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Summary Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span

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We are often asked how we came to write the Care Plan books. In the late 1970s we were involved with some publishing efforts that did not come to fruition. In this work we had included care plans, so ensuing discussions revolved around the need for a Care Plan book. We spent a year struggling to write care plans before we realized our major difficulty was the lack of standardized labels for client problems. At that time, we were given a list of nursing diagnoses from the Clearinghouse for Nursing Diagnosis, which became the North American Nursing Diagnosis Association (NANDA), and is now NANDA International (NANDA-I). This work answered our need by providing concise titles that could be used in various plans of care and followed across the spectrum of client care. We believed these nursing diagnosis labels would both define and focus nursing care. Because we had long been involved in direct client care in our nursing careers, we knew there was a need for guidelines to assist nurses in planning care. As we began to write, our focus was the nurse in a small rural community who at 2 a.m. needed the answer to a burning question for her client and had few resources available. We believed the book would give definition and direction to the development and use of individualized nursing care. Thus, in the first edition, the theory of nursing process, diagnosis, and intervention was brought to the clinical setting for implementation by the nurse. We also anticipated that nursing students would appreciate having access to these guidelines as they struggled to learn how to provide nursing care. Therefore, we did not consider the book to be an end in itself, but rather a vehicle for the continuing growth and development of the profession. Obviously we struck a chord and met a need because the first edition was an immediate success. In becoming involved with NANDA, we acknowledged that maintaining a strict adherence to their wording, while adding our own clearly identified recommendations, would help develop this neophyte standardized language and would promote the growth of nursing as a profession. We have continued our involvement with NANDA-I, promoting the use of the language by practicing nurses in the United States and around the world and encouraging them to participate in updating and refining the diagnoses. The wide use of our books within the student population has supported and fostered the acceptance of both the activity of diagnosing client problems or needs and the use of standardized language. Nursing instructors initially expressed concern that students would simply copy the plans of care and thus limit their learning. However, as students used the plans to individualize care and to develop practice priorities and client care outcomes, the book met with more acceptance. Instructors began not only to recommend the book, but also to adopt it as an adjunct text. Today, it remains the best-selling nursing care plan book recognized as an important adjunct for student learning. In writing the second edition, we recognized the need for an assessment tool with a nursing focus instead of a medical focus. Not finding one that met our needs, we constructed our own. To facilitate problem identification, we categorized the nursing diagnosis labels and the information obtained in the client assessment database into a framework entitled “Diagnostic Divisions.” Our philosophy is to provide a way in which to gather information and to intervene beneficially, while thinking about the rationale for every action we take and the standardized language that best expresses it. When nurses do this they are defining their practice and are able to identify it with a code and charge for it. By doing this, we promote client protection (quality of care issue), provide for the definition and protection of nursing practice, and the protection of the individual (legal implications). The latter is important because we live in a litigation-minded society and the nurse’s license and livelihood are at stake. One of the most significant achievements in the healthcare field over the past 20 or more years has been the emergence of the nurse as an active coordinator and initiator of client care. Although the transition from physician’s helpmate to healthcare professional has been painfully slow and is not yet complete, the importance of the nurse within the system can no longer be denied or ignored. Today’s nurse designs nursing care interventions that move the total client toward improved health and maximum independence. Professional care standards and healthcare providers and consumers will continue to increase the expectations for nurses’ performance. Each day brings new challenges in client care and the struggle to understand the human responses to actual and potential health problems. To meet these challenges competently, the nurse must have upto-date assessment skills and a working knowledge of pathophysiological concepts concerning the common diseases and conditions presented. We believe that this book is a tool, providing a means of attaining that competency. In the past, plans of care were viewed principally as learning tools for students and seemed to have little relevance after graduation. However, the need for a written format to communicate and document client care has beenxviii recognized in all care settings. In addition, healthcare policy, governmental regulations, and third-party payor requirements have created the need to validate many things, including appropriateness of care provided, staffing patterns, and monetary charges. Thus, although the student’s “case studies” are too cumbersome to be practical in the clinical setting, it has long been recognized that the client plan of care meets certain needs and therefore its appropriate use was validated. The practicing nurse, as well as the nursing student, can welcome this text as a ready reference in clinical practice. It is designed for use in the acute care, community, and home-care settings. It is organized by systems for easy reference. Chapter 1 examines current issues and trends and their implications for the nursing profession. An overview of cultural, community, sociological, and ethical concepts affecting the nurse is included. The importance of the nurse’s role in collaboration and coordination with other healthcare professionals is integrated throughout the plans of care. Chapter 2 reviews the historical use of the nursing process in formulating plans of care and the nurse’s role in the delivery of that care. Nursing diagnoses, outcomes, and interventions are discussed to assist the nurse in understanding her or his role in the nursing process. In this book, we have also linked NANDA-I diagnoses with Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) languages. Chapter 3 discusses care plan construction and describes the use and adaptation of the guides presented in this book. A nursing-based assessment tool is provided to assist the nurse in identifying appropriate nursing diagnoses. A sample client situation with individual database and a corresponding plan of care is included to demonstrate how critical thinking is used to adapt nursing process theory to practice. Finally, a dynamic and creative approach for developing and documenting the planning of care is also included. Mind Mapping is a new technique or learning tool provided to assist you in achieving a holistic view of your client, enhance your critical thinking skills, and facilitate the creative process of planning client care. Chapters 4 through 15 present plans of care that include information from multiple disciplines to assist the nurse in providing holistic care. Each plan includes a Client Assessment Database presented in a nursing format, and associated Diagnostic Studies. After the database is collected, Nursing Priorities are sifted from the information to help focus and structure the care. Discharge Goals are created to identify what should be generally accomplished by the time of discharge from the care setting. Nursing diagnosis labels are then chosen and combined with possible related factors disignated by “may be related to,” and the signs and symptoms or defining characteristics as “possibly evidenced by” if present to create Client Diagnostic Statements that provide a clear picture of the client’s needs. Next, Desired Client Outcomes are stated in measurable behavioral terms to evaluate both the client’s progress and the effectiveness of care provided. Corresponding actions/interventions are designed to promote resolution of the identified client needs. The nurse acting independently or collaboratively within the health team then uses a decision-making model to organize and prioritize nursing interventions. No attempt is made in this book to indicate whether independent or collaborative actions come first because this must be dictated by the individual situation. We do, however, believe that every collaborative action has a component that the nurse must identify and for which nursing has responsibility and accountability. Rationales for the nursing actions, which are not required in the customary plan of care, are included to assist the nurse in deciding whether the interventions are appropriate for an individual client. Additional information is provided to further assist the nurse in identifying and planning for rehabilitation as the client progresses toward discharge and across all care settings. A bibliography is provided as a reference and to allow further research as desired. This book is designed for students who will find the plans of care helpful as they learn and develop skills in applying the nursing process and using nursing diagnoses. It will complement their classroom work and support the critical thinking process. The book also provides a ready reference for the practicing nurse as a catalyst for thought in planning, evaluating, and documenting care. As a final note, this book is not intended to be a procedure manual, and efforts have been made to avoid detailed descriptions of techniques or protocols that might be viewed as individual or regional in nature. Instead, the reader is referred to a procedure manual or text covering Standards of Care if detailed direction is desired. As we always say when we sign a book, “Use and enjoy.”

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, INDEX OF DISEASES/DISORDERS
Acid-base imbalances Gastrectomy/gastric resection, 317 Pediatric considerations, 890
respiratory, 195 Gastric bypass, 396 Peritoneal dialysis, 570
metabolic, 483 Gastric partitioning, 396 Peritonitis, 349
AIDS, 709 Gastroplasty, 396 Pernicious anemia, 493
Alcohol: acute withdrawal, 819 Glaucoma, 204 Pneumonia, 131
Alzheimer’s disease, 764 Graves’ disease, 419 Pneumothorax, 154
Amputation, 646 Primary base bicarbonate deficiency, 483
Anemia–iron deficiency, anemia of chronic Heart failure: chronic, 48 Primary base bicarbonate excess, 488
disease, pernicious, aplastic, hemolytic, 493 Hemodialysis, 575 Primary carbonic acid deficit, 200
Angina (coronary artery disease, acute coronary Hemolytic anemia, 493 Primary carbonic acid excess, 195
syndrome), 64 Hemothorax, 154 Prostatectomy, 596
Anorexia nervosa, 369 Hepatitis, 434 Psychosocial aspects of care, 749
Aplastic anemia, 493 Herniated nucleus pulposus (ruptured invertebral Pulmonary emboli considerations, 111
Appendectomy, 344 disc), 254 Pulmonary tuberculosis, 186
Asthma, 120 HIV-positive client, 697
Hospice, 866 Radical neck surgery: laryngectomy
Bariatric surgery, 396 Hypercalcemia (calcium excess), 927 (postoperative care), 160
Benign prostatic hyperplasia, 588 Hyperkalemia (potassium excess), 921 Renal calculi, 603
Bulimia nervosa, 369 Hypermagnesemia (magnesium excess), 932 Renal dialysis, 560
Burns: thermal, chemical, and electrical—acute Hypernatremia (sodium excess), 915 Renal failure: acute, 536
and convalescent phases, 667 Hypertension: severe, 37 Renal failure: chronic, 548
Hyperthyroidism (Graves’ disease, Respiratory acid-base imbalances, 195
Cancer, 846 thyrotoxicosis), 419 Respiratory acidosis (primary carbonic acid
Cardiac surgery: postoperative care, 100 Hypervolemia (extracellular fluid volume excess), 195
Cardiomyoplasty, 100 excess), 905 Respiratory alkalosis (primary carbonic acid
Cerebrovascular accident/stroke, 238 Hypocalcemia (calcium deficit), 924 deficit), 200
Chemical burns, 667 Hypokalemia (potassium deficit), 918 Rheumatoid arthritis, 729
Cholecystectomy, 364 Hypomagnesemia (magnesium deficit), 930 Ruptured invertebral disc, 254
Cholecystitis with cholelithiasis, 357 Hyponatremia (sodium deficit), 914
Cholelithiasis, 357 Hypovolemia (extracellular fluid volume Seizure disorders, 210
Chronic obstructive pulmonary disease, 120 deficit), 908 Sepsis, 686
Cirrhosis of the liver, 445 Hysterectomy, 611 Septicemia, 686
Colostomy, 334 Sickle cell crisis, 503
Coronary artery bypass graft, 100 Ileostomy, 334 Spinal cord injury (acute rehabilitative phase),
Coronary artery disease, 64 Inflammatory bowel disease: ulcerative colitis, 271
Craniocerebral trauma–acute rehabilitative Crohn’s disease, 321 Stroke, 238
phase, 220 Iron deficiency anemia, 493 Substance dependence/abuse rehabilitation, 835
Crohn’s disease, 321 Surgical intervention, 782
Laminectomy, 262
Deep vein thrombosis, 111 Laryngectomy (postoperative care), 160 Thermal burns, 667
Dementia (Alzheimer’s type or vascular), 764 Leukemias, 516 Thrombophlebitis: deep vein thrombosis (including
Diabetes mellitus/diabetic ketoacidosis, 405 Lung cancer: postoperative care, 144 pulmonary emboli considerations), 111
Diabetic ketoacidosis, 405 Lymphomas, 525 Thyroidectomy, 429
Disaster considerations, 876 Thyrotoxicosis, 419
Disc surgery, 262 Mastectomy, 619 Total joint replacement, 655
Dysrthymias , 88 Metabolic acid-base imbalances, 483 Total nutritional support: parenteral/enteral
Metabolic acidosis—primary base bicarbonate feeding, 469
Eating disorders: anorexia nervosa/bulimia deficiency, 483 Transplantation considerations—postoperative
nervosa, 369 Metabolic alkalosis—primary base bicarbonate and lifelong, 739
Eating disorders: obesity, 387 excess, 488 Tuberculosis, pulmonary, 186
Electrical burns, 667 Minimally invasive direct coronary artery
End-of-life care/hospice, 866 bypass, 100 Ulcerative colitis, 321
Enteral feeding, 469 Multiple sclerosis, 290 Upper gastrointestinal/esophageal bleeding, 306
Esophageal bleeding, 306 Myocardial infarction, 74 Urinary diversions/urostomy (postoperative
Extended care, 801 care), 578
Obesity, 387 Urolithiasis (renal calculi), 603
Fecal diversions: postoperative care of ileostomy Obesity: bariatric surgery–gastric partitioning/ Urostomy, 578
and colostomy, 334 gastroplasty, gastric bypass, 396
Fluid and electrolyte imbalances, 903 Valve replacement, 100
Fluid and electrolyte imbalances, 903 Pancreatitis, 458 Vascular dementia, 764
Fractures, 632 Parenteral feeding, 469 Ventilatory assistance (mechanical), 173

, KEY TO ESSENTIAL TERMINOLOGY
Client Assessment Database
Provides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical
and/or surgical diagnosis as well as the signs and symptoms and corresponding diagnostic findings.

Nursing Priorities
Establishes a general ranking of needs and concerns on which the Nursing Diagnoses are ordered in constructing the plan of
care. This ranking would be altered according to the individual client situation.

Discharge Goals
Identifies generalized statements that could be developed into short-term and intermediate goals to be achieved by the client
before being “discharged” from nursing care. They may also provide guidance for creating long-term goals for the client to
work on after discharge.

Nursing Diagnosis
The general need or problem (diagnosis) is stated without the distinct cause and signs and symptoms, which would be added
to create a client diagnostic statement when specific client information is available. For example, when a client displays
increased tension, apprehension, quivering voice, and focus on self, the nursing diagnosis of Anxiety might be stated: severe
Anxiety related to unconscious conflict, threat to self-concept as evidenced by statements of increased tension, apprehension;
observations of quivering voice, focus on self.
In addition, diagnoses identified within these guides for planning care as actual or risk can be changed or deleted and
new diagnoses added, depending entirely on the specific client information.

May Be Related to/Possibly Evidenced by
These lists provide the usual or common reasons (etiology) why a particular need or problem may occur with probable signs
and symptoms, which would be used to create the “related to” and “evidenced by” portions of the client diagnostic statement
when the specific situation is known.
When a risk diagnosis has been identified, signs and symptoms have not yet developed and therefore are not included in
the nursing diagnosis statement. However, interventions are provided to prevent progression to an actual problem. The excep-
tion to this occurs in the nursing diagnosis risk for Violence, which has possible indicators that reflect the client’s risk status.

Desired Outcomes/Evaluation Criteria—Client Will
These give direction to client care as they identify what the client or nurse hopes to achieve. They are stated in general terms
to permit the practitioner to modify or individualize them by adding time lines and specific client criteria so they become
“measurable.” For example, “Client will appear relaxed and report anxiety is reduced to a manageable level within 24 hours.”
Nursing Outcomes Classification (NOC) labels are also included. The outcome label is selected from a standardized
nursing language and serves as a general header for the outcome indicators that follow.

Actions/Interventions
Nursing Interventions Classification (NIC) labels are drawn from a standardized nursing language and serve as a general
header for the nursing actions that follow.
Nursing actions are divided into independent—those actions that the nurse performs autonomously; and collaborative—
those actions that the nurse performs in conjunction with others, such as implementing physician orders. The interventions in
this book are generally ranked from most to least common. When creating the individual plan of care, interventions would nor-
mally be ranked to reflect the client’s specific needs and situation. In addition, the division of independent and collaborative is
arbitrary and is actually dependent on the individual nurse’s capabilities and hospital and community standards.

Rationale
Although not commonly appearing in client plans of care, rationale has been included here to provide a pathophysiological
basis to assist the nurse in deciding about the relevance of a specific intervention for an individual client situation.

Clinical Pathway
This abbreviated plan of care or care map is event- or task-oriented and provides outcome-based guidelines for goal achieve-
ment within a designated length of stay. Several samples have been included to demonstrate alternative planning formats.

, NURSING DIAGNOSES ACCEPTED FOR
USE AND RESEARCH FOR 2009–2011
Activity Intolerance [specify level] Fluid Volume, risk for imbalanced (Rape-Trauma Syndrome: silent reaction—retired
Activity Intolerance, risk for Gas Exchange, impaired 2009)
Activity Planning, ineffective Glucose Level, risk for unstable blood Relationship, readiness for enhanced
Airway Clearance, ineffective Grieving Religiosity, impaired
Allergy Response, latex Grieving, complicated Religiosity, risk for impaired
Allergy Response, risk for latex Grieving, risk for complicated Religiosity, readiness for enhanced
Anxiety [specify level] Growth, risk for disproportionate Relocation Stress Syndrome
Anxiety, death Growth and Development, delayed Relocation Stress Syndrome, risk for
Aspiration, risk for Health Maintenance, ineffective Resilience, impaired individual
Attachment, risk for impaired Health Management, ineffective self [formerly Resilience, readiness for enhanced
Autonomic Dysreflexia Therapeutic Regimen Management, ineffective] Resilience, risk for compromised
Autonomic Dysreflexia, risk for Health Management, readiness for enhanced self Role Performance, ineffective
Behavior, risk-prone health [formerly Therapeutic Regimen Management, Self-Care, readiness for enhanced
Bleeding, risk for readiness for enhanced] Self-Care Deficit: bathing
Body Image, disturbed Home Maintenance, impaired Self-Care Deficit: dressing
Body Temperature, risk for imbalanced Hope, readiness for enhanced Self-Care Deficit: feeding
Bowel Incontinence Hopelessness Self-Care Deficit: toileting
Breastfeeding, effective Hyperthermia Self-Concept, readiness for enhanced
Breastfeeding, ineffective Hypothermia Self-Esteem, chronic low
Breastfeeding, interrupted Identity, disturbed personal Self-Esteem, situational low
Breathing Pattern, ineffective Immunization Status, readiness for enhanced Self-Esteem, risk for situational low
Cardiac Output, decreased Infant Behavior, disorganized Self-Mutilation
Caregiver Role Strain Infant Behavior, readiness for enhanced organized Self-Mutilation, risk for
Caregiver Role Strain, risk for Infant Behavior, risk for disorganized Sensory Perception, disturbed (specify: visual,
Childbearing Process, readiness for enhanced Infection, risk for auditory, kinesthetic, gustatory, tactile, olfactory)
Comfort, impaired Injury, risk for Sexual Dysfunction
Comfort, readiness for enhanced Injury, risk for perioperative positioning Sexuality Pattern, ineffective
Communication, impaired verbal Insomnia Shock, risk for
Communication, readiness for enhanced Intracranial Adaptive Capacity, decreased Skin Integrity, impaired
Conflict, decisional Jaundice, neonatal Skin Integrity, risk for impaired
Conflict, parental role Knowledge, deficient [Learning Need] [specify] Sleep, readiness for enhanced
Confusion, acute Knowledge [specify], readiness for enhanced Sleep Deprivation
Confusion, risk for acute Lifestyle, sedentary Sleep Pattern, disturbed
Confusion, chronic Liver Function, risk for impaired Social Interaction, impaired
Constipation Loneliness, risk for Social Isolation
Constipation, perceived Maternal/Fetal Dyad, risk for disturbed Sorrow, chronic
Constipation, risk for Memory, impaired Spiritual Distress
Contamination Mobility, impaired bed Spiritual Distress, risk for
Contamination, risk for Mobility, impaired physical Spiritual Well-Being, readiness for enhanced
Coping, defensive Mobility, impaired wheelchair Stress Overload
Coping, ineffective Motility, dysfunctional gastointestinal Suffocation, risk for
Coping, readiness for enhanced Motility, risk for dysfunctional gastointestinal Suicide, risk for
Coping, ineffective community Nausea Surgical Recovery, delayed
Coping, readiness for enhanced community Neglect, self Swallowing, impaired
Coping, compromised family Neglect, unilateral (Therapeutic Regimen Management, effective—
Coping, disabled family Noncompliance [Adherence, ineffective] [specify] retired 2009)
Coping, readiness for enhanced family Nutrition: less than body requirements, imbalanced (Therapeutic Regimen Management, ineffective
Death Syndrome, risk for sudden infant Nutrition: more than body requirements, imbalanced community—retired 2009)
Decision-Making, readiness for enhanced Nutrition: more than body requirements, risk for Therapeutic Regimen Management, ineffective
Denial, ineffective imbalanced family
Dentition, impaired Nutrition, readiness for enhanced Thermoregulation, ineffective
Development, risk for delayed Oral Mucous Membrane, impaired (Thought Processes, disturbed—retired 2009)
Diarrhea Pain, acute Tissue Integrity, impaired
Dignity, risk for compromised human Pain, chronic Transfer Ability, impaired
Distress, moral Parenting, impaired Trauma, risk for
Disuse Syndrome, risk for Parenting, readiness for enhanced Trauma, risk for vascular
Diversional Activity, deficient Parenting, risk for impaired Urinary Elimination, impaired
Electrolyte Imbalance, risk for Perfusion, ineffective peripheral tissue Urinary Elimination, readiness for enhanced
Energy Field, disturbed Perfusion, risk for decreased cardiac tissue Urinary Incontinence, functional
Environmental Interpretation Syndrome, impaired Perfusion, risk for ineffective cerebral tisse Urinary Incontinence, overflow
Failure to Thrive, adult Perfusion, risk for ineffective gastrointestinal Urinary Incontinence, reflex
Falls, risk for Perfusion, risk for ineffective renal Urinary Incontinence, stress
Family Processes, dysfunctional Peripheral Neurovascular Dysfunction, risk for (Urinary Incontinence, total—retired 2009)
Family Processes, interrupted Poisoning, risk for Urinary Incontinence, urge
Family Processes, readiness for enhanced Post-Trauma Syndrome [specify stage] Urinary Incontinence, risk for urge
Fatigue Post-Trauma Syndrome, risk for Urinary Retention [acute/chronic]
Fear Power, readiness for enhanced Ventilation, impaired spontaneous
Feeding Pattern, ineffective infant Powerlessness [specify level] Ventilatory Weaning Response, dysfunctional
Fluid Balance, readiness for enhanced Powerlessness, risk for Violence, [actual/]risk for other-directed
[Fluid Volume, deficient hyper/hypotonic] Protection, ineffective Violence, [actual/]risk for self-directed
Fluid Volume, deficient [isotonic] Rape-Trauma Syndrome Walking, impaired
Fluid Volume, excess (Rape-Trauma Syndrome: compound reaction— Wandering [specify sporadic or continual]
Fluid Volume, risk for deficient retired 2009) [ ] author recommendations

Nursing Diagnoses—Definitions and Classification 2009–2011 © 2009, 2007, 2005, 2003, 2001, 1998, 1996, 1994 NANDA International. Used by arrangement with
Wiley-Blackwell Publishing, a company of John Wiley & Sons, Inc. In order to make safe and effective judgments using NANDA-I nursing diagnoses, it is
essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.
R372,38
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