Nursing Diagnosis Application to Clinical Practice

by Carpenito, Lynda Juall

• ISBN13: 9780781761314
• ISBN10: 078176131X
• Edition: 11th
• Format: Paperback
• Copyright: 2005-07-11
• Publisher: LWW

Summary

Revised to incorporate the latest NANDA-approved nursing diagnoses, the Eleventh Edition of this classic text offers definitive guidance on key elements of nursing diagnosis and its application to clinical practice. Section 1 thoroughly explains the role of nursing diagnosis in the nursing process and in care planning. Section 2 is a comprehensive A-to-Z guide to current nursing diagnoses. Section 3 focuses on collaborative problems. This edition lists associated NIC (Nursing Interventions Classifications) and NOC (Nursing Outcomes Classifications) for every NANDA diagnosis. New diagnoses added and modified in accordance with the latest NANDA meeting are in an appendix for easy access.

Table of Contents

SECTION ONE Nursing Diagnosis in the Nursing Process	1	(76)
Introduction	3	(1)
Development of Nursing Diagnosis	4	(4)
Nursing Diagnosis: Defined	4	(1)
Nursing Diagnosis: Process or Outcome?	5	(1)
The North American Nursing Diagnosis Association International	5	(1)
Nanda Taxonomy	6	(1)
Summary	7	(1)
Types and Components of Nursing Diagnoses	8	(9)
Actual Nursing Diagnosis	8	(2)
Risk and High-Risk Nursing Diagnoses	10	(1)
Possible Nursing Diagnoses	11	(1)
Wellness Nursing Diagnoses	12	(1)
Syndrome Nursing Diagnoses	13	(1)
Non-Nanda-Approved Diagnoses	14	(1)
Diagnostic Statements	14	(2)
Summary	16	(1)
Nursing Diagnosis: What It Is, What It Is Not	17	(9)
Understanding Collaborative Problems	19	(1)
Collaborative Problem Diagnostic Statements	20	(1)
Differentiating Nursing Diagnoses From Collaborative Problems	20	(4)
Summary	24	(2)
Nursing Diagnoses: Assessment and Diagnosis	26	(12)
Assessment	26	(10)
Diagnosis	36	(1)
Summary	37	(1)
Planning Care With Nursing Diagnosis	38	(26)
Are Care Plans Necessary?	38	(1)
The Care Planning Process	38	(1)
Planning	38	(9)
Implementation	47	(1)
Evaluation	47	(2)
Multidisciplinary Care Planning	49	(1)
Care Planning Systems	50	(8)
Case Study Applications of Care Planning	58	(6)
Ten Steps to Putting It All Together	64	(4)
Step 1: Assessment	64	(1)
Step 2: Same-Day Assessment	65	(1)
Step 3: Create Your Initial Care Plan	65	(1)
Step 4: Review the Collaborative Problems on the Generic Plan	65	(1)
Step 5: Review the Nursing Diagnoses on the Standard Plan	65	(1)
Step 6: Prepare the Care Plan (Written or Printed)	66	(1)
Step 7: Initial Care Plan Completed	66	(1)
Step 8: Additional Risk Factors	67	(1)
Step 9: Evaluate the Status of Your Client (After You Provide Care)	67	(1)
Step 10: Document the Care on the Agency's Forms, Flow Records, and Progress Notes	67	(1)
Nursing Diagnoses: Issues and Controversies	68	(9)
Why Can't We Just Use the Words We've Always Used?	68	(1)
Other Disciplines Will Not Understand Our Diagnoses	69	(1)
Clients Will Not Understand Our Diagnoses	70	(1)
Nurse Practitioners, Nurse Anesthetists, and Nurse Midwives Do Not Need Nursing Diagnoses	71	(1)
Nursing Diagnoses Are Not Culturally Sensitive	72	(1)
Nursing Diagnosis Is Unethical	73	(1)
Nursing Diagnoses Can Violate Confidentiality	73	(2)
Summary	75	(2)
SECTION TWO Manual of Nursing Diagnoses	77	(748)
Introduction	79	(1)
Activity Intolerance	80	(15)
Related to Insufficient Knowledge of Adaptive Techniques Needed Secondary to COPD	86	(3)
Related to Insufficient Knowledge of Adaptive Techniques Needed Secondary to Impaired Cardiac Function	89	(3)
Related to Bed Rest Deconditioning	92	(3)
Decreased Intracranial Adaptive Capacity	95	(1)
Impaired Adjustment	96	(1)
Anxiety	97	(13)
Related to Insufficient Knowledge of Preoperative Routines, Postoperative Exercises/Activities, Postoperative Alterations/Sensations	107	(3)
Death Anxiety	110	(2)
Risk for Imbalanced Body Temperature	112	(4)
Hyperthermia	116	(2)
Hypothermia	118	(3)
Ineffective Thermoregulation	121	(4)
Related to Newborn Transition to Extrauterine Environment	123	(2)
Bowel Incontinence	125	(3)
Effective Breast-feeding	128	(1)
Ineffective Breast-feeding	129	(6)
Interrupted Breast-feeding	135	(1)
Decreased Cardiac Output	136	(1)
Caregiver Role Strain	137	(7)
Risk for Caregiver Role Strain	144	(3)
Impaired Comfort	147	(7)
Acute Pain	154	(12)
Chronic Pain	166	(4)
Nausea	170	(3)
Impaired Communication	173	(13)
Related to Effects of Hearing Loss	180	(2)
Related to Effects of Aphasia on Expression or Interpretation	182	(2)
Related to Foreign Language Barrier	184	(2)
Impaired Verbal Communication	186	(2)
Confusion	188	(1)
Acute Confusion	189	(7)
Chronic Confusion	196	(6)
Constipation	202	(9)
Related to Effects of Immobility on Peristalsis	210	(1)
Perceived Constipation	211	(2)
Ineffective Coping	213	(10)
Defensive Coping	223	(2)
Ineffective Denial	225	(7)
Related to Impaired Ability to Accept Consequences of Own Behavior as Evidenced by Lack of Acknowledgment of Substance Abuse/Dependency	229	(3)
Disabled Family Coping	232	(16)
Related to (Specify), as Evidenced by Domestic Abuse	240	(3)
Related to (Specify), as Evidenced by Child Abuse/Neglect	243	(3)
Related to Multiple Stressors Associated With Elder Care: High Risk for	246	(2)
Compromised Family Coping	248	(1)
Readiness for Enhanced Family Coping	249	(1)
Ineffective Community Coping	249	(5)
Readiness for Enhanced Community Coping	254	(5)
Related to Availability of Community Programs to Augment (Specify)	257	(2)
Decisional Conflict	259	(7)
Diarrhea	266	(5)
Disuse Syndrome	271	(8)
Deficient Diversional Activity	279	(5)
Dysreflexia	284	(4)
Risk for Dysreflexia	288	(1)
Energy Field Disturbance	288	(3)
Impaired Environmental Interpretation Syndrome	291	(2)
Family Processes, Interrupted	293	(8)
Related to Impact (Specify) of Ill Member on Family System	299	(2)
Family Processes, Dysfunctional: Alcoholism	301	(5)
Fatigue	306	(8)
Fear	314	(7)
Deficient Fluid Volume	321	(8)
Related to Abnormal Fluid Loss	327	(2)
Excess Fluid Volume	329	(5)
Risk for Imbalanced Fluid Volume	334	(1)
Grieving	335	(8)
Grieving, Anticipatory	343	(4)
Grieving, Dysfunctional	347	(3)
Growth and Development, Delayed	350	(8)
Development, Risk for Delayed	358	(1)
Growth, Risk for Disproportionate	359	(1)
Adult Failure to Thrive	359	(3)
Ineffective Health Maintenance	362	(19)
Related to Insufficient Knowledge of Effects of Tobacco Use and Self-Help Resources Available	373	(4)
Related to Increased Food Consumption in Response to Stressors and Insufficient Energy Expenditure for Intake	377	(4)
Health-Seeking Behaviors	381	(6)
Impaired Home Maintenance	387	(5)
Hopelessness	392	(9)
Infant Behavior, Disorganized	401	(7)
Infant Behavior, Risk for Disorganized	408	(1)
Infant Behavior, Readiness for Enhanced Organized	409	(3)
Infection, Risk for	412	(9)
Infection Transmission, Risk for	421	(7)
Related to Lack of Knowledge of Reducing the Risk of Transmitting the AIDS Virus	426	(2)
Injury, Risk for	428	(18)
Related to Lack of Awareness of Environmental Hazards	437	(5)
Related to Lack of Awareness of Environmental Hazards Secondary to Maturational Age	442	(2)
Related to Vertigo Secondary to Orthostatic Hypotension	444	(2)
Risk for Aspiration	446	(5)
Risk for Falls	451	(1)
Risk for Poisoning	452	(1)
Risk for Suffocation	452	(1)
Risk for Trauma	452	(1)
Injury, Risk for Perioperative Positioning	453	(5)
Deficient Knowledge	458	(1)
Latex Allergy Response	459	(2)
Latex Allergy Response, Risk for	461	(1)
Lifestyle, Sedentary	462	(3)
Loneliness, Risk for	465	(5)
Therapeutic Regimen Management, Effective: Individual	470	(3)
Therapeutic Regimen Management, Ineffective	473	(7)
Therapeutic Regimen Management, Ineffective: Family	480	(1)
Therapeutic Regimen Management, Ineffective: Community	481	(4)
Mobility, Impaired Physical	485	(7)
Impaired Bed Mobility	492	(1)
Impaired Walking	493	(1)
Impaired Wheelchair Mobility	494	(1)
Impaired Wheelchair Transfer Ability	495	(1)
Noncompliance	496	(7)
Nutrition, Imbalanced: Less Than Body Requirements	503	(15)
Related to Anorexia Secondary to (Specify)	514	(2)
Related to Difficulty or Inability to Procure Food	516	(2)
Altered Dentition	518	(1)
Impaired Swallowing	518	(5)
Ineffective Infant Feeding Pattern	523	(5)
Nutrition, Imbalanced: More Than Body Requirements	528	(3)
Nutrition, Imbalanced: Potential for More Than Body Requirements	531	(1)
Parenting, Impaired	532	(5)
Parent-Infant Attachment, Risk for Impaired	537	(5)
Parental Role Conflict	542	(7)
Related to Effects of Illness and/or Hospitalization of a Child	546	(3)
Peripheral Neurovascular Dysfunction, Risk for	549	(6)
Post-Trauma Syndrome	555	(5)
Post-Trauma Syndrome, Risk for	560	(1)
Rape Trauma Syndrome	560	(9)
Powerlessness	569	(7)
Protection, Ineffective	576	(1)
Tissue Integrity, Impaired	577	(7)
Skin Integrity, Impaired	584	(5)
Related to the Effects of Pressure, Friction, Shear, Maceration	587	(2)
Oral Mucous Membrane, Impaired	589	(8)
Related to Inadequate Oral Hygiene or Inability to Perform Oral Hygiene: Risk for	594	(3)
Relocation Stress [Syndrome]	597	(11)
Related to Changes Associated With Health Care Facility Transfers or Admission to Long-Term Care Facility	604	(4)
Respiratory Function, Risk for Ineffective	608	(11)
Related to Allergic Response	615	(4)
Dysfunctional Ventilatory Weaning Response	619	(6)
Dysfunctional Ventilatory Weaning Response, Risk for	625	(3)
Ineffective Airway Clearance	628	(2)
Ineffective Breathing Patterns	630	(2)
Impaired Gas Exchange	632	(1)
Impaired Spontaneous Ventilation	633	(1)
Role Performance, Ineffective	634	(1)
Self-Care Deficit Syndrome	635	(6)
Feeding Self-Care Deficit	641	(2)
Bathing/Hygiene Self-Care Deficit	643	(2)
Dressing/Grooming Self-Care Deficit	645	(3)
Toileting Self-Care Deficit	648	(2)
Instrumental Self-Care Deficit	650	(3)
Self-Concept, Disturbed	653	(9)
Body Image, Disturbed	662	(5)
Personal Identity, Disturbed	667	(1)
Self-Esteem, Disturbed	667	(2)
Chronic Low Self-Esteem	669	(3)
Situational Low Self-Esteem	672	(3)
Situational Low Self-Esteem, Risk for	675	(1)
Risk for Self-Harm	676	(12)
Risk for Self-Abuse	688	(1)
Self-Mutilation	689	(1)
Risk for Self-Mutilation	690	(1)
Risk for Suicide	691	(4)
Disturbed Sensory Perception	695	(6)
Sexuality Patterns, Ineffective	701	(16)
Related to Prenatal and Postpartum Changes	712	(4)
Related to Fear of Pregnancy and/or Sexually Transmitted Diseases (STDs): Risk for	716	(1)
Sexual Dysfunction	717	(1)
Disturbed Sleep Pattern	718	(7)
Sleep Deprivation	725	(1)
Social Interaction, Impaired	726	(8)
Social Isolation	734	(1)
Sorrow, Chronic	735	(3)
Spiritual Distress	738	(14)
Related to Conflict Between Religious or Spiritual Beliefs and Prescribed Health Regimen	750	(2)
Spiritual Distress, Risk for	752	(1)
Spiritual Well-Being, Readiness for Enhanced	753	(1)
Impaired Religiosity	754	(3)
Impaired Religiosity, Risk for	757	(1)
Risk for Sudden Infant Death Syndrome	758	(2)
Surgical Recovery, Delayed	760	(1)
Thought Processes, Disturbed	761	(11)
Memory, Impaired	772	(4)
Tissue Perfusion, Ineffective (Specify: Renal, Cerebral, Cardiopulmonary, Gastrointestinal)	776	(1)
Tissue Perfusion, Ineffective Peripheral	777	(6)
Unilateral Neglect	783	(4)
Urinary Elimination, Impaired	787	(6)
Maturational Enuresis	793	(3)
Functional Incontinence	796	(4)
Reflex Incontinence	800	(2)
Stress Incontinence	802	(3)
Total Incontinence	805	(3)
Urge Incontinence	808	(3)
Urinary Retention	811	(3)
Violence, Risk for	814	(8)
Wandering	822	(3)
SECTION THREE Manual of Collaborative Problems	825	(108)
Introduction	827	(1)
Potential Complication: Cardiac/Vascular	828	(12)
PC: Decreased Cardiac Output	829	(1)
PC: Dysrhythmias	830	(2)
PC: Pulmonary Edema	832	(1)
PC: Deep Vein Thrombosis	833	(1)
PC: Hypovolemia	834	(2)
PC: Compartmental Syndrome	836	(1)
PC: Pulmonary Embolism	837	(3)
Potential Complication: Respiratory	840	(7)
PC: Hypoxemia	841	(1)
PC: Atelectasis, Pneumonia	842	(2)
PC: Tracheobronchial Constriction	844	(2)
PC: Pneumothorax	846	(1)
Potential Complication: Metabolic/Immune/Hematopoietic	847	(24)
PC: Hypo/Hyperglycemia	848	(3)
PC: Negative Nitrogen Balance	851	(1)
PC: Electrolyte Imbalances	852	(7)
PC: Sepsis	859	(1)
PC: Acidosis (Metabolic, Respiratory)	860	(2)
PC: Alkalosis (Metabolic, Respiratory)	862	(2)
PC: Allergic Reaction	864	(2)
PC: Thrombocytopenia	866	(2)
PC: Opportunistic Infections	868	(1)
PC: Sickling Crisis	869	(2)
Potential Complication: Renal/Urinary	871	(8)
PC: Acute Urinary Retention	872	(2)
PC: Renal Insufficiency	874	(3)
PC: Renal Calculi	877	(2)
Potential Complication: Neurologic/Sensory	879	(10)
PC: Increased Intracranial Pressure	880	(2)
PC: Seizures	882	(2)
PC: Increased Intraocular Pressure	884	(1)
PC: Neuroleptic Malignant Syndrome	885	(2)
PC: Alcohol Withdrawal	887	(2)
Potential Complication: Gastrointestinal/Hepatic/Biliary	889	(8)
PC: Paralytic Ileus	890	(1)
PC: GI Bleeding	891	(1)
PC: Hepatic Dysfunction	892	(3)
PC: Hyperbilirubinemia	895	(2)
Potential Complication: Muscular/Skeletal	897	(4)
PC: Pathologic Fractures	898	(1)
PC: Joint Dislocation	899	(2)
Potential Complication: Reproductive	901	(9)
PC: Prenatal Bleeding	902	(1)
PC: Preterm Labor	903	(2)
PC: Pregnancy-Associated Hypertension	905	(1)
PC: Fetal Distress	906	(2)
PC: Postpartum Hemorrhage	908	(2)
Potential Complication: Medication Therapy Adverse Effects	910	(23)
PC: Anticoagulant Therapy Adverse Effects	911	(2)
PC: Antianxiety Therapy Adverse Effects	913	(2)
PC: Adrenocorticosteroid Therapy Adverse Effects	915	(2)
PC: Antineoplastic Therapy Adverse Effects	917	(2)
PC: Anticonvulsant Therapy Adverse Effects	919	(2)
PC: Antidepressant Therapy Adverse Effects	921	(2)
PC: Antiarrhythmic Therapy Adverse Effects	923	(1)
PC: Antipsychotic Therapy Adverse Effects	924	(3)
PC: Antihypertensive Therapy Adverse Effects	927	(1)
PC: β-Adrenergic Blocker Therapy Adverse Effects	927	(2)
PC: Calcium Channel Blocker Therapy Adverse Effects	929	(2)
PC: Angiotensin-Converting Enzyme Inhibitor Therapy Adverse Effects	931	(2)
Appendix A: Nursing Diagnoses Grouped Under Functional Health Patterns	933	(4)
Appendix B: Health-Promotion/Wellness Diagnoses	937	(4)
Bibliography	941	(28)
Index	969