Tài liệu Nurse’s Pocket Guide: Diagnoses, Interventions, and Rationales pptx

GORDON’S FUNCTIONAL HEALTH

PATTERNS THROUGH 2003*

*Reprinted from Manual of Nursing Diagnosis, 10th ed., M. Gordon, Copyright 2002, with

permission from Elsevier.

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Health maintenance, ineffective 275–278

Therapeutic regimen: effective management 517–519

Therapeutic regimen: ineffective management 522–525

Therapeutic regimen: readiness for enhanced management 525–527

Therapeutic regimen: family, ineffective management 520–522

Therapeutic regimen: community, ineffective management 515–517

Noncompliance (specify) 343–347

Health-seeking behaviors (specify) 278–281

Energy field, disturbed 208–211

Falls, risk for 217–221

Infection, risk for 307–310

Injury (trauma), risk for 310–313

Protection, ineffective 411–412

Poisoning, risk for 393–396

Suffocation, risk for 500–503

Perioperative positioning injury, risk for 313–316

Sudden infant death syndrome 185–189

NUTRITIONAL-METABOLIC PATTERN

Nutrition: more than body requirements, imbalanced 352–355

Nutrition: more than body requirements, risk for imbalanced 356–358

Nutrition: less than body requirements, imbalanced 347–352

Nutrition, readiness for enhanced 359–362

Breastfeeding, ineffective 110–114

Breastfeeding, effective 108–110

Breastfeeding, interrupted 115–117

Infant feeding pattern, ineffective 304–306

Aspiration, risk for 86–89

Swallowing, impaired 510–515

Nausea 339–343

Oral mucous membrane, impaired 362–365

Dentition, impaired 191–194

Fluid balance, readiness for enhanced 239–242

Fluid volume imbalance, risk for 254–256

Fluid volume, risk for deficient 252–254

Fluid volume, deficient 245–248

Fluid volume, excess 249–252

Skin integrity, impaired 461–465

Skin integrity, risk for impaired 465–468

Tissue integrity (specify type), impaired 533–537

Body temperature, risk for imbalanced 102–104

Latex allergy response 73–75

Latex allergy response, risk for 76–78

Thermoregulation, ineffective 527–529

Hyperthermia 287–290

Hypothermia 291–295

Failure to thrive, adult 214–217

ELIMINATION PATTERN

Constipation 153–157

Constipation, risk for 159–161

Constipation, perceived 157–159

Diarrhea 197–200

Bowel incontinence 105–107

Urinary elimination, impaired 554–558

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Urinary elimination, readiness for enhanced 558–561

Urinary incontinence, functional 561–564

Urinary incontinence, reflex 564–566

Urinary incontinence, stress 567–569

Urinary incontinence, urge 572–575

Urinary urge incontinence, risk for 576–578

Incontinence, total 570–572

Urinary retention 578–581

ACTIVITY-EXERCISE PATTERN

Activity intolerance, risk for 60–63

Activity intolerance (specify level) 63–65

Adaptive capacity, decreased, intracranial 316–319

Infant behavior, disorganized 295–301

Infant behavior, risk for disorganized 303–304

Infant behavior, readiness for enhanced organized 301–303

Fatigue 232–236

Physical mobility, impaired 333–337

Bed mobility, impaired 331–333

Walking, impaired 597–599

Wheelchair mobility, impaired 337–339

Transfer ability, impaired 544–546

Development, risk for delayed 194–197

Autonomic dysreflexia 92–95

Autonomic dysreflexia, risk for 95–97

Disuse syndrome, risk for 200–205

Self-care deficit (specify: bathing/hygiene, dressing/grooming, feeding, toileting)

425–430

Diversional activity deficient 205–208

Home maintenance, impaired 281–283

Dysfunctional ventilatory weaning response 586–590

Ventilation, impaired spontaneous 581–586

Airway clearance, ineffective 69–72

Breathing pattern, ineffective 117–121

Gas exchange, impaired 256–260

Cardiac output, decreased 121–126

Tissue perfusion, alteration (specify) 537–544

Peripheral neurovascular dysfunction, risk for 387–390

Surgical recovery, delayed 507–510

Growth and development, delayed 266–271

Growth, risk for disproportionate 271–275

Wandering 599–602

SLEEP-REST PATTERN

Sleep-pattern disturbed 472–477

Sleep deprivation 468–472

Sleep, readiness for enhanced 477–480

COGNITIVE-PERCEPTUAL PATTERN

Acute pain 365–369

Chronic pain 370–374

Sensory perception, disturbed (specify) 449–454

Unilateral neglect 551–554

Knowledge deficit (specify) 319–323

Knowledge, readiness for enhanced 323–325

Memory, impaired 328–331

Thought processes, disturbed 529–533

Acute confusion 147–150

Chronic confusion 150–153

Environmental interpretation syndrome, impaired 211–214

Decisional conflict (specify) 144–147

SELF-PERCEPTION-SELF-CONCEPT PATTERN

Fear 236–239

Anxiety 78–83

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Anxiety, death 83–86

Hopelessness 283–287

Powerlessness 404–408

Powerlessness, risk for 408–410

Loneliness, risk for 326–328

Self-concept, readiness for enhanced 430–433

Chronic low self-esteem 433–437

Situational low self-esteem 437–440

Situational low self-esteem, risk for 440–441

Body image disturbed 98–102

Personal identity disturbed 390–393

Violence, risk for self-directed 591–596

ROLE-RELATIONSHIP PATTERN

Anticipatory grieving 260–263

Dysfunctional grieving 263–266

Chronic sorrow 487–489

Role performance, ineffective 422–425

Social isolation 484–487

Impaired social interaction 480–484

Relocation stress syndrome 417–420

Relocation stress syndrome, risk for 421–422

Family processes, interrupted 225–228

Family processes, readiness for enhanced 228–232

Dysfunctional family processes: alcoholism 221–225

Impaired parenting, risk for 385–387

Impaired parenting 377–381

Parenting, readiness for enhanced 381–385

Impaired parent/infant/child attachment, risk for 89–92

Parental role conflict 374–377

Caregiver role strain 126–132

Caregiver role strain, risk for 132–135

Impaired verbal communication 135–139

Communication, readiness for enhanced 139–143

Risk for violence, directed at others 590–591

SEXUALITY-REPRODUCTIVE

Sexual dysfunction 454–458

Ineffective sexuality patterns 472–477

Rape-trauma syndrome 412–417

Rape-trauma syndrome: compound reaction 413

Rape-trauma syndrome: silent reaction 413

COPING-STRESS TOLERANCE PATTERN

Ineffective coping 178–182

Coping, readiness for enhanced 182–185

Defensive coping 166–169

Community coping, ineffective 162–164

Community coping, readiness for enhanced 164–166

Ineffective denial 189–191

Impaired adjustment 66–69

Post-trauma syndrome 396–401

Post-trauma syndrome, risk for 402–404

Family coping: readiness for enhanced 175–177

Ineffective family coping: compromised 169–172

Ineffective family coping: disabling 172–175

Risk for suicide 503–507

Self-mutilation 442–445

Self-mutilation, risk for 445–449

VALUE-BELIEF PATTERN

Spiritual distress 490–494

Spiritual distress, risk for 494–497

Spiritual well-being, readiness for enhanced 497–500

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Nurse’s Pocket Guide

Diagnoses, Interventions,

and Rationales

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Nurse’s Pocket Guide

Diagnoses, Interventions,

and Rationales

NINTH EDITION

Marilynn E. Doenges, RN, BSN, MA

Clinical Specialist—Adult Psychiatric/Mental Health, Retired

Adjunct Faculty

Beth-El College of Nursing and Health Sciences CU-Springs

Colorado Springs, Colorado

Mary Frances Moorhouse, RN, BSN, CRRN, CLNC

Nurse Consultant

TNT-RN Enterprises

Adjunct Faculty

Pikes Peak Community College

Colorado Springs, Colorado

Alice C. Murr, RN, BSN

Telephone Triage Nurse

Legal Nurse Consultant

Colorado Springs, Colorado

F.A. Davis Company • Philadelphia

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F.A. Davis Company

1915 Arch Street

Philadelphia, PA 19103

www. fadavis.com

Copyright © 2004 by F.A. Davis Company

Copyright © 1985, 1988, 1991, 1993, 1996, 1998, 2000, 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 trans￾mitted in any form or by any means, electronic, mechanical, photo￾copying, recording, or otherwise, without written permission from the

publisher.

Printed in Canada

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher: Robert G. Martone

Cover Design: Joan Wendt

As new scientific information becomes available through basic and clin￾ical 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 stan￾dards at the time of publication. The authors, editors, and publisher are

not responsible for errors or omissions or for consequences from appli￾cation 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 stan￾dards of care used in regard to the unique circumstances that may apply

in each situation. The reader is advised always to check product infor￾mation (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.

ISBN 0-8036-1179-X

Authorization to photocopy items for internal or personal use, or the

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Sheila Marquez

Executive Director

Vice President/Chief Operating Officer

The Colorado SIDS Program, Inc.

Denver, Colorado

Contributor

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This book is dedicated to:

Our families, who helped with the mundane activities of

daily living that allowed us to write this book and who provide

us with love and encouragement in all our endeavors.

Our friends, who support us in our writing, put up with our

memory lapses, and love us still.

Bob Martone, Publisher, Nursing, who asks questions that

stimulate thought and discussion, and who maintains good

humor throughout.

The F.A. Davis production staff, who coordinated and expe￾dited the project through the printing process, meeting unreal

deadlines, and sending pages to us with bated breath.

Robert H. Craven, Jr., and the F.A. Davis family.

And last and most important:

The nurses we are writing for, to those who have found the

previous editions of the Pocket Guide helpful, and to other

nurses who are looking for help to provide quality nursing care

in a period of transition and change, we say, “Nursing Diagnosis

is the way.”

ACKNOWLEDGMENTS

A special acknowledgment to Marilynn’s friend, the late Diane

Camillone, who provoked an awareness of the role of the

patient and continues to influence our thoughts about the

importance of quality nursing care, and to our late colleague,

Mary Jeffries, who introduced us to nursing diagnosis.

To our colleagues in NANDA who continue to formulate and

refine nursing diagnoses to provide nursing with the tools to

enhance and promote the growth of the profession.

Marilynn E. Doenges

Mary Frances Moorhouse

Alice C. Murr

Dedication

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Health Conditions and Client Concerns with Associated Nursing

Diagnoses appear on pages 603-720.

How to Use the Nurse’s Pocket Guide ..................................xiii

CHAPTER 1

The Nursing Process ..................................................................1

CHAPTER 2

Application of the Nursing Process ..........................................4

CHAPTER 3

Putting Theory into Practice: Sample

Assessment Tools, Plan of Care,

and Documentation ................................................................12

SECTION 1

Assessment Tools for Choosing

Nursing Diagnoses ..............................................................15

Adult Medical/Surgical Assessment Tool 16

Excerpt from Psychiatric Assessment Tool 26

Excerpt from Prenatal Assessment Tool 29

Excerpt from Intrapartal Assessment Tool 31

SECTION 2

Diagnostic Divisions: Nursing Diagnoses

Organized According to a Nursing Focus ..........................33

SECTION 3

Client Situation and Prototype Plan of Care ......................39

SECTION 4

Documentation Techniques: SOAP

and Focus Charting® ............................................................55

CHAPTER 4

Nursing Diagnoses in Alphabetical Order ............................60

For each nursing diagnosis, the following information is provided:

Taxonomy II, Domain, Class, Code, Year Submitted

xi

Contents

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Diagnostic Division

Definition

Related/Risk Factors, Defining Characteristics:

Subjective/Objective

Desired Outcomes/Evaluation Criteria

Actions/Interventions

Nursing Priorities

Documentation Focus

Sample Nursing Outcomes & Interventions Classifications

(NOC/NIC)

CHAPTER 5

Health Conditions and Client Concerns

with Associated Nursing Diagnoses ....................................603

APPENDIX 1

NANDA’s Taxonomy II ..........................................................732

APPENDIX 2

Definitions of Taxonomy II Axes ..........................................736

Bibliography ..........................................................................739

Index ......................................................................................749

xii CONTENTS

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The American Nurses Association (ANA) Social Policy

Statement of 1980 was the first to define nursing as the diagno￾sis and treatment of human responses to actual and potential

health problems. This definition, when combined with the ANA

Standards of Practice, has provided impetus and support for the

use of nursing diagnosis. Defining nursing and its effect on

client care supports the growing awareness that nursing care is

a key factor in client survival and in the maintenance, rehabili￾tative, and preventive aspects of healthcare. Changes and new

developments in healthcare delivery in the last decade have

given rise to the need for a common framework of communica￾tion to ensure continuity of care for the client moving between

multiple healthcare settings and providers. Evaluation and

documentation of care are important parts of this process.

This book is designed to aid the practitioner and student

nurse in identifying interventions commonly associated with

specific nursing diagnoses as proposed by NANDA Inter￾national (formerly the North American Nursing Diagnosis

Association). These interventions are the activities needed to

implement and document care provided to the individual

client and can be used in varied settings from acute to commu￾nity/home care.

Chapters 1 and 2 present brief discussions of the nursing

process, data collection, and care plan construction. Chapter 3

contains the Diagnostic Divisions, Assessment Tool, a sample

plan of care, and corresponding documentation/charting exam￾ples. For more in-depth information and inclusive plans of care

related to specific medical/psychiatric conditions (with ration￾ale and the application of the diagnoses), the nurse is referred

to the larger works, all published by the F.A. Davis Company:

Nursing Care Plans: Guidelines for Planning and Documenting

Patient Care, ed. 6 (Doenges, Moorhouse, Geissler-Murr, 2002);

Psychiatric Care Plans: Guidelines for Planning and Documenting

Client Care, ed. 3 (Doenges, Townsend, Moorhouse, 1998); and

Maternal/Newborn Plans of Care: Guidelines for Planning and

Documenting Client Care, ed. 3 (Doenges, Moorhouse, 1999).

Nursing diagnoses are listed alphabetically in Chapter 4 for

ease of reference and include the diagnoses accepted for use by

xiii

How to Use the

Nurse’s Pocket Guide

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