Clinical Applications of Nursing Diagnosis: Adult, Child, Women's, Psychiatric, Gerontic, and Home Health Considerations

896 Pages·2007·7.45 MB·English

00Newfield (F)-FC-BC 4/3/07 9:47 PM Page 2
N D
URSING IAGNOSES
ACCEPTED FOR USE AND RESEARCH (2007-2008)
Health Maintenance, ineffective, 42 Sensory Perception, disturbed: (specify: visual,
Health-Seeking Behaviors (specify), 49 auditory, kinesthetic, gustatory, tactile,
Home Maintenance, impaired, 360 olfactory), 497
Activity Intolerance [specify level], 283
Hope, readiness for enhanced, 523 Sexual Dysfunction, 725
Activity Intolerance, risk for, 283
Hopelessness, 562 Sexuality Pattern, ineffective, 731
Airway Clearance, ineffective, 292
Hyperthermia, 176 Skin Integrity, impaired, 216
Allergy Response, latex, 70
Hypothermia, 182 Skin Integrity, risk for impaired, 216
Allergy response, latex, risk for, 70
Sleep, readiness for enhanced, 437
Anxiety [specify level], 530 Identify, disturbed personal, 575
Sleep Deprivation, 425
Anxiety, death, 548 Infant Behavior, disorganized, 365
Social Interaction, impaired, 684
Aspiration, risk for, 136 Infant Behavior, organized, readiness
Social Isolation, 688
Attachment, risk for impaired for enhanced, 365
Sorrow, chronic, 695
parent/infant/child, 659 Infant Behavior, risk for disorganized, 365
Spiritual Distress, 812
Autonomic Dysreflexia, 299 Infant Feeding Pattern, ineffective, 186
Spiritual Distress, risk for, 818
Autonomic Dysreflexia, risk for, 299 Infection, risk for, 54
Spiritual Well-Being, readiness for enhanced, 824
Injury, risk for, 59
Body Image, disturbed, 541 Stress Overload, 740
Injury, risk for perioperative positioning, 96
Body Temperature, risk for imbalanced, 139 Suicide, risk for, 791
Intracranial Adaptive Capacity, decreased, 450
Bowel Incontinence, 236 Surgical Recovery, delayed, 107
Breastfeeding, effective, 144 Knowledge, deficient [Learning Need] Swallowing, impaired, 209
Breastfeeding, ineffective, 148 [specify], 474
Therapeutic Regimen Management, effective, 75
Breastfeeding, interrupted, 152 Knowledge [specify], readiness for enhanced, 474
Therapeutic Regimen Management, ineffective, 80
Breathing Pattern, ineffective, 307
Lifestyle, sedentary, 381 Therapeutic Regimen Management, ineffective
Cardiac Output, decreased, 313 Loneliness, risk for, 569 community, 80
Caregiver Role Strain, 618 Therapeutic Regimen Management, ineffective
Memory, impaired, 482
Caregiver Role Strain, risk for, 618 family, 80
Mobility, impaired bed, 304
Communication, impaired verbal, 626 Therapeutic Regimen Management, readiness for
Mobility, impaired physical, 373
Communication, readiness for enhanced, 626 enhanced, 92
Mobility, impaired wheelchair, 415
Conflict, parental role, 463 Thermoregulation, ineffective, 213
Confusion, acute, 454 Nausea, 189 Thought Processes, disturbed, 506
Confusion, risk for acute, 454 Noncompliance, [Adherence, ineffective] Tissue Integrity, impaired, 216
Confusion, chronic, 454 [specify], 80 Tissue Perfusion, ineffective (specify type: cerebral,
Constipation, 240 Nutrition, less than body requirements, cardiopulmonary, renal, gastrointestinal,
Constipation, perceived, 240 imbalanced, 194 peripheral), 396
Constipation, risk for, 240 Nutrition, more than body requirements, Transfer Ability, impaired, 406
Coping, defensive, 771 imbalanced, 204
Unilateral Neglect Syndrome, 514
Coping, ineffective, 772 Nutrition, readiness for enhanced, 193
Urinary Elimination, readiness for enhanced, 252
Coping, readiness for enhanced, 767 Nutrition, more than body requirements, risk for
Urinary Incontinence, functional, 254
Coping, ineffective community, 756 imbalanced, 204
Urinary Incontinence, reflex, 254
Coping, readiness for enhanced community, 756
Oral Mucous Membrane, impaired, 216 Urinary Incontinence, stress, 254
Coping, compromised family, 760
Urinary Incontinence, total, 254
Coping, disabled family, 760 Pain, acute, 483
Urinary Incontinence, urge, 255
Coping, readiness for enhanced family, 767 Pain, chronic, 483
Urinary Incontinence, risk for urge, 255
Parenting, impaired, 662
Death Syndrome, risk for sudden infant, 111 Urinary Retention [acute/chronic], 263
Parenting, readiness for enhanced, 662
Decisional Conflict (specify), 463
Parenting, risk for impaired, 662 Ventilation, impaired spontaneous, 393
Denial, ineffective, 781
Perioperative Positioning, risk for, 96 Ventilatory Weaning Response, dysfunctional, 332
Dentition, impaired, 155
Peripheral Neurovascular Dysfunction, risk for, 370 Violence, [actual/] risk for other-directed, 700
Development, risk for delayed, 353
Poisoning, risk for, 60 Violence, [actual/] risk for self-directed, 700
Diarrhea, 248
Post-Trauma Syndrome [specify stage], 785
Disuse Syndrome, risk for, 321 Walking, impaired, 408
Post-Trauma Syndrome, risk for, 785
Diversional Activity, deficient, 327 Wandering [specify sporadic or continual], 411
Powerlessness [specify level], 579
Energy Field, disturbed (revised), 36 Powerlessness, risk for, 579 [ ] author recommendations
Environmental Interpretation Syndrome, Protection, ineffective, 100
Used with permission from NANDA International:
impaired, 469
Rape-Trauma Syndrome, 717 Definitions and Classification, 2007-2008. NANDA,
Failure to Thrive, adult, 127 Rape-Trauma Syndrome: compound reaction, 717 Philadelphia, PA 2007
Falls, risk for, 336 Rape-Trauma Syndrome: silent reaction, 717
New from NANDA 2007-2008
Family Processes: alcoholism, dysfunctional, 635 Religiosity, impaired, 802
Blood Sugar, risk for unstable
Family Processes, interrupted, 635 Religiosity, risk for impaired, 802
Comfort, readiness for enhanced
Family Processes, readiness for enhanced, 635 Religiosity, readiness for enhanced, 807
Contamination
Fatigue, 340 Relocation Stress Syndrome, 673
Contamination, risk for
Fear (specify focus), 553 Relocation Stress Syndrome, risk for, 673
Decision-Making, readiness for enhanced
Fluid Balance, readiness for enhanced, 158 Role Performance, ineffective, 678
Glucose, risk for unstable level
[Fluid Volume, deficient hyper/hypotonic]
Self-Care Deficit: bathing/hygiene, 386 Health Behavior, risk prone
Fluid Volume, deficient [isotonic], 161
Self-Care Deficit: dressing/grooming, 386 Human Dignity, risk for compromised
Fluid Volume, excess, 167
Self-Care Deficit: feeding, 386 Immunization Status, readiness for enhanced
Fluid Volume, risk for deficient, 161
Self-Care Deficit: toileting, 386 Insomnia
Fluid Volume risk for imbalanced, 173
Self-Care, readiness for enhanced, 386 Liver Function, risk for impaired
Gas Exchange, impaired, 346 Self-Concept, readiness for enhanced, 586 Moral Distress
Grieving, 646 Self-Esteem, chronic low, 590 Power, readiness for enhanced
Grieving, complicated, 654 Self Esteem, situational low, 590 Suffocation, risk for
Grieving, risk for complicated, 654 Self Esteem, risk for situational low, 590 Trauma, risk for
Growth, risk for disproportionate, 353 Self-Mutilation, 598 Urinary Elimination, impaired
Growth & Development, delayed, 353 Self-Mutilation, risk for, 598 Urinary Incontinence, overflow
00Newfield (F)-FC-BC 4/3/07 9:47 PM Page 3
G ’ F
ORDON S UNCTONAL
H P *
EALTH ATTERNS
HEALTH PERCEPTION-HEALTH Autonomic dysreflexia, 299 ROLE-RELATIONSHIP PATTERN
MANAGEMENT PATTERN Decreased cardiac output, 313 Anticipatory grieving, 654
Disturbed energy field, 36 Decreased intracranial adaptive capacity, 450 Caregiver role strain, 618
Effective therapeutic regimen management, 75 Deficient diversonal activity, 327 Chronic sorrow, 695
Health-seeking behaviors (specify), 49 Delayed growth and development, 353 Dysfunctional family processes: alcoholism, 635
Ineffective community therapeutic regimen Delayed surgical recovery, 107 Dysfunctional grieving, 654
management, 80 Disorganized infant behavior, 365 Impaired parenting, 662
Ineffective family therapeutic regimen Dysfunctional ventilatory weaning response, 331 Impaired social interaction, 684
management, 80 Fatigue, 340 Impaired verbal communication, 626
Ineffective health maintenance, 42 Impaired spontaneous ventilation, 393 Ineffective role performance, 678
Ineffective protection, 100 Impaired bed mobility, 304 Interrupted family processes, 635
Ineffective therapeutic regimen management, 80 Impaired gas exchange, 346 Parental role conflict, 662
Noncompliance (specify), 80 Impaired home maintenance, 360 Readiness for enhanced communication, 626
Readiness for enhanced immunization status, 30 Impaired physical mobility, 373 Readiness for enhanced family processes, 635
Readiness for enhanced therapeutic regimen Impaired transfer ability, 406 Readiness for enhanced parenting, 662
management, 92 Impaired walking, 408 Relocation stress syndrome, 673
Risk for falls, 336 Impaired wheelchair mobility, 415 Risk for caregiver role strain, 618
Risk for infection, 54 Ineffective airway clearance, 292 Risk for violence directed at others, 700
Risk for injury (trauma), 59 Ineffective breathing pattern, 307 Risk for dysfunctional grieving, 654
Risk for perioperative positioning injury, 96 Ineffective tissue perfusion (specify), 396 Risk for impaired parent/infant/child
Risk for suffocation, 60 Readiness for enhanced organized infant behavior, 365 attachment, 659
Risk for poisoning, 60 Readiness for enhanced self care, 386 Risk for impaired parenting, 662
Sudden infant death syndrome, 111–115 Risk for delayed development, 353 Risk for relocation stress syndrome, 673
Risk for disorganized infant behavior, 365 Social isolation, 688
Risk for disproportionate growth, 353
NUTRITIONAL-METABOLIC PATTERN
Risk for activity intolerance, 283 SEXUALITY-REPRODUCTIVE PATTERN
Adult failure to thrive, 127 Risk for autonomic dysreflexia, 299
Deficient fluid volume, 161 Risk for disuse syndrome, 321 Ineffective sexuality patterns, 731
Effective breastfeeding, 144 Risk for peripheral neurovascular dysfunction, 370 Rape-trauma syndrome, 717
Excess fluid volume, 167 Sedentary lifestyle, 381 Rape-trauma syndrome: compound reaction, 717
Hyperthermia, 176 Self-care deficit (specify: bathing/hygiene, Rape-trauma syndrome: silent reaction, 717
Hypothermia, 182 dressing/grooming, feeding, toileting), 386 Sexual dysfunction, 718
Imbalanced nutrition: more than body Wandering, 411
requirements, 204 COPING-STRESS TOLERANCE
Imbalanced nutrition: less than body SLEEP-REST PATTERN PATTERN
requirements, 194 Disturbed sleep pattern, 431 Compromised family coping, 760
Impaired dentition, 155 Readiness for enhanced sleep, 437 Defensive coping, 771
Impaired oral mucous membrane, 216 Sleep deprivation, 425 Disabled family coping, 760
Impaired skin integrity, 216 Impaired adjustment, 747
Impaired swallowing, 209 COGNITIVE-PERCEPTUAL Ineffective community coping, 756
Impaired tissue integrity (specify type), 216 Ineffective coping, 772
Ineffective breastfeeding, 148 PATTERN Ineffective denial, 781
Ineffective infant feeding pattern, 186 Acute confusion, 454 Post-trauma syndrome, 785
Ineffective thermoregulation, 213 Acute pain, 483 Readiness for enhanced community coping, 756
Interrupted breastfeeding, 152 Chronic confusion, 454 Readiness for enhanced coping, 767
Latex allergy response, 70 Chronic pain, 483 Readiness for enhanced family coping, 767
Nausea, 189 Decisional conflict (specify), 463 Risk for self-mutilation, 598
Readiness for enhanced fluid balance, 158 Deficient knowledge (specify), 474 Risk for suicide, 791
Readiness for enhanced nutrition, 193 Disturbed sensory perception (specify), 497 Risk for post-trauma syndrome, 785
Risk for aspiration, 136 Disturbed thought processes, 506 Self-mutilation, 598
Risk for deficient fluid volume, 161 Impaired environmental interpretation Stress overload, 740
Risk for imbalanced fluid volume, 173 syndrome, 469
Risk for imbalanced body temperature, 139 Impaired memory, 480 VALUE-BELIEF PATTERN
Risk for imbalanced nutrition: more than body Readiness for enhanced knowledge (specify), 474
Impaired religiosity, 804
requirements, 204 Risk for acute confusion, 454
Readiness for enhanced religiosity, 808
Risk for impaired skin integrity, 216 Unilateral neglect, 514
Readiness for enhanced spiritual well-being, 824
Risk for latex allergy response, 70
Risk for impaired religiosity, 804
SELF-PERCEPTION AND SELF-
Risk for spiritual distress, 818
ELIMINATION PATTERN CONCEPT PATTERN Spiritual distress, 812
Bowel incontinence, 236 Anxiety, 527
Constipation, 240 Body image disturbed, 541 *Modified by Marjory Gordon, 2007, with permission.
Diarrhea, 248 Chronic low self-esteem, 590 †New from NANDA 2007-2008
Functional urinary incontinence, 254 Death anxiety, 548 Contamination
Perceived constipation, 240 Disturbed personal identity, 575 Risk for exposure to contamination
Readiness for enhanced urinary elimination, 252 Fear, 553 Risk for impaired liver function
Reflex urinary incontinence, 254 Hopelessness, 562 Risk for unstable blood glucose
Risk for constipation, 240 Powerlessness, 579 Impaired urinary elimination
Risk for urge urinary incontinence, 255 Readiness for enhanced hope, 523 Overflow urinary incontinence
Stress urinary incontinence, 254 Readiness for enhanced self-concept, 586 Readiness for enhanced comfort
Total incontinence, 254 Risk for loneliness, 569 Readiness for enhanced decision-making
Urge urinary incontinence, 255 Risk for violence, self-directed, 700 Readiness for enhanced power
Urinary retention, 263 Risk for powerlessness, 579 Risk for compromised human dignity
Risk for situational low self-esteem, 590 Moral distress
ACTIVITY-EXERCISE PATTERN Situational low self-esteem, 590
Activity intolerance, 283
00Newfield (F)-FM 4/18/07 7:31 PM Page i
C ’ C
OX S LINICAL
A
PPLICATIONS OF
N D
URSING IAGNOSIS
00Newfield (F)-FM 4/18/07 7:31 PM Page ii
00Newfield (F)-FM 4/18/07 7:31 PM Page iii
C ’ C
OX S LINICAL
A
PPLICATIONS OF
N D
URSING IAGNOSIS
Adult, Child, Women’s, Mental Health,
Gerontic, and Home Health Considerations
Susan A. Newfield, PhD, RN, APRN, BC
Associate Professor
West Virginia University
Morgantown, West Virginia
Mittie D. Hinz, MSN, MBA, RNC
Partner
DXT Consulting
San Antonio, Texas
Program Administrator
Hamot For Women
Hamot Medical Center
Erie, Pennsylvania
Fifth Edition
Donna Scott Tilley, RN, PhD, CNE
Associate Professor
Texas Christian University
Fort Worth, Texas
Kathryn L. Sridaromont, RN, C, MSN
Assistant Professor
Texas Tech University Health Sciences Center
Lubbock, Texas
Patricia Joy Maramba, MSN, RN, APRN, BC
Senior Lecturer
West Virginia University
Morgantown, West Virginia
00Newfield (F)-FM 4/18/07 7:31 PM Page iv
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright ©2007 by F. A. Davis Company
Copyright ©1989, 1993, 1997, 2002 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No
part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without written permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Acquisitions Editor:Joanne Patzek DaCuhna, PR, MSN
Content Development Manager:Darlene D. Pedersen, RN, MSN
Senior Project Editor:Danielle J. Barsky
Art and Design Manager: Carolyn O’Brien
As new scientific information becomes available through basic and clinical research, recommended treatments and drug
therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date,
and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for
errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard
to the contents of the book. Any practice described in this book should be applied by the reader in accordance with
professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is
advised always to check product information (package inserts) for changes and new information regarding dose and
contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data
Cox’s clinical applications of nursing diagnosis : adult, child, women’s, mental health,
gerontic and home health considerations / Susan A. Newfield … [et al.]. — 5th ed.
p. ; cm.
Rev. ed. of: Clinical applications of nursing diagnosis. 4th ed. c2002.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1655-4
ISBN-10: 0-8036-1655-4
1. Nursing diagnosis. 2. Nursing assessment. 3. Nursing. I. Cox, Helen C. II. Newfield, Susan A.
III. Clinical applications of nursing diagnosis. IV. Title: Clinical applications of nursing diagnosis.
[DNLM: 1. Nursing Diagnosis. 2. Nursing Process. WY 100.4 C879 2007]
RT48.6.C6 2007
610.73—dc22 2007009325
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by
F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service,
provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those
organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee
code for users of the Transactional Reporting Service is: 8036-1169-2/04 0 (cid:2)$.10.
00Newfield (F)-FM 4/18/07 7:31 PM Page v
To Dr. Helen Cox, colleague, mentor, and friend, on her retirement. You took ambitious,
naive, young faculty members and turned us into authors and for that, we will be
eternally grateful.
To the memory of Dr. Mary Ann Lubno, colleague and friend.
00Newfield (F)-FM 4/18/07 7:31 PM Page vi
00Newfield (F)-FM 4/18/07 7:31 PM Page vii
P F E
REFACE TO THE IFTH DITION
Although the fifth edition of this book has seen many author changes, our commitment
and direction was clearly stated by, Dr. Helen Cox, in the preface to the fourth edition. We
continue our commitment to providing a nursing focus to the process of nursing care.
The fifth edition reflects seventeen new and six revised diagnoses accepted by
NANDA in 2003 and 2005 and updated information in each chapter. The chapter formats
remain the same. We have revised the integration of NANDA, NIC, and NOC terminology
to assist with understanding their integration. NANDA, NIC, and NOC concepts are
placed in charts which identify the linkages that can be found at the beginning of each
chapter. Evaluation guidance has also been revised. We provided a master evaluation flow
chart in Chapter 1 rather than providing one at the end of each care plan.
Two significant trends have impacted the practice of nursing since the fourth edition;
decreasing length of stay and increased emphasis on evidence based practice. The length
of stay continues to decrease and this is reflected in our revision of goals, interventions,
and discharge planning. As we developed care plans, current average length of stay for the
setting was the litmus test for our selection of interventions. The interventions for each
diagnosis reflect both current research in the area and recommended NIC interventions.
If you are new to nursing diagnosis, we encourage you to begin your journey with
reading Chapter 1. Taking a few minutes to do this will provide you with an understanding
of the authors’thought processes that will facilitate your use of the book.
We continue to appreciate the comments from nursing faculty, staff and students
who use the book. Your thoughtful comments have inspired each edition and we urge you
to continue to support us in this way. It is our sincerest wish that this book will continue
to provide a map for your journey in providing excellent client care.
Susan A. Newfield, PhD, RN, APRN, BC
vii