Readiness for enhanced relationship nursing diagnosis

A FAMILY HEALTH ASSESSMENT

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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http://www.wiley.com/go/nursingdiagnoses
http://lccn.loc.gov/2015042558
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.

Gail has been an active member and supporter of NANDA-I for many, many years.

Gail is the mother of 4 children and grandmother of 12 and loves to spend time with her grandchildren. She has been married to her husband Jerry for 51 years and is passionate about her family and the profession of nursing.

vii

Mary Beth Flynn Makic is an associate professor at the University of Colo- rado, College of Nursing, Aurora, Colorado. At the college she teaches in the undergraduate and graduate pro- grams. She is co-director of the Clini- cal Nurse Specialist graduate degree program at the College of Nursing. She

has worked predominately in critical care for 30 years. Mary Beth is best known for her publications and presentations, regionally and nationally, as an expert on evidence-based practice in nursing. Her practice expertise and research focuses on the care of the trauma, general surgical, and burn injured patient populations; acute wound healing; pressure ulcer prevention; and hospital-acquired conditions (HACs). She is passionate about nurses’ understanding and translating current best evidence into practice to optimize patient and family outcomes. She is co-author of Trauma Nursing: from Resuscitation through Rehabilitation and a section editor of American Association of Critical Care Nurses Procedure Manual for Critical Care. She is actively involved in several professional nursing and interprofessional organizations.

viii

Contributors

†Betty J. Ackley, MSN, EdS, RN President and Owner, The Betty Ackley, LLC; Consultant in Nursing Process, Evidence-Based Nursing,

and Pilates Jackson, Michigan

Michelle Acorn, DNP, NP PHC/adult, BA, BScN/ PHCNP, MN/ACNP, ENC(C), GNC(C), CAP, CGP Lead NP Lakeridge Health Whitby, Ontario; Primary Health Care NP, Global Health Coordinator Nursing Department University of Toronto Toronto, Ontario Canada

Keith A. Anderson, MSW, PhD Associate Professor School of Social Work University of Montana Missoula, Montana

Amanda Andrews, MA, Ed, BSc, DN, RN, HEA Fellow Program Lead Education for Health Group Warwick United Kingdom

Jessica Bibbo, MA Human Development and Family Science University of Missouri Columbia, Missouri

Kathaleen C. Bloom, PhD, CNM Professor and Associate Director Undergraduate Programs School of Nursing University of North Florida Jacksonville, Florida

Lina Daou Boudiab, MSN, RN VA Nursing Academic Partnership Faculty Nursing Services Aleda E. Lutz Veterans Affairs Medical Center Saginaw, Michigan

Lisa Burkhart, PhD, RN, ANEF Associate Professor Marcella Niehoff School of Nursing Loyola University Chicago, Illinois

Melodie Cannon, DNP, MSc/FNP, BHScN, RN(EC), NP-PHC, CEN, GNC(C) Nurse Practitioner Internal Medicine/Emergency Department Rouge Valley Health System Toronto, Ontario Canada; Adjunct Lecturer Lawrence S. Bloomberg Faculty of Nursing University of Toronto, Ontario Canada

Stacey M. Carroll, PhD, ANP-BC Nursing Department Rush University College of Nursing Chicago, Illinois; School of Nursing Anna Maria College Paxton, Massachusetts

Stephanie C. Christensen, PhD, CCC-SLP Senior Lecturer Health Sciences Northern Arizona University Flagstaff, Arizona

June M. Como, EdD, RN, CNS Assistant Professor–Nursing School of Health Sciences Graduate and Clinical Doctorate in Nursing Programs

Coordinator College of Staten Island—City University of New York Staten Island, New York

Maureen F. Cooney, DNP, FNP-BC Pain Management Nurse Practitioner Westchester Medical Center Valhalla, New York; Adjunct Associate Professor Pace University College of Health Professions Lienhard School of Nursing New York, New York

†Deceased.

Contributors ix

Vanessa Flannery, MSN, PHCNS-BC, CNE Associate Professor Nursing Department Morehead State University Morehead, Kentucky

Shari D. Froelich, DNP, MSN, MSBA, ANP, BC, ACHPN, PMHNP, BC Nurse Practitioner Alcona Health Center Alpena, Michigan

Tracy P. George, DNP, APRN-BC, CNE Instructor Nursing Department Francis Marion University Florence, South Carolina

Susanne W. Gibbons, PhD, C-ANP/GNP Assistant Professor Daniel K. Inouye Graduate School of Nursing Uniformed Services University of the Health Sciences Bethesda, Maryland

Barbara A. Given, PhD, RN, FAAN University Distinguished Professor College of Nursing Michigan State University East Lansing, Michigan

Mila W. Grady, MSN, RN Lecturer College of Nursing University of Iowa Iowa City, Iowa

Pauline McKinney Green, PhD, RN, CNE Professor Emeritus Graduate Nursing Howard University College of Nursing and Allied

Health Sciences Washington, DC

Sherry A. Greenberg, PhD, RN, GNP-BC Program Director, Advanced Certificate in Gerontology Adjunct Clinical Assistant Professor of Nursing The Hartford Institute for Geriatric Nursing NYU College of Nursing New York, New York

Dianne Frances Hayward, RN, MSN, WHNP Women’s Health Nurse Practitioner Nursing Education University of Michigan, Flint Flint, Michigan; Oakland Community College Waterford, Michigan

Ruth M. Curchoe, RN, BSN, MSN, CIC Independent Consultant, Infection Prevention Rochester, New York

Mary Alice DeWys, RN, BS, CIMI Infant Development and Feeding Specialist Grand Valley University Preemie Development Assessment

Team President of Hassle Free Feeding Program Division of

Harmony Through Touch Grand Rapids, Michigan

Susan M. Dirkes, RN, MS, CCRN Staff Nurse, Consultant Intensive Care University of Michigan Health System Ann Arbor, Michigan

Roberta Dobrzanski, MSN, RN Academic Instructional Staff College of Nursing University of Wisconsin Oshkosh Oshkosh, Wisconsin

Julianne E. Doubet, BSN, RN, CEN, NREMT-P Certified Emergency Nurse Pre-Hospital Care Educator Mason, Ohio

Lorraine Duggan, MSN, ACNP-BC United Health Group–Optum Clinical Stroudsburg, Pennsylvania

Shelly Eisbach, PhD, RN, PMHNP-BC Consulting Associate Duke University School of Nursing Durham, North Carolina

Dawn Fairlie, ANP, FNP, GNP, DNS(c) Faculty College of Staten Island The City University of New York Staten Island, New York

Arlene T. Farren, RN, PhD, AOCN, CTN-A Associate Professor College of Staten Island The City University of New York Staten Island, New York

Debora Yvonne Fields, RN, BSN, MA, LICDC, CCMC Cleveland, Ohio

Noelle L. Fields, PhD, LCSW Assistant Professor School of Social Work The University of Texas at Arlington Arlington, Texas

x Contributors

Marina Martinez-Kratz, MS, RN, CNE Professor of Nursing Nursing Department Jackson College Jackson, Michigan

Ruth McCaffrey, DNP, ARNP, FNP-BC, GNP-BC, FAAN Sharon Raddock Distinguished Professor Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida

Graham J. McDougall, Jr., PhD, RN, FAAN, FGSA Professor, Martha Saxon Endowed Chair Capstone College of Nursing University of Alabama Tuscaloosa, Alabama

Laura Mcilvoy, PhD, RN, CCRN, CNRN Associate Professor School of Nursing Indiana University Southeast New Albany, Indiana

Marsha McKenzie, MA Ed, BSN, RN Associate Dean of Academic Affairs Big Sandy Community and Technical College Prestonsburg, Kentucky

Annie Muller, DNP, APN-BC Assistant Professor of Nursing Francis Marion Univeristy Florence, South Carolina

Katherina Nikzad-Terhune, PhD, LCSW Therapist Beaumont Behavior Health; Adjunct Professor College of Social Work University of Kentucky Lexington, Kentucky

Barbara J. Olinzock, MSN, EdD, RN Assistant Professor in Nursing School of Nursing Brooks College of Health University of North Florida Jacksonville, Florida

Wolter Paans, MSc, PhD, RN Professor in Nursing Diagnostics Hanze University of Applied Sciences Groningen, The Netherlands

Margaret Elizabeth Padnos, RN, AB, BSN, MA Independent Nurse Consultant/Poet and Essayist Holland, Michigan

Paula D. Hopper, MSN, RN, CNE Professor of Nursing, Emeritus Jackson College; Lecturer Eastern Michigan University Jackson, Michigan

Wendie A. Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCC Life Care Planner, Legal Nurse Consultant Howland Health Consulting, Inc. Pocasset, Massachusetts

Rebecca Johnson, PhD, RN, FAAN, FNAP Millsap Professor of Gerontological Nursing MU Sinclair School of Nursing; Professor & Director Research Center for Human Animal Interaction MU College of Veterinary Medicine University of Missouri Columbia, Missouri

Nicole Jones, MSN, FNP-BC Family Nurse Practitioner, Adjunct Professor of Nursing Department of Advanced Nursing Northern Kentucky University Highland Heights, Kentucky

Jane M. Kendall, RN, BS, CHT Holistic Health Consultant Hilton Head, South Carolina

Katharine Kolcaba, PhD, RN Professor Emeritus Nursing Department The University of Akron Akron, Ohio

Gail B. Ladwig, MSN, RN Consultant in Guided Imagery, Healing Touch, Nursing

Diangosis Hilton Head, South Carolina

Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN Associate Professor University of Colorado College of Nursing Aurora, Colorado

Mary P. Mancuso, MA, Counseling Psychology Professional Research Assistant & Patient Education

Development Assistant University of Colorado Hospital Aurora, Colorado

Victoria K. Marshall, RN, BSN Graduate Research Assistant College of Nursing Michigan State University East Lansing, Michigan

Contributors xi

A.B. St. Aubyn, BSc (Hons), RGN, RM, RHV, DPS:N (CHS), MSc, PGCert (Education), HEA Fellow Senior Lecturer Faculty of Health, Education, and Life Sciences Birmingham City University Birmingham, United Kingdom

Andrea G. Steiner, MS, RD, LD, CNSC Clinical Dietitian Houston, Texas

Elaine E. Steinke, PhD, APRN, CNS-BC, FAHA, FAAN Professor School of Nursing Wichita State University Wichita, Kansas

Laura May Struble, PhD, GNP-BC Clinical Assistant Professor School of Nursing University of Michigan Ann Arbor, Michigan

Denise Sullivan, MSN, ANP-BC Adult Nurse Practitioner, Anesthesiology/Pain Management

Service Jacobi Medical Center Bronx, New York

Dennis C. Tanner, PhD Professor of Health Sciences Program in Speech-Language Sciences and Technology Department of Health Sciences Northern Arizona University Flagstaff, Arizona

Janelle M. Tipton, MSN, RN, AOCN Oncology Clinical Nurse Specialist; Manager, Outpatient

Infusion Center Eleanor N. Dana Cancer Center University of Toledo Medical Center Toledo, Ohio

William J. Trees, DNP, FNP-BC, CNP, RN Nurse Practitioner Occupational Medicine Trihealth, Good Samaritan Hospital; Clinical Faculty Advance Nursing Studies Northern Kentucky University; Adjunct Faculty College of Nursing University of Cincinnati Cincinnati, Ohio

Barbara Baele Vincensi, PhD, RN, FNP Assistant Professor of Nursing Hope College Holland, Michigan

Chris Pasero, MS, RN-BC, FAAN Pain Management Educator and Clinical Consultant Rio Rancho, New Mexico

Kathleen L. Patusky, MA, PhD, RN, CNS Assistant Professor School of Nursing Rutgers University Newark, New Jersey

Sherry H. Pomeroy, PhD, RN Associate Professor School of Nursing D’Youville College; Professor Emeritus School of Nursing University at Buffalo, The State University of New York Buffalo, New York

Ann Will Poteet, MS, RN, CNS Clinical Nurse Specialist College of Nursing University of Colorado Aurora, Colorado

Lori M. Rhudy, PhD, RN, CNRN, ACNS-BC Clinical Associate Professor School of Nursing University of Minnesota; Clinical Nurse Researcher Mayo Clinic Rochester, Minnesota

Mary Jane Roth, RN, BSN, MA Nurse Clinician Outpatient Psychiatry Ann Arbor Veterans Medical Center Ann Arbor, Michigan

Paula Riess Sherwood, RN, PhD, CNRN, FAAN Professor and Vice Chair of Research Acute and Tertiary Care Department School of Nursing University of Pittsburgh Pittsburgh, Pennsylvania

Debra Siela, PhD, RN, CCNS, ACNS-BC, CCRN-K, CNE, RRT Associate Professor of Nursing School of Nursing Ball University Muncie, Indiana

Kimberly Silvey, MSN, RN Minimum Data Set Coordinator Signature Healthcare Lexington, Kentucky

xii Contributors

Linda S. Williams, RN, MSN Professor of Nursing Jackson College Jackson, Michigan

David Wilson, MS, RNC Staff Nurse Children’s Hospital at Saint Francis Tulsa, Oklahoma

Ruth A. Wittmann-Price, PhD, RN, CNS, CNE, CHSE, ANEF, FAAN Professor and Chairperson, Department of Nursing Francis Marion University Florence, South Carolina

Melody Zanotti, RN Strongsville, Ohio

Karen Zulkowski, DNS, RN Associate Professor Nursing Department Montana State University—Bozeman Bozeman, Montana

Kerstin West-Wilson, RNC, IBCLC, BA Biology, BSN, MS Nutrition, Safe Kids NRP Car Seat Certified, BLS Instructor NICU Discharge Nurse and Lactation Consultant Henry Zarro Neonatal Intensive Care Unit at the Children’s

Hospital at Saint Francis Saint Francis Health System Tulsa, Oklahoma

Barbara J. Wheeler, RN, BN, MN, IBCLC Clinical Specialist and Lactation Consultant Women and Child Program St. Boniface Hospital; Instructor II Faculty of Health Sciences College of Nursing University of Manitoba; Professional Affiliate Manitoba Centre for Nursing and Health Research Winnipeg, Manitoba Canada

Suzanne White, MSN, RN, PHCNS-BC Assistant Professor of Nursing Morehead State University Morehead, Kentucky

xiii

Reviewers

Debbie Bomgaars, RN, BSN, MSN, PhD Associate Professor of Nursing Chair of the Department of Nursing Dordt College Sioux Center, Iowa

Anna M. Bruch, RN, MSN Nursing Professor Illinois Valley Community College Ogelsby, Illinois

Ruth A. Chaplen, RN, DNP, ACNS-BC, AOCN Assistant Professor, Clinical Wayne State University Detroit, Michigan

Marianne Curia, PhD, MSN, RN Assistant Professor University of St. Francis Joliet, Illinois

Annie Marie Graf, MSN, RN Advanced Medical Surgical Nursing Lead Faculty Georgia Southern University Statesboro, Georgia

Jean Herrmann, MSN, CNRN, RN Professor, Junior Level Coordinator Augustana College Sioux Falls, South Dakota

Jorie L. Kulczak, RN, MSN Associate Professor Joliet Junior College Joliet, Illinois

Marianne F. Moore, PhD, CNM, RN Assistant Professor Sam Houston State University Huntsville, Texas

Laurie J. Palmer, MS, RN, AOCN Chairperson, Professor Monroe Community College Rochester, New York

Charnelle Parmelee, RN, MSN-Nursing Education Associate Professor of Nursing Western New Mexico University Silver City, New Mexico

JoAnne M. Pearce, MS, RN Assistant Professor Director of Nursing of Programs (ADRN/PN) College of Technology Idaho State University Pocatello, Idaho

Jane E. Ransom, PhD, RN Associate Professor University of Toledo College of Nursing Toledo, Ohio

Barbara Voshall, DNP Professor of Nursing School of Nursing Graceland University Lamoni, Iowa

Kim Webb, MN, RN Adjunct Nursing Instructor Ponca City, Oklahoma

xiv

Preface

Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care is a convenient reference to help the practicing nurse or nursing student make a nursing diagnosis and write a care plan with ease and confidence. This handbook helps nurses correlate nursing diagnoses with known information about clients on the basis of assessment findings; established medical, surgical, or psychiatric diagnoses; and the current treatment plan.

Making a nursing diagnosis and planning care are complex processes that involve diagnostic reasoning and critical think- ing skills. Nursing students and practicing nurses cannot pos- sibly memorize the extensive list of defining characteristics, related factors, and risk factors for the 235 diagnoses approved by NANDA-International. There are two additional diagnoses that the authors think are significant: Hearing Loss and Vision Loss. These diagnoses are contained in Appendix E. This book correlates suggested nursing diagnoses with what nurses know about clients and offers a care plan for each nursing diagnosis.

Section I, Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing, is divided into two parts. Part A includes an overview of the nursing process. This section provides information on how to make a nursing diagnosis and directions on how to plan nursing care. It also includes information on using clinical reasoning skills and eliciting the “client’s story.” Part B includes advanced nursing concepts: Concept mapping, QSEN (Quality and Safety Education for Nurses), Evidence-based nursing care, Quality nursing care, Patient-centered care, Safety, Informatics in nursing, Team/collaborative work with multidisciplinary team, and Root cause thinking.

In Section II, Guide to Nursing Diagnoses, the nurse can look up symptoms and problems and their suggested nursing diagnoses for more than 1450 client symptoms; medical, surgical, and psychiatric diagnoses; diagnostic procedures; surgical interventions; and clinical states.

In Section III, Guide to Planning Care, the nurse can find care plans for all nursing diagnoses suggested in Section II. We have included the suggested nursing outcomes from the Nursing Outcomes Classification (NOC) and interven- tions from the Nursing Interventions Classification (NIC) by the Iowa Intervention Project. We believe this work is a sig- nificant addition to the nursing process to further define nursing practice with standardized language.

Scientific rationales based on research are included for most of the interventions. This is done to make the evidence base of nursing practice apparent to the nursing student and practicing nurse.

New special features of the eleventh edition of Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care include the following: • Labeling of classic older research studies that are still rel-

evant as Classic Evidence Based (CEB) • Twenty-six new nursing diagnoses recently approved by

NANDA-I, along with retiring seven nursing diagnoses: Disturbed energy field, Adult failure to thrive, Readiness for enhanced immunization status, Imbalanced nutrition: more than body requirements, Risk for imbalanced nutri- tion: more than body requirements, Impaired environ- mental interpretation syndrome, and Delayed growth and development

• Five revisions of nursing diagnoses made by NANDA-I in existing nursing diagnoses • Old diagnosis: Ineffective Self-Health management

Revised diagnosis: Ineffective Health management • Old diagnosis: Readiness for enhanced Self-Health

management Revised diagnosis: Readiness for enhanced Health management

• Old diagnosis: Ineffective family Therapeutic Regimen Management Revised diagnosis: Ineffective family Health management

• Old diagnosis: Impaired individual Resilience Revised diagnosis: Impaired Resilience

• Old diagnosis: Risk for compromised Resilience Revised diagnosis: Risk for impaired Resilience

• Further addition of pediatric and critical care interven- tions to appropriate care plans

• An associated Evolve Online Course Management System that includes a care plan constructor, critical thinking case studies, Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) labels, PowerPoint slides, and review questions for the NCLEX-RN® exam

• Appendixes for Nursing Diagnoses Arranged by Maslow’s Hierarchy of Needs, Nursing Diagnoses Arranged by Gor- don’s Functional Health Patterns, Motivational Interview- ing for Nurses, Wellness-Oriented Diagnostic Categories, and Nursing Care Plans for Hearing Loss and Vision Loss The following features of Nursing Diagnosis Handbook: A

Guide to Planning Care are also available: • Suggested nursing diagnoses for more than 1450 clinical

entities, including signs and symptoms, medical diagno- ses, surgeries, maternal-child disorders, mental health disorders, and geriatric disorders

Preface xv

• Inclusion of commonly used abbreviations (e.g., AIDS, MI, CHF) and cross-references to the complete term in Section II We acknowledge the work of NANDA-I, which is used

extensively throughout this text. In some rare cases, the authors and contributors have modified the NANDA-I work to increase ease of use. The original NANDA-I work can be found in NANDA-I Nursing Diagnoses: Definitions & Classi- fication 2015-2017. Several contributors are the original submitters/authors of the nursing diagnoses established by NANDA-I. These contributors include the following:

Lisa Burkhart, PhD, RN, ANEF Impaired Religiosity; Risk for impaired Religiosity; Readiness for enhanced Religiosity; Spiritual distress; Readiness for enhanced Spiritual well-being

Katharine Kolcaba, PhD, RN Impaired Comfort

Shelly Eisbach, PhD, PMHNP-BC, RN Risk for compromised Resilience; Impaired individual Resil- ience; Readiness for enhanced Resilience

David Wilson, MS, RNC Neonatal Jaundice

Susanne W. Gibbons, PhD, C-ANP/GNP Self-Neglect

Ruth A. Wittmann-Price, PhD, RN, CNS, CNE, CHSE, ANEF, FAAN

Impaired emancipated Decision-Making, Readiness for enhanced emancipated Decision-Making, Risk for impaired emancipated Decision-Making

Wolter Paans, MSCc, PhD, RN Labile Emotional Control

We and the consultants and contributors trust that nurses will find this eleventh edition of Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care a valuable tool that simplifies the process of identifying appropriate nursing diag- noses for clients and planning for their care, thus allowing nurses more time to provide evidence-based care that speeds each client’s recovery.

Betty J. Ackley Gail B. Ladwig

Mary Beth Flynn Makic

• Labeling of nursing research as EBN (Evidence-Based Nursing) and clinical research as EB (Evidence-Based) to identify the source of evidence-based rationales

• An Evolve Online Courseware System with the Ackley- Ladwig Care Plan Constructor that helps the student or nurse write a nursing care plan

• Rationales for nursing interventions that are for the most part based on nursing research

• Nursing references identified for each care plan • A complete list of NOC outcomes on the Evolve website • A complete list of NIC interventions on the Evolve website • Nursing care plans that contain many holistic

interventions • Care plans written by leading national nursing experts

from throughout the United States, along with interna- tional contributors, who together represent all of the major nursing specialties and have extensive experience with nursing diagnoses and the nursing process. Care plans written by experts include: • Caregiver Role Strain and Fatigue by Dr. Barbara A.

Given and Dr. Paula Riess Sherwood • Care plans for Spirituality by Dr. Lisa Burkhart • Care plans for Religiosity by Dr. Lisa Burkhart • Impaired Memory by Dr. Graham J. McDougall, Jr. • Decreased Intracranial adaptive capacity and Risk

for ineffective Cerebral tissue perfusion by Dr. Laura Mcilvoy

• Unilateral Neglect by Dr. Lori M. Rhudy • Anxiety, Death Anxiety, and Fear by Dr. Ruth

McCaffrey • Impaired Comfort by Dr. Katharine Kolcaba • Risk for Infection and Ineffective Protection by Ruth

M. Curchoe • Readiness for enhanced Communication and

Impaired verbal Communication by Dr. Stacey M. Carroll

• Sexual dysfunction and Ineffective Sexuality pattern by Dr. Elaine E. Steinke

• A format that facilitates analyzing signs and symptoms by the process already known by nurses, which involves using defining characteristics of nursing diagnoses to make a diagnosis

• Use of NANDA-I terminology and approved diagnoses • An alphabetical format for Sections II and III, which

allows rapid access to information • Nursing care plans for all nursing diagnoses listed in

Section II • Specific geriatric interventions in appropriate plans of care • Specific client/family teaching interventions in each plan

of care • Information on culturally competent nursing care included

where appropriate

xvi

Acknowledgments

We would like to thank the following people at Elsevier: Sandy E. Clark, Senior Content Strategist, who supported us with this eleventh edition of the text with intelligence and kindness; Jennifer Wade, Content Development Specialist, who was a continual source of support; a special thank you to Carol O’Connell for project management of this edition; and to Melanie Cole for her support.

We acknowledge with gratitude nurses and student nurses, who are always an inspiration for us to provide fresh and accurate material. We are honored that they continue to value this text and to use it in their studies and practice.

Care has been taken to confirm the accuracy of informa- tion presented in this book. However, the authors, editors, and publisher cannot accept any responsibility for conse-

quences resulting from errors or omissions of the information in this book and make no warranty, express or implied, with respect to its contents. The reader should use practices sug- gested in this book in accordance with agency policies and professional standards. Every effort has been made to ensure the accuracy of the information presented in this text.

We hope you find this text useful in your nursing practice.

Betty J. Ackley (Betty was very involved in planning and contributed much until she passed away)

Gail B. Ladwig Mary Beth Flynn Makic

xvii

How to Use Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

Nursing process, clinical reasoning, nursing diagnosis, and evidence-based nursing

and judgment, deliberative rationality, and clinical imagina- .) 0102 ,teyoM-otinepraC ( noit

STEP 1: ASSESSMENT ( A DPIE) lanoitadnuof si ssecorp gnisrun eht fo esahp tnemssessa ehT

for appropriate diagnosis, planning, and intervention. Data on all dimensions of the “patient’s story,” including biophysi- cal, psychological, sociocultural, spiritual, and environmental characteristics, are embedded in the assessment. It involves performing a thorough holistic nursing assessment of the cli- ent. This is the fi rst step needed to make an appropriate nurs- ing diagnosis, and it is done using the assessment format adopted by the facility or educational institution in which the practice is situated. Several organizational approaches to assessment are available, including Gordon’s Functional Health Patterns, a list of concepts relevant to the nurse (see Appendix B on the Evolve website), and head-to-toe and body systems approaches.

”yrots s’tneitap“ eht fo stnenopmoc sessessa esrun ehT every time they perform an assessment. Often, nurses focus on the physical component of the story (e.g., temperature, blood pressure, breath sounds). This component is certainly critical, but it is only one piece. Indeed, one of the unique and wonderful aspects of nursing is the holistic theory that is applied to clients and families. This process of meeting and getting to know the client as a person and bearing witness to the client’s situation or plight is one of the focal caring prac-

.) 0102 ,renneB ( sesrun fo secit fi deniatbo si noitamrofni tnemssessA rst by doing a thor-

ough health and medical history, and by listening to and observing the client. To elicit as much information as possi- ble, the nurse should use open-ended questions, rather than questions that can be answered by a simple yes or no.

gniwollof eht ,stneilc ylredle ni noisserped rof gnineercs nI open-ended questions were useful.

?yadot ereh emoc uoy edam tahW“ • ”?si melborp ruoy kniht uoy od tahW“ •

”?melborp ruoy desuac kniht uoy od tahW“ •

”?ralucitrap ni gnihtyna tuoba deirrow uoy erA“ • ”?raf os melborp eht tuoba od ot deirt uoy evah tahW“ • ”?melborp ruoy tuoba od ot em ekil uoy dluow tahW“ •

ssucsid ot ekil dluow uoy esle gnihtyna ereht sI“ • ) 1102 ,la te lingaM ( ”?yadot

evig ot tneilc eht egaruocne lliw snoitseuq fo sepyt esehT more information about his or her situation. Listen care- fully for cues and record relevant information that the client shares. Even when the client’s physical condition or devel- opmental age makes it impossible for them to verbally com- municate with the health care team, nurses may be able to communicate with the client’s family or signifi cant other to learn more about the client. This information that is obtained verbally from the client is considered subjective information.

lacisyhp a gnimrofrep yb deniatbo osla si noitamrofnI assessment, taking vital signs, and noting diagnostic test results. This information is considered objective .noitamrofni

-rof ot desu si secruos eseht fo lla morf noitamrofni ehT mulate a nursing diagnosis. All of this information needs to be carefully documented on the forms provided by the agency or school of nursing. When recording information, the HIPAA (Health Insurance Portability and Accountability

.ylluferac dewollof eb ot deen snoitaluger ) 7002 ,nworB ( )tcA To protect client confi dentiality, the client’s name should not be used on the student care plan. When the assessment is

.pets txen eht ot deecorp ,etelpmoc

STEP 2: NURSING DIAGNOSIS (A D PIE)

snigeb esrun eht ,ssecorp gnisrun eht fo esahp sisongaid eht nI clustering the information within the client story and formu- lates an evaluative judgment about a client’s health status. Only after a thorough analysis—which includes recognizing cues, sorting through and organizing or clustering the infor- mation, and determining client strengths and unmet needs— can an appropriate diagnosis be made. This process of thinking is called clinical reasoning. Clinical reasoning is the ability to think through a clinical situation as it changes, while taking into account the context and what is important to the

-loc dna senoJ-tteveL .) 0102 ,renneB ( ylimaf rieht dna tneilc fiitnedi evah )0102( seugael ed components of effective clini-

cal reasoning as the nurse’s ability to collect the right cues and to take the right action for the right client at the right time and for the right reason.

siht tuohguorht desu era taht sesongaid gnisrun ehT book are taken from North American Nursing Diagnosis

ehT .) 4102-2102 ,I-ADNAN ( lanoitanretnI—noitaicossA complete nursing diagnosis list is on the inside back cover of this text, and it can also be found on the EVOLVE website that accompanies this text. These diagnoses used throughout this text are listed in alphabetical order by the diagnostic concept. rof gnikool era uoy fI impaired wheelchair mobility, you would fi nd it under mobility, rednu ton wheelchair ro impaired .) 4102-2102 ,I-ADNAN (

Step II Nursing DiagnosisStep I

Assessment

Step III Planning

Outcomes Interventions

Step V Evaluation

Step IV Implementation

A D

P

I

E

Figure I-1 Nursing process.

STEP 2: DIAGNOSE Turn to Section II, Guide to Nursing Diagnoses, and locate the client’s symptoms, clinical state, medical or psychiatric diagnoses, and anticipated or prescribed diagnostic studies or surgical interventions (listed in alphabetical order). Note sug- gestions for appropriate nursing diagnoses.

Then use Section III, Guide to Planning Care, to evaluate each suggested nursing diagnosis and “related to” etiology statement. Section III is a listing of care plans according to NANDA-I, arranged alphabetically by diagnostic concept, for each nursing diagnosis referred to in Section II. Determine the appropriateness of each nursing diagnosis by comparing the Defining Characteristics and/or Risk Factors to the client data collected.

STEP 3: DETERMINE OUTCOMES

Use Section III, Guide to Planning Care, to find appropriate outcomes for the client. Use either the NOC outcomes with the associated rating scales or Client Outcomes as desired.

STEP 1: ASSESS Following the guidelines in Section I, begin to formulate your nursing diagnosis by gathering and documenting the objec- tive and subjective information about the client.

xviii How to Use Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

PLAN INTERVENTIONS Use Section III, Guide to Planning Care, to find appropriate interventions for the client. Use the Nursing Interventions as found in that section.

GIVE NURSING CARE Administer nursing care following the plan of care based on the interventions.

EVALUATE NURSING CARE Evaluate nursing care administered using either the NOC outcomes or Client Outcomes. If the outcomes were not met, and the nursing interventions were not effective, reassess the client and determine if the appropriate nursing diagnoses were made.

DOCUMENT Document all of the previous steps using the format provided in the clinical setting.

xix

Contents

SECTION I Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing, 1 An explanation of how to make a nursing diagnosis using diagnostic reasoning, which is critical thinking. Then information on how to plan care using the nursing process, standardized nursing language, and evidence-based nursing.

SECTION II Guide to Nursing Diagnosis, 17 An alphabetized list of medical, surgical, and psychiatric diagnoses; diagnostic procedures, clinical states, symptoms, and problems, with suggested nursing diagnoses. This section enables the nursing student as well as the practicing nurse to make a nursing diagnosis quickly, to save time.

SECTION III Guide to Planning Care, 121 Section III contains the actual nursing diagnosis care plans for each accepted nursing diagnosis of the North American Nursing Diagnosis Association-International (NANDA-I): the definition, defining characteristics, risk factors, related factors, suggested NOC outcomes, client outcomes, suggested NIC interventions, inter- ventions with rationales, geriatric interventions, pediatric interventions, critical care interventions (when appropriate), home care interventions, culturally competent nursing interventions (when appropriate), and client/family teaching and discharge planning for each alphabetized nursing diagnosis.

APPENDIX A Nursing Diagnoses Arranged by Maslow’s Hierarchy of Needs, 949

APPENDIX B Nursing Diagnoses Arranged by Gordon’s Functional Health Patterns, 952

APPENDIX C Motivational Interviewing for Nurses, 955

APPENDIX D Wellness-Oriented Diagnostic Categories, 957

APPENDIX E Nursing Care Plans for Hearing Loss and Vision Loss, 960

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1

SECTION

I Nursing Process, Clinical

Reasoning, Nursing Diagnosis, and Evidence-Based Nursing

Betty J. Ackley, MSN, EdS, RN, Gail B. Ladwig, MSN, RN,

Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN,

and Marina Martinez-Kratz, MS, RN, CNE

Section I is divided into two parts. Part A includes an overview of the nursing process. This section provides information on how to make a nursing diagnosis and directions on how to plan nursing care. It also includes information on using clinical reasoning skills and eliciting the “patient’s story.” Part B includes advanced nursing concepts.

Part A: The Nursing Process: Using Clinical Reasoning Skills to Determine Nursing Diagnosis and Plan Care 1. Assessing: performing a nursing assessment 2. Diagnosing: making nursing diagnoses 3. Planning: formulating and writing outcome statements and determining appropriate nursing interventions

based on appropriate best evidence (research) 4. Implementing care 5. Evaluating the outcomes and the nursing care that has been implemented. Make necessary revisions in

care interventions as needed

Part B: Advanced Nursing Concepts • Concept mapping • QSEN (Quality and Safety Education for Nurses) • Evidence-based nursing care • Quality nursing care • Patient-centered care • Safety • Informatics in nursing • Team/collaborative work with interprofessional team

2 Section i

The primary goals of nursing are to (1) determine client/ family responses to human problems, level of wellness, and need for assistance; (2) provide physical care, emotional care, teaching, guidance, and counseling; and (3) implement inter- ventions aimed at prevention and assisting the client to meet his or her own needs and health-related goals. The nurse must always focus on assisting clients and families to their highest level of functioning and self-care. The care that is provided should be structured in a way that allows clients the ability to influence their health care and accomplish their self- efficacy goals. The nursing process, which is a problem- solving approach to the identification and treatment of client problems, provides a framework for assisting clients and families to their optimal level of functioning. The nursing process involves five dynamic and fluid phases: assessment, diagnosis, planning, implementation, and evaluation. Within each of these phases, the client and family story is embedded and is used as a foundation for knowledge, judg- ment, and actions brought to the client care experience. A description of the “patient’s story” and each aspect of the nursing process follow.

THE “PATIENT’S STORY” The “patient’s story” is a term used to describe objective and subjective information about the client that describes who the client is as a person in addition to their usual medical history. Specific aspects of the story include physiological, psychological, and family characteristics; available resources; environmental and social context; knowledge; and motiva- tion. Care is influenced, and often driven, by what the client states—verbally or through their physiologic state. The “patient’s story” is fluid and must be shared and understood throughout the client’s health care experience.

There are multiple sources for obtaining the patient’s story. The primary source for eliciting this story is through communicating directly with the client and the client’s family. It is important to understand how the illness (or wellness) state has affected the client physiologically, psychologically, and spiritually. The client’s perception of his or her health state is important to understand and may have an impact on subsequent interventions. At times, clients will be unable to tell their story verbally, but there is still much they can com- municate through their physical state. The client’s family (as the client defines them) is a valuable source of information and can provide a rich perspective on the client. Other

valuable sources of the “patient’s story” include the client’s health record. Every time a piece of information is added to the health record, it becomes a part of the “patient’s story.” All nursing care is driven by the client’s story. The nurse must have a clear understanding of the story to effec- tively complete the nursing process. Understanding the full story also provides an avenue for identifying mutual goals with the client and family aimed at improving client out- comes and goals.

Note: The “patient’s story” is terminology that is used to describe a holistic assessment of information about the client, with the client’s and the family’s input as much as possible. In this text, we use the term “patient’s story” in quotes whenever we refer to the specific process. In all other places, we use the term client in place of the word patient; we think labeling the person as a client is more respectful and empowering for the person. Client is also the term that is used in the National Council Licensure Examination (NCLEX-RN) test plan (National Council of State Boards of Nursing, 2013).

Understanding the “patient’s story” is critically important, in that psychological, socioeconomic, and spiritual character- istics play a significant role in the client’s ability and desire to access health care. Also knowing and understanding the “patient’s story” is an integral first step in giving client- centered care. In today’s health care world, the focus is on the client, which leads to increased satisfaction with care. Improv- ing the client’s health care experience is part of the Affordable Care Act and is tied to reimbursement through value-based purchasing of care: “participating hospitals are paid for inpa- tient acute care services based on the quality of care, not just quantity of services they provide” (Centers for Medicare & Medicaid Services, 2014).

THE NURSING PROCESS The nursing process is an organizing framework for profes- sional nursing practice, a critical thinking process for the nurse to use to give the best care possible to the client. It is very similar to the steps used in scientific reasoning and problem solving. This section is designed to help the nursing student learn how to use this thinking process, the nursing process. Key components of the process include the steps listed below. An easy, convenient way to remember the steps of the nursing process is to use an acronym, ADPIE (Figure I-1):

PART

A The Nursing Process: Using Clinical Reasoning Skills to

Determine Nursing Diagnoses and Plan Care

nursing Process, clinical Reasoning, nursing Diagnosis, and evidence-Based nursing 3

the client. To elicit as much information as possible, the nurse should use open-ended questions, rather than questions that can be answered with a simple “yes” or “no.”

In screening for depression in older clients, the following open-ended questions are useful (Lusk & Fater, 2013): • What made you come here today? • What do you think your problem is? • What do you think caused your problem? • Are you worried about anything in particular? • What have you tried to do about the problem so far? • What would you like me to do about your problem? • Is there anything else you would like to discuss today?

These types of questions will encourage the client to give more information about his or her situation. Listen carefully for cues and record relevant information that the client shares. Even when the client’s physical condition or develop- mental age makes it impossible for them to verbally com- municate with the health care team, nurses may be able to communicate with the client’s family or significant other to learn more about the client. This information that is obtained verbally from the client is considered subjective information.

Information is also obtained by performing a physical assessment, taking vital signs, and noting diagnostic test results. This information is considered objective information.

The information from all of these sources is used to for- mulate a nursing diagnosis. All of this information needs to be carefully documented on the forms provided by the agency or school of nursing. When recording information, the HIPAA (Health Insurance Portability and Accountability Act) (Foster, 2012) regulations need to be followed carefully. To protect client confidentiality, the client’s name should not be used on the student care plan. When the assessment is complete, proceed to the next step.

STEP 2: NURSING DIAGNOSIS (ADPIE)

In the diagnosis phase of the nursing process, the nurse begins clustering the information within the client story and formulates an evaluative judgment about a client’s health status. Only after a thorough analysis—which includes recog- nizing cues, sorting through and organizing or clustering the information, and determining client strengths and unmet needs—can an appropriate diagnosis be made. This process of thinking is called clinical reasoning. Clinical reasoning is a cognitive process that uses formal and informal thinking strategies to gather and analyze client information, evaluate the significance of this information, and determine the value of alternative actions (Benner, 2010). Benner (2010) describes this cognitive process as “thinking like a nurse.” Watson and Rebair (2014) referred to “noticing” as a precursor to clinical reasoning. By noticing the nurse can preempt possible risks or support subtle changes toward recovery. Noticing can be the activity that stimulates nursing action before words are exchanged, preempting need. The nurse synthesizes the

1. Assess: perform a nursing assessment 2. Diagnose: make nursing diagnoses 3. Plan: formulate and write outcome/goal statements and

determine appropriate nursing interventions based on the client’s reality and evidence (research)

4. Implement care 5. Evaluate the outcomes and the nursing care that has been

implemented. Make necessary revisions in care interven- tions as needed. The following is an overview and practical application of

the steps of the nursing process. The steps are listed in the usual order in which they are performed.

STEP 1: ASSESSMENT (ADPIE) The assessment phase of the nursing process is foundational for appropriate diagnosis, planning, and intervention. Data on all dimensions of the “patient’s story,” including biophysi- cal, psychological, sociocultural, spiritual, and environmental characteristics, are embedded in the assessment. It involves performing a thorough holistic nursing assessment of the client. This is the first step needed to make an appropriate nursing diagnosis, and it is done using the assessment format adopted by the facility or educational institution in which the practice is situated.

The nurse assesses components of the “patient’s story” every time an assessment is performed. Often, nurses focus on the physical component of the story (e.g., temperature, blood pressure, breath sounds). This component is certainly critical, but it is only one piece. Indeed, one of the unique and wonderful aspects of nursing is the holistic theory that is applied to clients and families. Clients are active partners in the healing process. Nurses must increasingly develop the skills and systems to incorporate client preferences into care (Hess & Markee, 2014). “The challenge facing the nation, and the opportunity afforded by the Affordable Care Act, is to move from a culture of sickness to a culture of care and then to a culture of health” (Institute of Medicine, 2013). Assess- ment information is obtained first by completing a thorough health and medical history, and by listening to and observing

Figure I-1 Nursing process.

Step II Nursing DiagnosisStep I

Assessment

Step III Planning

Outcomes Interventions

Step V Evaluation

Step IV Implementation

A D

P

I

E

4 Section i

Here we use the example of a beginning nursing student who is attempting to understand the nursing process and how to make a nursing diagnosis:

Problem: Use the nursing diagnosis label deficient Knowl- edge from the NANDA-I list. Remember to check the definition: “Absence or deficiency of cognitive information related to a specific topic” (Herdman & Kamitsuru, 2014).

Etiology: r/t unfamiliarity with information about the nursing process and nursing diagnosis. At this point the beginning nurse would not be familiar with available resources regarding the nursing process.

Symptoms: Defining characteristics, as evidenced by (aeb) verbalization of lack of understanding: “I don’t understand this, and I really don’t know how to make a nursing diagnosis.”

When using the PES system, look at the S first, then for- mulate the three-part statement. (You would have gotten the S, symptoms, which are defining characteristics, from your assessment.)

Therefore, the three-part nursing diagnosis is: deficient Knowledge r/t unfamiliarity with information about the nursing process and nursing diagnosis aeb verbalization of lack of understanding.

Types of Nursing Diagnoses There are three different types of nursing diagnoses.

Problem-Focused Diagnosis. “A clinical judgment con- cerning an undesirable human response to a health condition/ process that exists in an individual, family, group or com- munity” (Herdman & Kamitsuru, 2014, p 22).

“Related factors are an integral part of all problem-focused diagnoses. They are etiologies, circumstances, facts or influ- ences that have some type of relationship with the nursing diagnosis” (Herdman & Kamitsuru, 2014, p 26).

Example of a Problem-Focused Nursing Diagnosis. Overweight related to excessive intake in relation to meta- bolic needs, concentrating food intake at the end of the day aeb weight 20% over ideal for height and frame. Note: This is a three-part nursing diagnosis.

Risk Nursing Diagnosis. Risk nursing diagnosis is a “clinical judgment concerning the vulnerability of an indi- vidual, family, group, or community for developing an unde- sirable human response to health conditions/life processes” (Herdman & Kamitsuru, 2014, p 22). “The risk diagnosis is supported by risk factors that increase the vulnerability of a client, family, group, or community to an unhealthy event” (Herdman & Kamitsuru, 2014, p 26). Defining characteristics and related factors are observable cues and circumstances or influences that have some type of relationship with the nursing diagnosis that may contribute to a health problem. Identification of related factors allows nursing interventions to be implemented to address the underlying cause of a nursing diagnosis (Herdman & Kamitsuru, 2014, p 26).

evidence while also knowing the client as part of clinical reasoning that informs client specific diagnoses (Cappelletti, Engel, & Prentice, 2014).

The nursing diagnoses that are used throughout this book are taken from North American Nursing Diagnosis Association—International (Herdman & Kamitsuru, 2014). The complete nursing diagnosis list is on the inside front cover of this text, and it can also be found on the EVOLVE website that accompanies this text. The diagnoses used throughout this text are listed in alphabetical order by the diagnostic concept. For example, impaired wheelchair mobil- ity is found under mobility, not under wheelchair or impaired (Herdman & Kamitsuru, 2014).

The holistic assessment of the client helps determine the type of diagnosis that follows. For example, if during the assessment a client is noted to have unsteady gait and balance disturbance and states, “I’m concerned I will fall while walking down my stairs,” but has not fallen previously, then the client would be identified as having a “risk” nursing diagnosis.

Once the diagnosis is determined, the next step is to deter- mine related factors and defining characteristics. The process for formulating a nursing diagnosis with related factors and defining characteristics follows. A client may have many nursing and medical diagnoses, and determining the priority with which each should be addressed requires clinical reason- ing and application of knowledge.

Formulating a Nursing Diagnosis with Related Factors and Defining Characteristics A working nursing diagnosis may have two or three parts. The two-part system consists of the nursing diagnosis and the “related to” (r/t) statement: “Related factors are factors that appear to show some type of patterned relationship with the nursing diagnosis: such factors may be described as ante- cedent to, associated with, relating to, contributing to, or abetting” (Herdman & Kamitsuru, 2014).

The two-part system is often used when the defining char- acteristics, or signs and symptoms identified in the assess- ment, may be obvious to those caring for the client.

The three-part system consists of the nursing diagnosis, the r/t statement, and the defining characteristics, which are “observable cues/inferences that cluster as manifestations of an actual or wellness nursing diagnosis” (Herdman & Kamitsuru, 2014).

Some nurses refer to the three-part diagnostic statement as the PES system:

P (problem)—The nursing diagnosis label: a concise term or phrase that represents a pattern of related cues. The nursing diagnosis is taken from the official NANDA- I list.

E (etiology)—“Related to” (r/t) phrase or etiology: related cause or contributor to the problem.

S (symptoms)—Defining characteristics phrase: symptoms that the nurse identified in the assessment.

nursing Process, clinical Reasoning, nursing Diagnosis, and evidence-Based nursing 5

his story, he is continually wringing his hands and looking out the window.

B. List the Symptoms (Subjective and Objective) “Difficulty breathing when walking short distances”; “heart feels like it is racing”; heart rate is 110 beats per minute; “tired all the time”; continually wringing his hands and looking out the window.

C. Cluster Similar Symptoms “Difficulty breathing when walking short distances” “Heart feels like it is racing”; heart rate = 110 bpm “Tired all the time” Continually wringing his hands Looking out the window

D. Analyze Interpret the Subjective Symptoms (What the Client Has Stated) • “Difficulty breathing when walking short distances” =

exertional discomfort: a defining characteristic of Activity intolerance

• “Heart feels like it is racing” = abnormal heart rate response to activity: a defining characteristic of Activity intolerance

• “Tired all the time” = verbal report of weakness: a defining characteristic of Activity intolerance

Interpret the Objective Symptoms (Observable Information) • Continually wringing his hands = extraneous movement,

hand/arm movements: a defining characteristic of Anxiety • Looking out the window = poor eye contact, glancing

about: a defining characteristic of Anxiety • Heart rate = 110 beats per minute

E. Select the Nursing Diagnosis Label In Section II, look up dyspnea (difficulty breathing) or dys- rhythmia (abnormal heart rate or rhythm), chosen because they are high priority, and you will find the nursing diagnosis Activity intolerance listed with these symptoms. Is this diagnosis appropriate for this client?

To validate that the diagnosis Activity intolerance is appropriate for the client, turn to Section III and read the NANDA-I definition of the nursing diagnosis Activity intol- erance: “Insufficient physiological or psychological energy to endure or complete required or desired daily activities” (Herdman & Kamitsuru, 2014, p 225). When reading the definition, ask, “Does this definition describe the symptoms demonstrated by the client?” “Is any more assessment infor- mation needed?” “Should I take his blood pressure or take an apical pulse rate?” If the appropriate nursing diagnosis has been selected, the definition should describe the condition that has been observed.

The client may also have defining characteristics for this particular diagnosis. Are the client symptoms that you

Example of a Risk Nursing Diagnosis. Risk for Over- weight: Risk factor: concentrating food at the end of the day. Note: This is a two-part nursing diagnosis.

Health Promotion Nursing Diagnosis. A clinical judg- ment concerning motivation and desire to increase well- being and to actualize human health potential that may be expressed by a readiness to enhance specific health behav- iors or health state. Health promotion responses may exist in an individual, family, group, or community (Herdman & Kamitsuru, 2014, p 22). Health promotion is different from prevention in that health promotion focuses on being as healthy as possible, as opposed to preventing a disease or problem. The difference between health promotion and disease prevention is that the reason for the health behavior should always be a positive one. With a health promotion diagnosis, the outcomes and interventions should be focused on enhancing health.

Example of a Health Promotion Nursing Diagnosis. Readiness for enhanced Nutrition aeb expresses willingness to change eating pattern and eat healthier foods. Note: This is a two-part nursing diagnosis.

Application and Examples of Making a Nursing Diagnosis When the assessment is complete, identify common patterns/ symptoms of response to actual or potential health problems from the assessment and select an appropriate nursing diag- nosis label using clinical reasoning skills. Use the steps with Case Study 1. (The same steps can be followed using an actual client assessment in the clinical setting or in a student assessment.) A. Highlight or underline the relevant symptoms (defining

characteristics). As you review your assessment informa- tion, ask: Is this normal? Is this an ideal situation? Is this a problem for the client? You may go back and validate information with the client.

B. Make a list of the symptoms (underlined or highlighted information).

C. Cluster similar symptoms. D. Analyze/interpret the symptoms. (What do these symp-

toms mean or represent when they are together?) E. Select a nursing diagnosis label from the NANDA-I list

that fits the appropriate defining characteristics and nursing diagnosis definition.

Case Study 1—An Older Client with Breathing Problems

A. Underline the Symptoms (Defining Characteristics) A 73-year-old man has been admitted to the unit with a diagnosis of chronic obstructive pulmonary disease (COPD). He states that he has “difficulty breathing when walking short distances.” He also states that his “heart feels like it is racing” (heart rate is 110 beats per minute) at the same time. He states that he is “tired all the time,” and while talking to you about

6 Section i

be appropriate for the individual client. If they are not appro- priate, the nurse should develop and write an r/t statement that is appropriate for the client. For the client from Case Study 1, a two-part statement could be made here:

Problem = Activity Intolerance Etiology = r/t imbalance between oxygen supply and demand

It was already determined that the client had Activity intolerance. With the respiratory symptoms identified from the assessment, imbalance between oxygen supply and demand is appropriate.

Defining Characteristics Phrase The defining characteristics phrase is the third part of the three-part diagnostic system, and it consists of the signs and symptoms that have been gathered during the assessment phase. The phrase “as evidenced by” (aeb) may be used to connect the etiology (r/t) with the defining characteristics. The use of identifying defining characteristics is similar to the process that the health care provider uses when making a medical diagnosis. For example, the health care provider who observes the following signs and symptoms—diminished inspiratory and expiratory capacity of the lungs, complaints of dyspnea on exertion, difficulty in inhaling and exhaling deeply, and sometimes chronic cough—may make the medical diagnosis of COPD. This same process is used to identify the nursing diagnosis of Activity intolerance.

Put It All Together: Writing the Three-Part Nursing Diagnosis Statement Problem—Choose the label (nursing diagnosis) using the

guidelines explained previously. A list of nursing diagnosis labels can be found in Section II and on the inside front cover.

Etiology—Write an r/t phrase (etiology). These can be found in Section II.

Symptoms—Write the defining characteristics (signs and symptoms), or the “as evidenced by” (aeb) list. A list of the signs and symptoms associated with each nursing diagno- sis can be found in Section III.

Case Study 1—73-Year-Old Male Client with COPD (Continued) Using the information from the earlier case study/example, the nursing diagnostic statement would be as follows:

Problem—Activity intolerance Etiology—r/t imbalance between oxygen supply and demand Symptoms—Verbal reports of fatigue, exertional dyspnea

(“difficulty breathing when walking”), and abnormal heart rate response to activity (“racing heart”), heart rate 110 beats per minute.

Therefore, the nursing diagnostic statement for the client with COPD is Activity intolerance r/t imbalance between

identified in the list of defining characteristics (e.g., verbal report of fatigue, abnormal heart rate response to activity, exertional dyspnea)?

Another way to use this text and to help validate the diagnosis is to look up the client’s medical diagnosis in Section II. This client has a medical diagnosis of COPD. Is Activity Intolerance listed with this medical diagnosis? Con- sider whether the nursing diagnosis makes sense given the client’s medical diagnosis (in this case, COPD). There may be times when a nursing diagnosis is not directly linked to a medical diagnosis (e.g., ineffective Coping) but is neverthe- less appropriate given nursing’s holistic approach to the client/family.

The process of identifying significant symptoms, cluster- ing or grouping them into logical patterns, and then choosing an appropriate nursing diagnosis involves diagnostic reason- ing (critical thinking) skills that must be learned in the process of becoming a nurse. This text serves as a tool to help the learner in this process.

“Related to” Phrase or Etiology The second part of the nursing diagnosis is the “related to” (r/t) phrase. Related factors are those that appear to show some type of patterned relationship with the nursing diagno- sis. Such factors may be described as antecedent to, associated with, related to, contributing to, or abetting. Pathophysiologi- cal and psychosocial changes, such as developmental age and cultural and environmental situations, may be causative or contributing factors.

Often, a nursing diagnosis is complementary to a medical diagnosis and vice versa. Ideally the etiology (r/t statement), or cause, of the nursing diagnosis is something that can be treated independently by a nurse. When this is the case, the diagnosis is identified as an independent nursing diagnosis.

If medical intervention is also necessary, it might be iden- tified as a collaborative nursing diagnosis. A carefully written, individualized r/t statement enables the nurse to plan nursing interventions and refer for diagnostic procedures, medical treatments, pharmaceutical interventions, and other inter- ventions that will assist the client/family in accomplishing goals and return to a state of optimum health. Diagnoses and treatments provided by the multidisciplinary team all con- tribute to the client/family outcome. The coordinated effort of the team can only improve outcomes for the client/family and decrease duplication of effort and frustration among the health care team and the client/family.

The etiology is not the medical diagnosis. It may be the underlying issue contributing to the nursing diagnosis, but a medical diagnosis is not something the nurse can treat inde- pendently, without health care provider orders. In the case of the man with COPD, think about what happens when someone has COPD. How does this affect the client? What is happening to him because of this diagnosis?

For each suggested nursing diagnosis, the nurse should refer to the statements listed under the heading “Related Factors (r/t)” in Section III. These r/t factors may or may not

nursing Process, clinical Reasoning, nursing Diagnosis, and evidence-Based nursing 7

This client states she is worrying too much, which may indicate anxiety; she also recently has increased job stress.

Look up Insomnia in Section III. Check the definition: “A disruption in amount and quality of sleep that impairs functioning” (Herdman & Kamitsuru, 2014). Does this describe the client in the case study? What are the related factors? What are the symptoms? Write the diagnostic statement:

Problem—Insomnia Etiology—r/t anxiety, stress Symptoms—Difficulty falling asleep, “I am so tired, I can’t

do anything.”

The nursing diagnostic statement is written in this format: Insomnia r/t anxiety and stress aeb (as evidenced by) diffi- culty falling asleep.

Note: There are more than 30 case studies available for both student and faculty use on the Evolve website that accompanies this text.

After the diagnostic statement is written, proceed to the next step: planning.

STEP 3: PLANNING (ADPIE) The planning phase of the nursing process includes the identification of priorities, as well as the determination of appropriate client-specific outcomes and interventions. The nurse in collaboration with the client and family (as appli- cable) and the rest of the health care team must determine the urgency of the identified problems and prioritize client needs. Mutual goal setting, along with symptom pattern rec- ognition and triggers, helps prioritize interventions and deter- mine which interventions are going to provide the greatest impact. Symptom pattern recognition and/or triggers is a process of identifying symptoms that clients have related to their illness, understanding which symptom patterns require intervention, and identifying the associated timeframe to intervene effectively. For example, a client with heart failure is noted to gain 5 pounds overnight. Coupling this symptom with other symptoms of edema and shortness of breath while walking can be referred to as “symptom pattern recogni- tion”—in this case, that the client is retaining fluid. The nurse, and often the client/family, recognize these symptoms as an immediate cause and that more action/intervention is needed to avoid a potential adverse outcome.

Nursing diagnoses should be prioritized first by immedi- ate needs based on ABC (airway, breathing, and circulation). The highest priority should also be determined by using Maslow’s hierarchy of needs. In this hierarchy, priority is given to immediate problems that may be life-threatening (thus ABC). For example, ineffective Airway clearance, as evidenced by the symptoms of increased secretions and increased use of inhaler related to asthma, creates an immedi- ate cause compared to the nursing diagnosis of Anxiety, a love and belonging or security need, which makes it a lesser

oxygen supply and demand aeb verbal reports of fatigue, exertional dyspnea, and abnormal heart rate in response to activity.

Consider a second case study:

Case Study 2—Woman with Insomnia As before, the nurse always begins with an assessment. To make the nursing diagnosis, the nurse follows the steps below.

A. Underline the Symptoms A 45-year-old woman comes to the clinic and asks for medi- cation to help her sleep. She states that she is worrying too much and adds, “It takes me about an hour to get to sleep, and it is very hard to fall asleep. I feel like I can’t do anything because I am so tired. My job has become very stressful because of a new boss and too much work.”

B. List the Symptoms (Subjective and Objective) Asks for medication to help her sleep; states she is worrying about too much; “It takes me about an hour to get to sleep”; “it is very hard to fall asleep”; “I feel like I can’t do anything because I am so tired”; “My job has become very stressful because of a new boss and too much work.”

C. Cluster Similar Symptoms Asks for medication to help her sleep “It takes me about an hour to get to sleep.” “It is very hard to fall asleep.” “I feel like I can’t do anything because I am so tired.” “I am worrying too much.” “My job is stressful.” “Too much work.”

D. Analyze/Interpret the Symptoms Subjective Symptoms • Asks for medication to help her sleep; “It takes me

about an hour to get to sleep”; “it is very hard to fall asleep”; “I feel like I can’t do anything because I am so tired.” (All defining characteristics = verbal complaints of difficulty with sleeping.)

• States she is worrying too much (anxiety): “My job is stressful.”

Objective Symptoms • None

E. Select a Nursing Diagnosis with Related Factors and Defining Characteristics Look up “sleep” in Section II. Listed under the heading “Sleep pattern, disturbed” in Section II is the following information:

Insomnia (nursing diagnosis) r/t anxiety and stress

8 Section i

outcome (NOC) is an individual, family or community state, behavior or perception that is measured along a continuum in response to nursing interventions. The outcomes are stated as concepts that reflect a client, caregiver, family, or commu- nity state, perception of behavior rather than as expected goals” (Moorhead et al, 2013).

It is very important for the nurse to involve the client and/ or family in determining appropriate outcomes. The use of outcomes information creates a continuous feedback loop that is essential to ensuring evidence-based care and the best possible client outcomes, not only for the patient care experi- ence, but also for improving the population’s health and reducing health care costs (Weston & Roberts, 2013). The minimum requirements for rating an outcome are when the outcome is selected (i.e., the baseline measure) and when care is completed (i.e., the discharge summary). This may be suf- ficient in short-stay, acute-care settings. Depending on how rapidly the client’s condition is expected to change, some set- tings may evaluate once a day or once a shift. Community agencies may evaluate every visit or every other visit, for example. Because measurement times are not standardized, they can be individualized for the client and the setting (Moorhead et al, 2013).

Development of appropriate outcomes can be done one of two ways: using the NOC list or developing an appropriate outcome statement, both of which are included in Section III. There are suggested outcome statements for each nursing diagnosis in this text that can be used as written or modified as necessary to meet the needs of the client.

The Evolve website includes a list of additional NOC out- comes. The use of NOC outcomes can be helpful to the nurse because they contain a five-point, Likert-type rating scale that can be used to evaluate progress toward achieving the outcome. In this text, the rating scale is listed, along with some of the more common indicators; for example, see the rating scale for the outcome Sleep (Table I-1).

Because the NOC outcomes are specific, they enhance the nursing process by helping the nurse measure and record the outcomes before and after interventions have been per- formed. The nurse can choose to have clients rate their own progress using the Likert-type rating scale. This involve- ment can help increase client motivation to progress toward outcomes.

After client outcomes are selected or written, and discussed with a client, the nurse plans nursing care with the client and establishes a means that will help the client achieve the selected outcomes. The usual means are nursing interventions.

Interventions Interventions are like roadmaps directing the best ways to provide nursing care. The more clearly a nurse writes an inter- vention, the easier it will be to complete the journey and arrive at the destination of desired client outcomes.

Section III includes suggested interventions for each nursing diagnosis. The interventions are identified as

priority than ineffective Airway clearance. Refer to Appendix A, Nursing Diagnoses Arranged by Maslow’s Hierarchy of Needs, for assistance in prioritizing nursing diagnoses.

The planning phase should be done—whenever possible— with the client/family and the multidisciplinary team to max- imize efforts and understanding, and increase compliance with the proposed plan and outcomes. For a successful plan of care, measurable goals and outcomes, including nursing interventions, must be identified.

SMART Outcomes When writing outcome statements, it can be helpful to use the acronym SMART, which means the outcome must be:

Specific Measurable Attainable Realistic Timed

The SMART acronym is used in business, education, and health care settings. This method assists the nurse in identify- ing patient outcomes more effectively.

Once priorities are established, outcomes for the client can be easily identified. Client-specific outcomes are determined based on the mutually set goals. Outcomes refer to the mea- surable degree of the client’s response. The client’s response/ outcome may be intentional and favorable, such as leaving the hospital 2 days after surgery without any complications. The client’s outcome can be negative and unintentional, such as demonstrating a surgical site infection. Generally, outcomes are described in relation to the client’s response to interven- tions, for example, the client’s cough becomes more produc- tive after the client begins using the controlled coughing technique.

Based on the “patient’s story,” the nursing assessment, the mutual goals and outcomes identified by the caregiving team and the client/family, and the clinical reasoning that the nurse uses to prioritize his or her work, the nurse then decides what interventions to employ. Based on the nurse’s clinical judg- ment and knowledge, nursing interventions are defined as all treatments that a nurse performs to enhance client outcomes.

The selection of appropriate, effective interventions can be individualized to meet the mutual goals established by the client/family. It is then the nurse’s education, experience, and skill that allow them to select and carry out interventions to meet that mutual goal.

Outcomes After the appropriate priority setting of the nursing diagnoses and interventions is determined, outcomes are developed or examined and decided upon. This text includes standardized Nursing Outcomes Classification (NOC) outcomes written by a large team of University of Iowa College of Nursing faculty and students in conjunction with clinicians from a variety of settings (Moorhead et al, 2013). “Nursing-sensitive

TABLE I-1

Example NOC Outcome

Sleep—0004

Domain—Functional Health (I) Care Recipient:

Class—Energy Maintenance (A) Data Source:

Scale(s)—Severely compromised to Not compromised (a) and Severe to None (n) Definition: Natural periodic suspension of consciousness during which the body is restored. Outcome Target Rating: Maintain at________ Increase to __________

Sleep Overall Rating

Severely Compromised

Substantially Compromised

Moderately Compromised

Mildly Compromised

Not Compromised

1 2 3 4 5

INDICATORS:

000401 Hours of sleep 1 2 3 4 5 NA

000402 Observed hours of sleep 1 2 3 4 5

000403 Sleep pattern 1 2 3 4 5 NA

000404 Sleep quality 1 2 3 4 5 NA

000405 Sleep efficiency 1 2 3 4 5 NA

000407 Sleep routine 1 2 3 4 5 NA

000418 Sleeps through the night consistently

1 2 3 4 5 NA

000408 Feelings of rejuvenation after sleep

1 2 3 4 5 NA

000410 Wakeful at appropriate times 1 2 3 4 5 NA

000419 Comfortable bed 1 2 3 4 5 NA

000420 Comfortable temperature in room

1 2 3 4 5 NA

000411 Electroencephalogram findings

1 2 3 4 5 NA

000412 Electromyogram findings 1 2 3 4 5 NA

000413 Electrooculogram findings 1 2 3 4 5 NA

Severe Substantial Moderate Mild None

000421 Difficulty getting to sleep 1 2 3 4 5 NA

000406 Interrupted sleep 1 2 3 4 5 NA

000409 Inappropriate napping 1 2 3 4 5 NA

000416 Sleep apnea 1 2 3 4 5 NA

000417 Dependence on sleep aids 1 2 3 4 5 NA

000422 Nightmares 1 2 3 4 5 NA

000423 Nocturia 1 2 3 4 5 NA

000424 Snoring 1 2 3 4 5 NA

000425 Pain 1 2 3 4 5 NA

Adapted from Moorhead S, Johnson, M, Maas ML, & Swanson E. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St Louis: Elsevier.

10 Section i

independent (autonomous actions that are initiated by the nurse in response to a nursing diagnosis) or collaborative (actions that the nurse performs in collaboration with other health care professionals, and that may require a health care provider’s order and may be in response to both medical and nursing diagnoses). The nurse may choose the interventions appropriate for the client and individualize them accordingly, or determine additional interventions.

This text also contains several suggested Nursing Interven- tions Classification (NIC) interventions for each nursing diagnosis to help the reader see how NIC is used along with NOC and nursing diagnoses. The NIC interventions are a comprehensive, standardized classification of treatments that nurses perform. The classification includes both physiological and psychosocial interventions, and covers all nursing spe- cialties. A list of NIC interventions is included on the Evolve website. For more information about NIC interventions, refer to the NIC text (Bulechek et al, 2013).

Putting It All Together—Recording the Care Plan The nurse must document the actual care plan, including prioritized nursing diagnostic statements, outcomes, and interventions. This may be done electronically or in writing. To ensure continuity of care, the plan must be documented and shared with all health care personnel caring for the client. This text provides rationales, most of which are research based, to validate that the interventions are appropriate and workable.

The Evolve website includes an electronic care plan con- structor that can be easily accessed, updated, and individual- ized. Many agencies are using electronic records, and this is an ideal resource. See the inside front cover of this text for information regarding access to the Evolve website, or go to http://evolve.elsevier.com/Ackley/NDH.

STEP 4: IMPLEMENTATION (ADPIE)

The implementation phase includes the “carrying out” of the specific, individualized, jointly agreed upon interventions in the plan of care. Often, the interventions implemented are focused on symptom management, which is alleviating symp- toms. Typically, nursing care does not involve “curing” the medical condition causing the symptom. Rather, nursing care focuses on caring for the client/family so they can function at their highest level.

The implementation phase of the nursing process is the point at which you actually give nursing care. You perform the interventions that have been individualized to the client. All the hard work you put into the previous steps (ADP) can now be actualized to assist the client. As the interventions are performed, make sure that they are appropriate for the client. Consider that the client who was having difficulty breathing was also older. He may need extra time to carry out any

activity. Check the rationale or research that is provided to determine why the intervention is being used. The evidence should support the individualized actions that you are implementing.

Client outcomes are achieved by the performance of the nursing interventions in collaboration with other disciplines and the client/family. During this phase, the nurse continues to assess the client to determine whether the interventions are effective and the desired outcomes are met.

STEP 5: EVALUATION (ADPIE) The final phase of the nursing process is evaluation. Evalua- tion occurs not only at the end of the nursing process, but throughout the process. Evaluation of an intervention is, in essence, another nursing assessment; hence the dynamic feature of the nursing process. The nurse reassesses the client, taking into consideration where the client was before the intervention (i.e., baseline) and where the client is after the intervention. Nurses are also in a great place (at the bedside) to evaluate how clients respond to other, multidisciplinary interventions, and their assessment of the client’s response is valuable to determine whether the client’s plan of care needs to be altered or not. For example, the client may receive 2 mg of morphine intravenously for pain (a pharmaceutical inter- vention to treat pain), and the nurse is the member of the health care team who can best assess how the client responded to that medication. Did the client receive relief from pain? Did the client develop any side effects? The nurse’s docu- mented evaluation of the client’s response will be very helpful to the entire health care team.

The client/family can often tell the nurse how the interven- tion helped or did not help. This reassessment requires the nurse to revisit the mutual outcomes/goals set earlier and ask, “Are we moving toward that goal, or does the goal seem unreachable after the intervention?” If the outcomes were not met, the nurse begins again with assessment and determines the reason they were not met. Consider the SMART acronym and Case Study 1. Were the outcomes Specific? Were the outcomes Measurable? Did the client’s heart rate decrease? Did the client indicate that it was easier to breathe when walking from his bed to the bathroom? Were the outcomes Attainable and Realistic? Did he still report “being tired”? Did you allow adequate Time for a positive outcome? Also ask yourself whether you identified the correct nursing diag- nosis. Should the interventions be changed? At this point, the nurse can look up any new symptoms or conditions that have been identified and adjust the care plan as needed. Decisions about implementing additional interventions may be neces- sary; if so, they should be made in collaboration with the client/family if possible.

In some instances, the client/family/nurse triad will establish new, achievable goals and continue to cycle through the nursing process until the mutual goals are achieved.

http://evolve.elsevier.com/Ackley/NDH