Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span

1027 Pages·2006·5.463 MB·English

by  Marilynn Doenges, Mary Moorhouse, Alice Murr, Mary Townsend

00Doenges(F)-FM 1/16/06 2:50 PM Page 2
INDEX OF DISEASES/DISORDERS
AIDS, 726 Heart failure: chronic, 47 Pneumonia, 128
Alcohol: acute withdrawal, 831 Hemodialysis, 581 Primary base bicarbonate deficiency, 492
Alzheimer’s disease, 945 Hemolytic anemia, 499 Primary base bicarbonate excess, 495
Amputation, 657 Hepatitis, 443 Primary carbonic acid deficit, 198
Anemias (iron deficiency, pernicious, Herniated nucleus pulposus (ruptured Primary carbonic acid excess, 194
aplastic, hemolytic), 499 intervertebral disc), 252 Prostatectomy, 604
Angina (coronary artery disease), 62 HIV-positive client, 712 Psychosocial aspects of care, 770
Anorexia nervosa, 376 Hospice care, 880 Pulmonary embolus, 108
Aplastic anemia, 499 Hypercalcemia (calcium excess), 938 Pulmonary tuberculosis, 184
Appendectomy, 350 Hyperkalemia (potassium excess), 933
Asthma, 117 Hypermagnesemia (magnesium excess), 943 Radical neck surgery: laryngectomy
Hypernatremia (sodium excess), 928 (postoperative care), 157
Benign prostatic hyperplasia, 596 Hypertension: severe, 35 Regional enteritis, 324
Bulimia nervosa, 376 Hyperthyroidism (thyrotoxicosis, Graves’ Renal calculi, 613
Burns: thermal/chemical/electrical (acute disease), 426 Renal dialysis, 564
and convalescent phases), 680 Hypervolemia (extracellular fluid volume Renal dialysis: peritoneal, 575
excess), 919 Renal failure: acute, 541
Cancer, 857 Hypocalcemia (calcium deficit), 936 Renal failure: chronic, 553
Cardiac surgery: postoperative care, 96 Hypokalemia (potassium deficit), 931 Respiratory acid-base imbalances, 194
Cardiomyoplasty, 96 Hypomagnesemia (magnesium deficit), 941 Respiratory acidosis (primary carbonic acid
Cerebrovascular accident/stroke, 236 Hyponatremia (sodium deficit), 925 excess), 194
Chemical burns, 680 Hypovolemia (extracellular fluid volume Respiratory alkalosis (primary carbonic acid
Cholecystectomy, 371 deficit), 922 deficit), 194
Cholecystitis with cholelithiasis, 364 Hysterectomy, 621 Rheumatoid arthritis, 750
Cholelithiasis, 364 Ruptured intervertebral disc, 252
Chronic obstructive pulmonary disease, 117 Ileocolitis, 324
Cirrhosis of liver, 453 Ileostomy, 338 Seizure disorders, 208
Colostomy, 338 Inflammatory bowel disease: ulcerative Sepsis/septicemia, 701
Coronary artery bypass graft, 96 colitis, regional enteritis (Crohn’s disease, Septicemia, 701
Coronary artery disease, 62 ileocolitis), 324 Sickle cell crisis, 509
Craniocerebral trauma (acute rehabilitative Iron deficiency anemia, 499 Spinal cord injury (acute rehabilitative
phase), 218 phase), 271
Crohn’s disease, 324 Laryngectomy (postoperative care), 157 Stroke, 236
Leukemias, 523 Substance dependence/abuse rehabilitation,
Deep vein thrombosis, 108 Lung cancer (postoperative care), 141 843
Diabetes mellitus/diabetic ketoacidosis, 412 Lymphomas, 532 Subtotal gastrectomy/gastric resection, 320
Diabetic ketoacidosis, 412 Surgical interventions, 788
Disaster considerations, 890 Mastectomy, 630
Disc surgery, 260 Metabolic acid-base imbalances, 491 Thermal burns, 680
Dysrhythmias (including digitalis toxicity), Metabolic acidosis (primary base Thrombophlebitis: deep vein thrombosis
85 bicarbonate deficit), 492 (including pulmonary emboli
Metabolic alkalosis (primary base considerations), 108
Eating disorders: anorexia nervosa/bulimia bicarbonate excess), 495 Thyroidectomy, 437
nervosa, 376 Minimally invasive direct coronary artery Thyrotoxicosis, 426
Eating disorders: obesity, 393 bypass, 96 Total joint replacement, 667
Electrical burns, 680 Multiple sclerosis, 291 Total nutritional support: parenteral/enteral
End of life/hospice care, 880 Myocardial infarction, 72 feeding, 478
Enteral feeding, 478 Transplantation (postoperative and
Esophageal bleeding, 309 Neurological/sensory disorders, 202 lifelong), 761
Extended care, 810
Obesity, 393 Ulcerative colitis, 324
Fecal diversions: postoperative care of Obesity: surgical interventions (gastric Upper gastrointestinal/esophageal
ileostomy and colostomy, 338 partitioning/gastroplasty, gastric bleeding, 309
Fluid and electrolyte imbalances, 919 bypass), 402 Urinary diversions/urostomy
Fluid balance, 919 (postoperative care), 585
Fractures, 642 Pancreatitis, 467 Urolithiasis (renal calculi), 613
Parenteral feeding, 478 Urostomy, 585
Gastric bypass, 402 Pediatric considerations, 905
Gastric partitioning, 402 Peritonitis, 355 Valve replacement, 96
Gastroplasty, 402 Pernicious anemia, 499 Ventilatory assistance (mechanical), 170
Glaucoma, 202
Graves’ disease, 426
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KEY TO ESSENTIAL TERMINOLOGY
CLIENT ASSESSMENT DATABASE
Provides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical/sur-
gical diagnosis as well as the signs/symptoms and corresponding diagnostic findings.
NURSING PRIORITIES
Establishes a general ranking of needs/concerns on which the Nursing Diagnoses are ordered in constructing the plan of care.
This ranking would be altered according to the individual client situation.
DISCHARGE GOALS
Identifies generalized statements that could be developed into short-term and intermediate goals to be achieved by the client
before being “discharged” from nursing care. They may also provide guidance for creating long-term goals for the client to
work on after discharge.
NURSING DIAGNOSIS
The general problem/need (diagnosis) is stated without the distinct cause and signs/symptoms, which would be added to cre-
ate a client diagnostic statement when specific client information is available. For example, when a client displays increased
tension, apprehension, quivering voice, and focus on self, the nursing diagnosis of Anxiety might be stated: severe Anxiety, re-
lated to unconscious conflict, threat to self-concept as evidenced by statements of increased tension, apprehension; observa-
tions of quivering voice, focus on self.
In addition, diagnoses identified within these guides for planning care as actual or risk can be changed or deleted and new
diagnoses added, depending entirely on the specific client information.
MAY BE RELATED TO/POSSIBLY EVIDENCED BY
These lists provide the usual/common reasons (etiology) why a particular problem may occur with probable signs/symptoms,
which would be used to create the “related to” and “evidenced by” portions of the client diagnostic statementwhen the specific
situation is known.
When a risk diagnosis has been identified, signs/symptoms have not yet developed and therefore are not included in the
nursing diagnosis statement. However, interventions are provided to prevent progression to an actual problem. The exception
to this occurs in the nursing diagnosis risk for Violence, which has possible indicators that reflect the client’s risk status.
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL
These give direction to client care as they identify what the client or nurse hopes to achieve. They are stated in general terms
to permit the practitioner to modify/individualize them by adding time lines and individual client criteria so they become
“measurable.” For example, “Client will appear relaxed and report anxiety is reduced to a manageable level within 24 hours.”
Nursing Outcomes Classification (NOC) labels are also included. The outcome label is selected from a standardized nurs-
ing language and serves as a general header for the outcome indicators that follow.
ACTIONS/INTERVENTIONS
NIC (Nursing Interventions Classification) intervention labels are drawn from a standardized nursing language and serve as
a general header for the nursing actions that follow.
Nursing actions are divided into independent (those actions that the nurse performs autonomously) and collaborative
(those actions that the nurse performs in conjunction with others, such as implementing physician orders) and are ranked in
this book from most to least common. When creating the individual plan of care, interventions would normally be ranked to
reflect the client’s specific needs/situation. In addition, the division of independent/collaborative is arbitrary and is actually
dependent on the individual nurse’s capabilities and hospital/community standards.
RATIONALE
Although not commonly appearing in client plans of care, rationale has been included here to provide a pathophysiologic ba-
sis to assist the nurse in deciding about the relevance of a specific intervention for an individual client situation.
CLINICAL PATHWAY
This abbreviated plan of care or care map is event (task) oriented and provides outcome-based guidelines for goal achievement
within a designated length of stay. Several samples have been included to demonstrate alternative planning formats.
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NURSING DIAGNOSES ACCEPTED FOR
USE AND RESEARCH THROUGH 2006
Activity Intolerance [specify level] Gas Exchange, impaired Role Performance, ineffective
Activity Intolerance, risk for Grieving, anticipatory Self-Care Deficit: bathing/hygiene
Adjustment, impaired Grieving, dysfunctional Self-Care Deficit: dressing/grooming
Airway Clearance, ineffective Grieving, risk for dysfunctional Self-Care Deficit: feeding
Allergy Response, latex Growth & Development, delayed Self-Care Deficit: toileting
Allergy response, risk for latex Growth, risk for disproportionate Self-Concept, readiness for enhanced
Anxiety [specify level] Health Maintenance, ineffective Self-Esteem, chronic low
Anxiety, death Health-Seeking Behaviors (specify) Self-Esteem, situational low
Aspiration, risk for Home Maintenance, impaired Self-Esteem, risk for situational low
Attachment, risk for impaired Hopelessness Self-Mutilation
parent/infant/child Hyperthermia Self-Mutilation, risk for
Autonomic Dysreflexia Hypothermia Sensory Perception, disturbed: (specify: visual,
Autonomic Dysreflexia, risk for Identity, disturbed personal auditory, kinesthetic, gustatory, tactile,
Body Image, disturbed Infant Behavior, disorganized olfactory)
Body Temperature, risk for imbalanced Infant Behavior, readiness for enhanced Sexual Dysfunction
Bowel Incontinence organized Sexuality Pattern, ineffective
Breastfeeding, effective Infant Behavior, risk for disorganized Skin Integrity, impaired
Breastfeeding, ineffective Infant Feeding Pattern, ineffective Skin Integrity, risk for impaired
Breastfeeding, interrupted Infection, risk for Sleep Deprivation
Breathing Pattern, ineffective Injury, risk for Sleep, readiness for enhanced
Cardiac Output, decreased Injury, risk for perioperative positioning Sleep Pattern, disturbed
Caregiver Role Strain Intracranial Adaptive Capacity, decreased Social Interaction, impaired
Caregiver Role Strain, risk for Knowledge, deficient [Learning Need] Social Isolation
Communication, impaired verbal [specify] Sorrow, chronic
Communication, readiness for enhanced Knowledge [specify], readiness for enhanced Spiritual Distress
Conflict, decisional (specify) Lifestyle, sedentary Spiritual Distress, risk for
Conflict, parental role Loneliness, risk for Spiritual Well-Being, readiness for enhanced
Confusion, acute Memory, impaired Suffocation, risk for
Confusion, chronic Mobility, impaired bed Suicide, risk for
Constipation Mobility, impaired physical Surgical Recovery, delayed
Constipation, perceived Mobility, impaired wheelchair Swallowing, impaired
Constipation, risk for Nausea Therapeutic Regimen Management, effective
Coping, defensive Neglect, unilateral Therapeutic Regimen Management, ineffective
Coping, ineffective Noncompliance, [Adherence, ineffective] Therapeutic Regimen Management, ineffective
Coping, readiness for enhanced [specify] community
Coping, ineffective community Nutrition: less than body requirements, Therapeutic Regimen Management, ineffective
Coping, readiness for enhanced community imbalanced family
Coping, compromised family Nutrition: more than body requirements, Therapeutic Regimen Management, readiness
Coping, disabled family imbalanced for enhanced
Coping, readiness for enhanced family Nutrition, readiness for enhanced Thermoregulation, ineffective
Death syndrome, risk for sudden infant Nutrition: more than body requirements, Thought Processes, disturbed
Denial, ineffective risk for imbalanced Tissue Integrity, impaired
Dentition, impaired Oral Mucous Membrane, impaired Tissue Perfusion, ineffective (specify type:
Development, risk for delayed Pain, acute cerebral, cardiopulmonary, renal,
Diarrhea Pain, chronic gastrointestinal, peripheral)
Disuse Syndrome, risk for Parenting, impaired Transfer Ability, impaired
Diversional Activity, deficient Parenting, readiness for enhanced Trauma, risk for
Energy Field disturbed Parenting, risk for impaired Urinary Elimination, impaired
Environmental Interpretation Syndrome, Peripheral Neurovascular Dysfunction, risk for Urinary Elimination, readiness for enhanced
impaired Poisoning, risk for Urinary Incontinence, functional
Failure to Thrive, adult Post-Trauma Syndrome [specify stage] Urinary Incontinence, reflex
Falls, risk for Post-Trauma Syndrome, risk for Urinary Incontinence, stress
Family Processes: alcoholism, dysfunctional Powerlessness [specify level] Urinary Incontinence, total
Family Processes, interrupted Powerlessness, risk for Urinary Incontinence, urge
Family Processes, readiness for enhanced Protection, ineffective Urinary Incontinence, risk for urge
Fatigue Rape-Trauma Syndrome Urinary Retention [acute/chronic]
Fear Rape-Trauma Syndrome: compound reaction Ventilation, impaired spontaneous
Fluid Balance, readiness for enhanced Rape-Trauma Syndrome: silent reaction Ventilatory Weaning Response, dysfunctional
[Fluid Volume, deficient hyper/hypotonic] Religiosity, impaired Violence, [actual/] risk for other-directed
Fluid Volume, deficient [isotonic] Religiosity, risk for impaired Violence, [actual/] risk for self-directed
Fluid Volume, excess Religiosity, readiness for enhanced Walking, impaired
Fluid Volume, risk for deficient Relocation Stress Syndrome Wandering [specify sporadic or continual]
Fluid Volume risk for imbalanced Relocation Stress Syndrome, risk for [ ] author recommendations
Used with permission from NANDAInternational: Definitions and Classification, 2005–-2006. NANDA, Philadelphia, 2005.
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NURSING CARE PLANS
GUIDELINES FOR INDIVIDUALIZING
CLIENT CARE ACROSS THE LIFE SPAN
EDITION 7
Marilynn E. Doenges, APRN, BC-Retired
Clinical Specialist, Adult Psychiatric/Mental Health Nursing, Retired
Adjunct Faculty
Beth-El College of Nursing and Health Sciences, UCCS
Colorado Springs, Colorado
Mary Frances Moorhouse, RN, MSN, CRRN, LNC
Adjunct Faculty/Clinical Instructor
Pikes Peak Community College
Nurse Consultant/TNT-RN Enterprises
Colorado Springs, Colorado
Alice C. Murr, RN, BSN, LNC
Legal Nurse Consultant
Telephone Triage Nurse
Jackson, Mississippi
F. A. DAVIS COMPANY • Philadelphia
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NURSING CARE PLANS,
7th Edition…
enges-04 12/9/05 7:25 PM Page 98 Includes lab and diagnostic studies
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00Doenges(F)-FM 1/17/06 8:01 PM Page v
Includes a Bonus CD-ROM—a Valuable Package of
Resources You Can Use!
Bonus CD-ROM
You will find 200 Care Plans with an index of the top 400
Diseases/Disorders and their associated nursing diagnoses. To
help make navigating the CD-ROM even easier, we’ve provided
a complete Table of Contents to the CD in the book. The CD is
a robust resource that will save valuable time and help you
put all the pieces together quickly and accurately!
1
200 Care Plans
The bonus CD-ROM contains 200 care plans that
Cardiovascular students can adapt and customize to fit their needs.
It also includes four NEW care plans covering
obesity surgery, fluids and electrolytes, extended
care, and pediatric considerations. A complete
package including all 116 care plans featured in the
2
book plus 84 additional found only on the CD-ROM—
that’s 200 care plans!
400 Diseases/Disorders
Hypertension: Severe
A complete index of 400 Disorders and Health
3 Conditions, with their associated nursing diagnoses,
is also included. The menu screen features a user-
friendly A to Z listing reflecting all specialty areas,
with associated nursing diagnoses, that include
"related to" and "evidenced by" statements.
2
AIDS
1
Includes 3+ books in 1,
that feature: 3
(cid:68) 115 Medical/Surgical care plans
A
(cid:68) 34 Psychiatric care plans
(cid:68) 50 Maternal/Newborn care plans
(cid:68) Pediatric Considerations
00Doenges(F)-FM 1/17/06 8:01 PM Page vi
F. A. Davis Company
1915 Arch Street
Philadelphia, PA19103
www.fadavis.com
Copyright © 2006 by F. A. Davis Company
Copyright © 1984, 1989, 1993, 1997, 2000, and 2002 by F. A. Davis Company. All rights reserved. This
product 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 other-
wise, 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 P. DaCunha, RN, MSN
Developmental Editor: Alan Sorkowitz
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 ac-
cordance with professional standards of care used in regard to the unique circumstances that may ap-
ply 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
Doenges, Marilynn E., 1922-
Nursing care plans : guidelines for individualizing client care/Marilynn E. Doenges, Mary Frances
Moorhouse, Alice C. Murr.—Ed. 7.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-8036-1294-X
1. Intensive nursing care—Handbooks, manuals, etc. 2. Nursing care plans—Handbooks, manuals,
etc.
[DNLM: 1. Patient Care Planning—Handbooks. 2. Nursing Process—Handbooks. WY49 D651na
2006] I. Moorhouse, Mary Frances, 1947-II. Geissler-Murr, Alice, 1946-III. Title.
RT49.D64 2006
610.73—dc22
2005036714
Authorization to photocopy items for internal or personal use, or the internal or personal use of spe-
cific 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 $.10 per copy is paid directly
to CCC, 222 Rosewood Drive, Danvers, MA01923. For those organizations that have been granted a
photocopy license by CCC, a separate system of payment has been arranged. The fee code for users
of the Transactional Reporting Service is: 8036-1294/07 0 (cid:2)$.10.
00Doenges(F)-FM 1/17/06 8:01 PM Page vii
DEDICATION
To our spouses, children, parents, and friends, who much of the
time have had to manage without us while we work as well as
having to cope with our struggles and frustrations.
The Doenges families: the late Dean, whose support and en-
couragement is sorely missed; Jim; Barbara and Bob Lanza; David,
Monita, Matthew, and Tyler; John, Holly, Nicole, and Kelsey; and
the Daigle family, Nancy, Jim, Jennifer, Brandon, Anna, Will, and
Henry Smith-Daigle, and Jonathan and Kim.
The Moorhouse family: Jan, Paul, Jason, Thenderlyn, Alexa,
and Mary.
To Mary and Marilynn, couldn’t have done it without you. In
loving memory of my parents, who were my biggest promoters in
my early days of writing. To my children and grandchildren with
love. You have expanded my horizons so wonderfully! Alice
To our FAD family, especially Bob Martone and Bob Butler,
whose support is so vital to the completion of a project of this
magnitude. And to Alan Sorkowitz, the one who really kept us all
together, our go-to-guy when the going got tough. We are fourtu-
nate to have you working with us.
To the nurses we are writing for, who daily face the challenge
of caring for the acutely ill client and are looking for a practical
way to organize and document this care. We believe that nursing
diagnosis and these guides will help.
To NANDAand to the international nurses who are develop-
ing and using nursing diagnoses—here we come!
Finally, to the late Mary Lisk Jeffries, who initiated the origi-
nal project. The memory of our early friendship and struggles re-
mains with us. We miss her and wish she were here to see the
growth of the profession and how nursing diagnosis has con-
tributed to the process.
vii
00Doenges(F)-FM 1/17/06 8:01 PM Page viii
REVIEWERS FOR THE BOOK
JANE V. ARNDT, MS, RN, CWOCN Senior Instructor
Nurse Clinician, Enterostomal Therapy University of Colorado Health Science
Poudre Valley Hospital Center School of Nursing
Ft. Collins, Colorado Denver, Colorado
JENNIFER AVERY
KIMBERLY TUCKER PFENNIGS, MA,
Senior Nursing Student
BAN, RN
College of the Sequoias
Pikes Peak Mental Health
Visalia, California
Program Manager, Lighthouse Assessment
Center
BETH HAMSTRA, RN, CNS, RCIS, PHD
Adult Treatment Units
Clinical Manager Invasive Cardiology
Colorado Springs, Colorado
Memorial Hospital
Colorado Springs, Colorado
GILDA ROLLS-DELLINGER, RN
SANDRA HARPER, RN, CCRN Staff Nurse, Skin, Wound, and Burn Team
Rehabilitation Care Specialist Penrose-St. Francis Health Services
HealthSouth Rehabilitation Hospital Colorado Springs, Colorado
Colorado Springs, Colorado
ROCHELLE SALMORE, MSN, RN, CGRN,
CHRISTIE A. HINDS, MSN, APRN-BC
CAN, BC
Primary Care Nurse Practitioner
Clincal Manager
Health Essentials
Digestive Disease Center
Chattanooga, Tennesse
Penrose–St. Francis Health Services
Colorado Springs, Colorado
SUSAN JANTY, VN, ACRN
SCD/HIV Medical Coordinator
El Paso Department of Heath and TRACY STEINBERG, RN, MSN, CNS
Environment Liver Transplant Coordinator
Colorado Springs, Colorado Division of Transplant Surgery
University of Colorado Health Sciences
Center
LAURA RUTH TEIGEN JOHNSON, RN, Denver, Colorado
MNE, CNOR
Perioperative Services Manager
GERI L. TIERNEY, RN, BSN, ONC
Colorado Springs, Colorado
Nursing Simulation Lab Coordinator
Pikes Peak Community College
LENORA KRAFT, RN Past-President National Association of
Surgical Clinical Manager Orthopaedic Nurses
Penrose St-Francis Hospital Colorado Springs, Colorado
Colorado Springs, Colorado
KATHLEEN H. WINDER, RN, BSN
SUZANNE LOGAN, MS, RD Clinical Manager, Pediatric Specialty
Manager, Dietetic Internship Clinic
Clinical Manager Memorial Hospital
Penrose–St. Francis Health Services Colorado Springs, Colorado
Colorado Springs, Colorado
ANNE ZOBEC, MS, RN, CS, NP,
MARY BETH FLYNN-MAKIC, RN, MS,
AOCN
CNS, CCRN Oncology Nurse Practitioner
Clinical Nurse Specialist/Educator The Oncology Clinic, P. C.
University of Colorado Hospital Colorado Springs, Colorado
viii