Nurse’s Pocket Guide

1 Nurse s Pocket GuideDiagnoses, PrioritizedInterventions, and Rationales00 Doenges Pocket (F)-FMR 2/7/06 1:52 PM Page iii00 Doenges Pocket (F)-FMR 2/7/06 1:52 PM Page ivNurse s Pocket GuideDiagnoses, PrioritizedInterventions, and RationalesEDITION 10 Marilynn E. Doenges, APRN, BC retiredClinical Specialist Adult Psychiatric/Mental Health NursingAdjunct FacultyBeth-El College of Nursing and Health Sciences, UCCSC olorado Springs, ColoradoMary Frances Moorhouse, RN, MSN, CRRN, LNCN urse ConsultantTNT-RN EnterprisesAdjunct FacultyPikes Peak Community CollegeColorado Springs, ColoradoAlice C. Murr, RN, BSN, LNCN urse Consultant/AuthorCollins, MississippiF. A. Davis Company Philadelphia00 Doenges Pocket (F)-FMR 2/7/06 1:52 PM Page Davis Company1915 Arch StreetPhiladelphia, PA 19103www. 2006 by Davis CompanyCopyright 1985, 1988, 1991, 1993, 1996, 1998, 2000, 2002, 2004 Davis Company.

2 All rights reserved. This book is protected by copy-right. No part of it may be reproduced, stored in a retrieval system, ortransmitted in any form or by any means, electronic, mechanical,photocopying, recording, or otherwise, without written permissionfrom the in CanadaLast digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher:Robert G. Martone, Joanne P. DaCunha, RN, MSNS enior Project Editor:Danielle J. BarskyManager of Art & Design:Carolyn O BrienAs new scientific information becomes available through basic and clin-ical research, recommended treatments and drug therapies undergochanges. The author(s) and publisher have done everything possible tomake this book accurate, up to date, and in accord with accepted stan-dards at the time of publication. The authors, editors, and publisher arenot responsible for errors or omissions or for consequences from appli-cation of the book, and make no warranty, expressed or implied, inregard to the contents of the book.

3 Any practice described in this bookshould be applied by the reader in accordance with professional stan-dards of care used in regard to the unique circumstances that may applyin each situation. The reader is advised always to check product infor-mation (package inserts) for changes and new information regardingdose and contraindications before administering any drug. Caution isespecially urged when using new or infrequently ordered : 9780-8036-1480-2 ISBN-10: 0-8036-1480-2 Authorization to photocopy items for internal or personal use, or theinternal or personal use of specific clients, is granted by DavisCompany for users registered with the Copyright Clearance Center(CCC) Transactional Reporting Service, provided that the fee of $.10per copy is paid directly to CCC, 222 Rosewood Drive, Danvers,MA 01923.

4 For those organizations that have been granted a photo-copy license by CCC, a separate system of payment has been fee code for users of the Transactional Reporting Service is: 8036-1480/06 0 $. Pocket (F)-FMR 2/7/06 1:52 PM Page viThis book is dedicated to:Our families, who helped with the mundane activities ofdaily living that allowed us to write this book and who provideus with love and encouragement in all our friends, who support us in our writing, put up with ourmemory lapses, and love us Martone, Publisher, Nursing, who asks questions thatstimulate thought and discussion, and who maintains goodhumor Davis production staff and Alan Sorkowitz, whocoordinated and expedited the project through the editing andprinting processes, meeting unreal deadlines, and sending pagesto us with bated H. Craven, Jr., and the Davis last and most important:The nurses we are writing for, to those who have found theprevious editions of the Pocket Guide helpful, and to othernurses who are looking for help to provide quality nursing carein a period of transition and change, we say, Nursing Diagnosisis the way.

5 CONTRIBUTORS heila MarquezExecutive DirectorVice President/Chief Operating OfficerThe Colorado SIDS Program, , ColoradoDedication00 Doenges Pocket (F)-FMR 2/7/06 1:52 PM Page vii00 Doenges Pocket (F)-FMR 2/7/06 1:52 PM Page viiiACKNOWLEDGMENTSA special acknowledgment to Marilynn s friend, the late DianeCamillone, who provoked an awareness of the role of thepatient and continues to influence our thoughts about theimportance of quality nursing care, and to our late colleague,Mary Jeffries, who introduced us to nursing our colleagues in NANDA who continue to formulate andrefine nursing diagnoses to provide nursing with the tools toenhance and promote the growth of the E. DoengesMary Frances MoorhouseAlice C. Murr00 Doenges Pocket (F)-FMR 2/7/06 1:52 PM Page ix00 Doenges Pocket (F)-FMR 2/7/06 1:52 PM Page xHealth Conditions and Client Concerns with Associated NursingDiagnoses appear on pages 1 The Nursing Process.

6 1 CHAPTER 2 Application of the Nursing Process ..7 CHAPTER 3 Putting Theory into Practice: Sample Assessment Tools, Planof Care, Mind Mapping, and Documentation ..16 SECTION 1 Assessment Tools for Choosing Nursing Diagnoses ..19 Adult Medical/Surgical Assessment Tool ..20 Excerpt from Psychiatric Assessment Tool ..30 Excerpt from Prenatal Assessment Tool ..33 Excerpt from Intrapartal Assessment Tool ..35 SECTION 2 Diagnostic Divisions: Nursing Diagnoses OrganizedAccording to a Nursing 3 Client Situation and Prototype Plan of Care ..43 Another Approach to Planning ClientCare Mind Mapping ..58 SECTION 4 Documentation Techniques: SOAP andFocus Charting ..60 CHAPTER 4 Nursing Diagnoses in Alphabetical Order ..65 For each nursing diagnosis, the following information is provided:Taxonomy II, Domain, Class, Code, Year SubmittedxiContents00 Doenges Pocket (F)-FMR 2/7/06 1:52 PM Page xiDiagnostic DivisionDefinitionRelated/Risk Factors, Defining Characteristics:Subjective/ObjectiveDesi red Outcomes/Evaluation CriteriaActions/InterventionsNursing PrioritiesDocumentation FocusSample Nursing Outcomes & Interventions Classifications (NOC/NIC)CHAPTER 5 Health Conditions and Client Concerns with AssociatedNursing Diagnoses.

7 628 APPENDIX 1 NANDA s Taxonomy II ..755 APPENDIX 2 Definitions of Taxonomy II Axes ..759 BIBLIOGRAPHY762 INDEX773xiiCONTENTS00 Doenges Pocket (F)-FMR 2/7/06 1:52 PM Page xiiThe American Nurses Association (ANA) Social PolicyStatement of 1980 was the first to define nursing as the diagno-sis and treatment of human responses to actual and potentialhealth problems. This definition, when combined with the ANAS tandards of Practice, has provided impetus and support for theuse of nursing diagnosis. Defining nursing and its effect onclient care supports the growing awareness that nursing care isa key factor in client survival and in the maintenance, rehabili-tative, and preventive aspects of healthcare. Changes and newdevelopments in healthcare delivery in the last decade havegiven rise to the need for a common framework of communica-tion to ensure continuity of care for the client moving betweenmultiple healthcare settings and providers.

8 Evaluation anddocumentation of care are important parts of this book is designed to aid the practitioner and studentnurse in identifying interventions commonly associated withspecific nursing diagnoses as proposed by NANDA Inter-national (formerly the North American Nursing DiagnosisAssociation). These interventions are the activities needed toimplement and document care provided to the individual clientand can be used in varied settings from acute to community/home 1 and 2 present brief discussions of the nursingprocess, data collection, and care plan construction . Chapter 3contains the Diagnostic Divisions, Assessment Tool, a sampleplan of care, mind map, and corresponding documentation/charting examples. For more in-depth information and inclu-sive plans of care related to specific medical/psychiatric condi-tions (with rationale and the application of the diagnoses), thenurse is referred to the larger works, all published by the Company:Nursing Care Plans Across the Life Span, (Doenges, Moorhouse, Geissler-Murr, 2006);Psychiatric CarePlans: Guidelines for Individualizing Care, ed.

9 3 (Doenges,Townsend, Moorhouse, 1998); and Maternal/Newborn Plans ofCare: Guidelines for Individualizing Care, ed. 3 (Doenges,Moorhouse, 1999) with updated versions included on the CD-ROM provided with Nursing Care to Use theNurse s Pocket Guide00 Doenges Pocket (F)-FMR 2/7/06 1:52 PM Page xiiiNursing diagnoses are listed alphabetically in Chapter 4 forease of reference and include the diagnoses accepted for use byNANDA through 2005 2006. Each diagnosis approved for test-ing includes its definition and information divided into theNANDA categories of Related or Risk Factors and DefiningCharacteristics. Related/Risk Factors information reflectscausative or contributing factors that can be useful for deter-mining whether the diagnosis is applicable to a particular Characteristics (signs and symptoms or cues) arelisted as subjective and/or objective and are used to confirmactual diagnoses, aid in formulating outcomes, and provideadditional data for choosing appropriate interventions.

10 Theauthors have not deleted or altered NANDA s listings; however,on occasion, they have added to their definitions and suggestedadditional criteria to provide clarification and direction. Theseadditions are denoted with brackets [ ].With the development and acceptance of Taxonomy IIfollowing the biennial conference in 2000, significant changeswere made to better reflect the content of the diagnoses withinthe taxonomy. Taxonomy II was designed to reduce miscalcula-tions, errors, and redundancies. The framework has beenchanged from the Human Response Patterns and is organized inDomains and Classes, with 13 domains, 47 classes, and 172diagnoses. Although clinicians will use the actual diagnoses,understanding the taxonomic structure will help the nurse tofind the desired information quickly. Taxonomy II is designed tobe multiaxial with 7 axes (see Appendix 2).