Nursing Diagnoses

CCC of Nursing Diagnoses (V2.5) consists of 176 Nursing Diagnoses (60 major & 116 sub-categories). The major categories represent concrete patient problems and the sub-categories represent more precise related concepts.  Concept Each depicts patient problems/ diagnoses and/or healthcare conditions requiring clinical care by nurses and other healthcare providers. The Nursing Diagnoses and/or Patient Problems were collected from the original live research data that represented unique diagnostic concepts structured as a noun clause.

Definition    

A Nursing Diagnosis is defined as “A clinical judgement about the healthcare consumer’s response to actual or potential health conditions or needs. The diagnosis provided the basis for determination of a plan to achieve expected outcomes.  Registered nurses utilize nursing and medical diagnoses depending upon education and clinical preparation and legal authority” (ANA, 2010, p.64).

Description

The CCC of Nursing Diagnoses were derived from the 40,361 patient problems and/or nursing diagnosis narrative statements collected from the research study patients for an entire episode of care as requiring nursing services including the actual outcome of the care on Discharge.  The diagnostic narrative statements analyzed using “keyword” sorts as well as other statistically analyses resulting in the development of the major categories and sub-categories for the varying concept scopes which were structured as noun clauses. As described, the statements were coded with the preliminary vocabulary and then categorized by the original 20 Care Component Classes. The diagnoses were also linked to the most appropriate interventions that were considered the key activities to treat them. You can explore them in the table below:

Component Letter Diagnosis Code Diagnosis Name Diagnosis Description
A 01.0 Activity Alteration Change in or modification of energy used by the body
01.1 Activity Intolerance Incapacity to carry out physiological or psychological daily activities
01.2 Activity Intolerance Risk Increased chance of an incapacity to carry out physiological or psychological daily activities
01.3 Diversional Activity Deficit Lack of interest or engagement in leisure activities
01.4 Fatigue Exhaustion that interferes with physical and mental activities
01.5 Physical Mobility Impairment Diminished ability to perform independent movement
01.6 Sleep Pattern Disturbance Imbalance in the normal sleep/wake cycle
01.7 Sleep Deprivation Lack of the normal sleep / wake cycle
02.0 Musculoskeletal Alteration Change in or modification of the muscles, bones or support structures
B 03.0 Bowel Elimination Alteration Change in or modification of the gastrointestinal system
03.1 Bowel Incontinence Involuntary defecation
03.3 Diarrhea Abnormal frequency and fluidity of feces
03.4 Fecal Impaction Feces wedged in intestine
03.5 Perceived Constipation Impression of infrequent or difficult passage of hard, dry feces without cause.
03.6 Constipation Difficult passage of hard, dry, feces
04.0 Gastrointestinal Alteration Change in or modification of the stomach or intestines
04.1 Nausea Distaste for food/fluid and an urge to vomit
04.2 Vomiting Expulsion of stomach contents through the mouth.
C 05.0 Cardiac Output Alteration Change in or modification of the pumping action of the heart or blood vessels
06.0 Cardiovascular Alteration Change in or modification of the heart or blood vessels
06.1 Blood Pressure Alteration Change in or modification of the systolic or diastolic pressure
06.2 Bleeding Risk Increased chance of loss of blood volume
D 07.0 Cerebral Alteration Change in or modification of mental processes
07.1 Confusion State of being disoriented (mixed-up)
08.0 Knowledge Deficit Lack of information, understanding, or comprehension
08.1 Knowledge Deficit of Diagnostic Test Lack of information on tests to identify disease or assess health condition
08.2 Knowledge Deficit of Dietary Regimen Lack of information on the prescribed diet/food intake
08.3 Knowledge Deficit of Disease Process Lack of information on the morbidity, course, or treatment of the health,condition
08.4 Knowledge Deficit of Fluid Volume Lack of information on fluid volume intake requirements
08.5 Knowledge Deficit of Medication Regimen Lack of information on prescribed regulated course of medicinal,substances
08.6 Knowledge Deficit of Safety Precautions Lack of information on measures to prevent injury, danger, or loss
08.7 Knowledge Deficit of Therapeutic Regimen Lack of information on regulated course of treating disease
09.0 Thought Processes Alteration Change in or modification of thought and cognitive processes
09.1 Memory Impairment Diminished or inability to recall past events
E 10.0 Dying Process Physical and behavioral responses associated with death
11.0 Family Coping Impairment Inadequate family response to problems or difficulties
11.2 Disabled Family Coping Inability of family to function optimally
12.0 Individual Coping Impairment Inadequate personal response to problems or difficulties
12.1 Adjustment Impairment Inadequate adaptation to condition or change in health status
12.2 Decisional Conflict Struggle related to determining a course of action
12.3 Defensive Coping Self-protective strategies to guard against threats to self
12.4 Denial Attempt to reduce anxiety by refusal to accept thoughts, feelings, or facts
13.0 Post-Trauma Response Sustained behavior related to a traumatic event
13.1 Rape Trauma Syndrome Group of symptoms related to a forced sexual act
14.0 Spiritual State Alteration Change in or modification of the spirit or soul
14.1 Spiritual Distress Anguish related to the spirit or soul
52.0 Community Coping Impairment Inadequate community response to problems or difficulties
53.0 Grieving Feeling of great sorrow
53.1 Anticipatory Grieving Feeling great sorrow before the event or loss
53.2 Dysfunctional Grieving Prolonged feeling of great sorrow
F 15.0 Fluid Volume Alteration Change in or modification of bodily fluid
15.1 Fluid Volume Deficit Dehydration or fluid loss
15.2 Fluid Volume Deficit Risk Increased chance of dehydration or fluid loss.
15.3 Fluid Volume Excess Fluid retention, overload, or edema
15.4 Fluid Volume Excess Risk Increased chance of fluid retention, overload, or edema
62.0 Electrolyte Imbalance Higher or lower body electrolyte levels
G 17.0 Health Maintenance Alteration Change in or modification of ability to manage health-related needs
17.1 Failure to Thrive Inability to grow and develop normally
18.0 Health Seeking Behavior Alteration Change in or modification of actions needed to improve health state
19.0 Home Maintenance Alteration Inability to sustain a safe, healthy environment
20.0 Noncompliance Failure to follow therapeutic recommendations
20.1 Noncompliance of Diagnostic Test Failure to follow therapeutic recommendations on tests to identify disease or assess health condition.
20.2 Noncompliance of Dietary Regimen Failure to follow the prescribed diet/food intake.
20.3 Noncompliance of Fluid Volume Failure to follow fluid volume intake requirements
20.4 Noncompliance of Medication Regimen Failure to follow prescribed regulated course of medicinal substances
20.5 Noncompliance of Safety Precautions Failure to follow measures to prevent injury, danger, or loss
20.6 Noncompliance of Therapeutic Regimen Failure to follow regulated course of treating disease
H 21.0 Medication Risk Increased chance of negative response to medicinal substance
21.1 Polypharmacy Use of two or more drugs together
I 22.0 Endocrine Alteration Change in or modification of internal secretions or hormones
23.0 Immunologic Alteration Change in or modification of the immune system
J 24.0 Nutrition Alteration Change in or modification of food or nutrients
24.1 Body Nutrition Deficit Less than adequate intake or absorption of food or nutrients
24.2 Body Nutrition Deficit Risk Increased chance of less than adequate intake or absorption of food or nutrients
24.3 Body Nutrition Excess More than adequate intake or absorption of food or nutrients
24.4 Body Nutrition Excess Risk Increased chance of more than adequate intake or absorption of food or,nutrients
24.5 Swallowing Impairment Inability to move food from mouth to stomach
54.0 Infant Feeding Pattern Impairment Imbalance in the normal feeding habits of an infant
55.0 Breastfeeding Impairment Diminished ability to nourish infant at the breast
K 25.0 Physical Regulation Alteration Change in or modification of somatic control
25.1 Autonomic Dysreflexia Life threatening inhibited sympathetic response to a noxious stimuli in a person with a spinal cord injury at T7 or above
25.2 Hyperthermia Abnormal high body temperature
25.3 Hypothermia Abnormal low body temperature
25.4 Thermoregulation Impairment Fluctuation of temperature between hypothermia and hyperthermia
25.5 Infection Risk Increased change of contamination with disease-producing germs
25.6 Infection Contamination with disease-producing germs
25.7 Intracranial Adaptive Capacity Impairment Intracranial fluid volumes are compromised
L 26.0 Respiration Alteration Change in or modification of the breathing function
26.1 Airway Clearance Impairment Inability to clear secretions/obstructions in airway
26.2 Breathing Pattern Impairment Inadequate inhalation or exhalation
26.3 Gas Exchange Impairment Imbalance of oxygen and carbon dioxide transfer between lung and vascular system
56.0 Ventilatory Weaning Impairment Inability to tolerate decreased levels of ventilator support
M 27.0 Role Performance Alteration Change in or modification of carrying out responsibilities
27.1 Parental Role Conflict Struggle with parental position and responsibilities
27.2 Parenting Alteration Change in or modification of nurturing figures ability to promote growth and development of infant/child
27.3 Sexual Dysfunction Deleterious change in sex response
27.4 Caregiver Role Strain Excessive tension of one who gives physical or emotional care and support to another person or patient
28.0 Communication Impairment Diminished ability to exchange thoughts, opinions, or information
28.1 Verbal Impairment Diminished ability to exchange thoughts, opinions, or information through, speech
29.0 Family Processes Alteration Change in or modification of usual functioning of a related group
31.0 Sexuality Patterns Alteration Change in or modification of persons's sexual response
32.0 Socialization Alteration Change in or modification of personal identity
32.1 Social Interaction Alteration Inadequate quantity or quality of personal relations
32.2 Social Isolation State of aloneness; lack of interaction with others
32.3 Relocation Stress Syndrome Excessive tension from moving to a new location
N 33.0 Injury Risk Increased chance of danger or loss
33.1 Aspiration Risk Increased chance of material into trachea-bronchial passages
33.2 Disuse Syndrome Group of symptoms related to effects of immobility
33.3 Poisoning Risk Exposure to or ingestion of dangerous products
33.4 Suffocation Risk Increase chance of inadequate air for breathing
33.5 Trauma Risk Increased chance of accidental tissue injury
33.6 Fall Risk Increased chance of conditions that results in falls
34.0 Violence Risk Increased chance of harming self or others
34.1 Suicide Risk Increased chance of taking one's life intentionally
34.2 Self mutilation Risk Increased chance of destroying a limb or essential part of the body
57.0 Perioperative Injury Risk Increased chance of injury during the operative processes
57.1 Perioperative Positioning Injury Damages from operative process positioning
57.2 Surgical Recovery Delay Slow or delayed recovery from a surgical procedure
58.0 Substance Abuse Excessive use of harmful bodily materials
58.1 Tobacco Abuse Excessive use of tobacco products
58.2 Alcohol Abuse Excessive use of distilled liquors
58.3 Drug Abuse Excessive use of habit forming medications
O 35.0 Bathing/Hygiene Deficit Impaired ability to cleanse oneself
36.0 Dressing/Grooming Deficit Impaired ability to clothe and groom oneself
37.0 Feeding Deficit Impaired ability to feed oneself
38.0 Self Care Deficit Impaired ability to maintain oneself
38.1 Activities of Daily Living (ADLs) Alteration Change in modification of ability to maintain oneself
38.2 Instrumental Activities of Daily Living (IADLs) Alteration Change in or modification of more complex activities than those needed to maintain oneself
39.0 Toileting Deficit Impaired ability to urinate or defecate for oneself
P 40.0 Anxiety Feeling of distress or apprehension whose source is unknown
41.0 Fear Feeling of dread or distress whose cause can be identified
42.0 Meaningfulness Alteration Change in or modification of the ability to see the significance, purpose, or,value in something
42.1 Hopelessness Feeling of despair or futility and passive abandonment
42.2 Powerlessness Feeling of helplessness, or inability to act
43.0 Self Concept Alteration Change in or modification of ability to maintain one's image of self
43.1 Body Image Disturbance Imbalance in the perception of the way one's body looks
43.2 Personal Identity Disturbance Imbalance in the ability to distinguish between the self and the non-self
43.3 Chronic Low Self-Esteem Disturbance Persistent negative evaluation of oneself
43.4 Situational Self-Esteem Disturbance Negative evaluation of oneself in response to a loss or change
Q 44.0 Sensory Perceptual Alteration Change in or modification of the response to stimuli
44.1 Auditory Alteration Change in or modification of diminished ability to hear
44.2 Gustatory Alteration Change in or modification of diminished ability to taste
44.3 Kinesthetic Alteration Change in or modification of diminished balance
44.4 Olfactory Alteration Change in or modification of diminished ability to smell
44.5 Tactile Alteration Change in or modification of diminished ability to feel
44.6 Unilateral Neglect Lack of awareness of one side of the body
44.7 Visual Alteration Change in or modification of diminished ability to see
45.0 Comfort Alteration Change in or modification of sensation that is distressing
63.0 Pain Physical suffering or distress, to hurt
63.1 Acute Pain Severe pain of limited duration
63.2 Chronic Pain Pain that persists over time
R 46.0 Skin Integrity Alteration Change in or modification of skin conditions
46.1 Oral Mucous Membranes Impairment Diminished ability to maintain the tissues of the oral cavity
46.2 Skin Integrity Impairment Diminished ability to maintain the integument
46.3 Skin Integrity Impairment Risk Increased chance of skin breakdown
46.4 Skin Incision Cutting of the integument/skin
46.5 Latex Allergy Response Pathological reaction to latex products
47.0 Peripheral Alteration Change in or modification of neurovascularization of the extremities
S 48.0 Tissue Perfusion Alteration Change in or modification of the oxygenation of tissues
T 49.0 Urinary Elimination Alteration Change in or modification of excretion of the waste matter of the kidneys
49.1 Functional Urinary Incontinence Involuntary, unpredictable passage of urine
49.2 Reflex Urinary Incontinence Involuntary passage of urine occurring at predictable intervals
49.3 Stress Urinary Incontinence Loss of urine occurring with increased abdominal pressure
49.5 Urge Urinary Incontinence Involuntary passage of urine following a sense of urgency to void
49.6 Urinary Retention Incomplete emptying of the bladder
50.0 Renal Alteration Change in or modification of the kidney function
U 59.0 Reproductive Risk Increased chance of harm in the process of replicating or giving rise to an offspring/child
59.1 Fertility Risk Increased chance of conception to develop an offspring/child
59.2 Infertility Risk Decreased chance of conception to develop an offspring/child
59.3 Contraception Risk Increased chance of harm by preventing the conception of an offspring/child
60.0 Perinatal Risk Increased chance of harm before, during, and immediately after the creation of an offspring / child
60.1 Pregnancy Risk Increased chance of harm during the gestational period of the formation of an offspring / child
60.2 Labor Risk Increased chance of harm during the period supporting the bringing forth of an offspring / child
60.3 Delivery Risk Increased chance of harm during the period supporting the expulsion of an offspring / child at birth
60.4 Postpartum Risk Increased chance of harm during the time period immediately following the delivery of an offspring / child
61.0 Growth and Development Alteration Change in or modification of age specific normal growth standards and/or developmental skills.
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