Ackley: Nursing Diagnosis Handbook, 12th Edition Revised Reprint with
q q q q q q q q q
2021-2023 NANDA-I® Updates
q q
LectureqNotes
Problem-
BasedqLearning/CriticalqThinkingqCaseqStu
dy—RestlessqLegqSyndrome
CaseqScenario
AbdulqMalekqisqaq21-year-
oldqcollegeqstudent.qHeqattendsqtheqlocalqstatequniversityqandqisqaqjuniorqstudyingqgraphicqdesign.qTh
reeqweeksqintoqhisqfallqsemester,qAbdul’sqprofessorsqnoticeqthatqheqisqfallingqasleepqinqclassqandqofte
nqlooksqrestless.qAbdulqtapsqhisqfootqandqsquirmsqaroundqinqhisqseat.qAbdul,qwhoqisqusuallyqanqexcell
entqstudent,qhasqfailedqhisqfirstqtestqinqhisqGraphicqDesignqIIqcourse.qHisqprofessorqasksqhimqtoqseeqhis
qadvisorqbecauseqtheqfearqisqthatqAbdulqhasqbecomeqchemicallyqimpaired.qHisqadvisorqsendsqAbdulqt
oqtheqstudentqhealthqservicesqandqhisqcaseqisqreviewedqbyqtheqnurse.
NursingqAssessment
Abdulqisqaqwell-developedq22-year-
oldqmaleqwithqaqBMIqofq20.qHisqvitalqsignsqareqbloodqpressureq104/78;qtemperatureq98.4°F;qheartqrat
e—64qbeatsqperqminute;qrespiratoryqrate—
16qbreathsqperqminute.qAqnutritionalqhistoryqconfirmsqaqwell-
balancedqdietqwithqtheqexclusionqofqporkqproducts.qAbdulqhadqbeenqworkingqoutqeveryqdayqatqtheqUni
versityqgymqbutqreportsqthatqheqisqcurrentlyq―tooqtired‖qtoqdoqso.qAbdulqdeniesqdrugqorqalcoholquseqa
ndqthisqisqconfirmedqbyqserumqanalysis.qAbdulqcomplainsqaboutqsleepingqpoorlyqandqfeelingqasqif,q―
Iqamqmovingqallqnight.‖qHeqstatesqthatqheqoftenqwakesqupqhisqdormqmateqandqfeelsqbadqaboutqthat.qThe
qnurseqreclinesqAbdulqonqtheqexaminationqtableqandqchecksqhisqdeepqtendonqreflexesq(DTRs)qwhichq
areqallq2+.qTheqnurseqasksqAbdulqtoqrelaxqandqdimsqtheqlightsqwhileqsheqconsultsqwithqtheqprimaryqcar
eqpractitioner.qWhileqtheqnurseqisqoutqofqtheqexaminationqroomqAbdulqdozes,qandqwhenqtheqnurseqret
urns,qtheqnurseqobservesqAbdul’sqrightqlegqjerkingqseveralqtimesqbeforeqsheqarousesqhim.
A. ASSESS
1. Identifyqsignificantqsymptomsqbyqunderliningqthemqinqtheqassessment.
2. Listqthoseqsymptomsqthatqindicateqtheqclientqhasqaqhealthqproblemq(thoseqyouqhavequnderlined).
• fallingqasleepqinqclass
• oftenqlooksqrestless
• tapsqhisqfoot
• squirmsqaroundqinqhisqseat
• failedqhisqfirstqtest
Copyrightq©q2022,qElsevierqInc.qAllqrightsqreserved.
,• ―tooqtired‖
Copyrightq©q2022,qElsevierqInc.qAllqrightsqreserved.
,CaseqStudyqAnswers 2
• complainsqaboutqsleepingqpoorly
• ―Iqamqmovingqallqnight‖
• oftenqwakesqup
• dozes
• rightqlegqjerkingqseveralqtimes
3. Groupqtheqsymptomsqthatqareqsimilar.
• fallingqasleepqinqclass
• oftenqlooksqrestless
• tapsqhisqfoot
• squirmsqaroundqinqhisqseat
• failedqhisqfirstqtest
• complainsqaboutqsleepingqpoorly
• dozes
• ―tooqtired‖
• ―Iqamqmovingqallqnight‖
• oftenqwakesqup
• rightqlegqjerkingqseveralqtimes
• DIAGNOSE
4. Selectqpossibleqnursingqdiagnosesqforqthisqclient.
Doqthisqbyqlookingqatqtheqlistqofqnursingqdiagnosesqin,qtheqbook,qAckley/LadwigqNursingqDiagnosisq
Handbook:qAnqEvidence-
BasedqGuideqtoqPlanningqCareqorqbyqaccessingqtheqcareqplanqconstructorqatqtheqEVOLVEqSITEqand
qviewingqnursingqdiagnosesqlistedqthere.
Possibleqnursingqdiagnoses:
SleepqdeprivationqDistu
rbedqsleepqpatternqFatig
ue
IneffectiveqcopingqStres
sqoverload
2. Validateqtheqpossibleqnursingqdiagnoses.
Compareqtheqsignsqandqsymptomsq(definingqcharacteristics)qthatqyouqhaveqidentifiedqfromqyourqclie
ntqassessmentqwithqtheqdefiningqcharacteristicsqforqtheqnursingqdiagnosisqthatqyouqhaveqselected.qAlso
qreadqtheqdefinitionqandqdetermineqifqthisqdiagnosisqfitsqthisqclient.
Validatedqnursingqdiagnosesqinclude:
Copyrightq©q2022,qElsevierqInc.qAllqrightsqreserved.
, CaseqStudyqAnswers 3
(YouqcanqcopyqandqpasteqtheqinformationqfromqtheqEVOLVEqSITEqinqtheqareasqbelow.)qSl
eepqdeprivation
3. Write/selectqaqnursingqdiagnosticqstatementqforqoneqofqtheqnursingqdiagnosesqbyqcombiningqtheqn
ursingqdiagnosisqlabelqwithqtheqrelatedqtoq(r/t)qfactors.
a. TheqlabelqisqtheqtitleqofqtheqnursingqdiagnosisqasqdefinedqbyqNANDA-I.
b. Aqrelatedqtoq(r/t)qstatementqdescribesqfactorsqthatqmayqbeqcontributingqtoqorqcausingqtheqproblemqt
hatqresultedqinqtheqnursingqdiagnosis.
NANDA-
Iqlabel:qSleepqdeprivationqDefinition
Prolongedqperiodsqofqtimeqwithoutqsustainedqnatural,qperiodicqsuspensionqofqrelativeqconsciousness
thatqprovidesqrest.
Definingqcharacteristics
Alteredqattention,qanxiety,qapathy,qcombativeness,qconfusion,qdecreaseqinqfunctionalqability,qdrows
iness,qexpressesqdistress,qfatigue,qfleetingqnystagmus,qhallucinations,qheightenedqsensitivityqtoqpain,
qirritableqmood,qlethargy,qprolongedqreactionqtime,qpsychomotorqagitation,qtransientqparanoia,qtrem
ors.
Relatedqfactorsq(r/t):qAge-
relatedqsleepqstageqshifts,qaverageqdailyqphysicalqactivityqisqlessqthanqrecommendedqforqgenderqan
dqage,qenvironmentalqdisturbances,qenvironmentalqoverstimulation,qnon-restorativeqsleep-
wakeqcycle,qsleepqterror,qsleepqwalking,qsustainedqcircadianqasynchrony,qsustainedqinadequateqsl
eepqhygiene.
Theqcompleteqnursingqdiagnosticqstatementqis:
Sleepqdeprivationqr/tqconditionsqwithqperiodicqlimbqmovement
Copyrightq©q2022,qElsevierqInc.qAllqrightsqreserved.
q q q q q q q q q
2021-2023 NANDA-I® Updates
q q
LectureqNotes
Problem-
BasedqLearning/CriticalqThinkingqCaseqStu
dy—RestlessqLegqSyndrome
CaseqScenario
AbdulqMalekqisqaq21-year-
oldqcollegeqstudent.qHeqattendsqtheqlocalqstatequniversityqandqisqaqjuniorqstudyingqgraphicqdesign.qTh
reeqweeksqintoqhisqfallqsemester,qAbdul’sqprofessorsqnoticeqthatqheqisqfallingqasleepqinqclassqandqofte
nqlooksqrestless.qAbdulqtapsqhisqfootqandqsquirmsqaroundqinqhisqseat.qAbdul,qwhoqisqusuallyqanqexcell
entqstudent,qhasqfailedqhisqfirstqtestqinqhisqGraphicqDesignqIIqcourse.qHisqprofessorqasksqhimqtoqseeqhis
qadvisorqbecauseqtheqfearqisqthatqAbdulqhasqbecomeqchemicallyqimpaired.qHisqadvisorqsendsqAbdulqt
oqtheqstudentqhealthqservicesqandqhisqcaseqisqreviewedqbyqtheqnurse.
NursingqAssessment
Abdulqisqaqwell-developedq22-year-
oldqmaleqwithqaqBMIqofq20.qHisqvitalqsignsqareqbloodqpressureq104/78;qtemperatureq98.4°F;qheartqrat
e—64qbeatsqperqminute;qrespiratoryqrate—
16qbreathsqperqminute.qAqnutritionalqhistoryqconfirmsqaqwell-
balancedqdietqwithqtheqexclusionqofqporkqproducts.qAbdulqhadqbeenqworkingqoutqeveryqdayqatqtheqUni
versityqgymqbutqreportsqthatqheqisqcurrentlyq―tooqtired‖qtoqdoqso.qAbdulqdeniesqdrugqorqalcoholquseqa
ndqthisqisqconfirmedqbyqserumqanalysis.qAbdulqcomplainsqaboutqsleepingqpoorlyqandqfeelingqasqif,q―
Iqamqmovingqallqnight.‖qHeqstatesqthatqheqoftenqwakesqupqhisqdormqmateqandqfeelsqbadqaboutqthat.qThe
qnurseqreclinesqAbdulqonqtheqexaminationqtableqandqchecksqhisqdeepqtendonqreflexesq(DTRs)qwhichq
areqallq2+.qTheqnurseqasksqAbdulqtoqrelaxqandqdimsqtheqlightsqwhileqsheqconsultsqwithqtheqprimaryqcar
eqpractitioner.qWhileqtheqnurseqisqoutqofqtheqexaminationqroomqAbdulqdozes,qandqwhenqtheqnurseqret
urns,qtheqnurseqobservesqAbdul’sqrightqlegqjerkingqseveralqtimesqbeforeqsheqarousesqhim.
A. ASSESS
1. Identifyqsignificantqsymptomsqbyqunderliningqthemqinqtheqassessment.
2. Listqthoseqsymptomsqthatqindicateqtheqclientqhasqaqhealthqproblemq(thoseqyouqhavequnderlined).
• fallingqasleepqinqclass
• oftenqlooksqrestless
• tapsqhisqfoot
• squirmsqaroundqinqhisqseat
• failedqhisqfirstqtest
Copyrightq©q2022,qElsevierqInc.qAllqrightsqreserved.
,• ―tooqtired‖
Copyrightq©q2022,qElsevierqInc.qAllqrightsqreserved.
,CaseqStudyqAnswers 2
• complainsqaboutqsleepingqpoorly
• ―Iqamqmovingqallqnight‖
• oftenqwakesqup
• dozes
• rightqlegqjerkingqseveralqtimes
3. Groupqtheqsymptomsqthatqareqsimilar.
• fallingqasleepqinqclass
• oftenqlooksqrestless
• tapsqhisqfoot
• squirmsqaroundqinqhisqseat
• failedqhisqfirstqtest
• complainsqaboutqsleepingqpoorly
• dozes
• ―tooqtired‖
• ―Iqamqmovingqallqnight‖
• oftenqwakesqup
• rightqlegqjerkingqseveralqtimes
• DIAGNOSE
4. Selectqpossibleqnursingqdiagnosesqforqthisqclient.
Doqthisqbyqlookingqatqtheqlistqofqnursingqdiagnosesqin,qtheqbook,qAckley/LadwigqNursingqDiagnosisq
Handbook:qAnqEvidence-
BasedqGuideqtoqPlanningqCareqorqbyqaccessingqtheqcareqplanqconstructorqatqtheqEVOLVEqSITEqand
qviewingqnursingqdiagnosesqlistedqthere.
Possibleqnursingqdiagnoses:
SleepqdeprivationqDistu
rbedqsleepqpatternqFatig
ue
IneffectiveqcopingqStres
sqoverload
2. Validateqtheqpossibleqnursingqdiagnoses.
Compareqtheqsignsqandqsymptomsq(definingqcharacteristics)qthatqyouqhaveqidentifiedqfromqyourqclie
ntqassessmentqwithqtheqdefiningqcharacteristicsqforqtheqnursingqdiagnosisqthatqyouqhaveqselected.qAlso
qreadqtheqdefinitionqandqdetermineqifqthisqdiagnosisqfitsqthisqclient.
Validatedqnursingqdiagnosesqinclude:
Copyrightq©q2022,qElsevierqInc.qAllqrightsqreserved.
, CaseqStudyqAnswers 3
(YouqcanqcopyqandqpasteqtheqinformationqfromqtheqEVOLVEqSITEqinqtheqareasqbelow.)qSl
eepqdeprivation
3. Write/selectqaqnursingqdiagnosticqstatementqforqoneqofqtheqnursingqdiagnosesqbyqcombiningqtheqn
ursingqdiagnosisqlabelqwithqtheqrelatedqtoq(r/t)qfactors.
a. TheqlabelqisqtheqtitleqofqtheqnursingqdiagnosisqasqdefinedqbyqNANDA-I.
b. Aqrelatedqtoq(r/t)qstatementqdescribesqfactorsqthatqmayqbeqcontributingqtoqorqcausingqtheqproblemqt
hatqresultedqinqtheqnursingqdiagnosis.
NANDA-
Iqlabel:qSleepqdeprivationqDefinition
Prolongedqperiodsqofqtimeqwithoutqsustainedqnatural,qperiodicqsuspensionqofqrelativeqconsciousness
thatqprovidesqrest.
Definingqcharacteristics
Alteredqattention,qanxiety,qapathy,qcombativeness,qconfusion,qdecreaseqinqfunctionalqability,qdrows
iness,qexpressesqdistress,qfatigue,qfleetingqnystagmus,qhallucinations,qheightenedqsensitivityqtoqpain,
qirritableqmood,qlethargy,qprolongedqreactionqtime,qpsychomotorqagitation,qtransientqparanoia,qtrem
ors.
Relatedqfactorsq(r/t):qAge-
relatedqsleepqstageqshifts,qaverageqdailyqphysicalqactivityqisqlessqthanqrecommendedqforqgenderqan
dqage,qenvironmentalqdisturbances,qenvironmentalqoverstimulation,qnon-restorativeqsleep-
wakeqcycle,qsleepqterror,qsleepqwalking,qsustainedqcircadianqasynchrony,qsustainedqinadequateqsl
eepqhygiene.
Theqcompleteqnursingqdiagnosticqstatementqis:
Sleepqdeprivationqr/tqconditionsqwithqperiodicqlimbqmovement
Copyrightq©q2022,qElsevierqInc.qAllqrightsqreserved.
