Nursing Diagnosis Handbook · an Evidence-Based Guide to Planning Care by Ackley, Betty J. -- Read -- Imperial Library of Trantor

Index

Title page Table of Contents 2012-2014 NANDA Diagnosis Copyright Dedication About the Authors Contributors Reviewers Preface Acknowledgments How to Use Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care SECTION I: Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing

Introduction Part A & B

Part A The Nursing Process: Using Clinical Reasoning Skills to Determine Nursing Diagnoses and Plan Care Part B Advanced Nursing Process Concepts

SECTION II: Guide to Nursing Diagnoses

Introduction List of Nursing Assessments by Letter: A Chapter 1: A

Abdominal Distention Abdominal Hysterectomy Abdominal Pain Abdominal Surgery Abdominal Trauma Ablation, Radiofrequency Catheter Abortion, Induced Abortion, Spontaneous Abruptio Placentae <36 Weeks Abscess Formation Abuse, Child Abuse, Spouse, Parent, or Significant Other Accessory Muscle Use (to Breathe) Accident Prone Achalasia Acid-Base Imbalances Acidosis, Metabolic Acidosis, Respiratory Acne ACS (Acute Coronary Syndrome) Acquired Immunodeficiency Syndrome Acromegaly Activity Intolerance, Potential to Develop Acute Abdominal Pain Acute Alcohol Intoxication Acute Back Pain Acute Confusion Acute Coronary Syndrome Acute Lymphocytic Leukemia (ALL) Acute Renal Failure Acute Respiratory Distress Syndrome Adams-Stokes Syndrome Addiction Addison’s Disease Adenoidectomy Adhesions, Lysis of Adjustment Disorder Adjustment Impairment Adolescent, Pregnant Adoption, Giving Child Up for Adrenocortical Insufficiency Advance Directives Affective Disorders Age-Related Macular Degeneration Aggressive Behavior Aging Agitation Agoraphobia Agranulocytosis AIDS (Acquired Immunodeficiency Syndrome) AIDS Dementia AIDS, Child Airway Obstruction/Secretions Alcohol Withdrawal Alcoholism Alcoholism, Dysfunctional Family Processes Alkalosis ALL (Acute Lymphocytic Leukemia) Allergies Alopecia Altered Mental Status ALS (Amyotrophic Lateral Sclerosis) Alzheimer’s Disease AMD (Age-Related Macular Degeneration) Amenorrhea AMI (Acute Myocardial Infarction) Amnesia Amniocentesis Amnionitis Amniotic Membrane Rupture Amputation Amyotrophic Lateral Sclerosis (ALS) Anal Fistula Anaphylactic Shock Anaphylaxis Prevention Anasarca Anemia Anemia, in Pregnancy Anemia, Sickle Cell Anencephaly Aneurysm, Abdominal Surgery Aneurysm, Cerebral Anger Angina Angiocardiography (Cardiac Catheterization) Angioplasty, Coronary Anomaly, Fetal/Newborn (Parent Dealing with) Anorectal Abscess Anorexia Anorexia Nervosa Anosmia (Smell, Loss of Ability to) Antepartum Period Anterior Repair, Anterior Colporrhaphy Anticoagulant Therapy Antisocial Personality Disorder Anuria Anxiety Anxiety Disorder Aortic Aneurysm Repair (Abdominal Surgery) Aortic Valvular Stenosis Aphasia Aplastic Anemia Apnea in Infancy Apneustic Respirations Appendectomy Appendicitis Apprehension ARDS (Acute Respiratory Distress Syndrome) Arrhythmia Arterial Insufficiency Arthritis Arthrocentesis Arthroplasty (Total Hip Replacement) Arthroscopy Ascites Asperger’s Syndrome Asphyxia, Birth Aspiration, Danger of Assault Victim Assaultive Client Asthma Ataxia Atelectasis Atherosclerosis Athlete’s Foot ATN (Acute Tubular Necrosis) Atrial Fibrillation Atrial Septal Defect Attention Deficit Disorder Auditory Problems Autism Autonomic Dysreflexia Autonomic Hyperreflexia

List of Nursing Assessments by Letter: B Chapter 2: B

Baby Care Back Pain Bacteremia Barrel Chest Bathing/Hygiene Problems Battered Child Syndrome Battered Person Bedbugs, Infestation Bed Mobility, Impaired Bed Rest, Prolonged Bedsores Bedwetting Bell’s Palsy Benign Prostatic Hypertrophy Bereavement Biliary Atresia Biliary Calculus Biliary Obstruction Bilirubin Elevation in Neonate Biopsy Bioterrorism Bipolar Disorder I (Most Recent Episode, Depressed or Manic) Birth Asphyxia Birth Control Bladder Cancer Bladder Distention Bladder Training Bladder Training, Child Bleeding Tendency Blepharoplasty Blindness Blood Disorder Blood Pressure Alteration Blood Sugar Control Blood Transfusion Body Dysmorphic Disorder Body Image Change Body Temperature, Altered Bone Marrow Biopsy Borderline Personality Disorder Boredom Botulism Bowel Incontinence Bowel Obstruction Bowel Resection Bowel Sounds, Absent or Diminished Bowel Sounds, Hyperactive Bowel Training Bowel Training, Child BPH (Benign Prostatic Hypertrophy) Bradycardia Bradypnea Brain Injury Brain Surgery Brain Tumor Braxton Hicks Contractions Breast Biopsy Breast Cancer Breast Examination, Self Breast Lumps Breast Pumping Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Breast Milk, Insufficient Breath Sounds, Decreased or Absent Breathing Pattern Alteration Breech Birth Bronchitis Bronchopulmonary Dysplasia Bronchoscopy Bruits, Carotid Bryant’s Traction Buck’s Traction Buerger’s Disease Bulimia Bunion Bunionectomy Burn Risk Burns Bursitis Bypass Graft

List of Nursing Assessments by Letter: C Chapter 3: C

CABG (Coronary Artery Bypass Grafting) Cachexia Calcium Alteration Cancer Candidiasis, Oral Capillary Refill Time, Prolonged Carbon Monoxide Poisoning Cardiac Arrest Cardiac Catheterization Cardiac Disorders Cardiac Disorders in Pregnancy Cardiac Dysrhythmia Cardiac Output, Decreased Cardiac Tamponade Cardiogenic Shock Caregiver Role Strain Carious Teeth Carotid Endarterectomy Carpal Tunnel Syndrome Carpopedal Spasm Casts Cataract Extraction Cataracts Catatonic Schizophrenia Catheterization, Urinary Cavities in Teeth Celiac Disease Cellulitis Cellulitis, Periorbital Central Line Insertion Cerebral Aneurysm Cerebral Palsy Cerebral Perfusion Cerebrovascular Accident (CVA) Cervicitis Cesarean Delivery Chemical Dependence Chemotherapy Chest Pain Chest Tubes Cheyne-Stokes Respiration CHF (Congestive Heart Failure) Chickenpox Child Abuse Childbearing Problems Child Neglect Child with Chronic Condition Childbirth Chills Chlamydia Infection Chloasma Choking or Coughing with Eating Cholecystectomy Cholelithiasis Chorioamnionitis Chronic Confusion Chronic Lymphocytic Leukemia Chronic Obstructive Pulmonary Disease (COPD) Chronic Pain Chronic Renal Failure Chvostek’s Sign Circumcision Cirrhosis Cleft Lip/Cleft Palate Clotting Disorder Cocaine Abuse Cocaine Baby Codependency Cold, Viral Colectomy Colitis Collagen Disease Colostomy Colporrhaphy, Anterior Coma Comfort, Loss of Communicable Diseases, Childhood (e.g., Measles, Mumps, Rubella, Chickenpox, Scabies, Lice, Impetigo) Communication Communication Problems Community Coping Community Health Problems Compartment Syndrome Compulsion Conduction Disorders (Cardiac) Confusion, Acute Confusion, Chronic Confusion, Possible Congenital Heart Disease/Cardiac Anomalies Congestive Heart Failure (CHF) Conjunctivitis Consciousness, Altered Level of Constipation Constipation, Perceived Constipation, Risk for Contamination Continent Ileostomy (Kock Pouch) Contraceptive Method Convulsions COPD (Chronic Obstructive Pulmonary Disease) Coping Coping Problems Corneal Reflex, Absent Corneal Transplant Coronary Artery Bypass Grafting (CABG) Costovertebral Angle Tenderness Cough, Ineffective Crack Abuse Crack Baby Crackles in Lungs, Coarse Crackles in Lungs, Fine Craniectomy/Craniotomy Crepitation, Subcutaneous Crisis Crohn’s Disease Croup Cryosurgery for Retinal Detachment Cushing’s Syndrome Cuts (Wounds) CVA (Cerebrovascular Accident) Cyanosis, Central with Cyanosis of Oral Mucous Membranes Cyanosis, Peripheral with Cyanosis of Nail Beds Cystic Fibrosis Cystitis Cystocele Cystoscopy

List of Nursing Assessments by Letter: D Chapter 4: D

Deafness Death Death, Oncoming Decisions, Difficulty Making Decubitus Ulcer Deep Vein Thrombosis (DVT) Defensive Behavior Dehiscence, Abdominal Dehydration Delirium Delirium Tremens (DT) Delivery Delusions Dementia Denial of Health Status Dental Caries Depression (Major Depressive Disorder) Dermatitis Despondency Destructive Behavior Toward Others Developmental Concerns Diabetes in Pregnancy Diabetes Insipidus Diabetes Mellitus Diabetes Mellitus, Juvenile (IDDM Type 1) Diabetic Coma Diabetic Ketoacidosis Diabetic Retinopathy Dialysis Diaphragmatic Hernia Diarrhea DIC (Disseminated Intravascular Coagulation) Digitalis Toxicity Dignity, Loss of Dilation and Curettage (D&C) Dirty Body (for Prolonged Period) Discharge Planning Discomforts of Pregnancy Dislocation of Joint Dissecting Aneurysm Disseminated Intravascular Coagulation (DIC) Dissociative Identity Disorder (Not Otherwise Specified) Distress Disuse Syndrome, Potential to Develop Diversional Activity, Lack of Diverticulitis Dizziness Domestic Violence Down Syndrome Dress Self (Inability to) Dribbling of Urine Drooling Dropout from School Drug Abuse Drug Withdrawal Dry Eye DT (Delirium Tremens) DVT (Deep Vein Thrombosis) Dying Client Dysfunctional Eating Pattern Dysfunctional Family Unit Dysfunctional Ventilatory Weaning Dysmenorrhea Dyspareunia Dyspepsia Dysphagia Dysphasia Dyspnea Dysrhythmia Dysthymic Disorder Dystocia Dysuria

List of Nursing Assessments by Letter: E Chapter 5: E

ECMO (Extracorporeal Membrane Oxygenator) E. coli Infection Ear Surgery Earache Eclampsia ECT (Electroconvulsive Therapy) Ectopic Pregnancy Eczema ED (Erectile Dysfunction) Edema Elder Abuse Elderly Electroconvulsive Therapy Electrolyte Imbalance Emaciated Person Embolectomy Emboli Embolism in Leg or Arm Emesis Emotional Problems Empathy Emphysema Emptiness Encephalitis Endocardial Cushion Defect Endocarditis Endometriosis Endometritis Enuresis Environmental Interpretation Problems Epididymitis Epiglottitis Epilepsy Episiotomy Epistaxis Epstein-Barr Virus Erectile Dysfunction (ED) Esophageal Varices Esophagitis ETOH Withdrawal Evisceration Exhaustion Exposure to Hot or Cold Environment External Fixation Extracorporeal Membrane Oxygenator (ECMO) Eye Discomfort Eye Surgery

List of Nursing Assessments by Letter: F Chapter 6: F

Failure to Thrive, Adult Failure to Thrive, Child Falls, Risk for Family Problems Family Process Fatigue Fear Febrile Seizures Fecal Impaction Fecal Incontinence Feeding Problems, Newborn Femoral Popliteal Bypass Fetal Alcohol Syndrome Fetal Distress/Nonreassuring Fetal Heart Rate Pattern Fever Fibrocystic Breast Disease Filthy Home Environment Financial Crisis in the Home Environment Fistulectomy Flail Chest Flashbacks Flat Affect Flesh-Eating Bacteria (Necrotizing Fasciitis) Fluid Balance Fluid Volume Deficit Fluid Volume Excess Fluid Volume Imbalance, Risk for Food Allergies Foodborne Illness Food Intolerance Foreign Body Aspiration Formula Feeding of Infant Fracture Fractured Hip Frequency of Urination Friendship Frostbite Frothy Sputum Fusion, Lumbar

List of Nursing Assessments by Letter: G Chapter 7: G

Gag Reflex, Depressed or Absent Gallop Rhythm Gallstones Gang Member Gangrene Gas Exchange, Impaired Gastric Ulcer Gastritis Gastroenteritis Gastroenteritis, Child Gastroesophageal Reflux Gastroesophageal Reflux, Child Gastrointestinal Bleeding (GI Bleed) Gastrointestinal Hemorrhage Gastrointestinal Surgery Gastroschisis/Omphalocele Gastrostomy Genital Herpes Genital Warts GERD Gestational Diabetes (Diabetes in Pregnancy) GI Bleed (Gastrointestinal Bleeding) Gingivitis Glaucoma Glomerulonephritis Gluten Allergy Gonorrhea Gout Grandiosity Grand Mal Seizure Grandparents Raising Grandchildren Graves’ Disease Grieving Grieving, Complicated Groom Self (Inability to) Growth and Development Lag Guillain-Barré Syndrome Guilt

List of Nursing Assessments by Letter: H Chapter 8: H

H1N1 Hair Loss Halitosis Hallucinations Head Injury Headache Health Behavior, Risk-Prone Health Maintenance Problems Health-Seeking Person Hearing Impairment Heart Attack Heartburn Heart Failure Heart Surgery Heat Stroke Hematemesis Hematuria Hemianopia Hemiplegia Hemodialysis Hemodynamic Monitoring Hemolytic Uremic Syndrome Hemophilia Hemoptysis Hemorrhage Hemorrhoidectomy Hemorrhoids Hemothorax Hepatitis Hernia Herniated Disk Herniorrhaphy Herpes in Pregnancy Herpes Simplex I Herpes Simplex II Herpes Zoster HHNC (Hyperosmolar Hyperglycemic Nonketotic Coma) Hiatal Hernia Hip Fracture Hip Replacement Hirschsprung’s Disease Hirsutism Hitting Behavior HIV (Human Immunodeficiency Virus) Hodgkin’s Disease Homelessness Home Maintenance Problems Hope Hopelessness Hospitalized Child Hostile Behavior HTN (Hypertension) Human Immunodeficiency Virus (HIV) Humiliating Experience Huntington’s Disease Hydrocele Hydrocephalus Hygiene, Inability to Provide Own Hyperactive Syndrome Hyperbilirubinemia Hypercalcemia Hypercapnia Hyperemesis Gravidarum Hyperglycemia Hyperkalemia Hypernatremia Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) Hyperphosphatemia Hypersensitivity to Slight Criticism Hypertension (HTN) Hyperthermia Hyperthyroidism Hyperventilation Hypocalcemia Hypoglycemia Hypokalemia Hypomagnesemia Hypomania Hyponatremia Hypoplastic Left Lung Hypotension Hypothermia Hypothyroidism Hypovolemic Shock Hypoxia Hysterectomy

List of Nursing Assessments by Letter: I Chapter 9: I

IBS (Irritable Bowel Syndrome) ICD (Implantable Cardioverter/Defibrillator) IDDM (Insulin-Dependent Diabetes) Identity Disturbance/Problems Idiopathic Thrombocytopenic Purpura (ITP) Ileal Conduit Ileostomy Ileus Immobility Immunization Immunosuppression Impaction of Stool Imperforate Anus Impetigo Implantable Cardioverter/Defibrillator (ICD) Impotence Impulsiveness Inactivity Incompetent Cervix Incontinence of Stool Incontinence of Urine Indigestion Induction of Labor Infant Apnea Infant Behavior Infant Care Infant Feeding Pattern, Ineffective Infant of Diabetic Mother Infant of Substance-Abusing Mother (Fetal Alcohol Syndrome, Crack Baby, Other Drug Withdrawal Infants) Infantile Polyarteritis Infection Infection, Potential for Infertility Inflammatory Bowel Disease (Child and Adult) Influenza Inguinal Hernia Repair Injury Insanity Insomnia Insulin Shock Intermittent Claudication Internal Cardioverter/Defibrillator (ICD) Internal Fixation Interstitial Cystitis Intervertebral Disk Excision Intestinal Obstruction Intestinal Perforation Intoxication Intraaortic Balloon Counterpulsation Intracranial Pressure, Increased Intrauterine Growth Retardation Intravenous Therapy Intubation, Endotracheal or Nasogastric Iodine Reaction with Diagnostic Testing Irregular Pulse Irritable Bowel Syndrome (IBS) Isolation Itching ITP (Idiopathic Thrombocytopenic Purpura)

List of Nursing Assessments by Letter: J Chapter 10: J

Jaundice Jaundice, Neonatal Jaw Pain and Heart Attacks Jaw Surgery Jittery Jock Itch Joint Dislocation Joint Pain Joint Replacement JRA (Juvenile Rheumatoid Arthritis) Juvenile Onset Diabetes

List of Nursing Assessments by Letter: K Chapter 11: K

Kaposi’s Sarcoma Kawasaki Disease Kegel Exercise Keloids Keratoconjunctivitis Sicca (Dry Eye Syndrome) Keratoplasty Ketoacidosis, Alcoholic Ketoacidosis, Diabetic Keyhole Heart Surgery Kidney Disease Screening Kidney Failure Kidney Stone Kidney Transplant Kidney Tumor Kissing Disease Knee Replacement Knowledge Knowledge, Deficient Kock Pouch Korsakoff’s Syndrome

List of Nursing Assessments by Letter: L Chapter 12: L

Labor, Induction of Labor, Normal Labyrinthitis Lacerations Lactation Lactic Acidosis Lactose Intolerance Laminectomy Language Impairment Laparoscopic Laser Cholecystectomy Laparoscopy Laparotomy Large Bowel Resection Laryngectomy Laser Surgery LASIK Eye Surgery (Laser-Assisted in Situ Keratomileusis) Latex Allergy Laxative Abuse Lead Poisoning Left Heart Catheterization Legionnaires’ Disease Lens Implant Lethargy/Listlessness Leukemia Leukopenia Level of Consciousness, Decreased Lice Lifestyle, Sedentary Lightheadedness Limb Reattachment Procedures Liposuction Lithotripsy Liver Biopsy Liver Cancer Liver Disease Liver Function Liver Transplant Living Will Lobectomy Loneliness Loose Stools (Bowel Movements) Loss of Bladder Control Loss of Bowel Control Lou Gehrig’s Disease Low Back Pain Low Blood Pressure Low Blood Sugar Lower GI Bleeding Lumbar Puncture Lumpectomy Lung Cancer Lung Surgery Lupus Erythematosus Lyme Disease Lymphedema Lymphoma

List of Nursing Assessments by Letter: M Chapter 13: M

Macular Degeneration Magnetic Resonance Imaging (MRI) Major Depressive Disorder Malabsorption Syndrome Maladaptive Behavior Malaise Malaria Male Infertility Malignancy Malignant Hypertension (Arteriolar Nephrosclerosis) Malignant Hyperthermia Malnutrition Mammography Manic Disorder, Bipolar I Manipulation of Organs, Surgical Incision Manipulative Behavior Marasmus Marfan Syndrome Marshall-Marchetti-Krantz Operation Mastectomy Mastitis Maternal Infection Maturational Issues, Adolescent Maze III Procedure MD (Muscular Dystrophy) Measles (Rubeola) Meconium Aspiration Meconium Delayed Melanoma Melena Memory Deficit Ménière’s Disease Meningitis/Encephalitis Meningocele Menopause Menorrhagia Mental Illness Mental Retardation Metabolic Acidosis Metabolic Alkalosis Metastasis Methicillin-Resistant Staphylococcus aureus (MRSA) MI (Myocardial Infarction) MIDCAB (Minimally Invasive Direct Coronary Artery Bypass) Midlife Crisis Migraine Headache Milk Intolerance Minimally Invasive Direct Coronary Bypass (MIDCAB) Miscarriage Mitral Stenosis Mitral Valve Prolapse Mobility, Impaired Bed Mobility, Impaired Physical Mobility, Impaired Wheelchair Modified Radical Mastectomy Mononucleosis Mood Disorders Moon Face Moral/Ethical Dilemmas Morning Sickness Motion Sickness Mottling of Peripheral Skin Mourning Mouth Lesions MRI (Magnetic Resonance Imaging) MRSA (Methicillin-Resistant Staphylococcus aureus) Mucocutaneous Lymph Node Syndrome Mucous Membrane, Impaired Oral Multiinfarct Dementia Multiple Gestation Multiple Personality Disorder (Dissociative Identity Disorder) Multiple Sclerosis (MS) Mumps Murmurs Muscular Atrophy/Weakness Muscular Dystrophy (MD) MVA (Motor Vehicle Accident) Myasthenia Gravis Mycoplasma Pneumonia Myelocele Myelogram, Contrast Myelomeningocele Myocardial Infarction (MI) Myocarditis Myringotomy Myxedema

List of Nursing Assessments by Letter: N Chapter 14: N

Narcissistic Personality Disorder Narcolepsy Narcotic Use Nasogastric Suction Nausea Near-Drowning Nearsightedness Nearsightedness; Corneal Surgery Neck Vein Distention Necrosis, Renal Tubular; ATN (Acute Tubular Necrosis); Necrosis, Acute Tubular Necrotizing Enterocolitis (NEC) Necrotizing Fasciitis (Flesh-Eating Bacteria) Negative Feelings About Self Neglect, Unilateral Neglectful Care of Family Member Neonatal Jaundice Neonate Neoplasm Nephrectomy Nephrostomy, Percutaneous Nephrotic Syndrome Nerve Entrapment Neural Tube Defects (Meningocele, Myelomeningocele, Spina Bifida, Anencephaly) Neuralgia Neuritis (Peripheral Neuropathy) Neurofibromatosis Neurogenic Bladder Neurologic Disorders Neuropathy, Peripheral Neurosurgery Newborn, Normal Newborn, Postmature Newborn, Small for Gestational Age (SGA) Nicotine Addiction NIDDM (Non-Insulin-Dependent Diabetes Mellitus) Nightmares Nipple Soreness Nocturia Nocturnal Myoclonus Nocturnal Paroxysmal Dyspnea Noncompliance Non–Insulin-Dependent Diabetes Mellitus (NIDDM) Normal Pressure Hydrocephalus (NPH) Norwalk Virus NSTEMI (non-ST-elevation myocardial infarction) Nursing Nutrition Nutrition, Imbalanced

List of Nursing Assessments by Letter: O Chapter 15: O

Obesity OBS (Organic Brain Syndrome) Obsessive-Compulsive Disorder (OCD) Obstruction, Bowel Obstructive Sleep Apnea OCD (Obsessive-Compulsive Disorder) ODD (Oppositional Defiant Disorder) Older Adult Oliguria Omphalocele Oophorectomy OPCAB (Off-Pump Coronary Artery Bypass) Open Heart Surgery Open Reduction of Fracture with Internal Fixation (Femur) Opiate Use Opportunistic Infection Oppositional Defiant Disorder (ODD) Oral Mucous Membrane, Impaired Oral Thrush Orchitis Organic Mental Disorders Orthopedic Traction Orthopnea Orthostatic Hypotension Osteoarthritis Osteomyelitis Osteoporosis Ostomy Otitis Media Ovarian Carcinoma

List of Nursing Assessments by Letter: P Chapter 16: P

Pacemaker Paget’s Disease Pain, Acute Pain, Chronic Painful Breasts, Engorgement Painful Breasts, Sore Nipples Pallor of Extremities Palpitations (Heart Palpitations) Pancreatic Cancer Pancreatitis Panic Disorder (Panic Attacks) Paralysis Paralytic Ileus Paranoid Personality Disorder Paraplegia Parathyroidectomy Parent Attachment Parental Role Conflict Parenting Parenting, Impaired Parenting, Risk for Impaired Paresthesia Parkinson’s Disease Paroxysmal Nocturnal Dyspnea (PND) Patent Ductus Arteriosus (PDA) Patient-Controlled Analgesia (PCA) Patient Education PCA (Patient-Controlled Analgesia) Pectus Excavatum Pediculosis PEG (Percutaneous Endoscopic Gastrostomy) Pelvic Inflammatory Disease (PID) Penile Prosthesis Peptic Ulcer Percutaneous Transluminal Coronary Angioplasty (PTCA) Pericardial Friction Rub Pericarditis Perioperative Positioning Peripheral Neuropathy Peripheral Neurovascular Dysfunction Peripheral Vascular Disease (PVD) Peritoneal Dialysis Peritonitis Pernicious Anemia Persistent Fetal Circulation Personal Identity Problems Personality Disorder Pertussis (Whooping Cough) Pesticide Contamination Petechiae Petit Mal Seizure Pharyngitis Phenylketonuria (PKU) Pheochromocytoma Phlebitis Phobia (Specific) Photosensitivity Physical Abuse Pica PID (Pelvic Inflammatory Disease) PIH (Pregnancy-Induced Hypertension/Preeclampsia) Piloerection Pimples Pink Eye Pinworms Pituitary Cushing’s PKU (Phenylketonuria) Placenta Abruptio Placenta Previa Plantar Fasciitis Pleural Effusion Pleural Friction Rub Pleural Tap Pleurisy PMS (Premenstrual Tension Syndrome) PND (Paroxysmal Nocturnal Dyspnea) Pneumonectomy Pneumonia Pneumothorax Poisoning, Risk for Poliomyelitis Polydipsia Polyphagia Polyuria Postoperative Care Postpartum Depression Postpartum Hemorrhage Postpartum, Normal Care Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Post-Traumatic Stress Disorder (PTSD) Potassium, Increase/Decrease Power/Powerlessness Preeclampsia Pregnancy, Cardiac Disorders Pregnancy-Induced Hypertension/Preeclampsia (PIH) Pregnancy Loss Pregnancy, Normal Premature Dilation of the Cervix (Incompetent Cervix) Premature Infant (Child) Premature Infant (Parent) Premature Rupture of Membranes Premenstrual Tension Syndrome (PMS) Prenatal Care, Normal Prenatal Testing Preoperative Teaching Pressure Ulcer Preterm Labor Problem-Solving Ability Projection Prolapsed Umbilical Cord Prostatectomy Prostatic Hypertrophy Prostatitis Protection, Altered Pruritus Psoriasis Psychosis PTCA (Percutaneous Transluminal Coronary Angioplasty) PTSD (Posttraumatic Stress Disorder) Pulmonary Edema Pulmonary Embolism Pulmonary Stenosis Pulse Deficit Pulse Oximetry Pulse Pressure, Increased Pulse Pressure, Narrowed Pulses, Absent or Diminished Peripheral Purpura Pyelonephritis Pyloric Stenosis Pyloromyotomy (Pyloric Stenosis Repair)

List of Nursing Assessments by Letter: R Chapter 17: R

RA (Rheumatoid Arthritis) Rabies Radial Nerve Dysfunction Radiation Therapy Radical Neck Dissection Rage Rape-Trauma Syndrome Rash Rationalization Rats, Rodents in the Home Raynaud’s Disease RDS (Respiratory Distress Syndrome) Rectal Fullness Rectal Lump Rectal Pain/Bleeding Rectal Surgery Rectocele Repair Reflex Incontinence Regression Regretful Rehabilitation Relationship Relaxation Techniques Religiosity Religious Concerns Relocation Stress Syndrome Renal Failure Renal Failure, Acute/Chronic, Child Renal Failure, Nonoliguric Renal Transplantation, Donor Renal Transplantation, Recipient Respiratory Acidosis Respiratory Conditions of the Neonate (Respiratory Distress Syndrome [RDS], Meconium Aspiration, Diaphragmatic Hernia) Respiratory Distress Respiratory Distress Syndrome (RDS) Respiratory Infections, Acute Childhood (Croup, Epiglottitis, Pertussis, Pneumonia, Respiratory Syncytial Virus) Respiratory Syncytial Virus Restless Leg Syndrome Retarded Growth and Development Retching Retinal Detachment Retinopathy, Diabetic Retinopathy of Prematurity (ROP) Reye’s Syndrome Rh Factor Incompatibility Rhabdomyolysis Rheumatic Fever Rheumatoid Arthritis (RA) Rib Fracture Ridicule of Others Ringworm of Body Ringworm of Nails Ringworm of Scalp Risk for Relocation Stress Syndrome Roaches, Invasion of Home with Role Performance, Altered ROP (Retinopathy of Prematurity) RSV (Respiratory Syncytial Virus) Rubella Rubor of Extremities Ruptured Disk

List of Nursing Assessments by Letter: S Chapter 18: S

SAD (Seasonal Affective Disorder) Sadness Safe Sex Safety, Childhood Salmonella Salpingectomy Sarcoidosis SARS (Severe Acute Respiratory Syndrome) SBE (Self-Breast Examination) Scabies Scared Schizophrenia Sciatica Scoliosis Sedentary Lifestyle Seizure Disorders, Adult Seizure Disorders, Childhood (Epilepsy, Febrile Seizures, Infantile Spasms) Self-Breast Examination (SBE) Self-Care Self-Care Deficit, Bathing Self-Care Deficit, Dressing Self-Care Deficit, Feeding Self-Care Deficit, Toileting Self-Concept Self-Destructive Behavior Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Health Management, Ineffective Self-Health Management, Readiness for Enhanced Self-Mutilation, Risk for Senile Dementia Separation Anxiety Sepsis, Child Septicemia Severe Acute Respiratory Syndrome (SARS) Sexual Dysfunction Sexuality, Adolescent Sexuality Pattern, Ineffective Sexually Transmitted Disease (STD) Shaken Baby Syndrome Shakiness Shame Shingles Shivering Shock, Cardiogenic Shock, Hypovolemic Shock, Septic Shoulder Repair Sickle Cell Anemia/Crisis SIDS (Sudden Infant Death Syndrome) Situational Crisis SJS (Stevens-Johnson Syndrome) Skin Cancer Skin Disorders Skin Integrity, Risk for Impaired Skin Turgor, Change in Elasticity Sleep Sleep Apnea Sleep Deprivation Sleep Pattern Disorders Sleep Pattern, Disturbed, Parent/Child Slurring of Speech Small Bowel Resection Smell, Loss of Ability to Smoke Inhalation Smoking Behavior Social Interaction, Impaired Social Isolation Sociopathic Personality Sodium, Decrease/Increase Somatization Disorder Sore Nipples, Breastfeeding Sore Throat Sorrow Spastic Colon Speech Disorders Spina Bifida Spinal Cord Injury Spinal Fusion Spiritual Distress Spiritual Well-Being Splenectomy Sprains Stapedectomy Stasis Ulcer STD (Sexually Transmitted Disease) STEMI (ST-Elevation Myocardial Infarction) Stent (Coronary Artery Stent) Sterilization Surgery Stertorous Respirations Stevens-Johnson Syndrome (SJS) Stillbirth Stoma Stomatitis Stone, Kidney Stool, Hard/Dry Straining with Defecation Strep Throat Stress Stress Overload Stress Urinary Incontinence Stridor Stroke Stuttering Subarachnoid Hemorrhage Substance Abuse Substance Abuse, Adolescent Substance Abuse in Pregnancy Sucking Reflex Sudden Infant Death Syndrome (SIDS) Suffocation, Risk for Suicide Attempt Support System Suppression of Labor Surgery, Perioperative Care Surgery, Postoperative Care Surgery, Preoperative Care Surgical Recovery, Delayed Suspected Child Abuse and Neglect (SCAN), Child Suspected Child Abuse and Neglect (SCAN), Parent Suspicion Swallowing Difficulties Swine Flu (H1N1) Syncope Syphilis Systemic Lupus Erythematosus

List of Nursing Assessments by Letter: T Chapter 19: T

T & A (Tonsillectomy and Adenoidectomy) Tachycardia Tachypnea Tardive Dyskinesia Taste Abnormality TB (Pulmonary Tuberculosis) TBI (Traumatic Brain Injury) TD (Traveler’s Diarrhea) Temperature, Decreased Temperature, Increased Temperature Regulation, Impaired TEN (Toxic Epidermal Necrolysis) Tension Terminally Ill Adult Terminally Ill Child, Adolescent Terminally Ill Child, Infant/Toddler Terminally Ill Child, Preschool Child Terminally Ill Child, School-Age Child/Preadolescent Terminally Ill Child/Death of Child, Parent Tetralogy of Fallot Tetraplegia Therapeutic Regimen Management, Ineffective: Family Therapeutic Touch Thermal Injury, Risk for (See Thermal Injury, Risk for, Section III) Thoracentesis Thoracotomy Thought Disorders Thrombocytopenic Purpura Thrombophlebitis Thyroidectomy TIA (Transient Ischemic Attack) Tic Disorder Tinea Capitis Tinea Corporis Tinea Cruris Tinea Pedis Tinea Unguium (Onychomycosis) Tinnitus Tissue Damage, Corneal, Integumentary, or Subcutaneous Tissue Perfusion, Ineffective Peripheral Toileting Problems Toilet Training Tonsillectomy and Adenoidectomy (T & A) Toothache Total Anomalous Pulmonary Venous Return Total Joint Replacement (Total Hip/Total Knee/Shoulder) Total Parenteral Nutrition (TPN) Tourette’s Syndrome (TS) Toxemia Toxic Epidermal Necrolysis (TEN) (Erythema Multiforme) TPN (Total Parenteral Nutrition) Tracheoesophageal Fistula Tracheostomy Traction and Casts Transfer Ability Transient Ischemic Attack (TIA) Transposition of Great Vessels Transurethral Resection of the Prostate (TURP) Trauma in Pregnancy Trauma, Risk for Traumatic Brain Injury (TBI) Traumatic Event Traveler’s Diarrhea (TD) Trembling of Hands Tricuspid Atresia Trigeminal Neuralgia Truncus Arteriosus TS (Tourette’s Syndrome) TSE (Testicular Self-Examination) Tubal Ligation Tube Feeding Tuberculosis (TB) TURP (Transurethral Resection of the Prostate)

List of Nursing Assessments by Letter: U Chapter 20: U

Ulcer, Peptic (Duodenal or Gastric) Ulcerative Colitis Ulcers, Stasis Unilateral Neglect of One Side of Body Unsanitary Living Conditions Urgency to Urinate Urinary Diversion Urinary Elimination, Impaired Urinary Incontinence Urinary Readiness Urinary Retention Urinary Tract Infection (UTI) Urolithiasis Uterine Atony in Labor Uterine Atony in Postpartum Uterine Bleeding UTI (Urinary Tract Infection)

List of Nursing Assessments by Letter: V Chapter 21: V

VAD (Ventricular Assist Device) Vaginal Hysterectomy Vaginitis Vagotomy Value System Conflict Varicose Veins Vascular Dementia (Formerly Called Multiinfarct Dementia) Vascular Obstruction, Peripheral Vasectomy Vasocognopathy Venereal Disease Ventilation, Impaired Spontaneous Ventilator Client Ventilatory Weaning Response, Dysfunctional (DVWR) Ventricular Assist Device (VAD) Ventricular Fibrillation Vertigo Violent Behavior Viral Gastroenteritis Vision Impairment Vomiting von Recklinghausen’s Disease

List of Nursing Assessments by Letter: W Chapter 22: W

Walking Impairment Wandering Weakness Weight Gain Weight Loss Wellness-Seeking Behavior Wernicke-Korsakoff Syndrome West Nile Virus Wheelchair Use Problems Wheezing Wilms’ Tumor Withdrawal from Alcohol Withdrawal from Drugs Wound Debridement Wound Dehiscence, Evisceration Wound Infection Wounds (open)

SECTION III: Guide to Planning Care

Chapter 23: Introduction

Making an Accurate Nursing Diagnosis Writing Outcomes Statements and Nursing Interventions

List of Nursing Diagnoses by Letter: A Chapter 24: A

Risk for Activity Intolerance Risk for ineffective Activity Planning Risk for Autonomic Dysreflexia

List of Nursing Diagnoses by Letter: B Chapter 25: B List of Nursing Diagnoses by Letter: C Chapter 26: C

Risk for Caregiver Role Strain Risk for ineffective Childbearing Process Risk for acute Confusion Risk for Constipation

List of Nursing Diagnoses by Letter: D Chapter 27: D List of Nursing Diagnoses by Letter: E Chapter 28: E

Impaired environmental Interpretation Syndrome

List of Nursing Diagnoses by Letter: F Chapter 29: F List of Nursing Diagnoses by Letter: G Chapter 30: G

Risk for Deficient Fluid Volume Risk for dysfunctional Gastrointestinal Motility Risk for complicated Grieving

List of Nursing Diagnoses by Letter: H Chapter 31: H List of Nursing Diagnoses by Letter: I Chapter 32: I

Risk for disturbed personal Identity Overflow urinary incontinence Risk for urge urinary Incontinence Readiness for enhanced organized infant behavior Risk for disorganized Infant behavior

List of Nursing Diagnoses by Letter: J Chapter 33: J List of Nursing Diagnoses by Letter: K Chapter 34: K List of Nursing Diagnoses by Letter: L Chapter 35: L List of Nursing Diagnoses by Letter: M Chapter 36: M List of Nursing Diagnoses by Letter: N Chapter 37: N

Noncompliance Risk for imbalanced Nutrition: more than body requirements

List of Nursing Diagnoses by Letter: O Chapter 38: O

Impaired Oral Mucous Membrane

List of Nursing Diagnoses by Letter: P Chapter 39: P

Risk for Impaired Parenting Risk for Post-Trauma Syndrome Risk for Powerlessness Ineffective Protection

List of Nursing Diagnoses by Letter: R Chapter 40: R

Ineffective Relationship Risk for ineffective Relationship Risk for impaired Religiosity Risk for Relocation Stress Syndrome

List of Nursing Diagnoses by Letter: S Chapter 41: S

Risk for chronic low Self-Esteem Risk for Spiritual Distress

List of Nursing Diagnoses by Letter: T Chapter 42: T

Risk for imbalanced body Temperature Risk for ineffective peripheral Tissue Perfusion

List of Nursing Diagnoses by Letter: U Chapter 43: U List of Nursing Diagnoses by Letter: V Chapter 44: V List of Nursing Diagnoses by Letter: W Chapter 45: W

Risk for self-directed Violence

Index

← Prev
Back
Next →

← Prev
Back
Next →