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Nursing Priorities Establishes a general ranking of needs and concerns on which the Nursing Diagnoses are ordered in constructing the plan of care This ranking would be altered according to the individual client situation Discharge Goals
INDEX OF DISEASES DISORDERS, Acid base imbalances Gastrectomy gastric resection 317 Pediatric considerations 890. respiratory 195 Gastric bypass 396 Peritoneal dialysis 570. metabolic 483 Gastric partitioning 396 Peritonitis 349. AIDS 709 Gastroplasty 396 Pernicious anemia 493, Alcohol acute withdrawal 819 Glaucoma 204 Pneumonia 131. Alzheimer s disease 764 Graves disease 419 Pneumothorax 154. Amputation 646 Primary base bicarbonate deficiency 483. Anemia iron deficiency anemia of chronic Heart failure chronic 48 Primary base bicarbonate excess 488. disease pernicious aplastic hemolytic 493 Hemodialysis 575 Primary carbonic acid deficit 200. Angina coronary artery disease acute coronary Hemolytic anemia 493 Primary carbonic acid excess 195. syndrome 64 Hemothorax 154 Prostatectomy 596, Anorexia nervosa 369 Hepatitis 434 Psychosocial aspects of care 749. Aplastic anemia 493 Herniated nucleus pulposus ruptured invertebral Pulmonary emboli considerations 111. Appendectomy 344 disc 254 Pulmonary tuberculosis 186. Asthma 120 HIV positive client 697,Hospice 866 Radical neck surgery laryngectomy. Bariatric surgery 396 Hypercalcemia calcium excess 927 postoperative care 160. Benign prostatic hyperplasia 588 Hyperkalemia potassium excess 921 Renal calculi 603. Bulimia nervosa 369 Hypermagnesemia magnesium excess 932 Renal dialysis 560. Burns thermal chemical and electrical acute Hypernatremia sodium excess 915 Renal failure acute 536. and convalescent phases 667 Hypertension severe 37 Renal failure chronic 548. Hyperthyroidism Graves disease Respiratory acid base imbalances 195. Cancer 846 thyrotoxicosis 419 Respiratory acidosis primary carbonic acid. Cardiac surgery postoperative care 100 Hypervolemia extracellular fluid volume excess 195. Cardiomyoplasty 100 excess 905 Respiratory alkalosis primary carbonic acid. Cerebrovascular accident stroke 238 Hypocalcemia calcium deficit 924 deficit 200. Chemical burns 667 Hypokalemia potassium deficit 918 Rheumatoid arthritis 729. Cholecystectomy 364 Hypomagnesemia magnesium deficit 930 Ruptured invertebral disc 254. Cholecystitis with cholelithiasis 357 Hyponatremia sodium deficit 914. Cholelithiasis 357 Hypovolemia extracellular fluid volume Seizure disorders 210. Chronic obstructive pulmonary disease 120 deficit 908 Sepsis 686. Cirrhosis of the liver 445 Hysterectomy 611 Septicemia 686. Colostomy 334 Sickle cell crisis 503, Coronary artery bypass graft 100 Ileostomy 334 Spinal cord injury acute rehabilitative phase. Coronary artery disease 64 Inflammatory bowel disease ulcerative colitis 271. Craniocerebral trauma acute rehabilitative Crohn s disease 321 Stroke 238. phase 220 Iron deficiency anemia 493 Substance dependence abuse rehabilitation 835. Crohn s disease 321 Surgical intervention 782,Laminectomy 262. Deep vein thrombosis 111 Laryngectomy postoperative care 160 Thermal burns 667. Dementia Alzheimer s type or vascular 764 Leukemias 516 Thrombophlebitis deep vein thrombosis including. Diabetes mellitus diabetic ketoacidosis 405 Lung cancer postoperative care 144 pulmonary emboli considerations 111. Diabetic ketoacidosis 405 Lymphomas 525 Thyroidectomy 429. Disaster considerations 876 Thyrotoxicosis 419, Disc surgery 262 Mastectomy 619 Total joint replacement 655. Dysrthymias 88 Metabolic acid base imbalances 483 Total nutritional support parenteral enteral. Metabolic acidosis primary base bicarbonate feeding 469. Eating disorders anorexia nervosa bulimia deficiency 483 Transplantation considerations postoperative. nervosa 369 Metabolic alkalosis primary base bicarbonate and lifelong 739. Eating disorders obesity 387 excess 488 Tuberculosis pulmonary 186. Electrical burns 667 Minimally invasive direct coronary artery. End of life care hospice 866 bypass 100 Ulcerative colitis 321. Enteral feeding 469 Multiple sclerosis 290 Upper gastrointestinal esophageal bleeding 306. Esophageal bleeding 306 Myocardial infarction 74 Urinary diversions urostomy postoperative. Extended care 801 care 578,Obesity 387 Urolithiasis renal calculi 603. Fecal diversions postoperative care of ileostomy Obesity bariatric surgery gastric partitioning Urostomy 578. and colostomy 334 gastroplasty gastric bypass 396, Fluid and electrolyte imbalances 903 Valve replacement 100. Fluid and electrolyte imbalances 903 Pancreatitis 458 Vascular dementia 764. Fractures 632 Parenteral feeding 469 Ventilatory assistance mechanical 173. KEY TO ESSENTIAL TERMINOLOGY,Client Assessment Database. Provides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical. and or surgical diagnosis as well as the signs and symptoms and corresponding diagnostic findings. Nursing Priorities, Establishes a general ranking of needs and concerns on which the Nursing Diagnoses are ordered in constructing the plan of. care This ranking would be altered according to the individual client situation. Discharge Goals, Identifies generalized statements that could be developed into short term and intermediate goals to be achieved by the client. before being discharged from nursing care They may also provide guidance for creating long term goals for the client to. work on after discharge,Nursing Diagnosis, The general need or problem diagnosis is stated without the distinct cause and signs and symptoms which would be added. to create a client diagnostic statement when specific client information is available For example when a client displays. increased tension apprehension quivering voice and focus on self the nursing diagnosis of Anxiety might be stated severe. Anxiety related to unconscious conflict threat to self concept as evidenced by statements of increased tension apprehension. observations of quivering voice focus on self, In addition diagnoses identified within these guides for planning care as actual or risk can be changed or deleted and. new diagnoses added depending entirely on the specific client information. May Be Related to Possibly Evidenced by, These lists provide the usual or common reasons etiology why a particular need or problem may occur with probable signs. and symptoms which would be used to create the related to and evidenced by portions of the client diagnostic statement. when the specific situation is known, When a risk diagnosis has been identified signs and symptoms have not yet developed and therefore are not included in. the nursing diagnosis statement However interventions are provided to prevent progression to an actual problem The excep. tion to this occurs in the nursing diagnosis risk for Violence which has possible indicators that reflect the client s risk status. Desired Outcomes Evaluation Criteria Client Will, These give direction to client care as they identify what the client or nurse hopes to achieve They are stated in general terms. to permit the practitioner to modify or individualize them by adding time lines and specific client criteria so they become. measurable For example Client will appear relaxed and report anxiety is reduced to a manageable level within 24 hours. Nursing Outcomes Classification NOC labels are also included The outcome label is selected from a standardized. nursing language and serves as a general header for the outcome indicators that follow. Actions Interventions, Nursing Interventions Classification NIC labels are drawn from a standardized nursing language and serve as a general. header for the nursing actions that follow, Nursing actions are divided into independent those actions that the nurse performs autonomously and collaborative. those actions that the nurse performs in conjunction with others such as implementing physician orders The interventions in. this book are generally ranked from most to least common When creating the individual plan of care interventions would nor. mally be ranked to reflect the client s specific needs and situation In addition the division of independent and collaborative is. arbitrary and is actually dependent on the individual nurse s capabilities and hospital and community standards. Although not commonly appearing in client plans of care rationale has been included here to provide a pathophysiological. basis to assist the nurse in deciding about the relevance of a specific intervention for an individual client situation. Clinical Pathway, This abbreviated plan of care or care map is event or task oriented and provides outcome based guidelines for goal achieve. ment within a designated length of stay Several samples have been included to demonstrate alternative planning formats. NURSING DIAGNOSES ACCEPTED FOR,USE AND RESEARCH FOR 2009 2011. Activity Intolerance specify level Fluid Volume risk for imbalanced Rape Trauma Syndrome silent reaction retired. Activity Intolerance risk for Gas Exchange impaired 2009. Activity Planning ineffective Glucose Level risk for unstable blood Relationship readiness for enhanced. Airway Clearance ineffective Grieving Religiosity impaired. Allergy Response latex Grieving complicated Religiosity risk for impaired. Allergy Response risk for latex Grieving risk for complicated Religiosity readiness for enhanced. Anxiety specify level Growth risk for disproportionate Relocation Stress Syndrome. Anxiety death Growth and Development delayed Relocation Stress Syndrome risk for. Aspiration risk for Health Maintenance ineffective Resilience impaired individual. Attachment risk for impaired Health Management ineffective self formerly Resilience readiness for enhanced. Autonomic Dysreflexia Therapeutic Regimen Management ineffective Resilience risk for compromised. Autonomic Dysreflexia risk for Health Management readiness for enhanced self Role Performance ineffective. Behavior risk prone health formerly Therapeutic Regimen Management Self Care readiness for enhanced. Bleeding risk for readiness for enhanced Self Care Deficit bathing. Body Image disturbed Home Maintenance impaired Self Care Deficit dressing. Body Temperature risk for imbalanced Hope readiness for enhanced Self Care Deficit feeding. Bowel Incontinence Hopelessness Self Care Deficit toileting. Breastfeeding effective Hyperthermia Self Concept readiness for enhanced. Breastfeeding ineffective Hypothermia Self Esteem chronic low. Breastfeeding interrupted Identity disturbed personal Self Esteem situational low. Breathing Pattern ineffective Immunization Status readiness for enhanced Self Esteem risk for situational low. Cardiac Output decreased Infant Behavior disorganized Self Mutilation. Caregiver Role Strain Infant Behavior readiness for enhanced organized Self Mutilation risk for. Caregiver Role Strain risk for Infant Behavior risk for disorganized Sensory Perception disturbed specify visual. Childbearing Process readiness for enhanced Infection risk for auditory kinesthetic gustatory tactile olfactory. Comfort impaired Injury risk for Sexual Dysfunction. Comfort readiness for enhanced Injury risk for perioperative positioning Sexuality Pattern ineffective. Communication impaired verbal Insomnia Shock risk for. Communication readiness for enhanced Intracranial Adaptive Capacity decreased Skin Integrity impaired. Conflict decisional Jaundice neonatal Skin Integrity risk for impaired. Conflict parental role Knowledge deficient Learning Need specify Sleep readiness for enhanced. Confusion acute Knowledge specify readiness for enhanced Sleep Deprivation. Confusion risk for acute Lifestyle sedentary Sleep Pattern disturbed. Confusion chronic Liver Function risk for impaired Social Interaction impaired. Constipation Loneliness risk for Social Isolation, Constipation perceived Maternal Fetal Dyad risk for disturbed Sorrow chronic. Constipation risk for Memory impaired Spiritual Distress. Contamination Mobility impaired bed Spiritual Distress risk for. Contamination risk for Mobility impaired physical Spiritual Well Being readiness for enhanced. Coping defensive Mobility impaired wheelchair Stress Overload. Coping ineffective Motility dysfunctional gastointestinal Suffocation risk for. Coping readiness for enhanced Motility risk for dysfunctional gastointestinal Suicide risk for. Coping ineffective community Nausea Surgical Recovery delayed. Coping readiness for enhanced community Neglect self Swallowing impaired. Coping compromised family Neglect unilateral Therapeutic Regimen Management effective. Coping disabled family Noncompliance Adherence ineffective specify retired 2009. Coping readiness for enhanced family Nutrition less than body requirements imbalanced Therapeutic Regimen Management ineffective. Death Syndrome risk for sudden infant Nutrition more than body requirements imbalanced community retired 2009. Decision Making readiness for enhanced Nutrition more than body requirements risk for Therapeutic Regimen Management ineffective. Denial ineffective imbalanced family, Dentition impaired Nutrition readiness for enhanced Thermoregulation ineffective. Development risk for delayed Oral Mucous Membrane impaired Thought Processes disturbed retired 2009. Diarrhea Pain acute Tissue Integrity impaired, Dignity risk for compromised human Pain chronic Transfer Ability impaired. Distress moral Parenting impaired Trauma risk for, Disuse Syndrome risk for Parenting readiness for enhanced Trauma risk for vascular. Diversional Activity deficient Parenting risk for impaired Urinary Elimination impaired. Electrolyte Imbalance risk for Perfusion ineffective peripheral tissue Urinary Elimination readiness for enhanced. Energy Field disturbed Perfusion risk for decreased cardiac tissue Urinary Incontinence functional. Environmental Interpretation Syndrome impaired Perfusion risk for ineffective cerebral tisse Urinary Incontinence overflow. Failure to Thrive adult Perfusion risk for ineffective gastrointestinal Urinary Incontinence reflex. Falls risk for Perfusion risk for ineffective renal Urinary Incontinence stress. Family Processes dysfunctional Peripheral Neurovascular Dysfunction risk for Urinary Incontinence total retired 2009. Family Processes interrupted Poisoning risk for Urinary Incontinence urge. Family Processes readiness for enhanced Post Trauma Syndrome specify stage Urinary Incontinence risk for urge. Fatigue Post Trauma Syndrome risk for Urinary Retention acute chronic. Fear Power readiness for enhanced Ventilation impaired spontaneous. Feeding Pattern ineffective infant Powerlessness specify level Ventilatory Weaning Response dysfunctional. Fluid Balance readiness for enhanced Powerlessness risk for Violence actual risk for other directed. Fluid Volume deficient hyper hypotonic Protection ineffective Violence actual risk for self directed. Fluid Volume deficient isotonic Rape Trauma Syndrome Walking impaired. Fluid Volume excess Rape Trauma Syndrome compound reaction Wandering specify sporadic or continual. Fluid Volume risk for deficient retired 2009 author recommendations. Nursing Diagnoses Definitions and Classification 2009 2011 2009 2007 2005 2003 2001 1998 1996 1994 NANDA International Used by arrangement with. Wiley Blackwell Publishing a company of John Wiley Sons Inc In order to make safe and effective judgments using NANDA I nursing diagnoses it is. essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work. Nursing Care,Guidelines for Individualizing Client. Care Across the Life Span,Nursing Care,Guidelines for Individualizing Client. Care Across the Life Span,Marilynn E Doenges APRN BC Retired. Clinical Specialist Adult Psychiatric Mental Health Nursing Retired. Adjunct Faculty, Beth El College of Nursing and Health Sciences UCCS. Colorado Springs Colorado,Mar y Frances Moorhouse RN MSN CRRN LNC. Adjunct Faculty Clinical Instructor,Pikes Peak Community College. Nurse Consultant TNT RN Enterprises,Colorado Springs Colorado. Alice C Murr RN BSN LNC,Legal Nurse Consultant,Telephone Triage Nurse. Macon Mississippi,F A Davis Company,1915 Arch Street. Philadelphia PA 19103,www fadavis com,Copyright 2010 by F A Davis Company. Copyright 1984 1989 1993 1997 2000 2002 and 2006 by F A Davis Company All rights reserved This book is protected by. copyright No part of it may be reproduced stored in a retrieval system or transmitted in any form or by any means electronic. mechanical photocopying recording or otherwise without written permission from the publisher. Printed in the United States of America, Last digit indicates print number 10 9 8 7 6 5 4 3 2 1. Publisher Nursing Joanne Patzek DaCunha RN MSN, Director of Content Development Darlene Pederson MSN APRN BC. Project Editor Kim DePaul Mackey,Design and Illustrations Manager Carolyn O Brien. As new scientific information becomes available through basic and clinical research recommended treatments and drug thera. pies undergo changes The author s and publisher have done everything possible to make this book accurate up to date and. in accord with accepted standards at the time of publication The author s editors and publisher are not responsible for errors. or omissions or for consequences from application of the book and make no warranty expressed or implied in regard to the. contents of the book Any practice described in this book should be applied by the reader in accordance with professional stan. dards of care used in regard to the unique circumstances that may apply in each situation The reader is advised always to check. product information package inserts for changes and new information regarding dose and contraindications before adminis. tering any drug Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging in Publication Data. Doenges Marilynn E 1922, Nursing care plans guidelines for individualizing client care across the life span Marilynn E Doenges Mary Frances. Moorhouse Alice C Murr Ed 8,Includes bibliographical references and index. ISBN 13 978 0 8036 2210 4,ISBN 10 0 8036 2210 4, 1 Nursing care plans Handbooks manuals etc I Moorhouse Mary Frances 1947 II Murr Alice C. 1946 III Title, DNLM 1 Patient Care Planning Handbooks 2 Nursing Process Handbooks WY 49 D651na 2010. RT49 D64 2010,610 73 dc22,2009014629, Authorization to photocopy items for internal or personal use or the internal or personal use of specific clients is granted by. F A Davis Company for users registered with the Copyright Clearance Center CCC Transactional Reporting Service pro. vided that the fee of 25 per copy is paid directly to CCC 222 Rosewood Drive Danvers MA 01923 For those organizations. that have been granted a photocopy license by CCC a separate system of payment has been arranged The fee code for users. of the Transactional Reporting Service is 8036 1169 2 04 0 25. To our spouses children parents and friends who much of the time. have had to manage without us while we work as well as having to. cope with our struggles and frustrations, The Doenges families the late Dean whose support and. encouragement is sorely missed Jim Barbara and Bob Lanza. David Monita Matthew and Tyler John Holly Nicole and. Kelsey and the Daigle families Nancy Jim Jennifer Brandon. Anna Will and Henry Smith Daigle and Jonathan Kim,and Mandalyn JoAn. The Moorhouse family Jan Paul Jason Thenderlyn Alexa. and Mary Isabella, To Mary and Marilynn I couldn t have done it without you. In loving memory of my parents who were my biggest promoters. in my early days of writing To my children and grandchildren. with love You have expanded my horizons so wonderfully Alice. To our F A Davis family especially Bob Martone and Bob Butler. whose support is so vital to the completion of a project of. this magnitude And to Joanne DaCunha who is not just our. acquisitions editor but also a colleague and friend who has seen. the project from both sides now Thank you for your support. and understanding We are fourtunate to have you working. To the nurses we are writing for who daily face the challenge of caring. for the acutely ill client and are looking for a practical way to organize. and document this care We believe that nursing diagnosis and these. guides will help, To NANDA and to the international nurses who are developing. and using nursing diagnoses here we come, Finally to the late Mary Lisk Jeffries who initiated the. original project The memory of our early friendship and struggles. remains with us We miss her and wish she were here to see the. growth of the profession and how nursing diagnosis has contributed. to the process,CONTRIBUTORS TO THE 8TH EDITION,Mope T Adeola RN MSN CNS OCN Julie Matheny RRT. Clinical Assistant Professor ICU Specialist, Purdue University School of Nursing Penrose Hospital. West Lafayette Indiana Colorado Springs Colorado, Jane V Arndt MS RN CWOCN Kathleen Molden RN MSN CNE. Clinical Nurse Specialist Nurse Educator, Poudre Valley Hospital St Francis Medical Center School of Nursing. Fort Collins Colorado Trenton New Jersey, Nancy Buttry MSN RN Kimberly Tucker Pfennigs MA BAN RN. Associate Dean of Nursing and Allied Health Case Manager Warrior Transition Unit. Illinois Eastern Community Colleges Fort Carson Colorado. Olney Illinois,Gilda Rolls Dellinger RN, Kathleen A Curtis RN MSN Staff Nurse Skin Wound and Burn Team. Instructor Course Coordinator Penrose St Francis Health Services. Mount Carmel College of Nursing Colorado Springs Colorado. Columbus Ohio,Rochelle Salmore MSN RN CGRN NE BC, Rosemary Fliszar PhD RN CNE Clincal Manager GI Lab Wound Clinic. Assistant Professor Nursing Penrose Centura Hospital. Kutztown University Colorado Springs Colorado,Kutztown Pennsylvania. April Sheker RN MSN c CMSRN,Brenda Hicks RN OCN Clinical Instructor. Memorial Cancer Medicine Specialists Pennsylvania State University. Memorial Hospital College of Nursing,Colorado Springs Colorado Allentown Pennsylvania. Christie A Hinds MSN APRN BC Geri L Tierney RN BSN ONC. Primary Care Nurse Practitioner Nursing Simulation Lab Coordinator. Health Essentials Pikes Peak Community College, Chattanooga Tennessee Past President National Association of Orthopaedic. Jennifer Limongiello MSN ARNP Colorado Springs Colorado. Associate Professor, NHTI Concord Community College Kathleen H Winder RN BSN. Concord New Hamshire Clinical Manager Pediatric Specialty Clinic. Memorial Hospital,Bill Loughmiller CRT Colorado Springs Colorado. Respiratory Therapist, St Francis Medical Center Anne Zobec MS RN CS NP AOCN. Colorado Springs Colorado Oncology Nurse Practitioner. Rocky Mountain Cancer Center,Larry Manalo RN MSN Colorado Springs Colorado. Nursing Instructor,Allan Hancock College,Santa Maria California xi. REVIEWERS FOR THE 8TH EDITION,Jennie C Denker RN MSN EdDc Priscilla A Lee MN NP. Director Year I Nurse Practitioner, Galen College of Nursing Assistant Clinical Professor. Goshen Kentucky UCLA Gonda Vascular Center,Los Angeles California. Dianne Marie Johnson MA APRN BC AHN BC, Assistant Professor School of Nursing Pamela Y Mahon PhD RN CNAA. College of St Scholastica Associate Professor,Duluth Minnesota Hunter College CUNY. New York New York,Carol A Kincaid RN MS CNS ANP,Full time faculty Mary Tan AAS ADN BSN MSN PhD RN. Chair of Fundamentals Level Assistant Director and Allied Health. Crouse Hospital School of Nursing Holmes Community College.