Nursing diagnoses

Nursing diagnosis is part of the nursing process. We must find the real and expected needs and problems of the patient. Discuss them with the patient if possible and work out the order of their urgency. Based on this, we will make a nursing plan.

Classification of nursing diagnoses [ edit | edit source ]
The North American Association for Nursing Diagnosis International (North American Association for Nursing Diagnosis International) created the NANDA domain diagnostic system. This system contains the names of nursing diagnoses. These are combined in the international classification of nursing diagnoses NANDA - International. These nursing diagnoses are divided into so-called diagnostic domains - circuits/areas and further into so-called classes.

Establishing a nursing diagnosis must be based on the anamnesis. The concept of the NANDA domain system is holistic and follows the individual in all areas of personality and life. The diagnostic domains follow Gordon's functional and dysfunctional patterns of health (valid since 2000). Domains declare the inclusion of client problems in 13 unmistakable areas. The domains offer nursing diagnoses (problems) that could appear in the client when their needs are not being met. Domains are divided into classesand each class defines the client's problems or nursing diagnoses that could occur in one of his human needs. If any of the client's human needs are not within the norm corresponding to age, development and culture, we speak of a nursing problem or a nursing diagnosis.

Each nursing diagnosis is determined by so-called diagnostic elements: numerical code, definition , defining features, related or risk factors.

We divide diagnoses into three basic groups:


 * current – ​​when the dysfunction of a need is determined, e.g. acute pain, functional urinary incontinence, etc.,
 * potential – the client is at risk of a possible nursing problem, e.g. risk of constipation, risk of infection,
 * educational - to support health, when no dysfunctions are proven, but with education and support we can improve the condition, the client behaves appropriately, but improvement can be achieved, e.g. willingness to improve the treatment regimen, willingness to improve nutrition. When creating nursing diagnoses, we always proceed according to the given scheme, which differs for each group.

Diagnostic domains
According to the NANDA system, we distinguish the following 13 diagnostic domains:


 * 1) Health promotion ( class: health management)
 * 2) Nutrition ( class: food intake, hydration)
 * 3) Excretion and exchange ( class: urinary excretion, gastrointestinal function, respiratory function)
 * 4) Activity, rest ( class: sleep - rest, activity - movement, energy balance, heart - lung response, self-care)
 * 5) Perception/cognition ( class: attention, orientation, feeling - perception, cognition, communication)
 * 6) Self-perception ( class: self-concept, self-esteem, body image)
 * 7) Relationships ( class: caregiver role, family relationships, role performance)
 * 8) Sexuality ( class: sexual function)
 * 9) Coping, stress resistance ( class: post-traumatic response, coping response, neurobehavioral stress)
 * 10) Life principle ( class: beliefs, alignment of values/beliefs and actions)
 * 11) Safety/Protection ( class: infection, bodily harm, violence, environmental hazards, defense processes, thermoregulation)
 * 12) Comfort ( class: physical comfort, social comfort)
 * 13) Growth, development ( class: growth, development)

Standardized names of nursing diagnoses according to NANDA [ edit | edit source ]
Numerical codes and names.

1. Health promotion
00078 Ineffective treatment regimen

00099 Ineffective health support

00080 Ineffective family treatment regimen

00081 Ineffective community treatment regimen

00082 An effective treatment regimen

00162 Willingness to improve treatment regimen

00084 The search for a healthy lifestyle

00163 Willingness to improve nutrition

2. Nutrition [ edit | edit source ]
00107 Inefficient infant feeding

00103 Impaired swallowing

00002 Inadequate nutrition

00001 Excessive nutrition

00003 Risk of overnutrition

00027 Deficiency of body fluids

00026 Increased volume of body fluids

00028 Risk of body fluid deficit

00025 Risk of unbalanced body fluid volume

00160 Willingness to improve fluid balance

3. Exclusion and replacement [ edit | edit source ]
00016 Impaired voiding of urine

00021 Complete urinary incontinence

00023 Urinary retention

00020 Functional urinary incontinence

00017 Stress urinary incontinence

00018 Reflex urinary incontinence

00019 Urgent urinary incontinence

00022 Risk of Urinary Urinary Incontinence

00166 Willingness to improve urination

00014 Faecal incontinence

00013 Diarrhea

00011 Constipation

00012 Habitual constipation

00015 Risk of constipation

00030 Violated gas exchange

4. Activity, rest [ edit | edit source ]
00095 Disturbed sleep

00096 Sleep deprivation

00165 Willingness to improve sleep

00085 Impaired mobility

00091 Impaired mobility in bed

00089 Impaired wheelchair control

00090 Impaired ability to relocate

00088 Impaired gait

00097 Lack of interest activities

00100 Delayed postoperative recovery

00168 Sedentary lifestyle

00040 Risk of immobilization syndrome

00050 Violated internal energy

00093 Fatigue

00029 Decreased cardiac output

00033 Weakened breathing

00032 Inefficient breathing

00092 Activity intolerance

00034 Dysfunctional disconnection of artificial pulmonary ventilation

00024 Inefficient tissue perfusion

00094 Risk of activity intolerance

00109 Self-care deficit in dressing and grooming

00108 Self-care deficit in bathing and hygiene

00102 Self-care deficit while eating

00110 Self-care deficit during defecation

5. Perception / Cognition [ edit | edit source ]
00123 Neglecting one side of the body

00127 Corrupted interpretation of surroundings

00154 Wandering

00122 Disorder of sensory perception

00126 Deficit knowledge

00128 Acute confusion

00129 Chronic confusion

00131 Corrupt memory

00130 Disrupted thinking

00161 Willingness to supplement deficient knowledge

00051 Impaired verbal communication

00157 Willingness to improve communication

6. Self-perception [ edit | edit source ]
00121 Personal identity breached

00125 Helplessness

00124 Hopelessness

00152 Risk of helplessness

00054 Risk of loneliness

00167 Willingness to improve self-concept

00119 Chronically low self-esteem

00120 Situationally low self-esteem

00153 Risk of situationally reduced self-esteem

00118 Distorted body image

7. Relationships [ edit | edit source ]
00061 Caregiver overload

00056 Impaired parental role

00062 Risk of caregiver overload

00057 Risk of deterioration of the parental role

00164 Willingness to improve the parental role

00060 Interrupted family life

00063 Dysfunctional family life with alcoholism

00058 Risk of weakening the parent-child bond

00159 Willingness to improve family function

00104 Ineffective breastfeeding

00105 Interrupted breastfeeding

00055 Inefficient role performance

00064 Parental role conflict

00052 Impaired social interaction

00106 Effective breastfeeding

8. Sexuality [ edit | edit source ]
00059 Sexual dysfunction

00065 Ineffective sex life

9. Coping with stress, resistance to stress [ edit | edit source ]
00114 Post-relocation stress syndrome

00142 Traumatic syndrome after rape

00144 Silent post-rape traumatic syndrome response

00143 Mixed post-rape traumatic syndrome reaction

00141 Post-traumatic syndrome

00149 Risk of post-relocation stress syndrome

00145 Risk of post-traumatic syndrome

00148 Fear

00146 Anxiety

00147 Fear of death

00137 Chronic grief

00072 Ineffective denial

00070 Weak customization

00069 Inefficient load handling

00071 Defensive load handling

00136 Anticipatory grief

00135 Dysfunctional grief

00073 Inability of the family to handle the burden

00074 Threatening family coping

00077 Inefficient management of the situation in the community

00172 The risk of dysfunctional grief

00158 Willingness to improve workload management

00075 Willingness of a close person to handle the load better

00076 Community willingness to improve burden management

00009 Autonomic dysreflexia

00116 Disturbed child behavior

00049 Reduced intracranial adaptive capacity

00010 Risk of autonomic dysreflexia

00115 Risk of disturbed child behavior

00117 Possible improvement of the child's behavior

10. Life principle [ edit | edit source ]
00068 Willingness to improve spiritual well-being

00066 Spiritual emergency

00083 Conflict in decision making

00079 Failure to comply

00169 Broken religiosity

00067 Risk of spiritual distress

00170 Risk of violation of religiosity

00171 Willingness to improve religiosity

11. Safety/Security [ edit | edit source ]
00004 Risk of infection

00045 Damaged oral mucosa

00046 Damaged skin integrity

00044 Damaged tissue integrity

00048 Damaged dentition

00031 Inefficient airway patency

00043 Ineffective resistance

00035 Risk of damage

00087 Risk of perioperative damage

00155 Risk of falls

00047 Risk of violation of skin integrity

00039 Risk of aspiration

00156 Risk of sudden infant death syndrome

00038 Risk of trauma

00036 Choking hazard

00086 Risk of peripheral neurovascular dysfunction

00151 Self-harm

00139 Risk of self harm

00138 Risk of violence towards others

00140 Risk of violence towards self

00150 Risk of suicide

00037 Risk of intoxication

00041 Allergic reaction to latex

00042 Risk of allergic reaction to latex

00008 Inefficient thermoregulation

00006 Hypothermia

00007 Hyperthermia

00005 Risk of body temperature imbalance

12. Comfort [ edit | edit source ]
00132 Acute pain

00133 Chronic pain

00134 Nausea

00053 Social isolation

13. Growth, development [ edit | edit source ]
00101 Failure to thrive as an adult

00113 Risk of uneven growth

00111 Delayed growth and development

00112 Risk of delayed development

An example of nursing diagnosis according to NANDA in practice [ edit | edit source ]
Numeric code and name of the nursing diagnosis :

00136 Mourning

Definition :

A normal, complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities integrate actual, anticipated, and/or perceived loss into their daily lives.

Determining characters :

altered activity, changes in sleep, impaired immunity, anger, blame, despair, distance, finding meaning in loss, guilt arising from a sense of relief, maintaining contact with the deceased, pain, panicked behavior, personal growth

Reason and expression :

Grieving due to the loss of a loved one, manifested by self-blame and tearfulness.

Goal :

- support the grieving process

- educate about the grieving process

Priority :

- medium

Resulting criteria :

- the patient is not afraid to turn to us for psychological support

- the patient is going through a grieving process

Intervention :

- approach the grieving person empathetically

- find out the cause of mourning

- educate the patient about the grieving process

- support the grieving process

- monitor possible pathologies in the grieving process

- report pathological mourning to doctors

Související články

 * Ošetřovatelský proces

Doporučená literatura
Příklady dalších ošetřovatelských diagnóz dle NANDA naleznete zde: