NANDA Nursing Diagnoses

Related to Activities and Exercise Patterns

Activity Intolerance
Risk for Activity Intolerance
Bathing/Hygiene Self-Care Deficit
Dressing/Grooming Self-Care Deficit
Impaired Bed Mobility
Risk for Disuse Syndrome
Deficient Diversional Activity
Fatigue
Risk for Falls
Impaired Home Maintenance
Impaired Physical Mobility
Impaired Wheelchair Mobility
Impaired Transfer Ability
Impaired Walking
Delayed Surgical Recovery
Decreased Cardiac Output
Ineffective Breathing Pattern
Ineffective Airway Clearance
Impaired Gas Exchange
Risk for Peripheral Neurovascular Dysfunction
Impaired Tissue Perfusion
Ineffective Tissue Perfusion
Impaired Spontaneous Ventilation
Dysfunctional Ventilatory Weaning Response

Related to Elimination Patterns

Bowel Incontinence
Constipation
Perceived Constipation
Risk for Constipation
Diarrhea
Impaired Urinary Elimination
Functional Urinary Incontinence
Reflex Urinary Incontinence
Stress Urinary Incontinence
Total Urinary Incontinence
Urge Urinary Incontinence
Risk for Urge Urinary Incontinence
Pereived Constipation
Urinary Retention
Self-Care Deficit: Toileting

Related to Nutrition and Metabolic Patterns

Risk for Aspiration
Risk for Imbalanced Body Temperature
Impaired Dentition
Feeding Self-Care Deficit
Fluid Volume Deficit
Fluid Volume Excess
Risk for Deficient Fluid Volume
Hyperthermia
Hypothermia
Risk for Infection
Impaired Oral Mucous Membranes
Nausea
Imbalanced Nutrition: Less than body requirements
Imbalanced Nutrition: More than body requirements
Impaired Skin Integrity
Risk for Impaired Skin Integrity
Impaired Swallowing
Ineffective Thermoregulation
Impaired Tissue Integrity
Risk for Trauma
Adult Failure to Thrive

Related to Cognitive Perceptual Patterns

Acute Confusion
Decreased Intracranial Adaptive Capacity
Autonomic Dysreflexia
Risk for Autonomic Dysreflexia
Chronic Confusion
Impaired Verbal Communication
Acute Pain
Chronic Pain
Impaired Memory
Unilateral Neglect
Risk for Peripheral Neurovascular Dysfunction
Risk for Post-Trauma Syndrome
Ineffective Protection
Disturbed Sensory Perception
Disturbed Thought Processes
Decisional Conflict
Risk for Trauma
Wandering
Unilateral Neglect
Impaired Environmental Interpretation Syndrome

Rlated to Sexuality-Reproductive Patterns

Rape-Trauma Syndrome
Sexual Dysfunction
Ineffective Sexuality Patterns

Related to Functional Health Petterns

Latex Allergy Response
Caregiver Role Strain
Chronic Sorrow
Compromised Family Coping
Death Anxiety
Anxiety
Decisional Conflict
Disturbed Body Image
Fatigue
Fear
Deficient Fluid Volume
Excess Fluid Volume
Ineffective Health Maintenance
Health-seeking Behaviors
Risk for infection
Deficient Knowledge
Nausea
Acute Pain
Chronic Pain
Risk for Injury
Powerlessness
Disturbed Personal Identity
Ineffective Protection
Delayed Surgical Recovery
Self-care Deficit
Low Se-festeem
Disturbed Sleep Pattern
Ineffective Therapeutic Regimen Management
Disturbed Through Process
Risk for Violence

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Communication in Nursing

" A person cannot not communicate"

1. Purpose

1) To establish nurse-patient relationship

2) To be effective in expressing interest/concern for patient/family

3) To provide health care information

2. Essential skills

1) Personal insight

2) Sensitivity

3) Knowledge of communication strategies

3. Definition

“ complex process of sending and receiving verbal and non-verbal messages. Allows for exchange of information, feelings, needs, and preferences”

Source/sender and receiver encode and decode message in a cyclic pattern.

4. Goal

Shared Meaning Mutual understanding of the meaning of the message Feedback/response indicates if the meaning of the message was communicated as intended:

5. Levels of communication

1) Social: safe

2) Structured: interviewing, teaching

3) Therapeutic: patient focused, purposeful, time limited Nurse comes to know the patient as a unique individual. Patient comes to trust nurse Context set for nurse to provide care and to help patient identify, resolve, or adapt to health problems

6. Types of Communication

1) Verbal :

conscious use of spoken or written word Choice of words can reflect age, education, developmental level, culture Feelings can be expressed through tone, pace, etc. Characteristics: simple, brief, clear, well timed, relevant, adaptable, credible

2) Non-verbal :

a. use of gestures, expressions, behaviors (body language)

b. 85% of communication

c. Less conscious than verbal

d. Requires systematic observation and valid interpretation

e. Nurse must be aware of personal style

f. How we communicate non-verbally:

physical appearance, posture/gait, facial expressions, gestures, touch (tactile defensiveness)

7. Relationship between verbal and non-verbal communication

Congruency: are verbal and non-verbal messages consistent?

Nurse states observations and validates with patient

Nurse to crying patient: "You seem upset today."

Patient: "I'm fine thanks."

8. Factors that affect communication

Nurse needs to assess and consider when communicating with patient:

“culture, developmental level, physical & psychological barriers, personal space (proxemics), territoriality, roles and relationships, environment, attitudes and values, level of self esteem”

9. Communication Strategies:

1) Active Listening is most critical strategy

2) Strategies that encourage Conversation and Elaboration:

broad opening statements, general leads, reflecting, open-ended and directing questions

3) Strategies that help patient express thoughts and feelings:

stating observations, acknowledging feelings, reflecting, using silence

4) Strategies that insure mutual understanding:

clarifying, validating, verbalizing implied thoughts and feelings, focusing, using closed questions and summary statements

10. Blocks/Barriers to Communication:

Behaviors or comments of the nurse that have a negative effect:

1) Not Listening is most harmful behavior!

reassuring cliches, giving advice, expressing approval/disapproval, requesting an explanation (asking why?), defending, belittling feelings, stereotyped comments, changing the subject

2) Reporting and Documenting

v Reporting: oral, written, or computer account of patient status; between members of health care team. Report should be clear, concise, and comprehensive.

v Documenting: patient record/chart provides written documentation of patient’s status and treatment

v Purpose: continuity of care, legal documentation, research, statistics, education, audits

3) Patient Privacy: Related terms

v Confidential Information: is specific to patients, their diagnosis and treatment.

v Privacy: refers to the patient’s right to control access to confidential information.

v Confidentiality: refers to the professional responsibility to protect patient privacy.

v Need to Know: who has access to what information.

4) Protection of Patient Privacy

Health Insurance Portability and Accountability Act (HIPAA)

Federal guidelines: effective April, 2003

1. Prohibit disclosure for reasons unrelated to health services.

2. Set civil and criminal penalties for violators.

3. Give patients the right to inspect and copy their records.

4. Require providers to notify patients of privacy policies.

11. Legal Concerns :

Record/chart is a legal document; may be admissable in court

If it’s not documented, it didn’t happen!

1) What to document: If it’s not documented, it didn’t happen!

assessment, plan of care, nursing interventions (care, teaching, safety measures), outcome of care, change in status, health care team communication, how the nurse left the patient

2) How to document:

- Use ink

- Write legibly

- Spell correctly

- Use standard abbreviations

- Date, time, chronological order

- Errors and blanks

- Signature and title

3) Characteristics of documentation:

brief, concise, comprehensive, factual, descriptive, objective, relevant/appropriate, legally prudent

4) Types of documentation: Based on how record is organized

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