Nursing Care Plans - الرئيسية

1 3041_FM_i-xxxii 29/01/14 9:16 AM Page iThe very best patient care begins with the very best care planning and throughout your career!Doenges, Moorhouse & MurrNurse s Pocket Guidediagnoses, Prioritized interventions and rationalesThe perfect portable guide for practitioners and Nursing students on the go! Here s everything you need to select the appropriate diagnoses for your patients and develop safe and effective care & MoorhouseAPPLicAtioN oF Nursing Process ANd Nursing diAGNosisAn interactive text for diagnostic reasoningMaster the Nursing process with this step-by-step approach to the whys and hows, while you develop the diagnostic reasoning and problem-solving skills you need to think like a nurse. Doenges, Moorhouse & MurrNursiNG diAGNosis MANuALPlanning, individualizing, and documenting client careRely 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 your coPies todAy!

2 Taber s 22brings meanings to life!Taber s 22 Edited by Donald Venes, MSJ, MDMeet the needs of diverse learning styles and today s time-pressed students with FREE mobile and web access, flash-card app, audio pronunciations, interactive learning activities, and more!Web. MObILe. PrINT. The choice is 29/01/14 9:16 AM Page iiDon t miss the Nursing diagnosis and care planning resources online atA wealth of online tools help you learn to plan and implement safe, individualized care . Visit today! Concept care Map Generator Learning Activities Interactive Assessment Tool care Plan Template care Plan Case Studies Gordon s Functional Health Case Studies Online Disorder Lookup Nursing Diagnoses Arranged by Maslow OF DISEASES/DISORDERSThis is 1 of 2 indexes in the book. It should be compiled by the indexer and only needs to contain the disorder/disease and the page numberin which the care plan for that disorder/disease , (Ed.)

3 Nursing Diagnoses Definitions and Classification 2012 2012, 1994 2012 NANDA by arrangement with John Wiley & Sons Limited. In order to make safe and effective judgments using NANDA-I Nursing diagnosesit is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this imbalancesrespiratory, 179metabolic, 450 Acquired immunodeficiency syndrome (AIDS),689 Acute coronary syndrome (ACS), 58 Acute kidney injury (acute renal failure), 505 Adult leukemias, 484 Alcohol: acute withdrawal, 800 Alzheimer s disease, 743 Amputation, 616 Anemia iron deficiency, anemia of chronic disease, pernicious, aplastic, hemolytic, 459 Angina: chronic/stable, 67 Anorexia nervosa, 340 Aplastic anemia, 459 Appendectomy, 315 Asthma, 118 Bariatric surgery, 367 Benign prostatic hyperplasia, 559 Brain infections: meningitis and encephalitis,229 Bulimia nervosa, 340 Burns: thermal, chemical, and electrical acuteand convalescent phases, 638 Cancer, 827 cardiac dysrhythmias, 87 cardiac surgery.

4 Postoperative care , 98 Cardiomyoplasty, 98 Cerebrovascular accident/stroke, 214 Chemical burns, 638 Cholecystectomy, 335 Cholecystitis with cholelithiasis, 329 Cholelithiasis, 329 Chronic obstructive pulmonary disease (COPD)and asthma, 118 Cirrhosis of the liver, 412 Colostomy, 304 Coronary artery bypass graft, 98 Craniocerebral trauma acute rehabilitativephase, 197 Crohn s disease, 291 Dementia (Alzheimer s type or vascular), 743 Diabetes mellitus/diabetic ketoacidosis, 377 Diabetic ketoacidosis, 377 Disaster considerations, 858 Disc surgery, 237 Dysrthymias, 87 Eating disorders : anorexia nervosa/bulimia nervosa, 340 Eating disorders : obesity, 358 Electrical burns, 638 Encephalitis, 229 End-of-life care /hospice, 848 End stage renal disease, 517 Enteral feeding, 437 Esophageal bleeding, 281 Extended care , 781 Fecal diversions: postoperative care of ileostomyand colostomy, 304 Fluid and electrolyte imbalances, 886 Fractures, 601 Gastrectomy/gastroplasty, DavisPlusGastric bypass, 367 Gastric partitioning, 367 Glaucoma, DavisPlusGraves disease, 391 Heart failure: chronic, 43 Hemodialysis, 544 Hemolytic anemia, 459 Hemothorax, 150 Hepatitis, 400 Herniated nucleus pulposus, DavisPlusHIV-positive client, 677 Hospice, 848 Hypercalcemia (calcium excess), 909 Hyperkalemia (potassium excess), 903 Hypermagnesemia (magnesium excess), 915 Hypernatremia (sodium excess), 897 Hypertension: severe, 33 Hyperthyroidism (Graves disease, thyrotoxicosis), 391 Hypervolemia (extracellular fluid volume excess), 886 Hypocalcemia (calcium deficit), 906 Hypokalemia (potassium deficit), 900 Hypomagnesemia (magnesium deficit), 912 Hyponatremia (sodium deficit), 893 Hypovolemia (extracellular fluid volume deficit), 890 Hysterectomy, 581 Ileostomy, 304 Inflammatory bowel disease.

5 Ulcerative colitis,Crohn s disease, 291 Iron deficiency anemia, 459 Laminectomy, 237 Laryngectomy, DavisPlusLewy body disease, 743 Leukemias, 484 Lung cancer: postoperative care , 141 Lymphomas, 494 Mastectomy, 589 Meningitis, 229 Metabolic acid-base imbalances, 450 Metabolic acidosis primary base bicarbonatedeficiency, 450 Metabolic alkalosis primary base bicarbonateexcess, 455 Minimally invasive direct coronary artery bypass, 98 Multiple sclerosis, 266 Myocardial infarction, 75 Obesity, 358 Obesity: bariatric surgery, 367 Pancreatitis, 426 Parenteral feeding, 437 Pediatric considerations, 872 Peritoneal dialysis, 539 Peritonitis, 320 Pernicious anemia, 459 Pneumonia, 129 Pneumothorax, 150 Primary base bicarbonate deficiency, 450 Primary base bicarbonate excess, 455 Primary carbonic acid deficit, 184 Primary carbonic acid excess, 179 Prostatectomy, 566 Psychosocial aspects of care , 729 Pulmonary emboli considerations, 109 Pulmonary tuberculosis (TB), 170 Radical neck surgery, DavisPlusRenal calculi, 573 Renal dialysis general considerations, 529 Renal failure: acute, 505 Renal failure.

6 Chronic, 517 Respiratory acid-base imbalances, 179 Respiratory acidosis (primary carbonic acid excess), 179 Respiratory alkalosis (primary carbonic aciddeficit), 184 Rheumatoid arthritis (RA), 709 Ruptured invertebral disc, DavisPlusSeizure disorders , 188 Sepsis/septicemia, 665 Sickle cell crisis, 469 Spinal cord injury (acute rehabilitative phase),248 Stroke, 214 Substance use disorders (SUDs), 815 Surgical intervention, 762 Thermal burns, 638 Thrombophlebitis: venous thromboembolism, 109 Thyroidectomy, DavisPlusThyrotoxicosis, 391 Total joint replacement, 625 Total nutritional support: parenteral/enteral feeding, 437 Transplantation considerations postoperativeand lifelong, 719 Tuberculosis (TB), pulmonary, 170 Ulcerative colitis, 291 Upper gastrointestinal/esophageal bleeding, 281 Urinary diversions/urostomy (postoperativecare), 548 Urolithiasis (renal calculi), 573 Urostomy, 548 Valve replacement, 98 Vascular dementia, 743 Ventilatory assistance (mechanical), 157 Wound care : complicated or chronic, 6573041_FM_i-xxxii 29/01/14 9:16 AM Page iiiKEY TO ESSENTIAL TERMINOLOGYC lient Assessment DatabaseProvides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical and/or surgical di-agnosis or health condition as well as the signs and symptoms and corresponding diagnostic PrioritiesEstablishes a general ranking of needs and concerns on which the Nursing Diagnoses are ordered in constructing the plan of care .

7 Thisranking would be altered according to the individual client GoalsIdentifies 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 DiagnosisThe general need or problem (diagnosis) is stated without the distinct cause and signs and symptoms, which would be added to create aclient 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 related to unconscious conflict, threatto self-concept as evidenced by statements of increased tension, apprehension; observations of quivering voice, focus on addition, diagnoses identified within these guides for planning care as actual, risk, or health-promotion can be changed or deletedand new diagnoses added, depending entirely on the specific client situation or available Be Related to/Possibly Evidenced byThese lists provide the usual or common reasons (etiology) why a particular need or problem may occur with probable signs and symptoms,which would be used to create the related to and evidenced by portions of the client diagnostic statementwhen the specific situation a risk diagnosis has been identified, signs and symptoms have not yet developed and therefore are not included in the nursingdiagnosis statement.

8 However, interventions are provided to prevent progression to an actual problem. Furthermore, health-promotion diag-noses (readiness for enhanced) do not contain related factors, but do have defining characteristics for the evidenced by segment of theclient diagnostic statement. Desired Outcomes/Evaluation Criteria Client WillThese give direction to client care as they identify what the client or nurse hopes to achieve. They are stated in general terms to permit thepractitioner to modify or individualize them by adding time lines and specific 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 Nursing languageand serves as a general header for the outcome indicators that Interventions Classification (NIC) labels are drawn from a third standardized Nursing language and serve as a general header forthe Nursing actions that actions are divided into independent those actions that the nurse performs autonomously and collaborative those actionsthat the nurse performs in conjunction with others, such as implementing physician orders.

9 The interventions in this book are generallyranked from most to least common. When creating the individual plan of care , interventions would normally be ranked to reflect the client sspecific needs and situation. In addition, the division of independent and collaborative is arbitrary and is actually dependent on the individualnurse s capabilities, agency protocols, and professional not commonly appearing in client Plans of care , rationale has been included here to provide a pathophysiological basis to assistthe nurse in deciding about the relevance of a specific intervention for an individual client PathwayThis abbreviated plan of care or care map is event- or task-oriented and provides outcome-based guidelines for goal achievement within adesignated length of stay. Several samples have been included to demonstrate alternative planning 29/01/14 9:16 AM Page ivActivity Intolerance [specify level]Activity Intolerance, risk forActivity Planning, ineffectiveActivity Planning, risk for ineffectiveAdverse Reaction to Iodinated Contrast Media, risk forAirway Clearance, ineffectiveAllergy Response, risk forAnxiety [specify level]

10 Aspiration, risk forAttachment, risk for impairedAutonomic DysreflexiaAutonomic Dysreflexia, risk forBehavior, disorganized infantBehavior, readiness for enhanced organized infantBehavior, risk for disorganized infantBleeding, risk forBlood Glucose Level, risk for unstable Body Image, disturbedBody Temperature, risk for imbalancedBreast Milk, insufficientBreastfeeding, ineffectiveBreastfeeding, interruptedBreastfeeding, readiness for enhancedBreathing Pattern, ineffectiveCardiac Output, decreasedCaregiver Role StrainCaregiver Role Strain, risk forChildbearing Process, ineffectiveChildbearing Process, readiness for enhancedChildbearing Process, risk for ineffectiveComfort, impairedComfort, readiness for enhancedCommunication, impaired verbalCommunication, readiness for enhancedConfusion, acuteConfusion, chronicConfusion, risk for acuteConstipationConstipation, perceivedConstipation, risk forContaminationContamination, risk forCoping, compromised familyCoping, defensiveCoping, disabled familyCoping, ineffectiveCoping, ineffective communityCoping, readiness for enhancedCoping, readiness for enhanced communityCoping, readiness for enhanced familyDeath AnxietyDecision-Making, readiness for enhancedDecisional ConflictDenial, ineffectiveDentition, impairedDevelopment, risk for delayedDiarrheaDignity, risk for compromised humanDisuse Syndrome, risk forDiversional Activity, deficientDry Eye, risk forElectrolyte Imbalance, risk forEnergy Field, disturbedEnvironmental Interpretation Syndrome, impairedFailure to Thrive, adultFalls, risk forFamily Processes, dysfunctionalFamily Processes, interruptedFamily Processes, readiness for enhancedFatigueFearFeeding Pattern, ineffective infantFluid Balance, readiness for enhanced[Fluid Volume, deficient hyper/hypotonic]Fluid Volume, deficient [isotonic]