Nursing Process

Record
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New Nursing
Diagnoses
Seventeen new diagnoses were approved by the
Diagnosis Development Committee, the NANDA-I
Board of Directors, and the NANDA-I membership.
New Nursing Diagnoses
Domain 1: Health Promotion
• Readiness for enhanced health literacy ( all patients
need to be literate)
Class 1: Health awareness
New Nursing Diagnoses
Domain 2: Nutrition
• Ineffective adolescent eating dynamics
Class 1: Ingestion
• Ineffective child eating dynamics
Class 1: Ingestion
• Ineffective infant eating dynamics
Class 1: Ingestion
• Risk for metabolic imbalance syndrome
Class 4: Metabolism
New Nursing Diagnoses
Domain 4: Activity/Rest
• Imbalanced energy field
Class 3: Energy balance
• Risk for unstable blood pressure
Class 4: Cardiovascular/pulmonary responses
New Nursing Diagnoses
Domain 9: Coping/Stress Tolerance
• Risk for complicated immigration transition
Class 1: Post-trauma responses
• Neonatal abstinence syndrome
Class 3: Neurobehavioral stress
• Acute substance withdrawal syndrome
Class 3: Neurobehavioral stress
• Risk for acute substance withdrawal syndrome
Class 3: Neurobehavioral stress
New Nursing Diagnoses
Domain 11: Safety/Protection
• Risk for surgical site infection
Class 1: Infection
• Risk for dry mouth
Class 2: Physical injury
• Risk for venous thromboembolism
Class 2: Physical injury
• Risk for female genital mutilation
Class 3: Violence
• Risk for occupational injury
Class 4: Environmental hazards
• Risk for ineffective thermoregulation
Class 6: Thermoregulation
Revised Nursing Diagnoses (Revised
NANDA-I Nursing Diagnoses, 2018-2020)
• Seventy-two diagnoses were revised during this cycle.
• Defining Characteristics removed, added; Related to/Risk
factors removed, added
Retired Nursing Diagnosis
These diagnoses were inconsistent with the current literature, or lacked
sufficient evidence to support their continuation within the terminology.

 Risk for disproportionate growth

 Noncompliance
 Readiness for enhanced fluid balance
 Readiness for enhanced urinary elimination
 Risk for impaired cardiovascular function
 Risk for ineffective gastrointestinal perfusion
 Risk for ineffective renal perfusion
 Risk for imbalanced body temperature
Revisions to Nursing Diagnosis Labels
• Changes were made to 11 nursing diagnosis labels. These changes were
made to ensure that the diagnostic label was consistent with current
literature, and reflected a human response.
Revisions to Nursing Diagnosis Labels
Previous diagnostic label
Deficient diversional activity
Insufficient breast milk
Neonatal jaundice
Risk for neonatal jaundice
Impaired oral mucous membrane
Risk for impaired oral mucous membrane
Risk for sudden infant death syndrome
Risk for trauma
Risk for allergy response
Latex allergy response
Risk for latex allergy response
New diagnostic label
Decreased diversional activity engagement
Insufficient breast milk production
Neonatal hyperbilirubinemia
Risk for hyperbilirubinemia
Impaired oral mucous membrane integrity
Risk for impaired oral mucous membrane
integrity
Risk for sudden infant death
Risk for physical trauma
Risk for allergic reaction
Latex allergic reaction
Risk for latex allergic reaction
Nursing Diagnosis Basics
Each health profession has a
way to describe “what” the
profession knows and “how” it
acts on what it knows.
• The NANDA-I taxonomy provides a way
to classify and categorize areas of
concern to the nursing professional (i.e.,
diagnostic foci). It contains 244 nursing
diagnoses grouped into 13 domains and
47 classes
•A nursing diagnosis can be
problem-focused, a state
of health promotion, or a
potential risk.
• Problem-focused diagnosis—a
clinical judgment concerning an
undesirable human response to a
health condition/life process that
exists in an individual, family, group,
or community
• Risk diagnosis—a clinical judgment
concerning the susceptibility of an
individual, family, group, or community
for developing an undesirable human
response to health conditions/life
processes
• Health promotion diagnosis—a clinical
judgment concerning motivation and desire to
increase well-being and to actualize health
potential. These responses are expressed by a
readiness to enhance specific health behaviors,
and can be used in any health state. Health
promotion responses may exist in an individual,
family, group, or community.
 How does a Nurse
(or Nursing Student)
Diagnose?
Understanding Nursing Concepts
• Knowledge of key concepts, or nursing
diagnostic foci, is necessary before
beginning an assessment.

*Examples of critical concepts important to nursing

practice include breathing, elimination, thermoregulation,
physical comfort, selfcare, and skin integrity.
• Understanding such concepts allows the nurse to
see patterns in the data and accurately diagnose.
Key areas to understand within the concept of
pain, for example, include manifestations of
pain, theories of pain, populations at risk,
related pathophysiological concepts (fatigue,
depression), and management of pain.
Full understanding of key concepts is needed,
as well, to differentiate diagnoses.
*For example, to understand issues related to respiration, a nurse must
first understand the core concepts of ventilation, gas exchange, and
breathing pattern.
• In looking at problems that can occur with regard to ventilation, the
nurse will be faced with the diagnoses of impaired spontaneous
ventilation (00033) and dysfunctional ventilatory weaning response
(00034).
• Concerns with gas exchange may lead the nurse to the diagnosis of
impaired gas exchange (00030), while issues related to breathing
pattern might lead to a diagnosis of ineffective breathing pattern
(00032).
Assessment
• Assessment involves the collection of subjective and objective data (e.g.,
vital signs, patient/family interview, physical exam) and review of
historical information provided by the patient/family, or found within the
patient chart.
• Nurses also collect data on patient/family strengths (to identify health
promotion opportunities) and risks (to prevent or postpone potential
problems).
• Assessments can be based on a specific nursing theory, such as one
developed by Florence Nightingale, Wanda Horta, or Sr. Callista Roy, or on
a standardized assessment framework such as Marjory Gordon's
Functional Health Patterns.
Nursing Diagnosis
• A nursing diagnosis is a clinical judgment concerning a human
response to health conditions/life processes, or vulnerability
for that response, by an individual, family, group, or community
(NANDA-I 2013).
• A nursing diagnosis typically contains two parts: (1) descriptor
or modifier and (2) focus of the diagnosis or the key concept of
the diagnosis.
• Problem-focused diagnoses should not be viewed as more
important than risk diagnoses. Sometimes a risk diagnosis can
be the diagnosis with the highest priority for a patient.
Modifier Focus of the diagnosis
Ineffective Breathing pattern
Risk for Constipation
Deficient Fluid volume
Impaired Skin integrity
Readiness for enhanced Resilience
It is critical that nurses know the definitions of
the diagnoses they most commonly use.

They need to know the “diagnostic indicators”— the

information that is used to diagnose and differentiate
one diagnosis from another.
These diagnostic indicators include defining
characteristics and related factors or risk factors.

• Defining characteristics are observable

cues/inferences that cluster as manifestations of a
diagnosis (e.g., signs or symptoms). An assessment that
identifies the presence of a number of defining
characteristics lends support to the accuracy of the
nursing diagnosis.
• Related factors are an integral component of all
problem-focused nursing diagnoses. Related factors are
etiologies, circumstances, facts, or influences that have
some type of relationship with the nursing diagnosis
(e.g., cause, contributed factor). A review of client
history often helps to identify related factors.
Whenever possible, nursing interventions should be
aimed at these etiological factors in order to remove
the underlying cause of the nursing diagnosis.
• Risk factors are influences that increase the
vulnerability of an individual, family, group, or
community to an unhealthy event (e.g.,
environmental, psychological, genetic).
• A nursing diagnosis does not need to
contain all types of diagnostic indicators
(i.e., defining characteristics, related
factors, and/or risk factors).
• Problem-focused nursing diagnoses contain
defining characteristics and related factors.
• Health promotion diagnoses generally have only
defining characteristics, although related factors
may be used if they might improve the
understanding of the diagnosis.
• Only risk diagnoses have risk factors.
• A common format used when learning
nursing diagnosis includes _____ [nursing
diagnosis] related to ______ [cause/related
factors] as evidenced by ____________
[symptoms/defining characteristics].
• For example, caregiver role strain related to
around-the-clock care responsibilities, complexity
of care activities, and unstable health condition of
the care receiver as evidenced by difficulty
performing required tasks, preoccupation with
care routine, fatigue, and alteration in sleep
pattern.
Planning/Intervention
• Once diagnoses are identified, prioritizing of selected
nursing diagnoses must occur to determine care
priorities.
• The Nursing Outcome Classification (NOC) is one system that
can be used to select outcome measures related to a nursing
diagnosis.
– Nurses often, and incorrectly, move directly from nursing diagnosis to
nursing intervention without consideration of desired outcomes.
– Instead, outcomes need to be identified before interventions are
determined.

• The Nursing Interventions Classification (NIC) is one taxonomy

of interventions that nurses may use across various care
settings.
Evaluation
• A nursing diagnosis “provides the basis for selection of
nursing interventions to achieve outcomes for which
nursing has accountability” (NANDA-I 2013).
The NANDA-I taxonomy was developed
based on Gordon's work; that is why the
two frameworks look similar.
13 Domains
Domain 1: Health Promotion Domain 2: Nutrition
• Health Awareness • Ingestion
• Health Management • Digestion
• Absorption
• Metabolism
• Hydration
13 Domains
Domain 3: Elimination/Exchange Domain 4: Activity/Rest
• Urinary function • Sleep/Rest
• Gastrointestinal function • Activity/Exercise
• Integumentary function • Energy balance
• Respiratory function • Cardiovascular/Pulmonary
responses
• Self-care
13 Domains
Domain 5: Perception/Cognition Domain 6: Self-Perception
• Attention • Self-concept
• Orientation • Self-esteem
• Sensation/Perception • Body image
• Cognition
• Communication
13 Domains
Domain 7: Role Relationship
• Caregiving roles
• Family relationships
• Role performance
Domain 8: Sexuality
• Sexual identity
• Sexual function
• Reproduction
13 Domains
Domain 9: Coping/Stress Domain 10: Life Principles
Tolerance
• Values
• Post-trauma responses
• Beliefs
• Coping responses
• Value/Belief/Action congruence
• Neuro-behavioral stress
13 Domains
Domain 11: Safety/Protection Domain 12: Comfort
• Infection • Physical comfort
• Physical injury • Environmental comfort
• Violence • Social comfort
• Environmental hazards
• Defensive processes
• Thermoregulation
13 Domains
Domain 13:
Growth/Development
• Growth
• Development
• “PES” is an acronym that stands for problem,
etiology (related factors), and signs/symptoms
(defining characteristics).
• The component parts of NANDA-I diagnoses are
now referred to as related factors and defining
characteristics, and therefore the wording “PES
format” is not used in current NANDA-I books.
• Problem-Focused Diagnosis. To use the PES format, start
with the diagnosis itself, followed by the etiologic factors
(related factors in a problem-focused diagnosis).
Ex: Impaired parenting related to insufficient cognitive
readiness for parenting and young parental age (related
factors) as evidenced by deficient parent – child
interaction, perceived role inadequacy, and
inappropriate care-taking skills (defining
characteristics).
• Risk Diagnosis. For risk diagnoses, there are no
related factors (etiological factors), since you are
identifying a vulnerability in a patient for a potential
problem; the problem is not yet present.
Ex: Risk for caregiver role strain as evidenced by
unpredictability of illness trajectory and caregiving task
complexity (risk factors).
• Health Promotion Diagnosis. Because health
promotion diagnoses do not require a related
factor, there may be no “related to” in the writing
of this diagnosis.
Ex: Readiness for enhanced sleep as evidenced by
expressed desire to enhance sleep.
NURSING OUTCOMES CLASSIFICATION
• Standardized terminology for nursing-sensitive
outcomes for use by nurses across specialties
and practice settings to capture changes in
patient status after intervention.
• Outcome – variable concepts that can be
measured along a continuum using a
measurement scale(s)
Measurement of an Outcome
• A five-point Likert type scale is used with all
outcomes and indicators providing an adequate
number of options to demonstrate variability in
the state, behavior, or perception described by
the outcome
NURSING INTERVENTIONS
CLASSIFICATION
• Comprehensive standardized classification of interventions that nurses
perform.
• Include interventions for physiological, psychosocial, illness treatment,
illness prevention, and health promotion.
• 554 interventions and 13,000 activities