.

0 (hodnocen0 x )

(20) Půjčeno:19x 

BK

Příručka

1st pub.

Chicester : Wiley-Blackwell, 2014

xxviii, 483 s. : il. ; 23 cm

ISBN 978-1-118-91493-9 (brož.)

"Tenth edition"--Tit. s.

Obsahuje bibliografie a rejstřík

000252188

Preface xxii // Introduction xxvi // About the Companion Website xxviii // PARTI CHANGES TO THE NANDA // INTERNATIONAL TERMINOLOGY 1 // Introduction 3 // T Heather Herdman, RN, PhD, FNI // What’s New in the 2015-2017 Edition of Diagnoses and Classification? // Acknowledgments 4 // Chapter authors 4 // Chapter reviewers 5 // Reviewer for standardization of diagnostic terms 5 // Changes to health promotion and risk diagnoses 5 // New nursing diagnoses, 2015-2017 5 // Revised nursing diagnoses, 2015-2017 7 // Changes to slotting of current diagnoses within the NANDA-I Taxonomy II, 2015-2017 11 // Revisions to nursing diagnosis labels within the NANDA-I Taxonomy II, 2015-2017 II // Nursing diagnoses removed from the NANDA-I Taxoqo.my ?, 2015-2017 11 // Standardization of diagnostic indicator terms 12 // NANDA-I Taxonomy II, 2015-2017 13 // Other changes made in the 2015-2017 edition 15 // PART 2 NURSING DIAGNOSIS 17 // Chapter I Nursing Diagnosis Basics 21 // Susan Gallagher-Lepak, RN, PhD // Understanding nursing concepts 24 // Assessment 24 // Nursing diagnosis 25 // Planning/intervention 27 // Evaluation 28 // Use of nursing diagnosis 28 // Brief chapter summary 29 // Questions commonly asked by new learners // about nursing diagnosis 29 // References 30 // Chapter 2 From Assessment to Diagnosis 31 // T. Heather Herdman, RN, PhD, FNI and ShiSemi Kamitsuru, RN, PhD, FNI What happens during nursing assessment? 31 // Why do nurses assess? 32 // The screening assessment 33 // Not a simple matter of "filling in the blanks" 34 // Assessment framework 35 // Should we use the NANDA-I taxonomy as an assessment framework? 35 // Data analysis 35 // Subjective versus objective data 37 // Clustering of information/seeing a pattern 38 // Identifying potential nursing diagnoses (diagnostic hypotheses) 39 // In-depth assessment 41 // Confirming/refuting potential nursing diagnoses 43 // Eliminating possible diagnoses 43 //

Potential new diagnoses 44 // Differentiating between similar diagnoses 44 // Making a diagnosis/prioritizing 49 // Summary 50 // References 50 // Chapter 3 An Introduction to the NANDA-I // Taxonomy 52 // T. Heather Herdman, RN, PhD. FNI Taxonomy: Visualizing a taxonomic structure 52 // Classification in nursing 56 // Using the NANDA-I taxonomy 60 // Structuring nursing curricula 60 // Identifying a nursing diagnosis outside your area of expertise 62 // Case Study: Mrs. Lendo 64 // The NANDA-I nursing diagnosis taxonomy: // A short history 65 // References 90 // Chapter 4 NANDA-I Taxonomy II: Specifications and Definitions 91 // T. Heather Herdman, RN, PhD, FNI Structure of Taxonomy II 91 // A multiaxial system for constructing diagnostic concepts 92 // Definitions of the axes 94 // Axis 1 The focus of the diagnosis 94 // Axis 2 Subject of the diagnosis 97 // Axis 3 Judgment 97 // Axis 4 Location 97 // Axis 6 Time 100 // Axis 7 Status of the diagnosis 100 // Developing and submitting a nursing diagnosis 101 // Risk for Disorganized Infant Behavior 102 // Readiness for Enhanced Family Coping 102 // Further development 103 // References 103 // Other recommended reading 104 // Chapter 5 Frequently Asked Questions 105 // T Heather Herdman, RN, PhD, FNI and Shißemi Kamitsuru, RN, PhD, FNI // Basic questions about standardized nursing languages 105 // Basic questions about NANDA-I 106 // Basic questions about nursing diagnoses 110 // Questions about defining characteristics 116 // Questions about related factors 11705// Questions about risk factors 118 // Differentiating between similar nursing diagnoses 119 // Questions regarding the development of a treatment plan 121 Questions about teaching/learning nursing diagnoses 123 // Questions about using NANDA-I in electronic health records 126 // Questions about diagnosis development and review 127 // Questions about the NANDA-I Definitions and // Classification text 127 // References 129 //

PART 3 THE NANDA INTERNATIONAL NURSING DIAGNOSES 131 // International Considerations on the use of the NANDA-I Nursing Diagnoses 133 // T. Heather Herdman, RN, PhD, FNI // Domain 1: Health Promotion 137 // Class 1. Health awareness 139 // Deficient diversional activity - 00097 139 // Sedentary lifestyle - 00168 140 // Class 2. Health management 141 // Frail elderly syndrome - 00257 141 // Risk for frail elderly syndrome - 00231 142 // Deficient community health - 00215 144 // Risk-prone health behavior - 00188 145 // Ineffective health maintenance - 00099 146 // Ineffective health management - 00078 147 // Readiness for enhanced health management - 00162 148 Ineffective family health management - 00080 149 // Noncompliance - 00079 150 // Ineffective protection - 00043 152 // Domain 2: Nutrition 153 // Class 1. Ingestion 155 // Insufficient breast milk - 00216 155 // Ineffective breastfeeding - 00104 156 // Interrupted breastfeeding - 00105 158 // Readiness for enhanced breastfeeding - 00106 159 // Ineffective infant feeding pattern - 00107 16006// Imbalanced nutrition: less than body requirements - 00002 161 // Readiness for enhanced nutrition - 00163 162 // Obesity - 00232 163 // Overweight - 00233 165 // Risk for overweight - 00234 167 // Impaired swallowing - 00103 169 // Class 2. Digestion None at present time Class 3. Absorption None at present time // Class 4. Metabolism 171 // Risk for unstable blood glucose level - 00179 171 // Neonatal jaundice - 00194 172 // Risk for neonatal jaundice-00230 173 // Risk for impaired liver function - 00178 174 // Class 5. Hydration 175 // Risk for electrolyte imbalance-00195 175 // Readiness for enhanced fluid balance - 00160 176 // Deficient fluid volume - 00027 177 // Risk for deficient fluid volume - 00028 178 // Excess fluid volume - 00026 179 // Risk for imbalanced fluid volume - 00025 180 // Domain 3: Elimination and Exchange 181 // Class 1. Urinary function 183 //

Impaired urinary elimination - 00016 183 // Readiness for enhanced urinary elimination - 00166 184 // Functional urinary incontinence - 00020 185 // Overflow urinary incontinence - 00176 186 // Reflex urinary incontinence - 00018 187 // Stress urinary incontinence - 00017 188 // Urge urinary incontinence - 00019 189 // Risk for urge urinary incontinence - 00022 190 // Urinary retention - 00023 191 // Class 2. Gastrointestinal function 192 // Constipation - 00011 192 // Risk for constipation - 00015 194 // Chronic functional constipation - 00235 196 // Risk for chronic functional constipation - 00236 198 // Perceived constipation - 00012 199 // Diarrhea - 00013 200 // Dysfunctional gastrointestinal motility - 00196 201 // Risk for dysfunctional gastrointestinal motility-00197 202 // Bowel incontinence - 00014 203 // Class 3. Integumentary function None at this time // Class 4. Respiratory function 204 // Impaired gas exchange - 00030 204 // Domain 4: Activity/Rest 205 // Class 1. Sleep/rest 209 // Insomnia-00095 209 // Sleep deprivation - 00096 210 // Readiness for enhanced sleep - 00165 212 // Disturbed sleep pattern - 00198 213 // Class 2. Activity/exercise 214 // Risk for disuse syndrome - 00040 214 // Impaired bed mobility - 00091 215 // Impaired physical mobility - 00085 216 // Impaired wheelchair mobility - 00089 218 // Impaired sitting - 00237 219 // Impaired standing - 00238 220 // Impaired transfer ability - 00090 221 // Impaired walking - 00088 222 // Class 3. Energy balance 223 // Fatigue - 00093 223 // Wandering - 00154 224 // Class 4. Cardiovascular/pulmonary responses 225 // Activity intolerance - 00092 225 // Risk for activity intolerance - 00094 226 // Ineffective breathing pattern - 00032 227 // Decreased cardiac output - 00029 228 // Risk for decreased cardiac output - 00240 230 // Risk for impaired cardiovascular function - 00239 231 // Risk for ineffective gastrointestinal perfusion - 00202 232 //

Risk for ineffective renal perfusion - 00203 233 // Impaired spontaneous ventilation - 00033 234 // Risk for decreased cardiac tissue perfusion - 00200 235 // Risk for ineffective cerebral tissue perfusion - 00201 236 // Ineffective peripheral tissue perfusion - 00204 237 // Risk for ineffective peripheral tissue perfusion - 00228 238 // Dysfunctional ventilatory weaning response - 00034 239 // Class 5. Self-care 241 // Impaired home maintenance - 00098 241 // Bathing self-care deficit - 00108 242 // Dressing self-care deficit - 00109 243 // Feeding self-care deficit - 00102 244 // Toileting self-care deficit - 00110 245 // Readiness for enhanced self-care - 00182 246 // Self-neglect - 00193 247 // Domain 5: Perception/Cognition 249 // Class 1. Attention 251 // Unilateral neglect - 00123 251 // Class 2. Orientation None at this time Class 3. Sensation/perception None at this time // Class 4. Cognition 252 // Acute confusion - 00128 252 // Risk for acute confusion - 00173 253 // Chronic confusion - 00129 254 // Labile emotional control - 00251 255 // Ineffective impulse control - 00222 256 // Deficient knowledge - 00126 257 // Readiness for enhanced knowledge - 00161 258 // Impaired memory - 00131 259 // Class 5. Communication 260 // Readiness for enhanced communication -00157 260 // Impaired verbal communication - 00051 261 // Domain 6: Self-Perception 263 // Class 1. Self-concept 265 // Readiness for enhanced hope - 00185 265 // Hopelessness - 00124 266 // Risk for compromised human dignity - 00174 267 // Disturbed personal identity - 00121 268 // Risk for disturbed personal identity - 00225 269 // Readiness for enhanced self-concept09- 00167 270 // Class 2. Self-esteem 271 // Chronic low self-esteem - 00119 271 // Risk for chronic low self-esteem - 00224 272 // Situational low self-esteem - 00120 273 // Risk for situational low self-esteem - 00153 274 // Class 3. Body image 275 // Disturbed body image - 00118 275 //

Domain 7: Role Relationships 277 // Class 1. Caregiving roles 279 // Caregiver role strain - 00061 279 // Risk for caregiver role strain - 00062 282 // Impaired parenting - 00056 283 // Readiness for enhanced parenting - 00164 286 // Risk for impaired parenting - 00057 287 // Class 2. Family relationships 289 // Risk for impaired attachment - 00058 289 // Dysfunctional family processes - 00063 290 // Interrupted family processes - 00060 293 // Readiness for enhanced family processes -00159 294 // Class 3. Role performance 295 // Ineffective relationship - 00223 295 // Readiness for enhanced relationship - 00207 296 // Risk for ineffective relationship - 00229 297 // Parental role conflict - 00064 298 // Ineffective role performance - 00055 299 // Impaired social interaction - 00052 301 // Domain 8: Sexuality 303 // Class 1. Sexual identity // None at present lime // Class 2. Sexual function 305 // Sexual dysfunction - 00059 305 // Ineffective sexuality pattern - 00065 306 // Class 3. Reproduction 307 // Ineffective childbearing process - 00221 307 // Readiness for enhanced childbearing process -00208 309 // Risk for ineffective childbearing process -00227 310 // Risk for disturbed maternal-fetal10dyad - 00209 311 // Domain 9: Coping/Stress Tolerance 313 // Class 1. Post-trauma responses 315 // Post-trauma syndrome - 00141 315 // Risk for post-trauma syndrome - 00145 317 // Rape-trauma syndrome - 00142 318 // Relocation stress syndrome - 00114 319 // Risk for relocation stress syndrome - 00149 320 // Class 2. Coping responses 321 // Ineffective activity planning - 00199 321 // Risk for ineffective activity planning - 00226 322 // Anxiety - 00146 323 // Defensive coping - 00071 325 // Ineffective coping - 00069 326 // Readiness for enhanced coping - 00158 327 // Ineffective community coping - 00077 328 // Readiness for enhanced community coping - 00076 329 // Compromised family coping - 00074 330 // Disabled family coping - 00073 332 //

Readiness for enhanced family coping - 00075 333 // Death anxiety - 00147 334 // Ineffective denial - 00072 335 // Fear-00148 335 // Grieving - 00136 338 // Complicated grieving - 00135 339 // Risk for complicated grieving - 00172 340 // Impaired mood regulation - 00241 341 // Readiness for enhanced power - 00187 342 // Powerlessness - 00125 343 // Risk for powerlessness - 001 52 344 // Impaired resilience - 00210 345 // Readiness for enhanced resilience - 00212 346 // Risk for impaired resilience - 00211 347 // Chronic sorrow - 00137 348 // Stress overload - 00177 349 // Class 3. Neurobehavioral stress 350 // Decreased intracranial adaptive capacity - 00049 350 // Autonomic dysreflexia - 00009 351 // Risk for autonomic dysreflexia11-00010 352 // Disorganized infant behavior - 00116 354 // Readiness for enhanced organized infant behavior - 00117 356 // Risk for disorganized infant behavior - 0011 5 357 // Domain 10: Life Principles 359 // Class 1. Values // None at this time // Class 2. Beliefs 361 // Readiness for enhanced spiritual well-being - 00068 361 // Class 3. Value/belief/action congruence 363 // Readiness for enhanced decision-making - 00184 363 // Decisional conf lict - 00083 364 // Impaired emancipated decision-making - 00242 365 // Readiness for enhanced emancipated decision-making - 00243 366 // Risk for impaired emancipated decision-making -00244 367 // Moral distress - 00175 368 // Impaired religiosity - 00169 369 // Readiness for enhanced religiosity - 00171 370 // Risk for impaired religiosity - 00170 371 // Spiritual distress - 00066 372 // Risk for spiritual distress - 00067 374 // Domain 11: Safety/Protection 375 // Class 1. Infection 379 // Risk for infection - 00004 379 // Class 2. Physical injury 380 // Ineffective airway clearance - 00031 380 // Risk for aspiration - 00039 381 // Risk for bleeding - 00206 382 // Risk for dry eye-00219 383 // Risk for falls-00155 384 // Risk for injury - 00035 386 //

Risk for corneal injury - 00245 387 // Risk for perioperative positioning injury -00087 388 // Risk for thermal injury - 00220 389 // Risk for urinary tract injury - 00250 390 // Impaired dentition - 00048 391 // Impaired oral mucous membrane - 00045 392 // Risk for impaired oral mucous membrane - 00247 394 // Risk for peripheral neurovascular dysfunction - 00086 395 // Risk for pressure ulcer - 00249 396 // Risk for shock - 00205 398 // Impaired skin integrity - 00046 399 // Risk for impaired skin integrity - 00047 400 // Risk for sudden infant death syndrome - 00156 401 // Risk for suffocation - 00036 402 // Delayed surgical recovery - 00100 403 // Risk for delayed surgical recovery - 00246 404 // Impaired tissue integrity - 00044 405 // Risk for impaired tissue integrity - 00248 406 // Risk for trauma - 00038 407 // Risk for vascular trauma - 00213 409 // Class 3. Violence 410 // Risk for other-directed violence - 00138 410 // Risk for self-directed violence - 00140 411 // Self-mutilation - 00151 412 // Risk for self-mutilation - 00139 414 // Risk for suicide - 00150 416 // Class 4. Environmental hazards 418 // Contamination - 00181 418 // Risk for contamination - 00180 420 // Risk for poisoning - 00037 421 // Class 5. Defensive processes 422 // Risk for adverse reaction to iodinated contrast media - 00218 422 // Risk for allergy response - 00217 423 // Latex allergy response - 00041 424 // Risk for latex allergy response - 00042 425 // Class 6. Thermoregulation 426 // Risk for imbalanced body temperature - 00005 426 // Hyperthermia - 00007 427 // Hypothermia - 00006 428 // Risk for hypothermia - 00253 430 // Risk for perioperative hypothermia - 00254 432 // Ineffective thermoregulation - 00008 433 // Domain 12: Comfort 435 // Class 1. Physical comfort 437 // Impaired comfort - 00214 437 // Readiness for enhanced comfort - 00183 438 // Nausea-00134 439 // Acute pain - 001 32 440 // Chronic pain - 0013 3 442 // Labor pain - 00256 444 //

Chronic pain syndrome - 00255 445 // Class 2. Environmental comfort 437 // Impaired comfort - 00214 437 // Readiness for enhanced comfort - 00183 438 // Class 3. Social comfort 437 // Impaired comfort - 00214 437 // Readiness for enhanced comfort - 00183 438 // Risk for loneliness - 00054 446 // Social isolation - 00053 447 // Domain 13: Growth/Development 449 // Class 1. Growth 451 // Risk for disproportionate growth - 00113 451 // Class 2. Development 452 // Risk for delayed development - 00112 452 // Nursing Diagnoses Accepted for Development // and Clinical Validation 2015-2017 455 // Disturbed energy field - 00050 455 // PART 4 NANDA INTERNATIONAL, INC. 2015-2017 457 // NANDA International Position Statements 459 // The use of Taxonomy II as an assessment framework 459 // The structure of the Nursing Diagnosis statement when included in a care plan 459 // NANDA International Processes and Procedures for Diagnosis Submission and Review 461 // NANDA-I Diagnosis Submission: Level of evidence criteria 461 // Glossary of Terms 464 // Nursing diagnosis 464 // Diagnostic axes 465 // Components of a nursing diagnosis 467 // Definitions for classification of nursing diagnoses 468 // References 469 // An Invitation to Join NANDA International 470 // NANDA International: A Member-Driven Organization 470 Our vision 470 // Our mission 470 // Our purpose 470 // Our history 471 // NANDA International’s Commitment 471 // Involvement Opportunities 472 // Why join NANDA-I? 472 // Who is using the NANDA International Taxonomy? 473 // Index 475