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rencana keperawatan

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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 Interventions (Gastric Partitioning/Gastroplasty, Gastric Bypass) 402 Breathing Pattern, ineffective 404 Tissue Perfusion, risk for ineffective 405 Fluid Volume, risk for deficient 406 Nutrition, risk for less than body requirements, imbalanced 407 Skin Integrity, risk for impaired 408 Infection, risk for 409 Diarrhea 410 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 411 Diabetes Mellitus/Diabetic Ketoacidosis 412 Fluid Volume, deficient [specify] 415 Nutrition: less than body requirements, imbalanced 417 Infection, risk for [sepsis] 419 Sensory Perception, risk for disturbed (specify) 420 Fatigue 421 Powerlessness 422 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 423 Hyperthyroidism (Thyrotoxicosis, Graves’ Disease) 426 Cardiac Output, risk for decreased 428 Fatigue 431 xxiii
  • 26. Copyright © 2006 by F. A. Davis. Nutrition: risk for less than body requirements, imbalanced 432 Anxiety [specify level] 433 Thought Processes, risk for disturbed 434 Tissue Integrity, risk for impaired 435 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 436 Thyroidectomy 437 Airway Clearance, risk for ineffective 438 Communication, impaired verbal 439 Injury, risk for [tetany] 440 Pain, acute 440 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 441 Hepatitis 443 Fatigue 445 Nutrition: less than body requirements, imbalanced 446 Fluid Volume, risk for deficient 447 Self-Esteem, situational low 449 Infection, risk for 450 Skin/Tissue Integrity, risk for impaired 451 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 452 Cirrhosis of the Liver 453 Nutrition: less than body requirements, imbalanced 456 Fluid Volume, excess 458 Skin Integrity, risk for impaired 460 Breathing Pattern, risk for ineffective 460 Injury, risk for [hemorrhage] 462 Confusion, risk for acute 463 Self-Esteem [specify] Body Image, disturbed 465 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 465 Pancreatitis 467 Pain, acute 470 Fluid Volume, risk for deficient 471 Nutrition: less than body requirements, imbalanced 473 Infection, risk for 474 Breathing Pattern, risk for ineffective 476 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 477 Total Nutritional Support: Parenteral/Enteral Feeding 478 Nutrition: less than body requirements, imbalanced 481 Infection, risk for 484 Injury, risk for [multifactor] 485 Aspiration, risk for 487 Fluid Volume, risk for imbalance 488 Fatigue 489 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 490 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 Activity intolerance 502 Nutrition: less than body requirements, imbalanced 504 Constipation/Diarrhea 505 xxiv
  • 27. Copyright © 2006 by F. A. Davis. Infection, risk for 506 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 507 Sickle Cell Crisis 509 Gas Exchange, impaired 512 Pain, acute/chronic 514 Tissue Perfusion, ineffective (specify) 515 Fluid Volume, risk for deficient 517 Mobility, impaired physical 518 Skin Integrity, risk for impaired 519 Infection, risk for 520 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 520 Leukemias 523 Infection, risk for 525 Fluid Volume, risk for deficient 527 Pain, acute 529 Activity Intolerance 530 Knowledge, deficient [Learning Need] regarding disease, prognosis, treatment, self-care, and discharge needs 531 Lymphomas 532 Gas Exchange, risk for impaired 536 Sexual Dysfunction 537 Knowledge, deficient [Learning Need] regarding disease process, prognosis, treatment regimen, self-care, and discharge needs 538 10 RENAL AND URINARY TRACT 541 Renal Failure: Acute 541 Fluid Volume, excess 544 Cardiac Output, risk for decreased 546 Nutrition: risk for less than body requirements, imbalanced 548 Infection, risk for 549 Fluid Volume, risk for deficient 550 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 551 Renal Failure: Chronic 553 Cardiac Output, risk for decreased 556 Protection, risk for ineffective 557 Thought Processes, disturbed 558 Skin Integrity, risk for impaired 559 Oral Mucous Membrane, risk for impaired 560 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 561 Renal Dialysis 564 Nutrition: less than body requirements, imbalanced 565 Mobility, impaired physical 567 Self-Care Deficit (specify) 568 Constipation, risk for 568 Thought Processes, risk for disturbed 569 Anxiety [specify level]/Fear 570 Body Image, disturbed/Self-Esteem, situational low 571 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 573 Renal Dialysis: Peritoneal 575 Fluid Volume, risk for excess 576 Fluid Volume, risk for deficient 577 Trauma, risk for 578 Pain, acute 578 xxv
  • 28. Copyright © 2006 by F. A. Davis. Infection, risk for [peritonitis] 579 Breathing Pattern, risk for ineffective 580 Hemodialysis 581 Injury, risk for [loss of vascular access] 582 Fluid Volume, risk for deficient 583 Fluid Volume, risk for excess 584 Urinary Diversions/Urostomy (Postoperative Care) 585 Skin Integrity, risk for impaired 586 Body Image, disturbed 588 Pain, acute 589 Infection, risk for 591 Urinary Elimination, impaired 592 Sexual Dysfunction, risk for 593 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 595 Benign Prostatic Hyperplasia (BPH) 596 Urinary Retention, acute/chronic 598 Pain, acute 600 Fluid Volume, risk for deficient 601 Fear/Anxiety [specify level] 602 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 603 Prostatectomy 604 Urinary Elimination, impaired 605 Fluid Volume, risk for deficient 606 Infection, risk for 607 Pain, acute 608 Sexual Dysfunction, risk for 609 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 610 Urolithiasis (Renal Calculi) 613 Pain, acute 615 Urinary Elimination, impaired 616 Fluid Volume, risk for deficient 617 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 618 11 WOMEN’S REPRODUCTIVE 621 Hysterectomy 621 Self-Esteem, situational low 622 Urinary Elimination, impaired/Urinary Retention [acute] 623 Constipation/Diarrhea, risk for 624 Tissue Perfusion, risk for ineffective (specify) 625 Sexual Dysfunction, risk for 626 Grieving, dysfunctional 627 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 628 Mastectomy 630 Fear/Anxiety [specify level] 632 Skin/Tissue Integrity, impaired 633 Pain, acute 635 Self-Esteem, situational low 636 Mobility, impaired physical 637 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 638 Sample Clinical Pathway 640 xxvi
  • 29. Copyright © 2006 by F. A. Davis. 12 ORTHOPEDIC 642 Fractures 642 Trauma, risk for [additional] 644 Pain, acute 645 Peripheral Neurovascular Dysfunction, risk for 647 Gas Exchange, risk for impaired 649 Mobility, impaired physical 650 Skin/Tissue Integrity, actual/risk for impaired 652 Infection, risk for 654 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 655 Amputation 657 Self-Esteem, situational low 659 Pain, acute 660 Tissue Perfusion, risk for ineffective peripheral 662 Infection, risk for 663 Mobility, impaired physical 664 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 666 Total Joint Replacement 667 Infection, risk for 669 Mobility, impaired physical 670 Peripheral Neurovascular, Dysfunction risk for 671 Pain, acute 673 Constipation, risk for 674 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 675 Sample Clinical Pathway 677 13 INTEGUMENTARY 680 Burns: Thermal/Chemical/Electrical (Acute and Convalescent Phases) 680 Airway Clearance, risk for ineffective 683 Fluid Volume, risk for deficient 684 Pain, acute 686 Infection, risk for 688 Tissue Perfusion, ineffective/Peripheral Neurovascular dysfunction, risk for 690 Nutrition: less than body requirements, imbalanced 691 Mobility, impaired physical 693 Skin Integrity, impaired [grafts] 694 Fear/Anxiety 696 Body Image, disturbed/Role Performance, ineffective 697 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 698 14 SYSTEMIC INFECTIONS AND IMMUNOLOGICAL DISORDERS 701 Sepsis/Septicemia 701 Infection, risk for [progression of sepsis to septic shock, development of opportunistic infections] 704 Hyperthermia 706 Tissue Perfusion, risk for ineffective 707 Fluid Volume, risk for deficient 709 Gas Exchange, risk for impaired 710 Knowledge, deficient [Learning Need] regarding illness, prognosis, treatment, self-care, and discharge needs 711 xxvii
  • 30. Copyright © 2006 by F. A. Davis. The HIV-Positive Client 712 Adjustment, impaired 714 Fatigue 715 Nutrition: risk for less than body requirements, imbalanced 716 Knowledge, deficient [Learning Need] regarding disease, prognosis, treatment self-care, and discharge needs 719 Social Isolation, risk for 722 Therapeutic Regimen Management, ineffective [Individual]/Family 723 AIDS 726 Infection, risk for [progression to sepsis/onset of new opportunistic infection] 730 Fluid Volume, risk for deficient 732 Breathing Pattern, ineffective/Gas Exchange, risk for impaired 733 Injury, risk for (hemorrhage) 735 Nutrition: less than body requirements, imbalanced 736 Pain, acute/chronic 738 Skin Integrity, actual and/or risk for impaired 739 Oral Mucous Membrane, impaired 740 Fatigue 742 Thought Processes, disturbed 743 Anxiety [specify level]/Fear 745 Social Isolation 746 Powerlessness 747 Knowledge, deficient [Learning Need] regarding disease, prognosis, current therapies, and self-care needs 748 Rheumatoid Arthritis 750 Pain, acute/chronic 752 Mobility, impaired physical/Walking, impaired 755 Body Image, disturbed/Role Performance, ineffective 756 Self-Care Deficit (specify) 757 Home Maintenance, risk for impaired 758 knowledge, deficient [Learning Need] regarding disease, prognosis, treatment, self-care, and discharge needs 759 Transplantation (Postoperative and Lifelong) 761 Infection, risk for 763 Anxiety [specify level]/Fear 764 Coping, risk for ineffective/compromised/disabled family 765 Knowledge, deficient [Learning Need] regarding prognosis, therapeutic regimen, self-care, and discharge needs 767 15 GENERAL 770 Psychosocial Aspects of Care 770 Coping, ineffective/decisional Conflict 771 Coping, risk for compromised family 773 Coping readiness for enhanced family 774 Anxiety [specify level]/Fear 775 Self-Esteem, situational low 778 Grieving [specify] 780 Religiosity, risk for impaired 782 Therapeutic Regimen: Management, risk for ineffective 783 Violence, risk for self-directed/other-directed 785 Post-Trauma Syndrome 787 Surgical Intervention 788 Knowledge, deficient [Learning Need] regarding condition, prognosis, self-care, and discharge needs 790 Fear/Anxiety [specify level] 792 Injury, risk for perioperative positioning 794 xxviii
  • 31. Copyright © 2006 by F. A. Davis. Injury, risk for 795 Infection, risk for 797 Body Temperature, risk for imbalanced 799 Breathing Pattern, ineffective 800 Sensory Perception, disturbed: (specify)/Thought Processes, disturbed 801 Fluid Volume, risk for deficient 802 Pain, acute 804 Skin/Tissue Integrity, impaired 806 Tissue Perfusion, risk for ineffective 808 Knowledge, deficient [Learning Need] regarding condition/ situation, prognosis, treatment, self-care, and discharge needs 809 Extended Care 810 Relocation Stress Syndrome, risk for 811 Grieving, anticipatory 813 Memory/Thought Processes, disturbed 814 Coping, compromised family 815 Poisoning, risk for 817 Communication, impaired verbal 818 Sleep Pattern, disturbed 819 Nutrition, less/more than body requirements, imbalanced 820 Self-Care Deficit 822 Skin Integrity, risk for impaired 823 Urinary Elimination, risk for impaired 825 Constipation/Diarrhea, risk for 826 Mobility, impaired physical 827 Diversional Activity, deficient 828 Sexuality Pattern, risk for ineffective 829 Health Maintenance, ineffective 830 Alcohol: Acute Withdrawal 831 Breathing Pattern, risk for ineffective 834 Cardiac Output, risk for decreased 835 Injury, risk for [specify] 837 Sensory Perception, disturbed (specify) 838 Anxiety [severe/panic]/Fear 840 Sample Clinical Pathway 841 Substance Dependence/Abuse Rehabilitation 843 Denial, ineffective 844 Coping, ineffective 846 Powerlessness 848 Nutrition: less than body requirements, imbalanced 849 Self-Esteem, chronic low 850 Family Processes: alcoholic [substance abuse], dysfunctional 852 Sexual Dysfunction 854 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 855 Cancer 857 Fear/Anxiety [specify level] 859 Grieving, anticipatory 861 Self-Esteem, situational low 862 Pain, acute/chronic 864 Nutrition: less than body requirements, imbalanced 866 Fluid Volume, risk for deficient 868 Fatigue 869 Infection, risk for 871 Oral Mucous Membrane, risk for impaired 872 Skin/Tissue Integrity, risk for impaired 873 Constipation/Diarrhea, risk for 875 xxix
  • 32. Copyright © 2006 by F. A. Davis. Sexuality Pattern, risk for ineffective 876 Family Processes, risk for interrupted 877 Knowledge, deficient [Learning Need] regarding illness, prognosis, treatment, self-care, and discharge needs 878 End of Life/Hospice Care 880 Pain, acute/chronic 881 Activity Intolerance/Fatigue 883 Grieving, anticipatory/Anxiety, death 884 Coping, compromised or disabled family Caregiver Role Strain, risk for 886 Spiritual Distress, risk for 888 Disaster Considerations 890 Injury, risk for/actual (trauma, suffocation, poisoning) 892 Infection, risk for 893 Anxiety [panic]/Fear 895 Spiritual Distress 896 Post-Trauma Syndrome, risk for 898 Coping, ineffective community 899 Coping, potential for enhanced community 900 Pediatric Considerations 905 Pain, acute 906 Anxiety/Fear: Coping, ineffective 907 Activity Intolerance/Fatigue 909 Growth and Development, risk for delayed 910 Nutrition, risk for less than body requirements, imbalanced 911 Injury, risk for 912 Family Processes Parenting impaired 915 Body Temperature, risk for imbalanced 916 Health Maintenance, risk for ineffective 917 Fluid and Electrolyte Imbalances 919 Fluid Balance 919 Hypervolemia (Extracellular Fluid Volume Excess) 919 Hypovolemia (Extracellular Fluid Volume Deficit) 922 Fluid Volume, deficient 923 Sodium 925 Hyponatremia (Sodium Deficit) 925 Hypernatremia (Sodium Excess) 928 Potassium 931 Hypokalemia (Potassium Deficit) 931 Hyperkalemia (Potassium Excess) 933 Calcium 936 Hypocalcemia (Calcium Deficit) 936 Hypercalcemia (Calcium Excess) 938 Magnesium 941 Hypomagnesemia (Magnesium Deficit) 941 Hypermagnesemia (Magnesium Excess) 943 Dementia of Alzheimer’ s Type/Vascular Dementia 945 Confusion, risk for 950 Sensory Perception, disturbed 953 Fear 954 Grieving, anticipatory 955 Sleep Pattern, disturbed 956 Self-Care deficit 957 Nutrition, risk for less than body requirements, imbalanced 959 Constipation/Bowel Incontinence, impaired 960 Sexual Dysfunction, risk for 961 xxx
  • 33. Copyright © 2006 by F. A. Davis. Coping, compromised family 961 Home Maintenance/Health Maintenance, impaired 963 Caregiver Role Strain, risk for 965 Relocation Stress Syndrome, risk for 966 BIBLIOGRAPHY 967 INDEX OF NURSING DIAGNOSES 983 xxxi
  • 34. Copyright © 2006 by F. A. Davis. CONTENTS OF THE CD-ROM MEDICAL/SURGICAL CARE PLANS (INCLUDES ALL CARE PLANS FROM THE BOOK) Cardiovascular Respiratory Neurologic/Sensory Disorders Gastrointestinal Disorders Metabolic and Endocrine Disorders Diseases of the Blood/Blood-Forming Organs Renal and Urinary Tract Women’s Reproductive Orthopedic Integumenatry Systemic Infections and Immunological Disorders General PSYCHIATRIC CARE PLANS Childhood and Adolescent Disorders Pervasive Developmental Disorders Attention-Deficit/Hyperactivity Disorder (ADHD) Conduct Disorder Oppositional Defiant Disorder Elimination Disorders: Enuresis/Encopresis Parenting: Growth-Promoting Relationship Dementia and Amnestic and Other Cognitive Disorders Dementia of Alzheimer’s Type/Vascular Dementia Dementia due to HIV Disease Substance-Related Disorders Alcohol-Related Disorders Stimulants (Amphetamines, Cocaine, Caffeine, and Nicotine) and Inhalant-Related Disorders Depressants (Barbiturates, Nonbarbiturates, Hypnotics and Anxiolytics, Opioids) Hallucinogen-, Phencyclidine-, and Cannabis-Related Disorders Substance Dependence/Abuse Rehabilatation Schizophrenia and Other Psychotic Disorders Schizophrenia Schizoaffective Disorder Delusional Disorder Mood Disorders Major Depressive/Dysthymic Disorder Bipolar Disorders Anxiety Disorders Generalized Anxiety Disorder Panic Disorders/Phobias Obsessive-Compulsive Disorder Posttrumatic Stress Disorder Somatofrom Disorders xxxii
  • 35. Copyright © 2006 by F. A. Davis. Dissociative Disorders Sexual and Gender Identity Disorders Sexual Dysfunctions and Paraphilias Gender Identity Disorder Eating Disorders Anorexia Nervosa/Bulimia Nervosa Obesity Adjustment Disorders Personality Disorders Antisocial Personality Disorder Borderline Personality Disorder Passive-Aggressive Personality Disorder Other Conditions that May Be a Focus of Attention Psychologic Factors Affecting Medical Condition Problems Related to Abuse or Neglect Premenstrual Dysphoric Disorder (Premenstrual Syndrome) MATERNAL/NEWBORN CARE PLANS Prenatal Concepts Genetic Counseling First Trimester Second Trimester Third Trimester The High-Risk Pregnancy Prenatal Substance Dependence/Abuse The Pregnant Adolescent Cardiac Conditions Pregnancy-Induced Hypertension Diabetes Mellitus: Prepregnancy/Gestational Prenatal Hemorrhage Prenatal Infection Premature Dilation of the Cervix (Incompetent/Dysfunctional Cervix) Spontaneous Termination Elective Termination Preterm Labor/Prevention of Delivery Intrapartal Concepts Labor Stage I—Latent Phase Labor Stage I—Active Phase Labor Stage I—Transition Phase (Deceleration) Labor Stage II—Expulsion Labor Stage III—Placental Expulsion Dysfunctional Labor/Dystocia Labor: Induced/Augmented Cesarean Birth Precipitous Labor/Delivery or Unplanned/Out-of-Hospital Delivery Intrapartal Hypertension Intrapartal Diabetes Mellitus Maternal Postpartal Concepts Stage IV—First 4 Hours Following Delivery of the Placenta The Client at 4 Hours to 2 Days Postpartum Care Following Cesarean Birth (4 Hours to 3 Days Postpartum) The Client at 24–48 Hours Following Early Discharge The Client at 1 Week Following Discharge The Client at 4–6 Weeks Following Discharge Postpartal Hemorrhage Postpartal Diabetes Mellitus Puerperal Infection xxxiii
  • 36. Copyright © 2006 by F. A. Davis. Postpartal Thrombophlebitis The Parents of a Child with Special Needs Perinatal Loss Newborn Concepts The First Hour of Life The Neonate at 2 Hours to 2 Days of Age The Neonate at 24–48 Hours Following Early Discharge The Neonate at 1 Week Following Discharge The Infant at 4 Weeks Following Birth The Preterm Infant Deviations in Growth Patterns Circumcision Hyperbilirubinemia The Infant of an Addicted Mother The Infant of an HIV-Positive Mother PEDIATRIC CONSIDERATIONS 400 HEALTH CONDITIONS AND CLIENT CONCERNS WITH ASSOCIATED NURSING DIAGNOSES xxxiv
  • 37. Copyright © 2006 by F. A. Davis. 1 C H A P T E R Issues and Trends in Medical/Surgical Nursing THE EVER-CHANGING ices, preferring to provide payment for outpatient services, or in some cases, in-home care. Third-party payors are nego- HEALTHCARE ENVIRONMENT tiating contracts with healthcare providers, including physi- cians, provider agencies, and facilities, in order to reduce Understanding trends in client care and dealing with the cur- reimbursement rates or even to capitate fees (providing serv- rent issues in nursing require looking at the overall trends in ices for a preset fee regardless of actual cost). This method of healthcare practice and the ongoing restructuring of health- payment is based on both the number and specific demo- care delivery systems within the healthcare industry. graphics of the insured population. At the same time, third- Factors driving the changes in healthcare include the rising party payors continue to pay for extra care associated with cost of care, the ever-increasing numbers of uninsured/ medical errors, but seem reluctant to pay for best practices or underinsured healthcare consumers, and the need for alloca- increase reimbursement in ways that can reduce untoward tion of limited healthcare dollars and resources. In addition, outcomes. other factors, such as technologic advances, ever-enlarging Public Law 98–21 changed the method of payment for fed- populations with special needs; changing roles for, and short- erally subsidized (Medicare) inpatient healthcare services ages of, healthcare providers; ethical issues associated with from a cost-based retrospective payment system (payment living in a technologic age; the potential conflict of the client’s for services after care was provided) to a prospective pay- or family’s wishes and prudent medical care; and liability ment system based on 467 diagnoses or diagnosis-related concerns will continue to affect nursing practice in the future. groups, referred to as DRGs. Upgrades to this payment sys- Nurses must be aware of these influences and be actively tem have been made to better reflect the severity of client involved in the formulation of policies and legislation affect- condition/care needs (known as all-patient-related, or APR- ing practice. As the definers of nursing practice, nurses must DRGs). However, reimbursement remains below billed set the standards of practice so that quality nursing care is costs. Most states are considering or have developed options provided with a high degree of client satisfaction and within to similarly curb Medicaid reimbursement. the constraints of available resources. Finally, although the federal government has recently agreed to provide a measure of funding to states located along the southern U.S. border to reimburse facilities for HEALTHCARE COSTS AND THE services provided to undocumented aliens, the high cost of ALLOCATION OF RESOURCES emergent care has required some hospitals to engage in cost- shifting to insurance carriers and cash pay clients, or in some Healthcare expenditures continue to rise. Both government cases, to even close emgergency departments. Adults who and private payors of healthcare are pursuing various meth- lack health insurance coverage are more likely to rate their ods of cost containment. One of the most widespread solu- health status as poor or fair, and are less likely to often rely tions for cost containment has been the implementation of on emergent care, receive preventive services, cancer screen- managed care services, and health maintenance organiza- ings, or dental care than adults with insurance, increasing tions (HMOs) or physician provider organizations (PPOs). In their overall care costs (State Health, 2002). some cases, special incentives are provided for the consumer to promote wellness or manage disease risk factors (e.g., pro- viding health club memberships or smoking cessation pro- MANAGED CARE: RESTRUCTURING grams). There may also be provider incentives such as bonus HEALTHCARE checks when the cost of care is below projected costs for the program or the individual provider. In recent years, these changes in reimbursement and the Most insurance plans require preauthorization for many practice of managed healthcare delivery have required hos- services and/or procedures based on established protocols, pitals to restructure. They adopted methods used in industry and encourage early discharge from acute or hospital serv- (such as reengineering and work redesign) or used methods 1
  • 38. Copyright © 2006 by F. A. Davis. developed specifically for the healthcare arena. The intent expected length of stay (ELOS). Their use provides a mecha- was to implement change aimed at reducing costs without nism for modifying care to reflect current clinical practice jeopardizing quality or consumer satisfaction. expectations based on clinical innovations and research Restructuring the workforce and the client care system findings. Clinical pathways may also be useful for timely was initially accomplished through mergers and consolida- identification of actual or potential outlyers, thus allowing tion of services, as well as downsizing professional staff by reallocation of resources to maximize client outcomes while means of normal attrition, early retirement programs, and controlling costs. However, although clinical pathways are layoffs. The responsibility for hands-on care in many settings useful for clients who fall within an expected course of ill- shifted away from registered nurses (RNs) to other providers ness, their lack of flexibility to accommodate preexisting such as licensed practical nurses (LPNs) and unlicensed multiple diagnoses (e.g., coronary bypass surgery for a client assistive personnel (UAPs). with diabetes mellitus and chronic renal insufficiency) or the Many healthcare professionals expressed great concern development of complications generally precludes their use regarding the effect of downsizing on the quality of care when greater individualization of care is required. In addi- provided, noting the decline in healthcare consumer satis- tion, because pathways generally address a specific episode faction reported on discharge surveys. Furthermore, a 1999 of care, they may not focus on care over a continuum. study by the Institute of Medicine conservatively projects Other structured care methodologies promoting standard- that 98,000 people a year die from medical errors. In contrast, ization of care processes include the use of algorithms, other studies (e.g., Blegen et al., 1998; Yang, 2003) have guidelines, or protocols (standing orders). In the field of shown that a higher ratio of professional nursing staff medicine, criteria have been developed such as the computer improves client outcomes and can lower medication errors program APACHE (Acute Physiology and Chronic Health and adverse events such as falls, and may even reduce mor- Evaluation) to assist providers in choosing appropriate treat- tality rates. However, facilities have been slow to improve ment options and to help allocate resources. This program staffing ratios (partly due to nursing shortages in some provides data on the likely outcomes of various treatments geographic areas and nursing specialties), resulting in in specific client populations. Thus, reimbursement could increased stress for staff and higher rates of errors and conceivably be tied to a scoring system reflecting the likeli- adverse incidents. hood of survival and corresponding treatment protocols. Responding to these concerns, many healthcare providers The advancement of knowledge continues with the work have formed collaborative practice teams whose goal is to of the U.S. Department of Health and Human Services’ revise the client care delivery system by reducing redun- Agency for Healthcare Research and Quality (formerly the dancy of services, eliminating nonproductive activities, and Agency for Health Care Policy and Research), whose pur- relocating ancillary services such as laboratory and radiog- pose is to enhance the quality, appropriateness, and effec- raphy to client care areas. The addition of a pharmacist as an tiveness of healthcare services. Multidisciplinary panels of active member of the healthcare team has been shown to clinicians (including nurses) created clinical practice and reduce preventable drug reactions by 78% (Leape and client teaching guidelines addressing specific client care sit- Berwick, 2005). Employers have implemented cross-training uations. These guidelines are intended not only to assist in of staff to enhance provider scope of services and qualifica- the prevention, diagnosis, and management of clinical con- tions. The reduction in the number of professional nurses ditions, but also to provide a resource by which client care providing direct client care has necessitated creative prob- can be evaluated, the provider is held accountable, and reim- lem solving to find ways to help nurses “work smarter” and bursement is justified. The agency now serves as a repository safer. for research resources and documents to provide a compre- The federal government has directed facilities to expand hensive database for the development of evidence-based computer capabilities to reduce errors and untoward out- clinical practice guidelines. comes by improving order entry, streamlining documenta- These processes tend to stabilize care practices and system tion, facilitating data retrieval, and developing structured processes and are designed to improve outcomes. By shifting care methodologies. Computerizing physician order entry some routine or nondirect care activities from the nurse to can reduce prescriptions errors by as much as 81% (Leape another provider, even the client or family, better use may be and Berwick, 2005). Access to computers, whether by central made of nursing time and efforts. In addition, promoting location, bedside terminal, or hand-held units, allows for the client self-care (through participation in the planning of care immediate entry and retrieval of client data by care and mutual goal setting as well as the self-administration of providers. Beepers, pagers, and cordless or cell phones have some therapies/medications) provides opportunities for the facilitated communication between the nurse and other client/family to maximize their control of/contribution to healthcare team members and clients, reducing response their health status, improve their acute care experience, and time for meeting client needs. Documentation time can be demonstrate newly learned skills. reduced through use of detailed flow sheets, charting by The need to provide services at lower costs has forced exception, standardized and computerized plans of care, providers to seek alternatives to inpatient care. Currently, and/or developing clinical pathways (care maps). the emphasis is on outpatient services and affiliations with Clinical pathways support the coordination and evalua- other provider groups to provide a wider continuum of tion of interdisciplinary care through the identification of client care. Healthcare networks have been created, some of specific outcomes (important in today’s focus of “outcomes- which encompass a major hub or tertiary hospital and based” client care) and corresponding activities for a given smaller affiliating hospitals, freestanding emergency clinics condition/procedure based on the DRG or the agency and surgical centers, subacute units, rehabilitation centers, 2
  • 39. Copyright © 2006 by F. A. Davis. long-term care facilities, and home-care agencies. These net- billing of services rendered. In those facilities/agencies ISSUES AND TRENDS IN MEDICAL-SURGICAL NURSING works are designed to meet all the client’s healthcare needs already billing for nursing services, the client plan of care is while keeping all the revenue within the network. However, an integral part of the justification of nursing care costs. this practice has the potential of limiting competition, The “what” and “how” of the work of nursing have been thereby causing the decline of independent healthcare agen- explained in part in a number of existing publications that cies, especially when physicians, pharmacies, and equip- help operationalize the work of nursing. NANDA ment supply companies join one network. International (formerly The North American Nursing One innovation was the creation of Community Nursing Diagnosis Association) developed a taxonomy in 1989 that Organization (CNO) demonstration projects that offered began a classification scheme to categorize and classify nurs- direct access to professional nursing care and nursing coor- ing diagnostic labels, which was subsequently revised in dination of all services with community-based care delivery. 2000. In 1992, the Iowa Intervention Project: Nursing The Centers for Medicare and Medicaid Services (CMS), for- Interventions Classification (NIC) directed our focus to the merly the Health Care Financing Administration (HCFA), content and process of nursing care by identifying and stan- developed this nursing model to provide Medicare benefici- dardizing some of the direct care activities nurses perform. A aries with a specific package of services (including preven- second group, the Iowa Outcomes Project: Nursing tion and health promtion) plus case management to promote Outcomes Classification (NOC), addresses client outcomes health and manage acute or chronic illnesses under a capi- responsive to and associated with nursing interventions. tated payment methodology. At four demonstration sites, all members were seen a minimum of twice a year to evaluate their health and to develop or check on progress of a plan of EARLY DISCHARGE care. The final report to Congress (Abt Associates, 2003) Clients are discharged from acute care as soon as they are revealed that although an overwhelming majority of out of danger or their condition is stabilized, but they may enrollees in the CNOs were satisfied with the care received still require specialized care. Subacute or transitional units and believed that the services helped with health needs and provide routine services (such as monitoring), ongoing ther- problems, the CNOs actually significantly increased the apies, and complex care (such as intravenous therapy, pain average monthly Medicare spending per client instead of and wound management, airway care, and ventilator wean- decreasing costs. Further study is required to determine if ing), rehabilitation services, and postsurgical recovery care. decreasing the capitated rate can reduce costs without nega- Shorter hospital stays have also shifted recovery care to tively impacting client satisfaction. the home setting. Families are expected to be more involved Significant changes in client care management are taking in postdischarge care. Although the rate of nosocomial infec- place because of implementation of case management, tions may decline, clients could be “abandoned” or recovery disease-state management, and evidence-based care. Case delayed or prolonged if the family’s personal resources can- management services are now provided across all settings not meet the new challenges associated with the recovery from case managers employed by insurers to entrepreneur- process. ial individuals engaged in “continuum of care” specialty areas and alternate sites, including outpatient, subacute, and home care. AGING POPULATION Healthcare-delivery systems use managed care to keep clients out of acute care hospitals by providing early inter- Individuals are living longer and often more active lives. As vention treatment, and by using less costly services within a result they expect access to procedures such as coronary the network. Whether the case manager is a physician, artery bypass, total joint replacements, aggressive cancer nurse, or insurance adjuster, all individuals involved in care care, and other interventions that in the past were not rec- are responsible for evaluating both the therapeutic benefit ommended in the presence of advanced age. The increased and cost effectiveness of the services provided. This need is mean age of clients requiring hospitalization necessitates especially critical for end-of-life care, for which a high per- some changes in the way their healthcare is provided. A gen- centage of healthcare dollars are spent. eral lack of knowledge among healthcare providers regard- ing special needs of the elderly, along with limited resources to meet these needs and the high incidence of adverse events NURSING CARE COSTS (such as confusion, falls, and incontinence), can contribute to instances of suboptimal client care. At the least, these factors Nurses have always been mainstays of care for people can cause prolonged facility stays, and increase the number throughout the life span and especially at the end of their and complexity of treatments, readmissions, and adverse lives. They continue to play a vital role in promoting respon- outcomes. To this end, the nursing profession is working to sible, appropriate, and ethical healthcare. develop models that will improve the care provided to this Today, the nurse’s attention is focused on providing nurs- population (e.g., Nurses Improving Care to the Hospitalized ing care to clients within the guidelines of prospective reim- Elderly [NICHE] Project). The provision of primary nurse bursement and capitation, scarce dollars, limited time, case managers to follow chronically ill clients across the con- reduced beds and staff, and restricted numbers of therapy tinuum of care (and other projects such as the CNO) work to and home-care visits. Quantifying the contribution of nurs- ensure that elderly clients are not lost to follow-up and ing to client care requires identification of the level of nursing receive ongoing monitoring for timely, cost-effective inter- care necessary for each client and translating that into direct vention. 3
  • 40. Copyright © 2006 by F. A. Davis. Healthcare decision making has changed dramatically in Additionally, point-of-care computer systems are being recent decades, with an explicit acknowledgment of the refined in an effort to cut documentation time, and to track client’s right to determine the course of care. In the nursing nursing time for the costing of care. Computers provid- profession, there has been a long-standing allegiance to the ing real-time updating of the client plan of care enable client’s role in decision making, but nurses, especially those the nurse to process data from monitoring activities and in elder care, fear that the interpretation and use of advance facilitate evaluation of the effectiveness of nursing actions directives are creating ethical conflicts regarding the with- and other therapies. drawal or withholding of treatment or care, especially when Telehealth is being used in the community to not only the client is concerned about being a “burden to others.” triage the needs of large populations, but also to provide Living wills and advance directives cannot be expected to direct client care to underserved areas via long-distance anticipate all situations that clients may encounter; however, communication lines. Video conferencing, the Internet, and they can provide information to a proxy (named in a medical interactive voice-response systems are being used to monitor durable power of attorney) to help in the decision-making chronically ill clients in their own homes. process. Even with advance directives in place, clients have Finally, work is progressing toward the creation of a com- a right to change their minds and redefine their wishes based puterized patient record (CPR) or electronic health record on changes in their health status/care options. (EHR) that will provide a composite “cradle to grave” record for each individual accessing healthcare in this country. However, many questions and concerns remain about on- TECHNOLOGIC ADVANCES line security and privacy. We are living in an age of escalating uncertainty and ten- Technology continues to evolve at an astounding rate in both sion. Scientific and technologic advances we so covet are the treatment and equipment. The purpose of technology is to same advances that strip life of its simplicity. In the future, improve clinical decision making and symptom manage- technologies can and will be created to support and, in some ment, facilitate early detection/prevention of illness, and cases, replace dependent and interdependent activities of enhance self-care and client outcomes. Robots are being used nursing. As a result of the efficiencies afforded by advances to dispense medications in pharmacies and to assist with in automation and information management, the focus of surgical procedures such as coronary artery bypass, mitral nursing practice could shift from primarily task-oriented valve repair, and prostate removal. Clients undergoing min- client interactions. Concrete activities, such as inserting an imally invasive surgery report less pain, have less blood loss intravenous line, assessing for respiratory sounds, and pro- and scarring, have shorter lengths of stay, and report faster viding client teaching, although vital, do not reflect what healing. nurses believe and value as the most important elements of The use of in-room cameras and computers combined practice. For even in a technologically driven healthcare sys- with video conferencing (eICU) to monitor the vital signs tem, clients will always feel the need to be comforted, lis- and status of multiple clients in intensive care units pro- tened to, and treated with dignity and respect. motes earlier recognition of changes and timely response by Nurses have long placed emphasis on the psychosocial, nurses and physicians, improving client outcomes and spiritual, and physical needs of their clients within the med- reducing mortality rates. Biventricular pacing for cardiac ical regimen. Today, individuals spend billions of dollars resynchronization is available, although underused, for the annually for therapies (ranging from guided imagery and treatment of clients with classes 3 and 4 heart failure. Brain meditation to homeopathy and acupuncture) not generally stimulators are being used to treat movement disorders such provided by their physicians or approved by their Health as Parkinson’s disease, dystonia, and essential tremors. And Maintenance Organizations. As technology changes and implantable insulin pumps are reducing or delaying the more people become knowledgeable partners in healthcare, complications associated with type 1 diabetus mellitus. many direct their therapies (challenging therapeutic plans In the near future, the expanded use of monoclonal anti- developed by healthcare providers or withdrawing from bodies to carry chemotherapy agents or radionuclides to established medical care), choosing alternative therapies and cancer cells will reduce adverse reactions and possibly the modalities. Nurses need to be knowledgeable and open need for acute care. Endotoxin antibodies (immune system minded regarding complementary/alternative therapies— molecules that can mediate sepsis) and gene therapies are supporting client choices and learning and evaluating new being developed that can manage or even eliminate heredi- techniques as appropriate. Although nurses and clients alike tary/degenerative diseases, thereby reducing high-cost ther- are turning to the Internet for medical information and ther- apy needs. Equipment developments that allow clients to apeutic options, this resource can be a double-edged sword leave acute care settings more quickly include user-friendly because data provided may or may not be accurate. ventilators, smaller implantable ventilator-assist devices, Therefore, nurses need to be aware and knowledgeable and artificial hearts. The cost of care and the incidence of regarding various sites in order to direct their clients to rep- complications or adverse outcomes have been reduced for utable and valid resources. many clients with the use of such procedures as noninvasive intracranial pressure monitoring, tube locators to verify placement of catheters or enteral tubes, and bedside moni- FUTURE OF NURSING toring of many laboratory studies (such as electrolytes, blood urea nitrogen, hematocrit, glucose, and coagulation Healthcare reform remains the focus of much writing and times). debate in this new century. Questions still abound about 4
  • 41. Copyright © 2006 by F. A. Davis. what constitutes healthcare reform. Whether brought about fails to define its contribution, then, as far as the reimburser ISSUES AND TRENDS IN MEDICAL-SURGICAL NURSING by statute, insurance payors, or healthcare providers, the is concerned, the contribution does not exist. changes in healthcare delivery are continuing and far reach- A recent focus of growth in the profession has been ing. These changes are, and should be, of great concern to the effort to standardize nursing language to better demon- nurses. strate what nursing is and what nurses do. As of this edition, We, the authors, are nurses who still believe that a nursing more than 10 versions of standardized nursing languages perspective is essential if nurses are to position themselves have been recognized by the American Nurses Association for a role in future healthcare-delivery systems. As Virginia (ANA) and submitted to the National Library of Medicine Henderson said, “The beauty of nursing is the combination for inclusion in the Unified Medical Language System of the heart, head, and hands” (Buerhaus, 1998). We are Metathesaurus. These nursing languages (e.g., NANDA, opposed to any system that reduces or eliminates the role of NIC/NOC, Omaha System, Clinical Care Classification, the nursing. Clients depend on the nurse to advocate for the Perioperative Minimum Data Set, and Ozbolt Patient Care rights of the client and the quality of care provided. Data Set) can enhance the ability of nurses to communicate In general, the public’s image of nursing remains positive; and document the care they provide, and to charge for these however, we can fall short of meeting the public’s expecta- services. This facilitates the recognition of nursing’s contri- tions because people are sometimes unaware of nurses’ var- bution to client care and promotes the view that nursing is a ied capabilities or their advanced practice potential. revenue-generating center. Although the public expects nurses to demonstrate technical In the midst of this whirlwind of change, as we experi- competence and academic knowledge, it is also now ment with new ways to provide cost-effective care within a demanding better consumer service; that is, friendliness, specified time frame, it is imperative that we build on attention to the client’s personal or special needs, concern for the foundation of the profession; that is, nursing is a science privacy, information about tests and therapies, and inclusion as well as an art, and nursing practice is rooted in the scien- of the family in the information loop. As the number of RNs tific process. Whether or not we choose to rename the steps in acute care facilities declines, and as they are replaced with we engage in (assessing clients and determining their less knowledgeable client care providers, nurses need to del- needs, choosing actions to meet those needs, and evaluating egate and supervise appropriately, using team members the effectiveness of those actions), our purpose remains the effectively and safely. Nurses, who now have less time for same—the diagnosis and treatment of human responses to nonclinical activities, are nonetheless spending more time health and illness. It reinforces the importance of critical collaborating with a wide variety of healthcare professionals thinking and reasoning to professional nursing practice as to manage and coordinate care, as well as to communicate well as the differences between basic and advanced nursing data regarding effectiveness of therapies. Nurses are inter- practice. If we allow our nursing focus to be replaced by the acting more with families, providing them with the informa- medical model, our practice will be subsumed, and much tion they need to make treatment decisions that reflect the more will be lost than the essence of our profession. client’s goals and values, and incorporating them into the caregiving process in preparation for the client’s discharge. To ensure that clients are getting what they need without CONCLUSION wasting healthcare dollars, nurses must be knowledgeable about costs and reimbursement plans, as well as the relative Rapid and continuous changes in the healthcare environ- benefits of treatment options. Downsizing produced the ment have greatly increased the responsibilities facing stimulus to nurses to broaden their skill base through cross- today’s nurse. To fulfill these responsibilities, planning and training and certification in order to document their exper- documentation of care are essential to satisfy client needs tise in a given area. Staff cutting requires that nurses remain and meet legal obligations. Documentation of the impact of flexible and perhaps trained to work in more than one clini- nursing on desired client outcomes provides a basis for eval- cal area. Healthcare systems can no longer employ RNs in uating continuing care needs, dealing with legal concerns, roles that do not directly, critically, and clearly contribute to and determining payment. the outcomes of the organization. Today’s nurse must be Therefore, as nurses work collaboratively with other disci- technically competent, skilled at critical thinking and prob- plines to provide client care, we need to continue to identify lem solving, able to work with a variety of people, and fis- and document the nursing care needs of clients through the cally responsible. use of the nursing process and nursing diagnosis. Although This is not enough, however, because the outcomes of this journey into change is not optional, nursing does have nursing care are the true measurement of the ability to pro- the opportunity and responsibility to take an active role in vide care. Nurses are entering (and even creating) new prac- shaping that change. tice environments in which to use their skills. They are also What lies ahead for nursing and planning of client working to further define nursing practice and the special care? Definitely, a tremendously exciting and exacting chal- contribution that nursing will continue to offer because that lenge! is how services will be evaluated and reimbursed. If nursing 5
  • 42. Copyright © 2006 by F. A. Davis. 2 C H A P T E R The Nursing Process: Planning Care Using Nursing Diagnoses Nurses and healthcare consumers agree that nursing care is tem. The process combines all the skills of critical thinking a key factor in achieving positive outcomes and enhancing and good nursing care because it creates a method of active client satisfaction. Nursing care is instrumental in all phases problem solving that is both dynamic and cyclic. Figure 2–1 of acute care as well as in the maintenance of general well- visualizes the way this cyclic process works. As we learn being (i.e., prevention of illness, rehabilitation, and maxi- more about diagnostic reasoning and critical thinking, some mization of health), or where a return to health is not scholars are proposing a new model of describing what possible, the relief of pain and discomfort and a peaceful nurses do. With the emphasis on outcomes (the most recent death. To this end, the nursing profession has identified a revision of the American Nurses Association [ANA] Social problem-solving process that “combines the most desirable Policy Statement [1995] focused on outcomes and deempha- elements of the art of nursing with the most relevant ele- sized problem-focused approaches to nursing care) and new ments of systems theory, using the scientific method” (Shore, research into the nature of thinking and reasoning, the nurs- 1988). ing process continues to be redefined (Pesut and Herman, The original concept of nursing process was introduced in 1999). the 1950s as a three-step process of assessment, planning, The “what” and “how” of the work of nursing have been and evaluation based on the scientific method of observing, explained in part in a number of existing publications that measuring, gathering data, and analyzing the findings. Over help operationalize the work of nursing. The ANA Social time, this process became part of the conceptual framework Policy Statement (1980) defined nursing as the “diagnosis of all nursing curricula and is included in the legal definition and treatment of human responses to actual and potential of nursing in the nurse practice acts of most states. After health problems.” It represents a framework for understand- years of study, use, and refinement, the three-step process ing nursing’s relationship with society and nursing’s obliga- was expanded. The five steps—(1) assessment (systematic tions to those who receive nursing care. In 1991, the ANA collection of data relating to clients and their Standards of Clinical Nursing Practice described the client care problems/needs), (2) problem identification (analysis and process and standards for professional performance, provid- interpretation of data), (3) planning (prioritizing needs, iden- ing impetus and support for the use of nursing diagnosis in tifying goals, and choosing solutions), (4) implementation the practice setting. The work of NANDA International (for- (putting the plan into action), and (5) evaluation (assessing merly North American Nursing Diagnosis Association) has the effectiveness of the plan and changing the plan as indi- been ongoing for more than 25 years, beginning with efforts cated by current needs)—are central to nursing actions and to identify client problems/needs for which nurses are the delivery of high-quality, individualized client care in any accountable. NANDA continues to develop nursing diag- setting. nostic labels (Table 2–1), which are now being comple- When a client enters the healthcare system, the nurse uses mented by the Iowa Intervention Project: Nursing the steps of the nursing process to work toward achieving Interventions Classification (NIC) and the Iowa Outcomes the desired outcomes and goals identified for the client. The Project: Nursing Outcomes Classification (NOC). NIC effectiveness of the plan of care is evaluated by ascertaining directs our focus to the content and process of nursing care whether or not the desired outcomes and goals have been by identifying and standardizing the care activities nurses attained (client’s problems/needs have been resolved) or perform while NIC describes client outcomes that are whether problems remain at the time of discharge. If prob- responsive to nursing intervention and developing corre- lems are unresolved, plans need to be made for further sponding measurement scales. follow-up including assessment, additional problem/need The implementation of prospective/capitated payment identification, alteration of desired outcomes and goals, plans has moved a greater portion of healthcare delivery and/or changes of interventions in the next care settings. away from acute care hospitals into the community, with an Although some nurses view the nursing process as sepa- emphasis on multifaceted free-standing care centers and rate, progressive steps; in reality, the elements are interre- home health services. Standards of care such as those pub- lated. Together, they form a continuous circle of thought and lished by the American Association of Critical-Care Nurses action throughout the client’s contact with the healthcare sys- (AACN) and the Joint Commission on Accreditation of 6
  • 43. Copyright © 2006 by F. A. Davis. THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES on n Pl nti Pl tio t ion an n ve an en en ing ter ni rv rv In ng te te In In NURSE CLIENT Ev Eva alu is Dia rsing luat is sis Dia rsing ag g os atio os Ev Di rsin no gn ion gn alu Nu n Nu Nu ati on Assessment Assessment ment Assess Figure 2–1. Diagram of the nursing process. The steps of the nursing process are interrelated, forming a continuous circle of thought and action that is both dynamic and cyclic. Table 2–1 Nursing Diagnoses Accepted for Use and Research Through 2006 Activity Intolerance [specify level] Death Syndrome, risk for sudden infant Activity Intolerance, risk for Denial, ineffective Adjustment, impaired Dentition, impaired Airway Clearance, ineffective Development, risk for delayed Allergy Response, latex Diarrhea Allergy Response, risk for latex Disuse Syndrome, risk for Anxiety [specify level] Diversional Activity, deficient Anxiety, death Aspiration, risk for Energy Field, disturbed Attachment, risk for impaired parent/infant/child Environmental Interpretation Syndrome, impaired Autonomic Dysreflexia Autonomic Dysreflexia, risk for Failure to Thrive, adult Falls, risk for Body Image, disturbed Family Processes: alcoholism, dysfunctional Body Temperature, risk for imbalanced Family Processes, interrupted Bowel Incontinence Family Processes, readiness for enhanced Breastfeeding, effective Fatigue Breastfeeding, ineffective Fear [specify focus] Breastfeeding, interrupted Fluid Balance, readiness for enhanced Breathing Pattern, ineffective [Fluid Volume, deficient hyper/hypotonic] Fluid Volume, deficient [isotonic] Cardiac Output, decreased Fluid Volume, excess Caregiver Role Strain Fluid Volume, risk for deficient Caregiver Role Strain, risk for Fluid Volume, risk for imbalanced Communication, impaired verbal Communication, readiness for enhanced Gas Exchange, impaired Conflict, decisional (specify) Grieving, anticipatory Conflict, parental role Grieving, dysfunctional Confusion, acute Grieving, risk for dysfunctional Confusion, chronic Growth, risk for disproportionate Constipation Growth & Development, delayed Constipation, perceived Constipation, risk for Health Maintenance, ineffective Coping, compromised family Health-Seeking Behaviors [specify] Coping, defensive Home Maintenance, impaired Coping, disabled family Hopelessness Coping, ineffective Hyperthermia Coping, readiness for enhanced Hypothermia Coping, ineffective community Coping, readiness for enhanced community Identity, disturbed personal Coping readiness for enhanced family Infant Behavior, disorganized (Continued on the following page) 7
  • 44. Copyright © 2006 by F. A. Davis. Table 2–1 Nursing Diagnoses Accepted for Use and Research Through 2006 (Continued) Infant Behavior, readiness for enhanced organized Self-Concept, readiness for enhanced Infant Behavior, risk for disorganized Self-Esteem, chronic low Infant Feeding Pattern, ineffective Self Esteem, situational low Infection, risk for Self Esteem, risk for situational low Injury, risk for Self-Mutilation Injury, risk for perioperative positioning Self-Mutilation, risk for Intracranial Adaptive Capacity, decreased Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Knowledge, deficient [Learning Need] [specify] Sexual Dysfunction Knowledge [specify], readiness for enhanced Sexuality Pattern, ineffective Skin Integrity, impaired Lifestyle, sedentary Skin Integrity, risk for impaired Loneliness, risk for Sleep, readiness for enhanced Sleep Deprivation Memory, impaired Sleep Pattern, disturbed Mobility, impaired bed Social Interaction, impaired Mobility, impaired physical Social Isolation Mobility, impaired wheelchair Sorrow, chronic Spiritual Distress Nausea Spiritual Distress, risk for Neglect, unilateral Spiritual Well-Being, readiness for enhanced Noncompliance, [ineffective Adherence] [specify] Suffocation, risk for Nutrition: less than body requirements, imbalanced Suicide, risk for Nutrition: more than body requirements, imbalanced Surgical Recovery, delayed Nutrition: more than body requirements, risk for imbalanced Swallowing, impaired Nutrition, readiness for enhanced Therapeutic Regimen Management, effective Oral Mucous Membrane, impaired Therapeutic Regimen Management, ineffective Therapeutic Regimen Management, ineffective community Pain, acute Therapeutic Regimen Management, ineffective family Pain, chronic Therapeutic Regimen Management, readiness for enhanced Parenting, impaired Thermoregulation, ineffective Parenting, readiness for enhanced Thought Processes, disturbed Parenting, risk for impaired Tissue Integrity, impaired Peripheral Neurovascular Dysfunction, risk for Tissue Perfusion, ineffective (specify type: cerebral, car- Poisoning, risk for diopulmonary, renal, gastrointestinal, peripheral) Post-Trauma Syndrome [specify stage] Transfer Ability, impaired Post-Trauma Syndrome, risk for Trauma, risk for Powerlessness [specify level] Urinary Elimination, impaired Powerlessness, risk for Urinary Elimination, readiness for enhanced Protection, ineffective Urinary Incontinence, functional Urinary Incontinence, reflex Rape-Trauma Syndrome Urinary Incontinence, risk for urge Rape-Trauma Syndrome: compound reaction Urinary Incontinence, stress Rape-Trauma Syndrome: silent reaction Urinary Incontinence, total Religiosity, impaired Urinary Incontinence, urge Religiosity, risk for impaired Urinary Retention [acute/chronic] Religiosity, readiness for enhanced Relocation Stress Syndrome Ventilation, impaired spontaneous Relocation Stress Syndrome, risk for Ventilatory Weaning Response, dysfunctional Role Performance, ineffective Violence, [actual/] risk for other-directed Violence, [actual/] risk for self-directed Self-Care Deficit, bathing/hygiene Walking, impaired Self-Care Deficit, dressing/grooming Wandering [specify sporadic or continual] Self-Care Deficit, feeding Self-Care Deficit, toileting [ ] author recommendations Used with permission from NANDA International: Definitions and Classification, 2005–-2006. NANDA, Philadelphia, 2005. Healthcare Organizations (JCAHO) emphasize that, even in define itself in a way that will complement and facilitate the these environments, nursing must meet standards that fur- provision of appropriate, cost-effective evidenced-based care ther specify the parameters of client assessment and docu- to all persons. Nurses need a common framework of com- mentation of care. munication and documentation so their contribution to Changes in the healthcare system continue to occur at an healthcare is recognized as being essential and they are remu- ever-increasing rate, requiring the profession of nursing to nerated appropriately. At the very least, nursing requires a 8
  • 45. Copyright © 2006 by F. A. Davis. commonality of words describing practice so it can be cap- lifestyle. These assessments, combined with the results of THE NURSING PROCESS: PLANNING CARE USING NURSING DIAGNOSES tured and is visible in the healthcare databases. medical findings and diagnostic studies, are documented in The linkage of nursing diagnoses to specific nursing inter- the client database and form the foundation for development ventions and client outcomes has led to the development of of the client’s plan of care. For each plan of care presented in a number of standardized nursing languages (e.g., Omaha this book, a client assessment database is created from infor- System, Clinical Care Classification [formerly Home mation that would likely be obtained from the history, phys- Healthcare Classification], Ozbolt Patient Care Data Set, ical examination, and related diagnostic studies. Nursing Perioperative Minimum Data Set). The purpose of these lan- priorities are then determined and ranked. Priorities are sim- guages is to help ensure continuity of appropriate high- ply stated and represent a general ranking system for the quality nursing care for the client regardless of setting. This nursing diagnoses in the plan of care. They can be reworded is accomplished in part through enhanced communication, and/or reorganized along with their timelines to create standardization of the process evaluating the care provided, short- and long-term goals. Next, the nursing diagnosis and facilitation of documentation. statements, which include possible related factors (etiology) and corresponding signs and symptoms (cues) when appro- priate, are presented. Desired client outcomes are then iden- PLANNING CARE tified and followed by appropriate independent and collaborative interventions with accompanying rationales. Medicine and nursing as well as other healthcare disciplines are interrelated, and therefore the actions for each discipline have implications for the others. This interrelationship Client Database allows for exchange of information and ideas and for devel- opment of plans of care that include all data pertinent to the In this book, each selected medical condition has an accom- individual client and/or family. In this book, the plan of care panying client database that includes subjective (“may contains not only the actions initiated by medical and nurs- report”) and objective (“may exhibit”) data that would ing orders, but also the coordination of care provided by all likely be collected through the history-taking interview, related healthcare disciplines. The nurse is often the person physical assessment, diagnostic studies, and review of prior responsible for coordinating these various activities into a records. The client database is organized within the 13 cate- comprehensive functional plan, essential in providing holis- gories of the Diagnostic Divisions. A sample medical/surgi- tic care for the client. Although independent nursing actions cal assessment tool, definitions of the divisions, and a client are an integral part of this process, collaborative actions are situation are included in Chapter 3. As the nurse develops usually present based on the medical regimen or orders from the plan of care, it will also be individualized to the client’s other disciplines participating in the care of the client. We situation. believe that nursing is an essential part of collaborative prac- tice, and, as such, nursing has a responsibility and accounta- Interviewing bility in every collaborative problem in which the nurse Interviewing the client and/or significant other(s) provides interacts with the client. The educational background and data that the nurse obtains through conversation and obser- expertise of the nurse, standing protocols, delegation of vation. This information includes the individual’s percep- tasks, the use of care partners, and the area of practice (rural tions; that is, what the client perceives to be a problem and or urban, acute care or community care settings) influence typically what he or she wants to share. Data may be col- whether an intervention is actually an independent nursing lected during one or more contact periods and should function or requires collaboration. include all relevant information. All participants in the inter- The well-written plan of care communicates the client’s view process need to know that collected data are used in past and present health status and current needs to all mem- planning the client’s care. Organizing and updating the data bers of the healthcare team involved in providing care. It assists in the ongoing identification of client care needs and identifies problems solved and those yet to be solved, can nursing diagnoses. inform of approaches that have been successful, and notes patterns of client responses to interventions. In legal terms, Physical Assessment the plan of care documents client care in areas of liability, accountability, and quality improvement. It also provides a During information gathering, the nurse exercises percep- mechanism to help ensure continuity of care when the client tual and observational skills, assessing the client through the leaves a care setting while still needing services. senses of sight, hearing, touch, and smell. The duration and depth of any physical assessment depend on the current con- dition of the client and the urgency of the situation, but it COMPONENTS OF THE usually includes inspection, palpation, percussion, and aus- cultation. In this book, the physical assessment data are pre- PLAN OF CARE sented within the client database as objective data. The critical element for providing effective planned nursing care is its relevance as identified in client assessments. Diagnostic Studies According to ANA Standards of Clinical Nursing Practice Interpretation of diagnostic test results is integrated with the (ANA, 1991), client assessment is required in the following history and physical findings as part of objective findings. areas: physical, psychologic, sociocultural, spiritual, cogni- Some tests are used to diagnose disease, whereas others are tive, functional abilities, developmental, economic, and useful in following the course of a disease or in adjusting 9
  • 46. Copyright © 2006 by F. A. Davis. therapies. The nurse needs to be aware of significant test BOX 2–1. NANDA DEFINITION results that require reporting to the physician and/or initia- OF NURSING DIAGNOSIS tion of specific nursing interventions. In many cases, the relationship of the test to the pathological physiology is clear, but in other cases it is not. This is the result of the inter- Nursing diagnosis is a clinical judgment about relationship between various organs and body systems. individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of Nursing Priorities nursing interventions to achieve outcomes for which the nurse is accountable. In this book, nursing priorities are listed in a certain order to facilitate the linking/ranking of selected associated nursing diagnoses that appear in the plan of care guidelines. In any There are several steps involved in the process of prob- given client situation, nursing priorities are based on the lem/need identification. Integrating these steps provides a client’s specific needs and can vary from minute to minute. systematic approach to accurately identifying nursing diag- A nursing diagnosis that is a priority today may be less of a noses using the process of critical thinking. priority tomorrow, depending on the fluctuating physical and psychosocial condition of the client or the client’s chang- 1. Collecting a client database (nursing interview, physical ing responses to the existing condition. assessment, and diagnostic studies) combined with infor- An example of nursing priorities for a client diagnosed mation collected by other healthcare providers with severe hypertension would include: 2. Reviewing and analyzing the client data 1. Maintain/enhance cardiovascular functioning. 3. Synthesizing the gathered client data as a whole and then 2. Prevent complications. labeling your clinical judgment about the client’s 3. Provide informatio