N 340 Women's Health & Illness in The Expanding Family & N345 Clinical Practicum

 

Nursing Diagnoses Arranged by Gordon's Health Patterns

Marjorie Gordon (1987) proposed functional health patterns as a guide for establishing a comprehensive nursing data base. These 11 categories make possible a systematic and standardized approach to data collection, and enable the nurse to determine aspects of health and human function: Under each health pattern is a partial list of NANDA (North American Nursing Diagnosis Association) nursing diagnoses arranged by health patterns identified as a taxonomy by Gordon (2000 ). It is intended to assist you in implementing the nursing process. You can find these and other nursing diagnoses in your Carpenito text from your sophomore year. These are examples you may find helpful when organizing and evaluating care for your patients. It will also be useful for your academic care plans.

Important Note: Each area must be addressed for each patient. If it truly doesn't apply, then right a brief explanation of your reasoning (i.e. Newborn and sexuality). A nursing diagnosis could fit under many different health patterns. For example: Breast feeding: Ineffective could fit under almost every category as could fear or lack of knowledge! Where you chose to place it would depend on your assessment while caring for the patient. This combines the science and art of nursing! Have fun with it. This is designed as a creative way for you to get a complete picture of your patient (that is the reason for the concept map format).

 

Health Perception – Health Management Pattern

This pattern is related to the client’s perceived pattern of health and or well-being, knowledge of lifestyle and the relationship to health, knowledge of preventive health practices and adherence to medical and nursing prescriptions. Data collection is focused on the person's perceived level of health and well-being, and on practices for maintaining health. Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use. Actual or potential problems related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the home.

Associated Nursing Diagnoses

Energy Field disturbance: A disruption of the flow of energy surrounding a person’s being, which results in a disharmony of mind and spirit.

Growth and Development, Delayed: Altered physical growth, delay or difficulty in exercising skills (motor, social expressive) typical of age group; inability to perform self-care or self-control activities appropriate for age; flat affect; listlessness; decreased responses.

Health Maintenance, Ineffective: Inability to identify, manage, or seek out help to maintain health.

Health Seeking Behaviors; Active seeking (by individual in stable heath) of ways to alter personal health habits and/or environment to move toward higher level of health.

Injury, Risk for (falls, trauma, poisoning, suffocation, aspiration): A risk of injury as a result of the interaction of environmental conditions interacting with the individual’s adaptive and defensive resources

Management of Therapeutic Regimen, Ineffective (individual, family, community): Pattern of regulating and integrating into daily living a program for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

Coping, Defensive

Disturbed Body Image: State in which a person experiences or is at risk to experience a disruption in the way (s)he perceives one's body. Negative response to actual or perceived change in structure and/or function.

Nutritional-Metabolic Pattern

Usual pattern of food, fluid intake, types of food, fluid intake, actual weight loss or gain, appetite, preferences. Inquire about – nutrition, fluid intake, peripheral edema, infection, oral cavity health. Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.

Associated Nursing Diagnoses:

Nausea: related to pain, medications, activity (labor), stress

Infant feeding pattern: ineffective

Hypo or Hyperglycemia: or at risk for related to infant of a diabetic mother, LGA , SGA or preterm

Risk of imbalanced Body Temperature: At risk for failure to maintain body temperature within a normal range.

Thermoregulation, Ineffective: Temperature fluctuation between hypothermia and hyperthermia

Fluid Volume Deficit: Decreased intravascular, interstitial, and/or intracellular fluid (refers to dehydration, water loss alone without change in sodium level.

Fluid Volume Excess: Increased isotonic fluid retention.

Infection, Risk for: At increased risk for being invaded by pathogenic organism.

Nutrition, Altered, Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.

Nutrition, Altered, More than Body Requirements: Intake of nutrients that exceeds metabolic needs.

Protection, Ineffective: Decrease in ability to guard self from internal or external threats such as illness or injury.

Tissue Integrity, Impaired: Damage to mucous membrane, corneal, integumentary or subcutaneous tissues.

Skin Integrity, Impaired: At risk for skin being adversely altered.

Elimination Pattern

Bowel and bladder elimination patterns, changes, control problems, use of assistive devices, use of medications. Inquire about – bowel elimination, incontinence. Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified.

Associated Nursing Diagnoses:

 Bowel Incontinence: Change in normal bowel elimination habits characterized by involuntary passage of stool.

 Constipation: Decrease in normal frequency of defecation accompanied by difficulty or incomplete passage of stool and/or passage of excessively hard, dry stool.

 Perceived Constipation: State in which individual makes a self-diagnosis of constipation and ensures daily bowel movement through abuse of laxatives, enemas, and suppositories.

Diarrhea: Passage of loose, unformed stools

Urinary Retention: Incomplete emptying of the bladder.

Incontinence, urinary, functional: Impairment of loss of continence due to functional deficits, including altered mobility, dexterity, or cognition, or environmental barriers.

Incontinence, urinary, reflex: Involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached.

Incontinence, urinary, stress: State in which the individual experiences urine loss of less than 50 ml accompanied by increased intro-abdominal pressure.

Impaired urinary retention: related to diminished bladder cues or impaired ability to recognize bladder cues due to anesthesia, child-birth, post indwelling catheter, impaired mobility, pain.

Activity Exercise Pattern

Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems. Pattern of exercise, activity, leisure, recreation, ability to perform activities of daily living. Inquire about – activities of daily living, leisure activities, home care, respiratory function, mobility.

Associated Nursing Diagnoses:

Aspiration, Risk for: state in which a person is at risk for entry of secretions, solids, or fluids into tracheobroncial passages. Related to: inability to elevate upper body, enlarged uterus, impaired suckling/swallowing, decrease muscle tone of esophageal sphincter, anesthesia, sedation, alcohol-drug induced.

Activity intolerance: Insufficient physiological or psychological energy to endure or complete required or desired daily activities. Related to increased metabolic demands, hyperventilation, panic, organic or physiologic, emotional or faulty breathing patterns.

Breathing patterns, Ineffective: State in which a person experiences an actual or potential loss of adequate ventilation related to an altered breathing pattern.

Cardiac Output, Decreased: Inadequate blood pumped by the heart to meet metabolic demands of the body.

Disorganized Infant behavior: The degree to which an infant has reached his or her organizational threshold and no longer is maintaining self, as reflected in his or her use of varying physiologic, postural or state strategies. Related to immature or altered CNS secondary to prematurity, hyperbilirubinemia, hypoglycemia, infection, congenital anomalies, prenatal drug exposure, decreased 02 sats, feeding intolerance, pain. Cardiac: tacycardia. Resp: apnea, tacypnea, gasping, grunting. Color: Pale, cyanosis, mottling, ruddiness. Visceral: spitting up. Motor: seizures, twitching, tremors, flaccid. Treatment related: Noise, invasive procedures, lights, disrupted sleep-wake cycles.

Disuse Syndrome: At risk for a deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity.

Diversional Activity Deficit: Decreased stimulation from or interest or engagement in recreational or leisure activities.

Home Maintenance Management, Impaired: Inability to independently maintain a safe and growth – promoting immediate environment

Mobility, Impaired Physical: A limitation in independent, purposeful physical movement of the body or of one or more extremities.

Peripheral Neurovascular Dysfunction, Risk for: At risk for disruption in circulation, sensation, or motion of an extremity.

Dysfunctional Ventilatory Weaning Response: Inability to adjust to lowered levels of mechanical ventilator support that interrupts and prolongs the weaning process.

Airway Clearance, Ineffective: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

Breathing patterns, Ineffective: Inspiration and/or expiration that does not provide adequate ventilation.

Gas Exchange, Impaired: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

Ventilation, Spontaneous, Impaired: Decreased energy reserves result in an individual’s inability to maintain breathing adequate for supporting life.

Self-Care Deficit Syndrome (Specify): (Feeding, Bathing/Hygiene, Dressing/Grooming,

Toileting, Instrumental: Inability to perform or complete …. For oneself.

Tissue Perfusion, ineffective: (Specify) (Cerebral, Cardiopulmonary, Renal, Gastrointestinal, Peripheral) Decrease in oxygenation resulting in failure to nourish tissues at capillary level

Sleep –Rest Pattern

Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified. Inquire about- Patterns of sleep, rest, perception of quality and quantity.

Associated Nursing Diagnoses:

Sleep pattern Disturbance: Time-limited disruption of sleep (natural periodic suspension of consciousness).

Sleep-deprivation: Prolonged periods without sleep.

Sudden Infant Death Syndrome, Risk for: Presence of risk factors

Cognitive-Perceptual Pattern

Assessment is focused on the ability to comprehend and use information and on the sensory functions. Data pertaining to neurological functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be identified and further evaluated. Vision, learning, taste, touch, smell, language adequacy, memory, decision-making ability, complaints of discomforts. Inquire about – decisions, comfort, knowledge, sensory input, learning.

Associated Nursing Diagnoses:

Parenting: Impaired: State in which one or more caregivers demonstrate a real or potential inability to provide a constructive environment that nurtures the growth and development of the child (children).

Social isolation: State in which a person or group experiences or perceives a need or desire for increased involvement with others but is unable to make contact.

Comfort, Impaired: State in which an individual experiences an uncomfortable sensation in response to a noxious stimulus. Related to uterine contractions during labor, trauma to perineum during labor, involution of uterus or engorged breasts.

Fear: related to: lack of knowledge, pain, failure, invasive procedures, financial

Acute Pain: Pain is whatever the experiencing person says it is, existing whenever the person says it does; unpleasant sensory and emotional experience arising from actual or potential tissue damage or describe in terms of such damage; sudden or slow onset of pain of any intensity from mild to severe with anticipated or predictable end. The discomfort of normal labor or abnormal conditions such as prolonged latent phase, abnormal fetal position, CPD, or side effects of sedation or analgesia

Chronic Pain: Pain is whatever the experiencing person says it is, existing whenever the person says it does ; unpleasant sensory and emotional experience arising from actual or potential tissue damage or describe in terms of such damage (International Association for the Study of Pain); sudden or slow onset of pain of any intensity from mild to severe, constant or recurring, without anticipated or predictable end; state in which the individual experiences pain that persists for a period of time beyond the expected course or reasonable duration.

Confusion, Acute: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity level, consciousness or sleep-wake cycle.

Confusion, Chronic: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli and decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation and behavior.

Decisional Conflict (specify) – Uncertainty about course of action to be taken when choice among competing actions involves risk, loss or challenge to personal life values.

Impaired verbal communication: The state in which a person experiences a decreased ability to speak and understand others. Related to: inability to speak or understand English.

Knowledge Deficit: (Specify) Absence of deficiency of cognitive information related to a specific topic.

Sensory-Perception, Disturbed: (Specify) (Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.

Thought Processes, Altered: Disruption in cognitive operations and activities.

Readiness for enhanced knowledge: Related to interest in acquiring cognitive information. Expresses interest in learning, explains knowledge of topic, previous experience.

Self-Perception, Self-concept Pattern

Assessment is focused on the person's attitudes toward self, including identity, body image, and sense of self-worth. The person's level of self-esteem and response to threats to his or her self-concept may be identified. Attitudes about self, sense of worth, perception of abilities, emotional patterns, body image, identity. Inquire about - Anxiety, fear, control, self concept.

Associated Nursing Diagnoses:

Self-Concept: Readiness for Enhanced: A pattern of perceptions or ideas about self that is sufficient for well-being and can be strengthened

Self-Concept: Disturbed: State in which a person experiences or is at risk of experiencing a negative state of change about the way she/he feels, thinks or views self. It may include a change in body image, self-esteem or personal identity.

Anxiety: A vague, uneasy feeling of discomfort or dread accompanied by an autonomic response, with the source often non-specific or unknown to the individual; a feeling of apprehension caused by anticipation of danger

Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.

Fear: Response to perceived threat that is consciously recognized as a danger.

Hopelessness: Subjective state in which individual sees limited or unavailable alternatives or personal choices and is unable to mobilize energy for problem solving on his or her own behalf.

Powerlessness: Perception that one’s own actions will not significantly affect an outcome; perceived lack of control over current situation or immediate happening.

Body image Disturbance: Confusion in mental picture of one’s physical self.

Chronic Low Self-Esteem: Long-standing negative self-evaluations/feelings about self or self-capabilities

Situational Low Self-Esteem: Development of a negative perception of self-worth in response to a current situation (specify)

Role-Relationship Pattern

Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated. Patterns of relationships, role responsibilities, satisfaction with relationships and responsibilities. Inquire about – Communication, family, loss, parenting, socialization, violence, responsibilities.

Associated Nursing Diagnoses:

Breast-feeding: effective: mother-baby dyad exhibits adequate proficiency and satisfaction with the breast-feeding process. Includes mother's ability to facilitate successful latch-on, infant is content after feeding, regular and sustained suckling, infant cues and maternal interpretation are in sync.

Breast-feeding: ineffective: The state in which a mother-infant dyad experience or is at risk for dissatisfaction or difficulty with the breast-feeding process. Includes: actual or perceived inadequate milk supply, inability of infant to latch on correctly and sustain suckling, sore or cracked nipples, fussy and crying infant. Can be related to maternal fatigue, anxiety, ambivalence, inadequate nutrition, history of unsuccessful breast-feeding, non supportive partner/family, lack of knowledge, mother or infant is ill, barriers in the work environment.

Caregiver role strain: A state in which a person is experiencing physical, emotional, social and/or financial burdens in the process of caregiving. Related to insufficient energy, conflicts in caregiving responsibilities, or unrealistic expectations of self.

Communication, Verbal, Impaired: Decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols.

Family Processes, Interrupted: change in family relationships and/or functioning.

Family Processes, Alcoholism, dysfunctional: The state in which the psychosocial, spiritual and physiological functions of the family unit are chronically disorganized, leading to conflict, denial of problems, resistance to change, ineffective problem solving, and a series of self-perpetuating crises.

Grieving, Anticipatory: Intellectual and emotional responses and behaviors by which individuals, families, and communities work through the process of modifying self-concept based on the perception of potential loss.

Loneliness, Risk for: At risk for experiencing vague dysphoria.

Parenting, Impaired: Inability of primary caretaker to create, maintain, or regain an environment that promotes optimum growth and development of the child.

Parenting: Readiness for Enhanced: A pattern of providing an environment for children or other dependent person(s) that is sufficient to nurture growth and development and can be strengthened.

Role performance, Ineffective: Patterns of behavior and self-expression that do not match the environmental context, norms, and expectations.

Social Interaction, Impaired: Insufficient or excessive quantity or ineffective quality of social exchange.

Social Isolation: Aloneness experience by the individual and perceived as imposed by others and as a negative or threatened state.

Sexual-Reproductive Pattern

Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may be identified. Menstrual, reproductive history, satisfaction with sexual relationships, sexual identity, premenopausal or postmenopausal problems, accuracy of sex education. Inquire about – problems with reproductive system and sexual response.

Associated Nursing Diagnoses:

Anxiety: A state in which an individual experiences feelings of uneasiness manifested by symptoms of physiologic, emotional and cognitive symptoms.

Fear: Start in which an individual/group experiences a feeling of physiologic and/or emotional disruption related to an identifiable source that is perceived as dangerous.

Fatigue: Self recognized state in which a person experiences an overwhelming/sustained sense of exhaustion and decreased capacity for physical and mental work that is not relieved by rest (or inability to get adequate est).

Knowledge deficit or readiness for enhanced knowledge: related to contraceptive choices

Sexual Dysfunction: Change in sexual function that is viewed as unsatisfying, unrewarding, inadequate, painful.

Sexual Patterns, Ineffective: Expressions of concern regarding own sexuality

Potential complication: Experiencing or at high risk for experiencing a problem in reproductive functioning such as: prenatal bleeding, preterm labor, or having a sexually transmitted infection (STI).

Coping-Stress Tolerance Pattern

Assessment is focused on the person's perception of stress and on his or her coping strategies Support systems are evaluated, and symptoms of stress are noted. The effectiveness of a person's coping strategies in terms of stress tolerance may be further evaluated. Ability to manage stress, knowledge of stress tolerance, sources of support, number of stressful life events in last year. Inquire about – coping, stress, events

Associated Nursing Diagnoses:

Adjustment, Impaired : Inability to modify lifestyle/behavior in a manner consistent with a change in health status.

Caregiver Role Strain: Difficulty in performing family caregiver role.

Impaired verbal communication: The state in which a person experiences a decreased ability to speak and understand others. Related to: inability to speak or understand English.

Coping, Ineffective, Individual: Inability to form a valid appraisal of internal or external stressors, inadequate choices of practiced responses, and/or inability to access or use available resources.

Coping, enhanced readiness for: An individual or family exhibit effective management of a family member's health challenge(s).

Defensive Coping: Repeated projection of falsely positive self-evaluations base on self-protective pattern that defends against underlying perceived threats to positive self-regard.

Denial, Ineffective: The conscious or unconscious attempt to reduce anxiety or fear by disavowing the knowledge or meaning of an event, leading to the detriment of health.

Coping, family, disabling: Behavior of significant person(family member or other primary person) that disables his or her capacity and client’s capacity to effectively address tasks essential to either person’s adaptation to the health challenge.

Coping, family, compromised: Situation in which usually supportive primary person (family member or close friend) provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that may be needed by client to manage or master adaptive tasks related to health challenge.

Coping, Community, Ineffective: Pattern of community activities (for adaptation and problem solving) that is unsatisfactory for meeting the demands or needs of the community.

Post-Trauma Syndrome: Sustained maladaptive response to a traumatic, overwhelming event.

Rape Trauma Syndrome: sustained maladaptive response to forced, violent sexual act against victim’s will and consent.

Relocation Stress Syndrome: Physiological and /or psychosocial disturbances that result from transfer from one environment to another.

Self-Mutilation, Risk for: At risk for deliberate self-injurious behavior causing tissue damage with the intent of causing non-fatal injury to attain relief of tension.

Suicide, Risk for: At risk for self-inflicted, life-threatening injury.

Violence, Risk for other directed: At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to others.

Value-Belief Pattern

Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her choices or decisions. Values, goals, beliefs, spiritual practices, perceived conflicts in values

Associated Nursing Diagnoses:

Self-Concept: Readiness for Enhanced: A pattern of perceptions or ideas about self that is sufficient for well-being and can be strengthened

Self-Concept: Disturbed: State in which a person experiences or is at risk of experiencing a negative state of change about the way she/he feels, thinks or views self. It may include a change in body image, self-esteem or personal identity.

Spiritual Distress: Impaired ability to experience and integrate meaning and purpose in life through the individual’s connectedness with self, others art, music, literature, nature, or a power greater than oneself.

Spiritual Well Being, Readiness for enhanced: Ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, or a power greater than oneself.

Health-Seeking Behaviors: State in which person in stable health activity seeks ways to alter personal health habits and/or environment to move toward a higher level of wellness.

Ackley, B, Ladwig, G., (2004). Nursing diagnosis handbook: A guide to planning care, (6 th Ed.) St. Louis: Mosby.

Carpenito, L. (2002). Nursing diagnosis: Application to clinical practice. Philadelphia PA: Lippincott.

 

 

 


Jeanette Koshar, RN, MSN, NP, PhD
Office: (707) 664-2649
Email: jeanette.koshar@sonoma.edu