rencana keperawatan


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

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rencana keperawatan

  1. 1. Copyright © 2006 by F. A. Davis.
  2. 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. 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. 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. 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