.

0 (hodnocen0 x )

BK

Příručka

1st pub.

Chichester : Wiley-Blackwell, 2012

xxxii, 533 s. : il. ; 25 cm

ISBN 978-0-4706-5482-8 (brož.)

Terminologický slovník

Část. text tištěn napříč

Obsahuje bibliografie a rejstřík

000241383

NANDA International Guidelines for Copyright Permission xvii // Preface xix // Introduction xxii // How to Use This Book xxii // Frequently Asked Questions xxiii // Acknowledgments xxv // Chapter Authors xxv // Chapter Reviewers xxv // New Nursing Diagnoses, 2012-2014 xxvi // Revised Nursing Diagnoses, 2012-2014 xxvii // Retired Nursing Diagnosis, 2012-2014 xxviii // Changes to Slotting of Current Diagnoses within the NANDA International Taxonomy II, 2012-2014 xxviii // Changes to Slotting of Current Diagnoses within the NANDA-I/NIC/NOC Taxonomy xxx // Revisions to Diagnoses within the NANDA International Taxonomy 2009-2011 xxx // PART 1 THE NANDA INTERNATIONAL TAXONOMY 1 // Introduction 3 // T Heather Herdman // Contributors to the NANDA-I Nursing Diagnosis Taxonomy 3 // Chapter 1 The NANDA International Taxonomy II 2012-2014 49 // T Heather Herdman, Gunn von Krogh // History of the Development of Taxonomy II 49 // Structure of Taxonomy II 50 // A Multiaxial System for Constructing Diagnostic Concepts 53 // Definitions of the Axes 55 // Axis 1: The Diagnostic Focus 55 // Axis 2: Subject of the Diagnosis 59 // Axis 3: Judgment 59 // Axis 4: Location 60 // Axis 5: Age 61 // Axis 6: Time * ‘ 61 // Axis 7: Status of the Diagnosis 61 // Construction of a Nursing Diagnostic Concept 62 // The NNN Taxonomy of Nursing Practice 63 // Further Development of the NANDA-I Taxonomy 64 // Contents v // PART 2 EDUCATION AND IMPLEMENTATION OF NANDA INTERNATIONAL NURSING DIAGNOSES WITHIN PRACTICE, ADMINISTRATION, RESEARCH, INFORMATICS AND EDUCATION 67 // Chapter 2 Nursing Assessment, Clinical Judgment, and Nursing // Diagnoses: How to Determine Accurate Diagnoses 71 // Margaret Lunney // Nurses Are Diagnosticians 72 // Intellectual, Interpersonal, and Technical Competencies 73 // Intellectual Competencies 73 // Interpersonal Competencies 74 // Technical Competencies 74 //

Personal Strengths: Tolerance for Ambiguity and Reflective Practice 75 // Tolerance for Ambiguity 75 // Reflective Practice 76 // Assessment and Nursing Diagnosis 76 // Assessment Framework 76 // Diagnostic Reasoning Associated with Nursing Assessment 77 // Recognizing the Existence of Cues 77 // Mentally Generating Possible Diagnoses 77 // Comparing Cues to Possible Diagnoses 78 // Conducting a Focused Data Collection 78 // Validating Diagnoses 79 // Case Study Example 79 // Analysis of Health Data: Nursing Diagnoses 81 // Nursing Outcomes Classification 82 // Nursing Interventions Classification 82 // Appendix: Functional Health Pattern Assessment Framework 84 // Directions 84 // Health Perception-Health Management Pattern 85 // Nutrition-Metabolic Pattern 85 // Elimination Pattern 86 // Activity-Exercise Pattern 86 // Sleep-Rest Pattern 86 // Cognitive-Perceptual Pattern 87 // Self-Perception-Self-Concept Pattern 87 // Role-Relationship Pattern 87 // Sexuality-Reproductive Pattern 88 // Coping-Stress Tolerance Pattern 88 // Value-Belief Pattern 88 // Analysis of Data, Nursing Diagnoses, Outcomes, and Interventions 89 // Chapter 3 Nursing Diagnosis in Education 90 // Barbara Krainovich-Miller, Fritz Frauenfelder, Maria Müller-Staub // Significance for Nursing Education 90 // Teaching the Nursing Process Framework 91 // Teaching the Assessment Phase of the Nursing Process 91 // vi Contents // Teaching Nursing Diagnoses as a Component of the Nursing Process 93 // The Nursing Process. Exemplar - Nursing History/Physical Assessment: Identifying Defining Characteristics and Related Factors 94 // The Nursing Process. Exemplar - Accuracy of the Nursing Diagnosis Label 95 // Risk Diagnoses 96 // Health-Promotion Diagnoses 96 // Prioritizing Diagnoses 96 // Linking Nursing Diagnoses to Outcomes and Interventions 97 //

Chapter 4 The Value of Nursing Diagnoses in Electronic // Health Records 99 // Jane M. Brokel, Kay C. Avant, Matthias Odenbreit // Student Use of the Electronic Health Record (EHR) 99 // Electronic Health Record 99 // Longitudinal Use 100 // Importance of Nursing Diagnoses in EHRs 100 // Documenting Nursing Diagnoses in the EHR 101 // Differences Between EHRs 102 // Documenting Defining Characteristics, Related Factors, and Risk Factors in the EHR 103 // Relationship of Nursing Diagnoses to Assessments 104 // Linking Nursing Diagnoses to Other Documentation 104 // An Organizing Framework for Nursing Assessments 105 // Link Between Assessment and a Short List of Nursing Diagnoses 105 // Link Between Nursing Diagnosis and Patient Outcome, // Current State, and Mutual Goal for an Outcome 105 // Link Between Nursing Diagnoses and Interventions in the Plan of Care 106 // Nursing Informatics Specialist/Graduate Student -Guiding Clinical Decision Support (CDS) within the EHR 106 // Role of Nursing Informatics 107 // Faculty Guide for Students in the Use of Nursing Diagnoses in the EHR 108 // Documentation 109 // Using the EHR 109 // Guiding Student Learning 109 // Learning the EHR, CDS and Health Information Exchange (HIE) 110 // Assessment Framework 110 // Knowledge Resources (Library) 110 // Problem List 111 // Interdisciplinary Care Planning 111 // Clinical Decision Support 111 // Health Information Exchange 111 // Personal Health Records 111 // Contents vii // Chapter 5 Nursing Diagnosis and Research 114 // Margaret Lunney, Maria Müller-Staub // Concept Analyses 114 // Content Validation 114 // Construct- and Criterion-Related Validity 116 // Consensus Validation 116 // Sensitivity, Specificity, and Predictive Value of Clinical Indicators 117 // Studies of Accuracy of Nurses’ Diagnoses 117 // Implementation Studies 117 // Prevalence Studies 118 // Summary 118 //

Chapter 6 Clinical Judgment and Nursing Diagnoses in Nursing // Administration 122 // T. Heather Herdman, Marcelo Chanes // Nursing Research Priorities of Importance to Nurse Administrators 122 // Nursing’s Role in Patient Safety 123 // Triple Model for Nursing Administrators 125 // Conclusion 130 // Chapter 7 Nursing Classifications: Criteria and Evaluation 133 // Matthias Odenbreit, Maria Müller-Staub, Jane M. Brokel, Kay C. Avant, / Gail Keenan // Characteristics of Classifications 134 // Classification Criteria 135 // Discussion 136 // Conclusion 141 // PART 3 NANDA-I NURSING DIAGNOSES 2012-2014 145 // International Considerations on the Use of the NANDA-I // Taxonomy of Nursing Diagnoses 147 // T. Heather Herdman // Domain 1: Health Promotion 149 // Class 1: Health Awareness 151 // Deficient Diversional Activity (00097) 151 // Sedentary Lifestyle (00168) 152 // Class 2: Health Management 153 // Deficient Community Health (00215) 153 // Risk-Prone Health Behavior (00188) 155 // Ineffective Health Maintenance (00099) 157 // Readiness for Enhanced Immunization Status (00186) 158 // Ineffective Protection (00043) 160 // Ineffective Self-Health Management (00078) 161 // Readiness for Enhanced Self-Health Management (00162) 164 // Ineffective Family Therapeutic Regimen Management (00080) 167 // Domain 2: Nutrition 169 // Class 1: Ingestion 171 // Insufficient Breast Milk (00216) 171 // Ineffective Infant Feeding Pattern (00107) 173 // Imbalanced Nutrition: Less Than Body Requirements (00002) 174 // Imbalanced Nutrition: More Than Body Requirements (00001) 175 // Readiness for Enhanced Nutrition (00163) 176 // Risk for Imbalanced Nutrition: More Than Body Requirements (00003) 177 // Impaired Swallowing (00103) 178 // Class 2: Digestion Class 3: Absorption // Class 4: Metabolism 180 // Risk for Unstable Blood Glucose Level (00179) 180 // Neonatal Jaundice (00194) 181 //

Risk for Neonatal Jaundice (00230) 182 // Risk for Impaired Liver Function (00178) 183 // Class 5: Hydration 184 // Risk for Electrolyte Imbalance (00195) 184 // Readiness for Enhanced Fluid Balance (00160) 185 // Deficient Fluid Volume (00027) 186 // Excess Fluid Volume (00026) 187 // Risk for Deficient Fluid Volume (00028) 188 // Risk for Imbalanced Fluid Volume (00025) 189 // Domain 3: Elimination and Exchange 191 // Class 1: Urinary Function 193 // Functional Urinary Incontinence (00020) 193 // Overflow Urinary Incontinence (00176) 194 // Reflex Urinary Incontinence (00018) 195 // Stress Urinary Incontinence (00017) 196 // Urge Urinary Incontinence (00019) 198 // Risk for Urge Urinary Incontinence (00022) 199 // Impaired Urinary Elimination (00016) 200 // Readiness for Enhanced Urinary Elimination (00166) 201 // Urinary Retention (00023) 202 // Class 2: Gastrointestinal Function 203 // Constipation (00011) 203 // Perceived Constipation (00012) 205 // Risk for Constipation (00015) 206 // Diarrhea (00013) 208 // Dysfunctional Gastrointestinal Motility (00196) 209 // Risk For Dysfunctional Gastrointestinal Motility (00197) 211 // Bowel Incontinence (00014) 213 // Class 3: Integumentary Function // Class 4: Respiratory Function 214 // Impaired Gas Exchange (00030) 214 // Domain 4: Activity/Rest 215 // Class 1: Sleep/Rest 217 // Insomnia (00095) 217 // Sleep Deprivation (00096) 219 // Readiness for Enhanced Sleep (00165) 220 // Disturbed Sleep Pattern (00198) 221 // Class 2: Activity/Exercise 222 // Risk for Disuse Syndrome (00040) 222 // Impaired Bed Mobility (00091) 223 // Impaired Physical Mobility (00085) 224 // Impaired Wheelchair Mobility (00089) 225 // Impaired Transfer Ability (00090) 226 // Impaired Walking (00088) 227 // Class 3: Energy Balance 228 // Disturbed Energy Field (00050) 228 // Fatigue (00093) 229 // Wandering (00154) 230 //

Class 4: Cardiovascular/Pulmonary Responses 231 // Activity Intolerance (00092) 231 // Risk for Activity Intolerance (00094) 232 // Ineffective Breathing Pattern (00032) 233 // Decreased Cardiac Output (00029) 235 // Risk for Ineffective Gastrointestinal Perfusion (00202) 237 // Risk for Ineffective Renal Perfusion (00203) 238 // Impaired Spontaneous Ventilation (00033) 239 // Ineffective Peripheral Tissue Perfusion (00204) 240 // Risk for Decreased Cardiac Tissue Perfusion (00200) 242 // Risk for Ineffective Cerebral Tissue Perfusion (00201) 243 // Risk for Ineffective Peripheral Tissue Perfusion (00228) 244 // Dysfunctional Ventilatory Weaning Response (00034) 246 // Class 5: Self-Care 248 // Impaired Home Maintenance (00098) 248 // Readiness for Enhanced Self-Care (00182) 249 // Bathing Self-Care Deficit (00108) 250 // Dressing Self-Care Deficit (00109) 251 // Feeding Self-Care Deficit (00102) 252 // Toileting Self-Care Deficit (00110) 253 // Self-Neglect (00193) 254 // Domain 5: Perception/Cognition 257 // Class 1: Attention 259 // Unilateral Neglect (00123) 259 // Class 2: Orientation 261 // Impaired Environmental Interpretation Syndrome (00127) 261 // Class 3: Sensation/Perception // Class 4: Cognition 262 // Acute Confusion (00128) 262 // Chronic Confusion (00129) 265 // x Contents // Risk for Acute Confusion (00173) 266 // Ineffective Impulse Control (00222) 269 // Deficient Knowledge (00126) 271 // Readiness for Enhanced Knowledge (00161) 272 // Impaired Memory (00131) 273 // Class 5: Communication 274 // Readiness for Enhanced Communication (00157) 274 // Impaired Verbal Communication (00051) 275 // Domain 6: Self-Perception 277 // Class 1: Self-Concept 279 // Hopelessness (00124) 279 // Risk for Compromised Human Dignity (00174) 280 // Risk for Loneliness (00054) 281 // Disturbed Personal Identity (00121) 282 //

Risk for Disturbed Personal Identity (00225) 283 // Readiness for Enhanced Self-Concept (00167) 284 // Class 2: Self-Esteem 285 // Chronic Low Self-Esteem (00119) 285 // Situational Low Self-Esteem (00120) 287 // Risk for Chronic Low Self-Esteem (00224) 288 // Risk for Situational Low Self-Esteem (00153) 290 // Class 3: Body Image 291 // Disturbed Body Image (00118) 291 // Domain 7: Role Relationships 293 // Class 1: Caregiving Roles 295 // Ineffective Breastfeeding (00104) 295 // Interrupted Breastfeeding (00105) 296 // Readiness for Enhanced Breastfeeding (00106) 297 // Caregiver Role Strain (00061) 298 // Risk for Caregiver Role Strain (00062) 301 // Impaired Parenting (00056) 302 // Readiness for Enhanced Parenting (00164) 304 // Risk for Impaired Parenting (00057) 305 // Class 2: Family Relationships 307 // Risk for Impaired Attachment (00058) 307 // Dysfunctional Family Processes (00063) 308 // Interrupted Family Processes (00060) 311 // Readiness for Enhanced Family Processes (00159) 312 // Class 3: Role Performance 313 // Ineffective Relationship (00223) 313 // Readiness for Enhanced Relationship (00207) 315 // Risk for Ineffective Relationship (00229) 316 // Parental Role Conflict (00064) 317 // Ineffective Role Performance (00055) 318 // Impaired Social Interaction (00052) 320 // Domain 8: Sexuality 321 // Class 1: Sexual Identity // Class 2: Sexual Function 323 // Sexual Dysfunction (00059) 323 // Ineffective Sexuality Pattem (00065) 325 // Class 3: Reproduction 326 // Ineffective Childbearing Process (00221) 326 // Readiness for Enhanced Childbearing Process (00208) 328 // Risk for Ineffective Childbearing Process (00227) 330 // Risk for Disturbed Maternal-Fetal Dyad (00209) 331 // Domain 9: Coping/Stress Tolerance 333 // Class 1: Post-Trauma Responses 335 // Post-Trauma Syndrome (00141) 335 // Risk for Post-Trauma Syndrome (00145) 336 //

Rape-Trauma Syndrome (00142) 337 // Relocation Stress Syndrome (00114) 338 // Risk for Relocation Stress Syndrome (00149) 339 // Class 2: Coping Responses 340 // Ineffective Activity Planning (00199) 340 // Risk for Ineffective Activity Planning (00226) 342 // Anxiety (00146) 344 // Defensive Coping (00071) 346 // Ineffective Coping (00069) 348 // Readiness for Enhanced Coping (00158) 349 // Ineffective Community Coping (00077) 350 // Readiness for Enhanced Community Coping (00076) 351 // Compromised Family Coping (00074) 352 // Disabled Family Coping (00073) 354 // Readiness for Enhanced Family Coping (00075) 355 // Death Anxiety (00147) 356 // Ineffective Denial (00072) 358 // Adult Failure to Thrive (00101) 360 // Fear (00148) 361 // Grieving (00136) 363 // Complicated Grieving (00135) 365 // Risk for Complicated Grieving (00172) 367 // Readiness for Enhanced Power (00187) 368 // Powerlessness (00125) 370 // Risk for Powerlessness (00152) 372 // Impaired Individual Resilience (00210) 374 // Readiness for Enhanced Resilience (00212) 376 // Risk for Compromised Resilience (00211) 378 // Chronic Sorrow (00137) 379 // Stress Overload (00177) 380 // Class 3: Neurobehavioral Stress 383 // Autonomic Dysreflexia (00009) 383 // Risk for Autonomic Dysreflexia (00010) 384 // Disorganized Infant Behavior (00116) 386 // Readiness for Enhanced Organized Infant Behavior (00117) 388 // Risk for Disorganized Infant Behavior (00115) 389 // Decreased Intracranial Adaptive Capacity (00049) 390 // Domain 10: Life Principles 391 // Class 1: Values 393 // Readiness for Enhanced Hope (00185) 393 // Class 2: Beliefs 394 // Readiness for Enhanced Spiritual Well-Being (00068) 394 // Class 3: Value/Belief/Action Congruence 395 // Readiness for Enhanced Decision-Making (00184) 395 // Decisional Conflict (00083) 396 // Moral Distress (00175) 398 // Noncompliance (00079) 400 //

Impaired Religiosity (00169) 402 // Readiness for Enhanced Religiosity (00171) 405 // Risk for Impaired Religiosity (00170) 407 // Spiritual Distress (00066) 410 // Risk for Spiritual Distress (00067) 412 // Domain 11: Safety/Protection 415 // Class 1: Infection 417 // Risk for Infection (00004) 417 // Class 2: Physical Injury 421 // Ineffective Airway Clearance (00031) 421 // Risk for Aspiration (00039) 422 // Risk for Bleeding (00206) 423 // Impaired Dentition (00048) 425 // Risk for Dry Eye (00219) 426 // Risk for Falls (00155) 428 // Risk for Injury (00035) 430 // Impaired Oral Mucous Membrane (00045) 431 // Risk for Perioperative Positioning Injury (00087) 433 // Risk for Peripheral Neurovascular Dysfunction (00086) 434 // Risk for Shock (00205) 435 // Impaired Skin Integrity (00046) 436 // Risk for Impaired Skin Integrity (00047) 437 // Risk for Sudden Infant Death Syndrome (00156) 438 // Risk for Suffocation (00036) 439 // Delayed Surgical Recovery (00100) 440 // Risk for Thermal Injury (00220) 442 // Impaired Tissue Integrity (00044) 443 // Risk for Trauma (00038) 444 // Risk for Vascular Trauma (00213) 446 // Class 3: Violence 447 // Risk for Other-Directed Violence (00138) 447 // Risk for Self-Directed Violence (00140) 448 // Self-Mutilation (00151) 449 // Risk for Self-Mutilation (00139) 451 // Risk for Suicide (00150) 452 // Class 4: Environmental Hazards 454 // Contamination (00181) 454 // Risk for Contamination (00180) 458 // Risk for Poisoning (00037) 460 // Class 5: Defensive Processes 461 // Risk for Adverse Reaction to lodinated Contrast Media (000218) 461 // Latex Allergy Response (00041) 463 // Risk for Allergy Response (00217) 465 // Risk for Latex Allergy Response (00042) 466 // Class 6: Thermoregulation 467 // Risk for Imbalanced Body Temperature (00005) 467 // Hyperthermia (00007) 468 // Hypothermia (00006) 469 //

Ineffective Thermoregulation (00008) 470 // Domain 12: Comfort 471 // Class 1: Physical Comfort 473 // Class 2: Environmental Comfort 473 // Class 3: Social Comfort 473 // Impaired Comfort (00214) 473 // Readiness for Enhanced Comfort (00183) 475 // Nausea (00134) 476 // Acute Pain (00132) 478 // Chronic Pain (00133) 479 // Social Isolation (00053) 480 // Domain 13: Growth/Development 481 // Class 1: Growth 483 // Risk for Disproportionate Growth (00113) 483 // Class 2: Development 484 // Delayed Growth and Development (00111) 484 // Risk for Delayed Development (00112) 485 // Nursing Diagnoses Retired from the NANDA-I Taxonomy 2009-2014 487 // Health-seeking Behaviors (00084) - Retired 2009-2011 489 // Disturbed Sensory Perception (Specify: Visual, Auditory, // Kinesthetic, Gustatory, Tactile, Olfactory) (00122) - // Retired 2012-2014 490 // PART 4 NANDA INTERNATIONAL 2012-2014 493 // NANDA International Think Tank Meeting 495 // Issues related to the DDC 495 // Globalization of the Taxonomy 496 // Issues for Future Discussion and Research 497 // NANDA International Position Statements 498 // NANDA-I Position Statement 1: The Use of Taxonomy II as an Assessment Framework 498 // NANDA-I Position Statement 2: The Structure of the Nursing Diagnosis Statement when Included in a Care Plan 498 // xiv Contents // Chapter 8 The Process for Development of an Approved NANDA International Nursing Diagnosis 499 // Leann M. Scroggins // Axis 1: The Diagnostic Focus 499 // Axis 2: Subject of the Diagnosis 500 // Axis 3: Judgment 500 // Axis 4: Location 500 // Axis 5: Age 501 // Axis 6: Time 501 // Axis 7: Status of the Diagnosis 501 // Label and Definition 503 // Defining Characteristics versus Risk Factors 503 // Taxonomy Rules 504 // Related Factors 505 // Identify Related Factors 505 // NANDA International Processes and Procedures 508 // Full Review Process 508 //

Expedited Review Process 509 // Submission Process for New Diagnoses 509 // Submission Process for Revising a Current Nursing Diagnosis 511 // Procedure to Appeal a DDC Decision on Diagnosis Review 512 // NANDA-I Diagnosis Submission: Level of Evidence Criteria 513 // 1. Received for Development (Consultation from DDC) 513 // 1.1 Label Only 513 // 1.2 Label and Definition 513 // 2. Accepted for Publication and Inclusion in the NANDA-I // Taxonomy 513 // 2.1 Label, Definition, Defining Characteristics or Risk Factors, // Related Factors, and References 513 // 2.2 Concept Analysis 513 // 2.3 Consensus Studies Related to Diagnosis Using Experts 513 // 3. Clinically Supported (Validation and Testing) 514 // 3.1 Literature Synthesis 514 // 3.2 Clinical Studies Related to Diagnosis, but Not // Generalizable to the Population 514 // 3.3 Well-designed Clinical Studies with Small Sample Sizes 514 // 3.4 Well-designed Clinical Studies with Random Sample of Sufficient Size to Allow for Generalizability to the // Overall Population 514 // Glossary of Terms 515 // Nursing Diagnosis 515 // Actual Nursing Diagnosis 515 // Health-promotion Nursing Diagnosis 515 // Risk Nursing Diagnosis 515 // Syndrome 515 // Wellness Nursing Diagnosis 516 // Contents XV // Components of a Nursing Diagnosis 516 // Diagnosis Label 516 // Definition 516 // Defining Characteristics 516 // Risk Factors 516 // Related Factors 516 // Definitions for Classification of Nursing Diagnoses 517 // Classification 517 // Level of Abstraction 517 // Nomenclature 517 // Taxonomy 517 // NANDA International 2010-2012 518 // NANDA International Board of Directors 518 // NANDA International Diagnosis Development Committee 518 // NANDA International Education