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I Sntans creeningD Aiagnoses ssesment

Intansari Nurjannah, BSN, MNSc

School of Nursing Faculty of MedicineGadjah Mada University

Indonesia

English Version

Inattention to one side andover attention to the oppositeside of the body which isexperiences impairmentin sensory and motor response

Any limitation in independent,purposeful physical movementof the body or of one ormore extremities

Unilateralneglect

Any limitation of independentmovement from one bedposition to another

Any limitation of independentmovement within theenvironment on foot

Any limitation of independentmovement between twonearby surfaces?

Continuous/frequent aimlessmovement from place to placethat expose individual to harm

Problem inmobility

Decreased stimulationfrom (or interest orengagement in)recreational or leisureactivities

Impairedbed mobility

Risk for ImbalancedBody temperature

Reports a habit of lifethat is characterizedby a low physicalactivity level

Decrease mobility

Inactivity/Insufficientphysical activity

Vigorous activity

Insufficient physiologicalor psychological energyto endure or completerequired or desired dailyactivities

Problemin activity

Assessment foractivity, restand mobility

History of previousintolerance

Risk for activityintolerance

Inexperience withthe activity

Patient

Risk for disuse syndrome

MechanicalImmobilzation

Paralysis

ImpairedWalking

ImpairedTransfer

Ability

Wandering

ImpairedPhysical

mobility

Risk forconstipation

Activityintolerance

Sedentarylifestyle

Risk elated toactivity and mobility

diagnoses r

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1Page of 60PREFACE

PREFACE

What is ?is a tool/pathway to help nurse to assess clients in order to screen all "possible nursing diagnoses" and "possible collaborative

problems" which may be experienced by clients.Sequences in are follows:

Assessment for vital signsAssessment for safetyAssessment for specific circumstances

Assessment for body functionAssessment for activity, rest and mobilityAssessment for comfort and skin integrityAssessment for nutritionAssessment for psychologicalAssessment for emotionAssessment for cognitive and perceptionAssessment for spiritual, values and religiousAssessment for behavior .Assessment for sexuality and socialAssessment for infant/childAssessment for caregiver and communityAssessment for familyAssessment related to support system/resourcesAssessment related to environmentAssessment related to demographic characteristicsAssessment related to disease/physiological problemsAssessment related to proceduresAssessment related to medications/therapiesAssessment related to laboratory results

How to use ?1. If possible, nurses need to assess patient based on the sequence in , however, it is depend on client's situations and

circumstances2. When nurse has found "possible nursing diagnoses" or "possible collaborative problems", it is suggested that nurse

a. Learn more about those diagnoses or collaborative problems from reliable sources before nurse can determine the most accurateof nursing diagnoses or collaborative problems

b. Look at "The map of Nursing Diagnoses" to find the relationship among nursing diagnoses in order to continue the assessmentin more focus/detail

3. Nurse need to remember that not all data can be screened by , in this situation, nurse can use the book with the tittle "The Fastmethod of Formulating Nursing Diagnoses for Diagnostic Reasoning in Nursing" to track the possible nursing diagnoses based onthe data that have been found from the previous assessment

Note:The use of which requiring approvals and/or license fees are listed bellow:

1. An author or company requests use in an audiovisual material2. A software developer or computer based-patient record vendor request use of3. Translation into an other language4. Any research about

Contact:Intansari NurjannahSchool of Nursing Faculty of MedicineUniversitas Gadjah MadaSekip Bulaksumur YogyakartaIndonesia (55284)

Phone office : +62 274 545674e-mail (priority) : intansari.nurjannah@my.jcu.edu.aue-mail (other) : intansarinurjannah@yahoo.com or intansarin@ugm.ac.id

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How to cite (APA style):Nurjannah, I. (2013) (2nd Ed). ISDA Intans Screening Diagnoses Assessment. English version. Yogyakarta: Mocomedia.

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2Page ofCONTENT

PREFACE ............................................................................................................................................

CONTENT ...........................................................................................................................................

ASSESSMENT FOR VITAL SIGNS (blood pressure) .......................................................................

ASSESSMENT FOR VITAL SIGNS (heart rate) ...............................................................................

ASSESSMENT FOR VITAL SIGNS (respiratory rate) ......................................................................

ASSESSMENT FOR VITAL SIGNS (temperature and weight) .........................................................

ASSESSMENT FOR SAFETY ...........................................................................................................

ASSESSMENT FOR SPECIFIC CIRCUMSTANCES.........................................................................

ASSESSMENT FOR SPECIFIC CIRCUMSTANCES (pregnancy) ....................................................

ASSESSMENT FOR BODY FUNCTION (GI system) ......................................................................

ASSESSMENT FOR BODY FUNCTION (urinary system) ...............................................................

ASSESSMENT FOR ACTIVITY, REST AND MOBILITY ...............................................................

ASSESSMENT FOR COMFORT AND SKIN INTEGRITY ..............................................................

ASSESSMENT FOR NUTRITION .....................................................................................................

ASSESSMENT FOR PSYCHOLOGICAL..........................................................................................

ASSESSMENT FOR EMOTION ........................................................................................................

ASSESSMENT FOR COGNITIVE AND PERCEPTION ..................................................................

ASSESSMENT FOR SPIRITUAL, VALUES AND RELIGIOUS .....................................................

ASSESSMENT FOR BEHAVIOR ......................................................................................................

ASSESSMENT FOR SEXUALITY AND SOCIAL ...........................................................................

ASSESSMENT FOR INFANT/CHILD ...............................................................................................

ASSESSMENT FOR CAREGIVER AND COMMUNITY ................................................................

ASSESSMENT FOR FAMILY ............................................................................................................

ASSESSMENT RELATED TO SUPPORT SYSTEMS/RESOURCES ..............................................

ASSESSMENT RELATED TO ENVIRONMENT .............................................................................

ASSESSMENT RELATED TO DEMOGRAPHIC CHARACTERISTICS ........................................

ASSESSMENT RELATED TO DISEASE/PHYSIOLOGY PROBLEMS ..........................................

ASSESSMENT RELATED TO PROCEDURES .................................................................................

ASSESSMENT RELATED TO MEDICATIONS/THERAPIES .........................................................

ASSESSMENT RELATED TO LABORATORY RESULTS ..............................................................

HEALTH PROMOTION DIAGNOSES ..............................................................................................

THE MAP OF COLLABORATIVE PROBLEMS ..............................................................................

REFERENCES .....................................................................................................................................

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CONTENTS

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Page of57 60COLOR SIGNS : actual diagnoses risk diagnoses health promotion diagnoses collaborative problems

ASSESSMENT RELATED TO LABORATORY RESULTS

LABORATORY RESULTS POSSIBLE DIAGNOSES

Sodium (elevated with nephritis lowered with

chronic renal insufficiency) PC: Renal/urinary

Sodium-excessive sodium intake (oral, IV,

medications) PC: Hyponatremia

Sputum culture positive Ineffective airway clearance

Deficient knowledge r.t spread of disease to others

Ineffective management of therapeutic regimen for TB

Stool culture positive Deficient knowledge r.t spread of infection to others

Deficient knowledge r.t effecto fo drugs

Tests for hypercoagulability (Inherited

Thrombophilia) Risk for injury related to clotting

Theophylline levels Risk for injury related to overdosage

Thrombocytopenia Risk for injury related to bleeding

Risk for injury related to clotting

Risk for infection

Risk for injury related to platelet transfusions or drugs

Thrombocytopenia-coagulation tests (elevated

in thrombocytopenia, purpura, and

hemophilia) PC: Metabolic/immune/hematopoietic

Thrombocytopenia-coagulation tests (elevatedin thrombocytopenia, purpura, and

hemophilia) PC: Thrombocytopenia

Thrombocytopenia-maternal systemic disease

(leukemia, thrombocytopenia, blood

dyscariasis) PC: Thrombocytopenia

Thrombocytopenia-thrombotic

thrombocytopenic purpura PC: Postpartum hemorrhage

Thrombolytic-coagulation studies (elevated

with anticoagulant and/or thrombolytic

therapy or coagulpathies) PC: Thrombocytopenia

Toxemia PC: Hypomagnesemia

Tumor markers elevationRisk for ineffecive coping related to severity of malignant conditionand prossible need for more treatment

Tyrosinemia PC: Hepatic dysfunction

Uric acid levels increased Alteration in comfort related to joint pain

Alteration in fluid requirements

Deficient knowledge related to any dietary modification

Deficient knowledge related to medications

Urinalysis PC: Gastrointestinal/hepatic/biliary

Urinary-creatinin-24 hours urine creatinine

clearance PC: Renal/urinary

Urinary-creatinine (elevated with kidney

disease) PC: Cardiac/vascular

Urinary-creatinine (elevated with kidneydisease) PC: Renal/urinary

Urinary-creatinine (elevated in acute/chronic

glumorulonenephritis, nephritis, lowered in

advanced degenarions of kidneys) PC: Renal/urinary

Urinary-creatinine phophokinnase, isoenzymes

(e.g., CK-MB, troponin) PC: Cardiac/vascular

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1 PC: Adrenocosticoteroid therapy adverse effect

2 PC: Allergic response

3 PC: Anticonvulsant therapy adverse effect

4 PC: Antidepressant therapy adverse Eefect

5 PC: Antineoplastic therapy adverse effect

6 PC: Atelectasis pneumonia

7 PC: Compartmental syndrome

8 PC: Deep vein thrombosis

9 PC: Dysrhytmias

0 PC: Hyerbilirubinemia

1 PC: Hypercalcemia

2 PC: Hyperchloremia

3 PC: Hyperglicemia

4 PC: Hyperkalemia

5 PC: Hypermagnesemia

6 PC: Hyperphosphatemia

7 PC: Hypophosphatemia

8 PC: Hypocalcemia

9 PC: Hypoglicemia

0 PC: Hypokalemia

1 PC: Hypomagnesemia

2 PC: Hyponatremia

3 PC: Hypovolemia

4 PC: Hypoxemia

5 PC: Increased intracranial pressure

6 PC: Intraocular pressure

7 PC: Metabolic acidosis

8 PC: Metabolic alkalosis

9 PC: Negative nitrogen balance

0 PC: Non reassuring fetal status

1 PC: Paralytic ileus

2 PC: Pneumothorax

3 PC: Pregnancy associated hypertension

4 PC: Pulmonary edema

5 PC: Pulmonary embolism

6 PC: Renal calculi

7 PC: Renal insufficiency8 PC: Respiratory acidosis

9 PC: Respiratory alkalosis

0 PC: Seizure

1 PC: Sepsis

PC: Sepsis(41)

PC: Negative nitrogen balance (29)

PC: Hyperbilirubinemia (10)

PC: Renal insufficiency(37)

PC: Anticonvulsant therapy adverse effect (3)

PC: Antineoplastic therapy adverse effect (5)

PC: Hypoglicemia(19) PC: Non reassuring fetal status(30)

PC: Adrenocosticoteroid therapy adverse effect (1)

PC: Antidepressant therapy adverse Effect (4)

PC: Pregnancy associatedhypertension (33)

PC: Intraocular pres(26)

PC: Hypovolemia(23)

PC: Paralytic ileus (31)

PC: Hyperglicemia(13)

PC: Hypokalemia(20)

PC: Hyponatremia

(22)

PC: Dysrhytmias(9)

PC: Metabolic alkalosis(28)

PC: Hypercalcemia(11)

PC: Renal calculi(36)

Excessive correction ofmetabolic acidosis

PC: Respiratory alkalosis (39)

PC: Increased intracranial pressure (25)

PC: Hypophosphate(17)

PC: Hyperphosphat(16)

PC: Hypocalcemia(18)

PC: Hyperkalemia (1

PC: Hypomagnesem(21)

PC: Hypermagnesem

(15)

PC: Pulmonary edema(34)

PC: Hypoxemia(24)

PC: Atelectasis pneumonia (6)

PC: Allergic response (2) PC: Compartmental syndrome (7)

PC: Metabolic acidosis (27) PC: Hyperchloremia (12)

PC: Pulmonary embolism(35)

PC: Deep vein thrombosis (8)

PC: Pneumothorax (32) PC: Respiratory acidosis (38)

PC: Seizure(40)

Severe pneumonia

Page ofTHE MAP OF COLLABORATIVE PROBLEMS

5960

Note:Look at the color and number to easily find the collaborative problemsHow to understand The map of collaborative problems?

means: If occurs then possible to occurX Y X Y

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Published in 2010, Yogyakarta 9 7 8 9 7 9 9 8 8 8 9 0 7

ISBN 979-98889-0-5

I n d o n e s i a