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5.4.1 Confusão agudaAgostini JV, Leo-Summers LS, Inouye SK. Cognitive and other adverse effects ofdiphenhydramine use in hospitalized older patients. Arch Intern Med. 2001; 161(17):2091–2097Alciati A, Scaramelli B, Fusi A, Butteri E, Cattaneo ML, Mellado C. Three cases of deliriumafter “ecstasy” ingestion. J Psychoactive Drugs. 1999; 31(2):167–170Aldemir M, Ozen S, Kara IH, Sir A, Baç B. Predisposing factors for delirium in the surgicalintensive care unit. Crit Care. 2001; 5(5):265–270 Bowman AM. Sleep satisfaction,perceived pain and acute confusion in elderly clients undergoing orthopaedic procedures. JAdv Nurs. 1997; 26(3):550–564Brauer C, Morrison RS, Silberzweig SB, Siu AL. The cause of delirium in patients with hipfracture. Arch Intern Med. 2000; 160(12):1856–1860 Coyle N, Breitbart W, Weaver S,Portenoy R. Delirium as a contributing factor to “crescendo” pain: three case reports. JPain Symptom Manage. 1994; 9(1):44–47Edlund A, Lundström M, Brännström B, Bucht G, Gustafson Y. Delirium before and afteroperation for femoral neck fracture. J Am Geriatr Soc. 2001; 49(10):1335–1340Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium risk factors in elderly hospitalizedpatients. J Gen Intern Med. 1998; 13(3):204–212 Erkinjuntti T, Wikström J, Palo J, Autio L.Dementia among medical inpatients. Evaluation of 2000 consecutive admissions. ArchIntern Med. 1986; 146(10):1923–1926Fisher BW, Flowerdew G. A simple model for predicting postoperative delirium in olderpatients undergoing elective orthopedic surgery. J Am Geriatr Soc. 1995; 43(2): 175–178Foreman MD. Confusion in the hospitalized elderly: incidence, onset, and associated factors.Res Nurs Health. 1989; 12(1):21–29
Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly.JAMA. 1990; 263(8):1097–1101Granberg Axèll AI, Malmros CW, Bergbom IL, Lundberg DB. Intensive care unitsyndrome/delirium is associated with anemia, drug therapy and duration of ventilationtreatment. Acta Anaesthesiol Scand. 2002; 46(6):726–731Gustafson Y, Berggren D, Brännström B, et al. Acute confusional states in elderly patientstreated for femoral neck fracture. J Am Geriatr Soc. 1988; 36(6):525–530Han L, McCusker J, Cole M, Abrahamowicz M, Primeau F, Elie M. Use of medicationswith anticholinergic effect predicts clinical severity of delirium symptoms in oldermedical inpatients. Arch Intern Med. 2001; 161(8):1099–1105Haynes C. Emergence delirium: a literature review. Br J Theatre Nurs. 1999; 9(11):502–503,506–510Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons.Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275(11):852–857Jitapunkul S, Pillay I, Ebrahim S. Delirium in newly admitted elderly patients: a prospectivestudy. Q J Med. 1992; 83(300):307–314 Kelly M. Postoperative delirium in the elderly.Todays Surg Nurse. 1997; 19(5):10–12Koponen H, Stenbäck U, Mattila E, Soininen H, Reinikainen K, Riekkinen PJ. Deliriumamong elderly persons admitted to a psychiatric hospital: clinical course during the acutestage and one-year follow-up. Acta Psychiatr Scand. 1989; 79(6):579–585Korevaar JC, van Munster BC, de Rooij SE. Risk factors for delirium in acutely admittedelderly patients: a prospective cohort study. Retrieved from https://bmcgeriatr.biomedcentral.com/arti- 5-6 ; 2005Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of
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advertenciaSe ha hecho todo lo posi
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Profesor Asociado, Departamento de
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Editada como libro impreso en 2018.
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graciasEs casi innecesario menciona
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Títulos de los diagnósticos que h
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el debate y la mejora de los miembr
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Los brotes en los diagnósticos enf
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diarreaalimentos dignidad humanadin
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motilidad gastrointestinal mutilaci
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sufrimiento espiritual quesufren la
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abstractoParte 1 La terminología d
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7 Introducción a la taxonomía de
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Estilo de vida La disposición a se
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riesgo incontinencia urinaria de ur
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en actividad toleranciaen el riesgo
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paternidad Riesgo de deterioro de l
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sobrecarga La negación demiedo y e
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riesgo aspiraciónriesgo sequedad e
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hipotermiariesgo hipotermiariesgo L
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La terminología de la NANDA Intern
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2 Lo que es nuevo en la edición 20
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disponible en nuestro sitio. Este p
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LOE 3.1: Síntesis de la literatura
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Nuevos diagnósticos de enfermería
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Diagnóstico de enfermería revisad
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riesgo deintolerancia a laactividad
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expresión "padres / pareja".proces
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emancipado problemas parala toma de
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3.5 Diagnósticos de enfermería re
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3.6 Revisión de títulos diagnóst
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Cuando usted dice falta en Inglés,
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3.8 Introducción de "en riesgo las
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profesión de enfermería; por lo q
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por la NANDA-I en cada país, sin d
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La NANDA-I cree que la estructura d
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La NANDA-I existe para desarrollar,
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La participación de los miembros d
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Aspectos teóricos de diagnósticos
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5.1 Introduccióncuidado de la salu
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Manual diagnóstico y estadístico
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5.2 Como enfermera (o estudiante de
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5.4 Evaluación del pacienteLa eval
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diagnóstico 5.5 de enfermeríaUn d
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usualmente recogida durante la eval
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5.6 Planificación / intervenciónU
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5.7 Reevaluación continuaUn diagn
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las revisiones de diagnóstico y /
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5:10 ReferenciasAsociación America
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6.1 IntroducciónEl razonamiento cl
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Sin una base sólida de los concept
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6.2 El proceso de enfermeríaLa eva
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Sin embargo, teniendo en cuenta est
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presuponer que todos los pacientes
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Global Subjetiva (ASG) y / o el Min
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puntos de presión y de posicionami
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6.3 Análisis de DatosEl segundo pa
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(Frequency 40) y la superficie marc
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se emplean las direcciones. Por eje
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6.4 diagnósticos de enfermería de
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intestinal, se puede empezar a ver
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esta situación - elementos muy imp
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si la información obtenida y compa
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Cambio en loshábitosalimenticiosDo
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enfermera está considerando las si
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Siempre es útil pedir a un colega
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6.6 ResumenLa evaluación juega un
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7 Introducción a la Taxonomía de
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aprendido a la taxonomía biológic
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Con la información recibida, nos e
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7.2 Clasificación en enfermeríaPr
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conocimientos de enfermería incluy
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7.4 Estructuración de programas de
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7.5 La identificación de un diagn
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riesgo o relacionado y las caracter
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tres diagnósticos potenciales: con
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control sanitarioIdentificación, c
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00015 riesgo estreñimiento00012 es
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Clase 2.OrientaciónPercepción del
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Sin diagnóstico en el momento.Clas
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Clase 1.ValoresIdentificación y cl
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riesgos ambientales00181 contaminac
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7.7 ReferenciasA. Abbott Los sistem
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8.1 Estructura de la Taxonomía IIU
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8.2 Un sistema multiaxial para cons
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8.3 Definiciones ejes8.3.1 Eje 1: E
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control de los impulsos decontrol e
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Toma de decisionesLa toma de decisi
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excesivoCantidad de algo que está
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olfativoEn relación con el sentido
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8.4 Preparación y presentación de
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8.5 Las perspectivas de futuroLa NA
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8.7 ReferenciasLundberg C, Warren J
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9.2 Cuando necesitamos diagnóstico
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Alrededor de 9,3 lenguajes enfermer
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9.4 Acerca de la NANDA-I¿Cuál es
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diagnósticos de enfermería,de enf
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La NANDA-I proporciona una lista de
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la mejora continua de la atención
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cirugía de hoy y las posibles comp
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específicos, tales como la insufic
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¿Puedo cambiar un diagnóstico de
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Esa es una pregunta difícil y que,
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9.8 Acerca de los factores de riesg
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Puedo añadir "riesgo" para un diag
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09:10 Sobre el desarrollo de un pla
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completado antes de ir a otra cosa
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Elijo un diagnóstico de cada uno d
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específica - se aprenderán con la
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Acerca de 9:13 preparación y el ex
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NANDA Internacional sólo se comenz
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10 Glosario10.1 diagnóstico de enf
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10.2 Eje diagnóstico10.2.1 EjeUn e
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Eje 3: EnsayoUn ensayo es un descri
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10.3 Componentes de un diagnóstico
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10.4 Definiciones para la clasifica
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diagnósticos de enfermería de la
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La participación en actividades re
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Área 1 • Promoción de la saludc
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bibliografía de apoyo original dis
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voluntad de control sanitario mejor
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control sanitario familia ineficace
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mantenimiento ineficaz saludAprobad
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las condiciones asociadasagente far
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salud comunidad pobreAprobado en 20
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Síndrome de ancianos frágilesApro
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pérdida no intencional de 25% del
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riesgo el síndrome de ancianos fr
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Dominio 2 • Nutriciónclase 1 •
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condición asociadaembarazobibliogr
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Amamantamiento ineficazAprobado en
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La asfixia arcadasdeglución repeti
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Este diagnóstico será retirado de
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la dinámica de los alimentos adole
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hora de las comidas estresantes nor
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desventaja económicaLa implicació
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estándar ineficaz de alimentación
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nutrición des equilibrada: menos q
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rápido aumento de peso durante la
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sobrepesoAprobado en 2013 • Revis
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rápido aumento de peso durante la
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riesgo la función hepática dañad
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riesgo glucosa en la sangre inestab
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hiperbilirrubinemia neonatalAprobad
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La infección viralNiño con defici
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riesgo síndrome de desequilibrio m
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des riesgo el equilibrio de electro
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el volumen de líquido deficienteAp
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Presencia accidental respiratoria u
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riesgo volumen de líquido des equi
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eliminación urinaria alteradaAprob
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incontinencia urinaria de esfuerzoA
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incontinencia urinaria de urgenciaA
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riesgo incontinencia urinaria de ur
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incontinencia urinaria funcionalApr
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incontinencia urinaria desbordamien
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incontinencia reflejo de micciónAp
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retención urinarioAprobado en 1986
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estreñimientoAprobado en 1975 •
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anorrectal estenosis defisuras Hemo
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riesgo estreñimientoAprobado en 19
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• Eliminación de dominio 3 y el
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taburete retención postura Presenc
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la diabetes mellitusLa distrofia mi
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diarreaAprobado en 1975 • Revisad
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aumento anormal de la capacidad de
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motilidad gastrointestinal disfunci
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Desequilibrio en la ventilación-pe
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insomnioAprobado en 2006 • Revisa
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Dominio 4 • Actividad / sueñocla
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Prolongado asincronía circadiano b
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voluntad de sueño mejoradoAprobado
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capacidad de transferencia dañadoA
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El levantarse heridoAprobado en 201
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lesión neuromuscularproblemas de v
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movilidad discapacitados físicosAp
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trastorno psicológicobibliografía
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riesgo síndrome de desusoAprobado
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campo de energía des equilibradoAp
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no estimular los factores de estré
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perambulationAprobado en 2000 • R
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Disminución de los pulsos perifér
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La posición del cuerpo que inhibe
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riesgo perfusión tisular disminuci
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riesgo perfusión tisular cerebro i
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de fumarlas condiciones asociadasLa
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riesgo perfusión tisular periféri
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riesgo presión arterial inestableA
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GravesagitaciónEl aumento de la fr
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Cambio en la pérdida de la funció
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déficit autocuidado, bañoAprobado
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déficit autocuidado para la higien
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déficit vestidor autocuidadoAproba
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mantenimiento del hogar dañadoApro
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El dominio 5 • La percepción / c
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Transferencia de la sensación de d
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confusión agudoAprobado en 1994
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confusión crónicaAprobado en 1994
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conocimiento deficienteAprobado en
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voluntad de conocimiento mejoradoAp
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control de los impulsos ineficazApr
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trastorno emocionallas condiciones
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memoria dañadoAprobado en 1994 •
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Domínio 5 • Percepção/cogniç
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Domínio 5 • Percepção/cogniç
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Verbalização inapropriadaFatores
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Disposição para autoconceito melh
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Risco de dignidade humana compromet
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Des esperançaAprovado em 1986 •
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Domínio 6 • AutopercepçãoClass
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Preconceito percebidoProcessos fami
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Risco de distúrbio na identidade p
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Baixa autoestima crônicaAprovado e
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Transição de desenvolvimentoCondi
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Risco de baixa autoestima situacion
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Distúrbio na imagem corporalAprova
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Domínio 7 • Papéis e relacionam
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HostilidadeInadequação ao papel p
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Disposição cognitiva insuficiente
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Risco de paternidade ou maternidade
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Grande número de gestaçõesGravid
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Disposição para paternidade ou ma
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Tensão do papel de cuidadorAprovad
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No cuidadorAbuso de substânciasAut
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No receptor de cuidadosAlteração
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Risco de tensão do papel de cuidad
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AlienaçãoApoio social insuficient
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Processos familiares disfuncionaisA
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AbandonoAnsiedadeAssumir responsabi
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Populações em riscoDesfavorecido
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Processos familiares interrompidosA
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Mudança na percepção de outros s
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História de violência domésticaC
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Risco de relacionamento ineficazApr
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Disposição para relacionamento me
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Domínio 8 • SexualidadeClasse 2
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Condições associadasAlteração n
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Padrão de sexualidade ineficazApro
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Risco de binômio mãe-feto perturb
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Processo perinatológico ineficazAp
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Domínio 9 • Enfrentamento/toler
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Aconselhamento insuficiente anterio
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Risco de síndrome do estresse por
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Síndrome do trauma de estuproAprov
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NegaçãoPalpitações cardíacasPe
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Lesão grave a entes queridosOcupa
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Risco de transição complicada na
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AnsiedadeAprovado em 1973 • Revis
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ParassimpáticasAlteração no padr
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Não aceitação da própria mortal
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Enfrentamento defensivoAprovado em
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Apoio social insuficiente Avaliaç
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Disposição para enfrentamento mel
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Enfrentamento familiar comprometido
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Fatores relacionadosEstilos de enfr
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Disposição para enfrentamento fam
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Enfrentamento ineficaz da comunidad
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Disposição para enfrentamento mel
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Sobrecarga de estresseAprovado em 2
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MedoAprovado em 1980 • Revisado e
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Medo da separação Medo de perda d
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PesarAprovado em 1980 • Revisado
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Sofrimento pela separação Sofrime
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Risco de pesar complicadoAprovado e
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Planejamento de atividade ineficazA
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Risco de planejamento de atividade
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Regulação do humor prejudicadaApr
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Recursos inadequadosRecursos insufi
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Risco de resiliência prejudicadaAp
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Desfavorecido economicamenteCondiç
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Risco de sentimento de impotênciaA
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TaquicardiaProblemas regulatóriosI
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Prejuízo oral do lactenteProcedime
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Disposição para comportamento org
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Disreflexia autonômicaAprovado em
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Populações em riscoEjaculaçãoEx
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Risco de disreflexia autonômicaApr
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Embolia pulmonarEpididimite Fratura
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Síndrome de abstinência de subst
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Risco de síndrome de abstinência
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Síndrome de abstinência neonatalA
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Domínio 10 • Princípios da vida
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Disposição para bem-estar espirit
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Crise espiritualCrise pessoalCrises
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Risco de religiosidade prejudicadaA
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Separação do sistema de apoioCone
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Conflito racialEnvelhecimentoEvento
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Sofrimento moralAprovado em 2006
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Conflito de decisãoAprovado em 198
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Sistemas de saúde tradicionais hie
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Risco de tomada de decisão emancip
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Disposição para tomada de decisã
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Risco de infecçãoAprovado em 1986
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Domínio 11 • Segurança/proteç
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Tipo de procedimento cirúrgico Uso
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Risco de aspiraçãoAprovado em 198
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Hábitos alimentares inadequados Hi
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Desobstrução ineficaz das vias a
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Manchas brancas na boca Manchasespo
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Doença autoimuneEstado de jejum or
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Integridade da pele prejudicadaApro
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Alteração no metabolismoAlteraç
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Integridade tissular prejudicadaApr
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Trauma vascularLiteratura de apoio
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Risco de lesãoAprovado em 1978 •
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Escore de classificação do estado
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Risco de lesão térmicaAprovado em
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Risco de morte súbita do lactenteA
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Mobilidade prejudicadaRedução da
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Escore de classificação do estado
Page 806 and 807:
Risco de recuperação cirúrgica r
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Ventilação mecânicaLiteratura de
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Risco de sangramentoAprovado em 200
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Risco de sufocaçãoAprovado em 198
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Fiação elétrica sem fixação Fu
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TrombofiliaUso de contraceptivos co
Page 826 and 827:
AutomutilaçãoAprovado em 2000 •
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Condições associadasAutismoDesper
Page 830 and 831:
Risco de automutilaçãoAprovado em
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DesesperançaDificuldades legaisIso
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Este diagnóstico será retirado da
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Risco de violência direcionada a s
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Efeitos neurológicos da exposiçã
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TabagismoPopulações em riscoCrian
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Risco de envenenamentoAprovado em 1
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Risco de lesão ocupacionalAprovado
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Características gastrintestinaisDo
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Risco de reação alérgica ao lát
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HipertermiaAprovado em 1986 • Rev
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PalidezSofrimento respiratórioFato
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Suprimento insuficiente de gordura
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Risco de hipotermia perioperatória
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Termorregulação ineficazAprovado
Page 880 and 881:
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Trauma
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Conforto prejudicadoAprovado em 200
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Domínio 12 • ConfortoClasse 1
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Agente físico lesivo Agentequímic
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Dor crônicaAprovado em 1986 • Re
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Fatores relacionadosA serem desenvo
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NáuseaAprovado em 1998 • Revisad
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Recursos insuficientesCondições a
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Disposição para conforto melhorad
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Conforto prejudicadoAprovado em 200
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Comportamento social incoerente com
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