Posted: October 23rd, 2023
A systematic taxonomy of nursing diagnoses is created and maintained by NANDA International (NANDA-I). Nurses utilize these nursing diagnoses to recognize and explain health concerns or issues that patients are having. NANDA nursing diagnoses are organized sentences that give a precise and detailed account of a patient’s medical condition.
The three elements of each NANDA nursing diagnostic are as follows:
Problem (P): This succinct description of the patient’s health issue or reaction to an issue with their health. Usually, it starts with a particular illness or condition.
Etiology (E): The root cause or contributing variables that are connected to the patient’s issue are identified by the etiology, sometimes referred to as the related factor. It clarifies the cause of the issue.
Signs and symptoms (S): The objective and evaluative information that supports the diagnosis is listed in this section. It explains how the nurse spots the issue.
Several NANDA nursing diagnoses are shown here:
A feeling of breath, low oxygen saturation, and coughing (S) are symptoms of impaired gas exchange (P), which is related to pneumonia (E).
Cool and pale extremities, a decreased capillary refill rate, and weak pulses (S) are indications of ineffective tissue perfusion (P), which is linked to atherosclerosis (E).
As shown by the patient’s verbal claims of pain, grimacing, and protective behavior (S), acute pain (P) is connected to the surgical incision (E).
Nurses can identify patient issues with the aid of NANDA nursing diagnoses, then develop suitable interventions and assess their efficacy. In order to provide patients with high-quality care, healthcare workers must be able to communicate clearly and consistently. To make sure that the requirements of patients are satisfied and that their medical issues are adequately addressed, nurses frequently include them in care plans.
The “NANDA-I Nursing Diagnoses: Definitions and Classification” is a nursing diagnosis reference book published and updated on a regular basis by NANDA-I (Nursing Diagnosis Association International). For nurses, nursing students, and other healthcare professionals who employ NANDA nursing diagnosis in their practice, this book is a thorough resource. It gives comprehensive details on each nursing diagnosis, including the problem (P), the cause (E), the signs and symptoms (S), as well as any unique defining traits and associated circumstances.
Additionally, the book provides instructions for developing care plans as well as details on how to apply NANDA nursing diagnoses and their role in nursing care. It is a crucial resource for healthcare practitioners to use when detecting and treating patient health issues to guarantee consistency and accuracy.
To ensure you have the most recent nursing diagnosis and information, you should purchase the most recent edition of the book as its content and layout may be altered from time to time. The NANDA-I Nursing Diagnoses book is normally available from online merchants, bookstores, NANDA International’s website, or its authorized distributors. To keep up with the most recent advancements in nursing diagnoses and care planning, be certain to check for the latest version or updates.
The patient’s history of falls, their unsteady walk, and their muscle weakness (S) all point to a risk for falls (P) that is related to their reduced mobility and balance (E).
Breathing difficulties (P): Associated with chronic obstructive pulmonary disease (COPD) (E) as seen by decreased oxygen saturation (S), the use of accessory muscles for breathing, and shortness of breath (E).
As shown by the patient’s expressed feelings of pain, his or her guarding behavior, as well as a spike in heart rate and blood pressure, acute pain (P) is connected to the post-operative incision (E).
Poor Skin Integrity (P): Shown by redness over prominences of bone, peeling skin, and open wounds (S). Related to immobilization and pressure ulcer risk (E).
Low blood pressure (S) and dry mucous membranes are signs of low fluid volume (P), which is linked to excessive vomiting (E).
Anxiety (P): Associated with an impending surgical procedure (E), as shown by agitation, an elevated heart rate, and anxious speech (S).
Risk for infection (P): Linked to an open wound (E), as shown by the existence of a surgical incision, and immune system weakness (S).
Impaired Swallowing (P): Linked to stroke (E) as shown by aspiration risk (S), difficulty swallowing, and coughing during meals.
Missed doses, improper administration, and insufficient control of the chronic illness (S) are signs of inadequate therapeutic regimen management (P), which is linked to a lack of understanding of the pharmaceutical regimen (E).Please be aware that these are merely examples and that the precise nursing diagnosis of a patient should be established after a careful examination of their unique needs and state of health. NANDA nursing diagnoses are used by nurses to create care plans that are specifically tailored to each patient’s needs and challenges.
Diabetes-related NANDA nursing diagnoses can assist identify certain health issues linked to the condition and direct nursing care. Here are a few NANDA nursing conditions that are frequently linked to diabetes:
Insufficient self-monitoring of blood glucose levels (E), as shown by inconsistent glucose monitoring and ignorance of goal ranges (S), is a risk factor for unstable blood glucose levels (P).
Nutritionally Unbalanced: Exceeding Body Needs (P) Weight gain, increased hemoglobin A1c levels, and exorbitant calorie intake (S) are indicators that the condition is related to overeating and insulin therapy (E).
Infection risk (P) is linked to a weakened immune system brought on by hyperglycemia (E), as seen by recurrent skin infections, infections of the urinary tract, or slow wound healing (S).
Peripheral neuropathy (P) risk factors include past experiences of poor glycemic control (S) and reports of numbness, tingling, and or burning in the extremities. These symptoms are linked to long-term hyperglycemia (E).
Lack of knowledge (P) about managing diabetes (E) is demonstrated by incorrect understanding of the causes, symptoms, treatments, and consequences (S).
A family history of heart disease, high blood pressure, and high cholesterol levels (S) are indicators of an increased risk for cardiovascular disease (P), which is linked to atherosclerosis and hypertension brought on by diabetes (E).
Reading trouble, difficulty seeing images clearly, and noticing changes in vision (S) are all symptoms of disturbed sensory perception (P), which is connected to diabetic retinopathy (E).
The psychosocial effects of having diabetes (E) are related to ineffective coping (P), which is shown by negative emotions including annoyance and worry as well as failing to adhere to treatment plans (S).
It’s crucial to remember that the selection of a particular nursing diagnosis is dependent on the patient’s unique circumstances and evaluation results. Nursing diagnosis should take the patient’s individual needs, diabetes treatment strategy, and probable consequences into consideration. These diagnoses are used by nurses to create care plans that support healthy living and effective diabetes management.
Nurses can address specific health concerns and create care plans to effectively manage the illness with the aid of nursing diagnosis related to hypertension. Here are a few NANDA nursing conditions that are frequently connected to hypertension:
Risk of Uncontrolled Blood Pressure (P): Linked to non-adherence to recommended antihypertensive drugs or lifestyle changes (E), as seen by erratic blood pressure readings & a lack of interest in blood pressure treatment (S).
Anxiety (P): Shown in a clinical setting by jitteriness, restlessness, and elevated blood pressure, which is linked to the diagnosis and treatment of hypertension (E).
Anxiety (P): Associated with the diagnosis and treatment of hypertension (E), as shown by unease, agitation, elevated blood pressure in a medical setting, and worries about the disease’s effects on general health (S).
Cardiovascular Complications Risk (P) related to high blood pressure (E), as shown by a history of the condition, a family history of the condition, and other risk factors like smoke or obesity (S).
Nutritionally Unbalanced: Exceeding Body Needs (P) High salt consumption, weight gain, and high blood pressure readings are all signs that something is wrong (E), which is related to eating too many calories and sodium (S).
Lack of knowledge about hypertension and how to manage it is demonstrated by ignorance of the condition, its risk factors, or the significance of taking medications and lifestyle changes.
Risk of Hypertension Complications (P): Associated with the possible negative effects of untreated or uncontrolled hypertension (E), as shown by risk factors including obesity, smoking, or a lack of physical activity, in addition to elevated blood pressure readings (S).
For directing patient care and education, hypertension-related nursing diagnoses are crucial. To determine the most suitable nursing diagnosis and to create a customized treatment plan that includes techniques for blood pressure control and lifestyle adjustments, nurses must carefully evaluate each patient’s particular circumstances and risk factors.
A NANDA nursing care plan must include a clear nursing diagnosis, quantifiable goals, a list of actions, and an assessment of the patient’s reaction to care. Examples of NANDA nursing care plans are provided below:
Example 1: Nursing Care Strategy for Falls Risk
Nursing Diagnosis: Decreased mobility and balance increase the risk of falling.
The patient won’t fall while they’re at the hospital.
The patient’s movement and balance will both be better.
When the patient is admitted, evaluate their balance and mobility.
Use fall prevention techniques include bed alarms, non-skid footwear, and routine safety inspections.Inform the patient and their family about the dangers of falling and how to avoid them.
Encourage the use of assistive aids (such a walker or cane) when necessary.
Keep track of and record any instances involving falls.
The patient didn’t fall once while they were in the hospital.
The patient’s enhanced mobility and balance were shown by a lower chance of falling.
Example 2: Nursing Care Program for Breathing Pattern That Is Ineffective
Chronic obstructive pulmonary disease (COPD) is the cause of the ineffective breathing pattern, according to the nursing diagnosis.
The patient will keep their breathing rate steady and sufficient.
The patient will report feeling more at ease and having less dyspnea.
Regularly check your breathing’s depth, pace, and effort.
Encourage and aid in the use of spirometry as an incentive and deep breathing exercises.
As directed, give prescription drugs (such bronchodilators) to patients.
Inform the patient about the ideal lung expansion location.
Administer oxygen therapy as directed.
Advocate a healthy lifestyle, which should include quitting smoking and, if necessary, pulmonary rehabilitation.
The patient’s breathing rate stayed steady and within the desired range.
During the hospital stay, the patient reported increased comfort and lessened dyspnea.
Just a few samples of NANDA nursing care plans are shown here. Care goals, patient needs, and unique nursing diagnoses can all be taken into account when creating highly tailored care plans. The most important thing is to make sure the treatment plan is thorough, patient-centered, and geared on enhancing the patient’s health and wellbeing.
Nursing diagnosis for anxiety can aid nurses in addressing the patients’ emotional and psychological well-being. Here are a few NANDA nursing diagnoses that are frequently linked to anxiety:
Anxiety (P): Shown as restlessness, elevated heart rate, excessive fretting, and verbal displays of unease (S) in response to situational stresses including a new diagnosis, hospitalization, or impending operation (E).
Poor problem-solving abilities, an inability to make sound decisions, and unhealthy coping habits (S) are signs of ineffective coping (P), which is related to excessive anxiety and trouble handling stressors (E).
The patient’s behavior indicative of suicidal ideation, self-destructive conduct, or a history of self-harm (S) are indicators of the patient’s risk for self-harm (P), which is linked to extreme anxiety and thoughts of self-harm (E).
Anxiety and excessive worrying are linked to disturbed sleep patterns (P), which are indicated by trouble falling asleep, awaking frequently, and complaints of a lack of sleep (S).
Fear (P): Associated with an imagined threat (E), as shown by increased anxiety, avoidance tendencies, and manifestations of panic (S).
Chronic Low Self-Esteem (P): Linked to a history of ongoing worry and self-doubt (E), as shown by a poor self-perception, self-deprecating remarks, and a lack of self-assurance (S).
Impaired Social Interaction (P): Related to anxiety regarding social situations (E) as shown by avoidance of encounters, withdrawal from social activities, and restricted interpersonal communication (S).
Plans for nursing care for anxiety frequently combine interventions like offering emotional support, teaching coping mechanisms, and encouraging relaxation techniques.
Sepsis is a potentially fatal illness that develops when the body’s reaction to an infection results in widespread inflammation and organ failure. It’s critical to concentrate on stabilizing the patient’s state, addressing the underlying illness, and provide supportive care while developing a nursing care plan for sepsis. Here are some NANDA nursing diagnosis that sepsis frequently accompanies:
Risk for infection (P): Associated with intrusive procedures (E) as shown by the existence of indwelling catheters, recent surgery, or immunosuppression (S), and related to a breach in the skin or mucous membranes.
Hypotension, tachycardia, and altered state of consciousness (S) are indicators of septic shock (E), which is associated with a risk for unstable blood pressure (P).
Ineffective tissue perfusion (P) is indicated by mottled skin, chilly extremities, reduced capillary refill, and impaired mental status (S). It is associated with a reduction in cardiac output and shock distribution (E).
Hypoxemia, an elevated respiratory rate, and the use of auxiliary muscles for breathing (S) are signs of impaired gas exchange (P), which is related to a condition called acute respiratory distress syndrome, or ARDS, or severe sepsis (E).
DIC (P): risk of diffuse intravascular coagulation According to abnormal laboratory results such a prolonged prothrombin time (PT) and an activated partial thromboplastin time (aPTT), a low platelet count, and bleeding or clotting symptoms (S), sepsis-induced coagulation pathway activation (E) is to blame.
Decreased urine production, increased thirst, and hypotension (S) are signs of inadequate fluid volume (P), which is connected to the capillary leak syndrome brought on by sepsis (E).
Risk factors for Impaired Skin Integrity (P) include protracted hospitalization, immobilization, and severe illness (E), which are shown to be related by the presence of invasive devices, pressure ulcers, or skin disintegration (S).
Associated with changed mental status brought on by sepsis (E), as shown by disorientation, delirium, or difficulties concentrating (S), is the thought process disturbance (P).
Stabilizing the patient’s state, giving antibiotics, and offering supportive measures including resuscitation with fluids and hemodynamic support are the main goals of nursing care for sepsis patients. Following the sepsis care instructions and procedures provided by the healthcare facility is crucial. The unique nursing diagnosis and care plan ought to be customized to the condition and needs of each patient.
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