, INDEX OF DISEASES/DISORDERS
Acid-base imbalances Gastrectomy/gastric resection, 317 Pediatric considerations, 890
respiratory, 195 Gastric bypass, 396 Peritoneal dialysis, 570
metabolic, 483 Gastric partitioning, 396 Peritonitis, 349
AIDS, 709 Gastroplasty, 396 Pernicious anemia, 493
Alcohol: acute withdrawal, 819 Glaucoma, 204 Pneumonia, 131
Alzheimer’s disease, 764 Graves’ disease, 419 Pneumothorax, 154
Amputation, 646 Primary base bicarbonate deficiency, 483
Anemia–iron deficiency, anemia of chronic Heart failure: chronic, 48 Primary base bicarbonate excess, 488
disease, pernicious, aplastic, hemolytic, 493 Hemodialysis, 575 Primary carbonic acid deficit, 200
Angina (coronary artery disease, acute coronary Hemolytic anemia, 493 Primary carbonic acid excess, 195
syndrome), 64 Hemothorax, 154 Prostatectomy, 596
Anorexia nervosa, 369 Hepatitis, 434 Psychosocial aspects of care, 749
Aplastic anemia, 493 Herniated nucleus pulposus (ruptured invertebral Pulmonary emboli considerations, 111
Appendectomy, 344 disc), 254 Pulmonary tuberculosis, 186
Asthma, 120 HIV-positive client, 697
Hospice, 866 Radical neck surgery: laryngectomy
Bariatric surgery, 396 Hypercalcemia (calcium excess), 927 (postoperative care), 160
Benign prostatic hyperplasia, 588 Hyperkalemia (potassium excess), 921 Renal calculi, 603
Bulimia nervosa, 369 Hypermagnesemia (magnesium excess), 932 Renal dialysis, 560
Burns: thermal, chemical, and electrical—acute Hypernatremia (sodium excess), 915 Renal failure: acute, 536
and convalescent phases, 667 Hypertension: severe, 37 Renal failure: chronic, 548
Hyperthyroidism (Graves’ disease, Respiratory acid-base imbalances, 195
Cancer, 846 thyrotoxicosis), 419 Respiratory acidosis (primary carbonic acid
Cardiac surgery: postoperative care, 100 Hypervolemia (extracellular fluid volume excess), 195
Cardiomyoplasty, 100 excess), 905 Respiratory alkalosis (primary carbonic acid
Cerebrovascular accident/stroke, 238 Hypocalcemia (calcium deficit), 924 deficit), 200
Chemical burns, 667 Hypokalemia (potassium deficit), 918 Rheumatoid arthritis, 729
Cholecystectomy, 364 Hypomagnesemia (magnesium deficit), 930 Ruptured invertebral disc, 254
Cholecystitis with cholelithiasis, 357 Hyponatremia (sodium deficit), 914
Cholelithiasis, 357 Hypovolemia (extracellular fluid volume Seizure disorders, 210
Chronic obstructive pulmonary disease, 120 deficit), 908 Sepsis, 686
Cirrhosis of the liver, 445 Hysterectomy, 611 Septicemia, 686
Colostomy, 334 Sickle cell crisis, 503
Coronary artery bypass graft, 100 Ileostomy, 334 Spinal cord injury (acute rehabilitative phase),
Coronary artery disease, 64 Inflammatory bowel disease: ulcerative colitis, 271
Craniocerebral trauma–acute rehabilitative Crohn’s disease, 321 Stroke, 238
phase, 220 Iron deficiency anemia, 493 Substance dependence/abuse rehabilitation, 835
Crohn’s disease, 321 Surgical intervention, 782
Laminectomy, 262
Deep vein thrombosis, 111 Laryngectomy (postoperative care), 160 Thermal burns, 667
Dementia (Alzheimer’s type or vascular), 764 Leukemias, 516 Thrombophlebitis: deep vein thrombosis (including
Diabetes mellitus/diabetic ketoacidosis, 405 Lung cancer: postoperative care, 144 pulmonary emboli considerations), 111
Diabetic ketoacidosis, 405 Lymphomas, 525 Thyroidectomy, 429
Disaster considerations, 876 Thyrotoxicosis, 419
Disc surgery, 262 Mastectomy, 619 Total joint replacement, 655
Dysrthymias , 88 Metabolic acid-base imbalances, 483 Total nutritional support: parenteral/enteral
Metabolic acidosis—primary base bicarbonate feeding, 469
Eating disorders: anorexia nervosa/bulimia deficiency, 483 Transplantation considerations—postoperative
nervosa, 369 Metabolic alkalosis—primary base bicarbonate and lifelong, 739
Eating disorders: obesity, 387 excess, 488 Tuberculosis, pulmonary, 186
Electrical burns, 667 Minimally invasive direct coronary artery
End-of-life care/hospice, 866 bypass, 100 Ulcerative colitis, 321
Enteral feeding, 469 Multiple sclerosis, 290 Upper gastrointestinal/esophageal bleeding, 306
Esophageal bleeding, 306 Myocardial infarction, 74 Urinary diversions/urostomy (postoperative
Extended care, 801 care), 578
Obesity, 387 Urolithiasis (renal calculi), 603
Fecal diversions: postoperative care of ileostomy Obesity: bariatric surgery–gastric partitioning/ Urostomy, 578
and colostomy, 334 gastroplasty, gastric bypass, 396
Fluid and electrolyte imbalances, 903 Valve replacement, 100
Fluid and electrolyte imbalances, 903 Pancreatitis, 458 Vascular dementia, 764
Fractures, 632 Parenteral feeding, 469 Ventilatory assistance (mechanical), 173
, KEY TO ESSENTIAL TERMINOLOGY
Client Assessment Database
Provides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical
and/or surgical diagnosis as well as the signs and symptoms and corresponding diagnostic findings.
Nursing Priorities
Establishes a general ranking of needs and concerns on which the Nursing Diagnoses are ordered in constructing the plan of
care. This ranking would be altered according to the individual client situation.
Discharge Goals
Identifies generalized statements that could be developed into short-term and intermediate goals to be achieved by the client
before being “discharged” from nursing care. They may also provide guidance for creating long-term goals for the client to
work on after discharge.
Nursing Diagnosis
The general need or problem (diagnosis) is stated without the distinct cause and signs and symptoms, which would be added
to create a client diagnostic statement when specific client information is available. For example, when a client displays
increased tension, apprehension, quivering voice, and focus on self, the nursing diagnosis of Anxiety might be stated: severe
Anxiety related to unconscious conflict, threat to self-concept as evidenced by statements of increased tension, apprehension;
observations of quivering voice, focus on self.
In addition, diagnoses identified within these guides for planning care as actual or risk can be changed or deleted and
new diagnoses added, depending entirely on the specific client information.
May Be Related to/Possibly Evidenced by
These lists provide the usual or common reasons (etiology) why a particular need or problem may occur with probable signs
and symptoms, which would be used to create the “related to” and “evidenced by” portions of the client diagnostic statement
when the specific situation is known.
When a risk diagnosis has been identified, signs and symptoms have not yet developed and therefore are not included in
the nursing diagnosis statement. However, interventions are provided to prevent progression to an actual problem. The excep-
tion to this occurs in the nursing diagnosis risk for Violence, which has possible indicators that reflect the client’s risk status.
Desired Outcomes/Evaluation Criteria—Client Will
These give direction to client care as they identify what the client or nurse hopes to achieve. They are stated in general terms
to permit the practitioner to modify or individualize them by adding time lines and specific client criteria so they become
“measurable.” For example, “Client will appear relaxed and report anxiety is reduced to a manageable level within 24 hours.”
Nursing Outcomes Classification (NOC) labels are also included. The outcome label is selected from a standardized
nursing language and serves as a general header for the outcome indicators that follow.
Actions/Interventions
Nursing Interventions Classification (NIC) labels are drawn from a standardized nursing language and serve as a general
header for the nursing actions that follow.
Nursing actions are divided into independent—those actions that the nurse performs autonomously; and collaborative—
those actions that the nurse performs in conjunction with others, such as implementing physician orders. The interventions in
this book are generally ranked from most to least common. When creating the individual plan of care, interventions would nor-
mally be ranked to reflect the client’s specific needs and situation. In addition, the division of independent and collaborative is
arbitrary and is actually dependent on the individual nurse’s capabilities and hospital and community standards.
Rationale
Although not commonly appearing in client plans of care, rationale has been included here to provide a pathophysiological
basis to assist the nurse in deciding about the relevance of a specific intervention for an individual client situation.
Clinical Pathway
This abbreviated plan of care or care map is event- or task-oriented and provides outcome-based guidelines for goal achieve-
ment within a designated length of stay. Several samples have been included to demonstrate alternative planning formats.
, NURSING DIAGNOSES ACCEPTED FOR
USE AND RESEARCH FOR 2009–2011
Activity Intolerance [specify level] Fluid Volume, risk for imbalanced (Rape-Trauma Syndrome: silent reaction—retired
Activity Intolerance, risk for Gas Exchange, impaired 2009)
Activity Planning, ineffective Glucose Level, risk for unstable blood Relationship, readiness for enhanced
Airway Clearance, ineffective Grieving Religiosity, impaired
Allergy Response, latex Grieving, complicated Religiosity, risk for impaired
Allergy Response, risk for latex Grieving, risk for complicated Religiosity, readiness for enhanced
Anxiety [specify level] Growth, risk for disproportionate Relocation Stress Syndrome
Anxiety, death Growth and Development, delayed Relocation Stress Syndrome, risk for
Aspiration, risk for Health Maintenance, ineffective Resilience, impaired individual
Attachment, risk for impaired Health Management, ineffective self [formerly Resilience, readiness for enhanced
Autonomic Dysreflexia Therapeutic Regimen Management, ineffective] Resilience, risk for compromised
Autonomic Dysreflexia, risk for Health Management, readiness for enhanced self Role Performance, ineffective
Behavior, risk-prone health [formerly Therapeutic Regimen Management, Self-Care, readiness for enhanced
Bleeding, risk for readiness for enhanced] Self-Care Deficit: bathing
Body Image, disturbed Home Maintenance, impaired Self-Care Deficit: dressing
Body Temperature, risk for imbalanced Hope, readiness for enhanced Self-Care Deficit: feeding
Bowel Incontinence Hopelessness Self-Care Deficit: toileting
Breastfeeding, effective Hyperthermia Self-Concept, readiness for enhanced
Breastfeeding, ineffective Hypothermia Self-Esteem, chronic low
Breastfeeding, interrupted Identity, disturbed personal Self-Esteem, situational low
Breathing Pattern, ineffective Immunization Status, readiness for enhanced Self-Esteem, risk for situational low
Cardiac Output, decreased Infant Behavior, disorganized Self-Mutilation
Caregiver Role Strain Infant Behavior, readiness for enhanced organized Self-Mutilation, risk for
Caregiver Role Strain, risk for Infant Behavior, risk for disorganized Sensory Perception, disturbed (specify: visual,
Childbearing Process, readiness for enhanced Infection, risk for auditory, kinesthetic, gustatory, tactile, olfactory)
Comfort, impaired Injury, risk for Sexual Dysfunction
Comfort, readiness for enhanced Injury, risk for perioperative positioning Sexuality Pattern, ineffective
Communication, impaired verbal Insomnia Shock, risk for
Communication, readiness for enhanced Intracranial Adaptive Capacity, decreased Skin Integrity, impaired
Conflict, decisional Jaundice, neonatal Skin Integrity, risk for impaired
Conflict, parental role Knowledge, deficient [Learning Need] [specify] Sleep, readiness for enhanced
Confusion, acute Knowledge [specify], readiness for enhanced Sleep Deprivation
Confusion, risk for acute Lifestyle, sedentary Sleep Pattern, disturbed
Confusion, chronic Liver Function, risk for impaired Social Interaction, impaired
Constipation Loneliness, risk for Social Isolation
Constipation, perceived Maternal/Fetal Dyad, risk for disturbed Sorrow, chronic
Constipation, risk for Memory, impaired Spiritual Distress
Contamination Mobility, impaired bed Spiritual Distress, risk for
Contamination, risk for Mobility, impaired physical Spiritual Well-Being, readiness for enhanced
Coping, defensive Mobility, impaired wheelchair Stress Overload
Coping, ineffective Motility, dysfunctional gastointestinal Suffocation, risk for
Coping, readiness for enhanced Motility, risk for dysfunctional gastointestinal Suicide, risk for
Coping, ineffective community Nausea Surgical Recovery, delayed
Coping, readiness for enhanced community Neglect, self Swallowing, impaired
Coping, compromised family Neglect, unilateral (Therapeutic Regimen Management, effective—
Coping, disabled family Noncompliance [Adherence, ineffective] [specify] retired 2009)
Coping, readiness for enhanced family Nutrition: less than body requirements, imbalanced (Therapeutic Regimen Management, ineffective
Death Syndrome, risk for sudden infant Nutrition: more than body requirements, imbalanced community—retired 2009)
Decision-Making, readiness for enhanced Nutrition: more than body requirements, risk for Therapeutic Regimen Management, ineffective
Denial, ineffective imbalanced family
Dentition, impaired Nutrition, readiness for enhanced Thermoregulation, ineffective
Development, risk for delayed Oral Mucous Membrane, impaired (Thought Processes, disturbed—retired 2009)
Diarrhea Pain, acute Tissue Integrity, impaired
Dignity, risk for compromised human Pain, chronic Transfer Ability, impaired
Distress, moral Parenting, impaired Trauma, risk for
Disuse Syndrome, risk for Parenting, readiness for enhanced Trauma, risk for vascular
Diversional Activity, deficient Parenting, risk for impaired Urinary Elimination, impaired
Electrolyte Imbalance, risk for Perfusion, ineffective peripheral tissue Urinary Elimination, readiness for enhanced
Energy Field, disturbed Perfusion, risk for decreased cardiac tissue Urinary Incontinence, functional
Environmental Interpretation Syndrome, impaired Perfusion, risk for ineffective cerebral tisse Urinary Incontinence, overflow
Failure to Thrive, adult Perfusion, risk for ineffective gastrointestinal Urinary Incontinence, reflex
Falls, risk for Perfusion, risk for ineffective renal Urinary Incontinence, stress
Family Processes, dysfunctional Peripheral Neurovascular Dysfunction, risk for (Urinary Incontinence, total—retired 2009)
Family Processes, interrupted Poisoning, risk for Urinary Incontinence, urge
Family Processes, readiness for enhanced Post-Trauma Syndrome [specify stage] Urinary Incontinence, risk for urge
Fatigue Post-Trauma Syndrome, risk for Urinary Retention [acute/chronic]
Fear Power, readiness for enhanced Ventilation, impaired spontaneous
Feeding Pattern, ineffective infant Powerlessness [specify level] Ventilatory Weaning Response, dysfunctional
Fluid Balance, readiness for enhanced Powerlessness, risk for Violence, [actual/]risk for other-directed
[Fluid Volume, deficient hyper/hypotonic] Protection, ineffective Violence, [actual/]risk for self-directed
Fluid Volume, deficient [isotonic] Rape-Trauma Syndrome Walking, impaired
Fluid Volume, excess (Rape-Trauma Syndrome: compound reaction— Wandering [specify sporadic or continual]
Fluid Volume, risk for deficient retired 2009) [ ] author recommendations
Nursing Diagnoses—Definitions and Classification 2009–2011 © 2009, 2007, 2005, 2003, 2001, 1998, 1996, 1994 NANDA International. Used by arrangement with
Wiley-Blackwell Publishing, a company of John Wiley & Sons, Inc. In order to make safe and effective judgments using NANDA-I nursing diagnoses, it is
essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.
