Concept, Readiness for Enhanced

Self-Esteem, Chronic Low

Self-Esteem, Situational Low

Self-Esteem, Risk for Situational Low

Self-Mutilation

Self-Mutilation, Risk for

Sensory Perception, Disturbed (Specify: Auditory,

Gustatory, Kinesthetic, Olfactory Tactile,

Visual)

Sexual Dysfunction

Sexuality Pattern, Ineffective

Skin Integrity, Impaired

Skin Integrity, Risk for Impaired

Sleep Deprivation

Sleep, Readiness for Enhanced

Social Interaction, Impaired

Social Isolation

Sorrow, Chronic

Spiritual Distress

Spiritual Distress, Risk for

Spiritual Well-Being, Readiness for Enhanced

Spontaneous Ventilation, Impaired

Stress, Overload

Sudden Infant Death Syndrome, Risk for

Suffocation, Risk for

Suicide, Risk for

Surgical Recovery, Delayed

Swallowing, Impaired

Therapeutic Regimen Management: Community,

Ineffective

Therapeutic Regimen Management, Effective

Therapeutic Regimen Management: Family,

Ineffective

Therapeutic Regimen Management, Ineffective

Therapeutic Regimen Management, Readiness for

Enhanced

Thermoregulation, Ineffective

Thought Processes, Disturbed

Tissue Integrity, Impaired

Tissue Perfusion, Ineffective (Specify: Cerebral,

Cardiopulmonary, Gastrointestinal, Renal)

APPENDIX C 1531

Tissue Perfusion, Ineffective, Peripheral

Transfer Ability, Impaired

Trauma, Risk for

Unilateral Neglect

Urinary Elimination, Impaired

Urinary Elimination, Readiness for Enhanced

Urinary Incontinence, Functional

Urinary Retention

Ventilatory Weaning Response, Dysfunctional

Violence: Other-Directed, Risk for

Violence: Self-Directed, Risk for

Walking, Impaired

Wandering

Urinary Incontinence, Overflow

Urinary Incontinence, Reflex

Urinary Incontinence, Stress

Urinary Incontinence, Total

Urinary Incontinence, Urge

Urinary Incontinence, Risk for Urge

Source : http://nandadiagnosis.blogspot.com/2011/09/appendix-2010-2011-nanda-approved.html

Nursing Diagnosis for Activity Intolerance

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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 Diagnosis for Acute Pain

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Nursing Diagnosis for Acute Pain

Definition

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Subjective data: from patient usually Verbal report of pain
Objective data: Observed evidence of pain, protective gestures avoid pain, Change in muscle tone, Expressive; restlessness, moaning, crying, vigilance, irritability, sighing.

Related factors :

• trauma
• injuring agents (biological, chemical, physical, psychological)

Nursing Outcomes :

• Report pain is relieved / controlled.
• Follow prescribed pharmacological regimen.
• Verbalize methods that provide relief.
• Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Priority :

• To Assess Etiology/Precipitating Contributory Factors:
• Evaluate Client’s Response To Pain:
• Assist Client To Explore Methods For Alleviation/Control Of Pain

Sample Clinical Applications :

• Traumatic Injuries
• Surgical Procedures
• Infections
• Cancer
• Burns
• Skin Lesions
• Gangrene
• Thrombophlebitis
• Pulmonary Embolus
• Neuralgia

Nursing Diagnosis for Acute Pain

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Nursing Diagnosis for Deficient Fluid Volume

Hypovolemia; Dehydration

Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium

Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal (GI) tract, polyuria, and increased perspiration. Fluid volume deficit 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 restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent potentially life-threatening hypovolemic shock. Elderly patients are more likely to develop fluid imbalances.

Defining Characteristics

• Decreased urine output
• Concentrated urine
• Output greater than intake
• Sudden weight loss
• Decreased venous filling
• Hemoconcentration
• Increased serum sodium
• Hypotension
• Thirst
• Increased pulse rate
• Decreased skin turgor
• Dry mucous membranes
• Weakness
• Possible weight gain
• Changes in mental status

Related Factors

• Inadequate fluid intake
• Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea)
• Failure of regulatory mechanisms
• Electrolyte and acid-base imbalances
• Increased metabolic rate (fever, infection)
• Fluid shifts (edema or effusions)

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

• Fluid Balance
• Hydration

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Fluid Monitoring
• Fluid Management
• Fluid Resuscitation

Expected Outcomes

Patient experiences adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr, normotensive blood pressure (BP), heart rate (HR) 100 beats/min, consistency of weight, and normal skin turgor.

Laporan Pendahuluan Skizofrenia

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Pengertian

Skizofrenia adalah suatu diskripsi sindrom dengan variasi penyebab (banyak belum diketahui) dan perjalanan penyakit (tak selalu bersifat kronis atau deteriorating) yang luas, serta sejumlah akibat yang tergantung pada pertimbangan pengaruh genetik, fisik dan sosial budaya (Rusdi Maslim, 1997; 46).

Penyebab

1. Keturunan

Telah dibuktikan dengan penelitian bahwa angka kesakitan bagi saudara tiri 0,9-1,8 %, bagi saudara kandung 7-15 %, bagi anak dengan salah satu orang tua yang menderita Skizofrenia 40-68 %, kembar 2 telur 2-15 % dan kembar satu telur 61-86 % (Maramis, 1998; 215 ).

2. Endokrin

Teori ini dikemukakan berhubung dengan sering timbulnya Skizofrenia pada waktu pubertas, waktu kehamilan atau puerperium dan waktu klimakterium., tetapi teori ini tidak dapat dibuktikan.

3. Metabolisme

Teori ini didasarkan karena penderita Skizofrenia tampak pucat, tidak sehat, ujung extremitas agak sianosis, nafsu makan berkurang dan berat badan menurun serta pada penderita dengan stupor katatonik konsumsi zat asam menurun. Hipotesa ini masih dalam pembuktian dengan pemberian obat halusinogenik.

4. Susunan saraf pusat

Penyebab Skizofrenia diarahkan pada kelainan SSP yaitu pada diensefalon atau kortek otak, tetapi kelainan patologis yang ditemukan mungkin disebabkan oleh perubahan postmortem atau merupakan artefakt pada waktu membuat sediaan.

5. Teori Adolf Meyer

Skizofrenia tidak disebabkan oleh penyakit badaniah sebab hingga sekarang tidak dapat ditemukan kelainan patologis anatomis atau fisiologis yang khas pada SSP tetapi Meyer mengakui bahwa suatu suatu konstitusi yang inferior atau penyakit badaniah dapat mempengaruhi timbulnya Skizofrenia. Menurut Meyer Skizofrenia merupakan suatu reaksi yang salah, suatu maladaptasi, sehingga timbul disorganisasi kepribadian dan lama kelamaan orang tersebut menjauhkan diri dari kenyataan (otisme).

6. Teori Sigmund Freud

Skizofrenia terdapat (1) kelemahan ego, yang dapat timbul karena penyebab psikogenik ataupun somatik (2) superego dikesampingkan sehingga tidak bertenaga lagi dan Id yang berkuasa serta terjadi suatu regresi ke fase narsisisme dan (3) kehilangan kapasitas untuk pemindahan (transference) sehingga terapi psikoanalitik tidak mungkin.

7. Eugen Bleuler

Penggunaan istilah Skizofrenia menonjolkan gejala utama penyakit ini yaitu jiwa yang terpecah belah, adanya keretakan atau disharmoni antara proses berfikir, perasaan dan perbuatan. Bleuler membagi gejala Skizofrenia menjadi 2 kelompok yaitu gejala primer (gangguan proses pikiran, gangguan emosi, gangguan kemauan dan otisme) gejala sekunder (waham, halusinasi dan gejala katatonik atau gangguan psikomotorik yang lain).

8. Teori lain

Skizofrenia sebagai suatu sindroma yang dapat disebabkan oleh bermacam-macam sebab antara lain keturunan, pendidikan yang salah, maladaptasi, tekanan jiwa, penyakit badaniah seperti lues otak, arterosklerosis otak dan penyakit lain yang belum diketahui.

9. Ringkasan

Sampai sekarang belum diketahui dasar penyebab Skizofrenia. Dapat dikatakan bahwa faktor keturunan mempunyai pengaruh. Faktor yang mempercepat, yang menjadikan manifest atau faktor pencetus (presipitating factors) seperti penyakit badaniah atau stress psikologis, biasanya tidak menyebabkan Skizofrenia, walaupun pengaruhnya terhadap suatu penyakit Skizofrenia yang sudah ada tidak dapat disangkal.( Maramis, 1998;218 ).

Pembagian Skizofrenia

Kraepelin membagi Skizofrenia dalam beberapa jenis berdasarkan gejala utama antara lain :

1. Skizofrenia Simplek

Sering timbul pertama kali pada usia pubertas, gejala utama berupa kedangkalan emosi dan kemunduran kemauan. Gangguan proses berfikir sukar ditemukan, waham dan halusinasi jarang didapat, jenis ini timbulnya perlahan-lahan.

2. Skizofrenia Hebefrenia

Permulaannya perlahan-lahan atau subakut dan sering timbul pada masa remaja atau antara 15-25 tahun. Gejala yang menyolok ialah gangguan proses berfikir, gangguan kemauan dan adanya depersenalisasi atau double personality. Gangguan psikomotor seperti manerism, neologisme atau perilaku kekanak-kanakan sering terdapat, waham dan halusinasi banyak sekali.

3. Skizofrenia Katatonia

Timbulnya pertama kali umur 15-30 tahun dan biasanya akut serta sering didahului oleh stress emosional. Mungkin terjadi gaduh gelisah katatonik atau stupor katatonik.

4. Skizofrenia Paranoid

Gejala yang menyolok ialah waham primer, disertai dengan waham-waham sekunder dan halusinasi. Dengan pemeriksaan yang teliti ternyata adanya gangguan proses berfikir, gangguan afek emosi dan kemauan.

5. Episode Skizofrenia akut

Gejala Skizofrenia timbul mendadak sekali dan pasien seperti dalam keadaan mimpi. Kesadarannya mungkin berkabut. Dalam keadaan ini timbul perasaan seakan-akan dunia luar maupun dirinya sendiri berubah, semuanya seakan-akan mempunyai suatu arti yang khusus baginya.

6. Skizofrenia Residual

Keadaan Skizofrenia dengan gejala primernya Bleuler, tetapi tidak jelas adanya gejala-gejala sekunder. Keadaan ini timbul sesudah beberapa kali serangan Skizofrenia.

7. Skizofrenia Skizo Afektif

Disamping gejala Skizofrenia terdapat menonjol secara bersamaaan juga gejala-gejala depresi (skizo depresif) atau gejala mania (psiko-manik). Jenis ini cenderung untuk menjadi sembuh tanpa defek, tetapi mungkin juga timbul serangan lagi.

Konsep Dasar Skizofrenia Hebefrenik

1. Batasan : Salah satu tipe skizofrenia yang mempunyai ciri ;

Inkoherensi yang jelas dan bentuk pikiran yang kacau (disorganized).
Tidak terdapat waham yang sistemik
Efek yang datar dan tak serasi / ketolol – tololan.

2. Gejala Klinik : Gambaran utama skizofrenia tipe hebefrenik berupa :

Inkoherensi yang jelas
Afek datar tak serasi atau ketolol – tololan.
Sering disertai tertawa kecil (gigling) atau senyum tak wajar.
Waham / halusinasi yang terpecah – pecah isi temanya tidak terorganisasi sebagai suatu kesadaran, tidak ada waham sistemik yang jelas gambaran penyerta yang sering di jumpai.
Menyertai pelanggaran (mennerism) berkelakar.
Kecenderungan untuk menarik diri secara ekstrem dari hubungan sosial.
Berbagai perilaku tanpa tujuan.

Gambaran klinik ini di mulai dalam usia muda (15-25 th) berlangsung pelan – pelan menahan tanpa remisi yang berarti peterroasi kepribadian dan sosial terjadi paling hebat di banding tipe yang lain.

Konsep Dasar Halusinasi

Pengertian

Halusinasi adalah hilangnya kemampuan manusia dalam membedakan rangsangan internal pikiran dan rangsang eksternal (dunia luar) klien memberi persepsi atau pendapat tentang lingkungan tanpa ada obyek atau rangsangan yang nyata, misalnya : klien menyatakan mendengar suara. Padahal tidak ada orang yang bicara.

Proses terjadinya halusinasi

1. Fase pertama

Klien mengalami stress, cemas, perasaan perpisahan, kesepian yang memuncak dan tidak dapat di selesaikan, klien mulai melamun dan memikirkan hal – hal yang menyenangkan cara ini hanya menolong sementara.

2. Fase kedua

Kecemasan meningkatkan, menurun dan berpikir sendiri jadi dominan. Mulai dirasakan ada bisikan yang tidak jelas, klien tidak ingin orang lain tahu ia tetap dapat mengontrol.

3. Fase ketiga.

Bisikan, suara, isi halusinasi semakin menonjol, menguasai dan mengotrol klien, Klien menjadi terbiasa dan tidak berdaya terhadap halusinasinya.

4. Fase keempat

Halusinasi berubah menjadi mengancam memerintah dan memarahi klien, klien menjadi takut, tidak berdaya hilang kontrol dan tidak berdaya, hilang dan tidak dapat berhubungan secara nyata dengan orang lain di lingkungan

Tanda – tanda halusinasi

Menurut diri, tersenyum sendiri duduk terpaku, bicara sendiri memandang satu arah, menyerang tiba – tiba, arah gelisah.

Jenis halusinasi

1. Halusinasi dengar

Dengar suatu membicarakan, mengejek, menertawakan, mengancam tetapi tidak ada sumbernya disekitarnya.

2. Halusinasi terlihat

Melihat pemandangan, orang, binatang atau sesuatu yang tidak ada tetapi klien yakin ada.

3. Halusinasi penciuman

Menyatakan mencium bau bunga kemenyan yang tidak dirasa orang lain dan ada sumber.

4. Halusinasi kecap

Merasa mengecap sesuatu rasa di mulut tetapi tidak ada.

5. Halusinasi raba

Merasa ada binatang merayap pada kulit tetapi tidak ada.