Nursing Diagnoses Organized According to Diagnostic Divisions (continued)

Elimination—ability to excrete waste products
• Bowel Incontinence
• Constipation
• Constipation, perceived
• Constipation, risk for
• Diarrhea
• Motility, dysfunctional gastrointestinal
• Motility, risk for dysfunctional gastrointestinal
• Urinary Elimination, impaired
• Urinary Elimination, readiness for enhanced
• Urinary Incontinence, functional
• Urinary Incontinence, overflow
• Urinary Incontinence, reflex
• Urinary Incontinence, stress
• Urinary Incontinence, urge
• Urinary Incontinence, risk for urge
• Urinary Retention [acute/chronic]

Food/Fluid—ability to maintain intake of and utilize nutrients and liquids to meet physiological needs
• Breastfeeding, effective
• Breastfeeding, ineffective
• Breastfeeding, interrupted
• Dentition, impaired
• Electrolyte Imbalance, risk for
• Failure to Thrive, adult

• Feeding Pattern, ineffective infant
• Fluid Balance, readiness for enhanced
• [Fluid Volume, deficient hypertonic or hypotonic]
• Fluid Volume, deficient [isotonic]
• Fluid Volume excess
• Fluid Volume, risk for deficient
• Fluid Volume, risk for imbalanced
• Glucose Level, risk for unstable blood
• Liver Function, risk for impaired
• Nausea
• Nutrition: less than body requirements, imbalanced
• Nutrition: more than body requirements, imbalanced
• Nutrition: more than body requirements, risk for imbalanced
• Nutrition, readiness for enhanced
• Oral Mucous Membrane, impaired
• Swallowing, impaired

Hygiene—ability to perform activities of daily living
• Neglect, self
• Self-Care, readiness for enhanced
• Self-Care Deficit: bathing
• Self-Care Deficit: dressing
• Self-Care Deficit: feeding
• Self-Care Deficit: toileting

Neurosensory—ability to perceive, integrate, and respond to internal and external cues
• Confusion, acute
• Confusion, risk for acute
• Confusion, chronic
• Infant Behavior, disorganized
• Infant Behavior, risk for disorganized
• Infant Behavior, readiness for enhanced organized
• Memory, impaired
• Neglect, unilateral
• Peripheral Neurovascular Dysfunction, risk for
• Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)
• Stress Overload
• [Thought Processes, disturbed]

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Nursing Diagnoses Organized According to Diagnostic Divisions

Activity/Rest—ability to engage in necessary or desired activities of life (work and leisure) and to obtain adequate sleep and rest

• Activity Intolerance
• Activity Intolerance, risk for
• Activity Planning, ineffective
• Disuse Syndrome, risk for
• Diversional Activity, deficient
• Fatigue
• Insomnia
• Lifestyle, sedentary
• Mobility, impaired bed
• Mobility, impaired wheelchair
• Sleep, readiness for enhanced
• Sleep Deprivation
• Sleep Pattern, disturbed
• Transfer Ability, impaired
• Walking, impaired

Circulation—ability to transport oxygen and nutrients necessary to meet cellular needs

• Autonomic Dysreflexia
• Autonomic Dysreflexia, risk for
• Bleeding, risk for
• Cardiac Output, decreased
• Intracranial Adaptive Capacity, decreased
• Perfusion, ineffective peripheral tissue
• Perfusion, risk for decreased cardiac tissue
• Perfusion, risk for ineffective cerebral tissue
• Perfusion, risk for ineffective gastrointestinal
• Perfusion, risk for ineffective renal
• Shock, risk for

Ego Integrity—ability to develop and use skills and behaviors to integrate and manage life experiences

• Anxiety [specify level]
• Anxiety, death
• Behavior, risk-prone health
• Body Image, disturbed
• Conflict, decisional (specify)
• Coping, defensive
• Coping, ineffective
• Coping, readiness for enhanced
• Decision Making, readiness for enhanced
• Denial, ineffective
• Dignity, risk for compromised human
• Distress, moral
• Energy Field, disturbed
• Fear
• Grieving
• Grieving, complicated
• Grieving, risk for complicated
• Hope, readiness for enhanced
• Hopelessness
• Identity, disturbed personal
• Post-Trauma Syndrome
• Post-Trauma Syndrome, risk for
• Power, readiness for enhanced
• Powerlessness
• Powerlessness, risk for
• Rape-Trauma Syndrome
• Relationships, readiness for enhanced
• Religiosity, impaired
• Religiosity, risk for impaired
• Religiosity, readiness for enhanced
• Relocation Stress Syndrome
• Relocation Stress Syndrome, risk for
• Resilience, impaired individual
• Resilience, readiness for enhanced
• Resilience, risk for compromised
• Self-Concept, readiness for enhanced
• Self-Esteem, chronic low
• Self-Esteem, situational low
• Self-Esteem, risk for situational low
• Sorrow, chronic
• Spiritual Distress
• Spiritual Distress, risk for
• Spiritual Well-Being, readiness for enhanced

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Nursing Diagnoses : Activity Intolerance

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Related Factors
Generalized weakness
Sedentary lifestyle
Bedrest or immobility
Imbalance between oxygen supply and demand
[Cognitive deficits/emotional status; secondary to underlying disease process/depression]
[Pain, vertigo, extreme stress]

Characteristics
SUBJECTIVE
Report of fatigue or weakness
Exertional discomfort or dyspnea
[Verbalizes no desire and/or lack of interest in activity]
OBJECTIVE
Abnormal heart rate or blood pressure response to activity
Electrocardiographic changes reflecting dysrhythmias or ischemia [pallor, cyanosis]

Functional Level Classification:
Level I: Walk, regular pace, on level indefinitely; one flight or more but more short of breath than normally
Level II: Walk one city block [or] 500 ft on level; climb one flight slowly without stopping
Level III: Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping
Level IV: Dyspnea and fatigue at rest

source : Nurse’s Pocket Guide : Diagnoses, Prioritized Interventions, and Rationales
download : link

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Nursing Diagnoses for Planning Care

Nurses and healthcare consumers agree that nursing care is a key factor in achieving positive outcomes and enhancing client satisfaction. Nursing care is instrumental in all phases of acute care as well as in the maintenance of general wellbeing (prevention of illness, rehabilitation, and maximization of health), or where a return to health is not possible, the relief of pain and discomfort and a peaceful death. To this end, the nursing profession has identified a problem-solving process that “combines the most desirable elements of the art of nursing with the most relevant elements of systems theory, using the scientific method”.

The original concept of nursing process was a three-step process of assessment, planning, and evaluation based on the scientific method of observing, measuring, gathering data, and analyzing the findings. After years of study, use, and refinement, the three-step process was expanded. The five steps—(1) assessment, (2) problem identification, (3) planning, (4) implementation (putting the plan into action), and (5) evaluation (assessing the effectiveness of the plan and changing the plan as indicated by current needs)—are central to nursing actions and the delivery of high-quality, individualized client care in any setting.

In 1991, the ANA Standards of Clinical Nursing Practice described the client care process and standards for professional performance, providing impetus and support for the use of nursing diagnosis in the practice setting. The work of NANDA International (formerly North American Nursing Diagnosis Association) has been ongoing for more than 25 years, beginning with efforts to identify client problems/needs for which nurses are accountable. NANDA continues to develop nursing diagnostic labels, which are now being complemented by the Iowa Intervention Project: Nursing Interventions Classification (NIC) and the Iowa Outcomes Project: Nursing Outcomes Classification (NOC). NIC directs our focus to the content and process of nursing care by identifying and standardizing the care activities nurses perform while NOC describes client outcomes that are responsive to nursing intervention and developing corresponding measurement scales.

Changes in the healthcare system continue to occur, requiring the profession of nursing to define itself in a way that will complement and facilitate the provision of appropriate, cost-effective evidenced-based care to all persons. Nurses need a common framework of communication and documentation so their contribution to healthcare is recognized as being essential and they are remunerated appropriately. At the very least, nursing requires a commonality of words describing practice so it can be captured and is visible in the healthcare databases.

The linkage of nursing diagnoses to specific nursing interventions and client outcomes has led to the development of a number of standardized nursing languages (Omaha System, Clinical Care Classification, Ozbolt Patient Care Data Set, Perioperative Minimum Data Set). The purpose of these languages is to help ensure continuity of appropriate highquality nursing care for the client regardless of setting. This is accomplished in part through enhanced communication, standardization of the process evaluating the care provided, and facilitation of documentation.

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