Contents
NANDA-I Diagnoses
Activity intolerance, 122
Risk for Activity intolerance, 127
Ineffective Activity planning, 127
Risk for Ineffective Activity planning, 130
Ineffective Airway clearance, 130
Risk for Allergy response, 136
Anxiety, 139
Death Anxiety, 144
Risk for Aspiration, 147
Risk for impaired Attachment, 152
Autonomic Dysreflexia, 158
Risk for Autonomic Dysreflexia, 161
Risk for Bleeding, 162
Disturbed Body Image, 167
Insufficient Breast Milk, 171
Ineffective Breastfeeding, 174
Interrupted Breastfeeding, 176
Readiness for enhanced Breastfeeding, 179
Ineffective Breathing pattern, 181
Decreased Cardiac output, 187
Risk for decreased Cardiac output, 194
Risk for decreased Cardiac tissue perfusion, 195
Risk for impaired Cardiovascular function, 200
Caregiver Role Strain, 200
Risk for Caregiver Role Strain, 206
Risk for ineffective Cerebral tissue perfusion, 207
Ineffective Childbearing process, 209
Readiness for enhanced Childbearing process, 213
Risk for ineffective Childbearing process, 218
Impaired Comfort, 219
Readiness for enhanced Comfort, 222
Readiness for enhanced Communication, 228
Impaired verbal Communication, 230
Acute Confusion, 236
Chronic Confusion, 243
Risk for acute Confusion, 251
Constipation, 251
Chronic functional Constipation, 259
Perceived Constipation, 263
Risk for Constipation, 266
Risk for chronic functional Constipation, 267
Contamination, 267
Risk for Contamination, 272
Risk for adverse reaction to iodinated Contrast Media, 272
Compromised family Coping, 275
Defensive Coping, 280
Ineffective community Coping, 284
Ineffective Coping, 287
Disabled family Coping, 294
Readiness for enhanced Coping, 297
Readiness for enhanced community Coping, 302
Readiness for enhanced family Coping, 303
Readiness for enhanced Decision-Making, 306
Impaired emancipated Decision-Making, 309
Readiness for enhanced emancipated DecisionMaking, 312
Risk for impaired emancipated Decision-Making, 315
Decisional Conflict, 317
Ineffective Denial, 321
Impaired Dentition, 324
Risk for delayed Development, 329
Diarrhea, 332
Risk for Disuse syndrome, 338
Deficient Diversional activity, 343
Risk for Electrolyte imbalance, 348
Labile Emotional Control, 350
Risk for dry Eye, 353
Risk for Falls, 355
Dysfunctional Family processes, 361
Interrupted Family processes, 366
Readiness for enhanced Family processes, 369
Fatigue, 372
Fear, 378
Ineffective infant Feeding pattern, 383
Readiness for enhanced Fluid balance, 386
Deficient Fluid volume, 388
Excess Fluid volume, 393
Risk for Deficient Fluid volume, 397
Risk for imbalanced Fluid volume, 397
Frail Elderly syndrome, 401
Risk for Frail Elderly syndrome, 403
Impaired Gas exchange, 404
Dysfunctional Gastrointestinal motility, 408
Risk for dysfunctional Gastrointestinal motility, 412
Risk for ineffective Gastrointestinal perfusion, 412
Risk for unstable blood Glucose level, 414
Grieving, 420
Complicated Grieving, 426
Risk for complicated Grieving, 431
Risk for disproportionate Growth, 431
Deficient community Health, 435
Risk-prone Health behavior, 438
Ineffective Health management, 443
Ineffective Family Health management, 448
Readiness for Enhanced Health management, 451
Ineffective Health maintenance, 455
Impaired Home maintenance, 459
Readiness for enhanced Hope, 463
Hopelessness, 466
Risk for compromised Human Dignity, 471
Hyperthermia, 473
Hypothermia, 478
Risk for Hypothermia, 484
Risk for Perioperative Hypothermia, 485
Disturbed personal Identity, 488
Risk for disturbed personal Identity, 495
Ineffective Impulse control, 495
Bowel Incontinence, 498
Functional urinary Incontinence, 503
Overflow urinary Incontinence, 507
Reflex urinary Incontinence, 507
Risk for urge urinary Incontinence, 511
Stress urinary Incontinence, 512
Urge urinary Incontinence, 517
Disorganized Infant behavior, 522
Readiness for enhanced organized Infant behavior, 527
Risk for disorganized Infant behavior, 527
Risk for Infection, 528
Risk for Injury, 534
Risk for corneal Injury, 540
Risk for urinary tract Injury, 542
Insomnia, 544
Decreased Intracranial adaptive capacity, 547
Neonatal Jaundice, 550
Risk for neonatal Jaundice, 554
Deficient Knowledge, 555
Readiness for enhanced Knowledge, 559
Latex Allergy response, 561
Risk for Latex Allergy response, 566
Risk for impaired Liver function, 568
Risk for Loneliness, 572
Risk for disturbed Maternal–Fetal dyad, 576
Impaired Memory, 579
Impaired bed Mobility, 583
Impaired physical Mobility, 588
Impaired wheelchair Mobility, 595
Impaired Mood regulation, 599
Moral Distress, 601
Nausea, 604
Noncompliance, 609
Readiness for enhanced Nutrition, 609
Imbalanced Nutrition: less than body requirements, 615
Obesity, 621
Impaired Oral Mucous Membrane, 625
Risk for impaired Oral Mucous Membrane, 630
Overweight, 631
Risk for Overweight, 635
Acute Pain, 639
Chronic Pain, 646
Labor Pain, 654
Chronic Pain syndrome, 654
Impaired Parenting, 655
Readiness for enhanced Parenting, 659
Risk for impaired Parenting, 662
Risk for Perioperative Positioning injury, 663
Risk for Peripheral Neurovascular dysfunction, 666
Risk for Poisoning, 668
Post-Trauma syndrome, 675
Risk for Post-Trauma syndrome, 679
Readiness for enhanced Power, 683
Powerlessness, 685
Risk for Powerlessness, 689
Risk for Pressure ulcer, 690
Ineffective Protection, 694
Rape-Trauma syndrome, 698
Ineffective Relationship, 704
Readiness for enhanced Relationship, 704
Risk for ineffective Relationship, 707
Impaired Religiosity, 708
Readiness for enhanced Religiosity, 710
Risk for impaired Religiosity, 711
Relocation stress syndrome, 712
Risk for Relocation stress syndrome, 717
Risk for ineffective Renal perfusion, 717
Impaired Resilience, 721
Readiness for enhanced Resilience, 723
Risk for impaired Resilience, 725
Parental Role conflict, 727
Ineffective Role performance, 730
Sedentary lifestyle, 735
Readiness for enhanced Self-Care, 740
Bathing Self-Care deficit, 747
Dressing Self-Care deficit, 751
Feeding Self-Care deficit, 753
Toileting Self-Care deficit, 757
Readiness for enhanced Self-Concept, 760
Chronic low Self-Esteem, 763
Risk for chronic low Self-Esteem, 767
Risk for situational low Self-Esteem, 767
Situational low Self-Esteem, 770
Self-Mutilation, 772
Risk for Self-Mutilation, 775
Self-Neglect, 780
Sexual dysfunction, 784
Ineffective Sexuality pattern, 790
Risk for Shock, 797
Impaired Sitting, 802
Impaired Skin integrity, 805
Risk for impaired Skin integrity, 808
Readiness for enhanced Sleep, 811
Sleep deprivation, 814
Disturbed Sleep pattern, 817
Impaired Social interaction, 820
Social Isolation, 824
Chronic Sorrow, 829
Spiritual distress, 833
Risk for Spiritual distress, 838
Readiness for enhanced Spiritual well-being, 838
Impaired Standing, 842
Stress overload, 845
Risk for Sudden Infant Death syndrome, 849
Risk for Suffocation, 852
Risk for Suicide, 855
Delayed Surgical recovery, 865
Risk for delayed Surgical recovery, 870
Impaired Swallowing, 870
Risk for imbalanced body Temperature, 875
Risk for Thermal injury, 875
Ineffective Thermoregulation, 877
Impaired Tissue integrity, 882
Risk for impaired Tissue integrity, 886
Ineffective peripheral Tissue Perfusion, 886
Risk for ineffective peripheral Tissue Perfusion, 891
Impaired Transfer ability, 891
Risk for Trauma, 895
Unilateral Neglect, 900
Impaired Urinary elimination, 902
Readiness for enhanced Urinary elimination, 905
Urinary Retention, 907
Risk for Vascular Trauma, 912
Impaired spontaneous Ventilation, 916
Dysfunctional Ventilatory weaning response, 922
Risk for other-directed Violence, 927
Risk for self-directed Violence, 939
Impaired Walking, 939
SECTION I Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing, 1
An explanation of how to make a nursing diagnosis using diagnostic reasoning, which is critical thinking. Then information on how to plan care using the nursing process, standardized nursing language, and evidence-based nursing.
SECTION II Guide to Nursing Diagnosis, 17
An alphabetized list of medical, surgical, and psychiatric diagnoses; diagnostic procedures, clinical states,
symptoms, and problems, with suggested nursing diagnoses. This section enables the nursing student as well as the practicing nurse to make a nursing diagnosis quickly, to save time.
SECTION III Guide to Planning Care,
121
Section III contains the actual nursing diagnosis care plans for each accepted nursing diagnosis of the North
American Nursing Diagnosis AssociationInternational (NANDA-I): the definition, defining characteristics, risk factors, related factors, suggested NOC outcomes, client outcomes, suggested NIC interventions, interventions with rationales, geriatric interventions, pediatric interventions, critical care interventions (when
appropriate), home care interventions, culturally competent nursing interventions (when appropriate), and client/family teaching and discharge planning for each alphabetized nursing diagnosis.
APPENDIX A Nursing Diagnoses Arranged by Maslow’s Hierarchy of Needs, 949
APPENDIX B Nursing Diagnoses Arranged by Gordon’s Functional Health Patterns, 952
APPENDIX C Motivational Interviewing for Nurses, 955
APPENDIX D Wellness-Oriented Diagnostic Categories, 957
APPENDIX E Nursing Care Plans for Hearing Loss and Vision Loss, 960
The Nursing Process: Using Clinical Reasoning Skills toDetermine Nursing
Diagnoses and Plan Care
The primary goals of nursing are to (1) determine client/ family responses to human problems, level of wellness, and need for assistance; (2) provide physical care, emotional care, teaching, guidance, and counseling; and (3) implement interventions aimed at prevention and assisting the client to meet his or her own needs and health-related goals. The nurse must always focus on assisting clients and families to their highest level of functioning and self-care. The care that is provided should be structured in a way that allows clients the ability
to influence their health care and accomplish their selfefficacy goals. The nursing process, which is a problemsolving approach to the identification and treatment of client problems, provides a framework for assisting clients and families to their optimal level of functioning. The nursing process involves five dynamic and fluid phases: assessment, diagnosis, planning, implementation, and evaluation. Within each of these phases, the client and family story is embedded and is used as a foundation for knowledge, judgment, and actions brought to the client care experience. A
description of the “patient’s story” and each aspect of the nursing process follow.
THE “PATIENT’S STORY”
The “patient’s story” is a term used to describe objective and subjective information about the client that describes who the client is as a person in addition to their usual medical history. Specific aspects of the story include physiological, psychological, and family characteristics; available resources; environmental and social context; knowledge; and motivation. Care is influenced, and often driven, by what the client states—verbally or through their physiologic state. The
“patient’s story” is fluid and must be shared and understood throughout the client’s health care experience. There are multiple sources for obtaining the patient’s story. The primary source for eliciting this story is through communicating directly with the client and the client’s family. It is important to understand how the illness (or wellness) state has affected the client physiologically, psychologically, and spiritually. The client’s perception of his or her health state is important to understand and may have an impact on subsequent interventions. At times, clients will be unable to tell their story verbally, but there is still much they can com-
municate through their physical state. The client’s family (as the client defines them) is a valuable source of information and can provide a rich perspective on the client.
Other valuable sources of the “patient’s story” include the client’s health record. Every time a piece of information is added to the health record, it becomes a part of the “patient’s story.” All nursing care is driven by the client’s story. The nurse must have a clear understanding of the story to effectively complete the nursing process. Understanding the full
story also provides an avenue for identifying mutual goals with the client and family aimed at improving client outcomes and goals.
Note: The “patient’s story” is terminology that is used to describe a holistic assessment of information about the client, with the client’s and the family’s input as much as possible. In this text, we use the term “patient’s story” in quotes whenever we refer to the specific process. In all other places, we use the term client in place of the word patient; we think labeling the person as a client is more respectful and empowering for the person. Client is also the term that
is used in the National Council Licensure Examination (NCLEX-RN) test plan (National Council of State Boards of Nursing, 2013). Understanding the “patient’s story” is critically important, in that psychological, socioeconomic, and spiritual characteristics play a significant role in the client’s ability and desire to access health care. Also knowing and understanding the “patient’s story” is an integral first step in giving clientcentered care. In today’s health care world, the focus is on the
client, which leads to increased satisfaction with care. Improving the client’s health care experience is part of the Affordable Care Act and is tied to reimbursement through value-based purchasing of care: “participating hospitals are paid for inpatient acute care services based on the quality of care, not just quantity of services they provide” (Centers for Medicare & Medicaid Services, 2014).
THE NURSING PROCESS
The nursing process is an organizing framework for professional nursing practice, a critical thinking process for the
nurse to use to give the best care possible to the client. It is very similar to the steps used in scientific reasoning and problem solving. This section is designed to help the nursing student learn how to use this thinking process, the nursing process. Key components of the process include the steps listed below. An easy, convenient way to remember the steps of the nursing process is to use an acronym,
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