Nursing Diagnosis Application to Clinical Practice

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ISBN: 9780781761314 | 078176131X
Cover: Paperback
Copyright: 7/11/2005

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Revised to incorporate the latest NANDA-approved nursing diagnoses, the Eleventh Edition of this classic text offers definitive guidance on key elements of nursing diagnosis and its application to clinical practice. Section 1 thoroughly explains the role of nursing diagnosis in the nursing process and in care planning. Section 2 is a comprehensive A-to-Z guide to current nursing diagnoses. Section 3 focuses on collaborative problems. This edition lists associated NIC (Nursing Interventions Classifications) and NOC (Nursing Outcomes Classifications) for every NANDA diagnosis. New diagnoses added and modified in accordance with the latest NANDA meeting are in an appendix for easy access.

SECTION ONE Nursing Diagnosis in the Nursing Process

(76)

Introduction

(1)

Development of Nursing Diagnosis

(4)

Nursing Diagnosis: Defined

(1)

Nursing Diagnosis: Process or Outcome?

(1)

The North American Nursing Diagnosis Association International

(1)

Nanda Taxonomy

(1)

Summary

(1)

Types and Components of Nursing Diagnoses

(9)

Actual Nursing Diagnosis

(2)

Risk and High-Risk Nursing Diagnoses

(1)

Possible Nursing Diagnoses

(1)

Wellness Nursing Diagnoses

(1)

Syndrome Nursing Diagnoses

(1)

Non-Nanda-Approved Diagnoses

(1)

Diagnostic Statements

(2)

Summary

(1)

Nursing Diagnosis: What It Is, What It Is Not

(9)

Understanding Collaborative Problems

(1)

Collaborative Problem Diagnostic Statements

(1)

Differentiating Nursing Diagnoses From Collaborative Problems

(4)

Summary

(2)

Nursing Diagnoses: Assessment and Diagnosis

(12)

Assessment

(10)

Diagnosis

(1)

Summary

(1)

Planning Care With Nursing Diagnosis

(26)

Are Care Plans Necessary?

(1)

The Care Planning Process

(1)

Planning

(9)

Implementation

(1)

Evaluation

(2)

Multidisciplinary Care Planning

(1)

Care Planning Systems

(8)

Case Study Applications of Care Planning

(6)

Ten Steps to Putting It All Together

(4)

Step 1: Assessment

(1)

Step 2: Same-Day Assessment

(1)

Step 3: Create Your Initial Care Plan

(1)

Step 4: Review the Collaborative Problems on the Generic Plan

(1)

Step 5: Review the Nursing Diagnoses on the Standard Plan

(1)

Step 6: Prepare the Care Plan (Written or Printed)

(1)

Step 7: Initial Care Plan Completed

(1)

Step 8: Additional Risk Factors

(1)

Step 9: Evaluate the Status of Your Client (After You Provide Care)

(1)

Step 10: Document the Care on the Agency's Forms, Flow Records, and Progress Notes

(1)

Nursing Diagnoses: Issues and Controversies

(9)

Why Can't We Just Use the Words We've Always Used?

(1)

Other Disciplines Will Not Understand Our Diagnoses

(1)

Clients Will Not Understand Our Diagnoses

(1)

Nurse Practitioners, Nurse Anesthetists, and Nurse Midwives Do Not Need Nursing Diagnoses

(1)

Nursing Diagnoses Are Not Culturally Sensitive

(1)

Nursing Diagnosis Is Unethical

(1)

Nursing Diagnoses Can Violate Confidentiality

(2)

Summary

(2)

SECTION TWO Manual of Nursing Diagnoses

(748)

Introduction

(1)

Activity Intolerance

(15)

Related to Insufficient Knowledge of Adaptive Techniques Needed Secondary to COPD

(3)

Related to Insufficient Knowledge of Adaptive Techniques Needed Secondary to Impaired Cardiac Function

(3)

Related to Bed Rest Deconditioning

(3)

Decreased Intracranial Adaptive Capacity

(1)

Impaired Adjustment

(1)

Anxiety

(13)

Related to Insufficient Knowledge of Preoperative Routines, Postoperative Exercises/Activities, Postoperative Alterations/Sensations

107

(3)

Death Anxiety

110

(2)

Risk for Imbalanced Body Temperature

112

(4)

Hyperthermia

116

(2)

Hypothermia

118

(3)

Ineffective Thermoregulation

121

(4)

Related to Newborn Transition to Extrauterine Environment

123

(2)

Bowel Incontinence

125

(3)

Effective Breast-feeding

128

(1)

Ineffective Breast-feeding

129

(6)

Interrupted Breast-feeding

135

(1)

Decreased Cardiac Output

136

(1)

Caregiver Role Strain

137

(7)

Risk for Caregiver Role Strain

144

(3)

Impaired Comfort

147

(7)

Acute Pain

154

(12)

Chronic Pain

166

(4)

Nausea

170

(3)

Impaired Communication

173

(13)

Related to Effects of Hearing Loss

180

(2)

Related to Effects of Aphasia on Expression or Interpretation

182

(2)

Related to Foreign Language Barrier

184

(2)

Impaired Verbal Communication

186

(2)

Confusion

188

(1)

Acute Confusion

189

(7)

Chronic Confusion

196

(6)

Constipation

202

(9)

Related to Effects of Immobility on Peristalsis

210

(1)

Perceived Constipation

211

(2)

Ineffective Coping

213

(10)

Defensive Coping

223

(2)

Ineffective Denial

225

(7)

Related to Impaired Ability to Accept Consequences of Own Behavior as Evidenced by Lack of Acknowledgment of Substance Abuse/Dependency

229

(3)

Disabled Family Coping

232

(16)

Related to (Specify), as Evidenced by Domestic Abuse

240

(3)

Related to (Specify), as Evidenced by Child Abuse/Neglect

243

(3)

Related to Multiple Stressors Associated With Elder Care: High Risk for

246

(2)

Compromised Family Coping

248

(1)

Readiness for Enhanced Family Coping

249

(1)

Ineffective Community Coping

249

(5)

Readiness for Enhanced Community Coping

254

(5)

Related to Availability of Community Programs to Augment (Specify)

257

(2)

Decisional Conflict

259

(7)

Diarrhea

266

(5)

Disuse Syndrome

271

(8)

Deficient Diversional Activity

279

(5)

Dysreflexia

284

(4)

Risk for Dysreflexia

288

(1)

Energy Field Disturbance

288

(3)

Impaired Environmental Interpretation Syndrome

291

(2)

Family Processes, Interrupted

293

(8)

Related to Impact (Specify) of Ill Member on Family System

299

(2)

Family Processes, Dysfunctional: Alcoholism

301

(5)

Fatigue

306

(8)

Fear

314

(7)

Deficient Fluid Volume

321

(8)

Related to Abnormal Fluid Loss

327

(2)

Excess Fluid Volume

329

(5)

Risk for Imbalanced Fluid Volume

334

(1)

Grieving

335

(8)

Grieving, Anticipatory

343

(4)

Grieving, Dysfunctional

347

(3)

Growth and Development, Delayed

350

(8)

Development, Risk for Delayed

358

(1)

Growth, Risk for Disproportionate

359

(1)

Adult Failure to Thrive

359

(3)

Ineffective Health Maintenance

362

(19)

Related to Insufficient Knowledge of Effects of Tobacco Use and Self-Help Resources Available

373

(4)

Related to Increased Food Consumption in Response to Stressors and Insufficient Energy Expenditure for Intake

377

(4)

Health-Seeking Behaviors

381

(6)

Impaired Home Maintenance

387

(5)

Hopelessness

392

(9)

Infant Behavior, Disorganized

401

(7)

Infant Behavior, Risk for Disorganized

408

(1)

Infant Behavior, Readiness for Enhanced Organized

409

(3)

Infection, Risk for

412

(9)

Infection Transmission, Risk for

421

(7)

Related to Lack of Knowledge of Reducing the Risk of Transmitting the AIDS Virus

426

(2)

Injury, Risk for

428

(18)

Related to Lack of Awareness of Environmental Hazards

437

(5)

Related to Lack of Awareness of Environmental Hazards Secondary to Maturational Age

442

(2)

Related to Vertigo Secondary to Orthostatic Hypotension

444

(2)

Risk for Aspiration

446

(5)

Risk for Falls

451

(1)

Risk for Poisoning

452

(1)

Risk for Suffocation

452

(1)

Risk for Trauma

452

(1)

Injury, Risk for Perioperative Positioning

453

(5)

Deficient Knowledge

458

(1)

Latex Allergy Response

459

(2)

Latex Allergy Response, Risk for

461

(1)

Lifestyle, Sedentary

462

(3)

Loneliness, Risk for

465

(5)

Therapeutic Regimen Management, Effective: Individual

470

(3)

Therapeutic Regimen Management, Ineffective

473

(7)

Therapeutic Regimen Management, Ineffective: Family

480

(1)

Therapeutic Regimen Management, Ineffective: Community

481

(4)

Mobility, Impaired Physical

485

(7)

Impaired Bed Mobility

492

(1)

Impaired Walking

493

(1)

Impaired Wheelchair Mobility

494

(1)

Impaired Wheelchair Transfer Ability

495

(1)

Noncompliance

496

(7)

Nutrition, Imbalanced: Less Than Body Requirements

503

(15)

Related to Anorexia Secondary to (Specify)

514

(2)

Related to Difficulty or Inability to Procure Food

516

(2)

Altered Dentition

518

(1)

Impaired Swallowing

518

(5)

Ineffective Infant Feeding Pattern

523

(5)

Nutrition, Imbalanced: More Than Body Requirements

528

(3)

Nutrition, Imbalanced: Potential for More Than Body Requirements

531

(1)

Parenting, Impaired

532

(5)

Parent-Infant Attachment, Risk for Impaired

537

(5)

Parental Role Conflict

542

(7)

Related to Effects of Illness and/or Hospitalization of a Child

546

(3)

Peripheral Neurovascular Dysfunction, Risk for

549

(6)

Post-Trauma Syndrome

555

(5)

Post-Trauma Syndrome, Risk for

560

(1)

Rape Trauma Syndrome

560

(9)

Powerlessness

569

(7)

Protection, Ineffective

576

(1)

Tissue Integrity, Impaired

577

(7)

Skin Integrity, Impaired

584

(5)

Related to the Effects of Pressure, Friction, Shear, Maceration

587

(2)

Oral Mucous Membrane, Impaired

589

(8)

Related to Inadequate Oral Hygiene or Inability to Perform Oral Hygiene: Risk for

594

(3)

Relocation Stress [Syndrome]

597

(11)

Related to Changes Associated With Health Care Facility Transfers or Admission to Long-Term Care Facility

604

(4)

Respiratory Function, Risk for Ineffective

608

(11)

Related to Allergic Response

615

(4)

Dysfunctional Ventilatory Weaning Response

619

(6)

Dysfunctional Ventilatory Weaning Response, Risk for

625

(3)

Ineffective Airway Clearance

628

(2)

Ineffective Breathing Patterns

630

(2)

Impaired Gas Exchange

632

(1)

Impaired Spontaneous Ventilation

633

(1)

Role Performance, Ineffective

634

(1)

Self-Care Deficit Syndrome

635

(6)

Feeding Self-Care Deficit

641

(2)

Bathing/Hygiene Self-Care Deficit

643

(2)

Dressing/Grooming Self-Care Deficit

645

(3)

Toileting Self-Care Deficit

648

(2)

Instrumental Self-Care Deficit

650

(3)

Self-Concept, Disturbed

653

(9)

Body Image, Disturbed

662

(5)

Personal Identity, Disturbed

667

(1)

Self-Esteem, Disturbed

667

(2)

Chronic Low Self-Esteem

669

(3)

Situational Low Self-Esteem

672

(3)

Situational Low Self-Esteem, Risk for

675

(1)

Risk for Self-Harm

676

(12)

Risk for Self-Abuse

688

(1)

Self-Mutilation

689

(1)

Risk for Self-Mutilation

690

(1)

Risk for Suicide

691

(4)

Disturbed Sensory Perception

695

(6)

Sexuality Patterns, Ineffective

701

(16)

Related to Prenatal and Postpartum Changes

712

(4)

Related to Fear of Pregnancy and/or Sexually Transmitted Diseases (STDs): Risk for

716

(1)

Sexual Dysfunction

717

(1)

Disturbed Sleep Pattern

718

(7)

Sleep Deprivation

725

(1)

Social Interaction, Impaired

726

(8)

Social Isolation

734

(1)

Sorrow, Chronic

735

(3)

Spiritual Distress

738

(14)

Related to Conflict Between Religious or Spiritual Beliefs and Prescribed Health Regimen

750

(2)

Spiritual Distress, Risk for

752

(1)

Spiritual Well-Being, Readiness for Enhanced

753

(1)

Impaired Religiosity

754

(3)

Impaired Religiosity, Risk for

757

(1)

Risk for Sudden Infant Death Syndrome

758

(2)

Surgical Recovery, Delayed

760

(1)

Thought Processes, Disturbed

761

(11)

Memory, Impaired

772

(4)

Tissue Perfusion, Ineffective (Specify: Renal, Cerebral, Cardiopulmonary, Gastrointestinal)

776

(1)

Tissue Perfusion, Ineffective Peripheral

777

(6)

Unilateral Neglect

783

(4)

Urinary Elimination, Impaired

787

(6)

Maturational Enuresis

793

(3)

Functional Incontinence

796

(4)

Reflex Incontinence

800

(2)

Stress Incontinence

802

(3)

Total Incontinence

805

(3)

Urge Incontinence

808

(3)

Urinary Retention

811

(3)

Violence, Risk for

814

(8)

Wandering

822

(3)

SECTION THREE Manual of Collaborative Problems

825

(108)

Introduction

827

(1)

Potential Complication: Cardiac/Vascular

828

(12)

PC: Decreased Cardiac Output

829

(1)

PC: Dysrhythmias

830

(2)

PC: Pulmonary Edema

832

(1)

PC: Deep Vein Thrombosis

833

(1)

PC: Hypovolemia

834

(2)

PC: Compartmental Syndrome

836

(1)

PC: Pulmonary Embolism

837

(3)

Potential Complication: Respiratory

840

(7)

PC: Hypoxemia

841

(1)

PC: Atelectasis, Pneumonia

842

(2)

PC: Tracheobronchial Constriction

844

(2)

PC: Pneumothorax

846

(1)

Potential Complication: Metabolic/Immune/Hematopoietic

847

(24)

PC: Hypo/Hyperglycemia

848

(3)

PC: Negative Nitrogen Balance

851

(1)

PC: Electrolyte Imbalances

852

(7)

PC: Sepsis

859

(1)

PC: Acidosis (Metabolic, Respiratory)

860

(2)

PC: Alkalosis (Metabolic, Respiratory)

862

(2)

PC: Allergic Reaction

864

(2)

PC: Thrombocytopenia

866

(2)

PC: Opportunistic Infections

868

(1)

PC: Sickling Crisis

869

(2)

Potential Complication: Renal/Urinary

871

(8)

PC: Acute Urinary Retention

872

(2)

PC: Renal Insufficiency

874

(3)

PC: Renal Calculi

877

(2)

Potential Complication: Neurologic/Sensory

879

(10)

PC: Increased Intracranial Pressure

880

(2)

PC: Seizures

882

(2)

PC: Increased Intraocular Pressure

884

(1)

PC: Neuroleptic Malignant Syndrome

885

(2)

PC: Alcohol Withdrawal

887

(2)

Potential Complication: Gastrointestinal/Hepatic/Biliary

889

(8)

PC: Paralytic Ileus

890

(1)

PC: GI Bleeding

891

(1)

PC: Hepatic Dysfunction

892

(3)

PC: Hyperbilirubinemia

895

(2)

Potential Complication: Muscular/Skeletal

897

(4)

PC: Pathologic Fractures

898

(1)

PC: Joint Dislocation

899

(2)

Potential Complication: Reproductive

901

(9)

PC: Prenatal Bleeding

902

(1)

PC: Preterm Labor

903

(2)

PC: Pregnancy-Associated Hypertension

905

(1)

PC: Fetal Distress

906

(2)

PC: Postpartum Hemorrhage

908

(2)

Potential Complication: Medication Therapy Adverse Effects

910

(23)

PC: Anticoagulant Therapy Adverse Effects

911

(2)

PC: Antianxiety Therapy Adverse Effects

913

(2)

PC: Adrenocorticosteroid Therapy Adverse Effects

915

(2)

PC: Antineoplastic Therapy Adverse Effects

917

(2)

PC: Anticonvulsant Therapy Adverse Effects

919

(2)

PC: Antidepressant Therapy Adverse Effects

921

(2)

PC: Antiarrhythmic Therapy Adverse Effects

923

(1)

PC: Antipsychotic Therapy Adverse Effects

924

(3)

PC: Antihypertensive Therapy Adverse Effects

927

(1)

PC: β-Adrenergic Blocker Therapy Adverse Effects

927

(2)

PC: Calcium Channel Blocker Therapy Adverse Effects

929

(2)

PC: Angiotensin-Converting Enzyme Inhibitor Therapy Adverse Effects

931

(2)

Appendix A: Nursing Diagnoses Grouped Under Functional Health Patterns

933

(4)

Appendix B: Health-Promotion/Wellness Diagnoses

937

(4)

Bibliography

941

(28)

Index

969

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Nursing Diagnosis Application to Clinical Practice

Summary

Table of Contents

Supplemental Materials