Intans Screening Diagnoses Assesment

English Version

Decreased stimulation from (or interest or engagement in) recreational or leisure activities Reports a habit of life that is characterized by a low physical activity level Decrease mobility Inactivity/Insufficient physical activity
Risk for Imbalanced Body temperature

Inattention to one side and over attention to the opposite side of the body which is experiences impairment in sensory and motor response

Unilateral neglect

Sedentary lifestyle

Risk for constipation

Problem in activity

Any limitation in independent, purposeful physical movement of the body or of one or more extremities Continuous/frequent aimless movement from place to place that expose individual to harm Problem in mobility Any limitation of independent movement between two nearby surfaces? Any limitation of independent movement within the environment on foot Any limitation of independent movement from one bed position to another

Impaired Physical mobility

Wandering

Vigorous activity Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Impaired Transfer Ability Impaired Walking Impaired bed mobility

Activity intolerance

Assessment for activity, rest and mobility

History of previous intolerance Patient Inexperience with the activity Mechanical Immobilzation Risk for disuse syndrome Paralysis Risk for activity intolerance

Risk diagnoses related to activity and mobility

Intansari Nurjannah, BSN, MNSc

School of Nursing Faculty of Medicine Gadjah Mada University Indonesia

PREFACE
What is ISDA? ISDA is a tool/pathway to help a nurse to assess a client in order to screen all "possible nursing diagnoses" and "possible collaborative problems" which may be experienced by the client. Sequences in ISDA are follows: Assessment for vital signs Assessment for safety Assessment for specific circumstances Assessment for body function Assessment for activity, rest and mobility Assessment for comfort, skin and tissue integrity Assessment for nutrition Assessment for psychological condition Assessment for emotional state Assessment for cognitive and perception Assessment for values, spiritual and religious view Assessment for behavior Assessment for sexuality and social aspect 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/physiological problems Assessment related to procedures Assessment related to medications/therapies Assessment related to laboratory results How to use ISDA? 1. If possible, the nurse need to assess his/her client based on the sequence in ISDA, however, it is depend on the client's situation and circumstances 2. When the "possible nursing diagnoses" or "possible collaborative problems" has been determined, it is suggested that nurses a. need to learn more about those diagnoses or collaborative problems from reliable sources before the nurse can determine the most accurate nursing diagnoses or collaborative problems b. need to look at "The map of Nursing Diagnoses" to find the relationship among nursing diagnoses in order to continue the assessment in more focus/detail 3. Nurses need to remember that not all data can be screened by ISDA; in this situation, nurse can use the book entitled "The Fast method of Formulating Nursing Diagnoses for Diagnostic Reasoning in Nursing" to track the possible nursing diagnoses based on the data that have been found from the previous assessment Note: The use of ISDA which requires approval and/or license fees are listed bellow: 1. An author or company requests to use ISDA in an audiovisual material 2. A software developer or computer based-patient record vendor request to use of ISDA 3. Translation into another language 4. Any research using ISDA Contact: Intansari Nurjannah School of Nursing Faculty of Medicine Universitas Gadjah Mada Sekip Bulaksumur Yogyakarta Indonesia (55284) Phone office e-mail (priority) e-mail (other) : +62 274 545674 : intansari.nurjannah@my.jcu.edu.au : intansarinurjannah@yahoo.com or intansarin@ugm.ac.id

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

PREFACE

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CONTENTS
PREFACE ............................................................................................................................................ 1 CONTENT ........................................................................................................................................... 2 ASSESSMENT FOR VITAL SIGNS (blood pressure) ....................................................................... 3 ASSESSMENT FOR VITAL SIGNS (heart rate) ............................................................................... 4 ASSESSMENT FOR VITAL SIGNS (respiratory rate) ...................................................................... 5 ASSESSMENT FOR VITAL SIGNS (temperature and weight) ......................................................... 6 ASSESSMENT FOR SAFETY ........................................................................................................... 7 ASSESSMENT FOR SPECIFIC CIRCUMSTANCES......................................................................... 9 ASSESSMENT FOR SPECIFIC CIRCUMSTANCES (pregnancy) .................................................... 10 ASSESSMENT FOR BODY FUNCTION (GI system) ...................................................................... 13 ASSESSMENT FOR BODY FUNCTION (urinary system) ............................................................... 14 ASSESSMENT FOR ACTIVITY, REST AND MOBILITY ............................................................... 16 ASSESSMENT FOR COMFORT, SKIN AND TISSUE INTEGRITY ............................................. 17 ASSESSMENT FOR NUTRITION ..................................................................................................... 18 ASSESSMENT FOR PSYCHOLOGICAL CONDITION................................................................... 19 ASSESSMENT FOR EMOTIONAL STATE ...................................................................................... 21 ASSESSMENT FOR COGNITIVE AND PERCEPTION .................................................................. 23 ASSESSMENT FOR VALUES, SPIRITUAL AND RELIGIOUS VIEW.......................................... 24 ASSESSMENT FOR BEHAVIOR ...................................................................................................... 25 ASSESSMENT FOR SEXUALITY AND SOCIAL ASPECT............................................................. 28 ASSESSMENT FOR INFANT/CHILD ............................................................................................... 29 ASSESSMENT FOR CAREGIVER AND COMMUNITY ................................................................ 30 ASSESSMENT FOR FAMILY ............................................................................................................ 31 ASSESSMENT RELATED TO SUPPORT SYSTEMS/RESOURCES .............................................. 32 ASSESSMENT RELATED TO ENVIRONMENT ............................................................................. 33 ASSESSMENT RELATED TO DEMOGRAPHIC CHARACTERISTICS ........................................ 34 ASSESSMENT RELATED TO DISEASE/PHYSIOLOGICAL PROBLEMS .................................. 35 ASSESSMENT RELATED TO PROCEDURES ................................................................................. 42 ASSESSMENT RELATED TO MEDICATIONS/THERAPIES ......................................................... 45 ASSESSMENT RELATED TO LABORATORY RESULTS .............................................................. 48 HEALTH PROMOTION DIAGNOSES .............................................................................................. 58 THE MAP OF COLLABORATIVE PROBLEMS .............................................................................. 59 REFERENCES ..................................................................................................................................... 60

CONTENT

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PC: Decreased Cardiac Output

PC: Calcium Channel Blocker Therapy Adverse Effects Decreased BP

PC: Fetal distress PC: Renal Insufficiency Primary hypertensive disease, in diabetes mellitus PC: Post partum Hemorrhage Check if jugular vein distended? PC: Pregnancy-Asociated Hypertension PC: Prenatal Bleeding PC: Preterm Labor PC: Thrombocytopenia Excess fluid volume (S3 heart sound) As a high risk population in

Consume calcium channel blocker

Ineffective peripheral tissue perfusion Activity intolerance

Blood pressure changes in extremities/limbs Abnormal blood pressure responses to activity (daily activity)?

PC: GI Bleeding

PC: Pulmonary Edema

As a high risk population in

S3 sound?

As sign and symptom of Decreased cardiac output (S3 and S4 heart sound), low blood pressure (Carpenito,2006) As sign and symptom of

PC: Pulmonary Embolism (General) PC: Atelectasis Pneumonia (sign and symptom of septic shock) PC: Hyperglicemia PC: Hypokalemia PC: Hypermagnesemia PC: Hypochloremia PC: Allergy Reaction PC: Sickling crises PC: Neuroleptic Malignant Syndrome PC: GI Bleeding PC: Paralytic Ileus PC:Hypovolemia PC: Decreased Cardiac Output Post shock status anaphylactic shock
Septic shock, cardiogenic shock

Acute Pain

PC: Hypoxemia (elevated diastolic pressure - sign of right - sided congestive heart failure) PC: Hypernatremia (Elevated Blood Pressure) If patient consumes Antipsychotic therapy

For Potential Complication As sign and symptom of

Blood pressure changes

For Potential Complication In hypertension condition

Consumes neuroleptic

Risk for shock

Hypotension
Decreased

Hypertension
Increased

If patient on medication as a high risk population in

Risk for falls If patient consumes antihypertensive therapy PC: Antihypertensive PC: Antipsychotic Therapy Adverse Therapy Adverse Effects Effects Risk for ineffective peripheral tissue perfusion Risk for decreased cardiac tissue perfusion

As a high risk population in

Blood pressure
Shock

As an etiology on Risk for ineffective cerebral tissue perfusion Risk for ineffective renal perfusion (Malignant hypertension) Check whether patient injured at T7 or above?

Risk for falls (for orthostastic hypotension) and Decreased Cardiac Output (Carpenito, 2006) Deficient fluid volume
Check if patient uses natural latex rubber product?

As a high risk population in

Autonomic dysreflexia (paroxysmal hypertension) Fear

Latex allergy response

For Nursing Diagnoses

As a high risk population in PC: Dysrhytmias

ICP (Intracranial Pressure) measurement?

Decreased intracranial adaptive capacity (with intracranial hypertension)

PC: Antiarrythmic Therapy Adverse Effects

For Nursing Diagnoses

Anxiety however, sometimes the blood pressure may Blood decrease on Anxiety in pressure NANDA-I increases Blood pressure increased diastolic pressure > 15 mm Hg Activity intolerance respond to activity (Carpenito, 2006) Body temperature Hypothermia below normal range? Temperature fluctuation between hypothermia and hyperthermia Ineffective thermoregulation

Possible Nursing Diagnoses

COLOR SIGNS : actual diagnoses risk diagnoses health promotion diagnoses collaborative problems

ASSESSMENT FOR VITAL SIGNS (blood pressure)

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PC: Acidosis respiratory PC: Atelectasis pneumonia PC: Allergic reaction PC: Hyponatremia PC: Hypernatremia PC: Metabolic acidosis Somnolen, irritability Drowsiness PC: Hypoxemia PC: Hypoglicemia PC: Hypophosphatemia PC: Hypomagnesemia PC: Anticonvulsant therapy adverse effect Confusion Coma As sign and symptom of Hyperiritability Decrease level of consciousness Decrease Mental status Altered PC: Hypercalcemia PC: Hyperchloremia PC: Pulmonary embolism PC: Hypocalcemia

History of falls Wound at face, neck, mouth because of surgery Risk for aspiration Situation hindering elevation of upper body

Risk for fall

Risk for disuse syndrome

Reduce level of consciousness

PC: Respiratory alkalosis/acidosis

Trauma Spine Injury

PC: Pulmonary edema Neurologic trauma Spinal injury (post trauma)/ PC: Paralytic Ileus acute spinal cord injury/lesion PC: Hypochloremia Thermal injury PC: Hypo/hyperglicemia PC: Pulmonary Embolism

CNS lesion Nervous system

PC: Compartmental syndrome Risk for powerlessness Spinal cord injury or lesion at T6 or above Ineffective breathing pattern Eye PC: Increased intracranial pressure Risk for autonomic dysreflexia Risk for other directed violence

Acute spinal cord injury

Trauma Head Injury

Risk for ineffective cerebral tissue perfusion Impaired swallowing

PC: Seizure PC: Increased intracranial pressure PC: Hypoxemia PC: GI Bleeding Chronic confusion Severe blunt and penetrating injury

Intracerebral lesions

PC: Hypoxemia Compromised chest wall movement Sepsis Fracture Ascites Risk for imbalanced fluid volume Hip Burns PC: Pulmonary embolism Trauma Pancreatitis Impaired oral mucouse membranes Trauma affecting Risk for imbalanced body temperature Hypothermia /hyperthemia temperature regulation Ineffective thermoregulation Risk for trauma Facial, neck, oral trauma Sexual dysfunction Risk for aspiration

Chest

injury Trauma injury

PC: Pneumotorax

Risk for bleeding

Assessment for safety

Trauma Impaired skin integrity Risk for injury Injury/Trauma/ Risk for infection (invasive lines) Risk for vascular trauma (catheter, infusion) Injury Risk for imbalanced fluid volume (major invasive procedure)

Assessment

Risk for infection Nursing diagnosis

PC: Opportunistic infection PC: Dysrhytmias PC: GI Bleeding
Cell damage

Risk for ineffective gastrointestinal perfusion Risk for peripheral neurovascular dysfunction
PC: Hypovolemia PC: Adrenocosticoteroid therapy adverse effect PC: Pulmonary embolism PC: Sepsis PC: Hypoxemia PC: Joint dislocation PC: Hepatic dysfunction PC: Seizure PC: Hyperkalemia
Trauma on pelvis, lower extremity wound, bite wound Multiple trauma Birth trauma Traumatic liver

PC: Hyperkalemia

Collaborative problems

Wound

Prenatal injury Crushing injury Vascular injury Leg, pelvic

Spinal cord lesion Pelvic, leg fracture

PC: Compartmental syndrom PC: Pulmonary embolism Post trauma syndrome

Serious injury to loved ones/self Brain

Unilateral neglect

PC: Compartmental syndrome PC: Deep vein thrombosis

Decreased intracranial adaptive capacity

Injury agents Injury process

Acute pain

Risk for suffocation Risk for autonomic dysreflexia

Irritating stimuli below level of injury

Disturbed body image

Fracture

Trauma Disturbed energy field, Risk for powerlessnes,s Risk for impaired religiosity PC: Hypercalcemia Multiple fractures Total hip/knee replacement PC: Joint dislocation Fracture of hip, knee, shoulder PC: Hyperphosphatemia Healing fracture Risk for autonomic dysreflexia
Nursing diagnoses Risk for peripheral neurovascular dysfunction Risk for imbalanced fluid volume Fracture hip

COLOR SIGNS : actual diagnoses risk diagnoses health promotion diagnoses collaborative problems

ASSESSMENT FOR SAFETY

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LABORATORY RESULTS Sodium (elevated with nephritis lowered with chronic renal insufficiency) Sodium-excessive sodium intake (oral, IV, medications) Sputum culture positive

POSSIBLE DIAGNOSES PC: Renal/urinary PC: Hyponatremia Ineffective airway clearance Deficient knowledge r.t spread of disease to others Ineffective management of therapeutic regimen for TB Deficient knowledge r.t spread of infection to others Deficient knowledge r.t effect of drugs Risk for injury r.t clotting Risk for injury r.t overdosage Risk for injury r.t bleeding Risk for injury r.t clotting Risk for infection Risk for injury r.t platelet transfusions or drugs

Stool culture positive Tests for hypercoagulability (Inherited Thrombophilia) Theophylline levels Thrombocytopenia

Thrombocytopenia-coagulation tests (elevated in thrombocytopenia, purpura, and hemophilia) Thrombocytopenia-coagulation tests (elevated in thrombocytopenia, purpura, and hemophilia) Thrombocytopenia-maternal systemic disease (leukemia, thrombocytopenia, blood dyscariasis) Thrombocytopenia-thrombotic thrombocytopenic purpura Thrombolytic-coagulation studies (elevated with anticoagulant and/or thrombolytic therapy or coagulpathies) Toxemia Tumor markers elevation Tyrosinemia Uric acid levels increased

PC: Metabolic/immune/hematopoietic

PC: Thrombocytopenia

PC: Thrombocytopenia PC: Postpartum hemorrhage

PC: Thrombocytopenia PC: Hypomagnesemia Risk for ineffecive coping r.t severity of malignant condition and prossible need for more treatment PC: Hepatic dysfunction Alteration in comfort r.t joint pain Alteration in fluid requirements Deficient knowledge r.t any dietary modification Deficient knowledge r.t medications PC: Gastrointestinal/hepatic/biliary PC: Renal/urinary PC: Cardiac/vascular PC: Renal/urinary

Urinalysis Urine-creatinin-24 hours urine creatinine clearance Urine-creatinine (elevated with kidney disease)

Urine-creatinine (elevated in acute/chronic glumorulonenephritis, nephritis, lowered in advanced degenarions of kidneys) Urine-creatinine phophokinnase, isoenzymes (e.g., CK-MB, troponin)

PC: Renal/urinary PC: Cardiac/vascular

COLOR SIGNS : actual diagnoses risk diagnoses health promotion diagnoses collaborative problems

ASSESSMENT RELATED TO LABORATORY RESULTS

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

PC: Adrenocosticoteroid therapy adverse effect PC: Allergic response PC: Anticonvulsant therapy adverse effect PC: Antidepressant therapy adverse Eefect PC: Antineoplastic therapy adverse effect PC: Atelectasis pneumonia PC: Compartmental syndrome PC: Deep vein thrombosis PC: Dysrhytmias PC: Hyerbilirubinemia PC: Hypercalcemia PC: Hyperchloremia PC: Hyperglicemia PC: Hyperkalemia PC: Hypermagnesemia PC: Hyperphosphatemia PC: Hypophosphatemia PC: Hypocalcemia PC: Hypoglicemia PC: Hypokalemia PC: Hypomagnesemia PC: Hyponatremia PC: Hypovolemia PC: Hypoxemia PC: Increased intracranial pressure PC: Intraocular pressure PC: Metabolic acidosis PC: Metabolic alkalosis PC: Negative nitrogen balance PC: Non reassuring fetal status PC: Paralytic ileus PC: Pneumothorax PC: Pregnancy associated hypertension PC: Pulmonary edema PC: Pulmonary embolism PC: Renal calculi PC: Renal insufficiency PC: Respiratory acidosis PC: Respiratory alkalosis PC: Seizure PC: Sepsis
PC: Sepsis (41)

PC: Negative nitrogen balance (29) PC: Hyperbilirubinemia (10) PC: Anticonvulsant therapy adverse effect (3) PC: Renal insufficiency (37)

PC: Antineoplastic therapy adverse effect (5)

PC: Hypoglicemia (19)

PC: Non reassuring fetal status (30)

PC: Pregnancy associated hypertension (33)

PC: Seizure (40)

PC: Adrenocosticoteroid therapy adverse effect (1)

PC: Antidepressant therapy adverse Effect (4)

PC: Intraocular pressure (26)

PC: Hypovolemia (23)

PC: Paralytic ileus (31)

PC: Hyperglicemia (13)

PC: Hyponatremia (22) PC: Hypokalemia (20)

PC: Increased intracranial pressure (25) PC: Hypophosphatemia (17) PC: Hyperphosphatemia (16) PC: Hypocalcemia (18) PC: Hyperkalemia (14) PC: Dysrhytmias (9) PC: Hypomagnesemia (21) PC: Hypermagnesemia (15)

Severe pneumonia PC: Respiratory alkalosis (39)

Excessive correction of metabolic acidosis

PC: Metabolic alkalosis (28)

PC: Hypercalcemia (11)

PC: Pulmonary edema (34) PC: Hypoxemia (24) PC: Atelectasis pneumonia (6)

PC: Renal calculi (36)

PC: Allergic response (2) PC: Metabolic acidosis (27)

PC: Compartmental syndrome (7) PC: Hyperchloremia (12) PC: Deep vein thrombosis (8)

PC: Pulmonary embolism (35)

PC: Pneumothorax (32)

PC: Respiratory acidosis (38)

Note: Look at the color and number to easily find the collaborative problems How to understand The map of collaborative problems? X Y means: If X occurs then Y possible to occur

THE MAP OF COLLABORATIVE PROBLEMS

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ISBN 979-98889-0-5

Published in 2010, Yogyakarta Indonesia

9 789799 888907