DOENGES MOORHOUSE MURR Guidelines for Individualizing Client Care Across the Life Span lOTH EDITION INDEX OF DISEASES/DISORDERS Acid- base imbalances DavisPlus Gastrectomy/gastroplasty (see DavisPlus) Acquired immunodefi ciency syndrome (AIDS), 800 Gastric bypass, 442 Acute coronary syndrome (ACS), 54 Glaucoma DavisPlus Acute kidney injury (acute renal failure), 595 Graves’ disease, 471 Adult leukemias, 569 Alcohol: acute withdrawal, 919 Heart failure: chronic, 38 Alzheimer’s disease, 851 Hemodialysis, 641 Amputation, 718 Hemolytic anemia, 541 Anemia— iron defi ciency, anemia of chronic disease, pernicious, Hemothorax, 169 aplastic, hemolytic, 541 Hepatitis, 482 Angina: chronic/stable, 64 Herniated nucleus pulposus (see DavisPlus) Anorexia nervosa, 413 HIV- positive client, 785 Aplastic anemia, 541 Hospice, 970 Appendectomy, 382 Hypercalcemia (calcium excess) (see DavisPlus) Asthma, 132 Hyperkalemia (potassium excess) (see DavisPlus) Hypermagnesemia (magnesium excess) (see DavisPlus) Bariatric surgery, 442 Hypernatremia (sodium excess) (see DavisPlus) Benign prostatic hyperplasia (BPH), 686 Hypertension: severe, 26 Brain infections: meningitis and encephalitis, 267 Hyperthyroidism (Graves’ disease, thyrotoxicosis, thyroid storm), 471 Bulimia nervosa, 413 Hypervolemia (extracellular fl uid volume excess) (see DavisPlus) Burns: thermal, chemical, and electrical— acute and convalescent Hypocalcemia (calcium defi cit) (see DavisPlus) phases, 740 Hypokalemia (potassium defi cit) (see DavisPlus) Hypomagnesemia (magnesium defi cit) (see DavisPlus) Cancer, general considerations, 945 Hyponatremia (sodium defi cit) (see DavisPlus) Cardiac dysrhythmias, 85, 86 Hypovolemia (extracellular fl uid volume defi cit) (see DavisPlus) Cardiac surgery: postoperative care, 98 Hysterectomy, 666 Cardiomyoplasty, 46 Cerebrovascular accident/stroke, 247 Ileostomy, 368 Chemical burns, 741 Infl ammatory bowel disease: ulcerative colitis, Crohn’s disease, 352 Cholecystectomy DavisPlus Iron- defi ciency anemia, 541 Cholecystitis with cholelithiasis, 399 Cholelithiasis, 399 Laminectomy (see Spinal Surgery), 276 Chronic obstructive pulmonary disease (COPD) and asthma, 132 Laryngectomy (see DavisPlus) Cirrhosis of the liver, 494 Lewy body disease, 851 Colostomy, 368 Leukemias, 569 Coronary artery bypass graft (CABG), 98 Lung cancer: postoperative care, 159 Cranioce re bral trauma— acute rehabilitative phase, 226 Lymphomas, 582 Crohn’s disease, 352 Mastectomy, 675 Dementia: Alzheimer’s type/vascular dementia/, Lewy body disease, Meningitis, 267 frontotemporal dementia, 851 Metabolic acid- base imbalances (see DavisPlus) Deep vein thrombosis (DVT), 120 Metabolic acidosis— primary base bicarbonate defi ciency Diabetes mellitus, 454 (see DavisPlus) Diabetic ketoacidosis, 454 Metabolic alkalosis— primary base bicarbonate excess Dialysis: hemodialysis (HD), 641 (see DavisPlus) Dialysis: peritoneal (PD), 635 Minimally invasive direct coronary artery bypass (MIDCAB), 98 Disaster considerations, 980 Multiple sclerosis, 311 Disc surgery (now called Spinal Surgery), 276 Myo car dial infarction, 72 Dysrhythmias, 85, 86 Obesity, 430 Eating disorders: anorexia nervosa/bulimia nervosa, 413 Electrolyte imbalances DavisPlus Bariatric surgery, 442 Electrical burns, 740 Encephalitis, 267 Pancreatitis, 511 End- stage renal disease, 607 Parkinson’s disease, 330 Enteral feeding, 525 Parenteral feeding, 525 Esophageal bleeding, 347 Pediatric considerations, 993 Extended care, 896 Peritoneal dialysis, 635 Peritonitis, 389 Fecal diversions: postoperative care of ileostomy and colostomy, 368 Pernicious anemia, 541 Fluid and electrolyte imbalances, DavisPlus Pneumonia, 147 Fractures, 702 Pneumothorax, 169 i 559988--7744555555__cchh0000__44PP..iinndddd ii 1122//1188//1188 1111::3377 aamm Primary base bicarbonate defi ciency (see DavisPlus) Stroke, 247 Primary base bicarbonate excess (see DavisPlus) Substance use disorders (SUDs), 929 Primary carbonic acid defi cit (see DavisPlus) Surgical interventions, 873 Primary carbonic acid excess (see DavisPlus) Prostatectomy, 694 Thermal burns, 740 Psychosocial aspects of care, 835 Thrombophlebitis: venous thromboembolism, 120 Pulmonary emboli (PE), 120 Thyroidectomy (see DavisPlus) Pulmonary tuberculosis (TB), 204 Thyrotoxicosis, 471 Total joint replacement, 729 Radical neck surgery (see DavisPlus) Total nutritional support: parenteral/enteral feeding, 525 Renal calculi, 656 Tuberculosis (TB), pulmonary, 204 Renal dialysis— general considerations, 623 Renal failure: acute, 595 Ulcerative colitis, 352 Renal failure: chronic, 607 Upper gastrointestinal bleeding, 340 Respiratory acid- base imbalances (see DavisPlus) Urinary diversions/urostomy (postoperative care) Respiratory acidosis (see DavisPlus) Urinary stones (calculi), 656 Respiratory alkalosis (see DavisPlus) Urostomy, 645 Rheumatoid arthritis (RA), 824 Respiratory failure/ventilatory assistance, 187 Valve replacement, 98 Ruptured intervertebral disc (see DavisPlus) Vascular dementia, 851 Venous thromboembolism (VTE) disease, 120 Seizure disorders, 216 Ventilatory assistance (mechanical), 187 Sepsis/Septic Shock, 772 Sickle cell crisis, 552 Wound care: complicated or chronic, 762 Spinal cord injury (acute rehabilitative phase), 288 ii 559988--7744555555__cchh0000__44PP..iinndddd iiii 1122//1188//1188 1111::3377 aamm KEY TO ESSENTIAL TERMINOLOGY CLIENT ASSESSMENT DATABASE When a risk diagnosis is used, the identifi ed risk Provides an overview of the more commonly occurring eti- f actors serve as the “evidenced by” segment of the nursing ology and coexisting f actors associated with a specifi c med- diagnosis statement, and interventions are provided to pre- ical and/or surgical diagnosis or health condition as well as vent progression to a problem- focused diagnosis. Further- the signs and symptoms and corresponding diagnostic fi nd- more, health- promotion diagnoses (readiness for enhanced) ings. The Database contains the information used to iden- do not contain related factors but do have defi ning charac- tify Nursing Diagnoses for planning client care. teristics for the “evidenced by” segment of the client diag- nostic statement. NURSING PRIORITIES DESIRED OUTCOMES/EVALUATION Establishes a general ranking of needs and concerns on which the Nursing Diagnoses are ordered in constructing the plan of CRITERIA— CLIENT WILL care. This ranking would be altered according to the individ- These give direction to client care as they identify what the ual client situation. client or nurse hopes to achieve. They are stated in general terms to permit the practitioner to modify or individualize DISCHARGE GOALS them by adding timelines and specifi c client criteria so they Identifi es generalized statements that could be developed into become “meas ura ble.” For example, “Client w ill appear re- short-t erm and intermediate goals to be achieved by the client laxed and report anxiety is reduced to a manageable level before being “discharged” from nursing care. They may also within 24 hours.” provide guidance for creating long- term goals for the client to Nursing Outcomes Classifi cation (NOC) labels are work on after discharge. also included. The outcome label is selected from a stan- dardized nursing language and serves as a general header NURSING DIAGNOSIS for the outcome indicators that follow. The general need or probl em diagnosis is stated without the distinct cause and signs and symptoms, which would be added ACTIONS/INTERVENTIONS to create a client diagnostic statement when specifi c client in- Nursing Interventions Classifi cation (NIC) labels are drawn formation is available. For example, when a client displays in- from a third standardized nursing language and serve as a creased tension, apprehension, quivering voice, and focus on general header for the nursing actions that follow. self, the nursing diagnosis of Anxiety might be stated: se- Nursing actions are divided into independent—t hose vere Anxiety related to value confl ict, threat to current sta- actions that the nurse performs autonomously—a nd tus as evidenced by increase in tension, apprehensiveness; collaborative—t hose actions that the nurse performs in con- voice quivering, self- focused. junction with o thers, such as implementing physician o rders. In addition, diagnoses identifi ed within t hese guides The interventions in this book are generally ranked from for planning care as a ctual, risk, health promotion, or syn- most to least common. When creating the individual plan of drome can be changed or deleted and new diagnoses added, care, interventions would normally be ranked to refl ect the depending entirely on the specifi c client situation or avail- client’s specifi c needs and situation. In addition, the division able information. of ind ep end ent and collaborative is arbitrary and is actually dependent on the individual nurse’s capabilities, agency pro- MAY BE RELATED TO/POSSIBLY tocols, and professional standards. EVIDENCED BY RATIONALE T hese lists provide the usual or common reasons (etiology) why a par tic u lar need or prob lem may occur with probable Although not commonly appearing in client plans of care, signs and symptoms, which would be used to create the “re- rationale has been included h ere to provide a pathophysiolog- lated to” and “evidenced by” portions of the client diagnos- ical basis to assist the nurse in deciding about the relevance tic statement when the specifi c situation is known. of a specifi c intervention for an individual client situation. iii 559988--7744555555__cchh0000__44PP..iinndddd iiiiii 1122//1188//1188 1111::3377 aamm 559988--7744555555__cchh0000__44PP..iinndddd iivv 1122//1188//1188 1111::3377 aamm NURSING DIAGNOSES ACCEPTED FOR USE AND RESEARCH FOR 2018–2020 Activity Intolerance [specify level] Diversional Activity Engagement, defi cient Activity Intolerance, risk for Dry Eye, risk for Activity Planning, in effec tive Dry Mouth, risk for Activity Planning, risk for in effec tive Eating Dynamics, in effec tive adolescent Acute Substance Withdrawal Syndrome Eating Dynamics, in effec tive child Acute Substance Withdrawal Syndrome, risk for Eating Dynamics, in effec tive infant Adaptive Capacity, decreased intracranial Electrolyte Imbalance, risk for Adverse Reaction to Iodinated Contrast Media, risk for Elimination, impaired urinary Airway Clearance, in effec tive Emancipated Decision- Making, impaired Allergy Reaction, risk for Emancipated Decision- Making, readiness for enhanced Anxiety Emancipated Decision- Making, risk for impaired Aspiration, risk for Emotional Control, labile Attachment, risk for impaired Energy Field, imbalanced Autonomic Dysrefl exia Falls, risk for Autonomic Dysrefl exia, risk for Family Pro cesses, dysfunctional Be hav ior, disor ga nized infant Family Pro cesses, interrupted Be hav ior, risk for disor ga nized infant Family Pro cesses, readiness for enhanced Be hav ior, readiness for enhanced or ga nized infant Fatigue Bleeding, risk for Fear Blood Glucose Level, risk for unstable Feeding Pattern, in effec tive infant Blood Pressure, risk for unstable Female Genital Mutilation, risk for Body Image, disturbed Fluid Balance, readiness for enhanced Breast Milk Production, insuffi cient [Fluid Volume, defi cient hyper/hypotonic] Breastfeeding, in effec tive Fluid Volume, defi cient [isotonic] Breastfeeding, interrupted Fluid Volume, excess Breastfeeding, readiness for enhanced Fluid Volume, risk for defi cient Breathing Pattern, in effec tive Fluid Volume, risk for imbalanced Cardiac Output, decreased Frail El derly Syndrome Cardiac Output, decreased, risk for Frail El derly Syndrome, risk for Childbearing Pro cess, in effec tive Gas Exchange, impaired Childbearing Pro cess, readiness for enhanced Gastrointestinal Motility, dysfunctional Childbearing Pro cess, risk for in effec tive Gastrointestinal Motility, risk for dysfunctional Chronic Pain Syndrome Grieving Comfort, impaired Grieving, complicated Comfort, readiness for enhanced Grieving, risk for complicated Communication, impaired verbal [Growth, risk for disproportionate] (retired 2018) Communication, readiness for enhanced Health, defi cient community Confusion, acute Health Be hav ior, risk- prone Confusion, risk for acute Health Literacy, readiness for enhanced Confusion, chronic Health Maintenance, in effec tive Constipation Health Management, in effec tive Constipation, chronic functional Health Management, in effec tive family Constipation, perceived Health Management, readiness for enhanced Constipation, risk for Home Maintenance, impaired Constipation, risk for chronic functional Hope, readiness for enhanced Contamination Hopelessness Contamination, risk for Human Dignity, risk for compromised Coping, compromised family Hyperthermia Coping, defensive Hyperbilirubinemia, neonatal Coping, disabled family Hyperbilirubinemia, risk for neonatal Coping, in effec tive Hypothermia Coping, in effec tive community Hypothermia, risk for Coping, readiness for enhanced Hypothermia, risk for perioperative Coping, readiness for enhanced community Immigration Transition, risk for complicated Coping, readiness for enhanced family Impulse Control, in effec tive Death Anxiety Incontinence, bowel Decision-M aking, readiness for enhanced Incontinence, functional urinary Decisional Confl ict Incontinence, overfl ow urinary Denial, in effec tive Incontinence, refl ex urinary Dentition, impaired Incontinence, risk for urge urinary Development, risk for delayed Incontinence, stress urinary Diarrhea Incontinence, urge urinary Disuse Syndrome, risk for Infection, risk for v 559988--7744555555__cchh0000__44PP..iinndddd vv 1122//1188//1188 1111::3377 aamm Injury, risk for Role Strain, caregiver Injury, risk for corneal Role Strain, risk for caregiver Injury, risk for urinary tract Self-C are, readiness for enhanced Insomnia Self- Care defi cit, Bathing Knowledge, defi cient Self- Care defi cit, Dressing Knowledge, readiness for enhanced Self- Care defi cit, Feeding Latex Allergy Reaction Self- Care defi cit, Toileting Latex Allergy Reaction, risk for Self- Concept, readiness for enhanced Lifestyle, sedentary Self- Esteem, chronic low Liver Function, risk for impaired Self- Esteem, risk for chronic low Loneliness, risk for Self- Esteem, risk for situational low Maternal- Fetal Dyad, risk for disturbed Self- Esteem, situational low Memory, impaired Self- Mutilation Mobility, impaired bed Self- Mutilation, risk for Mobility, impaired physical Self- Neglect Mobility, impaired wheelchair [Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, Mood Regulation, impaired gustatory, tactile, olfactory)] (retired 2012) Moral Distress Sexual Dysfunction Mucous Membrane Integrity, impaired oral Sexuality Pattern, in effec tive Mucous Membrane Integrity, risk for impaired oral Shock, risk for Nausea Sitting, impaired Neonatal Abstinence Syndrome Skin Integrity, impaired Neurovascular Dysfunction, risk for peripheral Skin Integrity, risk for impaired Nutrition: less than body requirements, imbalanced Sleep, readiness for enhanced Nutrition, readiness for enhanced Sleep Deprivation Obesity Sleep Pattern, disturbed Occupational Injury, risk for Social Interaction, impaired Overweight Social Isolation Overweight, risk for Sorrow, chronic Pain, acute Spiritual Distress Pain, chronic Spiritual Distress, risk for Pain, labor Spiritual Well- Being, readiness for enhanced Palliative/end- of- life care— hospice, Standing, impaired Parenting, impaired Stress Overload Parenting, readiness for enhanced Substance Withdrawal Syndrome, acute Parenting, risk for impaired Substance Withdrawal Syndrome, risk for acute Perioperative Positioning Injury, risk for Sudden infant Death, risk for Personal Identity, disturbed Suffocation, risk for Personal Identity, risk for disturbed Suicide, risk for Physical Trauma, risk for Surgical Recovery, delayed Poisoning, risk for Surgical Recovery, risk for delayed Post- Trauma Syndrome Surgical Site Infection, risk for Post- Trauma Syndrome, risk for Swallowing, impaired Power, readiness for enhanced Thermal Injury, risk for Powerlessness Thermoregulation, in effec tive Powerlessness, risk for Thermoregulation, risk for in effec tive Pressure Ulcer, risk for Thromboembolism, risk for venous Protection, in effec tive Tissue Integrity, impaired Rape- Trauma Syndrome Tissue Integrity, risk for impaired Relationship, in effec tive Tissue Perfusion, in effec tive peripheral Relationship, readiness for enhanced Tissue Perfusion, risk for decreased cardiac Relationship, risk for in effec tive Tissue Perfusion, risk for in effec tive ce re bral Religiosity, impaired Tissue Perfusion, risk for in effec tive peripheral Religiosity, readiness for enhanced Transfer Ability, impaired Religiosity, risk for impaired Trauma, risk for vascular Relocation Stress Syndrome Unilateral Neglect Relocation Stress Syndrome, risk for Ventilation, impaired spontaneous Resilience, impaired Ventilatory Weaning Response, dysfunctional Resilience, readiness for enhanced Vio lence, risk for other- directed Resilience, risk for impaired Vio lence, risk for self- directed Retention, urinary Walking, impaired Role Confl ict, parental Wandering [specify sporadic or continual] Role Per for mance, in effec tive [ ] author recommendations Herdman, TH, and Kamitsuru, S (eds): Nursing Diagnoses— Defi nitions and Classifi cation 2018–2020. Copyright © 2018, 1994–2018 NANDA International. Used by arrangement with Thieme. In order to make safe and effective judgments using NANDA- I nursing diagnoses, it is essential that nurses refer to the defi nitions and defi ning characteristics of the diagnoses listed in this work. vi 559988--7744555555__cchh0000__44PP..iinndddd vvii 1122//1188//1188 1111::3377 aamm NURSING CARE PLANS Guidelines for Individualizing Client Care Across the Life Span 10th EDITION Marilynn E. Doenges, APRN, BC- Retired Clinical Specialist, Adult Psychiatric/Mental Health Nursing, Retired Retired Adjunct Faculty Beth- El College of Nursing and Health Sciences, UCCS Colorado Springs, Colorado Mary Frances Moor house, RN, MSN, CRRN Adjunct Faculty/Clinical Instructor Pikes Peak Community College Nurse Consultant/TNT- RN Enterprises Colorado Springs, Colorado Alice C. Murr, BSN, RN- Retired Retired Legal Nurse Consultant, certified Rehabilitation Case Manager, and certified practitioner in Critical Care Nursing Parkville, Missouri 559988--7744555555__cchh0000__44PP..iinndddd vviiii 1122//1188//1188 1111::3377 aamm F. A. Davis Com pany 1915 Arch Street Philadelphia, PA 19103 www . fadavis . com Copyright © 2019 by F. A. Davis Com pany Copyright © 1984, 1989, 1993, 1997, 2000, 2002, 2006, 2010, 2019 by F. A. Davis Com pany. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or other wise, without written permission from the publisher. Printed in the United States of Amer i ca Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Jacalyn Sharp Se nior Content Proj ect Man ag er: Amy M. Romano Art and Design Man ag er: Carolyn O’Brien As new scientifi c information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The authors and publisher have done every thing pos si ble to make this book accu- rate, up- to- date, and in accord with accepted standards at the time of publica- tion. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check prod- uct information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is espe- cially urged when using new or infrequently ordered drugs. Library of Congress Cataloging- in- Publication Data Names: Doenges, Marilynn E., 1922– author. | Moorhouse, Mary Frances, 1947– author. | Murr, Alice C., 1946– author. Title: Nursing care plans : guidelines for individualizing client care across the life span / Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr. Description: Edition 10. | Philadelphia : F.A. Davis Company, [2019] | Includes bibliographical references and index. Identifi ers: LCCN 2018041708 (print) | LCCN 2018042523 (ebook) | ISBN 9780803694958 | ISBN 9780803660861 (pbk. : alk. paper) Subjects: | MESH: Patient Care Planning | Nursing Process | Handbooks Classifi cation: LCC RT49 (ebook) | LCC RT49 (print) | NLM WY 49 | DDC 610.73—dc23 LC record available at https://lccn.loc.gov/2018041708 Authorization to photocopy items for internal or personal use, or the internal or personal use of specifi c clients, is granted by F. A. Davis Comp any for users registered with the Copyright Clearance Center (CCC) Transactional Report- ing Serv ice, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For t hose organi zations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Serv ice is: 978-0-8036-6086-1/19 0 + $.25. 559988--7744555555__cchh0000__44PP..iinndddd vviiiiii 1122//1188//1188 1111::3377 aamm To our families, friends, and colleagues, who much of the time have had to manage without us while we work, as well as having to cope with our strug gles and frustrations. The Doenges families: the late Dean, whose support and encouragement is sorely missed; Jim; Barbara and Bob Lanza; David, Monita, and Tyler; Matthew, Trish, Sara, and Natilia; John, Holly, Nicole, and Kelsey; and the Daigle families: Nancy, Jim; Jennifer, Brandon, Annabelle, Will, and Henry Smith- Daigle, and Jonathan, Kim, and Mandalyn JoAn (MED). The Moor house family: the late and ever pres ent Jan; Paul Moor house and Jessica Kantorski; Jason and Thenderlyn Moor house; Alexa, Tanner, and Quinton Plant; and Mary Isabella Moor house and Richard Ortiz Vega (MFM). To the memory of my long- time dear friend Peggy French, who lost her battle with heart failure last year. I miss her laughter and jokes that carried me through many a day in my “writing cave” over the last 32 years (ACM). To our F. A. Davis family, especially Robert Allen whose support is so vital to the completion of a proj ect of this magnitude. We are happy to welcome Jacalyn Sharp, who is the Acquisitions Editor for this proj ect. And last but not least, Amy Romano, who supports us on a daily basis and keeps track of all the pieces. Thank you for your support and understanding. We are fortunate to have you working with us. To the nurses we are writing for, who daily face the challenge of caring for the acutely ill client and are looking for a practical way to or ga nize and document this care. We believe that nursing diagnosis and these guides will help. To NANDA- I and to the international nurses who are developing and using nursing diagnoses— here we come! Fi nally, to the late Mary Lisk Jeffries, who initiated the original proj ect. The memory of our early friendship and strug gles remains with us. We miss her and wish she were here to see the growth of the profession and how nursing diagnosis has contributed to the pro cess. 559988--7744555555__cchh0000__44PP..iinndddd iixx 1122//1188//1188 1111::3377 aamm