College of Eastern Utah Practical Nursing Program (2007-2008) NANDA Domain Definitions

HEALTH PROMOTION
The awareness of well-being or normalit of function an! strategies use! to maintain control of an! enhance that well-being or normalit of function "ealth #wareness$ %ecognition of normal function an! well-being "ealth &anagement$ '!entif ing( controlling( )erforming( an! integrating acti*ities to maintain health an! well-being

NUTRITION
The acti*ities of ta+ing in( assimilating( an! using nutrients for the )ur)oses of tissue maintenance( tissue re)air( an! the )ro!uction of energ , 'ngestion$ Ta+ing foo! or nutrients into the bo! -igestion$ The )h sical an! chemical acti*ities that con*ert foo!stuffs into substances suitable for absor)tion an! assimilation, #bsor)tion$ The act of ta+ing u) nutrients through bo! tissues, &etabolism$ The chemical an! )h sical )rocesses occurring in li*ing organisms an! cells for the !e*elo)ment an! use of )roto)lasm( )ro!uction of waste an! energ ( with the release of energ for all *ital )rocesses, " !ration$ The ta+ing in an! absor)tion of flui!s an! electrol tes,

ELIMINATION
.ecretion an! e/cretion of waste )ro!ucts from the bo! , Urinar s stem$ The )rocess of secretion an! e/cretion of urine, 0astrointestinal s stem$ E/cretion an! e/)ulsion of waste )ro!ucts from the bowel, 'ntegumentar s stem$ Process of secretion an! e/cretion through the s+in, Pulmonar s stem$ %emo*al of b )ro!ucts of metabolic )ro!ucts( secretions( an! foreign material from the lung or bronchi,

ACTIVITY/REST
The )ro!uction( conser*ation( e/)en!iture( or balance of energ resources, .lee) 1 %est .lumber( re)ose( ease( or inacti*it , #cti*it 1 E/ercise &o*ing )arts of the bo! (mobilit )( !oing wor+( or )romoting actions often (but not alwa s) against resistance, Energ 2alance # ! namic state of harmon between inta+e an! e/)en!iture of resources, Car!io*ascular-)ulmonar %es)onses Car!io)ulmonar mechanisms that su))ort acti*it 1rest,

PERCEPTION/COGNITION
The human information )rocessing s stem inclu!ing attention( orientation( sensation( )erce)tion( cognition( an! communication, #ttention$ &ental rea!iness to notice or obser*e, 3rientation$ #wareness of time( )lace( an! )erson, .ensation1Perce)tion$ %ecei*ing information through the senses of touch( taste( smell( *ision( hearing( an! +inesthesia an! the com)rehension of sense !ata resulting in naming( associating( an!1or )attern recognition, Cognition$ Use of memor ( learning( thin+ing( )roblem sol*ing( abstraction( 4u!gment( insight( intellectual ca)acit ( calculation( an! language, Communication$ .en!ing an! recei*ing *erbal an! non*erbal information,

SELF-PERCEPTION
#wareness about the self, .elf-Conce)t$ The )erce)tion1)erce)tions about the total self,

.elf-Esteem$ #ssessment of one5s own wor+( ca)abilit ( significance( an! success, 2o! 'mage$ # mental image of one5s own bo! ,

ROLE RELATIONSHIPS
The )ositi*e an! negati*e connections or associations between )ersons or grou)s of )ersons an! the means b which those connections are !emonstrate!, Caregi*ing %oles$ .ociall e/)ecte! beha*ior )atterns b )ersons )ro*i!ing care who are not health care )rofessionals, 6amil %elationshi)s$ #ssociations of )eo)le who are biologicall relate! or relate! b choice, %ole Performance$ 7ualit of functioning in sociall e/)ecte! beha*ior )atterns,

SE UALITY
.e/ual i!entit ( se/ual function( an! re)ro!uction, .e/ual '!entit $ The state of being a s)ecific )erson in regar! to se/ualit an!1or gen!er, .e/ual 6unction$ The ca)acit or abilit to )artici)ate in se/ual acti*ities, %e)ro!uction$ #n )rocess b which new in!i*i!uals ()eo)le) are re)ro!uce!,

COPING/STRESS TOLERANCE
Conten!ing with life e*ents1life )rocesses, Post-Trauma %es)onses$ %eactions occurring after )h sical or )s chological trauma, Co)ing %es)onses$ The )rocess of managing en*ironmental stress, Neuro-beha*ioral %es)onses 2eha*ioral res)onses reflecting ner*e an! brain function,

LIFE PRINCIPLES
Princi)les un!erl ing con!uct( thought an! beha*ior about acts( customs( or institutions *iewe! as being true or ha*ing intrinsic wor+, 8alues$ The i!entification an! ran+ing of )referre! mo!es of con!uct or en! states, 2eliefs$ 3)inions( e/)ectations( or 4u!gments about acts( customs( or institutions *iewe! as being true or ha*ing intrinsic wor+, 8alue12elief1#ction Congruence$ The corres)on!ence or balance achie*e! between *alues( beliefs( an! actions,

SAFETY/PROTECTION
6ree!om from !anger( )h sical in4ur or immune s stem !amage( )reser*ation from loss( an! )rotection of safet an! securit , 'nfection$ "ost res)onses following )athogenic in*asion, Ph sical 'n4ur $ 2o!il harm were hurt, 8iolence$ The e/ertion of the e/cessi*e force or )ower so as+e! to cause in4ur or abuse, En*ironmental "a9ar!s$ .ources of !anger in the surroun!ings -efensi*e Processes$ The )rocesses b which the self )rotects itself from the nonself, Thermoregulation$ The )h siologic )rocess of regulating heat an! energ within the bo! for )ur)oses of )rotecting organisms,

COMFORT
.ense of mental( )h sical( or social well-being or ease, Ph sical Comfort $ .ense of well-being or ease, .ocial Comfort $ .ense of well-being or ease with one5s social situations,

GRO!TH/DEVELOPMENT
#ge a))ro)riate increases in )h sical !imensions( organ s stems( an!1or attainment of !e*elo)mental milestones,

0rowth$ 'ncreases in )h sical !imensions or maturit of organ s stems, -e*elo)ment$ #ttainment( lac+ of attainment( or loss of !e*elo)mental milestones,

NANDA Assessment Fo"m

.tu!ent Name 'ntro!uce our )atient with a brief intro!uction inclu!ing age( gen!er( me!ical !iagnoses( an! )ertinent )re*ious histor , -o not )ut i!entifiers such as name or birth!ate in our assessment,

HEALTH PROMOTION
Hea#t$ A%a"eness/ Hea#t$ Mana&ement Subjective %eliabilit (:-;) (: is low an! ; is high) <nowle!ge of current illness 1 wh are ou here= "ow will ou manage our health1)h sical nee!s after !ischarge= &e!ication +nowle!ge Col!s 1 'llnesses in last ear ?ost time from wor+ !ue to illness 1 in4uries Cause of current illness 1 con!ition

>hat is our e/)ectation of current care Past illnesses or in4uries$ (e/)lain) 0eneral "ealth #cci!ents Com)liance with health care !irections Objective #llergies 1 sensiti*ities 0eneral "ealth #))earance 8ital .igns$ Tem)erature 2P Pulse

'mmuni9ations

%es)irations

.)0 2

&e!ication

-ose1%oute

6reAuenc

-osage range for age

Classification1Use

(use re*erse if more me!s)

&e!ications ta+en at home an! !ifferent from hos)ital me!ications (amount an! freAuenc ) 3*er the counter #lcohol Tobacco "erbs 3ther

.u))lements$ (8itamins( &inerals( Ensure( etc)

NUTRITION
In&estion1Di&estion/A'so"(tion/Meta'o#ism/H)*"ation Subjective Usual >eight Usual -iet (T )e) ?ast &eal1'nta+e Nausea18omiting 6oo! li+es 1 !isli+es "eartburn1'n!igestion #llerg 16oo! 'ntolerance "/ of -iabetes (t )e( onset) -entures Problems with !entures Treatment of -& %elate! to Changes in >eight (long term) No, of &eals1-a #))etite Changes #ltere! Taste 3bstacles to Eating %elie*e! b

Usual flui! inta+e$ (what( amt) Nausea 1 *omiting (amt) Objective 2&' (Chil!ren 2.#) 3ral &embranes Cough1gag refle/ 2loo! 0lucose (if a))licable) '8 rate 2; hr, N0 inta+e 2; hr, N0 out)ut 2; hr, Total 3ut)ut 2; hr, '8 flui! inta+e 2; hr, other (note) out)ut Chewing1.wallowing Con!ition of Teeth an! 0ums -iarrhea

Current >eight1"eight B of meals eaten '8 flui! 2; hr, oral inta+e 2; hr, urine out)ut 2; hr, Total 'nta+e

ELIMINATION
U"ina") s)stem Subjective Urinar *oi!ing )atterns$ 6reAuenc ( amount( !iscomfort( hesitanc 2la!!er !isease or !ifficult -ribbling 1 'ncontinence$ >hen 1 how often "istor of bla!!er !isease Objective #mount of urine$ Urine$ color consistenc Urinar )atterns se!iment o!or 6ole (!ate inserte!) si9e Pain 1 2urning 1 - suria Nocturia( hesitanc ( change in color of urine E/cessi*e )ers)iration( o!or )roblems

2la!!er !istention1Urinar retention

Gast"ointestina# s)stem Subjective "/ of 2owel -isease Character of stool "istor of 2lee!ing Consti)ation ?a/ati*e use Usual 2owel Pattern ?ast 2& "emorrhoi!s 'ncontinence 6actors that lea! to consti)ation$ !iet( !ecrease! flui! inta+e( stress( an/iet ( !ecrease! acti*it ( anesthesia( me!ications( others

3b4ecti*e ?ast 2&$ .i9e 1 color 1 consistenc Inte&+menta") s)stem Subjective .+in com)lications 1 brea+!own 1 ulcers1 lesions with !ifficult healing etc, Objective .+in assessment$ 'ntegrit 1 h !ration 1 turgor 1 color 1 tem)erature 1 change in fat !istribution from glucocorticoi!s '8 .ite$ location assessment$ catheter si9e !ate inserte! E/)osure to .un 1 Tanning be!s #b!ominal e/am$ Ten!er( )al)able masses( bowel soun!s (all ; Aua!rants)( soft1firm( .i9e1girth

P+#mona") s)stem ('nclu!e! in Car!io*ascular-)ulmonar %es)onses)

ACTIVITY/REST
S#ee( / Rest Subjective .lee) hours Na)s .lee) ai!s

'nsomnia$ (circle if a))lies)$ !ifficult falling aslee)( interru)te! slee)( earl awa+ening, E/)lain$ %este! u)on awa+ening Objective .lee)1%est obser*e! A,ti-it)/E.e",ise / Ene"&) /a#an,e Subjective 3ccu)ation ?imitations im)ose! b current con!ition #bilit to maintain usual routines "istor of fractures1!islocations #-?s$ 'n!e)en!ent= #-?s -e)en!ent= &obilit " giene Toileting Objective %es)onse to #cti*it (inclu!e )ulse( res) rate) 0eneral #))earance &uscle tone$ firm1har!1soft &uscle strength$ Coor!ination1tremors Posture .)astic1flacci! 0ait Contractures Coint )ain1bac+ )roblems #ssistance )ro*i!e! b $ 6ee!ing -ressing 3ther E/ercise "abits 6atigue #))earance

&uscle si9e$ h )ertro)h 1 atro)h %3& "igh ris+ for in4ur = Ca"*io-as,+#a"-(+#mona") Res(onses Subjective Ca"*io-as,+#a" "eart -isease 1 Phlebitis E/tremit wea+ness or numbness 1 col!ness .low healing -eformities

#n+le 1 leg or e/tremit e!ema %a)i! weight gain 1 loss (amount)

Objective /#oo* P"ess+"es0 ? ing .itting1.tan!ing Pulse -eficit 0enerali9e! e!ema local 1 general &ucous membranes -e)en!ent e!ema Ca)illar refill E/tremit color %ight ?eft P+#ses0 #)ical %a!ial Pe!al 3ther a))ro)riate )ulses Cugular *ein !istention .ensation of e/tremities E/tremit tem)erature %ight ?eft

.+in h !ration 1 turgor Color 1 c anosis )aral sis1 )ainD)assi*e mo*ement Res(i"ato") / Venti#ation Subjective %es)irator -isease (i!entif )

- )snea .)utum (amount( color( consistenc ) #mount -ecrease! e/ercise tolerance E rs

Cough (Pro!ucti*e1Non-)ro!ucti*e( triggers) 3ccu)ational1lifest le e/)osure to )articulates$ T )e 3/ gen use$ Objective %es), %ate %h thm Cough (moist( !r ( )ro!ucti*e) 2reath .oun!s$ T )e .)utum$ Color ?ocation #mount .)32 #ccessor &uscles Use ?iters1min >hen use!=

-e)th17ualit Nasal 6laring C anosis #!*entitious .oun!s$ T )e Consistenc

. mmetr of chest with res)irations

Pallor ?ocation

PERCEPTION/COGNITION
Attention / O"ientation/Co&nition Subjective %ea!iness for enhance! +nowle!ge E!ucation le*el .)ecial health care )ractices Objective 3rientation to time( )lace( )erson( F situation #ffect Thought )rocesses Coherenc 1)erce)tions &ental status %ea!iness to learn ?ong term 1 short term memor 1 recall Cu!gment 1 'nsight #ttention s)an #))ro)riateness -eficient <nowle!ge ?earning !isabilities <nowle!ge of illness1tests1surger

Sensation / Pe",e(tion Subjective "istor of .ei9ures( fainting s)ells1!i99iness "ea!aches ?ocation ?ocation 0lasses 1 "earing #i! -o the hel)= 6reAuenc

Tingling 1 Numbness 1 >ea+ness 8isual 1 "earing loss Objective 6acial grimace

Ph sical guar!ing

Emotional res)onse to )ain1!iscomfort$ Calm( #n/ious( #ngr ( >ith!rawn( 6earful( 'rritable( Eu)horic( 3ther E/)lain$ Change in *ital signs with )ain1!iscomfort Pu)il si9e1reaction (left( right) .enses$ .mell 6acial !roo) >ea+ness in e/tremities Comm+ni,ation Subjective Touch$ shar)1!ull hot 1 col! Taste$ .weet 1 sour sensations1!ifferentiation

Objective -oes the )atient communicate feelings( an/ieties( fears( nee!s etc,= ?anguages s)o+en$ -ifficult forming wor!s1sentences Clarit of s)eech1hoarseness -ifficult e/)ressing thoughts

SELF-PERCEPTION
Se#f-Con,e(t / Se#f-Esteem / /o*) Ima&e Subjective #n/iet 16ears Potential1#ctual losses %e)ort of stressors1financial concerns 6eelings of ho)elessness1 !iminishe! self esteem '!eation of *iolence to self1others 0rie*ing

Objective .cars -isfigurements #m)utations

Use of han!ica) ai!s$ wal+er( wheelchair( cane( etc,

ROLE RELATIONSHIPS
Ca"e&i-in& Ro#es / Fami#) Re#ations$i(s / Ro#e Pe"fo"man,e Subjective Primar caregi*er1s in care facilit an! when !ischarge! &arital status %ole in famil structure .u))ort )ersons

"ealth of significant other 3ther stress1concerns #bilit of significant other to )ro*i!e care 3ccu)ation %ecent changes in lifest le Objective 8isitors Communication between famil 1frien!s Pictures in room 'nteraction with others Change or conflict in role

SEXUALITY
Se.+a# I*entit) / Se.+a# F+n,tion/Re("o*+,tion Subjective .e/ualit concern 1 ! sfunction Fema#e ?ast &enstrual )erio! ?ength of c cle -uration &eno)ause 2lee!ing between )erio!s ?ast P#P smear

&etho! of 2irth Control if a))licable 8aginal !ischarge Practice breast self-e/am &etho! of birth control (if a))licable) 3b4ecti*e Fema#e Ma#e 2reast e/am (if a))ro)riate) 2reast E/am (if a))ro)riate)

Teaching )ro*i!e! Testicular e/am (if a))ro)riate)

COPING / STRESS TOLERANCE

Post-T"a+ma Res(onses / Co(in& Res(onses / Ne+"o-'e$a-io"a# Res(onses Subjective Percei*e! abilit to co)e T )ical wa s of co)ing Objective 2eha*iors that !emonstrate an/iet ( grie*ing( co)ing( fears 6ears .orrows 0rie*ing

LIFE PRINCIPLES
Va#+e / /e#ief / A,tion Con&"+en,e Subjective >hat !oes this )erson *alue in life= #bilit to )artici)ate in religious1s)iritual )ractices Cultural )ractices Concerns with life1!eath -ecision ma+ing abilit Usual )roblem sol*ing abilities Com)liance with health care regimes %eligious )reference1role of s)iritual )ractices 'm)ortant .)iritual )ractices .ource of ho)e an! comfort #wareness of #!*ance! !irecti*es

Objective #!*ance! -irecti*es note! in chart

SAFETY/PROTECTION
Infe,tion / P$)si,a# In1+") / Vio#en,e / En-i"onmenta# Ha2a"*s / Defensi-e P"o,esses / T$e"mo"e&+#ation Subjective c1o hot or col!G !esire for blan+ets Percei*e! ha9ar!s( in4uries( ina!eAuate immunit Objective Tem)erature1site Pers)iration %e!ness( swelling( heat( etc, Thermoregulation im)airment #llergies

#utoimmune !iseasesG brain in4ur G aging com)lications( *iolence( ha9ar!s %is+ for$ immobilit com)lications( falls( as)iration( )eri)heral neuro*ascular ! sfunction( h )ertensi*e state( blee!ing( h )ogl cemia( !isuse s n!rome( se!entar lifest le

COMFORT
P$)si,a# Comfo"t /En-i"onmenta# Comfo"t / So,ia# Comfo"t Subjective .ense of well being Pain0 ?ocation1%a!iation 6reAuenc #ggra*ating1)reci)itating factors 3ther !iscomfort (En*ironmental( .ocial) 3b4ecti*e #ccom)an ing s m)toms$ emesis( insomnia( lac+ of concentration( cr ing( other obser*e! beha*iors %es)onse to analgesic 6actors that influence )ain 'ntensit (:-:0) 7ualit -uration "ow %elie*e!

GROWTH/DEVELOPMENT
G"o%t$ / De-e#o(ment (Eri+son) >hat is e/)ecte! stage= >hat stage is )erson reall in= 'nclu!e all obser*ations about the )erson that hel)s ou ma+e this !ecision, Subjective

Objective #ttainment( loss of !e*elo)mental milestones ('f chil! use -en*er -e*elo)mental '' as reference) 6or the a!ult )atientDsee ob4ecti*e information regar!ing #!ult 6ailure to Thri*e in our nursing !iagnosis boo+,

Dis,$a"&e P#an Consi*e"ations

#ntici)ate! !ate of !ischarge$ -ischarge Teaching Pro*i!e! 6ollow-u) (!ate( )ro*i!er) 'f !ischarge! to home in!icate areas that ma reAuire assistance$ 6oo! )re)aration #-? assistance Trans)ortation1.ho))ing >oun! Care #mbulation "omema+er assistance EAui)ment &e!ication1'8 thera) Treatments -ischarge! to$ (home F1or agenc ) -ischarge 'nstructions

%esources a*ailable for care at home$ Persons "ome mo!ifications nee!e!$

Si&nifi,ant La'o"ato") an* Ra*io#o&) Data

Test 8alue Normal %ange Cause1.ignifiance