Nursing care plan readiness for enhanced knowledge

Diagnoses Activity intolerance, 122 Risk for Activity intolerance, 127 Ineffective Activity planning, 127 Risk for Ineffective Activity planning, 130 Ineffective Airway clearance, 130 Risk for Allergy response, 136 Anxiety, 139 Death Anxiety, 144 Risk for Aspiration, 147 Risk for impaired Attachment, 152 Autonomic Dysreflexia, 158 Risk for Autonomic Dysreflexia, 161 Risk for Bleeding, 162 Disturbed Body Image, 167 Insufficient Breast Milk, 171 Ineffective Breastfeeding, 174 Interrupted Breastfeeding, 176 Readiness for enhanced Breastfeeding, 179 Ineffective Breathing pattern, 181 Decreased Cardiac output, 187 Risk for decreased Cardiac output, 194 Risk for decreased Cardiac tissue perfusion, 195 Risk for impaired Cardiovascular function, 200 Caregiver Role Strain, 200 Risk for Caregiver Role Strain, 206 Risk for ineffective Cerebral tissue perfusion, 207 Ineffective Childbearing process, 209 Readiness for enhanced Childbearing process, 213 Risk for ineffective Childbearing process, 218 Impaired Comfort, 219 Readiness for enhanced Comfort, 222 Readiness for enhanced Communication, 228 Impaired verbal Communication, 230 Acute Confusion, 236 Chronic Confusion, 243 Risk for acute Confusion, 251 Constipation, 251 Chronic functional Constipation, 259 Perceived Constipation, 263 Risk for Constipation, 266 Risk for chronic functional Constipation, 267 Contamination, 267 Risk for Contamination, 272 Risk for adverse reaction to iodinated Contrast Media, 272 Compromised family Coping, 275 Defensive Coping, 280 Ineffective community Coping, 284 Ineffective Coping, 287 Disabled family Coping, 294 Readiness for enhanced Coping, 297 Readiness for enhanced community Coping, 302 Readiness for enhanced family Coping, 303 Readiness for enhanced Decision-Making, 306 Impaired emancipated Decision-Making, 309 Readiness for enhanced emancipated Decision-Making, 312 Risk for impaired emancipated Decision-Making, 315 Decisional Conflict, 317 Ineffective Denial, 321

Impaired Dentition, 324 Risk for delayed Development, 329 Diarrhea, 332 Risk for Disuse syndrome, 338 Deficient Diversional activity, 343 Risk for Electrolyte imbalance, 348 Labile Emotional Control, 350 Risk for dry Eye, 353 Risk for Falls, 355 Dysfunctional Family processes, 361 Interrupted Family processes, 366 Readiness for enhanced Family processes, 369 Fatigue, 372 Fear, 378 Ineffective infant Feeding pattern, 383 Readiness for enhanced Fluid balance, 386 Deficient Fluid volume, 388 Excess Fluid volume, 393 Risk for Deficient Fluid volume, 397 Risk for imbalanced Fluid volume, 397 Frail Elderly syndrome, 401 Risk for Frail Elderly syndrome, 403 Impaired Gas exchange, 404 Dysfunctional Gastrointestinal motility, 408 Risk for dysfunctional Gastrointestinal motility, 412 Risk for ineffective Gastrointestinal perfusion, 412 Risk for unstable blood Glucose level, 414 Grieving, 420 Complicated Grieving, 426 Risk for complicated Grieving, 431 Risk for disproportionate Growth, 431 Deficient community Health, 435 Risk-prone Health behavior, 438 Ineffective Health management, 443 Ineffective Family Health management, 448 Readiness for Enhanced Health management, 451 Ineffective Health maintenance, 455 Impaired Home maintenance, 459 Readiness for enhanced Hope, 463 Hopelessness, 466 Risk for compromised Human Dignity, 471 Hyperthermia, 473 Hypothermia, 478 Risk for Hypothermia, 484 Risk for Perioperative Hypothermia, 485 Disturbed personal Identity, 488 Risk for disturbed personal Identity, 495 Ineffective Impulse control, 495 Bowel Incontinence, 498 Functional urinary Incontinence, 503 Overflow urinary Incontinence, 507 Reflex urinary Incontinence, 507 Risk for urge urinary Incontinence, 511 Stress urinary Incontinence, 512 Urge urinary Incontinence, 517 Disorganized Infant behavior, 522 Readiness for enhanced organized Infant behavior, 527 Risk for disorganized Infant behavior, 527

Parental Role conflict, 727 Ineffective Role performance, 730 Sedentary lifestyle, 735 Readiness for enhanced Self-Care, 740 Bathing Self-Care deficit, 747 Dressing Self-Care deficit, 751 Feeding Self-Care deficit, 753 Toileting Self-Care deficit, 757 Readiness for enhanced Self-Concept, 760 Chronic low Self-Esteem, 763 Risk for chronic low Self-Esteem, 767 Risk for situational low Self-Esteem, 767 Situational low Self-Esteem, 770 Self-Mutilation, 772 Risk for Self-Mutilation, 775 Self-Neglect, 780 Sexual dysfunction, 784 Ineffective Sexuality pattern, 790 Risk for Shock, 797 Impaired Sitting, 802 Impaired Skin integrity, 805 Risk for impaired Skin integrity, 808 Readiness for enhanced Sleep, 811 Sleep deprivation, 814 Disturbed Sleep pattern, 817 Impaired Social interaction, 820 Social Isolation, 824 Chronic Sorrow, 829 Spiritual distress, 833 Risk for Spiritual distress, 838 Readiness for enhanced Spiritual well-being, 838 Impaired Standing, 842 Stress overload, 845 Risk for Sudden Infant Death syndrome, 849 Risk for Suffocation, 852 Risk for Suicide, 855 Delayed Surgical recovery, 865 Risk for delayed Surgical recovery, 870 Impaired Swallowing, 870 Risk for imbalanced body Temperature, 875 Risk for Thermal injury, 875 Ineffective Thermoregulation, 877 Impaired Tissue integrity, 882 Risk for impaired Tissue integrity, 886 Ineffective peripheral Tissue Perfusion, 886 Risk for ineffective peripheral Tissue Perfusion, 891 Impaired Transfer ability, 891 Risk for Trauma, 895 Unilateral Neglect, 900 Impaired Urinary elimination, 902 Readiness for enhanced Urinary elimination, 905 Urinary Retention, 907 Risk for Vascular Trauma, 912 Impaired spontaneous Ventilation, 916 Dysfunctional Ventilatory weaning response, 922 Risk for other-directed Violence, 927 Risk for self-directed Violence, 939 Impaired Walking, 939 Wandering, 943

Risk for Infection, 528 Risk for Injury, 534 Risk for corneal Injury, 540 Risk for urinary tract Injury, 542 Insomnia, 544 Decreased Intracranial adaptive capacity, 547 Neonatal Jaundice, 550 Risk for neonatal Jaundice, 554 Deficient Knowledge, 555 Readiness for enhanced Knowledge, 559 Latex Allergy response, 561 Risk for Latex Allergy response, 566 Risk for impaired Liver function, 568 Risk for Loneliness, 572 Risk for disturbed Maternal–Fetal dyad, 576 Impaired Memory, 579 Impaired bed Mobility, 583 Impaired physical Mobility, 588 Impaired wheelchair Mobility, 595 Impaired Mood regulation, 599 Moral Distress, 601 Nausea, 604 Noncompliance, 609 Readiness for enhanced Nutrition, 609 Imbalanced Nutrition: less than body requirements, 615 Obesity, 621 Impaired Oral Mucous Membrane, 625 Risk for impaired Oral Mucous Membrane, 630 Overweight, 631 Risk for Overweight, 635 Acute Pain, 639 Chronic Pain, 646 Labor Pain, 654 Chronic Pain syndrome, 654 Impaired Parenting, 655 Readiness for enhanced Parenting, 659 Risk for impaired Parenting, 662 Risk for Perioperative Positioning injury, 663 Risk for Peripheral Neurovascular dysfunction, 666 Risk for Poisoning, 668 Post-Trauma syndrome, 675 Risk for Post-Trauma syndrome, 679 Readiness for enhanced Power, 683 Powerlessness, 685 Risk for Powerlessness, 689 Risk for Pressure ulcer, 690 Ineffective Protection, 694 Rape-Trauma syndrome, 698 Ineffective Relationship, 704 Readiness for enhanced Relationship, 704 Risk for ineffective Relationship, 707 Impaired Religiosity, 708 Readiness for enhanced Religiosity, 710 Risk for impaired Religiosity, 711 Relocation stress syndrome, 712 Risk for Relocation stress syndrome, 717 Risk for ineffective Renal perfusion, 717 Impaired Resilience, 721 Readiness for enhanced Resilience, 723 Risk for impaired Resilience, 725

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NURSING DIAGNOSIS

HANDBOOK AN EVIDENCE-BASED GUIDE TO PLANNING CARE

Eleventh Edition

Betty J. Ackley, MSN, EdS, RN Gail B. Ladwig, MSN, RN Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN

3251 Riverport Lane St. Louis, Missouri 63043

NURSING DIAGNOSIS HANDBOOK, ELEVENTH EDITION ISBN: 978-0-323-32224-9

Copyright © 2017 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

NANDA International, Inc. Nursing Diagnoses: Definitions & Classifications 2015-2017, Tenth Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru. 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/nursingdiagnoses. In order to make safe and effective judgments using NANDA-I diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2014, 2011, 2008, 2006, 2004, 2002, 1999, 1997, 1995, 1993.

Library of Congress Cataloging-in-Publication Data

Names: Ackley, Betty J., editor. | Ladwig, Gail B., editor. | Makic, Mary Beth Flynn, editor. Title: Nursing diagnosis handbook : an evidence-based guide to planning care / [edited by] Betty J. Ackley,

Gail B. Ladwig, Mary Beth Flynn Makic. Description: Eleventh edition. | St. Louis, Missouri : Elsevier, [2017] | Includes bibliographical references

and index. Identifiers: LCCN 2015042558 | ISBN 9780323322249 (pbk. : alk. paper) Subjects: | MESH: Nursing Diagnosis—Handbooks. | Evidence-Based Nursing—methods—Handbooks. |

Patient Care Planning—Handbooks. Classification: LCC RT48.6 | NLM WY 49 | DDC 616.07/5—dc23 LC record available at http://lccn.loc.gov/2015042558

Content Strategist: Sandra Clark Content Development Specialist:

Jennifer Wade Publishing Services Manager: Jeff Patterson

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Book Production Specialist: Carol O’Connell

Production Manager: Andrea Villamero Design Direction: Paula Catalano

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In Memory of Betty J. Ackley

Dreams Dreams come

Dreams go Whispers, shouts, images

Dreams come Dreams go

Follow, follow*

Betty believed in dreams. This textbook was our dream. We set out to write the best nursing diagnosis textbook ever. Our book is now in 1400 nursing programs. It has been high on Amazon’s best seller list. I think her dream is realized. From a handout to students to an international publication. Thank you, dear friend Betty.

Betty passed away in December 2014 at her home with her husband (Dale) and daughter (Dawn) present.

Betty fought a gallant battle with pancreatic cancer for nine months. She loved life, her family, and the profession of nursing. She was an active member of NANDA-I for more than two decades. She was also Professor Emeritus, Jackson Community College (Jackson, Michigan). Betty was an instructor at Jackson Community College for 34 years and was named Faculty of the Year.

Betty provided presentations on nursing diagnosis in Japan and across the United States. She wrote a column on nursing diagnosis for a Japanese journal, Expert Nurse. Betty was known for her work as a co-author of several textbooks on diagnoses, outcomes, and interventions. She served on several NANDA-I committees over the years, the most recent of which was as Chair of the most recent nomi- nating committee. She recruited one of the strongest slates of nominees that NANDA-I has had in many years, due to her tireless efforts.

Betty will be remembered as a very giving person. She had an ability to help others in their time of need and provide comfort and direction for them. She was a certified instructor in aerobics, spin- ning, Zumba, and Pilates. For years she loved to run, and she finished two Detroit Marathons. Her passion included gardening, traveling, authoring this textbook, and watching her two grandchil- dren grow.

The following is a quote from Betty’s husband: Betty saw a need and was able to help fill that need by working to complete this book and see it through to publication. She was very proud of each edition of this book. She always strived to make each edition as good as it could be.

Betty was a loving daughter, grandmother, mother, and wife. She cared about people and was always helping everyone to be their very best. This book will continue to be her way of giving to the profession she loved. Nursing gave a lot to Betty, and she returned the love of nursing by writing the most helpful book she could write.

Dale Ackley

Also Dedicated to Jerry Ladwig, my wonderful husband, who, after 51 years, is still supportive and helpful—he has been “my right-hand man” in every revision of this book. Also to my very special children, their spouses, and all of my grandchildren: Jerry, Kathy, Alexandra, Elizabeth, and Benjamin Ladwig; Christine, John, Sean, Ciara, and Bridget McMahon; Jennifer, Jim, Abby, Katelyn, Blake, and Connor Martin; Amy, Scott, Ford, and Vaughn Bertram—the greatest family anyone could ever hope for.

Gail B. Ladwig

My husband, Zlatko, and children, Alexander and Erik, whose unconditional love and support are ever present in my life. To my parents and sisters for always encouraging me to follow my passion. To Gail, for her incredible mentorship, guidance, and encouragement this past year. And finally to Betty, for believing in me and providing me with an opportunity to more fully contribute to this amazing textbook in support of nurses and the patients and families we serve.

Mary Beth Flynn Makic

*Gail Ladwig, 2015

vi

About the Authors

Betty Ackley worked in nursing for 40 years in many capacities. She was a staff nurse on a CCU unit, medical ICU unit, respiratory ICU unit, inten- sive care unit, and step-down unit. She worked on a gynecological surgery floor and on an orthopedic floor, and spent many years working in oncol-

ogy. She also was in management and nursing education in a hospital, and she spent 31 years as a professor of nursing at Jackson Community College. At the college she taught med- ical-surgical nursing, critical care nursing, fundamentals of nursing, nursing leadership, and nutrition. In addition she served as a nursing consultant for nursing continuing educa- tion at the college. In 1996 she began the online learning program at Jackson Community College, offering an online course in nutrition. In 2000, Betty was named Faculty of the Year at her college.

Betty presented conferences nationally and internationally in the areas of nursing diagnosis, nursing process, online learning, and evidence-based nursing. She wrote NCLEX- RN questions for the national licensure examination four times and was an expert in the area of testing and NCLEX preparation.

Betty obtained her BSN from Michigan State University, MS in nursing from the University of Michigan, and educa- tion specialist degree from Michigan State University.

Betty is co-author of Nursing Diagnosis: Guide to Planning Care, which has been a successful text for 20 years, and co- author for four editions of Mosby’s Guide to Nursing Diagno- sis. She was also a lead co-author/editor of Evidence-Based Nursing Care Guidelines: Medical-Surgical Interventions. This text is designed to help nurses easily find and use evidence to provide excellence in nursing care. The text was published in 2008 and was named AJN book of the year.

Her free time was spent exercising, especially teaching Zumba and Pilates, and also taking spinning classes, kick boxing, and keeping moving. She taught classes in Total Control, a program to help women with urinary inconti- nence. In addition, she loved to travel, read, garden, spend time with her grandchildren, and learn anything new!

Gail Ladwig is a professor emeritus of Jackson Community College. During her tenure, she served 4 years as the Department Chairperson of Nursing and as a nurse consultant for Continu- ing Education. She was instrumental in starting a BSN transfer program with the University of Michigan.

Gail has taught classroom and clinical at JCC in funda- mentals, med-surg, mental health, and a transfer course for BSN students. In addition, she has taught online courses in pharmacology, as well as a hybrid course (partially online) for BSN transfer students. She has also taught an online course in pathophysiology for the Medical University of South Carolina.

She worked as a staff nurse in medical-surgical nursing and intensive care for more than 20 years prior to beginning her teaching career. She was a certified critical-care nurse for several years and has a master’s degree in Psychiatric Mental Health Nursing from Wayne State University. Her master’s research was published in the International Journal of Addictions.

She has presented nationally and internationally, includ- ing Paris, Tokyo, and Puerto Rico, on many topics, including nursing diagnosis, computerized care planning, and holistic nursing topics.

Gail is co-author of Nursing Diagnosis: Guide to Planning Care, which has been a very successful text for more than 20 years, and she has been co-author for all editions of Mosby’s Guide to Nursing Diagnosis, now in its fifth edition. She is also a co-author/editor of Evidence-Based Nursing Care Guide- lines: Medical-Surgical Interventions. This text was published in 2008 and was named AJN book of the year.