Nurse’s pocket guide : diagnoses, prioritized interventions, and rationales PDF
Preview Nurse’s pocket guide : diagnoses, prioritized interventions, and rationales
Name /bks_51993_doenges_npg/51993_fm_01_02 01/09/2013 01:33PMp g 1 P l a#t e1 # 0-Composite GORDON’SFUNCTIONALHEALTHPATTERNS* HEALTHPERCEPTION–HEALTH Riskforelectrolyteimbalance 341–349 MANAGEMENTPATTERN Riskforimbalancedfluidvolume 417–421 Contamination 259–267 Riskforimbalancedbodytemperature Deficientcommunityhealth 466–469 142–146 Disturbedenergyfield 349–352 Riskforimpairedliverfunction 588–593 Ineffectivefamilytherapeuticregimen Riskforimpairedskinintegrity 864–869 management 939–942 Riskforlatexallergyresponse 581–583 Ineffectivehealthmaintenance 474–478 Riskforneonataljaundice 565–568 Ineffectiveprotection 723–725 Riskforunstablebloodglucoselevel Ineffectiveself-healthmanagement 818–820 132–136 Noncompliance[ineffectiveAdherence] ELIMINATIONPATTERN [specify] 629–633 Bowelincontinence 511–516 Readinessforenhancedimmunizationstatus Constipation 246–252 503–507 Diarrhea 321–326 Readinessforenhancedselfhealth Dysfunctionalgastrointestinalmotility 426–432 management 820–823 Functionalurinaryincontinence 516–520 Riskforcontamination 267–272 Impairedurinaryelimination 992–997 Riskforbleeding 127–132 Overflowurinaryincontinence 520–523 Riskforfalls 362–368 Perceivedconstipation 252–255 Riskforinfection 538–543 Readinessforenhancedurinaryelimination Riskforinjury 544–549 998–1000 Riskforperioperativepositioninginjury Reflexurinaryincontinence 523–527 681–684 Riskforconstipation 255–259 Riskforpoisoning 696–701 Riskfordysfunctionalgastrointestinal Riskforsuffocation 917–921 motility 433–437 Riskforthermalinjury 942–947 Riskforurgeurinaryincontinence 535–538 Riskfortrauma 980–987 Stressurinaryincontinence 527–531 Riskforvasculartrauma 1007–1011 Urgeurinaryincontinence 531–535 Risk-pronehealthbehavior 470–473 Urinaryretention[acute/chronic] 1001–1006 NUTRITIONAL–METABOLIC ACTIVITY–EXERCISEPATTERN PATTERN Activityintolerance 69–73 Adultfailuretothrive 358–362 Autonomicdysreflexia 108–112 [Deficientfluidvolume:hyper/hypotonic] Decreasedcardiacoutput 172–179 399–404 Decreasedintracranialadaptivecapacity Deficientfluidvolume[isotonic] 404–409 555–559 Excessfluidvolume 409–413 Deficientdiversionalactivity 334–337 Hyperthermia 493–498 Delayedgrowthanddevelopment 459–466 Hypothermia 498–503 Delayedsurgicalrecovery 926–931 Imbalancednutrition:lessthanbody Disorganizedinfantbehavior 116–123 requirements 634–639 Dysfunctionalventilatoryweaningresponse Imbalancednutrition:morethanbody 1018–1023 requirements 640–644 Fatigue 381–386 Imbalancednutrition:riskformorethanbody Impairedspontaneousventilation requirements 645–648 1011–1017 Impaireddentition 312–316 Impairedbedmobility 607–611 Impairedoralmucousmembrane 652–657 Impairedgasexchange 421–426 Impairedskinintegrity 857–864 Impairedhomemaintenance 478–482 Impairedswallowing 931–938 Impairedphysicalmobility 611–616 Impairedtissueintegrity 950–957 Impairedtransferability 976–979 Ineffectivebreastfeeding 151–157 Impairedwalking 1032–1036 Ineffectiveinfantfeedingpattern 392–395 Impairedwheelchairmobility 616–619 Ineffectivethermoregulation 947–950 Ineffectiveairwayclearance 85–90 Interruptedbreastfeeding 157–162 Ineffectivebreathingpattern 167–171 Insufficientbreastmilk 146–150 Ineffectiveperipheraltissueperfusion Latexallergyresponse 576–580 957–963 Nausea 623–629 Readinessforenhancedorganizedinfant Neonataljaundice 559–565 behavior 125–127 Readinessforenhancedbreastfeeding 162– Readinessforenhancedself-care 784–787 166 Riskfordecreasedcardiactissueperfusion Readinessforenhancedfluidbalance 395–399 963–967 Readinessforenhancednutrition 649–652 Riskfordelayeddevelopment 317–321 Riskforadversereactiontoiodinatedcontrast Riskfordisorganizedinfantbehavior media 82–85 123–124 Riskforallergyresponse 90–93 Riskfordisproportionategrowth 454–459 Riskforaspiration 100–104 Riskforactivityintolerance 73–76 Riskfordeficientfluidvolume 413–417 Riskforautonomicdysreflexia 112–116 Riskfordryeye 338–341 Riskfordisusesyndrome 327–334 *ModifiedbyMarjoryGordon,2012,withpermission. Name /bks_51993_doenges_npg/51993_fm_01_02 01/10/2013 08:22AMp g 2 P l a#t e1 # 0-Composite Riskforineffectivecerebraltissueperfusion ROLE–RELATIONSHIPPATTERN 968–972 Caregiverrolestrain 179–186 Riskforineffectivegastrointestinalperfusion Chronicsorrow 891–894 437–441 Complicatedgrieving 446–451 Riskforineffectiveperipheraltissue Dysfunctionalfamilyprocesses 368–373 perfusion 972–976 Grieving 442–454 Riskforineffectiverenalperfusion 761–765 Impairedparenting 670–675 Riskforperipheralneurovasculardysfunction Impairedsocialinteraction 881–886 684–689 Impairedverbalcommunication 221–228 Riskforshock 852–857 Ineffectiverelationship 731–735 Riskforsuddeninfantdeathsyndrome Ineffectiveroleperformance 780–784 912–917 Interruptedfamilyprocesses 373–376 Sedentarylifestyle 584–588 Parentalroleconflict 777–780 Self-caredeficit:bathing,dressing,feeding, Readinessforenhancedcommunication toileting 787–796 228–232 Selfneglect 832–836 Readinessforenhancedfamilyprocesses Wandering[specifysporadicorcontinual] 376–380 1036–1040 Readinessforenhancedparenting 675–679 SLEEP–RESTPATTERN Readinessforenhancedrelationship 735–739 Disturbedsleeppattern 878–881 Relocationstresssyndrome 752–757 Insomnia 549–555 Readinessforenhancedsleep 869–872 Riskforcaregiverrolestrain 186–190 Sleepdeprivation 873–877 Riskforcomplicatedgrieving 451–454 Riskforimpairedattachment 105–108 COGNITIVE–PERCEPTUAL Riskforimpairedparenting 679–681 PATTERN Riskforineffectiverelationship 739–743 Riskforother-directedviolence 1024–1031 Acuteconfusion 233–238 Riskforrelocationstresssyndrome 757–761 Acutepain 658–663 Socialisolation 886–890 Chronicconfusion 242–246 Chronicpain 663–670 SEXUALITY–REPRODUCTIVE Decisionalconflict[specify] 306–309 Ineffectivechildbearingprocess 190–199 Deficientknowledge[learningneed](specify) Ineffectivesexualitypattern 848–851 569–573 Rape-traumasyndrome 726–731 Disturbedsensoryperception(specify:visual, Readinessforenhancedchildbearingprocess auditory,kinesthetic,gustatory,tactile, 200–209 olfactory) 837–843 Riskfordisturbedmaternal-fetaldyad Impairedcomfort 210–215 Impairedenvironmentalinterpretation 596–603 syndrome 353–357 Riskforineffectivechildbearingprocess Impairedmemory 603–606 209–210 Ineffectiveactivityplanning 76–79 Sexualdysfunction 843–847 Readinessforenhancedcomfort 216–221 COPING–STRESSTOLERANCE Readinessforenhanceddecision-making 303–305 PATTERN Readinessforenhancedknowledge(specify) Compromisedfamilycoping 272–275 573–576 Defensivecoping 275–279 Riskforineffectiveactivityplanning 79–82 Disabledfamilycoping 279–282 Riskforacuteconfusion 238–241 Impairedindividualresilience 766–769 Unilateralneglect 987–992 Ineffectivecommunitycoping 288–290 Ineffectivecoping 283–287 SELF-PERCEPTION–SELF- Ineffectivedenial 310–312 CONCEPTPATTERN Post-traumasyndrome[specifystage] Anxiety[specifylevel:mild,moderate, 702–708 severe,panic] 94–100 Readinessforenhancedcommunitycoping Chroniclowself-esteem 800–804 294–296 Deathanxiety 299–303 Readinessforenhancedcoping 290–294 Disturbedbodyimage 137–142 Readinessforenhancedfamilycoping Disturbedpersonalidentity 689–692 296–299 Fear 387–382 Readinessforenhancedresilience 770–773 Hopelessness 485–489 Riskforcompromisedresilience 773–776 Ineffectiveimpulsecontrol 508–511 Riskforself-mutilation 828–832 Powerlessness 716–720 Riskforsuicide 921–926 Readinessforenhancedhope 482–485 Riskforpost-traumasyndrome 709–713 Readinessforenhancedpower 713–716 Self-mutilation 823–827 Readinessforenhancedself-concept 796–800 Stressoverload 907–912 Riskforchroniclowself-esteem 808–812 Riskforcompromisedhumandignity VALUE–BELIEFPATTERN 490–492 Impairedreligiosity 743–746 Riskfordisturbedpersonalidentity Moraldistress 620–623 693–696 Readinessforenhancedreligiosity 746–749 Riskforloneliness 593–596 Readinessforenhancedspiritualwell-being Riskforpowerlessness 720–723 903–907 Riskforsituationallowself-esteem 813–815 Riskforimpairedreligiosity 749–752 Riskforself-directedviolence 1024–1031 Riskforspiritualdistress 900–903 Situationallowself-esteem 805–808 Spiritualdistress 894–899 Name /bks_51993_doenges_npg/51993_fm_03_18 10/22/2012 03:43PMp g 4 P l a#t e2 # 0-Composite Great care begins with great care planning! Doenges, Moorhouse & Murr nursing Diagnosis Manual Planning, Individualizing, and Documenting Client Care Rely on this complete reference to identify interventions commonly associated with specific nursing diagnoses across the lifespan, and to help plan, individualize, and document care for more than 800 diseases and disorders. Doenges & Moorhouse application of nursing process anD nursing Diagnosis An Interactive Text for Diagnostic Reasoning Master the nursing process with this interactive, step-by-step approach to the whys and hows. Doenges, Moorhouse & Murr nursing care plans Guidelines for Individualizing Client Care Across the Life Span Three care plan resources in one—medical-surgical, maternity, and psychiatric/mental health—170 customizable plans in all! Take a multimedia approach to care planning with guidelines that make it easier to apply the nursing process and to individualize care. Name /bks_51993_doenges_npg/51993_fm_03_18 10/22/2012 03:43PMp g 4 P l a#t e2 # 0-Composite Don’t miss the nursing Diagnosis and care planning resources online at a wealth of online tools help you learn to plan and implement safe, individualized care. § Concept Care Map Generator • Select your template from the list of potential diseases and disorders or create your own. • Customize your template; add directional arrows to link concepts. • Print or e-mail your completed concept care map. § Online Disorder Lookup § Learning Activities § Interactive Assessment Tool § Care Plan Case Studies § Gordon’s Functional Health Case Studies § Nursing Diagnoses Arranged by Maslow’s Hierarchy see what’s available for your title. Visit: DavisPlus.faDavis.com Keyword: Doenges Name /bks_51993_doenges_npg/51993_fm_03_18 11/30/2012 03:25PMp g 5 P l a#t e3 # 0-Composite Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales MarilynnE.Doenges,APRN,BC—Retired ClinicalSpecialist—AdultPsychiatric/MentalHealthNursing RetiredAdjunctFaculty Beth-ElCollegeofNursingandHealthSciences,UCCS ColoradoSprings,Colorado MaryFrancesMoorhouse,RN,MSN,CRRN,LNC NurseConsultant TNT-RNEnterprises AdjunctFaculty PikesPeakCommunityCollege ColoradoSprings,Colorado AliceC.Murr,BSN,RN—Retired Independence,Missouri EDITION 13 Name /bks_51993_doenges_npg/51993_fm_03_18 01/09/2013 01:55PMp g 6 P l a#t e1 # 0-Composite F.A.DavisCompany 1915ArchStreet Philadelphia,PA19103 www.fadavis.com Copyright(cid:2)2013byF.A.DavisCompany Copyright (cid:2) 1985, 1988, 1991, 1993, 1996, 1998, 2000, 2002, 2004, 2006, 2008,2010byF.A.DavisCompany.Allrightsreserved.Thisbookisprotected bycopyright.Nopartofitmaybereproduced,storedinaretrievalsystem,or transmittedinanyformorbyanymeans,electronic,mechanical,photocopying, recording,orotherwise,withoutwrittenpermissionfromthepublisher. PrintedintheUnitedStatesofAmerica Lastdigitindicatesprintnumber:10987654321 Publisher,Nursing:JoannePatzekDaCunha,RN,MSN ProjectEditor:ElizabethHart DesignandIllustrationManager:CarolynO’Brien As new scientific information becomes available through basic and clinical research,recommendedtreatmentsanddrugtherapiesundergochanges.The author(s)andpublisherhavedoneeverythingpossibletomakethisbookac- curate,uptodate,andinaccordancewithacceptedstandardsatthetimeof publication.Theauthor(s),editors,andpublisherarenotresponsibleforerrors oromissionsorforconsequencesfromapplicationofthebookandmakeno warranty, expressed or implied, in regard to the contents of the book. Any practicedescribedinthisbookshouldbeappliedbythereaderinaccordance withprofessionalstandardsofcareusedinregardtotheuniquecircumstances thatmayapplyineachsituation.Thereaderisadvisedalwaystocheckproduct information(packageinserts)forchangesandnewinformationregardingdose and contraindications before administering any drug. Caution is especially urgedwhenusingneworinfrequentlyordereddrugs. LibraryofCongressCataloging-in-PublicationData Proudly sourced and uploaded by [StormRG] Doenges,MarilynnE.,1922– Kickass Torrents | TPB | ET | h33t Nurse’s pocket guide : diagnoses, prioritized interventions, and rationales / DoengesMarilynnE.,MoorhouseMaryFrances,MurrAliceC.—Ed.13 p.;cm. Includesbibliographicalreferencesandindex. ISBN-13:978-0-8036-2782-6 ISBN-10:0-8036-2782-6 I.Moorhouse,MaryFrances,1947– II.Murr,AliceC.,1946– III.Title. [DNLM: 1. Nursing Diagnosis—Handbooks. 2. Nursing Care—classifica- tion—Handbooks.3.PatientCarePlanning—Handbooks.WY49] 616.07(cid:2)5—dc23 2012036506 Authorizationtophotocopyitemsforinternalorpersonaluse,ortheinternalor personaluseofspecificclients,isgrantedbyF.A.DavisCompanyforusers registeredwiththeCopyrightClearanceCenter(CCC)TransactionalReporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 RosewoodDrive,Danvers,MA01923.Forthoseorganizationsthathavebeen grantedaphotocopylicensebyCCC,aseparatesystemofpaymenthasbeen arranged.ThefeecodeforusersoftheTransactionalReportingServiceis:978- 0-8036-2782/130(cid:3)$.25. Nursing Diagnoses—Definitions and Classification 2012–2014. Copyright (cid:2) 2012,1994–2012byNANDAInternational.UsedbyarrangementwithBlack- wellPublishingLimited,acompanyofJohnWiley&Sons,Inc.Inordertomake safeandeffectivejudgmentsusingNANDA-Inursingdiagnoses,itisessential thatnursesrefertothedefinitionsanddefiningcharacteristicsofthediagnoses listedinthiswork. Name /bks_51993_doenges_npg/51993_fm_03_18 11/30/2012 03:25PMp g 7 P l a#t e5 # 0-Composite DEDICATION Thisbookisdedicatedto: Ourfamilies,whohelpedwiththemundaneactivitiesofdaily livingthatallowedustowritethisbookandwhoprovideuswith loveandencouragementinallourendeavors. Ourfriends,whosupportusinourwriting,putupwithour memorylapses,andloveusstill. Bob Martone, Publisher, Nursing, who germinated the idea forthisprojectsolongago.JoanneDaCunhaandElizabethHart, whoprovideddirectsupportandkeptusfocused.RobertAllen, whohasguidedusthroughtheXMLmazesincethebookwent hightech.TheF.A.Davisproductionstaff,whocoordinatedand expeditedtheprojectthroughtheeditingandprintingprocesses, meeting unreal deadlines, and sending pages to us with bated breath. RobertH.Craven,Jr.,andtheF.A.Davisfamily. Andlastandmostimportant: Thenurseswearewritingfor,tothosewhohavefoundthe previouseditionsofthePocketGuidehelpful,andtoothernurses who are looking for help to provide quality nursing care in a period of transition and change, wesay, “NursingDiagnosisis theway.” Name /bks_51993_doenges_npg/51993_fm_03_18 11/30/2012 03:25PMp g 8 P l a#t e6 # 0-Composite Name /bks_51993_doenges_npg/51993_fm_03_18 01/09/2013 01:55PMp g 9 P l a#t e1 # 0-Composite CONTRIBUTORS SheilaMarquez FormerlyExecutiveDirector VicePresident/ChiefOperatingOfficer TheColoradoSIDSProgram,Inc. Denver,Colorado CayrnF.Demaree,RN,BSN,IBCLC LactationSpecialist DenverHealthMedicalCenter Denver,Colorado ResearchAssistant MaryKatherineBlackwell MississippiStateUniversity
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