The Foci Of The Nursing Diagnoses In NANDA-I Taxonomy II, And Their .

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The foci of the nursing diagnoses in NANDA-I Taxonomy II, and their associated diasgnoses,start on the following pages:Activity planning 322–323Activity tolerance 228–229Acute substance withdrawalsyndrome 351–352Adaptive capacity 357Adverse reaction to iodinatedcontrast media 429Airway clearance 384Allergy reaction 430Anxiety 324Aspiration 385Attachment 289Autonomic dysreflexia 353, 355Balanced energy field 225Balanced fluid volume 183Balanced nutrition 157Bathing self-care 243Bleeding 386Blood glucose level 177Body image 276Breast milk production 159Breastfeeding 160–162Breathing pattern 230Cardiac output 231, 233Childbearing process 307,309–310Chronic pain syndrome 448Comfort 442–443, 450–453Communication 262Confusion 254–256Constipation 197, 199–200Contamination 424, 426Coping 326–331, 333–334Death anxiety 335Decision-making 366Decisional conflict 367Denial 336Dentition 387Development 459Diarrhea 204Disuse syndrome 217Diversional activity engagement142Dressing self-care 244Dry eye 388Dry mouth 389Eating dynamics 163–164Electrolyte balance 182Elimination 189Emancipated decision-making368–370Emotional control 257Falls 390Family processes 290, 293–294Fatigue 226Fear 337Feeding dynamics 166Feeding pattern 168Feeding self-care 245Female genital mutilation 415Fluid volume 184–186Frail elderly syndrome 145, 147Functional constipation 201, 203Gas exchange 209Gastrointestinal motility 205–206Grieving 339–341Health 148Health behavior 149Health literacy 143Health maintenance 150Health management 151–153Home maintenance 242Hope 266–267Human dignity 268Hyperbilirubinemia 178Hyperthermia 434Hypothermia 435, 437Immigration transition 315Impulse control 258Incontinence 190–195, 207Infection 382Injury 392–394Insomnia 213Knowledge 259–260Labor pain 449Latex allergy reaction 431, 433Lifestyle 144Liver function 180Loneliness 454Maternal-fetal dyad 311Memory 261Metabolic imbalance syndrome181Mobility 218–220Mood regulation 342Moral distress 371Mucous membrane integrity 397,399Nausea 444Neonatal abstinence syndrome358Neurovascular function 400Nutrition 158Obesity 169Occupational injury 427Organized behavior 359, 361–362Other-directed violence 416Overweight 170, 172Pain 445–446Parenting 283, 286, 288Perioperative hypothermia 438Perioperative positioning injury395Personal identity 269–270Physical trauma 401Poisoning 428Post-trauma syndrome 316, 318Power 343–345Pressure ulcer 404Protection 154Rape-trauma syndrome 319Relationship 295–297Religiosity 372–374Relocation stress syndrome320–321Resilience 346–348Retention 196Role conflict 298Role performance 299Role strain 278, 281Self-care 247Self-concept 271Self-directed violence 417Self-esteem 272–275Self-mutilation 418, 420Self-neglect 248Sexual function 305Sexuality pattern 306Shock 405Sitting 221Skin integrity 406–407Sleep 214–215Sleep pattern 216Social interaction 301Social isolation 455Sorrow 349Spiritual distress 375, 377Spiritual well-being 365Spontaneous ventilation 234stable blood pressure 235standing 222stress 350sudden death 408suffocation 409suicide 422surgical recovery 410–411surgical site infection 383swallowing 173Thermal injury 396thermoregulation 439–440tissue integrity 412–413tissue perfusion 236–239toileting self-care 246transfer ability 223trauma 403unilateral neglect 251venous thromboembolism 414ventilatory weaning response 240verbal communication 263walking 224wandering 227

NANDA International, Inc.Nursing DiagnosesDefinitions and Classification2018–2020Eleventh EditionEdited byT. Heather Herdman, PhD, RN, FNIandShigemi Kamitsuru, PhD, RN, FNIThiemeNew York Stuttgart Delhi Rio de Janeiro

International Rights Manager: Heike SchwabenthanEditorial Services Manager: Mary Jo CaseyEditorial Director: Sue HodgsonManaging Editor: Kenneth SchubachProduction Editor: Sean WoznickiEditorial Assistant: Mary WilsonDirector, Clinical Solutions: Michael WachingerBook Production Manager, Stuttgart: Sophia HengstInternational Production Editor: Andreas SchabertInternational Marketing Director: Fiona HendersonDirector of Sales, North America: Mike RosemanInternational Sales Director: Louisa TurrellSenior Vice President and Chief Operating Officer: Sarah VanderbiltPresident: Brian D. ScanlanLibrary of Congress Cataloging-in-Publication DataCopyright 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 otherworks, please e-mail: nanda-i@thieme.com; additional product information can be found by visiting: www.thieme.com/nanda-i.Copyright 2018 NANDA InternationalThieme Publishers New York333 Seventh Avenue, New York, NY 10001 USA 1 800 782 3488, customerservice@thieme.comThieme Publishers StuttgartRüdigerstrasse 14, 70469 Stuttgart, Germany 49 [0]711 8931 421, customerservice@thieme.deThieme Publishers DelhiA-12, Second Floor, Sector-2, NOIDA-201301Uttar Pradesh, India 91 120 45 566 00, customerservice@thieme.inThieme Publishers Rio de JaneiroThieme Revinter Publicações Ltda.Rua do Matoso 170,Rio de Janeiro, CEP 20270-135 RJ, Brazil, 55 21 2563 9700, cliente@thieme.comPrinted in Canada by MarquisISBN 978-1-62623-929-6ISSN 1943-0728Also 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 andSurgeons, on the Internet at surgeons.htm (visited May 17, 2017)Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience arecontinually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this bookmentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort toensure 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 toany dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully themanufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether thedosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in thepresent book. Such examination is particularly important with drugs that are either rarely used or have been newly released on themarket. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors andpublishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are foundafter 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 orproprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a namewithout 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, orcommercialization outside the narrow limits set by copyright legislation without the publisher’s consent isillegal and liable to prosecution. This applies in particular to photostat reproduction, copying,mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic dataprocessing and storage.

The editors of this edition would like todedicate this book to the memory of our founder,Dr. Marjory Gordon

ContentsContentsPart 1 The NANDA International Terminology – Organizationand General Information1Introduction.22What's New in the 2018–2020 Edition of Diagnosesand Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Changes and Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43.13.23.33.43.53.63.73.8Processes 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 . .46777921234Governance and Organization . . . . . . . . . . . . . . . . . . . . . . . . . .254.1International Considerations on the Use of the NANDA-I NursingDiagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NANDA International Position Statements . . . . . . . . . . . . . . . . . . . . .An Invitation to Join NANDA International . . . . . . . . . . . . . . . . . . . . .2527284.24.3Part 2 The Theory Behind NANDA International NursingDiagnoses5Nursing Diagnosis Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .345.15.25.35.45.55.65.75.85.95.10Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34363737384142434444vi

Contents6Clinical Reasoning: From Assessment to Diagnosis . . . .456.16.26.36.46.56.66.7Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The Nursing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Identifying Potential Nursing Diagnoses (Diagnostic Hypotheses) .In-Depth Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .454855606272727Introduction to the NANDA International Taxonomyof Nursing Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .747.17.27.37.47.57.67.7Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .747982828386978Specifications and Definitions Within the NANDAInternational Taxonomy of Nursing Diagnoses . . . . . . . .988.18.28.38.48.58.68.7Structure of Taxonomy II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A Multiaxial System for Constructing Diagnostic Concepts . . . . . . .Definitions of the Axes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Developing and Submitting a Nursing Diagnosis . . . . . . . . . . . . . . . .Further Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Recommended Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98991001061071081089Frequently Asked 129.13Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .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 . . . . . . . . . . .109109110111115121122122123125127129130vii

Contents9.149.15Questions about the NANDA-I Definitions and Classification Text .References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13013210Glossary of Terms.13310.110.210.310.410.5Nursing Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Diagnostic Axes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Components of a Nursing Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . .Definitions for Classification of Nursing Diagnoses . . . . . . . . . . . . . .References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133134136137138Part 3 The NANDA International Nursing DiagnosesDomain 1. Health promotion.141Decreased diversional activity engagement . . . . . . . . . . . . . . . . . . . . . . .Readiness for enhanced health literacy. . . . . . . . . . . . . . . . . . . . . . . . . . . .Sedentary lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142143144Class 1. Health awarenessClass 2. Health managementFrail 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145147148149150151152153154Domain 2. Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155Class 1. IngestionImbalanced 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii157158159160161162163164166168169170

ContentsRisk for overweight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired swallowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .172173Class 2. DigestionThis class does not currently contain any diagnoses. . . . . . . . . . . . . . . . . . .175Class 3. AbsorptionThis class does not currently contain any diagnoses. . . . . . . . . . . . . . . . . . .176Class 4. MetabolismRisk for unstable blood glucose level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Neonatal hyperbilirubinemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for neonatal hyperbilirubinemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for impaired liver function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for metabolic imbalance syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . .177178179180181Class 5. HydrationRisk for electrolyte imbalance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for imbalanced fluid volume. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Deficient fluid volume . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for deficient fluid volume . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Excess fluid volume . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182183184185186Domain 3. Elimination and exchange . . . . . . . . . . . . . . . . . . . . . . . . . . .187Class 1. Urinary functionImpaired urinary elimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Functional urinary incontinence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Overflow urinary incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Reflex urinary incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Stress urinary incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Urge urinary incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for urge urinary incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Urinary retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189190191192193194195196Class 2. Gastrointestinal functionConstipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Perceived constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Chronic functional constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for chronic functional constipation . . . . . . . . . . . . . . . . . . . . . . . . . . .Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Dysfunctional gastrointestinal motility . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for dysfunctional gastrointestinal motility . . . . . . . . . . . . . . . . . . . . . .Bowel incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197199200201203204205206207ix

ContentsClass 3. Integumentary functionThis class does not currently contain any diagnoses. . . . . . . . . . . . . . . . . .208Class 4. Respiratory functionImpaired gas exchange . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209Domain 4. Activity/rest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .211Class 1. Sleep/restInsomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sleep deprivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Readiness for enhanced sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Disturbed sleep pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213214215216Class 2. Activity/exerciseRisk for disuse syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired bed mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired physical mobility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired wheelchair mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired sitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired standing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired transfer ability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired walking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217218219220221222223224Class 3. Energy balanceImbalanced energy field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Wandering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225226227Class 4. Cardiovascular/pulmonary responsesActivity intolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for activity intolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ineffective breathing pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Decreased cardiac output . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for decreased cardiac output . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .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 . . . . . . . . . . . . . . . . . . . . . . .228229230231233234235236237238239240Class 5. Self-careImpaired home maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bathing self-care deficit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Dressing self-care deficit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .x242243244

ContentsFeeding self-care deficit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Toileting self-care deficit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Readiness for enhanced self-care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Self-neglect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .245246247248Domain 5. Perception/cognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .249Class 1. AttentionUnilateral neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .251Class 2. OrientationThis class does not currently contain any diagnoses. . . . . . . . . . . . . . . . . . .252Class 3. Sensation/perceptionThis class does not currently contain any diagnoses. . . . . . . . . . . . . . . . . . .253Class 4. CognitionAcute confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for acute confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Chronic confusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Labile emotional control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ineffective impulse control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Deficient knowledge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Readiness for enhanced knowledge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254255256257258259260261Class 5. CommunicationReadiness for enhanced communication . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired verbal communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .262263Domain 6. Self-perception. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265Class 1. Self-conceptHopelessness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Readiness for enhanced hope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for compromised human dignity . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Disturbed personal identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for disturbed personal identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Readiness for enhanced self-concept. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .266267268269270271Class 2. Self-esteemChronic low self-esteem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for chronic low self-esteem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Situational low self-esteem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for situational low self-esteem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .272273274275Class 3. Body imageDisturbed body image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .276xi

ContentsDomain 7. Role relationship.277Caregiver role strain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for caregiver role strain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for impaired parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Readiness for enhanced parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .278281283286288Class 1. Caregiving rolesClass 2. Family relationshipsRisk for impaired attachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Dysfunctional family processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Interrupted family processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Readiness for enhanced family processes. . . . . . . . . . . . . . . . . . . . . . . . . .289290293294Class 3. Role performanceIneffective relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Risk for ineffective relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Readiness for enhanced relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Parental role conflict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ineffective role performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Impaired social interaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .295296297298299301Domain 8. Sexuality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .303Class 1. Sexual identityThis class does not currently contain any diagnoses. . . . . . . . . . . . . . . . . .304Class 2.

The foci of the nursing diagnoses in NANDA-I Taxonomy II, and their associated diasgnoses, . Self-care 247 Self-concept 271 Self-directed violence 417 Self-esteem 272-275 Self-mutilation 418, 420 . 6.3 Data Analysis. 55 6.4 Identifying Potential Nursing .

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