Handbook of Nursing Diagnosis

Description

Carpenito’s “Handbook of Nursing Diagnosis” is the ideal quick reference for Nursing Diagnosis information. This handbook offers practical guidance on nursing diagnoses and associated care. Compared to Carpenito’s textbook, the handbook is a quick-reference type scope of content, easy for students to use while in clinical, in the classroom or simulation lab. From goals to specific interventions, Handbook of Nursing Diagnosis focuses on nursing. It provides a condensed, organized outline of clinical nursing practice designed to communicate creative clinical nursing. It is not meant to replace nursing textbooks, but rather to provide nurses who work in a variety of settings with the information they need without requiring a time-consuming review of the literature. It will assist students in transferring their theoretical knowledge to clinical practice. This title is intended for nursing students to use through their curriculum. The 15th edition is organized in three sections. Section 1 provides an alphabetical reference to nursing diagnoses, including NANDA-I definition and Section 2 focuses organizes all the health promotion/wellness nursing diagnoses for individuals. Under each diagnosis, Author’s Notes will elaborate on the clinical usefulness of the diagnosis. Additional foundational knowledge is included in each diagnosis: • NANDA-I definition • Defining characteristics (physiologic, emotional and cognitive) • Related factors including pathophysiologic, treatment related, and situational (personal and environmental) • Maturational: infant/child, adolescent, adult and older adult • Errors in Diagnostic Statements • Key Concepts & General Considerations • Special Population Consideration (Pediatric, Maternal, Geriatric, and Transcultural) • Focused Assessment Criteria • Goals (NIC/NOC) with Rationale • Interventions for Special Population Lastly, section 3 covers Diagnostic Clusters, which presents medical conditions with associated collaborative problems and nursing diagnoses, designed for easy reference in the clinical setting. The handbook differs from the main textbook because it doesn’t go into the foundation for understanding nursing diagnoses, including care planning and concept mapping. The handbook only covers the NANDA-I diagnoses and collaborative problems. Introduction Section I Nursing Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Activity Intolerance 28 Activity Planning, Ineffective 33 Activity Planning, Risk for Ineffective 34 Adverse Reaction to Iodinated Contrast Media, Risk for 35 Allergy Response, Risk for 41 Anxiety 46 Anxiety, Death 54 Bleeding, Risk for 58 Blood Glucose Level, Risk for Unstable 59 Bowel Incontinence 60 Breastfeeding, Ineffective 63 Breastfeeding, Interrupted 70 Breast Milk, Insufficient 71 Cardiac Output, Decreased 72 Caregiver Role Strain 73 Caregiver Role Strain, Risk for 80 Childbearing Process, Ineffective 83 Childbearing Process, Risk for Ineffective 85 Comfort, Impaired 86 Pain, Acute 92 Pain, Chronic I 0 I Chronic Pain Syndrome I 06 Pain, Labor I I 0 Nausea I 17 Communication, Impaired 121 Communication, Impaired Verbal 126 Confusion, Acute 128 Confusion, Risk for Acute 134 XI xii Contents Confusion, Chronic 134 Contamination, Individual 139 Contamination, Risk for Individual 145 Contamination, Family 146 Contamination, Risk for Community 147 Coping, Ineffective 149 Coping, Defensive 157 Impulse Control, Ineffective 161 Denial, Ineffective 163 Labile Emotional Control I 68 Impaired Mood Regulation 17 1 Coping, Ineffective Community 172 Coping, Compromised Family 175 Coping, Disabled Family 176 Decisional Conflict 183 Diarrhea 188 Disuse Syndrome, Risk for 193 Diversional Activity, Deficient 20 I Dysreflexia, Autonomic 206 Dysreflexia, Risk for Autonomic 2 1 0 Electrolyte Imbalance, Risk for 21 0 Family Processes, Interrupted 21 I Family Processes, Dysfunctional 2 16 Fear 220 Fluid Volume, Deficient 226 Fluid Volume, Risk for Deficient 23 I Fluid Volume, Excess 232 Fluid Volume, Risk for Imbalanced 237 Gastrointestinal Motility, Dysfunctional 238 Gastrointestinal Motility, Risk for Dysfunctional 239 Grieving 240 Grieving, Anticipatory 248 Grieving, Complicated 252 Grieving, Risk for Complicated 256 Health, Deficient Community 257 Health Behavior, Risk-Prone 259 Health Maintenance, Ineffective 264 Health Management, Ineffective 275 Home Maintenance, Impaired 281 Hopelessness 286 Human Dignity, Risk for Compromised 293 Infant Behavior, Disorganized 296 Infant Behavior, Risk for Disorganized 304 Infection, Risk for 305 Infection Transmission, Risk for 3 12 Injury, Risk for 317 Aspiration, Risk for 325 Falls, Risk for 328 Poisoning, Risk for 333 Suffocation, Risk for 333 Thermal Injury, Risk for 333 Trauma, Risk for 335 Perioperative Positioning Injury, Risk for 335 Urinary Tract Injury, Risk for 338 Intracranial Adaptive Capacity, Decreased 342 Jaundice, Neonatal 342 Jaundice, Risk for Neonatal 343 Knowledge, Deficient 344 Latex Allergy Response 345 Latex Allergy Response, Risk for 348 Lifestyle, Sedentary 350 Liver Function, Risk for Impaired 353 Maternal/Fetal Dyad, Risk for Disturbed 354 Memory, Impaired 355 Mobility, Impaired Physical 358 Bed Mobility, Impaired 365 Sitting, Impaired 367 Standing, Impaired 368 Walking, Impaired 369 Wheelchair Mobility, Impaired 370 Transfer Ability, Impaired 372 Moral Distress 374 Moral Distress, Risk for 378 Neglect, Self 381 Neglect, Unilateral 382 Noncompliance 386 Nutrition, Imbalanced 388 Dentition, Impaired 396 Swallowing, Impaired 396 Infant Feeding Pattern, Ineffective 400 Contents xiii xiv Contents Obesity 404 Overweight 4 I 0 Risk for Overweight 4 13 Parenting, Impaired 419 Post-Trauma Syndrome 424 Post-Trauma Syndrome, Risk for 430 Rape-Trauma Syndrome (Sexual Assault Trauma Syndrome) 430 Powerlessness 436 Powerlessness, Risk for 44 1 Protection, Ineffective 441 Corneal Injury, Risk for 444 Dry Eye, Risk for 446 Oral Mucous Membrane, Impaired 448 Oral Mucous Membrane, Risk for Impaired 454 T issue Integrity, Impaired 456 Skin Integrity, Impaired 459 Skin Integrity, Risk for Impaired 459 Pressure Ulcer 460 Pressure Ulcer, Risk for 467 Relationship, Ineffective 474 Relationship, Risk for Ineffective 475 Relocation Stress [Syndrome] 476 Relocation Stress [Syndrome], Risk for 480 Resilience, Risk for Compromised 484 Resilience, Impaired Individual 484 Respiratory Function, Risk for Ineffective 486 Ventilatory Weaning Response, Dysfunctional 489 Ventilatory Weaning Response, Risk for Dysfunctional 494 Airway Clearance, Ineffective 497 Breathing Pattern, Ineffective 500 Gas Exchange, Impaired 504 Spontaneous Ventilation, Impaired 505 Role Performance, Ineffective 506 Self-Care Deficit Syndrome 507 Feeding Self-Care Deficit 5 12 Bathing Self-Care Deficit 5 I 5 Dressing Self-Care Deficit 5 I 8 Instrumental Self-Care Deficit 52 1 Toileting Self-Care Deficit 524 Self-Concept, Disturbed 526 Body Image, Disturbed 530 Personal Identity, Disturbed 537 Personal Identity, Risk for Disturbed 538 Self-Esteem, Disturbed 539 Self-Esteem, Chronic Low 542 Self-Esteem, Risk for Chronic Low 545 Self-Esteem, Situational Low 546 Self-Esteem, Risk for Situational Low 549 Self-Harm, Risk for 550 Self-Mutilation 556 Self-Mutilation, Risk for 557 Suicide, Risk for 559 Sexuality Pattern, Ineffective 566 Sexual Dysfunction 572 Shock, Risk for 573 Sleep Pattern, Disturbed 574 Insomnia 582 Sleep Deprivation 584 Social Isolation 584 Sorrow, Chronic 586 Spiritual Distress 589 Spiritual Distress, Risk for 595 Religiosity, Impaired 596 Religiosity, Risk for Impaired 599 Stress Overload 600 Sudden Infant Death Syndrome, Risk for 605 Surgical Recovery, Delayed 607 Surgical Recovery, Risk for Delayed 608 Tissue Perfusion, Ineffective 61 I Contents xv Cardiac T issue Perfusion, Risk for Decreased 612 Cerebral Tissue Perfusion, Risk for Ineffective 6 13 Gastrointestinal Tissue Perfusion, Risk for Ineffective 61 5 Peripheral Tissue Perfusion, Ineffective 6 16 Peripheral Tissue Perfusion, Risk for Ineffective 620 Peripheral Neurovascular Dysfunction, Risk for 62 1 Renal Perfusion, Risk for Ineffective 622 xvi Contents Urinary Elimination, Impaired 624 Maturational Enuresis 628 Functional Urinary Incontinence 632 Refiex Urinary Incontinence 637 Stress Urinary Incontinence 639 Continuous Urinary Incontinence 642 Urge Urinary Incontinence 644 Urge Urinary Incontinence, Risk for 648 Overfiow Urinary Incontinence 648 Vascular Trauma, Risk for 65 I Section 2 Health-Promotion Nursing Diagnoses . . . . . . . . . . 653 Readiness for Enhanced Breastfeeding 657 Readiness for Enhanced Childbearing Process 658 Readiness for Enhanced Comfort 659 Readiness for Enhanced Communication 659 Readiness for Enhanced Coping 660 Readiness for Enhanced Community Coping 662 Readiness for Enhanced Decision Making 666 Readiness for Enhanced Emancipated Decision-Making 667 Readiness for Enhanced Family Coping 668 Readiness for Enhanced Family Processes 669 Readiness for Enhanced Fluid Balance 671 Readiness for Enhanced Health Management 672 Readiness for Enhanced Hope 676 Readiness for Enhanced Organized Infant Behavior 677 Readiness for Enhanced Knowledge (Specify) 681 Readiness for Enhanced Nutrition 681 Readiness for Enhanced Parenting 682 Readiness for Enhanced Power 683 Readiness for Enhanced Relationship 684 Readiness for Enhanced Religiosity 685 Readiness for Enhanced Resilience 686 Readiness for Enhanced Self-Care 688 Contents xvii Readiness for Enhanced Self-Concept 688 Readiness for Enhanced Sleep 689 Readiness for Enhanced Spiritual Well-Being 690 Readiness for Enhanced Urinary Elimination 692 Section 3 Manual of Collaborative Problems . . . . . . . . . . . . . 693 Risk for Complications of Cardiac/Vascular/Respiratory Dysfunction 696 Risk for Complications of Arrhythmias 703 Risk for Complications of Bleeding 706 Risk for Complications of Decreased Cardiac Output 71 I Risk for Complications of Compartment Syndrome 714 Risk for Complications of Deep Vein Thrombosis 719 Risk for Complications of Hypovolemia 728 Risk for Complications of Systemic Inflammatory Response Syndrome (SIRS)/SEPSIS 731 Risk for Complications of Acute Urinary Retention 735 Risk for Complications of Renal Insufficiency/Failure 738 Risk for Complications of Gl Bleeding 746 Risk for Complications of Paralytic Ileus 750 Section 4 Diagnostic Clusters Part I MEDICAL CONDIT IONS 757 Card iac Cond itions 757 Part 2 SURGICAL PROCEDURES 759 General Su rgery 759 Part 3 OBST ETRIC/GYNECOLOGIC CONDIT IONS 761 Prenatal Period (General) 761 Part 4 NEONATAL CONDIT IONS 763 Neonate , Normal 763 755 xviii Contents Part 5 PEDIAT RIC/ADOLESCENT DISORDERS 765 Developmental Problems/Needs Related to C h ronic I l l ness (Permanent Disabil ity, M u ltiple Hand icaps, Developmental Disabil ity [Mental/Physical] , Life-Threaten i ng I l l ness) 765 Part 6 MENTAL HEALTH DISORDERS 767 Alcoholism 767 Part 7 DIAGNOST IC AND THERAPEUTIC PROCEDURES 769 Angioplasty (Pe rcutaneous, Tran s l u m i nal , Coronary, Peripheral) 769 Appendix A Nursing Diagnoses Grouped Under Functional Health Patterns 77 I Appendix B Nursing Admission Data Baseline Assessment 772 Appendix C Strategies to Promote Engagement of Individual/Families for Healthier Outcomes 773 Appendix D High-Risk Assessment Tools for Preventable Hospital-Acquired Conditions 784 Bibliography 790 Index