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Nursing Diagnosis : Application to Clinical Practice

ISBN: 9780781761314 | 078176131X
Format: Trade Paper
Publisher: LIPPINCOTT WILLIAMS & WILKINS
Pub. Date: 7/11/2005

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SummaryTable of Contents
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 Classificati... MORE
SECTION ONE Nursing Diagnosis in the Nursing Process
1(76)
Introduction
3(1)
... MORE
Development of Nursing Diagnosis
4(4)
Nursing Diagnosis: Defined
4(1)
Nursing Diagnosis: Process or Outcome?
5(1)
The North American Nursing Diagnosis Association International
5(1)
Nanda Taxonomy
6(1)
Summary
7(1)
Types and Components of Nursing Diagnoses
8(9)
Actual Nursing Diagnosis
8(2)
Risk and High-Risk Nursing Diagnoses
10(1)
Possible Nursing Diagnoses
11(1)
Wellness Nursing Diagnoses
12(1)
Syndrome Nursing Diagnoses
13(1)
Non-Nanda-Approved Diagnoses
14(1)
Diagnostic Statements
14(2)
Summary
16(1)
Nursing Diagnosis: What It Is, What It Is Not
17(9)
Understanding Collaborative Problems
19(1)
Collaborative Problem Diagnostic Statements
20(1)
Differentiating Nursing Diagnoses From Collaborative Problems
20(4)
Summary
24(2)
Nursing Diagnoses: Assessment and Diagnosis
26(12)
Assessment
26(10)
Diagnosis
36(1)
Summary
37(1)
Planning Care With Nursing Diagnosis
38(26)
Are Care Plans Necessary?
38(1)
The Care Planning Process
38(1)
Planning
38(9)
Implementation
47(1)
Evaluation
47(2)
Multidisciplinary Care Planning
49(1)
Care Planning Systems
50(8)
Case Study Applications of Care Planning
58(6)
Ten Steps to Putting It All Together
64(4)
Step 1: Assessment
64(1)
Step 2: Same-Day Assessment
65(1)
Step 3: Create Your Initial Care Plan
65(1)
Step 4: Review the Collaborative Problems on the Generic Plan
65(1)
Step 5: Review the Nursing Diagnoses on the Standard Plan
65(1)
Step 6: Prepare the Care Plan (Written or Printed)
66(1)
Step 7: Initial Care Plan Completed
66(1)
Step 8: Additional Risk Factors
67(1)
Step 9: Evaluate the Status of Your Client (After You Provide Care)
67(1)
Step 10: Document the Care on the Agency's Forms, Flow Records, and Progress Notes
67(1)
Nursing Diagnoses: Issues and Controversies
68(9)
Why Can't We Just Use the Words We've Always Used?
68(1)
Other Disciplines Will Not Understand Our Diagnoses
69(1)
Clients Will Not Understand Our Diagnoses
70(1)
Nurse Practitioners, Nurse Anesthetists, and Nurse Midwives Do Not Need Nursing Diagnoses
71(1)
Nursing Diagnoses Are Not Culturally Sensitive
72(1)
Nursing Diagnosis Is Unethical
73(1)
Nursing Diagnoses Can Violate Confidentiality
73(2)
Summary
75(2)
SECTION TWO Manual of Nursing Diagnoses
77(748)
Introduction
79(1)
Activity Intolerance
80(15)
Related to Insufficient Knowledge of Adaptive Techniques Needed Secondary to COPD
86(3)
Related to Insufficient Knowledge of Adaptive Techniques Needed Secondary to Impaired Cardiac Function
89(3)
Related to Bed Rest Deconditioning
92(3)
Decreased Intracranial Adaptive Capacity
95(1)
Impaired Adjustment
96(1)
Anxiety
97(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 Patterns933(4)
Appendix B: Health-Promotion/Wellness Diagnoses937(4)
Bibliography941(28)
Index969

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