Table Of Content

This unique book has four sections for medical-surgical, pediatric, maternity, and psychiatric nursing care plans. The medical-surgical care plans are organized alphabetically within each body system. Each care plan uses the following consistent format: OVERVIEW/PATHOPHYSIOLOGY • Brief introduction to the disorder or condition • Includes a review of pathophysiology, where appropriate HEALTH CARE SETTING • Specified for each care plan, because these conditions are treated in various settings • Examples include acute, primary, community, and long-term care ASSESSMENT • Covers signs and symptoms of the disorder, divided into chronic and acute indicators, where appropriate • Includes key health history and physical assessment points DIAGNOSTIC TESTS • Summarizes tests that might be used to diagnose (or rule out), treat, and monitor the condition NURSING DIAGNOSIS WITH DESIRED OUTCOME • Includes the most recent NANDA nursing diagnoses • Outcome criteria with specific timelines ASSESSMENT/INTERVENTIONS AND RATIONALES • Two-column format for quick reference • Detailed rationales for each nursing intervention help you apply concepts to clinical practice • Safety icons alert you to assessment and intervention data that necessitate special care and attention PATIENT-FAMILY TEACHING AND DISCHARGE PLANNING • Highlight key patient education topics such as recommended follow-up care, when to contact a health care provider, and considerations related to medications, diet, and exercise • Include referrals to community resources and organizations for further information How to Use This Book ALL-IN-ONE NURSING CARE PLANNING RESOURCE Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health This page intentionally left blank 4e ALL-IN-ONE NURSING CARE PLANNING RESOURCE Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health Pamela L. Swearingen, RN Special Project Editor 3251 Riverport Lane St. Louis, Missouri 63043 ALL-IN-ONE NURSING CARE PLANNING RESOURCE, FOURTH EDITION ISBN: 978-0-323-26286-6 Copyright © 2016 by Mosby, an imprint of Elsevier Inc. Copyright © 2012, 2008, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data All-in-one nursing care planning resource : medical-surgical, pediatric, maternity, psychiatric nursing care plans / Pamela L. Swearingen, special project editor. – 4th edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-323-26286-6 I. Swearingen, Pamela L., editor. [DNLM: 1. Nursing Process–organization & administration. 2. Nursing Care–methods. 3. Patient Care Planning. WY 100.1] RT49 610.73–dc23 2014043475 Executive Content Strategist: Lee Henderson Content Development Manager: Billie Sharp Content Development Specialist: Charlene Ketchum Publishing Services Manager: Hemamalini Rajendrababu Project Manager: Maria Bernard Design Direction: Ashley Miner Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2 1 v To the memory of Carol Monlux Swift, RN, BSN, CNRN, whose integrity, talent, and dedication to the nursing profession live on. Dedication This page intentionally left blank vii Contributors MEDICAL-SURGICAL NURSING CARE PLANS Lolita M. Adrien-Dunlap, RN, MS, CNS, CWON Professor of Nursing, Retired Contra Costa College San Pablo, California *Contributed care plans for Crohn’s Disease, Fecal Diversions, and Ulcerative Colitis. Marianne Baird, RN, MN Clinical Nurse Specialist Magnet Program Director Saint Joseph’s Hospital of Atlanta Atlanta, Georgia *Contributed Endocrine Care Plans. Lynda K. Ball, RN, MSN, CNN Quality Improvement Coordinator Northwest Renal Network Seattle, Washington *Contributed care plan for Care of the Renal Transplant Recipient. Barbara S. Bishop, MS, ANP-BC, MSCN, CNRN Nurse Practitioner, Adult Neurology and Multiple Sclerosis Specialist Virginia Beach Neurology Virginia Beach, Virginia *Contributed care plans for Neurologic Care Plans. Maureen Bel Boardman, MSN, APRN-BC Instructor Dartmouth Medical School Hanover, New Hampshire *Contributed care plans for Pneumonia and Respiratory Failure, Acute. Jenny Bosley, RN, MS, CEN Nursing Clinical Adjunct Faculty Thomas Jefferson University Philadelphia, Pennsylvania *Contributed care plans for Cholelithiasis, Cholecystitis and Cholangitis and Cirrhosis. Michelle T. Bott, RN, MN Senior Director, Patient Care Services Guelph General Hospital Guelph, Ontario, Canada *Contributed care plans for Acute Renal Failure, Chronic Kidney Disease, Care of the Patient Undergoing Hemodialysis, Care of the Patient Undergoing Peritoneal Dialysis, and Laboratory Tests: Reference Ranges for Adult Patients appendix. Michael W. Day, RN, MSN CCRN Trauma Care Coordinator Providence Sacred Heart Medical Center & Children’s Hospital Spokane, Washington *Contributed care plan for COPD. Vicki Good, MSN, RN, CENP, CPPS Practitioner System Director Clinical Safety Cox Health Springfield, Missouri *Contributed care plan for Pulmonary Tuberculosis. R. Mark Hovis, CRNA Nurse Anesthetist Washington University School of Medicine St. Louis, Missouri *Contributed care plan for Perioperative Care. Patricia Jansen, RN, MSN, CNS, GCS-BC, OCN Medical Surgical Clinical Nurse Specialist Regional Medical Center of San Jose San Jose, California *Contributed care plans for Benign Prostatic Hypertrophy, Older Adult Care, Ureteral Calculi, Urinary Diversions, and Urinary Tract Obstruction. Suzanne Jed, MSN, FNP-BC Instructor of Clinical Family Medicine Pacific AIDS Education and Training Center Keck School of Medicine University of Southern California Los Angeles, California *Contributed care plan for Caring for Individuals with Human Immunodeficiency Virus and Infection Prevention and Control appendix. CONTRIBUTORS viii Nancy A. Stotts, EdD, RN, FAAN Professor Emeritus University of California, San Francisco San Francisco, California *Contributed care plan for Managing Wound Care. Beth Taylor, RD, MS, CNSD, FCCM Nutrition Support Specialist Barnes-Jewish Hospital St. Louis, Missouri *Contributed care plan for Providing Nutritional Support. Mary E. Young, APRN, MSN, BC Adult Nurse Practitioner Assistant Dean and Director of Nursing and Allied Health Hartnell College Salinas, California *Contributed care plan for Abdominal Trauma and Cardiovascular Care Plans. PEDIATRIC NURSING CARE PLANS Sherry D. Ferki, RN, MSN Adjunct Faculty Old Dominion University, School of Nursing Norfolk, Virginia * Contributed Pediatric Care Plans and Laboratory Tests: Reference Ranges for Pediatric Patients appendix. MATERNITY NURSING CARE PLANS Jacqueline Wright, RNC-OB, MSN, C-EFM, IBCLC Professor of Nursing-Maternity Contra Costa College San Pablo, California PSYCHIATRIC CARE PLANS Donna Rolin-Kenny Assistant Professor Family Psychiatric Mental Health Nurse Practitioner Program University of Texas at Austin School of Nursing Austin, Texas *Contributed care plans for Dementia-Alzheimer’s Type and Substance-Related and Addictive Disorders. Anthony Steele, DNP, FNP-C, PMHNP-C Director of Medical Services Alcohol and Drug Services Greensboro, North Carolina *Contributed care plans for Bipolar Disorder (Manic Component) and Schizophrenia. Sylvia Rae Stevens, PhD APRN-BC Professor Montgomery College Takoma Park/Silver Spring, Maryland *Contributed care plans for Anxiety Disorders and Major Depression. Kim Kuebler, DNP, APRN, ANP-BC Associate Professor South University Savannah, Georgia *Contributed care plan for Palliative and End-of-Life Care. Charlene Warren Myers Associate Professor University of South Alabama Mobile, Alabama *Contributed care plans for Hepatitis, Pancreatitis, and Peritonitis Misty Kirby-Nolan, MSN, APN-CNP Nurse Practitioner Northwestern Memorial Hospital Adjunct Faculty Saint Xavier University Chicago, Illinois *Contributed care plan for Pain. Ann Will Poteet, MS, RN, CCNS Graduate Clinical Placements Office of Academic Programs University of Colorado, College of Nursing Aurora, Colorado *Contributed care plans for Pneunothorax/Hemothorax and Pulmonary Embolus. Barbara D. Powe, RN, PhD Director, Underserved Populations Research American Cancer Society Atlanta, Georgia *Contributed care plan for Cancer Care, Psychosocial Support, and Psychosocial Support of the Patient’s Family and Significant Other. Dottie Roberts, RN, MSN, MACI, CMSRN, OCNS-C® Nursing Instructor South University Clinical Nurse Specialist Palmetto Health Baptist Columbia, South Carolina *Contributed Musculoskeletal Care Plans. Sandra Rome, RN, MN, AOCN Hematology/Oncology Clinical Nurse Specialist Cedars-Sinai Medical Center Assistant Clinical Professor, UCLA School of Nursing Los Angeles, California *Contributed Hematologic Care Plans. Laura Steadman, EdD Associate Professor of Nursing University of Alabama Birmingham, Alabama *Contributed care plan for Prolonged Bedrest. ix Catherine Corrigan, APRN, MSN, BC Assistant Professor University of Detroit Mercy Detroit, Michigan Terry Delpier, RN, DNP, CPNP Professor of Nursing Northern Michigan University Marquette, Michigan Angela DiSabatino, RN, MS Manager, Cardiovascular Clinical Trials Center for Heart and Vascular Health Christiana Care Health System Newark, Delaware Adjunct Nursing Faculty Wilmington University Wilmington, Delaware Jennifer Duhon, RN, MS Public Health Nurse Peoria City/County Health Department Peoria, Illinois Jean Gash, APRN, PhD, BC Assistant Professor University of Detroit Mercy Detroit, Michigan Susan J. Grant, MSN, MS, APN, FNP-BC Clinical Instructor Family Nurse Practitioner College of Nursing University of Arkansas for Medical Sciences Fayetteville, Arkansas Leanna Kinney, RN Director of Nursing Pediatric Home Health Care Epic MedStaff Services, Inc. San Antonio, Texas Margaret Malone, RN, MN, CCRN Clinical Nurse Specialist Critical Care and Cardiology St. John Medical Center Longview, Washington Joyce Marrs, MS, FNP-BC, AOCNP Nurse Practitioner Hematology and Oncology Dayton Physicians Dayton, Ohio Charles Preston Molsbee, MSN, RN, CNE Assistant Professor Nursing University of Arkansas at Little Rock Little Rock, Arkansas Gina M. Newman, RN Infection Preventionist Infection Prevention and Clinical Epidemiology Sharp Memorial Hospital San Diego, California Casey Norris, BSN, MSN, PCNS, BC Pulmonary Clinical Specialist East Tennessee Children’s Hospital Knoxville, Tennessee Harriett Pitt, RN, MS, CIC Infection Preventionist President EPIC Management Group, Inc. Mount St. Mary School of Nursing Adjunct Professor Healthcare Epidemiology Los Angeles, California Mary Rodts, DNP, CNP, ONC, FAAN Associate Professor Rush College of Nursing Chicago, Illinois Richard J. Slote, RN, MS, ONC, RNC Clinical Nurse II Hospital for Special Surgery New York, New York Jessica Gaither Vandett, RN, MSN, ARNP, FNP-C Assistant Professor Department of Nursing University of Arkansas at Little Rock Little Rock, Arkansas Reviewers REVIEWERS x Kathleen S. Whalen, RN, PhD Assistant Professor of Nursing Loretto Heights School of Nursing Regis University Denver, Colorado Alan H.B. Wu, PhD, DABCC Professor Laboratory Medicine University of California San Francisco San Francisco, California Marge Zerbe, RN, BS Consultant and Education Noelle Project Gaumard Scientific, Inc. Miami, Florida Adjunct Faculty Lake Sumter Community College Leesburg, Florida xi Preface All-in-One Nursing Care Planning Resource is a one-of-a-kind book featuring nursing care plans for all four core clinical areas. The inclusion of pediatric, maternity, and psychiatric- mental health nursing in addition to medical-surgical nursing care plans enables students to use one book throughout the entire nursing curriculum. This unique presentation— combined with solid content, an open and accessible format, and clinically relevant features—makes this a must-have care plans book for nursing students. ORGANIZATION This book is organized into four separate sections for medical- surgical, pediatric, maternal, and psychiatric-mental health care plans. Within each section, care plans are listed alphabetically by disorder or condition (the medical-surgical nursing care plans are organized alphabetically within each body system). General information that applies to more than one disorder can be found in the General Care Plans section, where nursing diagnoses and interventions for perioperative care, pain, prolonged bedrest, cancer care, psychosocial support for patients, psychosocial support for the patient’s family and significant others, older adult care, and palliative/end-of-life care are discussed. Each disorder uses the following consistent format: • Overview/Pathophysiology, which includes a synopsis of the disorder and its pathophysiology, where appropriate • Health Care Setting, such as hospital, primary, community, or long-term care • Assessment, covering signs and symptoms and physical assessment • Diagnostic Tests • Nursing Diagnoses with Desired Outcomes • Assessment/Interventions and Rationales in a clear, two-column format • Patient-Family Teaching and Discharge Planning This book is organized to provide the most important information related to various disorders. By providing a consistent format for each disorder, key information that a nurse needs to know is fully covered. For example, the rationales given for the interventions are supported by supplemental information provided in the “Overview/Pathophysiology” and “Assess- ment” sections. FEATURES The care plans in this book were written by clinical experts in each subject area to ensure the most current and accurate information. In addition to reliable content, the book offers the following special features: • A consistent, easy-to-use format facilitates quick and easy retrieval of information. • The Health Care Setting is specified for each care plan, because these conditions are treated in various settings such as hospital, primary care, long-term care facility, community, and home care. • Outcome criteria with specific timelines assist in setting realistic goals for nursing outcomes and providing quality, cost-effective care. • Detailed, specific rationales for each nursing intervention apply concepts to clinical practice. • The Patient-Family Teaching and Discharge Planning section highlights key patient education topics, as well as resources for further information. • The newest NANDA-International nursing diagnoses are included in each care plan. • Separate care plans on Pain and End-of-Life Care focus on palliative care for patients with terminal illnesses, as well as relief of acute and chronic pain. • Current care and patient safety standards and clinical practice guidelines in nursing and other health care disciplines are incorporated throughout the interventions and rationales. • Infection prevention and control guidelines from the Centers for Disease Control and Prevention (CDC) are included in the appendix. • Normal laboratory values for adults are listed in Appendix B, including separate tables for Complete Blood Count; Serum, Plasma, and Whole Blood Chem- istry; and Urine Chemistry. Normal laboratory values for pediatric patients are included in Appendix C. New to this edition are: • A special index that lists all the nursing diagnoses used in this book along with their descriptive data and page numbers. • Safety alert icons that alert nurses to interventions that necessitate special attention and care. • Complimentary and Alternative Therapies icons that alert nurses to supplements that patients may be using and how they can interact with conventional medication. • Canadian Resources icons that alert Canadian nurses to especially relevant references and journals. • A new care plan for Normal Labor and Birth. This book was carefully prepared to meet the needs of today’s busy nursing student. We welcome comments on how we can enhance its usefulness in subsequent editions. Pamela L. Swearingen This page intentionally left blank xiii PART I MEDICAL-SURGICAL NURSING, 1 GENERAL CARE PLANS 1 Cancer Care, 1 2 Pain, 39 3 Perioperative Care, 45 4 Prolonged Bedrest, 61 5 Psychosocial Support, 72 6 Psychosocial Support for the Patient’s Family and Significant Others, 84 7 Older Adult Care, 90 8 Palliative and End-of-Life Care, 103 RESPIRATORY CARE PLANS 9 Chronic Obstructive Pulmonary Disease, 111 10 Pneumonia, 116 11 Pneumothorax/Hemothorax, 122 12 Pulmonary Embolus, 127 13 Pulmonary Tuberculosis, 133 14 Respiratory Failure, Acute, 136 CARDIOVASCULAR CARE PLANS 15 Aneurysms, 137 16 Atherosclerotic Arterial Occlusive Disease, 140 17 Cardiac and Noncardiac Shock (Circulatory Failure), 145 18 Cardiac Surgery, 149 19 Coronary Artery Disease, 152 20 Dysrhythmias and Conduction Disturbances, 164 21 Heart Failure, 168 22 Hypertension, 179 23 Pulmonary Arterial Hypertension, 181 24 Venous Thrombosis/Thrombophlebitis, 186 RENAL-URINARY CARE PLANS 25 Acute Renal Failure, 190 26 Benign Prostatic Hypertrophy, 197 27 Chronic Kidney Disease, 205 28 Care of the Patient Undergoing Hemodialysis, 212 29 Care of the Patient Undergoing Peritoneal Dialysis, 216 30 Care of the Renal Transplant Recipient, 220 31 Ureteral Calculi, 224 32 Urinary Diversions, 230 33 Urinary Tract Obstruction, 238 NEUROLOGIC CARE PLANS 34 General Care of Patients with Neurologic Disorders, 242 35 Bacterial Meningitis, 262 36 Guillain-Barré Syndrome, 267 37 Intervertebral Disk Disease, 275 Contents 38 Multiple Sclerosis, 286 39 Parkinsonism, 293 40 Seizures and Epilepsy, 304 41 Spinal Cord Injury, 313 42 Stroke, 329 43 Traumatic Brain Injury, 340 ENDOCRINE CARE PLANS 44 Diabetes Insipidus, 352 45 Diabetes Mellitus, 355 46 Diabetic Ketoacidosis, 365 47 Hyperglycemic Hyperosmolar Syndrome, 373 48 Hyperthyroidism, 377 49 Hypothyroidism, 385 50 Syndrome of Inappropriate Antidiuretic Hormone, 392 GASTROINTESTINAL CARE PLANS 51 Abdominal Trauma, 395 52 Appendicitis, 405 53 Cholelithiasis, Cholecystitis, and Cholangitis, 409 54 Cirrhosis, 413 55 Crohn’s Disease, 420 56 Fecal Diversions: Colostomy, Ileostomy, and Ileal Pouch Anal Anastomoses, 429 57 Hepatitis, 437 58 Pancreatitis, 442 59 Peptic Ulcer Disease, 450 60 Peritonitis, 454 61 Ulcerative Colitis, 459 HEMATOLOGIC CARE PLANS 62 Anemias of Chronic Disease, 468 63 Disseminated Intravascular Coagulation, 471 64 Polycythemia, 475 65 Thrombocytopenia, 479 MUSCULOSKELETAL CARE PLANS 66 Amputation, 484 67 Fractures, 490 68 Joint Replacement Surgery, 498 69 Osteoarthritis, 504 70 Osteoporosis, 509 71 Rheumatoid Arthritis, 515 SPECIAL NEEDS CARE PLANS 72 Caring for Individuals with Human Immunodeficiency Virus, 521 73 Managing Wound Care, 533 74 Providing Nutritional Support, 539