College of Eastern Utah

Practical Nursing Program (2007-2008)

NANDA Domain Definitions

HEALTH PROMOTION
The awareness of well-being or normality of function and strategies used to maintain control of and enhance
that well-being or normality of function
Health Awareness: Recognition of normal function and well-being
Health Management: Identifying, controlling, performing, and integrating activities to maintain health and well-being

NUTRITION
The activities of taking in, assimilating, and using nutrients for the purposes of tissue maintenance, tissue
repair, and the production of energy.
Ingestion: Taking food or nutrients into the body
Digestion: The physical and chemical activities that convert foodstuffs into substances suitable for absorption and
assimilation.
Absorption: The act of taking up nutrients through body tissues.
Metabolism: The chemical and physical processes occurring in living organisms and cells for the development and
use of protoplasm, production of waste and energy, with the release of energy for all vital processes.
Hydration: The taking in and absorption of fluids and electrolytes.

ELIMINATION
Secretion and excretion of waste products from the body.
Urinary system: The process of secretion and excretion of urine.
Gastrointestinal system: Excretion and expulsion of waste products from the bowel.
Integumentary system: Process of secretion and excretion through the skin.
Pulmonary system: Removal of byproducts of metabolic products, secretions, and foreign material from the lung or
bronchi.

ACTIVITY/REST
The production, conservation, expenditure, or balance of energy resources.
Sleep / Rest Slumber, repose, ease, or inactivity.
Activity / Exercise Moving parts of the body (mobility), doing work, or promoting actions often (but not always)
against resistance.
Energy Balance A dynamic state of harmony between intake and expenditure of resources.
Cardiovascular-pulmonary Responses Cardiopulmonary mechanisms that support activity/rest.

PERCEPTION/COGNITION
The human information processing system including attention, orientation, sensation, perception, cognition,
and communication.
Attention: Mental readiness to notice or observe.
Orientation: Awareness of time, place, and person.
Sensation/Perception: Receiving information through the senses of touch, taste, smell, vision, hearing, and
kinesthesia and the comprehension of sense data resulting in naming, associating, and/or pattern
recognition.
Cognition: Use of memory, learning, thinking, problem solving, abstraction, judgment, insight, intellectual capacity,
calculation, and language.
Communication: Sending and receiving verbal and nonverbal information.

SELF-PERCEPTION
Awareness about the self.

Self-Concept: The perception/perceptions about the total self.

Self-Esteem: Assessment of one's own work, capability, significance, and success.
Body Image: A mental image of one's own body.

ROLE RELATIONSHIPS
The positive and negative connections or associations between persons or groups of persons and the means
by which those connections are demonstrated.
Caregiving Roles: Socially expected behavior patterns by persons providing care who are not health care
professionals.
Family Relationships: Associations of people who are biologically related or related by choice.
Role Performance: Quality of functioning in socially expected behavior patterns.

SEXUALITY
Sexual identity, sexual function, and reproduction.
Sexual Identity: The state of being a specific person in regard to sexuality and/or gender.
Sexual Function: The capacity or ability to participate in sexual activities.
Reproduction: Any process by which new individuals (people) are reproduced.

COPING/STRESS TOLERANCE
Contending with life events/life processes.
Post-Trauma Responses: Reactions occurring after physical or psychological trauma.
Coping Responses: The process of managing environmental stress.
Neuro-behavioral Responses Behavioral responses reflecting nerve and brain function.

LIFE PRINCIPLES
Principles underlying conduct, thought and behavior about acts, customs, or institutions viewed as being true
or having intrinsic work.
Values: The identification and ranking of preferred modes of conduct or end states.
Beliefs: Opinions, expectations, or judgments about acts, customs, or institutions viewed as being true or having
intrinsic work.
Value/Belief/Action Congruence: The correspondence or balance achieved between values, beliefs, and actions.

SAFETY/PROTECTION
Freedom from danger, physical injury or immune system damage, preservation from loss, and protection of
safety and security.
Infection: Host responses following pathogenic invasion.
Physical Injury: Bodily harm were hurt.
Violence: The exertion of the excessive force or power so asked to cause injury or abuse.
Environmental Hazards: Sources of danger in the surroundings
Defensive Processes: The processes by which the self protects itself from the nonself.
Thermoregulation: The physiologic process of regulating heat and energy within the body for purposes of protecting
organisms.

COMFORT
Sense of mental, physical, or social well-being or ease.
Physical Comfort : Sense of well-being or ease.
Social Comfort : Sense of well-being or ease with one's social situations.

GROWTH/DEVELOPMENT
Age appropriate increases in physical dimensions, organ systems, and/or attainment of developmental
milestones.

Growth: Increases in physical dimensions or maturity of organ systems.

Development: Attainment, lack of attainment, or loss of developmental milestones.

NANDA Assessment Form

Student Name
Introduce your patient with a brief introduction including age, gender, medical diagnoses, and pertinent previous history.
Do not put identifiers such as name or birthdate in your assessment.

HEALTH PROMOTION
Health Awareness/ Health Management
Subjective
Reliability (1-4)

(1 is low and 4 is high)

Knowledge of current illness / why are you here?

What is your expectation of current care

How will you manage your health/physical needs

after discharge?

Past illnesses or injuries: (explain)

Medication knowledge

General Health

Colds / Illnesses in last year

Accidents

Lost time from work due to illness / injuries

Compliance with health care directions

Cause of current illness / condition

Objective
Allergies / sensitivities

Immunizations

General Health Appearance

Vital Signs: Temperature

Medication

BP

Pulse

Dose/Route

Frequency

Respirations

Dosage range for age

Sp0 2

Classification/Use

(use reverse if more meds)

Medications taken at home and different from hospital medications (amount and frequency)
Over the counter

Herbs

Alcohol

Tobacco

Other

Supplements: (Vitamins, Minerals, Ensure, etc)

NUTRITION
Ingestion/Digestion/Absorption/Metabolism/Hydration
Subjective
Usual Weight

Changes in Weight (long term)

Usual Diet (Type)

No. of Meals/Day

Last Meal/Intake

Appetite Changes

Nausea/Vomiting

Altered Taste

Food likes / dislikes

Obstacles to Eating

Heartburn/Indigestion

Related to

Relieved by

Allergy/Food Intolerance
Hx of Diabetes (type, onset)
Dentures

Treatment of DM
Problems with dentures

Usual fluid intake: (what, amt)

Nausea / vomiting (amt)

Diarrhea

Objective
BMI

(Children BSA)

Oral Membranes

Chewing/Swallowing

Current Weight/Height

Cough/gag reflex

Condition of Teeth and Gums

% of meals eaten

Blood Glucose (if applicable)

IV fluid

IV rate

24 hr. oral intake

24 hr. NG intake

24 hr. IV fluid intake

24 hr. urine output

24 hr. NG output

24 hr. other (note) output

24 hr. Total Intake

24 hr. Total Output

ELIMINATION
Urinary system
Subjective
Urinary voiding patterns:

Excessive perspiration, odor problems

Frequency, amount, discomfort, hesitancy

Bladder disease or difficulty

Pain / Burning / Dysuria

Dribbling / Incontinence: When / how often

Nocturia, hesitancy, change in color of urine

History of bladder disease

Objective
Amount of urine:
Urine: color

Urinary patterns
consistency

Foley (date inserted)

sediment

odor

size

Bladder distention/Urinary
retention

Gastrointestinal system
Subjective
Hx of Bowel Disease

Usual Bowel Pattern

Character of stool

Last BM

History of Bleeding

Hemorrhoids

Constipation

Incontinence

Laxative use

Factors that lead to constipation: diet, decreased

fluid intake, stress, anxiety, decreased activity,
anesthesia, medications, others

Objective
Last BM:
Size / color / consistency

Abdominal exam: Tender, palpable masses, bowel sounds (all 4

quadrants), soft/firm, Size/girth

Integumentary system
Subjective
Skin complications / breakdown / ulcers/ lesions
with difficult healing etc.

Exposure to Sun / Tanning beds

Objective
Skin assessment: Integrity / hydration / turgor / color / temperature / change in fat distribution from
glucocorticoids
IV Site:

location

assessment:

catheter size

Pulmonary system (Included in Cardiovascular-pulmonary Responses)

date inserted

ACTIVITY/REST
Sleep / Rest
Subjective
Sleep hours

Naps

Sleep aids

Insomnia: (circle if applies): difficulty falling asleep, interrupted sleep, early awakening.
Explain:
Appearance

Rested upon awakening

Objective
Sleep/Rest observed
Activity/Exercise / Energy Balance
Subjective
Occupation

Exercise Habits

Limitations imposed by current condition

Fatigue

Ability to maintain usual routines

History of fractures/dislocations

Joint pain/back problems

ADLs: Independent?

Assistance provided by:

ADLs Dependent? Mobility

Feeding

Hygiene

Dressing

Toileting

Other

Objective
Response to Activity (include pulse, resp rate)
General Appearance
Muscle tone: firm/hard/soft

Muscle strength:

Muscle size: hypertrophy/ atrophy

ROM

Deformities

Coordination/tremors
Posture

Gait

Spastic/flaccid

Contractures

High risk for injury?

Cardiovascular-pulmonary Responses
Subjective
Cardiovascular
Heart Disease / Phlebitis

Ankle / leg or extremity edema

Extremity weakness or numbness / coldness

Rapid weight gain / loss (amount)

Slow healing
Objective
Blood
Pressures:

Right

Left

Pulses:

Right

Left

Apical

Lying

Radial

Sitting/Standing

Pedal

Pulse Deficit

Generalized
edema

Mucous
membranes

Other
appropriate
pulses

Skin hydration / turgor

Dependent edema

Jugular vein distention

Color / cyanosis

Capillary refill

Sensation of extremities

Extremity color

Extremity temperature

local / general

paralysis/ painpassive
movement
Respiratory / Ventilation
Subjective
Respiratory Disease (identify)

Dypsnea

Cough (Productive/Non-productive, triggers)

Sputum (amount, color, consistency)

Occupational/lifestyle exposure to particulates: Type

Oxygen use:

Liters/min

When used?

Amount

# yrs

Decreased exercise tolerance

Objective
Resp. Rate

SpO2

Depth/Quality

Rhythm

Accessory Muscles Use

Nasal Flaring

Cough (moist, dry, productive)

Symmetry of chest with

respirations

Cyanosis

Breath Sounds: Type

Location

Sputum: Color

Amount

Pallor

Adventitious Sounds: Type

Location

Consistency

PERCEPTION/COGNITION
Attention / Orientation/Cognition
Subjective
Readiness for enhanced knowledge

Deficient Knowledge

Education level

Learning disabilities

Special health care practices

Knowledge of illness/tests/surgery

Objective
Orientation to time, place, person, & situation

Attention span

Affect

Thought processes

Judgment / Insight

Appropriateness

Coherency/perceptio
ns
Mental status

Readiness to learn

Long term / short term memory / recall

Sensation / Perception
Subjective
History of Seizures, fainting spells/dizziness
Headaches

Location

Frequency

Tingling / Numbness / Weakness

Visual / Hearing loss

Location
Glasses / Hearing Aid

Do they help?

Objective
Facial grimace

Physical guarding

Emotional response to pain/discomfort: Calm, Anxious, Angry , Withdrawn, Fearful, Irritable, Euphoric, Other
Explain:
Change in vital signs with pain/discomfort
Pupil size/reaction (left, right)
Senses:

Touch: sharp/dull hot / cold

Smell

Taste:

sensations/differentiation

Sweet / sour

Facial droop
Weakness in extremities
Communication
Subjective

Objective
Does the patient communicate feelings, anxieties, fears, needs etc.?
Languages spoken:

Clarity of speech/hoarseness

Difficulty forming words/sentences

Difficulty expressing thoughts

SELF-PERCEPTION
Self-Concept / Self-Esteem / Body Image
Subjective
Anxiety/Fears
Potential/Actual losses

Grieving

Report of stressors/financial concerns

Feelings of hopelessness/ diminished self esteem
Ideation of violence to self/others

Objective
Scars

Disfigurements

Amputations

Use of handicap aids: walker, wheelchair, cane, etc.

ROLE RELATIONSHIPS
Caregiving Roles / Family Relationships / Role Performance
Subjective
Primary caregiver/s in care facility and when discharged
Marital status

Role in family structure

Support persons

Health of significant other

Other stress/concerns
Ability of significant other to provide care
Occupation

Change or conflict in role

Recent changes in lifestyle

Objective
Visitors
Communication between family/friends
Pictures in room
Interaction with others

SEXUALITY
Sexual Identity / Sexual Function/Reproduction
Subjective
Sexuality concern / dysfunction
Female
Last Menstrual period

Length of cycle

Duration

Method of Birth Control if applicable

Menopause

Vaginal discharge

Bleeding between periods

Practice breast self-exam

Last PAP smear

Method of birth control (if applicable)

Objective
Female

Breast exam (if appropriate)

Teaching provided

Male

Breast Exam (if appropriate)

Testicular exam (if appropriate)

COPING / STRESS TOLERANCE

Post-Trauma Responses / Coping Responses / Neuro-behavioral Responses
Subjective
Perceived ability to cope

Fears

Sorrows

Grieving

Typical ways of coping

Objective
Behaviors that demonstrate anxiety, grieving, coping, fears

LIFE PRINCIPLES
Value / Belief / Action Congruence
Subjective
What does this person value in life?

Religious preference/role of spiritual practices

Ability to participate in religious/spiritual practices

Important Spiritual practices

Cultural practices

Source of hope and comfort

Concerns with life/death

Awareness of Advanced directives

Decision making ability

Usual problem solving abilities
Compliance with health care regimes

Objective
Advanced Directives noted in chart

SAFETY/PROTECTION
Infection / Physical Injury / Violence / Environmental Hazards / Defensive Processes / Thermoregulation
Subjective
c/o hot or cold; desire for blankets
Perceived hazards, injuries, inadequate immunity

Allergies

Objective
Temperature/site

Redness, swelling, heat, etc.

Perspiration

Thermoregulation impairment

Autoimmune diseases; brain injury; aging complications, violence, hazards

Risk for: immobility complications, falls, aspiration, peripheral neurovascular dysfunction, hypertensive state, bleeding,
hypoglycemia, disuse syndrome, sedentary lifestyle

COMFORT
Physical Comfort /Environmental Comfort / Social Comfort
Subjective
Sense of well being

Factors that influence pain

Pain:

Intensity (1-10)

Location/Radiation

Quality

Frequency

Duration

Aggravating/precipitating factors

How Relieved

Other discomfort (Environmental, Social)

Objective
Accompanying symptoms: emesis, insomnia, lack
of concentration, crying, other observed behaviors

Response to analgesic

GROWTH/DEVELOPMENT
Growth / Development
(Erikson) What is expected stage? What stage is person really in? Include all observations about the person that helps
you make this decision.
Subjective

Objective
Attainment, loss of developmental milestones (If child use Denver Developmental II as reference)
For the adult patientsee objective information regarding Adult Failure to Thrive in your nursing diagnosis book.

Discharge Plan Considerations

Anticipated date of discharge:

Discharged to: (home &/or agency)

Discharge Teaching Provided

Discharge Instructions

Follow-up (date, provider)

If discharged to home indicate areas that may require assistance:
Food preparation

Transportation/Shopping

Ambulation

Medication/IV therapy

ADL assistance

Wound Care

Homemaker assistance

Treatments

Resources available for care at home: Persons

Home modifications needed:

Equipment

Significant Laboratory and Radiology Data

Test

Value

Normal Range

Cause/Signifiance