Additional Information
Book Details
Abstract
Practical and comprehensive, this essential resource helps you plan individualized care for clients in a variety of settings, including acute care, extended care, and home care environments. It features 33 detailed nursing diagnosis care plans and 65 disease/disorder care plans that are keyed to specific expected outcomes and interventions. This book also includes the popular Online Care Planner that allows you to edit and print standardized nursing diagnosis care plans.
- Offers the most in-depth care plans of any planning book, fostering critical thinking and promoting effective clinical decision-making.
- 33 separate nursing diagnosis care plans provide detailed interventions with rationales and documentation guidelines for the most common nursing diagnoses.
- 65 comprehensive care plans serve as a complete reference for the most common disorders in acute care, extended care, and home care settings.
- Body system organization makes content easy to locate.
- Nursing/collaborative diagnoses are linked to actions and rationales.
- Specific points for discharge teaching serve as guidelines for planning client education.
- A complete discussion of caring for older adult clients and changes that occur with aging helps you understand the unique considerations of caring for this population group.
- A new care plan format focuses on prioritized nursing interventions, interventions that can be delegated, and documentation criteria, as well as differentiating between independent and collaborative nursing actions.
- Features 8 new nursing diagnosis care plans on topics such as comfort, confusion, contamination, decision-making, falls/injury, unstable glucose level, risk-prone health behavior, and self-care.
- Includes 9 new disease/disorder care plans for Abdominal Trauma, Alzheimer’s Disease, Asthma, Enteral Nutrition, Intravenous Conscious Sedation, Internal Radiation Therapy (Brachytherapy), Mechanical Ventilation, Parkinson’s Disease, and Total Parenteral Nutrition.
- Evidence-based practice content presents the latest research findings and standards of care.
- Updated NANDA nursing diagnoses, NIC interventions, and NOC outcomes reflect the latest nursing taxonomies.
- An open, user-friendly design makes it easy to quickly locate essential information.
- The companion Evolve website features 71 new narrated 3D pathophysiology animations that correspond to disorders content in the text.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front cover | Cover | ||
| ifc | ifc | ||
| Title page | iii | ||
| Copyright page | iv | ||
| Dedication | v | ||
| About the Authors | vi | ||
| Reviewers | vii | ||
| Preface | ix | ||
| Table of contents | xii | ||
| Chapter 1: Prioritization, Delegation, and Critical Thinking in Client Management | 1 | ||
| PRIORITIZATION | 1 | ||
| DELEGATION | 1 | ||
| CRITICAL THINKING | 2 | ||
| Chapter 2: Selected Nursing Diagnoses, Interventions, Rationales, and Documentation | 9 | ||
| ACTIVITY INTOLERANCE | 9 | ||
| AIRWAY CLEARANCE, INEFFECTIVE | 11 | ||
| ANXIETY | 12 | ||
| ASPIRATION, RISK FOR | 15 | ||
| BREATHING PATTERN, INEFFECTIVE | 17 | ||
| CARDIAC OUTPUT, DECREASED | 19 | ||
| COMFORT, READINESS FOR ENHANCED | 22 | ||
| CONFUSION, RISK FOR ACUTE | 22 | ||
| CONSTIPATION | 24 | ||
| CONTAMINATION/CONTAMINATION, RISK FOR | 27 | ||
| COPING, INEFFECTIVE | 29 | ||
| DECISION-MAKING, READINESS FOR ENHANCED | 29 | ||
| DIARRHEA | 29 | ||
| FALLS, RISK FOR/INJURY, RISK FOR | 31 | ||
| FLUID VOLUME, DEFICIENT | 33 | ||
| FLUID VOLUME, EXCESS | 34 | ||
| GAS EXCHANGE, IMPAIRED | 36 | ||
| GLUCOSE LEVEL, BLOOD, RISK FOR UNSTABLE | 38 | ||
| GRIEVING | 40 | ||
| HEALTH BEHAVIORS, RISK PRONE | 42 | ||
| INFECTION, RISK FOR | 42 | ||
| MOBILITY, PHYSICAL, IMPAIRED | 45 | ||
| NUTRITION: LESS THAN BODY REQUIREMENTS, IMBALANCED | 47 | ||
| ORAL MUCOUS MEMBRANE, IMPAIRED | 50 | ||
| PAIN, ACUTE | 52 | ||
| SELF-CARE, READINESS FOR ENHANCED | 54 | ||
| SELF-CONCEPT, DISTURBED | 55 | ||
| SKIN INTEGRITY, IMPAIRED, RISK FOR | 55 | ||
| SLEEP PATTERN, DISTURBED | 57 | ||
| SWALLOWING, IMPAIRED | 59 | ||
| TISSUE PERFUSION, INEFFECTIVE | 62 | ||
| URINARY ELIMINATION, IMPAIRED | 64 | ||
| URINARY RETENTION | 66 | ||
| Chapter 3: Nursing Care of the ClientHaving Surgery | 69 | ||
| OUTCOME/DISCHARGE CRITERIA | 69 | ||
| ACTUAL/RISK FOR IMPAIRED RESPIRATORY FUNCTION | 69 | ||
| ADDITIONAL CARE PLANS | 74 | ||
| PREOPERATIVE GOALS | 75 | ||
| FEAR NDx/ANXIETY NDx | 75 | ||
| CLIENT TEACHING | 80 | ||
| DEFICIENT KNOWLEDGE NDx | 80 | ||
| OUTCOME/DISCHARGE CRITERIA | 82 | ||
| INEFFECTIVE TISSUE PERFUSION NDx (RENAL, CEREBRAL, CARDIOPULMONARY, GASTROINTESTINAL, PERIPHERAL) | 82 | ||
| ADDITIONAL CARE PLANS | 115 | ||
| Chapter 4: The Client with Alterations in Respiratory Function | 116 | ||
| OUTCOME/DISCHARGE CRITERIA | 116 | ||
| IMPAIRED RESPIRATORY FUNCTION | 116 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 120 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE HEALTH MAINTENANCE; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 120 | ||
| ADDITIONAL NURSING DIAGNOSES | 123 | ||
| OUTCOME/DISCHARGE CRITERIA | 123 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 138 | ||
| DEFICIENT KNOWLEDGE OR INEFFECTIVE HEALTH MAINTENANCE | 138 | ||
| ADDITIONAL NURSING DIAGNOSES | 144 | ||
| OUTCOME/DISCHARGE CRITERIA | 144 | ||
| ADDITIONAL NURSING DIAGNOSES | 155 | ||
| OUTCOME/DISCHARGE CRITERIA | 155 | ||
| DISCHARGE TEACHING: CONTINUED CARE | 168 | ||
| DEFICIENT KNOWLEDGE, INEFFECTIVE HEALTH MAINTENANCE, OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 168 | ||
| ADDITIONAL NURSING DIAGNOSES | 170 | ||
| OUTCOME/DISCHARGE CRITERIA | 170 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 179 | ||
| DEFICIENT KNOWLEDGE, INEFFECTIVE HEALTHMAINTENANCE, OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 179 | ||
| ADDITIONAL NURSING DIAGNOSES | 181 | ||
| OUTCOME/DISCHARGE CRITERIA | 182 | ||
| INEFFECTIVE BREATHING PATTERN | 182 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 193 | ||
| DEFICIENT KNOWLEDGE, INEFFECTIVE HEALTHMAINTENANCE, OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 193 | ||
| OUTCOME/DISCHARGE CRITERIA | 197 | ||
| FEAR AND ANXIETY | 197 | ||
| OUTCOME/DISCHARGE CRITERIA | 211 | ||
| IMPAIRED RESPIRATORY FUNCTION | 211 | ||
| IMBALANCED NUTRITION: LESS THAN BODYREQUI REMENTS | 213 | ||
| ACTIVITY INTOLERANCE | 215 | ||
| RISK FOR INFECTION: EXTRAPULMONARY (E.G., PERICARDIAL, LARYNGEAL, SKELETAL, JOINT, RENAL, BRAIN, ADRENAL, LYMPHATIC) AND/OR SUPERINFECTION (E.G., CANDIDIASIS) | 217 | ||
| RISK FOR PLEURAL EFFUSION | 219 | ||
| RISK FOR PNEUMOTHORAX | 220 | ||
| RISK FOR ATELECTASIS | 221 | ||
| DEFICIENT KNOWLEDGE, INEFFECTIVE HEALTH MAINTENANCE, OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 222 | ||
| ADDITIONAL NURSING DIAGNOSES | 225 | ||
| Chapter 5: The Client with Alterations inCardiovascular Function | 226 | ||
| OUTCOME DISCHARGE CRITERIA | 226 | ||
| PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN | 226 | ||
| RISK FOR IMBALANCED FLUID AND RISK FOR ELECTROLYTE IMBALANCE | 227 | ||
| RISK FOR HYPOVOLEMIC SHOCK | 229 | ||
| RISK FOR LOWER EXTREMITY ARTERIAL EMBOLIZATION | 231 | ||
| RISK FOR CARDIAC DYSRHYTHMIAS | 231 | ||
| RISK FOR ISCHEMIC COLITIS | 233 | ||
| IMPAIRED RENAL FUNCTION | 234 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE HEALTH MAINTENANCE; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 235 | ||
| ADDITIONAL NURSING DIAGNOSIS | 237 | ||
| RELATED CARE PLANS | 237 | ||
| OUTCOME DISCHARGE CRITERIA | 237 | ||
| ACTUAL/RISK FOR DECREASED CARDIAC OUTPUT | 237 | ||
| ACUTE PAIN (RADIATING OR NONRADIATING CHEST PAIN/DISCOMFORT) | 239 | ||
| RISK FOR CARDIAC DYSRHYTHMIAS | 240 | ||
| RISK FOR MYOCARDIAL INFARCTION | 241 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 243 | ||
| ADDITIONAL NURSING DIAGNOSES | 246 | ||
| OUTCOME DISCHARGE CRITERIA | 247 | ||
| RISK FOR DECREASED CARDIAC OUTPUT | 247 | ||
| RISK FOR ACTIVITY INTOLERANCE | 249 | ||
| RISK FOR FALLS | 251 | ||
| RISK FOR SYSTEMIC ARTERIAL EMBOLISM | 252 | ||
| RISK FOR HEART FAILURE | 253 | ||
| RISK FOR SUDDEN CARDIAC DEATH | 254 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 255 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE HEALTH MAINTENANCE; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 255 | ||
| OUTCOME/DISCHARGE CRITERIA | 258 | ||
| NURSING/COLLABORATIVE DIAGNOSIS: PREOPERATIVE | 258 | ||
| RISK FOR INEFFECTIVE CEREBRAL TISSUE PERFUSION | 259 | ||
| RISK FOR CEREBRAL ISCHEMIA | 260 | ||
| RISK FOR RESPIRATORY DISTRESS | 261 | ||
| RISK FOR CRANIAL NERVE DAMAGE (FACIAL, HYPOGLOSSAL, GLOSSOPHARYNGEAL, VAGUS, AND/OR ACCESSORY NERVES) | 262 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 264 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE HEALTH MAINTENANCE; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 264 | ||
| RELATED CARE PLANS | 266 | ||
| OUTCOME DISCHARGE CRITERIA | 267 | ||
| INEFFECTIVE TISSUE PERFUSION: PERIPHERAL | 267 | ||
| ACUTE PAIN (AFFECTED EXTREMITY) | 268 | ||
| RISK FOR IMPAIRED TISSUE INTEGRITY | 270 | ||
| RISK FOR PULMONARY EMBOLISM | 271 | ||
| RISK FOR BLEEDING | 272 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 274 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE HEALTH MAINTENANCE; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 274 | ||
| OUTCOME/DISCHARGE CRITERIA | 276 | ||
| PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN | 277 | ||
| INEFFECTIVE TISSUE PERFUSION: PERIPHERAL | 277 | ||
| ACUTE/CHRONIC PAIN (INTERMITTENT CLAUDICATION AND REST PAIN) | 278 | ||
| POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED POSTOPERATIVE CARE PLAN | 280 | ||
| INEFFECTIVE TISSUE PERFUSION: PERIPHERAL | 280 | ||
| RISK FOR GRAFT OCCLUSION | 281 | ||
| RISK FOR COMPARTMENT SYNDROME | 282 | ||
| RISK FOR SAPHENOUS NERVE DAMAGE | 283 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 284 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 284 | ||
| RELATED CARE PLANS | 286 | ||
| OUTCOME/DISCHARGE CRITERIA | 287 | ||
| USE IN CONJUNCTION WITH THE CARE PLAN ON IMMOBILITY | 287 | ||
| IMPAIRED RESPIRATORY FUNCTION | 289 | ||
| RISK FOR IMBALANCED FLUID AND RISK FOR ELECTROLYTE IMBALANCE | 291 | ||
| RISK FOR RENAL INSUFFICIENCY | 294 | ||
| RISK FOR CARDIAC DYSRHYTHMIAS | 295 | ||
| RISK FOR ACUTE PULMONARY EDEMA | 296 | ||
| RISK FOR THROMBOEMBOLISM | 297 | ||
| RISK FOR CARDIOGENIC SHOCK | 298 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 299 | ||
| ADDITIONAL NURSING DIAGNOSES | 302 | ||
| OUTCOME/DISCHARGE CRITERIA | 304 | ||
| PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN | 304 | ||
| FEAR/ANXIETY | 304 | ||
| POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED POSTOPERATIVE CARE PLAN | 304 | ||
| DECREASED CARDIAC OUTPUT | 304 | ||
| RISK FOR IMPAIRED RESPIRATORY FUNCTION | 307 | ||
| RISK FOR IMBALANCED FLUID AND RISK FOR ELECTROLYTE IMBALANCE | 309 | ||
| RISK FOR INFECTION | 311 | ||
| RISK FOR MYOCARDIAL INFARCTION | 312 | ||
| RISK FOR CARDIAC DYSRHYTHMIAS | 313 | ||
| RISK FOR HEART FAILURE | 314 | ||
| RISK FOR CARDIAC TAMPONADE | 315 | ||
| RISK FOR BLEEDING | 316 | ||
| RISK FOR THROMBOEMBOLISM | 317 | ||
| RISK FOR NEUROLOGICAL DYSFUNCTION | 318 | ||
| RISK FOR IMPAIRED RENAL FUNCTION | 320 | ||
| RISK FOR PNEUMOTHORAX | 320 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 322 | ||
| ADDITIONAL NURSING DIAGNOSES | 325 | ||
| RELATED CARE PLANS | 325 | ||
| OUTCOME/DISCHARGE CRITERIA | 326 | ||
| INEFFECTIVE TISSUE PERFUSION | 326 | ||
| ACUTE PAIN (HEADACHE) | 328 | ||
| RISK FOR CEREBROVASCULAR ACCIDENT/HYPERTENSIVE ENCEPHALOPATHY | 329 | ||
| RISK FOR ANGINA AND/OR MYOCARDIAL INFARCTION | 330 | ||
| RISK FOR IMPAIRED RENAL FUNCTION | 331 | ||
| RISK FOR HEART FAILURE | 332 | ||
| RISK FOR AORTIC DISSECTION | 333 | ||
| INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT | 334 | ||
| DEFICIENT KNOWLEDGE OR INEFFECTIVE HEALTH MAINTENANCE | 336 | ||
| RELATED NURSING DIAGNOSES | 338 | ||
| OUTCOME/DISCHARGE CRITERIA | 339 | ||
| PREOPERATIVE | 339 | ||
| RISK FOR/ACTUAL DECREASED CARDIAC OUTPUT | 339 | ||
| RISK FOR PACEMAKER/IMPLANTABLE CARDIOVERTER DEFIBRILLATOR(ICD) MALFUNCTION | 341 | ||
| RISK FOR CARDIAC TAMPONADE | 343 | ||
| RISK FOR PNEUMOTHORAX | 343 | ||
| RISK FOR UNDESIRED STIMULATION OF THE HEART AND/OR CERTAIN NERVES AND MUSCLES | 344 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 345 | ||
| DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 345 | ||
| ADDITIONAL NURSING DIAGNOSES | 348 | ||
| RELATED CARE PLANS | 348 | ||
| OUTCOME/DISCHARGE CRITERIA | 349 | ||
| RISK FOR DECREASED CARDIAC OUTPUT | 349 | ||
| ACUTE PAIN (CHEST PAIN/DISCOMFORT THAT MAY RADIATE TO ARM, NECK, JAW, OR BACK) | 351 | ||
| RISK FOR ACTIVITY INTOLERANCE | 352 | ||
| RISK FOR CARDIAC DYSRHYTHMIAS | 354 | ||
| RISK FOR HEART FAILURE | 355 | ||
| RISK FOR THROMBOEMBOLISM | 356 | ||
| RISK FOR RUPTURE OF A PORTION OF THE HEART (E.G., VENTRICULAR FREE WALL, INTERVENTRICULAR SEPTUM, PAPILLARY MUSCLE) | 357 | ||
| RISK FOR PERICARDITIS | 358 | ||
| RISK FOR INFARCTION EXTENSION OR RECURRENCE | 359 | ||
| RISK FOR CARDIOGENIC SHOCK | 360 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 361 | ||
| DEFICIENT KNOWLEDGE OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 361 | ||
| ADDITIONAL NURSING DIAGNOSES | 365 | ||
| Chapter 6: The Client with Alterations in Neurological Function | 366 | ||
| OUTCOME/DISCHARGE CRITERIA | 367 | ||
| RISK FOR VIOLENCE: SELF-DIRECTED OR OTHER-DIRECTED | 367 | ||
| SELF-CARE DEFICIT: DRESSING, BATHING, FEEDING, AND TOILETING | 369 | ||
| CHRONIC CONFUSION | 370 | ||
| IMPAIRED HOME MAINTENANCE | 371 | ||
| RISK FOR CAREGIVER ROLE STRAIN | 372 | ||
| ADDITIONAL NURSING DIAGNOSES | 373 | ||
| OUTCOME/DISCHARGE CRITERIA | 374 | ||
| DECREASED INTRACRANIAL ADAPTIVE CAPACITY RELATED TO TRAUMA/NEUROLOGICAL ILLNESS | 374 | ||
| RISK FOR INEFFECTIVE AIRWAY CLEARANCE | 375 | ||
| RISK FOR ASPIRATION | 376 | ||
| INEFFECTIVE TISSUE PERFUSION: CEREBRAL | 378 | ||
| DISTURBED SENSORY PERCEPTION (AUDITORY, KINESTHETIC, VISUAL, TACTILE) | 379 | ||
| UNILATERAL NEGLECT | 380 | ||
| IMPAIRED VERBAL COMMUNICATION | 381 | ||
| SELF-CARE DEFICIT (BATHING, FEEDING, DRESSING, TOILETING) | 382 | ||
| ACUTE AND CHRONIC CONFUSION | 384 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 385 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE HEALTH MAINTENANCE | 385 | ||
| ADDITIONAL NURSING DIAGNOSES | 388 | ||
| OUTCOME/DISCHARGE CRITERIA | 390 | ||
| DECREASED INTRACRANIAL ADAPTIVE CAPACITY | 390 | ||
| ACUTE PAIN (HEADACHE) | 392 | ||
| RISK FOR ACUTE CONFUSION | 394 | ||
| RISK FOR MENINGITIS | 395 | ||
| RISK FOR INCREASED INTRACRANIAL PRESSURE (ICP) | 397 | ||
| RISK FOR SEIZURES | 398 | ||
| RISK FOR CRANIAL NERVE DAMAGE | 399 | ||
| RISK FOR DIABETES INSIPIDUS | 401 | ||
| RISK FOR SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH) | 402 | ||
| RISK FOR GASTROINTESTINAL (GI) BLEEDING | 403 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE HEALTH MAINTENANCE; OR INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT | 404 | ||
| ADDITIONAL NURSING DIAGNOSES | 408 | ||
| OUTCOME/DISCHARGE CRITERIA | 409 | ||
| RISK FOR INEFFECTIVE CEREBRAL TISSUE PERFUSION | 409 | ||
| INEFFECTIVE THERMOREGULATION | 410 | ||
| RISK FOR IMPAIRED TISSUE INTEGRITY | 412 | ||
| SELF-CARE DEFICIT (BATHING, DRESSING, FEEDING, AND TOILETING) | 414 | ||
| RISK FOR INJURY | 415 | ||
| RISK FOR AUTONOMIC DYSREFLEXIA | 416 | ||
| RISK FOR ASCENDING SPINAL CORD INJURY | 418 | ||
| RISK FOR PARALYTIC ILEUS | 420 | ||
| RISK FOR DEEP VEIN THROMBUS | 420 | ||
| RISK FOR PULMONARY EMBOLISM | 422 | ||
| RISK FOR GASTROINTESTINAL BLEEDING | 423 | ||
| RISK FOR CONTRACTURES | 424 | ||
| RISK FOR SEXUAL DYSFUNCTION | 425 | ||
| INTERRUPTED FAMILY PROCESSES | 427 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 429 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE HEALTH MAINTENANCE | 429 | ||
| ADDITIONAL NURSING DIAGNOSES | 433 | ||
| OUTCOME/DISCHARGE CRITERIA | 435 | ||
| IMPAIRED PHYSICAL MOBILITY | 436 | ||
| IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS | 437 | ||
| RISK FOR ASPIRATION | 440 | ||
| CONSTIPATION | 441 | ||
| IMPAIRED VERBAL COMMUNICATION | 443 | ||
| DISTURBED SELF-CONCEPT | 444 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE HEALTH MAINTENANCE | 445 | ||
| ADDITIONAL NURSING DIAGNOSES | 448 | ||
| Chapter 7: The Client with Alterations inHematologic and Immune Function | 449 | ||
| OUTCOME/DISCHARGE CRITERIA | 450 | ||
| IMPAIRED RESPIRATORY FUNCTION | 450 | ||
| ACUTE/CHRONIC PAIN | 452 | ||
| IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS | 454 | ||
| RISK FOR IMBALANCED FLUID VOLUME NDx AND RISK FOR ELECTROLYTE IMBALANCE | 456 | ||
| HYPERTHERMIA | 458 | ||
| FATIGUE | 459 | ||
| DISTURBED THOUGHT PROCESSES | 461 | ||
| RISK FOR INFECTION (OPPORTUNISTIC INFECTION OR SEPSIS) | 463 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 466 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE HEALTH MAINTENANCE | 466 | ||
| ADDITIONAL NURSING DIAGNOSES | 471 | ||
| OUTCOME/DISCHARGE CRITERIA | 473 | ||
| IMPAIRED GAS EXCHANGE | 473 | ||
| INEFFECTIVE TISSUE PERFUSION | 475 | ||
| RISK FOR DEFICIENT FLUID VOLUME | 476 | ||
| HYPERTHERMIA | 477 | ||
| RISK FOR INFECTION (SUPERINFECTION) | 478 | ||
| COLLABORATIVE DIAGNOSIS | 480 | ||
| COLLABORATIVE DIAGNOSIS | 481 | ||
| COLLABORATIVE DIAGNOSIS | 482 | ||
| ADDITIONAL NURSING DIAGNOSES | 483 | ||
| OUTCOME/DISCHARGE CRITERIA | 484 | ||
| Chapter 8: The Client with Alterationsin Metabolic Function | 485 | ||
| OUTCOME/DISCHARGE CRITERIA | 485 | ||
| RISK FOR UNSTABLE BLOOD GLUCOSE LEVEL | 486 | ||
| IMPAIRED COMFORT (BURNING, ACHING, CRAMPING, HYPERESTHESIA, NUMBNESS, AND/OR TINGLING [PARTICULARLY IN LOWER EXTREMITIES]) | 487 | ||
| RISK FOR DYSFUNCTIONAL GASTROINTESTINAL MOTILITY | 489 | ||
| DISTURBED SENSORY PERCEPTION (VISUAL) | 490 | ||
| RISK FOR DIABETIC KETOACIDOSIS (DKA) | 492 | ||
| RISK FOR HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC COMA (SYNDROME) | 493 | ||
| INEFFECTIVE FAMILY THERAPEUTIC REGI MENMANAGEMENT | 494 | ||
| DEFICIENT KNOWLEDGE NDx OR INEFFECTIVE SELF HEALTH MANAGEMENT | 496 | ||
| ADDITIONAL CARE PLANS | 503 | ||
| OUTCOME/DISCHARGE CRITERIA | 504 | ||
| RISK FOR DECREASED CARDIAC OUTPUT | 504 | ||
| RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS | 506 | ||
| ACTIVITY INTOLERANCE | 508 | ||
| DISTURBED SLEEP PATTERN | 509 | ||
| PREOPERATIVE—USE IN CONJUNCTION WITH PREOPERATIVE CARE PLAN | 511 | ||
| DEFICIENT KNOWLEDGE | 511 | ||
| POSTOPERATIVE—USE IN CONJUNCTION WITH THE STANDARDIZED POSTOPERATIVE CARE PLAN | 512 | ||
| RISK FOR INEFFECTIVE AIRWAY CLEARANCE | 512 | ||
| RISK FOR HEMORRHAGE | 514 | ||
| RISK FOR RESPIRATORY DISTRESS | 515 | ||
| RISK FOR HYPOCALCEMIA | 516 | ||
| RISK FOR THYROID STORM (THYROTOXIC CRISIS) | 517 | ||
| RISK FOR LARYNGEAL NERVE DAMAGE | 518 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 519 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE SELF-HEALTH MANAGEMENT; OR INEFFECTIVE HEALTH MAINTENANCE | 519 | ||
| OUTCOME/DISCHARGE CRITERIA | 521 | ||
| IMBALANCED NUTRITION: MORE THAN BODY REQUIREMENTS | 521 | ||
| ACTIVITY INTOLERANCE | 522 | ||
| CONSTIPATION | 524 | ||
| RISK FOR MYXEDEMA COMA | 525 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE HEALTH MAINTENANCE; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 526 | ||
| Chapter 9: The Client with Alterations in the Gastrointestinal Tract | 529 | ||
| OUTCOME/DISCHARGE CRITERIA | 529 | ||
| INEFFECTIVE BREATHING PATTERN | 530 | ||
| RISK FOR IMBALANCED FLUID VOLUME; RISK FOR ELECTROLYTE IMBALANCE | 531 | ||
| INEFFECTIVE PERIPHERAL TISSUE PERFUSION | 533 | ||
| ACUTE PAIN | 534 | ||
| RISK FOR PERITONITIS | 535 | ||
| RISK FOR SEPTIC SHOCK | 536 | ||
| RISK FOR ORGAN ISCHEMIA/DYSFUNCTION (MULTIPLE ORGAN DYSFUNCTION SYNDROME [MODS]) | 537 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 539 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE HEALTH MANAGEMENT | 539 | ||
| Chapter 10: Nursing Care of the Client with Disturbances of the Liver, Biliary Tract, and Pancreas | 639 | ||
| OUTCOME/DISCHARGE CRITERIA | 639 | ||
| INEFFECTIVE BREATHING PATTERN | 639 | ||
| RISK FOR ABSCESS FORMATION | 641 | ||
| RISK FOR PERITONITIS | 642 | ||
| RISK FOR CONTINUED OBSTRUCTION OF BILE FLOW | 643 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 644 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 644 | ||
| OUTCOME/DISCHARGE CRITERIA | 647 | ||
| OUTCOME/DISCHARGE CRITERIA | 648 | ||
| INEFFECTIVE BREATHING PATTERN | 648 | ||
| RISK FOR EXCESS FLUID VOLUME AND THIRD-SPACING | 650 | ||
| RISK FOR HYPOKALEMIA | 651 | ||
| RISK FOR HYPONATREMIA | 652 | ||
| IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS | 653 | ||
| IMPAIRED COMFORT (PRURITUS) | 655 | ||
| IMPAIRED COMFORT (DYSPEPSIA) | 656 | ||
| ACTIVITY INTOLERANCE | 657 | ||
| ACUTE AND CHRONIC CONFUSION | 659 | ||
| RISK FOR BLEEDING | 661 | ||
| RISK FOR ASCITES | 663 | ||
| RISK FOR HEPATORENAL SYNDROME | 664 | ||
| RISK FOR BLEEDING ESOPHAGEAL VARICES | 665 | ||
| RISK FOR HEPATIC (PORTAL-SYSTEMIC) ENCEPHALOPATHY (HEPATIC COMA) | 666 | ||
| INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT | 668 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 669 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE SELF-HEALTH MANAGEMENT | 669 | ||
| ADDITIONAL NURSING DIAGNOSES | 673 | ||
| OUTCOME/DISCHARGE CRITERIA | 675 | ||
| RISK FOR DEFICIENT FLUID VOLUME | 675 | ||
| IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS | 676 | ||
| IMPAIRED COMFORT (PRURITUS) | 678 | ||
| NAUSEA | 679 | ||
| RISK FOR BLEEDING | 680 | ||
| RISK FOR PROGRESSIVE LIVER DEGENERATION (E.G., FULMINANT HEPATITIS, CHRONIC ACTIVE HEPATITIS) | 682 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 683 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 683 | ||
| ADDITIONAL NURSING DIAGNOSES | 687 | ||
| OUTCOME/DISCHARGE CRITERIA | 687 | ||
| INEFFECTIVE BREATHING PATTERN | 688 | ||
| IMBALANCED FLUID AND ELECTROLYTES | 689 | ||
| IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS | 692 | ||
| ACUTE PAIN (EPIGASTRIC WITH RADIATION TO THE BACK) | 694 | ||
| NAUSEA | 696 | ||
| IMPAIRED COMFORT (ABDOMINAL DISTENTION AND GAS PAIN) | 697 | ||
| RISK FOR INFECTION (SEPSIS) | 698 | ||
| RISK FOR HYPOVOLEMIC SHOCK | 700 | ||
| RISK FOR PERITONITIS | 701 | ||
| RISK FOR HYPERGLYCEMIA | 702 | ||
| RISK FOR PLEURAL EFFUSION | 703 | ||
| RISK FOR ORGAN ISCHEMIA/DYSFUNCTION (MULTIPLE ORGAN DYSFUNCTION SYNDROME [MODS]) | 704 | ||
| DISCHARGE CARE/CONTINUED CARE | 705 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; or INEFFECTIVE SELF HEALTH MANAGEMENT | 705 | ||
| ADDITIONAL DIAGNOSES | 708 | ||
| Chapter 11: The Client with Alterations in the Kidney and Urinary Tract | 709 | ||
| OUTCOME/DISCHARGE CRITERIA | 709 | ||
| URINARY RETENTION | 709 | ||
| RISK FOR CONSTIPATION | 711 | ||
| RISK FOR BLADDER, URETHRAL, OR URETERAL INJURY | 713 | ||
| RISK FOR URINARY TRACT INFECTION; WOUND INFECTION | 713 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 714 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MAINTENANCE; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 714 | ||
| OUTCOME/DISCHARGE CRITERIA | 717 | ||
| OUTCOME/DISCHARGE CRITERIA | 718 | ||
| INEFFECTIVE BREATHING PATTERN | 718 | ||
| RISK FOR HYPOVOLEMIC SHOCK | 720 | ||
| RISK FOR PARALYTIC ILEUS | 721 | ||
| RISK FOR PNEUMOTHORAX | 722 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 724 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE HEALTH MAINTENANCE | 724 | ||
| OUTCOME/DISCHARGE CRITERIA | 727 | ||
| RISK FOR EXCESS FLUID VOLUME | 727 | ||
| RISK FOR SODIUM IMBALANCE | 729 | ||
| RISK FOR HYPERKALEMIA | 730 | ||
| RISK FOR HYPOCALCEMIA | 731 | ||
| HYPERPHOSPHATEMIA | 732 | ||
| RISK FOR HYPERMAGNESEMIA | 733 | ||
| RISK FOR METABOLIC ACIDOSIS | 734 | ||
| IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS | 735 | ||
| RISK FOR UREMIA SYNDROME | 736 | ||
| RISK FOR HYPERTENSION | 738 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 739 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 739 | ||
| ADDITIONAL NURSING DIAGNOSES | 744 | ||
| Chapter 12: The Client with Alterations in Musculoskeletal Function | 745 | ||
| OUTCOME/DISCHARGE CRITERIA | 745 | ||
| OUTCOME/DISCHARGE CRITERIA | 746 | ||
| Chapter 13: The Client with Alterations in the Breast and Reproductive System | 788 | ||
| OUTCOME/DISCHARGE CRITERIA | 788 | ||
| PREOPERATIVE: REFER TO THE STANDARDIZED PREOPERATIVE CARE PLAN | 789 | ||
| POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED POSTOPERATIVE CARE PLAN | 789 | ||
| URINARY RETENTION | 789 | ||
| RISK FOR CONSTIPATION | 790 | ||
| RISK FOR INFECTION | 791 | ||
| RISK FOR REHERNIATION OF THE BLADDER OR RECTUM | 793 | ||
| RISK FOR BLADDER, URETHRAL, OR URETERAL INJURY | 793 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 794 | ||
| DEFICIENT KNOWLEDGE, INEFFECTIVE FAMILY THERAPEUTIC REGIMEN, OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 794 | ||
| ADDITIONAL CARE PLANS | 796 | ||
| OUTCOME/DISCHARGE CRITERIA | 796 | ||
| PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN | 797 | ||
| RELATED PREOPERATIVEN URSING DIAGNOSES | 797 | ||
| POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED POSTOPERATIVE CARE PLAN | 797 | ||
| URINARY RETENTION | 797 | ||
| RISK FOR BLADDER OR URETERAL INJURY | 798 | ||
| RISK FOR THROMBOEMBOLISM | 799 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 800 | ||
| DEFICIENT KNOWLEDGE, INEFFECTIVE FAMILY THERAPEUTIC REGIMEN OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 800 | ||
| ADDITIONAL CARE PLANS | 802 | ||
| OUTCOME/DISCHARGE CRITERIA | 803 | ||
| PREOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED PREOPERATIVE CARE PLAN | 803 | ||
| RELATED PREOPERATIVE NURSING DIAGNOSES | 803 | ||
| DEFICIENT KNOWLEDGE | 804 | ||
| POSTOPERATIVE: USE IN CONJUNCTION WITH THE STANDARDIZED POSTOPERATIVE CARE PLAN | 805 | ||
| ACUTE PAIN (CHEST AND ARM ON OPERATIVE SIDE) | 805 | ||
| RISK FOR LYMPHEDEMA OF ARM ON OPERATIVE SIDE | 806 | ||
| RISK FOR MOTOR AND SENSORY IMPAIRMENT OF THE ARM AND/OR SHOULDER ON THE OPERATIVE SIDE | 807 | ||
| RISK FOR SEROMA FORMATION | 808 | ||
| RISK FOR HEMATOMA FORMATION | 809 | ||
| RISK FOR NECROSIS OF SKIN FLAP | 809 | ||
| DISTURBED SELF-CONCEPT | 810 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 812 | ||
| DEFICIENT KNOWLEDGE, INEFFECTIVE FAMILY THERAPEUTIC REGIMEN, OR INEFFECTIVE SELF-HEALTH MANAGEMENT | 812 | ||
| ADDITIONAL CARE PLANS | 816 | ||
| OUTCOME/DISCHARGE CRITERIA | 816 | ||
| Chapter 14: The Client Receiving Treatment for Neoplastic Disorders | 829 | ||
| OUTCOME/DISCHARGE CRITERIA | 829 | ||
| IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS | 830 | ||
| ACUTE/CHRONIC PAIN | 832 | ||
| IMPAIRED ORAL MUCOUS MEMBRANE | 834 | ||
| RISK FOR BLEEDING | 836 | ||
| RISK FOR IMPAIRED RENAL FUNCTION | 837 | ||
| RISK FOR HEMORRHAGIC CYSTITIS | 838 | ||
| RISK FOR DRUG EXTRAVASATION | 839 | ||
| RISK FOR CARDIAC DYSRHYTHMIAS | 841 | ||
| RISK FOR INFLAMMATION AND FIBROSIS OF LUNG TISSUE | 842 | ||
| RISK FOR NEUROTOXICITY | 843 | ||
| RISK FOR ANAPHYLAXIS | 844 | ||
| RISK FOR DISTURBED SELF-CONCEPT | 845 | ||
| DISCHARGE TEACHING/CONTINUED CARE | 848 | ||
| DEFICIENT KNOWLEDGE; INEFFECTIVE THERAPEUTIC REGIMEN MANAGEMENT; OR INEFFECTIVE HEALTH MAINTENANCE | 848 | ||
| ADDITIONAL NURSING DIAGNOSES | 856 | ||
| OUTCOME/DISCHARGE CRITERIA | 857 | ||
| OUTCOME/DISCHARGE CRITERIA | 858 | ||
| Chapter 15: Nursing Care of the Elderly Client | 859 | ||
| INEFFECTIVE TISSUE PERFUSION | 859 | ||
| IMPAIRED RESPIRATORY FUNCTION | 862 | ||
| RISK FOR DEFICIENT FLUID VOLUME | 864 | ||
| IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS | 865 | ||
| IMPAIRED COMFORT (DYSPEPSIA, GASTRIC FULLNESS, AND/OR GAS PAIN) | 867 | ||
| DISTURBED SENSORY PERCEPTION | 869 | ||
| RISK FOR IMPAIRED SKIN INTEGRITY | 871 | ||
| IMPAIRED ORAL MUCOUS MEMBRANE | 873 | ||
| RISK FOR ACTIVITY INTOLERANCE | 874 | ||
| IMPAIRED PHYSICAL MOBILITY | 876 | ||
| SELF-CARE DEFICIT (BATHING, DRESSING, FEEDING, AND/OR TOILETING) | 877 | ||
| IMPAIRED URINARY ELIMINATION | 878 | ||
| RISK FOR CONSTIPATION | 881 | ||
| DISTURBED SLEEP PATTERN | 882 | ||
| RISK FOR INFECTION | 884 | ||
| RISK FOR FALLS | 887 | ||
| RISK FOR ASPIRATION | 888 | ||
| RISK FOR INJURY (BURNS) | 889 | ||
| RISK FOR INJURY (PATHOLOGICAL FRACTURES) | 890 | ||
| DRUG TOXICITY | 891 | ||
| INEFFECTIVE SEXUALITY PATTERN | 893 | ||
| RISK FOR LONELINESS | 895 | ||
| INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT | 896 | ||
| INTERRUPTED FAMILY PROCESSES | 898 | ||
| ADDITIONAL NURSING DIAGNOSES | 900 | ||
| Chapter 16: End-of-Life Nursing Care | 901 | ||
| IMPAIRED RESPIRATORY FUNCTION | 901 | ||
| RISK FOR ASPIRATION | 903 | ||
| ACUTE/CHRONIC PAIN | 905 | ||
| NAUSEA | 906 | ||
| IMPAIRED COMFORT (ABDOMINAL DISTENTION AND GAS PAIN) | 908 | ||
| RISK FOR IMPAIRED TISSUE INTEGRITY | 909 | ||
| IMPAIRED ORAL MUCOUS MEMBRANE (DRYNESS AND IRRITATION) | 910 | ||
| FUNCTIONAL URINARY INCONTINENCE | 912 | ||
| RISK FOR CONSTIPATION | 913 | ||
| BOWEL INCONTINENCE | 914 | ||
| DISTURBED THOUGHT PROCESSES | 915 | ||
| DEATH ANXIETY | 916 | ||
| GRIEVING | 917 | ||
| RISK FOR SPIRITUAL DISTRESS | 919 | ||
| HOPELESSNESS | 920 | ||
| INTERRUPTED FAMILY PROCESSES | 921 | ||
| ADDITIONAL NURSING DIAGNOSES | 923 | ||
| Bibliography | 925 | ||
| GENERAL BIBLIOGRAPHY | 925 | ||
| CHAPTER-BY-CHAPTER BIBLIOGRAPHY | 925 | ||
| Index | 935 |