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Nursing Diagnosis Handbook - E-Book

BOOK

Nursing Diagnosis Handbook - E-Book

Betty J. Ackley | Gail B. Ladwig

(2013)

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Additional Information

Book Details

ISBN
978-0-323-08922-7
Edition
10
Language
English
Pages
912
Subjects
Medical diagnosis
Nursing
Evolution

Abstract

The 10th edition of the Nursing Diagnosis Handbook makes formulating nursing diagnoses and creating individualized care plans a breeze. Updated with the most recent NANDA-I approved nursing diagnoses, this convenient reference shows you how to build customized care plans in three easy steps: assess, diagnose, plan. Authors Elizabeth Ackley and Gail Ladwig use Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC) to guide you in creating care plans that include desired outcomes, interventions, patient teaching, and evidence-based rationales.

  • Unique! Care Plan Constructor on the companion Evolve website offers hands-on practice creating customized plans of care.
  • Alphabetical thumb tabs allow quick access to specific symptoms and nursing diagnoses.
  • Suggested NIC interventions and NOC outcomes in each care plan.
  • Recent and classic research examples promote evidence-based interventions and rationales.
    • NEW! 4 Color text
    • NEW! Includes updated 2012-2014 NANDA-I approved nursing diagnoses
    • NEW! Provides the latest NIC/NOC, interventions, and rationales for every care plan.
    • NEW! QSEN Safety interventions and rationales
    • NEW! 100 NCLEX exam-style review questions are available on the companion Evolve website.
    • NEW! Root Causing Thinking and Motivational Interviewing appendixes on the companion Evolve website.

    Table of Contents

    Section Title Page Action Price
    Front Cover Cover
    IFC i
    Evolve iii
    Nursing Diagnosis Handbook iv
    Copyright v
    Dedication vi
    About the Authors vii
    Contributors ix
    Reviewers xv
    Preface xvii
    Acknowledgments xix
    How to Use Nursing Diagnosis Handbook:An Evidence-Based Guide to Planning Care xx
    Step 1: ASSESS xx
    Step 2: DIAGNOSE xx
    Step 3: DETERMINE OUTCOMES xx
    PLAN INTERVENTIONS xxi
    GIVE NURSING CARE xxi
    EVALUATE NURSING CARE xxi
    DOCUMENT xxi
    Contents xxii
    Section I -\rNursing Process, Clinical Reasoning, Nursing Diagnosis,and Evidence-Based Nursing 1
    Part A -\rThe Nursing Process: Using Clinical Reasoning Skills to Determine Nursing Diagnoses and Plan Care 2
    The “Patient’s Story” 2
    The Nursing Process 2
    Step 1: Assessment (ADPIE) 3
    Step 2: Nursing Diagnosis (ADPIE) 3
    Step 3: Planning (ADPIE) 7
    Step 4: Implementation (ADPIE) 10
    Step 5: Evaluation (ADPIE) 10
    Part B -\rAdvanced Nursing Process Concepts 11
    References 14
    Section II -\rGuide to Nursing Diagnoses 17
    List of Nursing Assessments by Letter: A e1
    A 18
    Abdominal Distention 18
    Abdominal Hysterectomy 18
    Abdominal Pain 18
    Abdominal Surgery 18
    Abdominal Trauma 18
    Ablation, Radiofrequency Catheter 18
    Abortion, Induced 18
    Abortion, Spontaneous 18
    Abruptio Placentae <36 Weeks 18
    Abscess Formation 19
    Abuse, Child 19
    Abuse, Spouse, Parent, or Significant Other 19
    Accessory Muscle Use (to Breathe) 19
    Accident Prone 19
    Achalasia 19
    Acid-Base Imbalances 19
    Acidosis, Metabolic 19
    Acidosis, Respiratory 19
    Acne 19
    ACS (Acute Coronary Syndrome) 19
    Acquired Immunodeficiency Syndrome 19
    Acromegaly 19
    Activity Intolerance, Potential to Develop 19
    Acute Abdominal Pain 20
    Acute Alcohol Intoxication 20
    Acute Back Pain 20
    Acute Confusion 20
    Acute Coronary Syndrome 20
    Acute Lymphocytic Leukemia (ALL) 20
    Acute Renal Failure 20
    Acute Respiratory Distress Syndrome 20
    Adams-Stokes Syndrome 20
    Addiction 20
    Addison’s Disease 20
    Adenoidectomy 20
    Adhesions, Lysis of 20
    Adjustment Disorder 20
    Adjustment Impairment 20
    Adolescent, Pregnant 20
    Adoption, Giving Child Up for 21
    Adrenocortical Insufficiency 21
    Advance Directives 21
    Affective Disorders 21
    Age-Related Macular Degeneration 21
    Aggressive Behavior 21
    Aging 21
    Agitation 21
    Agoraphobia 22
    Agranulocytosis 22
    AIDS Dementia 22
    AIDS, Child 22
    Airway Obstruction/Secretions 22
    Alcohol Withdrawal 22
    Alcoholism 22
    Alcoholism, Dysfunctional Family Processes 23
    Alkalosis 23
    ALL (Acute Lymphocytic Leukemia) 23
    Allergies 23
    Alopecia 23
    Altered Mental Status 23
    ALS (Amyotrophic Lateral Sclerosis) 23
    Alzheimer’s Disease 23
    AMD (Age-Related Macular Degeneration) 23
    Amenorrhea 23
    AMI (Acute Myocardial Infarction) 23
    Amnesia 23
    Amniocentesis 23
    Amnionitis 23
    Amniotic Membrane Rupture 23
    Amputation 23
    Amyotrophic Lateral Sclerosis (ALS) 24
    Anal Fistula 24
    Anaphylactic Shock 24
    Anaphylaxis Prevention 24
    Anasarca 24
    Anemia 24
    Anemia, in Pregnancy 24
    Anemia, Sickle Cell 24
    Anencephaly 24
    Aneurysm, Abdominal Surgery 24
    Aneurysm, Cerebral 24
    Anger 24
    Angina 25
    Angioplasty, Coronary 25
    Anorectal Abscess 25
    Anorexia 25
    Anorexia Nervosa 25
    Anosmia (Smell, Loss of Ability to) 26
    Antepartum Period 26
    Anterior Repair, Anterior Colporrhaphy 26
    Anticoagulant Therapy 26
    Antisocial Personality Disorder 26
    Anuria 26
    Anxiety 26
    Anxiety Disorder 26
    Aortic Valvular Stenosis 26
    Aphasia 26
    Aplastic Anemia 26
    Apnea in Infancy 26
    Apneustic Respirations 26
    Appendectomy 26
    Appendicitis 27
    Apprehension 27
    Arrhythmia 27
    Arterial Insufficiency 27
    Arthritis 27
    Arthrocentesis 27
    Arthroplasty (Total Hip Replacement) 27
    Arthroscopy 27
    Ascites 27
    Asperger’s Syndrome 27
    Asphyxia, Birth 27
    Aspiration, Danger of 27
    Assault Victim 27
    Assaultive Client 28
    Asthma 28
    Ataxia 28
    Atelectasis 28
    Atherosclerosis 28
    Athlete’s Foot 28
    ATN (Acute Tubular Necrosis) 28
    Atrial Fibrillation 28
    Atrial Septal Defect 28
    Attention Deficit Disorder 28
    Auditory Problems 28
    Autism 28
    Autonomic Dysreflexia 28
    List of Nursing Assessments by Letter: B e3
    B 29
    Baby Care 29
    Back Pain 29
    Bacteremia 29
    Barrel Chest 29
    Bathing/Hygiene Problems 29
    Battered Child Syndrome 29
    Battered Person 29
    Bedbugs, Infestation 29
    Bed Mobility, Impaired 29
    Bed Rest, Prolonged 29
    Bedsores 29
    Bedwetting 29
    Bell’s Palsy 29
    Benign Prostatic Hypertrophy 29
    Bereavement 29
    Biliary Atresia 29
    Biliary Calculus 30
    Biliary Obstruction 30
    Bilirubin Elevation in Neonate 30
    Biopsy 30
    Bioterrorism 30
    Birth Asphyxia 30
    Birth Control 30
    Bladder Cancer 30
    Bladder Distention 30
    Bladder Training 30
    Bladder Training, Child 30
    Bleeding Tendency 30
    Blepharoplasty 30
    Blindness 30
    Blood Disorder 30
    Blood Pressure Alteration 30
    Blood Sugar Control 30
    Blood Transfusion 30
    Body Dysmorphic Disorder 30
    Body Image Change 31
    Body Temperature, Altered 31
    Bone Marrow Biopsy 31
    Borderline Personality Disorder 31
    Boredom 31
    Botulism 31
    Bowel Incontinence 31
    Bowel Obstruction 31
    Bowel Resection 31
    Bowel Sounds, Absent or Diminished 31
    Bowel Sounds, Hyperactive 31
    Bowel Training 31
    Bowel Training, Child 31
    BPH (Benign Prostatic Hypertrophy) 31
    Bradycardia 31
    Bradypnea 31
    Brain Injury 32
    Brain Surgery 32
    Brain Tumor 32
    Braxton Hicks Contractions 32
    Breast Biopsy 32
    Breast Cancer 32
    Breast Examination, Self 32
    Breast Lumps 32
    Breast Pumping 32
    Breastfeeding, Effective 32
    Breastfeeding, Ineffective 32
    Breastfeeding, Interrupted 32
    Breast Milk, Insufficient 32
    Breath Sounds, Decreased or Absent 32
    Breathing Pattern Alteration 32
    Breech Birth 32
    Bronchitis 32
    Bronchopulmonary Dysplasia 32
    List of Nursing Assessments by Letter: C e5
    C 33
    CABG (Coronary Artery Bypass Grafting) 33
    Cachexia 33
    Calcium Alteration 33
    Cancer 33
    Candidiasis, Oral 34
    Capillary Refill Time, Prolonged 34
    Carbon Monoxide Poisoning 34
    Cardiac Arrest 34
    Cardiac Catheterization 34
    Cardiac Disorders 34
    Cardiac Disorders in Pregnancy 34
    Cardiac Dysrhythmia 35
    Cardiac Output, Decreased 35
    Cardiac Tamponade 35
    Cardiogenic Shock 35
    Caregiver Role Strain 35
    Carious Teeth 35
    Carotid Endarterectomy 35
    Carpal Tunnel Syndrome 35
    Carpopedal Spasm 35
    Casts 35
    Cataract Extraction 35
    Cataracts 35
    Catatonic Schizophrenia 35
    Catheterization, Urinary 35
    Cavities in Teeth 35
    Celiac Disease 35
    Cellulitis 36
    Cellulitis, Periorbital 36
    Central Line Insertion 36
    Cerebral Aneurysm 36
    Cerebral Palsy 36
    Cerebral Perfusion 36
    Cerebrovascular Accident (CVA) 36
    Cervicitis 36
    Cesarean Delivery 36
    Chemical Dependence 36
    Chemotherapy 36
    Chest Pain 37
    Chest Tubes 37
    Cheyne-Stokes Respiration 37
    CHF (Congestive Heart Failure) 37
    Chickenpox 37
    Child Abuse 37
    Childbearing Problems 37
    Child Neglect 37
    Child with Chronic Condition 37
    Childbirth 38
    Chills 38
    Chlamydia Infection 38
    Chloasma 38
    Choking or Coughing with Eating 38
    Cholecystectomy 38
    Cholelithiasis 38
    Chorioamnionitis 38
    Chronic Confusion 38
    Chronic Lymphocytic Leukemia 38
    Chronic Pain 38
    Chronic Renal Failure 38
    Chvostek’s Sign 38
    Circumcision 38
    Cirrhosis 38
    Cleft Lip/Cleft Palate 39
    Clotting Disorder 39
    Cocaine Abuse 39
    Cocaine Baby 39
    Codependency 39
    Cold, Viral 39
    Colectomy 39
    Colitis 39
    Collagen Disease 39
    Colostomy 39
    Colporrhaphy, Anterior 40
    Coma 40
    Comfort, Loss of 40
    Communication 40
    Communication Problems 40
    Community Coping 40
    Community Health Problems 40
    Compartment Syndrome 40
    Compulsion 40
    Conduction Disorders (Cardiac) 40
    Confusion, Acute 40
    Confusion, Chronic 40
    Confusion, Possible 40
    Congestive Heart Failure (CHF) 41
    Conjunctivitis 41
    Consciousness, Altered Level of 41
    Constipation 41
    Constipation, Perceived 41
    Constipation, Risk for 41
    Contamination 41
    Continent Ileostomy (Kock Pouch) 41
    Contraceptive Method 41
    Convulsions 41
    Coping 42
    Coping Problems 42
    Corneal Reflex, Absent 42
    Corneal Transplant 42
    Coronary Artery Bypass Grafting (CABG) 42
    Costovertebral Angle Tenderness 42
    Cough, Ineffective 42
    Crack Abuse 42
    Crack Baby 42
    Crackles in Lungs, Coarse 42
    Crackles in Lungs, Fine 42
    Craniectomy/Craniotomy 42
    Crepitation, Subcutaneous 42
    Crisis 42
    Crohn’s Disease 42
    Croup 43
    Cryosurgery for Retinal Detachment 43
    Cushing’s Syndrome 43
    Cuts (Wounds) 43
    CVA (Cerebrovascular Accident) 43
    Cystic Fibrosis 43
    List of Nursing Assessments by Letter: D e7
    D 44
    Deafness 44
    Death 44
    Death, Oncoming 44
    Decisions, Difficulty Making 44
    Decubitus Ulcer 44
    Deep Vein Thrombosis (DVT) 44
    Defensive Behavior 44
    Dehiscence, Abdominal 44
    Dehydration 44
    Delirium 44
    Delirium Tremens (DT) 44
    Delivery 44
    Delusions 45
    Dementia 45
    Denial of Health Status 45
    Dental Caries 45
    Depression (Major Depressive Disorder) 45
    Dermatitis 45
    Despondency 45
    Destructive Behavior Toward Others 45
    Developmental Concerns 45
    Diabetes in Pregnancy 45
    Diabetes Insipidus 45
    Diabetes Mellitus 46
    Diabetes Mellitus, Juvenile (IDDM Type 1) 46
    Diabetic Coma 46
    Diabetic Ketoacidosis 46
    Diabetic Retinopathy 46
    Dialysis 46
    Diaphragmatic Hernia 46
    Diarrhea 46
    Digitalis Toxicity 46
    Dignity, Loss of 46
    Dilation and Curettage (D&C) 46
    Dirty Body (for Prolonged Period) 47
    Discharge Planning 47
    Discomforts of Pregnancy 47
    Dislocation of Joint 47
    Dissecting Aneurysm 47
    Distress 47
    Disuse Syndrome, Potential to Develop 47
    Diversional Activity, Lack of 47
    Diverticulitis 47
    Dizziness 47
    Domestic Violence 47
    Down Syndrome 47
    Dress Self (Inability to) 47
    Dribbling of Urine 48
    Drooling 48
    Dropout from School 48
    Drug Abuse 48
    Drug Withdrawal 48
    Dry Eye 48
    DT (Delirium Tremens) 48
    DVT (Deep Vein Thrombosis) 48
    Dying Client 48
    Dysfunctional Eating Pattern 48
    Dysfunctional Family Unit 48
    Dysfunctional Ventilatory Weaning 48
    Dysmenorrhea 48
    Dyspareunia 48
    Dyspepsia 48
    Dysphagia 48
    List of Nursing Assessments by Letter: E e8
    E 49
    E. coli Infection 49
    Ear Surgery 49
    Earache 49
    Eclampsia 49
    ECT (Electroconvulsive Therapy) 50
    Ectopic Pregnancy 50
    Eczema 50
    ED (Erectile Dysfunction) 50
    Edema 50
    Elder Abuse 50
    Elderly 50
    Electroconvulsive Therapy 50
    Electrolyte Imbalance 50
    Emaciated Person 50
    Embolectomy 50
    Emboli 50
    Embolism in Leg or Arm 50
    Emesis 50
    Emotional Problems 50
    Empathy 50
    Emphysema 50
    Emptiness 50
    Encephalitis 50
    Endocardial Cushion Defect 50
    Endocarditis 50
    Endometriosis 51
    Endometritis 51
    Enuresis 51
    Environmental Interpretation Problems 51
    Epididymitis 51
    Epiglottitis 51
    Epilepsy 51
    Episiotomy 51
    Epistaxis 51
    Epstein-Barr Virus 51
    Erectile Dysfunction (ED) 51
    Esophageal Varices 51
    Esophagitis 51
    ETOH Withdrawal 51
    Evisceration 51
    Exhaustion 51
    Exposure to Hot or Cold Environment 51
    External Fixation 51
    List of Nursing Assessments by Letter: F e9
    F 52
    Failure to Thrive, Adult 52
    Failure to Thrive, Child 52
    Falls, Risk for 52
    Family Problems 52
    Family Process 52
    Fatigue 52
    Fear 52
    Febrile Seizures 52
    Fecal Impaction 52
    Fecal Incontinence 52
    Feeding Problems, Newborn 52
    Femoral Popliteal Bypass 52
    Fetal Alcohol Syndrome 52
    Fever 53
    Fibrocystic Breast Disease 53
    Filthy Home Environment 53
    Financial Crisis in the Home Environment 53
    Fistulectomy 53
    Flail Chest 53
    Flashbacks 53
    Flat Affect 53
    Flesh-Eating Bacteria (Necrotizing Fasciitis) 53
    Fluid Balance 53
    Fluid Volume Deficit 53
    Fluid Volume Excess 53
    Fluid Volume Imbalance, Risk for 53
    Food Allergies 53
    Foodborne Illness 53
    Food Intolerance 53
    Foreign Body Aspiration 53
    Formula Feeding of Infant 53
    Fracture 53
    List of Nursing Assessments by Letter: G e10
    G 54
    Gag Reflex, Depressed or Absent 54
    Gallop Rhythm 54
    Gallstones 54
    Gang Member 54
    Gangrene 54
    Gas Exchange, Impaired 54
    Gastric Ulcer 54
    Gastritis 54
    Gastroenteritis 54
    Gastroenteritis, Child 54
    Gastroesophageal Reflux 54
    Gastroesophageal Reflux, Child 54
    Gastrointestinal Bleeding (GI Bleed) 55
    Gastrointestinal Hemorrhage 55
    Gastrointestinal Surgery 55
    Gastroschisis/Omphalocele 55
    Gastrostomy 55
    Genital Herpes 55
    Genital Warts 55
    GERD 55
    GI Bleed (Gastrointestinal Bleeding) 55
    Gingivitis 55
    Glaucoma 55
    Glomerulonephritis 55
    Gluten Allergy 55
    Gonorrhea 55
    List of Nursing Assessments by Letter: H e11
    H 56
    H1N1 56
    Hair Loss 56
    Halitosis 56
    Hallucinations 56
    Head Injury 56
    Headache 56
    Health Behavior, Risk-Prone 57
    Health Maintenance Problems 57
    Health-Seeking Person 57
    Hearing Impairment 57
    Heart Attack 57
    Heartburn 57
    Heart Failure 57
    Heart Surgery 57
    Heat Stroke 57
    Hematemesis 57
    Hematuria 57
    Hemianopia 57
    Hemiplegia 57
    Hemodialysis 57
    Hemodynamic Monitoring 57
    Hemolytic Uremic Syndrome 57
    Hemophilia 57
    Hemoptysis 58
    Hemorrhage 58
    Hemorrhoidectomy 58
    Hemorrhoids 58
    Hemothorax 58
    Hepatitis 58
    Hernia 58
    Herniated Disk 58
    Herniorrhaphy 58
    Herpes in Pregnancy 58
    Herpes Simplex I 58
    Herpes Simplex II 58
    Herpes Zoster 58
    Hiatal Hernia 58
    Hip Fracture 58
    Hip Replacement 59
    Hirschsprung’s Disease 59
    Hirsutism 59
    Hitting Behavior 59
    HIV (Human Immunodeficiency Virus) 59
    Hodgkin’s Disease 59
    Homelessness 59
    Home Maintenance Problems 59
    Hope 59
    Hopelessness 59
    Hospitalized Child 59
    Hostile Behavior 59
    HTN (Hypertension) 60
    Human Immunodeficiency Virus (HIV) 60
    Humiliating Experience 60
    Huntington’s Disease 60
    Hydrocele 60
    Hydrocephalus 60
    Hygiene, Inability to Provide Own 60
    Hyperactive Syndrome 60
    Hyperbilirubinemia 60
    Hypercalcemia 60
    Hypercapnia 60
    Hyperemesis Gravidarum 60
    Hyperglycemia 61
    Hyperkalemia 61
    Hypernatremia 61
    Hyperphosphatemia 61
    Hypersensitivity to Slight Criticism 61
    Hypertension (HTN) 61
    Hyperthermia 61
    Hyperthyroidism 61
    Hyperventilation 61
    Hypocalcemia 61
    Hypoglycemia 61
    Hypokalemia 61
    Hypomagnesemia 61
    Hypomania 61
    Hyponatremia 61
    Hypoplastic Left Lung 61
    Hypotension 61
    List of Nursing Assessments by Letter: I e13
    I 62
    IBS (Irritable Bowel Syndrome) 62
    IDDM (Insulin-Dependent Diabetes) 62
    Identity Disturbance/Problems 62
    Idiopathic Thrombocytopenic Purpura (ITP) 62
    Ileal Conduit 62
    Ileostomy 62
    Ileus 62
    Immobility 63
    Imperforate Anus 63
    Inactivity 63
    Influenza 65
    Intermittent Claudication 65
    Internal Cardioverter/Defibrillator (ICD) 65
    Internal Fixation 65
    Interstitial Cystitis 65
    Intrauterine Growth Retardation 65
    List of Nursing Assessments by Letter: J e14
    J 66
    Jaundice 66
    List of Nursing Assessments by Letter: K e15
    K 67
    List of Nursing Assessments by Letter: L e16
    L 68
    Lactose Intolerance 69
    Laparotomy 69
    Large Bowel Resection 69
    Laryngectomy 69
    Legionnaires’ Disease 70
    Lens Implant 70
    Lethargy/Listlessness 70
    Leukemia 70
    Leukopenia 70
    Level of Consciousness, Decreased 70
    Lice 70
    Lifestyle, Sedentary 70
    Lightheadedness 70
    Living Will 71
    Lobectomy 71
    Loneliness 71
    Lower GI Bleeding 71
    Lumbar Puncture 71
    Lumpectomy 71
    Lung Cancer 71
    Lung Surgery 71
    Lupus Erythematosus 71
    List of Nursing Assessments by Letter: M e17
    M 72
    Manipulation of Organs, Surgical Incision 73
    Manipulative Behavior 73
    Mastectomy 74
    Mastitis 74
    Maturational Issues, Adolescent 74
    Memory Deficit 75
    Ménière’s Disease 75
    Metabolic Acidosis 76
    Metabolic Alkalosis 76
    Metastasis 76
    Midlife Crisis 76
    Migraine Headache 76
    Mouth Lesions 78
    Mumps 79
    Murmurs 79
    Muscular Atrophy/Weakness 79
    Muscular Dystrophy (MD) 79
    List of Nursing Assessments by Letter: N e19
    N 80
    Near-Drowning 80
    Necrotizing Fasciitis (Flesh-Eating Bacteria) 81
    Negative Feelings About Self 81
    Neglect, Unilateral 81
    Neglectful Care of Family Member 81
    Neoplasm 81
    Nephrectomy 81
    Nephrostomy, Percutaneous 81
    Nephrotic Syndrome 81
    Nerve Entrapment 81
    Neuralgia 82
    Neuritis (Peripheral Neuropathy) 82
    Neurofibromatosis 82
    Neurogenic Bladder 82
    Neurologic Disorders 82
    Neuropathy, Peripheral 82
    Normal Pressure Hydrocephalus (NPH) 83
    List of Nursing Assessments by Letter: O e20
    O 84
    Obesity 84
    OBS (Organic Brain Syndrome) 84
    Obstruction, Bowel 84
    Obstructive Sleep Apnea 84
    OCD (Obsessive-Compulsive Disorder) 84
    Open Heart Surgery 85
    Opiate Use 85
    Opportunistic Infection 85
    Oppositional Defiant Disorder (ODD) 85
    Orthopedic Traction 85
    Orthopnea 85
    Orthostatic Hypotension 85
    Osteoarthritis 85
    Osteomyelitis 85
    Osteoporosis 85
    List of Nursing Assessments by Letter: P e21
    P 86
    Painful Breasts, Engorgement 86
    Painful Breasts, Sore Nipples 86
    Pallor of Extremities 86
    Panic Disorder (Panic Attacks) 87
    Paralysis 87
    Paralytic Ileus 87
    Paranoid Personality Disorder 87
    Paraplegia 87
    Parent Attachment 88
    Parental Role Conflict 88
    Parenting 88
    Parenting, Impaired 88
    Parenting, Risk for Impaired 88
    Paresthesia 88
    Parkinson’s Disease 88
    Patent Ductus Arteriosus (PDA) 88
    Patient-Controlled Analgesia (PCA) 88
    Patient Education 88
    PCA (Patient-Controlled Analgesia) 88
    Pectus Excavatum 88
    Pediculosis 88
    Pericardial Friction Rub 89
    Pericarditis 89
    Perioperative Positioning 89
    Peripheral Neuropathy 89
    Peripheral Neurovascular Dysfunction 89
    Peripheral Vascular Disease (PVD) 89
    Peritoneal Dialysis 89
    Peritonitis 89
    Pernicious Anemia 89
    Persistent Fetal Circulation 89
    Personal Identity Problems 89
    Personality Disorder 89
    Pertussis (Whooping Cough) 90
    Pesticide Contamination 90
    Petechiae 90
    Petit Mal Seizure 90
    Pharyngitis 90
    Photosensitivity 90
    Physical Abuse 90
    Pica 90
    PID (Pelvic Inflammatory Disease) 90
    Piloerection 91
    Pimples 91
    Pink Eye 91
    Pleural Tap 92
    Pleurisy 92
    PMS (Premenstrual Tension Syndrome) 92
    PND (Paroxysmal Nocturnal Dyspnea) 92
    Postpartum Hemorrhage 93
    Postpartum, Normal Care 93
    Preeclampsia 93
    Pregnancy Loss 94
    Premature Infant (Parent) 95
    Premature Rupture of Membranes 95
    Premenstrual Tension Syndrome (PMS) 95
    Prenatal Care, Normal 95
    Prenatal Testing 95
    Preoperative Teaching 95
    Pressure Ulcer 95
    Preterm Labor 95
    Prostatic Hypertrophy 96
    PTSD (Posttraumatic Stress Disorder) 97
    Pulmonary Stenosis 97
    Pulse Deficit 97
    Pulse Oximetry 97
    Pulse Pressure, Increased 97
    Pulse Pressure, Narrowed 97
    Pulses, Absent or Diminished Peripheral 97
    Purpura 97
    Pyelonephritis 97
    Pyloric Stenosis 97
    Pyloromyotomy (Pyloric Stenosis Repair) 97
    List of Nursing Assessments by Letter: R e23
    R 97
    Rabies 98
    Radial Nerve Dysfunction 98
    Radiation Therapy 98
    Radical Neck Dissection 98
    Rage 98
    Rape-Trauma Syndrome 98
    Rationalization 98
    Rats, Rodents in the Home 98
    Raynaud’s Disease 98
    RDS (Respiratory Distress Syndrome) 98
    Rectal Fullness 98
    Rectal Lump 98
    Rectal Pain/Bleeding 98
    Regression 99
    Regretful 99
    Rehabilitation 99
    Relationship 99
    Relaxation Techniques 99
    Religiosity 99
    Religious Concerns 99
    Relocation Stress Syndrome 99
    Renal Failure 99
    Retinal Detachment 101
    Retinopathy, Diabetic 101
    Retinopathy of Prematurity (ROP) 101
    Reye’s Syndrome 101
    Rh Factor Incompatibility 101
    Rhabdomyolysis 101
    Rheumatic Fever 101
    Rheumatoid Arthritis (RA) 101
    Rib Fracture 101
    Ridicule of Others 101
    List of Nursing Assessments by Letter: S e24
    S 102
    Safe Sex 102
    Safety, Childhood 102
    Salmonella 102
    Salpingectomy 102
    Sarcoidosis 102
    SARS (Severe Acute Respiratory Syndrome) 103
    SBE (Self-Breast Examination) 103
    Scabies 103
    Scared 103
    Schizophrenia 103
    Self-Breast Examination (SBE) 104
    Self-Care 104
    Self-Care Deficit, Bathing 104
    Self-Care Deficit, Dressing 104
    Self-Care Deficit, Feeding 104
    Separation Anxiety 105
    Sepsis, Child 105
    Septicemia 105
    Severe Acute Respiratory Syndrome (SARS) 105
    Sexual Dysfunction 105
    Sexuality, Adolescent 105
    Sexuality Pattern, Ineffective 105
    Sexually Transmitted Disease (STD) 105
    Shaken Baby Syndrome 105
    Shakiness 105
    Shame 105
    Shingles 105
    Shivering 105
    Shock, Cardiogenic 105
    Shock, Hypovolemic 105
    Shock, Septic 106
    Shoulder Repair 106
    Sickle Cell Anemia/Crisis 106
    SIDS (Sudden Infant Death Syndrome) 106
    Situational Crisis 106
    SJS (Stevens-Johnson Syndrome) 106
    Skin Cancer 106
    Skin Disorders 106
    Skin Integrity, Risk for Impaired 106
    Skin Turgor, Change in Elasticity 106
    Sleep 106
    Sleep Apnea 106
    Sleep Deprivation 106
    Sleep Pattern Disorders 106
    Sleep Pattern, Disturbed, Parent/Child 106
    Slurring of Speech 106
    Small Bowel Resection 107
    Smell, Loss of Ability to 107
    Smoke Inhalation 107
    Smoking Behavior 107
    Social Interaction, Impaired 107
    Social Isolation 107
    Sociopathic Personality 107
    Sodium, Decrease/Increase 107
    Somatization Disorder 107
    Sore Nipples, Breastfeeding 107
    Sore Throat 107
    Sorrow 107
    Spastic Colon 107
    Speech Disorders 107
    Spina Bifida 107
    Spinal Cord Injury 107
    Spinal Fusion 108
    Spiritual Distress 108
    Spiritual Well-Being 108
    Splenectomy 108
    Sprains 108
    Stapedectomy 108
    Stasis Ulcer 108
    STD (Sexually Transmitted Disease) 108
    STEMI (ST-Elevation Myocardial Infarction) 108
    Stent (Coronary Artery Stent) 108
    Sterilization Surgery 108
    Stertorous Respirations 108
    Stevens-Johnson Syndrome (SJS) 108
    Stillbirth 108
    Stoma 108
    Stomatitis 108
    Stone, Kidney 108
    Stool, Hard/Dry 108
    Straining with Defecation 108
    Strep Throat 109
    Stress 109
    Stress Overload 109
    Stress Urinary Incontinence 109
    Stridor 109
    Stroke 109
    Stuttering 109
    Subarachnoid Hemorrhage 109
    Substance Abuse 109
    Substance Abuse, Adolescent 109
    Substance Abuse in Pregnancy 109
    Sucking Reflex 109
    Sudden Infant Death Syndrome (SIDS) 109
    Suffocation, Risk for 109
    Suicide Attempt 110
    Support System 110
    Suppression of Labor 110
    Surgery, Perioperative Care 110
    Surgery, Postoperative Care 110
    Surgery, Preoperative Care 110
    Surgical Recovery, Delayed 110
    List of Nursing Assessments by Letter: T e26
    T 111
    T & A (Tonsillectomy and Adenoidectomy) 111
    Tachycardia 111
    Tachypnea 111
    Tardive Dyskinesia 111
    Taste Abnormality 111
    TB (Pulmonary Tuberculosis) 111
    TBI (Traumatic Brain Injury) 111
    TD (Traveler’s Diarrhea) 111
    Temperature, Decreased 112
    Temperature, Increased 112
    Temperature Regulation, Impaired 112
    TEN (Toxic Epidermal Necrolysis) 112
    Tension 112
    Terminally Ill Adult 112
    Terminally Ill Child, Adolescent 112
    Terminally Ill Child, Infant/Toddler 112
    Terminally Ill Child, Preschool Child 112
    Terminally Ill Child/Death of Child, Parent 112
    Tetralogy of Fallot 112
    Tetraplegia 112
    Therapeutic Touch 113
    Thoracentesis 113
    Thoracotomy 113
    Thought Disorders 113
    Thrombocytopenic Purpura 113
    Thrombophlebitis 113
    Thyroidectomy 113
    TIA (Transient Ischemic Attack) 113
    Tic Disorder 113
    Tinea Capitis 113
    Tinea Corporis 113
    Tinea Cruris 113
    Tinea Pedis 113
    Tinea Unguium (Onychomycosis) 113
    Tinnitus 113
    Tissue Perfusion, Ineffective Peripheral 113
    Toileting Problems 113
    Toilet Training 113
    Tonsillectomy and Adenoidectomy (T & A) 114
    Tracheoesophageal Fistula 114
    Tracheostomy 114
    Traction and Casts 114
    Transfer Ability 114
    Transient Ischemic Attack (TIA) 114
    Transposition of Great Vessels 114
    Trauma in Pregnancy 114
    List of Nursing Assessments by Letter: U e28
    U 115
    Ulcer, Peptic (Duodenal or Gastric) 115
    Ulcerative Colitis 115
    Ulcers, Stasis 115
    Unilateral Neglect of One Side of Body 115
    Unsanitary Living Conditions 115
    Urgency to Urinate 115
    List of Nursing Assessments by Letter: V e29
    V 116
    VAD (Ventricular Assist Device) 116
    Vaginal Hysterectomy 116
    Vaginitis 116
    Vagotomy 116
    Value System Conflict 116
    Varicose Veins 116
    Vascular Obstruction, Peripheral 116
    Vasectomy 116
    Vasocognopathy 116
    Venereal Disease 116
    Ventilation, Impaired Spontaneous 116
    Ventilator Client 116
    List of Nursing Assessments by Letter: W e30
    W 117
    Walking Impairment 117
    Wandering 117
    Weakness 117
    Weight Gain 117
    Weight Loss 117
    Wellness-Seeking Behavior 117
    Wernicke-Korsakoff Syndrome 117
    West Nile Virus 117
    Wheelchair Use Problems 117
    Wheezing 117
    Wilms’ Tumor 117
    Withdrawal from Alcohol 117
    Withdrawal from Drugs 117
    Wound Debridement 118
    Wound Dehiscence, Evisceration 118
    Wound Infection 118
    Wounds (open) 118
    Section III - Guide to Planning Care 119
    List of Nursing Diagnoses by Letter: A e31
    A 120
    Activity Intolerance\r 120
    Risk for Activity Intolerance\r 125
    Ineffective Activity PlanningGail B. Ladwig, MSN, RN 126
    Risk for ineffective Activity PlanningGail B. Ladwig, MSN, RN 128
    ?Ineffective Airway Clearance\r 129
    ?Risk for Allergy Response\r 134
    ?Anxiety\r 137
    Death Anxiety\r 140
    ?Risk for Aspiration\r 143
    ?Risk for impaired Attachment\r 148
    Autonomic Dysreflexia\r 153
    List of Nursing Diagnoses by Letter: B e32
    B\r 156
    Risk for Autonomic Dysreflexia\r 156
    ?Risk for Bleeding\r 156
    ?Disturbed Body Image\r 160
    Insufficient Breast Milk\r 165
    ?Ineffective Breast\r 167
    Interrupted Breast\r 170
    Readiness for enhanced Breastfeeding*\r 172
    Ineffective - Ineffective breathing pattern 175
    List of Nursing Diagnoses by Letter: C e33
    C\r 179
    ?Decreased cardiac output\r 179
    ?Risk for decreased cardiac tissue perfusion\r 187
    ?Caregiver role strain\r 191
    Risk for caregiver role strain\r 198
    ?Risk for ineffective cerebral tissue perfusion\r 199
    ?Ineffective childbearing process\r 201
    Readiness for enhanced childbearing Process\r 205
    Risk for ineffective childbearing process\r 209
    ?Impaired comfort\r 210
    ?Readiness for enhanced comfort \r 213
    Readiness for enhanced Communication\r 218
    ?Impaired verbal Communication \r 220
    ?Acute confusion\r 225
    ?Chronic confusion\r 230
    Risk for acute Confusion\r 238
    Constipation\r 238
    Perceived Constipation\r 245
    Risk for Constipation\r 248
    Contamination\r 249
    Risk for Contamination \r 252
    Risk for adverse reaction to iodinated Contrast media\r 254
    Readiness for enhanced community coping\r 256
    ?Defensive Coping\r 258
    ?Ineffective coping\r 261
    Readiness for enhanced coping\r 268
    ?Ineffective community coping\r 272
    ?Compromised family coping\r 274
    ?Disabled family coping\r 280
    ?Readiness for enhanced family coping\r 283
    List of Nursing Diagnoses by Letter: D e34
    D 286
    Decisional conflict\r 286
    Readiness for enhanced decision-making\r 289
    Ineffective denial\r 292
    Impaired dentition\r 296
    ?Risk for delayed development\r 301
    ?Diarrhea\r 303
    ?Risk for disuse Syndrome\r 308
    Deficient diversional Activity\r 313
    List of Nursing Diagnoses by Letter: E e35
    E\r 318
    ?Risk for electrolyte Imbalance\r 318
    Disturbed Energy Field\r 321
    Impaired environmental Interpretation Syndrome\r 325
    ?Risk for dry eye\r 325
    List of Nursing Diagnoses by Letter: F e36
    F 327
    ?Adult failure to thrive\r 327
    ?Risk for falls\r 332
    Dysfunctional family Processes 338
    Interrupted family Processes\r 342
    Readiness for enhanced family Processes\r 345
    ?Fatigue\r 348
    Fear 353
    ?Ineffective infant feeding pattern\r 357
    ?Readiness for enhanced fluid balance\r 360
    ?Risk for imbalanced Fluid Volume \r 361
    ?Deficient fluid Volume\r 365
    ?Excess fluid Volume\r 370
    List of Nursing Diagnoses by Letter: G e37
    G\r 374
    ?Risk for Deficient fluid Volume\r 374
    ?Impaired gas Exchange\r 374
    ?Risk for dysfunctional Gastrointestinal Motility\r 379
    ?Risk for ineffective Gastrointestinal Perfusion\r 382
    ?Risk for unstable blood glucose level\r 386
    ?Grieving\r 391
    ?Complicated grieving\r 395
    ?Risk for complicated grieving\r 398
    ?Risk for disproportionate growth\r 399
    ?Delayed growth and Development\r 402
    List of Nursing Diagnoses by Letter: H e38
    H 406
    Deficient community health\r 406
    Risk-prone health behavior\r 408
    Ineffective Health Maintenance\r 412
    ?Impaired home Maintenance\r 416
    ?Readiness for enhanced hope\r 420
    ?Hopelessness\r 422
    ?Risk for compromised Human Dignity\r 426
    ?Hyperthermia\r 430
    Hypothermia\r 435
    List of Nursing Diagnoses by Letter: I e39
    I\r 440
    Disturbed personal Identity\r 440
    Risk for disturbed personal identity\r 445
    ?Readiness for enhanced immunization Status\r 445
    ?Ineffective impulse control\r 449
    Functional urinary incontinence\r 451
    ?Overflow urinary incontinence\r 456
    ?Reflex urinary incontinence\r 456
    ?Stress urinary incontinence\r 460
    ?Urge urinary incontinence\r 464
    Risk for urge urinary incontinence\r 469
    Bowel incontinenceMary Beth Flynn Makic, RN, PhD, CNS, CCNS 470
    ?Disorganized infant behavior\r 475
    Readiness for enhanced organized infant behavior\r 479
    Risk for disorganized infant behaviorGail B. Ladwig, MSN, RN 479
    ?Risk for Infection\r 480
    Risk for Injury\r 485
    Insomnia\r 490
    ?Decreased Intracranial Adaptive Capacity\r 493
    List of Nursing Diagnoses by Letter: J e40
    J\r 496
    ?Neonatal Jaundice\r 496
    Risk for neonatal Jaundice\r 500
    List of Nursing Diagnoses by Letter: K e41
    K\r 504
    ?Deficient Knowledge\r 504
    Readiness for enhanced Knowledge\r 508
    List of Nursing Diagnoses by Letter: L e42
    L 510
    ?Latex Allergy Response\r 510
    Risk for Latex Allergy Response\r 515
    Risk for impaired Liver Function\r 517
    Risk for Loneliness\r 521
    List of Nursing Diagnoses by Letter: M e43
    M\r 547
    Risk for disturbed Maternal/Fetal Dyad\r 524
    ?Impaired Memory\r 527
    Impaired bed Mobility\r 532
    ?Impaired physical Mobility\r 536
    Impaired wheelchair Mobility\r 543
    Moral Distress\r 547
    List of Nursing Diagnoses by Letter: N e44
    N\r 549
    ?Nausea\r 549
    Noncompliance\r 553
    Readiness for enhanced Nutrition 554
    Imbalanced Nutrition: less than body req 558
    Risk for imbalanced Nutrition: more than 564
    Imbalanced Nutrition: more than body req 565
    List of Nursing Diagnoses by Letter: O e45
    O\r 571
    Impaired Oral Mucous Membrane 571
    List of Nursing Diagnoses by Letter: P e46
    P\r 575
    Acute Pain 575
    Chronic Pain 584
    Impaired Parenting 594
    Readiness for enhanced Parenting 599
    Risk for impaired Parenting 602
    Risk for Perioperative Positioning Injur 603
    Risk for Peripheral Neurovascular Dysfun 607
    Risk for Poisoning 610
    Post-Trauma Syndrome 616
    Risk for Post-Trauma Syndrome 620
    Readiness for enhanced Power 623
    Powerlessness 625
    Risk for Powerlessness 629
    Ineffective Protection 629
    List of Nursing Diagnoses by Letter: R e47
    R\r 634
    Rape-Trauma Syndrome 634
    Ineffective Relationship 639
    Readiness for enhanced Relationship 639
    Risk for ineffective Relationship 642
    Readiness for enhanced Religiosity 645
    Risk for impaired Religiosity 646
    Relocation Stress Syndrome 647
    Risk for Relocation Stress Syndrome 651
    Risk for ineffective Renal Perfusion 652
    Impaired individual Resilience 654
    Readiness for enhanced Resilience 657
    Risk for compromised Resilience 658
    Parental Role Conflict 660
    Ineffective Role Performance 663
    List of Nursing Diagnoses by Letter: S e48
    S\r 668
    Sedentary lifestyle 668
    Readiness for enhanced Self-Care 672
    Bathing Self-Care deficit 677
    Dressing Self-Care deficit 680
    Feeding Self-Care deficit 683
    Toileting Self-Care deficit 686
    Readiness for enhanced Self-Concept 688
    Chronic low Self-Esteem 691
    Situational low Self-Esteem 694
    Risk for chronic low Self-Esteem 697
    Risk for situational low Self-Esteem 697
    Ineffective Self-Health Management 699
    Readiness for enhanced Self-Health Manag 702
    Risk for Self-Mutilation 705
    Self-Mutilation 711
    Self-Neglect 714
    Sexual Dysfunction 717
    Ineffective Sexuality Pattern 724
    Risk for Shock 730
    Impaired Skin Integrity 734
    Risk for impaired Skin Integrity 738
    Sleep deprivation 740
    Readiness for enhanced Sleep 743
    Disturbed Sleep Pattern 746
    Impaired Social Interaction 748
    Social Isolation 752
    Chronic Sorrow 757
    Spiritual Distress 761
    Risk for Spiritual Distress 765
    Readiness for enhanced Spiritual Well-Be 765
    Stress overload 769
    Risk for Sudden Infant Death Syndrome 773
    Risk for Suffocation 776
    Risk for Suicide 779
    Delayed Surgical Recovery 788
    Impaired Swallowing 792
    List of Nursing Diagnoses by Letter: T e49
    T\r 798
    Risk for imbalanced body Temperature 798
    Ineffective family Therapeutic Regimen M 798
    Risk for Thermal Injury 801
    Ineffective Thermoregulation 802
    Impaired Tissue Integrity 807
    Ineffective peripheral Tissue Perfusion 810
    Risk for ineffective peripheral Tissue P 815
    Impaired Transfer Ability 815
    Risk for Trauma 819
    List of Nursing Diagnoses by Letter: U e50
    U\r 824
    Unilateral Neglect 824
    Impaired Urinary Elimination 826
    Readiness for enhanced Urinary Eliminati 829
    Urinary Retention 831
    List of Nursing Diagnoses by Letter: V e51
    V\r 835
    Risk for Vascular Trauma 835
    Impaired spontaneous Ventilation 840
    Dysfunctional Ventilatory Weaning Respon 845
    Risk for other-directed Violence 849
    List of Nursing Diagnoses by Letter: W e52
    W\r 860
    Risk for self-directed Violence 860
    Impaired Walking 860
    Wandering 864
    Index 869

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