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APPENDIX

NANDA International–Approved

Nursing Diagnoses

The following list of nursing diagnoses represents those most frequently used in the emergency department setting. Diagnoses may be Actual but may also include a Risk for. For a complete listing of the nursing diagnoses approved by the NANDA International, the reader is referred to a nursing diagnosis textbook.

Airway related Ineffective airway clearance Risk for ineffective clearance Risk for aspiration

Breathing related Ineffective breathing pattern Risk for ineffective breathing pattern Impaired gas exchange Risk for impaired gas exchange

Circulation/Perfusion related Decreased cardiac output Risk for decreased cardiac output Deficient fluid volume Risk for deficient fluid volume Excess fluid volume Risk for excess fluid volume Ineffective tissue perfusion: peripheral, renal,

cerebral, cardiopulmonary, spinal cord, gastrointestinal, testicular, ocular, optic, maternal, fetal

Risk for ineffective tissue perfusion: peripheral, renal cerebral, cardiopulmonary, spinal cord, gastrointestinal, testicular, ocular, optic, maternal, fetal

Pain related Acute pain Chronic pain

Temperature related Ineffective thermoregulation Risk for ineffective thermoregulation Hyperthermia Risk for hyperthermia Hypothermia Risk for hypothermia Infection (not an approved NANDA diagnosis) Risk for infection Ineffective protection

Mobility related Activity intolerance Risk for activity intolerance Risk for falls Risk for injury Impaired physical mobility Risk for impaired physical mobility Fatigue

Neurologic/Sensory related Decreased intracranial adaptive capacity Acute confusion

1074 APPENDIX A

Risk for acute confusion Chronic confusion Impaired memory Disturbed sensory perception: tactile, kinesthetic

Abdominal/Genitourinary related Constipation Diarrhea Impaired urinary elimination

Dermatology related Impaired skin integrity Impaired tissue integrity

Psychological related Anxiety Fear Risk for poisoning Ineffective denial Ineffective coping: individual and/or family Risk for ineffective coping: individual and/or

family Risk for caregiver role strain Dysfunctional family processes: alcoholism Interrupted family processes Grieving

Anticipatory grieving Dysfunctional grieving Powerlessness Impaired parenting Disturbed thought processes Disturbed sensory perception: visual, auditory Rape-trauma syndrome Risk for suicide/suicidal thoughts Self-care deficit Disturbed body image Chronic/situational low self-esteem Self-mutilation Ineffective role performance Risk for self/other-directed violence Impaired verbal communication Risk for unilateral neglect

Education/Health Status related Imbalanced nutrition: less than body

requirements Ineffective health maintenance Deficient knowledge Risk for deficient knowledge Noncompliance

APPENDIX

Current Evaluations and Outcomes

Correlated with Current Nursing

Diagnoses

Nursing Diagnosis Desired Expected Outcome

Airway Related The patient will maintain a patent airway as Ineffective airway clearance evidenced by Risk for ineffective clearance Absence of stridor, hoarseness, cyanosis Risk for aspiration Equal, bilateral chest expansion

Effective cough-gag reflex Ability to handle secretions independently

Breathing Related The patient will have effective breathing as evidenced by Ineffective breathing pattern Regular rate, depth, and pattern of respirations Risk for ineffective breathing pattern Absence of cyanosis Impaired gas exchange Absence of chest/abdominal retractions, nasal flaring or Risk for impaired gas exchange use of accessory muscles

Clear, equal bilateral breath sounds Pulse oximetry readings greater than 94% Arterial blood gas results within normal limits Alert and oriented level of consciousness

Circulation/Perfusion Related The patient will have effective circulation/perfusion Decreased cardiac output as evidenced by Risk for decreased cardiac output Blood pressure measurements, pulse rates appropriate for age Deficient fluid volume Strong, palpable peripheral pulses Risk for deficient fluid volume Alert and oriented level of consciousness Excess fluid volume Skin warm and dry, normal in color Risk for excess fluid volume Urinary output appropriate for age/weight Ineffective tissue perfusion: peripheral, renal, Diminished fluid volume loss

cerebral, cardiopulmonary, spinal cord, gastro- Absence of ischemic pain intestinal, testicular, ocular, optic, maternal, fetal Clear, equal bilateral breath sounds

Risk for ineffective tissue perfusion: peripheral, renal, Clear and nonmuffled heart sounds cerebral, cardiopulmonary, spinal cord, gastro- Absence of cardiac dysrhythmias intestinal, testicular, ocular, optic, maternal, fetal Normal hemoglobin and hematocrit levels

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Continued

1076 APPENDIX B

Nursing Diagnosis Desired Expected Outcome

Pain Related The patient will have a lessening or absence of pain Acute pain as evidenced by Chronic pain Verbal acknowledgment of pain relief

Absence or lessening of physiologic pain indicators: skin pallor, tachycardia, hypertension, tachypnea, diaphoresis, restlessness

Temperature Related The patient will maintain effective body temperature Ineffective thermoregulation regulation as evidenced by Risk for ineffective thermoregulation Core body temperature maintained at 98°F to 99.5°F Hyperthermia (36°C to 37.5°C) Risk for hyperthermia Skin warm and dry, normal in color Hypothermia Absence of seizure activity Risk for hypothermia Alert and oriented level of consciousness Infection (not an approved NANDA International Blood pressure measurements, pulse rate appropriate for age

diagnosis) Absence of cardiac dysrhythmias Risk for infection Urinary output appropriate for age/weight Ineffective protection

Mobility Related The patient will demonstrate adequate mobility as Activity intolerance evidenced by Risk for activity intolerance Ability to ambulate unassisted or with appropriate assistance Risk for falls Appropriate use of assistive devices Risk for injury Absence of falls Impaired physical mobility Absence of further injury Risk for impaired physical mobility Fatigue

Neurologic/Sensory Related The patient will maintain neurologic and sensory Decreased intracranial adaptive capacity functioning as evidenced by Acute confusion Alert and oriented level of consciousness Risk for acute confusion Normal intracranial pressures Chronic confusion Blood pressure measurements, pulse rate appropriate for age Impaired memory Absence of seizure activity Disturbed sensory perception: tactile, kinesthetic Decrease in sensory/perceptual dysfunction

Maintenance of spinal immobilization Normal papillary reaction

Abdominal/Genitourinary Related The patient will maintain adequate function of the Constipation abdominal/genitourinary system as evidenced by Diarrhea Normal bowel sounds Impaired urinary elimination Absence of abdominal distention

Urinary output appropriate for age/weight

Dermatology related The patient will maintain skin integrity as evidenced by Impaired skin integrity Appropriate cleansing of wounds Impaired tissue integrity Appropriate closure of wounds

Decreased skin irritation, erythema Burn tissue cooled Preservation of amputated parts

Nursing Diagnosis Desired Expected Outcome

Psychological Related The patient will demonstrated an increase in Anxiety psychological functioning as evidenced by Fear Verbal communication of less anxiety or fear Risk for poisoning Commitment to seek further psychological help Ineffective denial Verbal acknowledgment of possible psychological dysfunction Ineffective coping: individual and/or family Poison absorption decreased Risk for ineffective coping: individual and/or family Decrease in hallucinations Risk for caregiver role strain Dysfunctional family processes: alcoholism Interrupted family processes Grieving Anticipatory grieving Dysfunctional grieving Powerlessness Impaired parenting Disturbed thought processes Disturbed sensory perception: visual, auditory Rape-trauma syndrome Risk for suicide/suicidal thoughts Self-care deficit Disturbed body image Chronic/situational low self-esteem Self-mutilation Ineffective role performance Risk for self/other-directed violence Impaired verbal communication Risk for unilateral neglect

Education/Health Status Related The patient will demonstrate adequate knowledge of Imbalanced nutrition: less than body requirements health status as evidenced by Ineffective health maintenance Accurate verbalization/demonstration of discharge Deficient knowledge instructions Risk for deficient knowledge Verbal commitment to maintain effective health staus Noncompliance

CURRENT EVALUATIONS AND OUTCOMES CORRELATED WITH CURRENT NURSING DIAGNOSES 1077

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Age Heart Rate Systolic Blood Pressure Respiratory Rate

Preterm newborn 120–180 beats/min 40–60 mm Hg 55–65 breaths/min Term newborn 90–170 beats/min 52–92 mm Hg 40–60 breaths/min 1 mo 110–180 beats/min 60–104 mm Hg 30–50 breaths/min 6 mo 110–180 beats/min 65–125 mm Hg 25–35 breaths/min 1 yr 80–160 beats/min 70–118 mm Hg 20–30 breaths/min 2 yr 80–130 beats/min 73–117 mm Hg 20–30 breaths/min 4 yr 80–120 beats/min 65–117 mm Hg 20–30 breaths/min 6 yr 75–115 beats/min 76–116 mm Hg 18–24 breaths/min 8 yr 70–110 beats/min 76–119 mm Hg 18–22 breaths/min 10 yr 70–110 beats/min 82–122 mm Hg 16–20 breaths/min 12 yr 60–110 beats/min 84–128 mm Hg 16–20 breaths/min 14 yr 60–105 beats/min 84–136 mm Hg 16–20 breaths/min

From Proehl, J. (1999). Secondary survey. In Emergency Nursing Procedures (p. 6). Philadelphia: Saunders.

APPENDIX

Age-Specific Vital Signs

Area of Measurement Coded Value

Systolic Blood Pressure (mm Hg)

Greater than 89 4 76–89 3 50–75 2 1–49 1 0 0

Respiratory Rate (spontaneous inspirations/minute)*

10–29 4 Greater than 29 3 6–9 2 1–5 1 0 0 *patient initiated, not artificial ventilations

Glasgow Coma Scale Score

13–15 4 9–12 3 6–8 2 4–5 1 3 0 Total possible points: 0–12

From Champion, H. R., Sacco, W. J., Copes, W. S., Gann, D. S., Gennarelli, T. A., & Flanagan, M. E. (1989). A revision of the trauma score. J Trauma, 29, 623–629.

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APPENDIX

Revised Trauma Score

Downloaded from www.rehabmeasures.org Test instructions derived from McCaffery et al, 1989 Page 1

The Numeric Pain Rating Scale Instructions

General Information:

The patient is asked to make three pain ratings, corresponding to

current, best and worst pain experienced over the past 24 hours.

The average of the 3 ratings was used to represent the patient’s level

of pain over the previous 24 hours.

Patient Instructions (adopted from (McCaffery, Beebe et al. 1989): “Please indicate the intensity of current, best, and worst pain levels over the past 24 hours on a scale of 0 (no pain) to 10 (worst pain imaginable)”

Reference: McCaffery, M., Beebe, A., et al. (1989). Pain: Clinical manual for nursing practice, Mosby St. Louis, MO.

INFORMATION POINT:

Visual Analogue

Scale (VAS)

A Visual Analogue Scale (VAS) is a measurement instrument that tries to

measure a characteristic or attitude that is believed to range across a continuum

of values and cannot easily be directly measured. For example, the amount of

pain that a patient feels ranges across a continuum from none to an extreme

amount of pain. From the patient's perspective this spectrum appears

continuous ± their pain does not take discrete jumps, as a categorization of

none, mild, moderate and severe would suggest. It was to capture this idea of an

underlying continuum that the VAS was devised.

Operationally a VAS is usually a horizontal line, 100 mm in length, anchored

by word descriptors at each end, as illustrated in Fig. 1. The patient marks on

the line the point that they feel represents their perception of their current state.

The VAS score is determined by measuring in millimetres from the left hand

end of the line to the point that the patient marks.

Figure 1 Effects of the interpersonal, technical and communication skills of the nurse on the

effectiveness of treatment.

There are many other ways in which VAS have been presented, including

vertical lines and lines with extra descriptors. Wewers & Lowe (1990) provide an

informative discussion of the bene®ts and shortcomings of different styles of

VAS.

As such an assessment is clearly highly subjective, these scales are of most

value when looking at change within individuals, and are of less value for

comparing across a group of individuals at one time point. It could be argued

that a VAS is trying to produce interval/ratio data out of subjective values that

are at best ordinal. Thus, some caution is required in handling such data. Many

researchers prefer to use a method of analysis that is based on the rank ordering

of scores rather than their exact values, to avoid reading too much into the

precise VAS score.

Further reading Wewers M.E. & Lowe N.K. (1990) A critical review of visual analogue scales in the measurement of clinical phenomena. Research in Nursing and Health 13, 227±236.

N I C O L A C R I C H T O N

Ó 2001 Blackwell Science Ltd, Journal of Clinical Nursing, 10, 697±706

706 D. Gould et al.

NEONATAL INFANT PAIN SCALE (NIPS)*

Variables Scoring Range

Facial expression 0–1 Cry 0–2 Breathing patterns 0–1 Arms 0–1 Legs 0–1 State of arousal 0–1

*Scoring range: 0 = no pain; 7 = worst pain.

APPENDIX

Infant Pain Scales

NEONATAL PAIN, AGITATION, AND SEDATION SCALE (NPASS)*

Variables Scoring Range

Cry/irritability 0–2 Behavior/state 0–2 Facial expression 0–2 Extremities/tone 0–2 Vital signs: heart rate, 0–2

respiratory rate, blood pressure, oxygen saturation

*Scoring range: 0 = no pain; 10 = intense pain. Sedation score: 0 = no sedation; 10 = deep sedation.

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INFANT PAIN SCALES 1083

PAIN ASSESSMENT TOOL (PAT)*

Variables Scoring Range

Posture/tone 1–2 Sleep pattern 0–2 Expression 1–2 Color 0–2 Cry 0–2 Respiration 1–2 Heart rate 1–2 Oxygen saturation 0–2 Blood pressure 0–2 Nurse’s perception 0–2

*Scoring rage 4 = no pain; 20 = worst pain. Modified from Hockenberry M. J., Wilson, D., Winkelstein, M. L., & Kline, N. E. (Eds.). (2003). Wong’s nursing care of infants and children (7th ed.). St. Louis, MO: Mosby.

(REVISED) FLACC Scale SCORING

Categories 0 1 2 Face No particular

expression or smile. Occasional grimace or frown, withdrawn, disinterested, Sad, appears worried.

Frequent to constant quivering chin, clenched jaw, distressed looking face, expression of fright/ panic.

Legs Normal position or relaxed; usual tone and motion to limbs.

Uneasy, restless, tense, occasional tremors.

Kicking, or legs drawn up, marked increase in spasticity, constant tremors, jerking.

Activity Lying quietly, normal position, moves easily, regular, rhythmic respirations.

Squirming, shifting back and forth, tense, tense/guarded movements, mildly agitated, shallow/ splinting respirations, intermittent sighs

Arched, rigid or jerking, severe agitation, head banging, shivering, breath holding, gasping, severe splinting.

Cry No cry (awake or asleep)

Moans or whimpers: occasional complaint, occasional verbal outbursts, constant grunting

Crying steadily, screams or sobs, frequent complaints, repeated outbursts, constant grunting.

Consolability Content, relaxed Reassured by occasional touching, hugging, or being talked to: distractible

Difficult to console or comfort, pushing caregiver away, resisting care or comfort measures.

Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, which results in a total score between zero and ten.

References: Merkel, S. et al. The FLACC: A Behavioural Scale for Scoring Postoperative Pain in Young Children, Pediatric Nurse 23(3): 293-297, 1997. Copyright: Jannetti Co. University of Michigan Medical Centre. Malviya, S., Vopel-Lewis, T. Burke, Merkel, S., Tait, A.R. (2006). The revised FLACC Observational Pain Tool: Improved Reliability and Validity for Pain Assessment in Children with Cognitive Impairment. (Pediatric Anesthesia 16: 258-265).