Summary Nursing Diagnosis Handbook, 12th Edition Revised Reprint with NANDA-I® Updates

Ackley: Nursing Diagnosis Handbook, 12th Edition Revised Reprint with
2024-2026 NANDA-I® Updates
LectureJNotes

Problem-

BasedJLearning/CriticalJThinkingJCaseJStu

dy—RestlessJLegJSyndrome

CaseJScenario

AbdulJMalekJisJaJ21-year-
oldJcollegeJstudent.JHeJattendsJtheJlocalJstateJuniversityJandJisJaJjuniorJstudyingJgraphicJdesign.JThre
eJweeksJintoJhisJfallJsemester,JAbdul’sJprofessorsJnoticeJthatJheJisJfallingJasleepJinJclassJandJoftenJlo
oksJrestless.JAbdulJtapsJhisJfootJandJsquirmsJaroundJinJhisJseat.JAbdul,JwhoJisJusuallyJanJexcellentJstu
dent,JhasJfailedJhisJfirstJtestJinJhisJGraphicJDesignJIIJcourse.JHisJprofessorJasksJhimJtoJseeJhisJadvisorJ
becauseJtheJfearJisJthatJAbdulJhasJbecomeJchemicallyJimpaired.JHisJadvisorJsendsJAbdulJtoJtheJstude
ntJhealthJservicesJandJhisJcaseJisJreviewedJbyJtheJnurse.

NursingJAssessment

AbdulJisJaJwell-developedJ22-year-
oldJmaleJwithJaJBMIJofJ20.JHisJvitalJsignsJareJbloodJpressureJ104/78;JtemperatureJ98.4°F;JheartJrate
—64JbeatsJperJminute;JrespiratoryJrate—
16JbreathsJperJminute.JAJnutritionalJhistoryJconfirmsJaJwell-
balancedJdietJwithJtheJexclusionJofJporkJproducts.JAbdulJhadJbeenJworkingJoutJeveryJdayJatJtheJUniv
ersityJgymJbutJreportsJthatJheJisJcurrentlyJ―tooJtired‖JtoJdoJso.JAbdulJdeniesJdrugJorJalcoholJuseJandJt
hisJisJconfirmedJbyJserumJanalysis.JAbdulJcomplainsJaboutJsleepingJpoorlyJandJfeelingJasJif,J―IJamJ
movingJallJnight.‖JHeJstatesJthatJheJoftenJwakesJupJhisJdormJmateJandJfeelsJbadJaboutJthat.JTheJnurseJr
eclinesJAbdulJonJtheJexaminationJtableJandJchecksJhisJdeepJtendonJreflexesJ(DTRs)JwhichJareJallJ2+.
JTheJnurseJasksJAbdulJtoJrelaxJandJdimsJtheJlightsJwhileJsheJconsultsJwithJtheJprimaryJcareJpractition

er.JWhileJtheJnurseJisJoutJofJtheJexaminationJroomJAbdulJdozes,JandJwhenJtheJnurseJreturns,JtheJnurs
eJobservesJAbdul’sJrightJlegJjerkingJseveralJtimesJbeforeJsheJarousesJhim.

A. ASSESS

1. IdentifyJsignificantJsymptomsJbyJunderliningJthemJinJtheJassessment.

2. ListJthoseJsymptomsJthatJindicateJtheJclientJhasJaJhealthJproblemJ(thoseJyouJhaveJunderlined).

 fallingJasleepJinJclass
 oftenJlooksJrestless
 tapsJhisJfoot
 squirmsJaroundJinJhisJseat
 failedJhisJfirstJtest
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, ―tooJtired‖




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,CaseJStudyJAnswers 2


 complainsJaboutJsleepingJpoorly
 ―IJamJmovingJallJnight‖
 oftenJwakesJup
 dozes
 rightJlegJjerkingJseveralJtimes

3. GroupJtheJsymptomsJthatJareJsimilar.

 fallingJasleepJinJclass
 oftenJlooksJrestless
 tapsJhisJfoot
 squirmsJaroundJinJhisJseat
 failedJhisJfirstJtest
 complainsJaboutJsleepingJpoorly
 dozes



 ―tooJtired‖
 ―IJamJmovingJallJnight‖
 oftenJwakesJup
 rightJlegJjerkingJseveralJtimes
 DIAGNOSE

4. SelectJpossibleJnursingJdiagnosesJforJthisJclient.

DoJthisJbyJlookingJatJtheJlistJofJnursingJdiagnosesJin,JtheJbook,JAckley/LadwigJNursingJDiagnosisJHa
ndbook:JAnJEvidence-
BasedJGuideJtoJPlanningJCareJorJbyJaccessingJtheJcareJplanJconstructorJatJtheJEVOLVEJSITEJandJv
iewingJnursingJdiagnosesJlistedJthere.

PossibleJnursingJdiagnoses:

SleepJdeprivationJDistu
rbedJsleepJpatternJFatig
ue
IneffectiveJcopingJStres
sJoverload

2. ValidateJtheJpossibleJnursingJdiagnoses.

CompareJtheJsignsJandJsymptomsJ(definingJcharacteristics)JthatJyouJhaveJidentifiedJfromJyourJclient
JassessmentJwithJtheJdefiningJcharacteristicsJforJtheJnursingJdiagnosisJthatJyouJhaveJselected.JAlsoJrea

dJtheJdefinitionJandJdetermineJifJthisJdiagnosisJfitsJthisJclient.

ValidatedJnursingJdiagnosesJinclude:

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, CaseJStudyJAnswers 3


(YouJcanJcopyJandJpasteJtheJinformationJfromJtheJEVOLVEJSITEJinJtheJareasJbelow.)JSlee

pJdeprivation

3. Write/selectJaJnursingJdiagnosticJstatementJforJoneJofJtheJnursingJdiagnosesJbyJcombiningJtheJnu
rsingJdiagnosisJlabelJwithJtheJrelatedJtoJ(r/t)Jfactors.

a. TheJlabelJisJtheJtitleJofJtheJnursingJdiagnosisJasJdefinedJbyJNANDA-I.
b. AJrelatedJtoJ(r/t)JstatementJdescribesJfactorsJthatJmayJbeJcontributingJtoJorJcausingJtheJproblemJtha
tJresultedJinJtheJnursingJdiagnosis.

NANDA-

IJlabel:JSleepJdeprivationJDefinition
ProlongedJperiodsJofJtimeJwithoutJsustainedJnatural,JperiodicJsuspensionJofJrelativeJconsciousness
thatJprovidesJrest.
DefiningJcharacteristics
AlteredJattention,Janxiety,Japathy,Jcombativeness,Jconfusion,JdecreaseJinJfunctionalJability,Jdrowsi
ness,JexpressesJdistress,Jfatigue,JfleetingJnystagmus,Jhallucinations,JheightenedJsensitivityJtoJpain,Jir
ritableJmood,Jlethargy,JprolongedJreactionJtime,JpsychomotorJagitation,JtransientJparanoia,Jtremors.


RelatedJfactorsJ(r/t):JAge-
relatedJsleepJstageJshifts,JaverageJdailyJphysicalJactivityJisJlessJthanJrecommendedJforJgenderJandJ
age,JenvironmentalJdisturbances,JenvironmentalJoverstimulation,Jnon-restorativeJsleep-
wakeJcycle,JsleepJterror,JsleepJwalking,JsustainedJcircadianJasynchrony,JsustainedJinadequateJsle
epJhygiene.


TheJcompleteJnursingJdiagnosticJstatementJis:

SleepJdeprivationJr/tJconditionsJwithJperiodicJlimbJmovement




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