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Nursing Diagnosis Handbook - E-Book

Nursing Diagnosis Handbook - E-Book

Betty J. Ackley | Gail B. Ladwig | Mary Beth Flynn Makic

(2016)

Additional Information

Book Details

Abstract

Ackley’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 11th Edition helps practicing nurses and nursing students select appropriate nursing diagnoses and write care plans with ease and confidence. This convenient handbook shows you how to correlate nursing diagnoses with known information about clients on the basis of assessment findings, established medical or psychiatric diagnoses, and the current treatment plan. Extensively revised and updated with the new 2015-2017 NANDA-I approved nursing diagnoses, it integrates the NIC and NOC taxonomies, evidence-based nursing interventions, and adult, pediatric, geriatric, multicultural, home care, and client/family teaching and discharge planning considerations to guide you in creating unique, individualized care plans.

  • Comprehensive, up-to-date information on all the 2015-2017 NANDA-I nursing diagnoses so you stay in the know.
  • UNIQUE! Provides care plans for every NANDA-I approved nursing diagnosis plus two unique care plans for Hearing Loss and Vision Loss.
  • Includes pediatric, geriatric, multicultural, client/family teaching and discharge planning, home care, and safety interventions as necessary for plans of care.
  • Presents examples of and suggested NIC interventions and NOC outcomes in each care plan.
  • UNIQUE! Care Plan Constructor on the companion Evolve website offers hands-on practice creating customized plans of care.
  • 150 NCLEX exam-style review questions are available on Evolve.
  • Promotes evidence-based interventions and rationales by including recent or classic research that supports the use of each intervention.
  • Classic evidence-based references promote evidence-based interventions and rationales.
  • Clear, concise interventions are usually only a sentence or two long and use no more than two references.
  • Safety content emphasizes what must be considered to provide safe patient care.
  • Step-by-step instructions show you how to use the Guide to Nursing Diagnoses and Guide to Planning Care sections to create a unique, individualized plan of care.
  • List of Nursing Diagnosis Index in back inside cover of book for quick reference.   
  • Three-column index is easy to use.
  • Easy-to-follow sections I and II guide you through the nursing process and selecting appropriate nursing diagnoses.
  • Alphabetical thumb tabs allow quick access to specific symptoms and nursing diagnoses.

Table of Contents

Section Title Page Action Price
Front Cover cover
Inside Front Cover ifc1
Evolve page ii
Nursing Diagnosis Handbook iii
Copyright Page iv
Dedication v
About the Authors vi
Contributors viii
Reviewers xiii
Preface xiv
Acknowledgments xvi
How to Use Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care xvii
Step 1: Assess xvii
Step 2: Diagnose xvii
Step 3: Determine Outcomes xvii
Plan Interventions xviii
Give Nursing Care xviii
Evaluate Nursing Care xviii
Document xviii
Table Of Contents xix
I Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing 1
Part A The 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
Formulating a Nursing Diagnosis with Related Factors and Defining Characteristics 4
Types of Nursing Diagnoses 4
Problem-Focused Diagnosis. 4
Example of a Problem-Focused Nursing Diagnosis. 4
Risk Nursing Diagnosis. 4
Example of a Risk Nursing Diagnosis. 5
Health Promotion Nursing Diagnosis. 5
Example of a Health Promotion Nursing Diagnosis. 5
Application and Examples of Making a Nursing Diagnosis 5
Case Study 1—An Older Client with Breathing Problems 5
A. Underline the Symptoms (Defining Characteristics) 5
B. List the Symptoms (Subjective and Objective) 5
C. Cluster Similar Symptoms 5
D. Analyze 5
Interpret the Subjective Symptoms (What the Client Has Stated) 5
Interpret the Objective Symptoms (Observable Information) 5
E. Select the Nursing Diagnosis Label 5
“Related to” Phrase or Etiology 6
Defining Characteristics Phrase 6
Put It All Together: Writing the Three-Part Nursing Diagnosis Statement 6
Case Study 1—73-Year-Old Male Client with COPD (Continued) 6
Case Study 2—Woman with Insomnia 7
A. Underline the Symptoms 7
B. List the Symptoms (Subjective and Objective) 7
C. Cluster Similar Symptoms 7
D. Analyze/Interpret the Symptoms 7
Subjective Symptoms 7
Objective Symptoms 7
E. Select a Nursing Diagnosis with Related Factors and Defining Characteristics 7
Step 3: Planning (ADPIE) 7
SMART Outcomes 8
Outcomes 8
Interventions 8
Putting It All Together—Recording the Care Plan 10
Step 4: Implementation (ADPIE) 10
Step 5: Evaluation (ADPIE) 10
Part B Advanced Nursing Process Concepts 11
Conceptual Mapping and the Nursing Process 11
Quality and Safety Education for Nurses 11
Patient-Centered Care 11
Teamwork and Collaboration 12
Evidence-Based Practice 13
Quality Improvement 13
Safety 13
Informatics 13
References 14
II Guide to Nursing Diagnosis 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 20
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/Acute Kidney 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 22
Agoraphobia 22
Agranulocytosis 22
AIDS (Acquired Immunodeficiency Syndrome) 22
AIDS Dementia 22
AIDS, Child 22
Airway Obstruction/Secretions 22
Alcohol Withdrawal 22
Alcoholism 23
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 24
AMI (Acute Myocardial Infarction) 24
Amnesia 24
Amniocentesis 24
Amnionitis 24
Amniotic Membrane Rupture 24
Amputation 24
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 25
Anencephaly 25
Aneurysm, Abdominal Surgery 25
Aneurysm, Cerebral 25
Anger 25
Angina 25
Angiocardiography (Cardiac Catheterization) 25
Angioplasty, Coronary 25
Anomaly, Fetal/Newborn (Parent Dealing with) 25
Anorectal Abscess 26
Anorexia 26
Anorexia Nervosa 26
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 Aneurysm Repair (Abdominal Surgery) 27
Aortic Valvular Stenosis 27
Aphasia 27
Aplastic Anemia 27
Apnea in Infancy 27
Apneustic Respirations 27
Appendectomy 27
Appendicitis 27
Apprehension 27
ARDS (Acute Respiratory Distress Syndrome) 27
Arrhythmia 27
Arterial Insufficiency 27
Arthritis 27
Arthrocentesis 27
Arthroplasty (Total Hip Replacement) 27
Arthroscopy 28
Ascites 28
Asperger’s Syndrome 28
Asphyxia, Birth 28
Aspiration, Danger of 28
Assault Victim 28
Assaultive Client 28
Asthma 28
Ataxia 28
Atelectasis 28
Atherosclerosis 28
Athlete’s Foot 28
ATN (Acute Tubular Necrosis) 29
Atrial Fibrillation 29
Atrial Septal Defect 29
Attention Deficit Disorder 29
Auditory Problems 29
Autism 29
Autonomic Dysreflexia 29
Autonomic Hyperreflexia 29
List of Nursing Assessments by Letter: B e3
B 29
Baby Care 29
Bacteremia 29
Barrel Chest 29
Bathing/Hygiene Problems 29
Battered Child Syndrome 29
Battered Person 30
Bedbugs, Infestation 30
Bed Mobility, Impaired 30
Bed Rest, Prolonged 30
Bedsores 30
Bedwetting 30
Bell’s Palsy 30
Benign Prostatic Hypertrophy 30
Bereavement 30
Biliary Atresia 30
Biliary Calculus 30
Biliary Obstruction 30
Bilirubin Elevation in Neonate 30
Biopsy 30
Bioterrorism 30
Bipolar Disorder I (Most Recent Episode, Depressed or Manic) 30
Birth Asphyxia 31
Birth Control 31
Bladder Cancer 31
Bladder Distention 31
Bladder Training 31
Bladder Training, Child 31
Bleeding Tendency 31
Blepharoplasty 31
Blindness 31
Blood Disorder 31
Blood Pressure Alteration 31
Blood Sugar Control 31
Blood Transfusion 31
Body Dysmorphic Disorder 31
Body Image Change 31
Body Temperature, Altered 31
Bone Marrow Biopsy 31
Borderline Personality Disorder 31
Boredom 32
Botulism 32
Bowel Incontinence 32
Bowel Obstruction 32
Bowel Resection 32
Bowel Sounds, Absent or Diminished 32
Bowel Sounds, Hyperactive 32
Bowel Training 32
Bowel Training, Child 32
BPH (Benign Prostatic Hypertrophy) 32
Bradycardia 32
Bradypnea 32
Brain Injury 32
Brain Surgery 32
Brain Tumor 32
Braxton Hicks Contractions 32
Breast Biopsy 33
Breast Cancer 33
Breast Examination, Self 33
Breast Lumps 33
Breast Pumping 33
Breastfeeding, Effective 33
Breastfeeding, Ineffective 33
Breastfeeding, Interrupted 33
Breast Milk, Insufficient 33
Breath Sounds, Decreased or Absent 33
Breathing Pattern Alteration 33
Breech Birth 33
Bronchitis 33
Bronchopulmonary Dysplasia 33
Bronchoscopy 33
Bruits, Carotid 33
Bryant’s Traction 33
Buck’s Traction 33
Buerger’s Disease 33
Bulimia 33
Bunion 34
Bunionectomy 34
Burn Risk 34
Burns 34
Bursitis 34
Bypass Graft 34
List of Nursing Assessments by Letter: C e4
C 34
CABG (Coronary Artery Bypass Grafting) 34
Cachexia 34
Calcium Alteration 34
Cancer 34
Candidiasis, Oral 35
Capillary Refill Time, Prolonged 35
Carbon Monoxide Poisoning 35
Cardiac Arrest 35
Cardiac Catheterization 35
Cardiac Disorders 35
Cardiac Disorders in Pregnancy 35
Cardiac Dysrhythmia 36
Cardiac Output, Decreased 36
Cardiac Tamponade 36
Cardiogenic Shock 36
Cardiovascular Function: Risk for Impaired 36
Caregiver Role Strain 36
Carious Teeth 36
Carotid Endarterectomy 36
Carpal Tunnel Syndrome 36
Carpopedal Spasm 36
Casts 36
Cataract Extraction 36
Cataracts 36
Catatonic Schizophrenia 36
Catheterization, Urinary 36
Cavities in Teeth 36
Celiac Disease 36
Cellulitis 37
Cellulitis, Periorbital 37
Central Line Insertion 37
Cerebral Aneurysm 37
Cerebral Palsy 37
Cerebral Perfusion 37
Cerebrovascular Accident (CVA) 37
Cervicitis 37
Cesarean Delivery 37
Chemical Dependence 37
Chemotherapy 37
Chest Pain 38
Chest Tubes 38
Cheyne-Stokes Respiration 38
CHF (Congestive Heart Failure) 38
Chickenpox 38
Child Abuse 38
Childbearing Problems 38
Child Neglect 38
Child with Chronic Condition 38
Childbirth 39
Chills 39
Chlamydia Infection 39
Chloasma 39
Choking or Coughing with Eating 39
Cholecystectomy 39
Cholelithiasis 39
Chorioamnionitis 39
Chronic Confusion 39
Chronic Functional Constipation 39
Chronic Lymphocytic Leukemia 39
Chronic Obstructive Pulmonary Disease (COPD) 39
Chronic Pain 39
Chronic Renal Failure (Chronic kidney disease) 39
Chvostek’s Sign 39
Circumcision 39
Cirrhosis 39
Cleft Lip/Cleft Palate 40
Clotting Disorder 40
Cocaine Abuse 40
Cocaine Baby 40
Codependency 40
Cold, Viral 40
Colectomy 40
Colitis 40
Collagen Disease 40
Colostomy 40
Colporrhaphy, Anterior 41
Coma 41
Comfort, Loss of 41
Communicable Diseases, Childhood (e.g., Measles, Mumps, Rubella, Chickenpox, Scabies, Lice, Impetigo) 41
Communication 41
Communication Problems 41
Community Coping 41
Community Health Problems 41
Compartment Syndrome 41
Compulsion 41
Conduction Disorders (Cardiac) 41
Confusion, Acute 41
Confusion, Chronic 41
Confusion, Possible 41
Congenital Heart Disease/ Cardiac Anomalies 41
Congestive Heart Failure (CHF)/Heart Failure (HF) 42
Conjunctivitis 42
Consciousness, Altered Level of 42
Constipation 42
Constipation, Chronic Functional 42
Constipation, Perceived 42
Constipation, Risk for 42
Contamination 42
Continent Ileostomy (Kock Pouch) 42
Contraceptive Method 42
Convulsions 42
COPD (Chronic Obstructive Pulmonary Disease) 42
Coping 43
Coping Problems 43
Corneal Injury 43
Corneal Reflex, Absent 43
Corneal Transplant 43
Coronary Artery Bypass Grafting (CABG) 43
Costovertebral Angle Tenderness 43
Cough, Ineffective 43
Crack Abuse 43
Crack Baby 43
Crackles in Lungs, Coarse 43
Crackles in Lungs, Fine 43
Craniectomy/Craniotomy 43
Crepitation, Subcutaneous 43
Crisis 44
Crohn’s Disease 44
Croup 44
Cryosurgery for Retinal Detachment 44
Cushing’s Syndrome 44
Cuts (Wounds) 44
CVA (Cerebrovascular Accident) 44
Cyanosis, Central with Cyanosis of Oral Mucous Membranes 44
Cyanosis, Peripheral with Cyanosis of Nail Beds 45
Cystic Fibrosis 45
Cystitis 45
Cystocele 45
Cystoscopy 45
List of Nursing Assessments by Letter: D e6
D 45
Deafness 45
Death 45
Death, Oncoming 45
Decisions, Difficulty Making 45
Decubitus Ulcer 45
Deep Vein Thrombosis (DVT) 45
Defensive Behavior 45
Dehiscence, Abdominal 45
Dehydration 46
Delirium 46
Delirium Tremens (DT) 46
Delivery 46
Delusions 46
Dementia 46
Denial of Health Status 46
Dental Caries 46
Depression (Major Depressive Disorder) 46
Dermatitis 47
Despondency 47
Destructive Behavior Toward Others 47
Developmental Concerns 47
Diabetes in Pregnancy 47
Diabetes Insipidus 47
Diabetes Mellitus 47
Diabetes Mellitus, Juvenile (IDDM Type 1) 47
Diabetic Coma 47
Diabetic Ketoacidosis 47
Diabetic Retinopathy 47
Dialysis 47
Diaphragmatic Hernia 48
Diarrhea 48
DIC (Disseminated Intravascular Coagulation) 48
Digitalis Toxicity 48
Dignity, Loss of 48
Dilation and Curettage (D&C) 48
Dirty Body (for Prolonged Period) 48
Discharge Planning 48
Discomforts of Pregnancy 48
Dislocation of Joint 48
Dissecting Aneurysm 48
Disseminated Intravascular Coagulation (DIC) 48
Dissociative Identity Disorder (Not Otherwise Specified) 48
Distress 48
Disuse Syndrome, Potential to Develop 48
Diversional Activity, Lack of 48
Diverticulitis 48
Dizziness 49
Domestic Violence 49
Down Syndrome 49
Dress Self (Inability to) 49
Dribbling of Urine 49
Drooling 49
Dropout from School 49
Drug Abuse 49
Drug Withdrawal 49
Dry Eye 49
DT (Delirium Tremens) 49
DVT (Deep Vein Thrombosis) 49
Dying Client 50
Dysfunctional Eating Pattern 50
Dysfunctional Family Unit 50
Dysfunctional Ventilatory Weaning 50
Dysmenorrhea 50
Dyspareunia 50
Dyspepsia 50
Dysphagia 50
Dysphasia 50
Dyspnea 50
Dysrhythmia 50
Dysthymic Disorder 50
Dystocia 50
Dysuria 50
List of Nursing Assessments by Letter: E e7
E 51
ECMO (Extracorporeal Membrane Oxygenator) 51
E. coli Infection 51
Ear Surgery 51
Earache 51
Ebola Virus Disease 51
Eclampsia 51
ECT (Electroconvulsive Therapy) 51
Ectopic Pregnancy 51
Eczema 51
ED (Erectile Dysfunction) 51
Edema 51
Elder Abuse 51
Elderly 52
Electroconvulsive Therapy 52
Electrolyte Imbalance 52
Emancipated Decision-Making, Impaired 52
Emaciated Person 52
Embolectomy 52
Emboli 52
Embolism in Leg or Arm 52
Emesis 52
Emotional Problems 52
Empathy 52
Emphysema 52
Emptiness 52
Encephalitis 52
Endocardial Cushion Defect 52
Endocarditis 52
Endometriosis 52
Endometritis 52
Enuresis 52
Environmental Interpretation Problems 52
Epididymitis 52
Epiglottitis 53
Epilepsy 53
Episiotomy 53
Epistaxis 53
Epstein-Barr Virus 53
Erectile Dysfunction (ED) 53
Esophageal Varices 53
Esophagitis 53
ETOH Withdrawal 53
Evisceration 53
Exhaustion 53
Exposure to Hot or Cold Environment 53
External Fixation 53
Extracorporeal Membrane Oxygenator (ECMO) 53
Eye Discomfort 53
Eye Surgery 53
List of Nursing Assessments by Letter: F e8
F 53
Failure to Thrive, Child 53
Falls, Risk for 54
Family Problems 54
Family Process 54
Fatigue 54
Fear 54
Febrile Seizures 54
Fecal Impaction 54
Fecal Incontinence 54
Feeding Problems, Newborn 54
Femoral Popliteal Bypass 54
Fetal Alcohol Syndrome 54
Fetal Distress/Nonreassuring Fetal Heart Rate Pattern 54
Fever 54
Fibrocystic Breast Disease 54
Filthy Home Environment 54
Financial Crisis in the Home Environment 54
Fistulectomy 54
Flail Chest 54
Flashbacks 55
Flat Affect 55
Flesh-Eating Bacteria (Necrotizing Fasciitis) 55
Fluid Balance 55
Fluid Volume Deficit 55
Fluid Volume Excess 55
Fluid Volume Imbalance, Risk for 55
Food Allergies 55
Foodborne Illness 55
Food Intolerance 55
Foreign Body Aspiration 55
Formula Feeding of Infant 55
Fracture 55
Fractured Hip 55
Frail Elderly Syndrome 55
Frequency of Urination 55
Friendship 55
Frostbite 56
Frothy Sputum 56
Fusion, Lumbar 56
List of Nursing Assessments by Letter: G e9
G 56
Gag Reflex, Depressed or Absent 56
Gallop Rhythm 56
Gallstones 56
Gang Member 56
Gangrene 56
Gas Exchange, Impaired 56
Gastric Ulcer 56
Gastritis 56
Gastroenteritis 56
Gastroenteritis, Child 56
Gastroesophageal Reflux (GERD) 56
Gastroesophageal Reflux, Child 56
Gastrointestinal Bleeding (GI Bleed) 57
Gastrointestinal Hemorrhage 57
Gastrointestinal Surgery 57
Gastroschisis/Omphalocele 57
Gastrostomy 57
Genital Herpes 57
Genital Warts 57
GERD 57
Gestational Diabetes (Diabetes in Pregnancy) 57
GI Bleed (Gastrointestinal Bleeding) 57
Gingivitis 57
Glaucoma 57
Glomerulonephritis 57
Gluten Allergy 57
Gonorrhea 57
Gout 57
Grandiosity 58
Grand Mal Seizure 58
Grandparents Raising Grandchildren 58
Graves’ Disease 58
Grieving 58
Grieving, Complicated 58
Groom Self (Inability to) 58
Growth and Development Lag 58
Guillain-Barré Syndrome 58
Guilt 58
List of Nursing Assessments by Letter: H e10
H 58
H1N1 58
Hair Loss 58
Halitosis 58
Hallucinations 58
Head Injury 58
Headache 59
Health Behavior, Risk-Prone 59
Health Maintenance Problems 59
Health-Seeking Person 59
Hearing Impairment 59
Heart Attack 59
Heartburn 59
Heart Failure 59
Heart Surgery 59
Heat Stroke 59
Hematemesis 59
Hematuria 59
Hemianopia 59
Hemiplegia 59
Hemodialysis 59
Hemodynamic Monitoring 60
Hemolytic Uremic Syndrome 60
Hemophilia 60
Hemoptysis 60
Hemorrhage 60
Hemorrhoidectomy 60
Hemorrhoids 60
Hemothorax 60
Hepatitis 60
Hernia 60
Herniated Disk 60
Herniorrhaphy 60
Herpes in Pregnancy 60
Herpes Simplex I 60
Herpes Simplex II 61
Herpes Zoster 61
HHNS (Hyperosmolar Hyperglycemic Nonketotic Syndrome) 61
Hiatal Hernia 61
Hip Fracture 61
Hip Replacement 61
Hirschsprung’s Disease 61
Hirsutism 61
Hitting Behavior 61
HIV (Human Immunodeficiency Virus) 61
Hodgkin’s Disease 61
Homelessness 61
Home Maintenance Problems 61
Hope 61
Hopelessness 61
Hospitalized Child 61
Hostile Behavior 62
HTN (Hypertension) 62
Human Immunodeficiency Virus (HIV) 62
Humiliating Experience 62
Huntington’s Disease 62
Hydrocele 62
Hydrocephalus 62
Hygiene, Inability to Provide Own 62
Hyperactive Syndrome 62
Hyperbilirubinemia (Infant) 63
Hypercalcemia 63
Hypercapnia 63
Hyperemesis Gravidarum 63
Hyperglycemia 63
Hyperkalemia 63
Hypernatremia 63
Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) 63
Hyperphosphatemia 63
Hypersensitivity to Slight Criticism 63
Hypertension (HTN) 63
Hyperthermia 63
Hyperthyroidism 63
Hyperventilation 64
Hypocalcemia 64
Hypoglycemia 64
Hypokalemia 64
Hypomagnesemia 64
Hypomania 64
Hyponatremia 64
Hypoplastic Left Lung 64
Hypotension 64
Hypothermia 64
Hypothyroidism 64
Hypovolemic Shock 64
Hypoxia 64
Hysterectomy 64
List of Nursing Assessments by Letter: I e12
I 64
IBS (Irritable Bowel Syndrome) 64
ICD (Implantable Cardioverter/Defibrillator) 65
IDDM (Insulin-Dependent Diabetes) 65
Identity Disturbance/Problems 65
Idiopathic Thrombocytopenic Purpura (ITP) 65
Ileal Conduit 65
Ileostomy 65
Ileus 65
Immobility 65
Immunization 65
Immunosuppression 65
Impaction of Stool 65
Imperforate Anus 65
Impaired Sitting 65
Impaired Standing 65
Impetigo 66
Implantable Cardioverter/Defibrillator (ICD) 66
Impotence 66
Impulsiveness 66
Inactivity 66
Incompetent Cervix 66
Incontinence of Stool 66
Incontinence of Urine 66
Indigestion 66
Induction of Labor 66
Infant Apnea 66
Infant Behavior 66
Infant Care 66
Infant Feeding Pattern, Ineffective 66
Infant of Diabetic Mother 66
Infant of Substance-Abusing Mother (Fetal Alcohol Syndrome, Crack Baby, Other Drug Withdrawal Infants) 67
Infantile Polyarteritis 67
Infection 67
Infection, Potential for 67
Infertility 67
Inflammatory Bowel Disease (Child and Adult) 67
Influenza 67
Inguinal Hernia Repair 67
Injury 67
Insanity 68
Insomnia 68
Insulin Shock 68
Intellectual Disability 68
Intermittent Claudication 68
Internal Cardioverter/Defibrillator (ICD) 68
Internal Fixation 68
Interstitial Cystitis 68
Intervertebral Disk Excision 68
Intestinal Obstruction 68
Intestinal Perforation 68
Intoxication 68
Intraaortic Balloon Counterpulsation 68
Intracranial Pressure, Increased 68
Intrauterine Growth Retardation 69
Intravenous Therapy 69
Intubation, Endotracheal or Nasogastric 69
Iodine Reaction with Diagnostic Testing 69
Irregular Pulse 69
Irritable Bowel Syndrome (IBS) 69
Isolation 69
Itching 69
ITP (Idiopathic Thrombocytopenic Purpura) 69
List of Nursing Assessments by Letter: J e13
J 69
Jaundice 69
Jaundice, Neonatal 69
Jaw Pain and Heart Attacks 69
Jaw Surgery 69
Jittery 69
Jock Itch 69
Joint Dislocation 69
Joint Pain 70
Joint Replacement 70
JRA (Juvenile Rheumatoid Arthritis) 70
List of Nursing Assessments by Letter: K e14
K 70
Kaposi’s Sarcoma 70
Kawasaki Disease 70
Keloids 70
Keratoconjunctivitis Sicca (Dry Eye Syndrome) 70
Keratoplasty 70
Ketoacidosis, Alcoholic 70
Ketoacidosis, Diabetic 70
Keyhole Heart Surgery 70
Kidney Disease Screening 70
Kidney Failure 70
Kidney Failure Acute/Chronic, Child 71
Kidney Failure, Nonoliguric 71
Kidney Stone 71
Kidney Transplantation, Donor 71
Kidney Transplantation, Recipient 71
Kidney Transplant 71
Kidney Tumor 71
Kissing Disease 71
Knee Replacement 71
Knowledge 72
Knowledge, Deficient 72
Kock Pouch 72
Korsakoff’s Syndrome 72
List of Nursing Assessments by Letter: L e15
L 72
Labor, Induction of 72
Labor, Normal 72
Labor Pain 72
Labyrinthitis 72
Lacerations 72
Lactation 72
Lactic Acidosis 72
Lactose Intolerance 72
Laminectomy 72
Language Impairment 73
Laparoscopic Laser Cholecystectomy 73
Laparoscopy 73
Laparotomy 73
Large Bowel Resection 73
Laryngectomy 73
Laser Surgery 73
LASIK Eye Surgery (Laser-Assisted in Situ Keratomileusis) 73
Latex Allergy 73
Laxative Abuse 73
Lead Poisoning 73
Left Heart Catheterization 73
Legionnaires’ Disease 73
Lens Implant 73
Lethargy/Listlessness 73
Leukemia 74
Leukopenia 74
Level of Consciousness, Decreased 74
Lice 74
Lifestyle, Sedentary 74
Lightheadedness 74
Limb Reattachment Procedures 74
Liposuction 74
Lithotripsy 74
Liver Biopsy 74
Liver Cancer 74
Liver Disease 74
Liver Function 74
Liver Transplant 74
Living Will 75
Lobectomy 75
Loneliness 75
Loose Stools (Bowel Movements) 75
Loss of Bladder Control 75
Loss of Bowel Control 75
Lou Gehrig’s Disease 75
Low Back Pain 75
Low Blood Pressure 75
Low Blood Sugar 75
Lower GI Bleeding 75
Lumbar Puncture 75
Lumpectomy 75
Lung Cancer 75
Lung Surgery 75
Lupus Erythematosus 75
Lyme Disease 75
Lymphedema 76
Lymphoma 76
List of Nursing Assessments by Letter: M e16
M 76
Macular Degeneration 76
Magnetic Resonance Imaging (MRI) 76
Major Depressive Disorder 76
Malabsorption Syndrome 76
Maladaptive Behavior 76
Malaise 76
Malaria 76
Male Infertility 76
Malignancy 76
Malignant Hypertension (Arteriolar Nephrosclerosis) 76
Malignant Hyperthermia 77
Malnutrition 77
Mammography 77
Manic Disorder, Bipolar I 77
Manipulative Behavior 77
Marfan Syndrome 77
Mastectomy 77
Mastitis 78
Maternal Infection 78
Maturational Issues, Adolescent 78
Maze III Procedure 78
MD (Muscular Dystrophy) 78
Measles (Rubeola) 78
Meconium Aspiration 78
Meconium Delayed 78
Melanoma 78
Melena 78
Memory Deficit 78
Ménière’s Disease 78
Meningitis/Encephalitis 78
Meningocele 79
Menopause 79
Menorrhagia 79
Mental Illness 79
Metabolic Acidosis 79
Metabolic Alkalosis 79
Metastasis 79
Methicillin-Resistant Staphylococcus aureus (MRSA) 79
MI (Myocardial Infarction) 79
MIDCAB (Minimally Invasive Direct Coronary Artery Bypass) 80
Midlife Crisis 80
Migraine Headache 80
Milk Intolerance 80
Minimally Invasive Direct Coronary Bypass (MIDCAB) 80
Miscarriage 80
Mitral Stenosis 80
Mitral Valve Prolapse 80
Mobility, Impaired Bed 80
Mobility, Impaired Physical 80
Mobility, Impaired Wheelchair 80
Modified Radical Mastectomy 80
Mononucleosis 80
Mood Disorders 81
Moon Face 81
Moral/Ethical Dilemmas 81
Morning Sickness 81
Motion Sickness 81
Mottling of Peripheral Skin 81
Mourning 81
Mouth Lesions 81
MRI (Magnetic Resonance Imaging) 81
MRSA (Methicillin-Resistant Staphylococcus aureus) 81
Mucocutaneous Lymph Node Syndrome 81
Mucous Membrane, Impaired Oral 81
Multi-Infarct Dementia 81
Multiple Gestations 81
Multiple Personality Disorder (Dissociative Identity Disorder) 82
Multiple Sclerosis (MS) 82
Mumps 82
Murmurs 82
Muscular Atrophy/Weakness 82
Muscular Dystrophy (MD) 82
MVC (Motor Vehicle Crash) 83
Myasthenia Gravis 83
Mycoplasma Pneumonia 83
Myelocele 83
Myelomeningocele 83
Myocardial Infarction (MI) 83
Myocarditis 83
Myringotomy 83
Myxedema 83
List of Nursing Assessments by Letter: N e18
N 83
Narcissistic Personality Disorder 83
Narcolepsy 83
Narcotic Use 83
Nasogastric Suction 83
Nausea 83
Near-Drowning 83
Nearsightedness 84
Nearsightedness; Corneal Surgery 84
Neck Vein Distention 84
Necrosis, Kidney Tubular; Necrosis, Acute Tubular 84
Necrotizing Enterocolitis 84
Negative Feelings About Self 84
Neglect, Unilateral 84
Neglectful Care of Family Member 84
Neonatal Jaundice 84
Neonate 84
Neoplasm 84
Nephrectomy 84
Nephrostomy, Percutaneous 84
Nephrotic Syndrome 85
Neural Tube Defects (Meningocele, Myelomeningocele, Spina Bifida, Anencephaly) 85
Neuralgia 85
Neuritis (Peripheral Neuropathy) 85
Neurogenic Bladder 85
Neurologic Disorders 85
Neuropathy, Peripheral 86
Neurosurgery 86
Newborn, Normal 86
Newborn, Postmature 86
Newborn, Small for Gestational Age (SGA) 86
Nicotine Addiction 86
NIDDM (Non-Insulin-Dependent Diabetes Mellitus) 86
Nightmares 86
Nipple Soreness 86
Nocturia 86
Nocturnal Myoclonus 86
Nocturnal Paroxysmal Dyspnea 86
Noncompliance 86
Non–Insulin-Dependent Diabetes Mellitus (NIDDM) 86
Normal Pressure Hydrocephalus (NPH) 87
Norovirus 87
NSTEMI (non-ST-elevation myocardial infarction) 87
Nursing 87
Nutrition 87
Nutrition, Imbalanced 87
List of Nursing Assessments by Letter: O e19
O 87
Obesity 87
OBS (Organic Brain Syndrome) 87
Obsessive-Compulsive Disorder (OCD) 87
Obstruction, Bowel 87
Obstructive Sleep Apnea 87
OCD (Obsessive-Compulsive Disorder) 87
ODD (Oppositional Defiant Disorder) 87
Older Adult 87
Oliguria 88
Omphalocele 88
Oophorectomy 88
OPCAB (Off-Pump Coronary Artery Bypass) 88
Open Heart Surgery 88
Open Reduction of Fracture with Internal Fixation (Femur) 88
Opiate Use 88
Opportunistic Infection 88
Oppositional Defiant Disorder (ODD) 88
Oral Mucous Membrane, Impaired 88
Oral Thrush 88
Orchitis 88
Organic Mental Disorders 88
Orthopedic Traction 88
Orthopnea 88
Orthostatic Hypotension 88
Osteoarthritis 88
Osteomyelitis 88
Osteoporosis 89
Ostomy 89
Otitis Media 89
Ovarian Carcinoma 89
List of Nursing Assessments by Letter: P e20
P 89
Pacemaker 89
Paget’s Disease 89
Pain, Acute 89
Pain, Chronic 89
Painful Breasts, Engorgement 89
Painful Breasts, Sore Nipples 89
Pallor of Extremities 89
Palpitations (Heart Palpitations) 89
Pancreatic Cancer 89
Pancreatitis 90
Panic Disorder (Panic Attacks) 90
Paralysis 90
Paralytic Ileus 90
Paranoid Personality Disorder 90
Paraplegia 91
Parathyroidectomy 91
Parent Attachment 91
Parental Role Conflict 91
Parenting 91
Parenting, Impaired 91
Parenting, Risk for Impaired 91
Paresthesia 91
Parkinson’s Disease 91
Paroxysmal Nocturnal Dyspnea (PND) 91
Patent Ductus Arteriosus (PDA) 91
Patient-Controlled Analgesia (PCA) 91
Patient Education 91
PCA (Patient-Controlled Analgesia) 91
Pectus Excavatum 91
Pediculosis 91
PEG (Percutaneous Endoscopic Gastrostomy) 91
Pelvic Inflammatory Disease (PID) 91
Penile Prosthesis 92
Peptic Ulcer 92
Percutaneous Transluminal Coronary Angioplasty (PTCA) 92
Pericardial Friction Rub 92
Pericarditis 92
Periodontal Disease 92
Perioperative Hypothermia 92
Perioperative Positioning 92
Peripheral Neuropathy 92
Peripheral Neurovascular Dysfunction 92
Peripheral Vascular Disease (PVD) 92
Peritoneal Dialysis 92
Peritonitis 92
Pernicious Anemia 92
Persistent Fetal Circulation 93
Personal Identity Problems 93
Personality Disorder 93
Pertussis (Whooping Cough) 93
Pesticide Contamination 93
Petechiae 93
Petit Mal Seizure 93
Pharyngitis 93
Phenylketonuria (PKU) 93
Pheochromocytoma 93
Phlebitis 93
Phobia (Specific) 93
Photosensitivity 93
Physical Abuse 93
Pica 93
PID (Pelvic Inflammatory Disease) 93
PIH (Pregnancy-Induced Hypertension/Preeclampsia) 94
Piloerection 94
Pimples 94
Pink Eye 94
Pinworms 94
Pituitary Tumor, Benign 94
PKU (Phenylketonuria) 94
Placenta Abruptio 94
Placenta Previa 94
Plantar Fasciitis 95
Pleural Effusion 95
Pleural Friction Rub 95
Pleural Tap 95
Pleurisy 95
PMS (Premenstrual Tension Syndrome) 95
PND (Paroxysmal Nocturnal Dyspnea) 95
Pneumonectomy 95
Pneumonia 95
Pneumothorax 95
Poisoning, Risk for 95
Poliomyelitis 95
Polydipsia 95
Polyphagia 96
Polyuria 96
Postoperative Care 96
Postpartum Depression 96
Postpartum Hemorrhage 96
Postpartum, Normal Care 96
Post-Trauma Syndrome 96
Post-Trauma Syndrome, Risk for 96
Post-Traumatic Stress Disorder (PTSD) 96
Potassium, Increase/Decrease 96
Power/Powerlessness 96
Preeclampsia 97
Pregnancy, Cardiac Disorders 97
Pregnancy-Induced Hypertension/Preeclampsia (PIH) 97
Pregnancy Loss 97
Pregnancy, Normal 97
Premature Dilation of the Cervix (Incompetent Cervix) 97
Premature Infant (Child) 98
Premature Infant (Parent) 98
Premature Rupture of Membranes 98
Premenstrual Tension Syndrome (PMS) 98
Prenatal Care, Normal 98
Prenatal Testing 98
Preoperative Teaching 98
Pressure Ulcer 98
Preterm Labor 99
Problem-Solving Dysfunction 99
Projection 99
Prolapsed Umbilical Cord 99
Prostatectomy 99
Prostatic Hypertrophy 99
Prostatitis 99
Pruritus 99
Psoriasis 99
Psychosis 99
PTCA (Percutaneous Transluminal Coronary Angioplasty) 100
PTSD (Posttraumatic Stress Disorder) 100
Pulmonary Edema 100
Pulmonary Embolism 100
Pulmonary Stenosis 100
Pulse Deficit 100
Pulse Oximetry 100
Pulse Pressure, Increased 100
Pulse Pressure, Narrowed 100
Pulses, Absent or Diminished Peripheral 100
Purpura 100
Pyelonephritis 100
Pyloric Stenosis 101
Pyloromyotomy (Pyloric Stenosis Repair) 101
List of Nursing Assessments by Letter: R e22
R 101
RA (Rheumatoid Arthritis) 101
Rabies 101
Radial Nerve Dysfunction 101
Radiation Therapy 101
Radical Neck Dissection 101
Rage 101
Rape-Trauma Syndrome 101
Rash 101
Rationalization 101
Rats, Rodents in Home 101
Raynaud’s Disease 102
RDS (Respiratory Distress Syndrome) 102
Rectal Fullness 102
Rectal Lump 102
Rectal Pain/Bleeding 102
Rectal Surgery 102
Rectocele Repair 102
Reflex Incontinence 102
Regression 102
Regretful 102
Rehabilitation 102
Relationship 102
Relaxation Techniques 102
Religiosity 102
Religious Concerns 102
Relocation Stress Syndrome 103
Respiratory Acidosis 103
Respiratory Conditions of the Neonate (Respiratory Distress Syndrome [RDS], Meconium Aspiration, Diaphragmatic Hernia) 103
Respiratory Distress 103
Respiratory Distress Syndrome (RDS) 103
Respiratory Infections, Acute Childhood (Croup, Epiglottitis, Pertussis, Pneumonia, Respiratory Syncytial Virus) 103
Respiratory Syncytial Virus 103
Restless Leg Syndrome 103
Retarded Growth and Development 103
Retching 103
Retinal Detachment 103
Retinopathy, Diabetic 103
Retinopathy of Prematurity (ROP) 103
Rh Factor Incompatibility 103
Rhabdomyolysis 104
Rheumatic Fever 104
Rheumatoid Arthritis (RA) 104
Rib Fracture 104
Ridicule of Others 104
Ringworm of Body 104
Ringworm of Nails 104
Ringworm of Scalp 104
Roaches, Invasion of Home with 104
Role Performance, Altered 104
ROP (Retinopathy of Prematurity) 104
RSV (Respiratory Syncytial Virus) 104
Rubella 104
Rubor of Extremities 104
Ruptured Disk 104
List of Nursing Assessments by Letter: S e23
S 104
SAD (Seasonal Affective Disorder) 104
Sadness 104
Safe Sex 104
Safety, Childhood 104
Salmonella 105
Salpingectomy 105
Sarcoidosis 105
SARS (Severe Acute Respiratory Syndrome) 105
SBE (Self-Breast Examination) 105
Scabies 105
Scared 105
Schizophrenia 105
Sciatica 106
Scoliosis 106
Sedentary Lifestyle 106
Seizure Disorders, Adult 106
Seizure Disorders, Childhood (Epilepsy, Febrile Seizures, Infantile Spasms) 106
Self-Breast Examination (SBE) 106
Self-Care 106
Self-Care Deficit, Bathing 106
Self-Care Deficit, Dressing 107
Self-Care Deficit, Feeding 107
Self-Care Deficit, Toileting 107
Self-Concept 107
Self-Destructive Behavior 107
Self-Esteem, Chronic Low 107
Self-Esteem, Situational Low 107
Self-Mutilation 107
Senile Dementia 107
Separation Anxiety 107
Sepsis, Child 107
Septicemia 107
Severe Acute Respiratory Syndrome (SARS) 107
Sexual Dysfunction 107
Sexuality, Adolescent 107
Sexuality Pattern, Ineffective 108
Sexually Transmitted Disease (STD) 108
Shaken Baby Syndrome 108
Shakiness 108
Shame 108
Shingles 108
Shivering 108
Shock, Cardiogenic 108
Shock, Hypovolemic 108
Shock, Septic 108
Shoulder Repair 108
Sickle Cell Anemia/Crisis 108
SIDS (Sudden Infant Death Syndrome) 108
Sitting Problems 108
Situational Crisis 108
SJS (Stevens-Johnson Syndrome) 109
Skin Cancer 109
Skin Disorders 109
Skin Turgor, Change in Elasticity 109
Sleep 109
Sleep Apnea 109
Sleep Deprivation 109
Sleep Problems 109
Sleep Pattern, Disturbed, Parent/Child 109
Slurring of Speech 109
Small Bowel Resection 109
Smell, Loss of Ability to 109
Smoke Inhalation 109
Smoking Behavior 109
Social Interaction, Impaired 109
Social Isolation 109
Sociopathic Personality 109
Sodium, Decrease/Increase 109
Somatization Disorder 109
Sore Nipples, Breastfeeding 110
Sore Throat 110
Sorrow 110
Spastic Colon 110
Speech Disorders 110
Spina Bifida 110
Spinal Cord Injury 110
Spinal Fusion 110
Spiritual Distress 110
Spiritual Well-Being 110
Splenectomy 110
Sprains 110
Standing Problems 110
Stapedectomy 110
Stasis Ulcer 110
STD (Sexually Transmitted Disease) 110
STEMI (ST-Elevation Myocardial Infarction) 111
Stent (Coronary Artery Stent) 111
Sterilization Surgery 111
Stertorous Respirations 111
Stevens-Johnson Syndrome (SJS) 111
Stillbirth 111
Stoma 111
Stomatitis 111
Stone, Kidney 111
Stool, Hard/Dry 111
Straining with Defecation 111
Strep Throat 111
Stress 111
Stress Urinary Incontinence 111
Stridor 111
Stroke 111
Stuttering 111
Subarachnoid Hemorrhage 111
Substance Abuse 111
Substance Abuse, Adolescent 112
Substance Abuse in Pregnancy 112
Sucking Reflex 112
Sudden Infant Death Syndrome (SIDS) 112
Suffocation, Risk for 112
Suicide Attempt 112
Support System, Inadequate 112
Suppression of Labor 112
Surgery, Perioperative Care 112
Surgery, Postoperative Care 112
Surgery, Preoperative Care 113
Surgical Recovery, Delayed 113
Suspected Child Abuse and Neglect (SCAN), Child 113
Suspected Child Abuse and Neglect (SCAN), Parent 113
Suspicion 113
Swallowing Difficulties 113
Swine Flu (H1N1) 113
Syncope 113
Syphilis 113
Systemic Lupus Erythematosus 113
List of Nursing Assessments by Letter: T e25
T 114
T & A (Tonsillectomy and Adenoidectomy) 114
Tachycardia 114
Tachypnea 114
Tardive Dyskinesia 114
Taste Abnormality 114
TB (Pulmonary Tuberculosis) 114
TBI (Traumatic Brain Injury) 114
TD (Traveler’s Diarrhea) 114
Temperature, Decreased 114
Temperature, High 114
Temperature Regulation, Impaired 114
TEN (Toxic Epidermal Necrolysis) 114
Tension 114
Terminally Ill Adult 114
Terminally Ill Child, Adolescent 114
Terminally Ill Child, Infant/Toddler 115
Terminally Ill Child, Preschool Child 115
Terminally Ill Child, School-Age Child/Preadolescent 115
Terminally Ill Child/Death of Child, Parent 115
Tetralogy of Fallot 115
Tetraplegia 115
Thermoregulation, Ineffective 115
Thoracentesis 115
Thoracotomy 115
Thought Disorders 115
Thrombocytopenic Purpura 115
Thrombophlebitis 115
Thyroidectomy 116
TIA (Transient Ischemic Attack) 116
Tic Disorder 116
Tinea Capitis 116
Tinea Corporis 116
Tinea Cruris 116
Tinea Pedis 116
Tinea Unguium (Onychomycosis) 116
Tinnitus 116
Tissue Damage, Corneal 116
Tissue Damage, Integumentary 116
Tissue Perfusion, Peripheral 116
Toileting Problems 116
Toilet Training 116
Tonsillectomy and Adenoidectomy (T & A) 116
Toothache 116
Total Anomalous Pulmonary Venous Return 116
Total Joint Replacement (Total Hip/Total Knee/Shoulder) 116
Total Parenteral Nutrition (TPN) 116
Tourette’s Syndrome (TS) 116
Toxemia 116
Toxic Epidermal Necrolysis (TEN) (Erythema Multiforme) 116
TPN (Total Parenteral Nutrition) 116
Tracheoesophageal Fistula 117
Tracheostomy 117
Traction and Casts 117
Transfer Ability 117
Transient Ischemic Attack (TIA) 117
Transposition of Great Vessels 117
Transurethral Resection of the Prostate (TURP) 117
Trauma in Pregnancy 117
Trauma, Risk for 117
Traumatic Brain Injury (TBI) 117
Traumatic Event 117
Traveler’s Diarrhea (TD) 117
Trembling of Hands 117
Tricuspid Atresia 117
Trigeminal Neuralgia 117
Truncus Arteriosus 117
TS (Tourette’s Syndrome) 117
TSE (Testicular Self-Examination) 118
Tubal Ligation 118
Tube Feeding 118
Tuberculosis (TB) 118
TURP (Transurethral Resection of the Prostate) 118
List of Nursing Assessments by Letter: U e27
U 118
Ulcer, Peptic (Duodenal or Gastric) 118
Ulcerative Colitis 118
Ulcers, Stasis 118
Unilateral Neglect of One Side of Body 118
Unsanitary Living Conditions 118
Urgency to Urinate 118
Urinary Catheter 118
Urinary Diversion 118
Urinary Elimination, Impaired 118
Urinary Incontinence 118
Urinary Retention 118
Urinary Tract Infection (UTI) 118
Urolithiasis 118
Uterine Atony in Labor 118
Uterine Atony in Postpartum 118
Uterine Bleeding 118
UTI (Urinary Tract Infection) 118
List of Nursing Assessments by Letter: V e28
V 119
VAD (Ventricular Assist Device) 119
Vaginal Hysterectomy 119
Vaginitis 119
Vagotomy 119
Value System Conflict 119
Varicose Veins 119
Vascular Dementia (Formerly Called Multiinfarct Dementia) 119
Vascular Obstruction, Peripheral 119
Vasectomy 119
Venereal Disease 119
Ventilated Client, Mechanically 119
Ventricular Assist Device (VAD) 119
Ventricular Fibrillation 119
Vertigo 119
Violent Behavior 119
Viral Gastroenteritis 119
Vision Impairment 119
Vomiting 120
VTE (Venous Thromboembolism) 120
List of Nursing Assessments by Letter: W e29
W 120
Walking Impairment 120
Wandering 120
Weakness 120
Weight Gain 120
Weight Loss 120
Wellness-Seeking Behavior 120
Wernicke-Korsakoff Syndrome 120
West Nile Virus 120
Wheelchair Use Problems 120
Wheezing 120
Wilms’ Tumor 120
Withdrawal from Alcohol 120
Withdrawal from Drugs 120
Wound Debridement 120
Wound Dehiscence, Evisceration 120
Wound Infection 120
Wounds, Open 120
III Guide to Planning Care 121
Making an Accurate Nursing Diagnosis 121
Appendix A Nursing Diagnoses Arranged by Maslow’s Hierarchy of Needs 949
Physiological Needs 949
Safety and Security Needs 950
Love and Belonging Needs 950
Self-Esteem Needs 951
Self-Actualization Needs 951
Appendix B Nursing Diagnoses Arranged by Gordon’s Functional Health Patterns 952
Health-Perception— Health-Management Pattern 952
Nutritional-Metabolic Pattern 952
Elimination Pattern 952
Activity-Exercise Pattern 953
Sleep-Rest Pattern 953
Cognitive-Perceptual Pattern 953
Self-Perception— Self-Concept Pattern 953
Role-Relationship Pattern 953
Sexuality-Reproductive Pattern 954
Coping—Stress-Tolerance Pattern 954
Value-Belief Pattern 954
Appendix C Motivational Interviewing for Nurses 955
Helpful Websites 956
Bibliography 956
Appendix D Wellness-Oriented Diagnostic Categories 957
Physiological 957
Airway/Breathing 957
Circulation 957
Cognition/Sensory Perception 957
Injury: Falls/Infection/Poisoning/Trauma 957
Homeostasis 957
Fluid/Nutrition/Gastrointestinal/Oral/Dental Management 957
Elimination 957
Urinary Elimination 957
Incontinence, Bowel 958
Incontinence, Bladder 958
Bowel Elimination 958
Constipation 958
Diarrhea 958
Activity/Movement/Self-Care 958
Skin/Tissue 958
Sleep 958
Psychosocial 958
Comfort 958
Communication/Healthy Behaviors/Therapeutic Regimen/Knowledge 958
Appendix E Nursing Care Plans for Hearing Loss and Vision Loss 960
Hearing Loss 960
NANDA-I 960
Definition 960
Defining Characteristics 960
Related Factors (r/t) 960
NOC \t(Nursing Outcomes Classification) 960
Suggested NOC Outcomes (Auditory) 960
Client Outcomes 960
Client Will (Specify Time Frame) 960
NIC \t(Nursing Interventions Classification) 960
Suggested NIC Interventions 960
Nursing Interventions and Rationales 961
Critical Care 961
Pediatric 962
Geriatric 962
Home Care 962
Client/Family Teaching and Discharge Planning 962
References 963
Vision Loss 963
Definition 963
Defining Characteristics 963
Related Factors 963
NOC \t(Nursing Outcomes Classification) 963
Suggested NOC Outcomes (Visual) 963
Client Outcomes 963
Client Will (Specify Time Frame) 963
NIC \t(Nursing Interventions Classification) 964
Suggested NIC Interventions 964
Nursing Interventions and Rationales 964
Multicultural 965
Geriatric 965
Home Care 966
Client/Family Teaching and Discharge Planning 966
Low Vision 966
References 967
Index 969
A 969
B 970
C 971
D 973
E 974
F 975
G 975
H 976
I 977
J 978
K 978
L 978
M 979
N 980
O 981
P 981
Q 983
R 983
S 984
T 986
U 987
V 987
W 988