Intan’s Screening

Diagnoses Assesment
English Version

Decreased stimulation
Inattention to one side and
from (or interest or
over attention to the opposite
engagement in) Unilateral
side of the body which is
recreational or leisure neglect
experiences impairment
activities
in sensory and motor response

Reports a habit of life

Sedentary that is characterized
Any limitation in independent,
lifestyle by a low physical Impaired
purposeful physical movement
activity level Physical
of the body or of one or
more extremities mobility
Risk for Problem
Decrease mobility
constipation in activity Continuous/frequent aimless
movement from place to place Wandering
Inactivity/Insufficient that expose individual to harm
physical activity
Risk for Imbalanced Problem in Any limitation of independent Impaired
Body temperature Vigorous activity mobility movement between two Transfer
nearby surfaces? Ability
Insufficient physiological
or psychological energy Any limitation of independent
Activity to endure or complete movement within the Impaired
intolerance required or desired daily environment on foot Walking
activities
Any limitation of independent
movement from one bed Impaired
position to another bed mobility
Assessment for
activity, rest
and mobility

History of previous
intolerance
Patient Risk for activity
intolerance
Inexperience with
the activity
Risk diagnoses related to
activity and mobility Mechanical
Immobilzation
Risk for disuse syndrome
Paralysis

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 nurse to assess patient in order to screen all "possible nursing diagnoses" and "possible collaborative
problems" which may be experienced by patient.
Sequences in ISDA are follows:
a. Assessment for vital sign
b. Assessment for safety
c. Assessment for specific circumstances
d. Assessment for body function
e. Assessment for psychology
f. Assessment for cognitive, perception and sensory
g. Assessment for spiritual, values and religiosity
h. Assessment for behavior
i. Assessment for sexuality
j. Assessment for social
k. Assessment for infant/child
l. Assessment for caregiver, family, community
m. Assessment for environment
n. Additional assessment for risk diagnoses
o. Assessment for wellness diagnoses
p. Assessment for data that belong to collaborative problems and nursing diagnoses
q. Assessment for data that only belong to collaborative problems

How to use ISDA?

1. If possible, nurses need to assess patient based on the sequence in ISDA, however, it is depend on client's situations and
circumstances
2. 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 accurate
of nursing diagnoses or collaborative problems
b. Look at "The map of Nursing Diagnoses Based on NANDA-I 2007-2008" to find the relationship among nursing diagnoses in
order to continue the assessment in more focus/detail
3. Nurse need to remember that not all data can be screened by ISDA, in this situation, nurse can use the book with the tittle "The Fast
method of Formulating Nursing Diagnoses" to track the possible nursing diagnoses based on the data that have been found from the
previous assessment

Note:
The use of ISDA which requiring approvals and/or license fees are listed bellow:
1. An author or company requests use ISDA in an audiovisual material
2. A software developer or computer based-patient record vendor request use of ISDA
3. Translation in other language
4. Any research about ISDA

Contact:
Intansari Nurjannah
School of Nursing Faculty of Medicine
Universitas Gadjah Mada
Sekip Bulaksumur Yogyakarta
Indonesia (55284)

Phone office : +62 274 545674

e-mail (priority) : intansarinurjannah@yahoo.com
e-mail (other) : intansarin@ugm.ac.id

This page in Indonesian version can be found in http://keperawatan.ugm.ac.id/id/download-files/cat_view/16-cpublications.html click

Apakah ISDA?

PREFACE Page 1 of 40
 CONTENTS

PREFACE 1
CONTENT 2
Assessment for vital sign 3
Assessment for safety 7
Assessment for specific circumstances 8
Assessment for body function 12
Assessment for psychology 18
Assessment for cognitive, perception and sensory 22
Assessment for spiritual, values and religiosity 23
Assessment for behavior 24
Assessment for sexuality 26
Assessment for social 26
Assessment for infant/child 27
Assessment for caregiver, family, community 28
Assessment for environment 30
Additional assessment for risk diagnoses 31
Assessment for wellness diagnoses 40
Assessment for data that belong to collaborative problems and nursing diagnoses 40
Assessment for data that only belong to collaborative problems 40
REFERENCES 40

CONTENT Page 2 of 40
 PC: Decreased
Cardiac Output

PC: Calcium Channel PC: Fetal distress

Blocker Therapy
Adverse Effects
PC: Renal Primary hypertensive
Insufficiency disease, in diabetes
Decreased BP
mellitus

Ineffective tissue Blood pressure PC: Post partum Hemorrhage

Consume calcium perfusion (specify: change in Check is there PC: Pregnancy-Asociated Hypertension
channel blocker peripheral) extremitas any jugular vein As a high
distention? PC: Prenatal Bleeding
risk popu-
Abnormal blood PC: Preterm Labor lation in
Activity pressure response
intolerance to activity (daily PC: Thrombocytopenia
PC: GI Bleeding activity)?
Excess fluid volume
(S3 heart sound) PC: Pulmonary Edema
As a high risk S3 sound? As sign and
population in symptom in
Decreased cardiac output (S3

ASSESSMENT FOR VITAL SIGN

and S4 heart sound), low blood
pressure (Carpenito,2006)
PC: Pulmonary Acute Pain
Embolism (General)
Ineffective tissue perfu-
PC: Atelectasis Pneumonia
(sign and symptom of septic) sion (specify: renal)
PC: Hyperglicemia For Potential
Complication Blood pressure Altered blood pressure PC: Hypoxemia (elevated diastolic
PC: Hypokalemia outside of acceptable
As sign and change pressure - sign of right - sided
PC: Hypermagnesemia parameters As a sign and
symptom in congestive heart failure)
PC: Hypochloremia symptom in
PC: Allergy Reaction PC: Hypernatremia (Elevated Blood
PC: Sickling crises For Potential Pressure)
Hypotension Hypertension Complication
PC: Dysrhytmias
Consume If patient consume
PC: Neuroleptic neuroleptic Antipsychotic
Malignant Syndrome Decreased Increased In hyper- therapy Risk for falls
tension
If patient has condition If patient consume
PC: GI BLeeding got therapy - antihypertensive
as a high risk therapy
Post shock population in PC:
PC: Paralytic Ileus Blood Antihypertensive
status
pressure Therapy Adverse
anaphylactic As a high risk Effects
PC:Hypovolemia shock Shock PC: Antipsychotic
population in Therapy Adverse Effects
PC: Decreased Septic shock,
Cardiac Output cardiogenic shock

Risk for falls (for Check whether patient

As high risk has got an injury Autonomic dysreflexia
orthostastic hypotension)

Page
population in in T7 or above? (paroxysmal hypertension)
and Decreased Cardiac

COLOR SIGNS : actual diagnoses risk diagnoses wellness diagnoses collaborative problems
Output (Carpenito, 2006) Fear
Possible Nursing
Diagnoses Anxiety however, sometimes
Deficient fluid volume the blood pressure may
Blood

3
Check if patient For For decrease on Anxiety in
use natural latex Latex allergy response Nursing Nursing pressure NANDA-I
rubber product? Diagnoses PC: Antiarrythmic Diagnoses increase Blood pressure increased
Decreased intracranial Therapy Adverse Effects diastolic pressure > 15 mm Hg Activity intolerance
As High risk ICP (Intracranial respond to activity (Carpenito,
Pressure) adaptive capacity (with 2006)
population in measurement? intracranial hypertension) Body temperature
below normal range? Hypothermia

of 40
PC: Dysrhytmias
Temperature fluctuation between
hypothermia and hyperthermia Ineffective thermoregulation