Introduction
Section I
Nursing Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Activity Intolerance 28
Activity Planning, Ineffective 33
Activity Planning, Risk for Ineffective 34
Adverse Reaction to Iodinated Contrast Media, Risk for 35
Allergy Response, Risk for 41
Anxiety 46
Anxiety, Death 54
Bleeding, Risk for 58
Blood Glucose Level, Risk for Unstable 59
Bowel Incontinence 60
Breastfeeding, Ineffective 63
Breastfeeding, Interrupted 70
Breast Milk, Insufficient 71
Cardiac Output, Decreased 72
Caregiver Role Strain 73
Caregiver Role Strain, Risk for 80
Childbearing Process, Ineffective 83
Childbearing Process, Risk for Ineffective 85
Comfort, Impaired 86
Pain, Acute 92
Pain, Chronic I 0 I
Chronic Pain Syndrome I 06
Pain, Labor I I 0
Nausea I 17
Communication, Impaired 121
Communication, Impaired Verbal 126
Confusion, Acute 128
Confusion, Risk for Acute 134
XI
xii Contents
Confusion, Chronic 134
Contamination, Individual 139
Contamination, Risk for Individual 145
Contamination, Family 146
Contamination, Risk for Community 147
Coping, Ineffective 149
Coping, Defensive 157
Impulse Control, Ineffective 161
Denial, Ineffective 163
Labile Emotional Control I 68
Impaired Mood Regulation 17 1
Coping, Ineffective Community 172
Coping, Compromised Family 175
Coping, Disabled Family 176
Decisional Conflict 183
Diarrhea 188
Disuse Syndrome, Risk for 193
Diversional Activity, Deficient 20 I
Dysreflexia, Autonomic 206
Dysreflexia, Risk for Autonomic 2 1 0
Electrolyte Imbalance, Risk for 21 0
Family Processes, Interrupted 21 I
Family Processes, Dysfunctional 2 16
Fear 220
Fluid Volume, Deficient 226
Fluid Volume, Risk for Deficient 23 I
Fluid Volume, Excess 232
Fluid Volume, Risk for Imbalanced 237
Gastrointestinal Motility, Dysfunctional 238
Gastrointestinal Motility, Risk for Dysfunctional 239
Grieving 240
Grieving, Anticipatory 248
Grieving, Complicated 252
Grieving, Risk for Complicated 256
Health, Deficient Community 257
Health Behavior, Risk-Prone 259
Health Maintenance, Ineffective 264
Health Management, Ineffective 275
Home Maintenance, Impaired 281
Hopelessness 286
Human Dignity, Risk for Compromised 293
Infant Behavior, Disorganized 296
Infant Behavior, Risk for Disorganized 304
Infection, Risk for 305
Infection Transmission, Risk for 3 12
Injury, Risk for 317
Aspiration, Risk for 325
Falls, Risk for 328
Poisoning, Risk for 333
Suffocation, Risk for 333
Thermal Injury, Risk for 333
Trauma, Risk for 335
Perioperative Positioning Injury, Risk for 335
Urinary Tract Injury, Risk for 338
Intracranial Adaptive Capacity, Decreased 342
Jaundice, Neonatal 342
Jaundice, Risk for Neonatal 343
Knowledge, Deficient 344
Latex Allergy Response 345
Latex Allergy Response, Risk for 348
Lifestyle, Sedentary 350
Liver Function, Risk for Impaired 353
Maternal/Fetal Dyad, Risk for Disturbed 354
Memory, Impaired 355
Mobility, Impaired Physical 358
Bed Mobility, Impaired 365
Sitting, Impaired 367
Standing, Impaired 368
Walking, Impaired 369
Wheelchair Mobility, Impaired 370
Transfer Ability, Impaired 372
Moral Distress 374
Moral Distress, Risk for 378
Neglect, Self 381
Neglect, Unilateral 382
Noncompliance 386
Nutrition, Imbalanced 388
Dentition, Impaired 396
Swallowing, Impaired 396
Infant Feeding Pattern, Ineffective 400
Contents xiii
xiv Contents
Obesity 404
Overweight 4 I 0
Risk for Overweight 4 13
Parenting, Impaired 419
Post-Trauma Syndrome 424
Post-Trauma Syndrome, Risk for 430
Rape-Trauma Syndrome (Sexual Assault Trauma
Syndrome) 430
Powerlessness 436
Powerlessness, Risk for 44 1
Protection, Ineffective 441
Corneal Injury, Risk for 444
Dry Eye, Risk for 446
Oral Mucous Membrane, Impaired 448
Oral Mucous Membrane, Risk for Impaired 454
T issue Integrity, Impaired 456
Skin Integrity, Impaired 459
Skin Integrity, Risk for Impaired 459
Pressure Ulcer 460
Pressure Ulcer, Risk for 467
Relationship, Ineffective 474
Relationship, Risk for Ineffective 475
Relocation Stress [Syndrome] 476
Relocation Stress [Syndrome], Risk for 480
Resilience, Risk for Compromised 484
Resilience, Impaired Individual 484
Respiratory Function, Risk for Ineffective 486
Ventilatory Weaning Response, Dysfunctional 489
Ventilatory Weaning Response, Risk for Dysfunctional 494
Airway Clearance, Ineffective 497
Breathing Pattern, Ineffective 500
Gas Exchange, Impaired 504
Spontaneous Ventilation, Impaired 505
Role Performance, Ineffective 506
Self-Care Deficit Syndrome 507
Feeding Self-Care Deficit 5 12
Bathing Self-Care Deficit 5 I 5
Dressing Self-Care Deficit 5 I 8
Instrumental Self-Care Deficit 52 1
Toileting Self-Care Deficit 524
Self-Concept, Disturbed 526
Body Image, Disturbed 530
Personal Identity, Disturbed 537
Personal Identity, Risk for Disturbed 538
Self-Esteem, Disturbed 539
Self-Esteem, Chronic Low 542
Self-Esteem, Risk for Chronic Low 545
Self-Esteem, Situational Low 546
Self-Esteem, Risk for Situational Low 549
Self-Harm, Risk for 550
Self-Mutilation 556
Self-Mutilation, Risk for 557
Suicide, Risk for 559
Sexuality Pattern, Ineffective 566
Sexual Dysfunction 572
Shock, Risk for 573
Sleep Pattern, Disturbed 574
Insomnia 582
Sleep Deprivation 584
Social Isolation 584
Sorrow, Chronic 586
Spiritual Distress 589
Spiritual Distress, Risk for 595
Religiosity, Impaired 596
Religiosity, Risk for Impaired 599
Stress Overload 600
Sudden Infant Death Syndrome, Risk for 605
Surgical Recovery, Delayed 607
Surgical Recovery, Risk for Delayed 608
Tissue Perfusion, Ineffective 61 I
Contents xv
Cardiac T issue Perfusion, Risk for Decreased 612
Cerebral Tissue Perfusion, Risk for Ineffective 6 13
Gastrointestinal Tissue Perfusion, Risk for Ineffective 61 5
Peripheral Tissue Perfusion, Ineffective 6 16
Peripheral Tissue Perfusion, Risk for Ineffective 620
Peripheral Neurovascular Dysfunction, Risk for 62 1
Renal Perfusion, Risk for Ineffective 622
xvi Contents
Urinary Elimination, Impaired 624
Maturational Enuresis 628
Functional Urinary Incontinence 632
Refiex Urinary Incontinence 637
Stress Urinary Incontinence 639
Continuous Urinary Incontinence 642
Urge Urinary Incontinence 644
Urge Urinary Incontinence, Risk for 648
Overfiow Urinary Incontinence 648
Vascular Trauma, Risk for 65 I
Section 2
Health-Promotion Nursing Diagnoses . . . . . . . . . . 653
Readiness for Enhanced Breastfeeding 657
Readiness for Enhanced Childbearing Process 658
Readiness for Enhanced Comfort 659
Readiness for Enhanced Communication 659
Readiness for Enhanced Coping 660
Readiness for Enhanced Community Coping 662
Readiness for Enhanced Decision Making 666
Readiness for Enhanced Emancipated Decision-Making 667
Readiness for Enhanced Family Coping 668
Readiness for Enhanced Family Processes 669
Readiness for Enhanced Fluid Balance 671
Readiness for Enhanced Health Management 672
Readiness for Enhanced Hope 676
Readiness for Enhanced Organized Infant Behavior 677
Readiness for Enhanced Knowledge (Specify) 681
Readiness for Enhanced Nutrition 681
Readiness for Enhanced Parenting 682
Readiness for Enhanced Power 683
Readiness for Enhanced Relationship 684
Readiness for Enhanced Religiosity 685
Readiness for Enhanced Resilience 686
Readiness for Enhanced Self-Care 688
Contents xvii
Readiness for Enhanced Self-Concept 688
Readiness for Enhanced Sleep 689
Readiness for Enhanced Spiritual Well-Being 690
Readiness for Enhanced Urinary Elimination 692
Section 3
Manual of Collaborative Problems . . . . . . . . . . . . . 693
Risk for Complications of Cardiac/Vascular/Respiratory
Dysfunction 696
Risk for Complications of Arrhythmias 703
Risk for Complications of Bleeding 706
Risk for Complications of Decreased Cardiac Output 71 I
Risk for Complications of Compartment Syndrome 714
Risk for Complications of Deep Vein Thrombosis 719
Risk for Complications of Hypovolemia 728
Risk for Complications of Systemic Inflammatory Response Syndrome
(SIRS)/SEPSIS 731
Risk for Complications of Acute Urinary Retention 735
Risk for Complications of Renal Insufficiency/Failure 738
Risk for Complications of Gl Bleeding 746
Risk for Complications of Paralytic Ileus 750
Section 4
Diagnostic Clusters
Part I MEDICAL CONDIT IONS 757
Card iac Cond itions 757
Part 2 SURGICAL PROCEDURES 759
General Su rgery 759
Part 3 OBST ETRIC/GYNECOLOGIC CONDIT IONS 761
Prenatal Period (General) 761
Part 4 NEONATAL CONDIT IONS 763
Neonate , Normal 763
755
xviii Contents
Part 5 PEDIAT RIC/ADOLESCENT DISORDERS 765
Developmental Problems/Needs Related to C h ronic I l l ness
(Permanent Disabil ity, M u ltiple Hand icaps, Developmental Disabil ity
[Mental/Physical] , Life-Threaten i ng I l l ness) 765
Part 6 MENTAL HEALTH DISORDERS 767
Alcoholism 767
Part 7 DIAGNOST IC AND THERAPEUTIC PROCEDURES 769
Angioplasty (Pe rcutaneous, Tran s l u m i nal ,
Coronary, Peripheral) 769
Appendix A
Nursing Diagnoses Grouped Under Functional Health
Patterns 77 I
Appendix B
Nursing Admission Data Baseline Assessment 772
Appendix C
Strategies to Promote Engagement of Individual/Families for
Healthier Outcomes 773
Appendix D
High-Risk Assessment Tools for Preventable Hospital-Acquired
Conditions 784
Bibliography 790
Index
