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rencana keperawatan untuk merawat dan menolong nyawa pasien (In_English).

rencana keperawatan untuk merawat dan menolong nyawa pasien (In_English).

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  • 1. Copyright © 2006 by F. A. Davis.
  • 2. Copyright © 2006 by F. A. Davis. INDEX OF DISEASES/DISORDERS AIDS, 726 Heart failure: chronic, 47 Pneumonia, 128 Alcohol: acute withdrawal, 831 Hemodialysis, 581 Primary base bicarbonate deficiency, 492 Alzheimer’s disease, 945 Hemolytic anemia, 499 Primary base bicarbonate excess, 495 Amputation, 657 Hepatitis, 443 Primary carbonic acid deficit, 198 Anemias (iron deficiency, pernicious, Herniated nucleus pulposus (ruptured Primary carbonic acid excess, 194 aplastic, hemolytic), 499 intervertebral disc), 252 Prostatectomy, 604 Angina (coronary artery disease), 62 HIV-positive client, 712 Psychosocial aspects of care, 770 Anorexia nervosa, 376 Hospice care, 880 Pulmonary embolus, 108 Aplastic anemia, 499 Hypercalcemia (calcium excess), 938 Pulmonary tuberculosis, 184 Appendectomy, 350 Hyperkalemia (potassium excess), 933 Asthma, 117 Hypermagnesemia (magnesium excess), 943 Radical neck surgery: laryngectomy Hypernatremia (sodium excess), 928 (postoperative care), 157 Benign prostatic hyperplasia, 596 Hypertension: severe, 35 Regional enteritis, 324 Bulimia nervosa, 376 Hyperthyroidism (thyrotoxicosis, Graves’ Renal calculi, 613 Burns: thermal/chemical/electrical (acute disease), 426 Renal dialysis, 564 and convalescent phases), 680 Hypervolemia (extracellular fluid volume Renal dialysis: peritoneal, 575 excess), 919 Renal failure: acute, 541 Cancer, 857 Hypocalcemia (calcium deficit), 936 Renal failure: chronic, 553 Cardiac surgery: postoperative care, 96 Hypokalemia (potassium deficit), 931 Respiratory acid-base imbalances, 194 Cardiomyoplasty, 96 Hypomagnesemia (magnesium deficit), 941 Respiratory acidosis (primary carbonic acid Cerebrovascular accident/stroke, 236 Hyponatremia (sodium deficit), 925 excess), 194 Chemical burns, 680 Hypovolemia (extracellular fluid volume Respiratory alkalosis (primary carbonic acid Cholecystectomy, 371 deficit), 922 deficit), 194 Cholecystitis with cholelithiasis, 364 Hysterectomy, 621 Rheumatoid arthritis, 750 Cholelithiasis, 364 Ruptured intervertebral disc, 252 Chronic obstructive pulmonary disease, 117 Ileocolitis, 324 Cirrhosis of liver, 453 Ileostomy, 338 Seizure disorders, 208 Colostomy, 338 Inflammatory bowel disease: ulcerative Sepsis/septicemia, 701 Coronary artery bypass graft, 96 colitis, regional enteritis (Crohn’s disease, Septicemia, 701 Coronary artery disease, 62 ileocolitis), 324 Sickle cell crisis, 509 Craniocerebral trauma (acute rehabilitative Iron deficiency anemia, 499 Spinal cord injury (acute rehabilitative phase), 218 phase), 271 Crohn’s disease, 324 Laryngectomy (postoperative care), 157 Stroke, 236 Leukemias, 523 Substance dependence/abuse rehabilitation, Deep vein thrombosis, 108 Lung cancer (postoperative care), 141 843 Diabetes mellitus/diabetic ketoacidosis, 412 Lymphomas, 532 Subtotal gastrectomy/gastric resection, 320 Diabetic ketoacidosis, 412 Surgical interventions, 788 Disaster considerations, 890 Mastectomy, 630 Disc surgery, 260 Metabolic acid-base imbalances, 491 Thermal burns, 680 Dysrhythmias (including digitalis toxicity), Metabolic acidosis (primary base Thrombophlebitis: deep vein thrombosis 85 bicarbonate deficit), 492 (including pulmonary emboli Metabolic alkalosis (primary base considerations), 108 Eating disorders: anorexia nervosa/bulimia bicarbonate excess), 495 Thyroidectomy, 437 nervosa, 376 Minimally invasive direct coronary artery Thyrotoxicosis, 426 Eating disorders: obesity, 393 bypass, 96 Total joint replacement, 667 Electrical burns, 680 Multiple sclerosis, 291 Total nutritional support: parenteral/enteral End of life/hospice care, 880 Myocardial infarction, 72 feeding, 478 Enteral feeding, 478 Transplantation (postoperative and Esophageal bleeding, 309 Neurological/sensory disorders, 202 lifelong), 761 Extended care, 810 Obesity, 393 Ulcerative colitis, 324 Fecal diversions: postoperative care of Obesity: surgical interventions (gastric Upper gastrointestinal/esophageal ileostomy and colostomy, 338 partitioning/gastroplasty, gastric bleeding, 309 Fluid and electrolyte imbalances, 919 bypass), 402 Urinary diversions/urostomy Fluid balance, 919 (postoperative care), 585 Fractures, 642 Pancreatitis, 467 Urolithiasis (renal calculi), 613 Parenteral feeding, 478 Urostomy, 585 Gastric bypass, 402 Pediatric considerations, 905 Gastric partitioning, 402 Peritonitis, 355 Valve replacement, 96 Gastroplasty, 402 Pernicious anemia, 499 Ventilatory assistance (mechanical), 170 Glaucoma, 202 Graves’ disease, 426
  • 3. Copyright © 2006 by F. A. Davis. KEY TO ESSENTIAL TERMINOLOGY CLIENT ASSESSMENT DATABASE Provides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical/sur- gical diagnosis as well as the signs/symptoms and corresponding diagnostic findings. NURSING PRIORITIES Establishes a general ranking of needs/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 problem/need (diagnosis) is stated without the distinct cause and signs/symptoms, which would be added to cre- ate 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, re- lated to unconscious conflict, threat to self-concept as evidenced by statements of increased tension, apprehension; observa- tions 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/common reasons (etiology) why a particular problem may occur with probable signs/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/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 exception 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/individualize them by adding time lines and individual 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 nurs- ing language and serves as a general header for the outcome indicators that follow. ACTIONS/INTERVENTIONS NIC (Nursing Interventions Classification) intervention 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) and are ranked in this book from most to least common. When creating the individual plan of care, interventions would normally be ranked to reflect the client’s specific needs/situation. In addition, the division of independent/collaborative is arbitrary and is actually dependent on the individual nurse’s capabilities and hospital/community standards. RATIONALE Although not commonly appearing in client plans of care, rationale has been included here to provide a pathophysiologic ba- sis 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 (task) oriented and provides outcome-based guidelines for goal achievement within a designated length of stay. Several samples have been included to demonstrate alternative planning formats.
  • 4. Copyright © 2006 by F. A. Davis. NURSING DIAGNOSES ACCEPTED FOR USE AND RESEARCH THROUGH 2006 Activity Intolerance [specify level] Gas Exchange, impaired Role Performance, ineffective Activity Intolerance, risk for Grieving, anticipatory Self-Care Deficit: bathing/hygiene Adjustment, impaired Grieving, dysfunctional Self-Care Deficit: dressing/grooming Airway Clearance, ineffective Grieving, risk for dysfunctional Self-Care Deficit: feeding Allergy Response, latex Growth & Development, delayed Self-Care Deficit: toileting Allergy response, risk for latex Growth, risk for disproportionate Self-Concept, readiness for enhanced Anxiety [specify level] Health Maintenance, ineffective Self-Esteem, chronic low Anxiety, death Health-Seeking Behaviors (specify) Self-Esteem, situational low Aspiration, risk for Home Maintenance, impaired Self-Esteem, risk for situational low Attachment, risk for impaired Hopelessness Self-Mutilation parent/infant/child Hyperthermia Self-Mutilation, risk for Autonomic Dysreflexia Hypothermia Sensory Perception, disturbed: (specify: visual, Autonomic Dysreflexia, risk for Identity, disturbed personal auditory, kinesthetic, gustatory, tactile, Body Image, disturbed Infant Behavior, disorganized olfactory) Body Temperature, risk for imbalanced Infant Behavior, readiness for enhanced Sexual Dysfunction Bowel Incontinence organized Sexuality Pattern, ineffective Breastfeeding, effective Infant Behavior, risk for disorganized Skin Integrity, impaired Breastfeeding, ineffective Infant Feeding Pattern, ineffective Skin Integrity, risk for impaired Breastfeeding, interrupted Infection, risk for Sleep Deprivation Breathing Pattern, ineffective Injury, risk for Sleep, readiness for enhanced Cardiac Output, decreased Injury, risk for perioperative positioning Sleep Pattern, disturbed Caregiver Role Strain Intracranial Adaptive Capacity, decreased Social Interaction, impaired Caregiver Role Strain, risk for Knowledge, deficient [Learning Need] Social Isolation Communication, impaired verbal [specify] Sorrow, chronic Communication, readiness for enhanced Knowledge [specify], readiness for enhanced Spiritual Distress Conflict, decisional (specify) Lifestyle, sedentary Spiritual Distress, risk for Conflict, parental role Loneliness, risk for Spiritual Well-Being, readiness for enhanced Confusion, acute Memory, impaired Suffocation, risk for Confusion, chronic Mobility, impaired bed Suicide, risk for Constipation Mobility, impaired physical Surgical Recovery, delayed Constipation, perceived Mobility, impaired wheelchair Swallowing, impaired Constipation, risk for Nausea Therapeutic Regimen Management, effective Coping, defensive Neglect, unilateral Therapeutic Regimen Management, ineffective Coping, ineffective Noncompliance, [Adherence, ineffective] Therapeutic Regimen Management, ineffective Coping, readiness for enhanced [specify] community Coping, ineffective community Nutrition: less than body requirements, Therapeutic Regimen Management, ineffective Coping, readiness for enhanced community imbalanced family Coping, compromised family Nutrition: more than body requirements, Therapeutic Regimen Management, readiness Coping, disabled family imbalanced for enhanced Coping, readiness for enhanced family Nutrition, readiness for enhanced Thermoregulation, ineffective Death syndrome, risk for sudden infant Nutrition: more than body requirements, Thought Processes, disturbed Denial, ineffective risk for imbalanced Tissue Integrity, impaired Dentition, impaired Oral Mucous Membrane, impaired Tissue Perfusion, ineffective (specify type: Development, risk for delayed Pain, acute cerebral, cardiopulmonary, renal, Diarrhea Pain, chronic gastrointestinal, peripheral) Disuse Syndrome, risk for Parenting, impaired Transfer Ability, impaired Diversional Activity, deficient Parenting, readiness for enhanced Trauma, risk for Energy Field disturbed Parenting, risk for impaired Urinary Elimination, impaired Environmental Interpretation Syndrome, Peripheral Neurovascular Dysfunction, risk for Urinary Elimination, readiness for enhanced impaired Poisoning, risk for Urinary Incontinence, functional Failure to Thrive, adult Post-Trauma Syndrome [specify stage] Urinary Incontinence, reflex Falls, risk for Post-Trauma Syndrome, risk for Urinary Incontinence, stress Family Processes: alcoholism, dysfunctional Powerlessness [specify level] Urinary Incontinence, total Family Processes, interrupted Powerlessness, risk for Urinary Incontinence, urge Family Processes, readiness for enhanced Protection, ineffective Urinary Incontinence, risk for urge Fatigue Rape-Trauma Syndrome Urinary Retention [acute/chronic] Fear Rape-Trauma Syndrome: compound reaction Ventilation, impaired spontaneous Fluid Balance, readiness for enhanced Rape-Trauma Syndrome: silent reaction Ventilatory Weaning Response, dysfunctional [Fluid Volume, deficient hyper/hypotonic] Religiosity, impaired Violence, [actual/] risk for other-directed Fluid Volume, deficient [isotonic] Religiosity, risk for impaired Violence, [actual/] risk for self-directed Fluid Volume, excess Religiosity, readiness for enhanced Walking, impaired Fluid Volume, risk for deficient Relocation Stress Syndrome Wandering [specify sporadic or continual] Fluid Volume risk for imbalanced Relocation Stress Syndrome, risk for [ ] author recommendations Used with permission from NANDA International: Definitions and Classification, 2005–-2006. NANDA, Philadelphia, 2005.
  • 5. Copyright © 2006 by F. A. Davis. NURSING CARE PLANS GUIDELINES FOR INDIVIDUALIZING CLIENT CARE ACROSS THE LIFE SPAN EDITION 7 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 Mary 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 Jackson, Mississippi F. A. DAVIS COMPANY • Philadelphia
  • 6. Copyright © 2006 by F. A. Davis. NURSING CARE PLANS, 7th Edition… 7:25 PM Page 98 enges-04 12/9/05 Includes lab and diagnostic studies , and transportatio n, self-care needs NING ration, shopping, TEACHING/LEAR nce with food prepa Short-term assista The Guideline Approach Discharge plan maintenance tasks homemaker/home considerations: ions. ischarge considerat end of plan for postd Refer to section at cell VE) IES (POSTOPERATI ty and indicates need for red blood DIAGNOSTIC STUD s oxyge n-carrying capaci A low Hb reduce for fluid replacement . eutic ematocrit (Hct): to determine therap Hemoglobin (Hb)/h sts dehydration/need count, bleeding and clotting time) ion of Hct sugge to Individualized Care Planning replacement. Elevat platelet s may be done (e.g., affect cardiac s: Various studie hypocalcemia) can Coagulation studie t therapy when used. ponatremia, and level of anticoagulan hypernatremia/hy ia/hypokalemia, ances (hyperkalem Electrolytes: Imbal on, and acid-base balance. balance. function and fluid s of respiratory functi nation status, effectivenes at tissue level. ABGs: Verifies oxyge re of oxygenation ement. es noninvasive measu ion/function. going valve replac Pulse oximetry: Provid adequacy of renal and liver perfus heart failure under of Reflects ; e.g., those with an dysfunction, rate BUN/creatinine: in high-risk clients ce of diabetes/org is occasionally seen onal status, presen Amylase: Elevation preoperative nutriti occur because of Gluco se: Fluctuations may perioperativ e MI. s of acute, recent, or nary complication dextrose infusions. ed in the presence chang es indicative of pulmo r/cardiac enzymes: Elevat vasculature, and leads, intravascula Cardiac enzymes/iso position, pulmonary and sternal wires, position of pacing ls heart size and Chest x-ray: Revea of valve prosthesis Contains all the elements needed to make individualized patient care (e.g., atelectasis). lines. ECG: Identifies chang Verifies condition es in electrical, mecha nical function such nction, and/or perica as might occur in rditis. immediate postop erative phase, across valves, identi fies e MI, valve dysfu pressure gradients acute/perioperativ er pressures and es. choices, while teaching you how to critically analyze each component occlusions of arterie am/catheterizatio echocardiography: n: Measures chamb Cardiac echocardiogr s, impaired coronary perfusion, Usefu and possible wall l in diagnosing cardia motion abnormaliti c valve and chamb ach is not feasib le. er abnormalities, such as regurgitation coronary artery diseas e, heart , Transesophageal transthoracic appro scans demonstrate is in clients in whom m/Persantine): Heart and create the correct care plan for your patient. More than just a book shunting, or stenos Nuclear studies (e.g., chamber dimensions, thalliu m-201, DPY-thalliu and presurgical/ postsurgical functi onal capabilities. RITIES NURSING PRIO of Med-Surg care plans—this is an all-in-one resource that includes four 1. Support hemod 2. Promote relief ynamic stability/ve of pain/discomfort. ntilatory function. en. g. and treatment regim 3. Promote healin erative expectations new care plans, an introduction to Mind Mapping, and a bonus CD-ROM 4. Provide inform DISCHARGE GOA LS ation about postop nce adequate to meet self-care needs. Features diagnoses by priority covering all the care plans found in the book (plus 84 only available on 1. Activity tolera 2. Pain alleviated/m 3. Complications anaged. prevented/minimiz ed. understood. 4. Incisio ns healing. se, diet, therapy medications, exerci the disc) and the top 400 health conditions. 5. Postdischarge 6. Plan in place to meet needs after discharge. ut ased Cardiac Outp NOSIS: risk for decre NURSING DIAG Risk factors may include s (e.g., ventricular to temporary factor ctility secondary ) Loaded with care plans, including four new to this edition: Decreased myocardial contra wall surgery, recen Decreased t MI, response to preload (hypovolem tions in electrical ia) certain medications conduction (dysrh ythmias) /drug interactions Altera by osis.] Possibly evidenced ishes an actual diagn and symptoms establ Obesity Surgery – Complete coverage of gastric bypass surgery; [Not applicable; presence of signs ACTIONS/INTERVEN TIONS a procedure becoming more common across the country. 98 Investigate report leg, abdomen) or cially when accom s of pain in unusu vague complaints al areas (e.g., calf of discomfort, espe- of RATIONALE May be an early manifestation of panied by chang such as thrombophl developing compl es in mentation, ication Fluid and Electrolyte Imbalances – Clear and definitive care signs, respiratory Note reports of pain (fourth and fifth rate. and/or numbness digits) of the hand, in ulnar area vital function. ebitis, infection, Indicative of a stretch gastrointestinal dys- by pain/discomfort often accompanied injury of the brachi planning covering the role fluid and electrolyte imbalances that the problem Collaborative of the arms and should usually resolves with time. ers. Tell client result of the positio cific treatment is n of the arms during currently useful. al plexus as a surgery. No spe- play in many disorders. Administer medic and acetaminoph ations as indicated, en (Darvocet-N), e.g., propoxyphe ne Usually provides Highlights nursing diagnoses—now easier to find and use oxycodone (Tylox acetaminophen and ), and/or ketorolac (Toradol). for adequate contro mation, and reduce l of pain and inflam - More Life Span coverage – Extended Care and Pediatric comfort and promo s muscle tension, tes healing. which improves client care plans are also included. NURSING DIAG May be related to NOSIS: ineffective Role Performanc e Situational crisis (dependent role)/r Uncertainty about ecuperative proce future ss Possibly evidenced by Delay/alteration in physical capacity Change in usual to resume role role or Change in self/others’ responsibility perception of role DESIRED OUTCOMES /EVALUATION CRITE RIA—CLIENT WILL Here’s just a sample of what you’ll find PSYC HOSOCIAL ADJU Verbalize realistic Talk with SO about STMENT: perception and accep situation and chang : Life Chan ge (NOC) tance of self in chang ed role. Develop realistic es that have occur plans for adapting red. in the pages that follow… 7:25 PM Page 107 to perceived role changes. Doenges-04 12/9/05 ACTIONS/INTERVEN TIONS Role Enhancement RATIONALE Care plans you can adapt and customize to fit patient needs: CARDIOVAS (NIC) Independent RATIONALE ns depend on type of Asses NS s client role in family es and expectatio physical S/INTERVENTIO about role dysfuise pro- consteIndividual capa concerns ac function, and prior ital re- llation. Identify biliti • CD-ROM includes all 116 care plans from the book ACTION Review presc ribed cardiac exerc nction/inter ress to date. Assis health ion/ t client/SO to underlying cardi rehabilitat-illness transitrealistic set ions. Helps ruption; e.g., recupe surgery, conditioning. of hosp to know client’s is a predictor Note: Obesity affects this role. ons. responsibilities and how illness ration, tional interventi Dependent role may require addi concern Note: Strenuous of client provokes anxiet and CULAR: CAR gram and prog admission and verexhaustion. about how client plus 84 more—200 care plans! goals. Assess level of anxiet threat to self/life. Noteroutines; e y, client’s percep ents excessive fatigue/o role responsibilities. e.g., self-c cipation in hom cultural factors affecting are, activity and Prev of degree of undue stress on sternotom tion use of arms can place Information provid ing plan of care. y. will be able to manag es baseline for identi fying/individualiz y e usual Encourage parti nating rest perio ds with et- role changes. - Suggest alter y lifting, isom use of inter- - 115 Medical/Surgical care plans cooking. light tasks with heavy tasks. Avoi upper-body exerc d heav ise. res- Having a plan g up exercise forestalls givin determine can as weather. rent situation beca Cultural expectations regarding male/ how client/SO reacts female illness role DIAC SURGER ric/strenuous continue prog ferences such to and deals with Maintain to client/SO ways positive attitud and and may affect future cur- Prob lem-solve with erature extremes e toward client, provid changes. adaptation to percei ved ram during temp opportunities for etermined ing - 34 Psychiatric care plans sive activity prog n dayspossible. ing pred high wind/pol distance with lutio in own house ; e.g., walk or local indoor client to exercise shopping control as much Rest and sleep as enhance copin Helps client accept changes that g abilit control over self/situatio ote healing. ess realize thaties, reduce nervousn are occurring and begin n is possible. to mall/exercise track. 102 several times a day. phase), and prom pera- and short naps (common in this nt until after the first posto - 50 Maternal/Newborn care plans Schedule rest periods s are prese These restriction assessment of sternum heali ng. Y: lifting, driv- for ations about tive office visit ician’s time limit sexual activity, and exer- Postoperative Reinforce phys pressed, but to work, resum ing ity often go unex t sexual activ to expect. In - Pediatric Considerations ing, returning cising that invo Discuss issue lves upper extre s concerning mities. resumption of s of sexual inter sexual activity; cour se with other Concerns abou clients usually general, clien desire informati at which on about what ge in sex when activity level t can safely enga client can climb two flights n- e.g., comp arison of stres has adva nced to point same amou nt of energy expe ch is about the Prioritized nursing diagnoses to help students write activities: of stairs (whi diture). that restrict breat hing (sexual tion). Client Care avoid positions Client should nd and consump ases oxygen dema ort self or partner with measurable goal statements Position recom mendations; activity incre with sternotom arms (breast y should not bone healing, supp support musc ars to occur with les stretched) some regularity . in postop- is Impotence appe ugh etiology ry clients. Altho without spe- Focused on the patient, and applies the body system Expectatio ns of sexual perfo rmance; Loaded with rationales for every intervention erative cardiac unknown, cond cific interventi surge ition usually on. If situation resolves in time persists, may requ ire further evaluation. of complica- ce occurrence approach to care planning Appropriate sexual intercour timing; e.g., avoid ds of emotional dis- se fol- Timing of activ tions /angina. ity may redu use of antiangi- meal, during perio prophylactic lowing heavy exhausted; may benefit from ity. Some clients Guidelines covering total patient needs—physical, cultural, tress, when clien Pharmacologic t is fatigued/ considerations . nal medicatio Facilitates trans ns for sexual ition to home; ion of presc activ provides for ribed therapies, ongoing mon opportunity to i- discharge. toring, continuat available after anxiety. sexual, nutritional, and psychosocial Identify servi Provide telep ces/resources hone calls as appropria contact number/ te. Include refer schedule follo ral names for w-up hom e care discuss concerns and alleviate ated. services, as indic t’s age, physical Updated with the latest NANDA, NIC, and NOC content SIDERATIONS arge from care setting (dependes) following disch urces, and life responsib onal reso ilitie nt on clien POTENTIAL CON e of complications, pers senc condition/pre New emphasis on complementary therapies Activity Intol erance—genera ness, sede lized weak ntary lifestyle. surgical incis ions, puncture wounds. ms, reluctance to request assis tance. Tissue Integrity— support syste impaired Skin/ , inadequate to perform tasks New chapter on mind mapping impaired Hom e Maintenance—a broken skin, ltered ability traumatized tissu e, invasive proce dures, decreased hemo globin. risk for Infection— endurance, disco mfort. strength and future. it—decreased rtainty about Self-Care Defic ive process, unce ituational crisis/recuperat Performance—s 107 ineffective Role
  • 7. Copyright © 2006 by F. A. Davis. Includes a Bonus CD-ROM—a Valuable Package of Resources You Can Use! Bonus CD-ROM You will find 200 Care Plans with an index of the top 400 Diseases/Disorders and their associated nursing diagnoses. To help make navigating the CD-ROM even easier, we’ve provided a complete Table of Contents to the CD in the book. The CD is a robust resource that will save valuable time and help you put all the pieces together quickly and accurately! 1 200 Care Plans The bonus CD-ROM contains 200 care plans that Cardiovascular students can adapt and customize to fit their needs. It also includes four NEW care plans covering obesity surgery, fluids and electrolytes, extended care, and pediatric considerations. A complete package including all 116 care plans featured in the 2 book plus 84 additional found only on the CD-ROM— that’s 200 care plans! Hypertension: Severe 400 Diseases/Disorders A complete index of 400 Disorders and Health 3 Conditions, with their associated nursing diagnoses, is also included. The menu screen features a user- friendly A to Z listing reflecting all specialty areas, with associated nursing diagnoses, that include "related to" and "evidenced by" statements. 2 AIDS 1 Includes 3+ books in 1, that feature: 3 115 Medical/Surgical care plans A 34 Psychiatric care plans 50 Maternal/Newborn care plans Pediatric Considerations
  • 8. Copyright © 2006 by F. A. Davis. F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2006 by F. A. Davis Company Copyright © 1984, 1989, 1993, 1997, 2000, and 2002 by F. A. Davis Company. All rights reserved. This product 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 other- wise, 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 Acquisitions Editor: Joanne P. DaCunha, RN, MSN Developmental Editor: Alan Sorkowitz Art and Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies 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 ac- cordance with professional standards of care used in regard to the unique circumstances that may ap- ply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering 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/Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr.—Ed. 7. p. ; cm. Includes bibliographical references and index. ISBN 0-8036-1294-X 1. Intensive nursing care—Handbooks, manuals, etc. 2. Nursing care plans—Handbooks, manuals, etc. [DNLM: 1. Patient Care Planning—Handbooks. 2. Nursing Process—Handbooks. WY 49 D651na 2006] I. Moorhouse, Mary Frances, 1947-II. Geissler-Murr, Alice, 1946-III. Title. RT49.D64 2006 610.73—dc22 2005036714 Authorization to photocopy items for internal or personal use, or the internal or personal use of spe- cific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 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: 8036-1294/07 0 $.10.
  • 9. Copyright © 2006 by F. A. Davis. DEDICATION 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 en- couragement is sorely missed; Jim; Barbara and Bob Lanza; David, Monita, Matthew, and Tyler; John, Holly, Nicole, and Kelsey; and the Daigle family, Nancy, Jim, Jennifer, Brandon, Anna, Will, and Henry Smith-Daigle, and Jonathan and Kim. The Moorhouse family: Jan, Paul, Jason, Thenderlyn, Alexa, and Mary. To Mary and Marilynn, 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 FAD family, especially Bob Martone and Bob Butler, whose support is so vital to the completion of a project of this magnitude. And to Alan Sorkowitz, the one who really kept us all together, our go-to-guy when the going got tough. We are fourtu- nate to have you working with us. 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 develop- ing and using nursing diagnoses—here we come! Finally, to the late Mary Lisk Jeffries, who initiated the origi- nal project. The memory of our early friendship and struggles re- mains with us. We miss her and wish she were here to see the growth of the profession and how nursing diagnosis has con- tributed to the process. vii
  • 10. Copyright © 2006 by F. A. Davis. REVIEWERS FOR THE BOOK JANE V. ARNDT, MS, RN, CWOCN Senior Instructor Nurse Clinician, Enterostomal Therapy University of Colorado Health Science Poudre Valley Hospital Center School of Nursing Ft. Collins, Colorado Denver, Colorado JENNIFER AVERY KIMBERLY TUCKER PFENNIGS, MA, Senior Nursing Student College of the Sequoias BAN, RN Visalia, California Pikes Peak Mental Health Program Manager, Lighthouse Assessment Center BETH HAMSTRA, RN, CNS, RCIS, PHD Adult Treatment Units Clinical Manager Invasive Cardiology Colorado Springs, Colorado Memorial Hospital Colorado Springs, Colorado GILDA ROLLS-DELLINGER, RN SANDRA HARPER, RN, CCRN Staff Nurse, Skin, Wound, and Burn Team Rehabilitation Care Specialist Penrose-St. Francis Health Services HealthSouth Rehabilitation Hospital Colorado Springs, Colorado Colorado Springs, Colorado ROCHELLE SALMORE, MSN, RN, CGRN, CHRISTIE A. HINDS, MSN, APRN-BC CAN, BC Primary Care Nurse Practitioner Clincal Manager Health Essentials Digestive Disease Center Chattanooga, Tennesse Penrose–St. Francis Health Services Colorado Springs, Colorado SUSAN JANTY, VN, ACRN SCD/HIV Medical Coordinator El Paso Department of Heath and TRACY STEINBERG, RN, MSN, CNS Environment Liver Transplant Coordinator Colorado Springs, Colorado Division of Transplant Surgery University of Colorado Health Sciences Center LAURA RUTH TEIGEN JOHNSON, RN, Denver, Colorado MNE, CNOR Perioperative Services Manager Colorado Springs, Colorado GERI L. TIERNEY, RN, BSN, ONC Nursing Simulation Lab Coordinator Pikes Peak Community College LENORA KRAFT, RN Past-President National Association of Surgical Clinical Manager Orthopaedic Nurses Penrose St-Francis Hospital Colorado Springs, Colorado Colorado Springs, Colorado KATHLEEN H. WINDER, RN, BSN SUZANNE LOGAN, MS, RD Clinical Manager, Pediatric Specialty Manager, Dietetic Internship Clinic Clinical Manager Memorial Hospital Penrose–St. Francis Health Services Colorado Springs, Colorado Colorado Springs, Colorado ANNE ZOBEC, MS, RN, CS, NP, MARY BETH FLYNN-MAKIC, RN, MS, AOCN CNS, CCRN Oncology Nurse Practitioner Clinical Nurse Specialist/Educator The Oncology Clinic, P. C. University of Colorado Hospital Colorado Springs, Colorado viii
  • 11. Copyright © 2006 by F. A. Davis. REVIEWERS FOR THE CD-ROM CYNTHIA ASKVIG, RN, MS JILL MEIDER, APRN, BC Nursing Faculty Adjunct Instructor Pikes Peak Community College Pikes Peak Community College Colorado Springs, Colorado Colorado Springs, Colorado SUSAN JANTY, VN, ACRN SUSAN M. MOBERLY, RNC, BSN, ICCE Board Certified in HIV/AIDS Nursing Maternal/Newborn Nurse Consultant SCD/HIV Medical Coordinator ICEA Certified Childbirth Educator El Paso Department of Heath and Pikes Peak Choices in Childbirth Evironment Colorado Springs, Colorado Colorado Springs, Colorado LESLIE MURTAGH, MS, APRN, BC NOLA LANGE, MS, APRN, BC Board Certified Child and Adolescent Adjunct Psychiatric Instructor Clinical Nurse Specialist Pikes Peak Community College Casper, Wyoming Colorado Springs, Colorado ix
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  • 13. Copyright © 2006 by F. A. Davis. ACKNOWLEDGEMENTS JOE RUSKIN, RPH THE LATE NANCY LEA CARTER, RN, Colorado Springs, Colorado MA Clinical Nurse, Orthopedics JAMES I. BURNS, BS Albuquerque, New Mexico Systems Analyst Disaster Science Coronado, California xi
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  • 15. Copyright © 2006 by F. A. Davis. INTRODUCTION We are often asked how we came to write the Care Plan books. In the late 1970s we were involved with some publishing efforts that did not come to fruition. In this work we had included care plans, so ensuing discussions revolved around the need for a Care Plan book. We spent a year struggling to write care plans before we realized our major difficulty was the lack of standardized labels for client problems. At that time, we were given a list of nursing diagnoses from the Clearinghouse for Nursing Diagnosis, which became the North American Nursing Diagnosis Association (NANDA), and is now NANDA International. This work answered our need by providing concise titles that could be used in various care plans and followed across the spectrum of client care. We believed these nursing diagnosis labels would both define and focus nursing care. Because we had long been involved in direct client care in our nursing careers, we knew there was a need for guidelines to assist nurses in planning care. As we began to write, our focus was the nurse in a small rural community who at 2 AM needed the answer to a burning question for her client and had few resources available. We believed the book would give definition and direction to the development and use of individualized nursing care. Thus, in the first edition, the theory of nursing process, diagnosis, and intervention was brought to the clinical setting for implementation by the nurse. We also anticipated that nursing students would appreciate having access to these guidelines as they struggled to learn how to give nursing care. Therefore, we did not consider the book to be an end in itself, but rather a vehicle for the continuing growth and development of the profession. Obvi- ously we struck a chord and met a need because the first edition was an immediate success. In becoming involved with NANDA, we acknowledged that maintaining a strict adherence to their wording, while adding our own clearly identified recommendations, would help develop this neophyte standardized language and would promote the growth of nursing as a profession. We have continued our involvement with NANDA, promoting the use of the language by practicing nurses in the United States and around the world and encouraging them to participate in updating and refining the diagnoses. The wide use of our books within the student population has supported and fostered the acceptance of both the activity of diagnosing client problems/needs and the use of stan- dardized language. Nursing instructors initially expressed concern that students would simply copy the plans of care and thus limit their learning. However, as students used the plans to individualize care and to develop practice priorities and client care outcomes, the book met with more acceptance. Instructors began not only to recommend the book, but also to adopt it as an adjunct text. Today, it remains the best-selling nursing care plan book recognized as an important adjunct for student learning. In writing the second edition, we recognized the need for an assessment tool with a nursing focus instead of a medical focus. Not finding one that met our needs, we constructed our own. To facilitate problem identification, we categorized the nursing diagnosis labels and the information obtained in the client assessment database into a framework entitled “Diagnostic Divisions.” Our philosophy is to provide a way in which to gather information and to intervene beneficially, while thinking about the rationale for every action we take and the standardized language that best expresses it. When nurses do this they are defining their practice and are able to identify it with a code and charge for it. By doing this, we promote client protection (quality of care issue), provide for the definition and protection of nursing practice, and the protection of the individual (legal implica- tions). The latter is important because we live in a litigation-minded society and the nurse’s license and livelihood are at stake. One of the most significant achievements in the healthcare field over the past 20 or more years has been the emergence of the nurse as an active coordinator and initiator of client care. Although the transition from physician’s helpmate to healthcare professional has been painfully slow and is not yet complete, the importance of the nurse within the system can no longer be denied or ignored. Today’s nurse designs nursing care interventions that move the total client toward improved health and maximum independence. Professional care standards and healthcare providers and consumers will continue to increase the expectations for nurses’ performance. Each day brings new challenges in client care and the xiii
  • 16. Copyright © 2006 by F. A. Davis. struggle to understand the human responses to actual and potential health problems. To meet these challenges competently, the nurse must have up-to-date assessment skills and a working knowledge of pathophysiologic concepts concerning the common diseases/conditions presented. We believe that this book is a tool, providing a means of attaining that competency. In the past, plans of care were viewed principally as learning tools for students and seemed to have little relevance after graduation. However, the need for a written format to communicate and document client care has been recognized in all care settings. In addition, healthcare policy, govern- mental regulations, and third-party payor requirements have created the need to validate many things, including appropriateness of care provided, staffing patterns, and monetary charges. Thus, although the student’s “case studies” were considered to be too cumbersome to be practical in the clinical setting, it has long been recognized that the client plan of care meets certain needs and there- fore its appropriate use was validated. The practicing nurse, as well as the nursing student, can welcome this text as a ready reference in clinical practice. It is designed for use in the acute care, community, and homecare settings. It is organized by systems for easy reference. Chapter 1 examines current issues and trends and their implications for the nursing profession. An overview of cultural, community, sociologic, and ethical concepts affecting the nurse is included. The importance of the nurse’s role in collaboration and coordination with other healthcare profes- sionals is integrated throughout the plans of care. Chapter 2 reviews the historical use of the nursing process in formulating plans of care and the nurse’s role in the delivery of that care. Nursing diagnoses, outcomes, and interventions are discussed to assist the nurse in understanding her or his role in the nursing process. In this book, we have also linked NANDA diagnoses with Nursing Intervention Classification (NIC) and Nursing Outcomes Classification (NOC) language. Chapter 3 discusses care plan construction and describes the use and adaptation of the guides presented in this book. A nursing-based assessment tool is provided to assist the nurse in identifying appropriate nursing diagnoses. A sample client situation (with individual database and a correspon- ding plan of care) is included to demonstrate how critical thinking is used to adapt nursing process theory to practice. Finally, a dynamic and creative approach for developing and documenting the planning of care is also included. Mind Mapping is a new technique or learning tool provided to assist you in achieving a holistic view of your client, enhance your critical thinking skills, and facili- tate the creative process of planning client care. Chapters 4 through 15 present plans of care that include information from multiple disciplines to assist the nurse in providing holistic care. Each plan includes a Client Assessment Database (presented in a nursing format) and associated Diagnostic Studies. After the database is collected, Nursing Priorities are sifted from the information to help focus and structure the care. Discharge Goals are created to identify what should be generally accomplished by the time of discharge from the care setting. Next, Desired Client Outcomes are stated in measurable behavioral terms to eval- uate both the client’s progress and the effectiveness of care provided. The nursing diagnoses listed in the plans of care are developed by identifying “may be related to” and “possibly evidenced by” factors that provide an explanation of client problems/needs. Corresponding actions/interventions are designed to promote resolution of the identified client needs. The nurse acting independently or collaboratively within the health team then uses a decision-making model to organize and prioritize nursing interventions. No attempt is made in this book to indicate whether independent or collaborative actions come first because this must be dictated by the individual situation. We do, however, believe that every collaborative action has a component that the nurse must identify and for which nursing has responsibility and accountability. Rationales for the nursing actions (which are not required in the customary plan of care) are included to assist the nurse in deciding whether the interventions are appropriate for an individual client. Additional information is provided to further assist the nurse in identifying and planning for rehabilitation as the client progresses toward discharge and across all care settings. A bibliography is provided as a reference and to allow further research as desired. This book is designed for students who will find the plans of care helpful as they learn and develop skills in applying the nursing process and using nursing diagnoses. It will complement their classroom work and support the critical thinking process. The book also provides a ready reference for the practicing nurse as a catalyst for thought in planning, evaluating, and documenting care. As a final note, this book is not intended to be a procedure manual, and efforts have been made to avoid detailed descriptions of techniques or protocols that might be viewed as individual or regional in nature. Instead the reader is referred to a procedure manual or text covering Standards of Care if detailed direction is desired. As we always say when we sign a book, “Use and enjoy.” MD, MM, and AM xiv
  • 17. Copyright © 2006 by F. A. Davis. CONTENTS IN BRIEF INDEX OF NURSING DIAGNOSES APPEARS ON PAGES 983–988 INTRODUCTION vii 1 ISSUES AND TRENDS IN MEDICAL/SURGICAL NURSING 1 2 THE NURSING PROCESS: PLANNING CARE WITH NURSING DIAGNOSES 6 3 CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE 13 4 CARDIOVASCULAR 35 Hypertension: Severe 35 Heart Failure: Chronic 47 Angina (Coronary Artery Disease) 62 Myocardial Infarction 72 Dysrhythmias (Including Digitalis Toxicity) 85 Cardiac Surgery: Postoperative Care—Coronary Artery Bypass Graft (CABG), Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), Cardiomyoplasty, Valve Replacement 96 Thrombophlebitis: Deep Vein Thrombosis (Including Pulmonary Emboli Considerations) 108 5 RESPIRATORY 117 Chronic Obstructive Pulmonary Disease (COPD) and Asthma 117 Pneumonia 128 Lung Cancer: Postoperative Care 141 Pneumothorax/Hemothorax 150 Radical Neck Surgery: Laryngectomy (Postoperative Care) 157 Ventilatory Assistance (Mechanical) 170 Pulmonary Tuberculosis (TB) 184 Respiratory Acid-Base Imbalances 194 Respiratory Acidosis (Primary Carbonic Acid Excess) 194 Respiratory Alkalosis (Primary Carbonic Acid Deficit) 198 6 NEUROLOGICAL/SENSORY DISORDERS 202 Glaucoma 202 Seizure Disorders 208 Craniocerebral Trauma (Acute Rehabilitative Phase) 218 Cerebrovascular Accident (CVA)/Stroke 236 Herniated Nucleus Pulposus (Ruptured Intervertebral Disc) 252 Disc Surgery 260 Spinal Cord Injury (Acute Rehabilitative Phase) 271 Multiple Sclerosis 291 7 GASTROINTESTINAL DISORDERS 309 Upper Gastrointestinal/Esophageal Bleeding 309 Subtotal Gastrectomy/Gastric Resection 320 Inflammatory Bowel Disease: Ulcerative Colitis, Regional Enteritis (Crohn’s Disease, Ileocolitis) 324 Fecal Diversions: Postoperative Care of Ileostomy and Colostomy 338 xv
  • 18. Copyright © 2006 by F. A. Davis. Appendectomy 350 Peritonitis 355 Cholecystitis with Cholelithiasis 364 Cholecystectomy 371 8 METABOLIC AND ENDOCRINE DISORDERS 376 Eating Disorders: Anorexia Nervosa/Bulimia Nervosa 376 Eating Disorders: Obesity 393 Obesity: Surgical Interventions (Gastric Partitioning/Gastroplasty, Gastric Bypass) 402 Diabetes Mellitus/Diabetic Ketoacidosis 412 Hyperthyroidism (Thyrotoxicosis, Graves’ Disease) 426 Thyroidectomy 437 Hepatitis 443 Cirrhosis of the Liver 453 Pancreatitis 467 Total Nutritional Support: Parenteral/Enteral Feeding 478 Metabolic Acid-Base Imbalances 491 Metabolic Acidosis (Primary Base Bicarbonate [HCO3] Deficit) 492 Metabolic Alkalosis (Primary Base Bicarbonate Excess) 495 9 DISEASES OF THE BLOOD/BLOOD-FORMING ORGANS 499 Anemias (Iron Deficiency, Pernicious, Aplastic, Hemolytic) 499 Sickle Cell Crisis 509 Leukemias 523 Lymphomas 532 10 RENAL AND URINARY TRACT 541 Renal Failure: Acute 541 Renal Failure: Chronic 553 Renal Dialysis 564 Renal Dialysis: Peritoneal 575 Hemodialysis 581 Urinary Diversions/Urostomy (Postoperative Care) 585 Benign Prostatic Hyperplasia (BPH) 596 Prostatectomy 604 Urolithiasis (Renal Calculi) 613 11 WOMEN’S REPRODUCTIVE 621 Hysterectomy 621 Mastectomy 630 12 ORTHOPEDIC 642 Fractures 642 Amputation 657 Total Joint Replacement 667 13 INTEGUMENTARY 680 Burns: Thermal/Chemical/Electrical (Acute and Convalescent Phases) 680 14 SYSTEMIC INFECTIONS AND IMMUNOLOGICAL DISORDERS 701 Sepsis/Septicemia 701 The HIV-Positive Client 712 AIDS 726 Rheumatoid Arthritis 750 Transplantation (Postoperative and lifelong) 761 15 GENERAL 770 Psychosocial Aspects of Care 770 Surgical Intervention 788 Extended Care 810 Alcohol: Acute Withdrawal 831 xvi
  • 19. Copyright © 2006 by F. A. Davis. Substance Dependence/Abuse Rehabilitation 843 Cancer 857 End of Life/Hospice Care 880 Disaster Considerations 890 Pediatric Considerations 905 Fluid and Electrolyte lmbalances 919 Dementia of alzheimer’s Type/Vascular Dementia 945 BIBLIOGRAPHY 967 INDEX OF NURSING DIAGNOSES 983 A TABLE OF CONTENTS INCLUDING NURSING DIAGNOSES FOLLOWS. xvii
  • 20. Copyright © 2006 by F. A. Davis. DETAILED CONTENTS INDEX OF NURSING DIAGNOSES APPEARS ON PAGES 983–988 INTRODUCTION vii 1 ISSUES AND TRENDS IN MEDICAL/SURGICAL NURSING 1 The Ever-Changing Healthcare Environment 1 Healthcare Costs and the Allocation of Resources 1 Managed Care: Restructuring Healthcare 1 Nursing Care Costs 3 Early Discharge 3 Aging Population 3 Technological Advances 4 Future of Nursing 4 Conclusion 5 2 THE NURSING PROCESS: PLANNING CARE WITH NURSING DIAGNOSES 6 Planning Care 9 Components of the Plan of Care 9 Client Database 9 Nursing Priorities 10 Discharge Goals 10 Nursing Diagnosis (Problem/Need Identification) 10 Desired Client Outcomes 11 Planning (Goals and Actions/Interventions) 11 Rationale 11 Conclusion 12 3 CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE 13 Client Situation: Diabetes Mellitus 22 Admitting Physician’s Orders 22 Client Assessment Database 22 Evaluation 26 Documentation 26 Plan of Care: Mr. R. S. 27 Mind Map 31 Sample Clinical Pathway 33 4 CARDIOVASCULAR 35 Hypertension: Severe 35 Cardiac Output, risk for decreased 38 Activity Intolerance 40 Pain, acute, headache 41 Nutrition: more than body requirements, imbalanced 42 Coping, ineffective 43 Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care and discharge needs 44 Heart Failure: Chronic 47 Cardiac Output, decreased 50 xviii
  • 21. Copyright © 2006 by F. A. Davis. Activity Intolerance 54 Fluid Volume, excess 55 Gas Exchange, risk for impaired 57 Skin Integrity, risk for impaired 58 Knowledge, deficient [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs 59 Sample Clinical Pathway 61 Angina (Coronary Artery Disease) 62 Pain, acute 65 Cardiac Output, risk for decreased 67 Anxiety [specify level] 69 Knowledge, deficient [Learning Need] regarding condition, treatment needs, self-care, and discharge needs 70 Myocardial Infarction 72 Pain, acute 75 Activity Intolerance 76 Anxiety [specify level]/Fear 77 Cardiac Output, risk for decreased 79 Tissue Perfusion, ineffective 81 Fluid Volume, risk for excess 83 Knowledge, deficient [Learning Need] regarding cause/treatment of condition, self-care, and discharge needs 83 Dysrhythmias (Including Digitalis Toxicity) 85 Cardiac Output, risk for decreased 88 Poisoning, risk for digitalis toxicity 92 Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care, and discharge needs 93 Cardiac Surgery: Postoperative Care—Coronary Artery Bypass Graft (CABG), Minimally Invasive Direct Coronary Artery Bypass (MIDCAB), Cardiomyoplasty, Valve Replacement 96 Cardiac Output, risk for decreased 98 Pain, acute/[Discomfort] 100 Role Performance, ineffective 102 Breathing Pattern, risk for ineffective 103 Skin Integrity, impaired 105 Knowledge, deficient [Learning Need] regarding condition, treatment plan, postoperative care, self-care, and discharge needs 106 Thrombophlebitis: Deep Vein Thrombosis (Including Pulmonary Emboli Considerations) 108 Tissue Perfusion, ineffective 109 Pain, acute/[Discomfort] 112 Gas Exchange, impaired (in presence of pulmonary embolus) 113 Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care, and discharge needs 115 5 RESPIRATORY Chronic Obstructive Pulmonary Disease (COPD) and Asthma 117 Airway Clearance, ineffective 120 Gas Exchange, impaired 123 Nutrition: less than body requirements, imbalanced 125 Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care, and discharge needs 126 Pneumonia 128 Airway Clearance, ineffective 131 Gas Exchange, impaired 132 Infection, risk for [spread] 133 Activity Intolerance 134 Pain, acute 135 xix
  • 22. Copyright © 2006 by F. A. Davis. Nutrition: risk for less than body requirements, imbalanced 136 Fluid Volume, risk for deficient 137 Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care, and discharge needs 138 Sample Clinical Pathway 140 Lung Cancer: Postoperative Care 141 Gas Exchange, impaired 143 Airway Clearance, ineffective 145 Pain, acute 146 Fear/Anxiety [specify level] 147 Knowledge, deficient [Learning Need] regarding condition, treatment, prognosis, self-care, and discharge needs 148 Pneumothorax/Hemothorax 150 Breathing Pattern, ineffective 152 Trauma/Suffocation 155 Knowledge, deficient [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs 156 Radical Neck Surgery: Laryngectomy (Postoperative Care) 157 Airway Clearance, ineffective/Aspiration, risk for 159 Communication, impaired verbal 160 Skin/Tissue Integrity, impaired 162 Oral Mucous Membrane, impaired 163 Pain, acute 164 Nutrition: less than body requirements, imbalanced 165 Body Image, disturbed/Role Performance, ineffective 167 Knowledge, deficient [Learning Need] regarding condition, treatment, self-care, and discharge needs 168 Ventilatory Assistance (Mechanical) 170 Breathing Pattern, ineffective/Spontaneous Ventilation, impaired 171 Airway Clearance, ineffective 174 Communication, impaired verbal 176 Fear/Anxiety [specify level] 177 Oral Mucous Membrane, impaired 178 Nutrition: less than body requirements, imbalanced 179 Infection, risk for 180 Ventilatory Weaning Response, risk for dysfunctional 181 Knowledge, deficient [Learning Need] regarding condition, prognosis and therapy, self-care, and discharge needs 183 Pulmonary Tuberculosis (TB) 184 Infection, risk for [spread/reactivation] 187 Airway Clearance, ineffective 189 Gas Exchange, risk for impaired 190 Nutrition: less than body requirements, imbalanced 191 Knowledge, deficient [Learning Need] regarding condition, treatment, prevention, self-care, and discharge needs 192 Respiratory Acid-Base Imbalances 194 Respiratory Acidosis (Primary Carbonic Acid Excess) 194 Gas Exchange, impaired 196 Respiratory Alkalosis (Primary Carbonic Acid Deficit) 198 Gas Exchange, impaired 200 6 NEUROLOGICAL/SENSORY DISORDERS 202 Glaucoma 202 Sensory Perception, disturbed visual 204 Anxiety [specify level] 206 Seizure Disorders 208 Trauma/Suffocation, risk for 211 xx
  • 23. Copyright © 2006 by F. A. Davis. Airway Clearance/Breathing Pattern, risk for ineffective 214 Self-Esteem, [specify situational or chronic) low 215 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment regimen, self-care, and discharge needs 216 Craniocerebral Trauma (Acute Rehabilitative Phase) 218 Tissue Perfusion, ineffective cerebral 221 Breathing Pattern, risk for ineffective 224 Sensory Perception, disturbed (specify) 225 Thought Processes, disturbed 227 Mobility, impaired physical 229 Infection, risk for 231 Nutrition: risk for less than body requirements, imbalanced 232 Family Processes, interrupted 233 Knowledge, deficient [Learning Need] regarding condition, prognosis, potential complications, treatment, self-care, and discharge needs 234 Cerebrovascular Accident (CVA)/Stroke 236 Tissue Perfusion, ineffective cerebral 238 Mobility, impaired physical 241 Communication, impaired verbal [and/or written] 243 Sensory Perception, disturbed (specify) 244 Self-Care Deficit (specify) 246 Coping, ineffective 247 Swallowing, risk for impaired 248 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 250 Herniated Nucleus Pulposus (Ruptured Intervertebral Disc) 252 Pain, acute/chronic 254 Mobility, impaired physical 256 Anxiety [specify level]/Coping, ineffective 257 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 258 Disc Surgery 260 Tissue Perfusion, ineffective (specify) 261 Trauma, risk for (spinal) 262 Breathing Pattern/Airway Clearance, risk for ineffective 263 Pain, acute 264 Mobility, impaired physical 265 Constipation 266 Urinary Retention, risk for 267 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 268 Sample Clinical Pathway 270 Spinal Cord Injury (Acute Rehabilitative Phase) 271 Breathing Pattern, risk for ineffective 273 Trauma, risk for [additional spinal injury] 275 Mobility, impaired physical 276 Sensory Perception, disturbed 278 Pain, acute 279 Grieving, anticipatory 280 Self-Esteem, situational low 282 Bowel Incontinence/Constipation 283 Urinary Elimination, impaired 285 Autonomic Dysreflexia, risk for 286 Skin Integrity, risk for impaired 288 Knowledge, deficient [Learning Need] regarding condition, prognosis, potential complications, treatment, self-care, and discharge needs 289 xxi
  • 24. Copyright © 2006 by F. A. Davis. Multiple Sclerosis 291 Fatigue 295 Self-Care Deficit (specify) 297 Self-Esteem, specify situational /chronic low 298 Powerlessness [specify degree]/Hopelessness 300 Coping, risk for ineffective 301 Coping, compromised/disabled family 302 Urinary Elimination, impaired 304 Caregiver Role Strain, risk for 305 Knowledge, deficient [Learning Need] regarding condition, prognosis, complications, treatment, self-care, and discharge needs 306 7 GASTROINTESTINAL DISORDERS 309 Upper Gastrointestinal/Esophageal Bleeding 309 Fluid Volume, deficient [isotonic] 312 Tissue Perfusion, risk for ineffective 315 Fear/Anxiety [specify level] 316 Pain, acute/chronic 317 Knowledge, deficient [Learning Need] regarding disease process, prognosis, treatment, self-care, and discharge needs 319 Subtotal Gastrectomy/Gastric Resection 320 Nutrition, imbalanced, risk for less than body requirements 321 Knowledge, deficient [Learning Need] regarding procedure, prognosis, treatment, self-care, and discharge needs 322 Inflammatory Bowel Disease: Ulcerative Colitis, Regional Enteritis (Crohn’s Disease, Ileocolitis) 324 Diarrhea 328 Fluid Volume, risk for deficient 330 Nutrition: less than body requirements, imbalanced 331 Anxiety [specify level] 333 Pain, acute 334 Coping, ineffective 335 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 336 Fecal Diversions: Postoperative Care of Ileostomy and Colostomy 338 Skin Integrity, risk for impaired 338 Body Image, disturbed 340 Pain, acute 341 Skin/Tissue Integrity, impaired 342 Fluid Volume, risk for deficient 343 Nutrition: risk for less than body requirements, imbalanced 344 Sleep Pattern, disturbed 345 Constipation/Diarrhea, risk for 346 Sexual Dysfunction, risk for 347 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 348 Appendectomy 350 Infection, risk for 352 Pain, acute 353 Knowledge, deficient Learning Need regarding condition, prognosis, treatment, self-care, and discharge needs 354 Peritonitis 355 Infection, risk for [septicemia] 357 Fluid Volume, deficient [mixed] 359 Pain, acute 360 Nutrition: risk for less than body requirements, imbalanced 361 xxii
  • 25. Copyright © 2006 by F. A. Davis. Anxiety [specify level]/Fear 362 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 363 Cholecystitis with Cholelithiasis 364 Pain, acute 366 Fluid Volume, risk for deficient 367 Nutrition: risk for less than body requirements, imbalanced 368 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care and discharge needs 369 Cholecystectomy 371 Breathing Pattern, ineffective 371 Fluid Volume, risk for deficient 372 Skin/Tissue Integrity, impaired 373 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 374 8 METABOLIC AND ENDOCRINE DISORDERS 376 Eating Disorders: Anorexia Nervosa/Bulimia Nervosa 376 Nutrition: less than body requirements, imbalanced 379 Fluid Volume, actual or risk for deficient 382 Thought Processes, disturbed 383 Body Image, disturbed/Self-Esteem, chronic low 383 Parenting, impaired 386 Skin Integrity, risk for impaired 387 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 388 Sample Clinical Pathway 390 Eating Disorders: Obesity 393 Nutrition: more than body requirements, imbalanced 394 Lifestyle, sedentary 397 Body Image, disturbed/Self-Esteem, chronic low 398 Social Interaction, impaired 400 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 401 Obesity: Surgical In