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Nurse's Pocket Guide
Nurse's Pocket Guide
Nurse's Pocket Guide
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Nurse’s <strong>Pocket</strong> <strong>Guide</strong> Diagnoses, Prioritized Interventions, and Rationales
- Page 2 and 3: ACTIVITY/REST—Ability to engage i
- Page 4 and 5: GORDON’S FUNCTIONAL HEALTH PATTER
- Page 8 and 9: Nurse’s Pocket Guide Diagnoses, P
- Page 10: Dedication This book is dedicated t
- Page 14: ACKNOWLEDGMENTS A special acknowled
- Page 17 and 18: Taxonomy II, Domain, Class, Code, Y
- Page 19 and 20: NANDA-I through 2007-2008. Each dia
- Page 21 and 22: and help validate the assessment an
- Page 23 and 24: the client interview and physical a
- Page 25 and 26: expertise and agency routines allow
- Page 27 and 28: In 2003, the definition of nursing
- Page 29 and 30: Table 2-1. NURSING DIAGNOSES ACCEPT
- Page 31 and 32: Table 2-1. NURSING DIAGNOSES ACCEPT
- Page 33 and 34: Table 2-1. NURSING DIAGNOSES ACCEPT
- Page 35 and 36: healthcare delivery and reimburseme
- Page 37 and 38: • It provides for the safety of t
- Page 39 and 40: epresent the client’s situation.
- Page 41 and 42: SECTION 1 ASSESSMENT TOOLS FOR CHOO
- Page 43 and 44: OBJECTIVE (EXHIBITS) Observed respo
- Page 45 and 46: Elimination SUBJECTIVE (REPORTS) Us
- Page 47 and 48: Mobility: _____ Assistance needed (
- Page 49 and 50: Airway clearance (e.g., spontaneous
- Page 51 and 52: Sexuality [Component of Social Inte
- Page 53 and 54: Health and illness beliefs/practice
- Page 55 and 56: EXCERPT FROM PSYCHIATRIC NURSING AS
- Page 57 and 58:
Ability to follow directions: _____
- Page 59 and 60:
Fetal: Heart rate: ____________ Loc
- Page 61 and 62:
OBJECTIVE (EXHIBITS) Temperature: _
- Page 63 and 64:
Tissue Perfusion, ineffective (spec
- Page 65 and 66:
HYGIENE—Ability to perform activi
- Page 67 and 68:
Coping, compromised family Coping,
- Page 69 and 70:
time to do much. Anyway, I’m too
- Page 71 and 72:
Dietary pattern: B: fruit juice/toa
- Page 73 and 74:
Safety SUBJECTIVE (REPORTS) Allergi
- Page 75 and 76:
Reason for hospitalization (client)
- Page 77 and 78:
Outcome: Blood Glucose Control (NOC
- Page 79 and 80:
Client Diagnostic Statement: ineffe
- Page 81 and 82:
ACTIONS/INTERVENTIONS RATIONALE Tea
- Page 83 and 84:
ACTIONS/INTERVENTIONS RATIONALE Ins
- Page 85 and 86:
leads to demonstrates ND: unstable
- Page 87 and 88:
Example 1. SAMPLE SOAP/IER CHARTING
- Page 89 and 90:
Example 2. SAMPLE OF FOCUS CHARTING
- Page 91 and 92:
CHAPTER 4 70 Nursing Diagnoses in A
- Page 93 and 94:
ACTIVITY INTOLERANCE • Identify a
- Page 95 and 96:
isk for ACTIVITY INTOLERANCE DISCHA
- Page 97 and 98:
isk for ACTIVITY INTOLERANCE Unders
- Page 99 and 100:
ineffective AIRWAY CLEARANCE Desire
- Page 101 and 102:
ineffective AIRWAY CLEARANCE NURSIN
- Page 103 and 104:
latex ALLERGY RESPONSE Related Fact
- Page 105 and 106:
latex ALLERGY RESPONSE • Monitor
- Page 107 and 108:
isk for latex ALLERGY RESPONSE Desi
- Page 109 and 110:
ANXIETY Anxiety [Specify Level: Mil
- Page 111 and 112:
ANXIETY Parasympathetic Urinary urg
- Page 113 and 114:
ANXIETY • Acknowledge anxiety/fea
- Page 115 and 116:
death ANXIETY IMPLEMENTATION/EVALUA
- Page 117 and 118:
death ANXIETY • Identify coping s
- Page 119 and 120:
isk for ASPIRATION risk for Aspirat
- Page 121 and 122:
isk for ASPIRATION • Assist with
- Page 123 and 124:
isk for impaired parent/child ATTAC
- Page 125 and 126:
isk for impaired parent/child ATTAC
- Page 127 and 128:
AUTONOMIC DYSREFLEXIA • Demonstra
- Page 129 and 130:
isk for AUTONOMIC DYSREFLEXIA Docum
- Page 131 and 132:
isk for AUTONOMIC DYSREFLEXIA Desir
- Page 133 and 134:
isk-prone health BEHAVIOR Related F
- Page 135 and 136:
isk-prone health BEHAVIOR rehabilit
- Page 137 and 138:
disturbed BODY IMAGE Verbalization
- Page 139 and 140:
disturbed BODY IMAGE • Identify s
- Page 141 and 142:
isk for imbalanced BODY TEMPERATURE
- Page 143 and 144:
isk for imbalanced BODY TEMPERATURE
- Page 145 and 146:
BOWEL INCONTINENCE Related Factors
- Page 147 and 148:
BOWEL INCONTINENCE • Provide inco
- Page 149 and 150:
effective BREASTFEEDING OBJECTIVE M
- Page 151 and 152:
ineffective BREASTFEEDING Note: Sma
- Page 153 and 154:
ineffective BREASTFEEDING • Ident
- Page 155 and 156:
ineffective BREASTFEEDING • Sugge
- Page 157 and 158:
interrupted BREASTFEEDING PLANNING
- Page 159 and 160:
interrupted BREASTFEEDING requires
- Page 161 and 162:
ineffective BREATHING PATTERN • R
- Page 163 and 164:
ineffective BREATHING PATTERN • A
- Page 165 and 166:
ineffective BREATHING PATTERN • R
- Page 167 and 168:
decreased CARDIAC OUTPUT resistance
- Page 169 and 170:
decreased CARDIAC OUTPUT • Restri
- Page 171 and 172:
decreased CARDIAC OUTPUT • Review
- Page 173 and 174:
CAREGIVER ROLE STRAIN Marginal copi
- Page 175 and 176:
CAREGIVER ROLE STRAIN FAMILY PROCES
- Page 177 and 178:
CAREGIVER ROLE STRAIN • Encourage
- Page 179 and 180:
isk for CAREGIVER ROLE STRAIN risk
- Page 181 and 182:
isk for CAREGIVER ROLE STRAIN • F
- Page 183 and 184:
eadiness for enhanced COMFORT Defin
- Page 185 and 186:
eadiness for enhanced COMFORT • E
- Page 187 and 188:
impaired verbal COMMUNICATION • S
- Page 189 and 190:
impaired verbal COMMUNICATION Desir
- Page 191 and 192:
impaired verbal COMMUNICATION • I
- Page 193 and 194:
eadiness for enhanced COMMUNICATION
- Page 195 and 196:
eadiness for enhanced COMMUNICATION
- Page 197 and 198:
decisional CONFLICT DISCHARGE PLANN
- Page 199 and 200:
decisional CONFLICT NURSING PRIORIT
- Page 201 and 202:
parental role CONFLICT parental rol
- Page 203 and 204:
parental role CONFLICT • Encourag
- Page 205 and 206:
acute CONFUSION Lack of motivation
- Page 207 and 208:
acute CONFUSION • Give simple dir
- Page 209 and 210:
chronic CONFUSION Cerebral vascular
- Page 211 and 212:
chronic CONFUSION • Administer me
- Page 213 and 214:
isk for acute CONFUSION NOTE: A ris
- Page 215 and 216:
CONSTIPATION Documentation Focus AS
- Page 217 and 218:
CONSTIPATION Presence of soft paste
- Page 219 and 220:
CONSTIPATION • Provide privacy an
- Page 221 and 222:
perceived CONSTIPATION Desired Outc
- Page 223 and 224:
isk for CONSTIPATION Inadequate den
- Page 225 and 226:
CONTAMINATION • Encourage/support
- Page 227 and 228:
CONTAMINATION SUBJECTIVE/OBJECTIVE
- Page 229 and 230:
CONTAMINATION • Determine factors
- Page 231 and 232:
CONTAMINATION • Cooperate with/re
- Page 233 and 234:
isk for CONTAMINATION IMPLEMENTATIO
- Page 235 and 236:
isk for CONTAMINATION Actions/Inter
- Page 237 and 238:
isk for CONTAMINATION • Encourage
- Page 239 and 240:
compromised family COPING Defining
- Page 241 and 242:
defensive COPING PLANNING • Plan
- Page 243 and 244:
defensive COPING and illnesses, esp
- Page 245 and 246:
disabled family COPING Related Fact
- Page 247 and 248:
disabled family COPING • Refer cl
- Page 249 and 250:
ineffective COPING Abuse of chemica
- Page 251 and 252:
ineffective COPING pressure during
- Page 253 and 254:
ineffective community COPING ineffe
- Page 255 and 256:
eadiness for enhanced COPING • Se
- Page 257 and 258:
eadiness for enhanced COPING abilit
- Page 259 and 260:
eadiness for enhanced community COP
- Page 261 and 262:
eadiness for enhanced family COPING
- Page 263 and 264:
eadiness for enhanced family COPING
- Page 265 and 266:
isk for sudden infant DEATH SYNDROM
- Page 267 and 268:
isk for sudden infant DEATH SYNDROM
- Page 269 and 270:
eadiness for enhanced DECISION MAKI
- Page 271 and 272:
ineffective DENIAL Related Factors
- Page 273 and 274:
impaired DENTITION PLANNING • Pla
- Page 275 and 276:
impaired DENTITION NURSING PRIORITY
- Page 277 and 278:
isk for delayed DEVELOPMENT SAMPLE
- Page 279 and 280:
isk for delayed DEVELOPMENT • Asc
- Page 281 and 282:
DIARRHEA Related Factors PSYCHOLOGI
- Page 283 and 284:
DIARRHEA • Adjust strength/rate o
- Page 285 and 286:
isk for compromised human DIGNITY S
- Page 287 and 288:
moral DISTRESS • Discuss/assist w
- Page 289 and 290:
moral DISTRESS based on the individ
- Page 291 and 292:
isk for DISUSE SYNDROME DISCHARGE P
- Page 293 and 294:
isk for DISUSE SYNDROME SKIN • Mo
- Page 295 and 296:
isk for DISUSE SYNDROME • Limit/m
- Page 297 and 298:
deficient DIVERSIONAL ACTIVITY defi
- Page 299 and 300:
deficient DIVERSIONAL ACTIVITY •
- Page 301 and 302:
disturbed ENERGY FIELD Temperature
- Page 303 and 304:
disturbed ENERGY FIELD • Discuss
- Page 305 and 306:
impaired ENVIRONMENTAL INTERPRETATI
- Page 307 and 308:
impaired ENVIRONMENTAL INTERPRETATI
- Page 309 and 310:
adult FAILURE TO THRIVE Unintention
- Page 311 and 312:
adult FAILURE TO THRIVE • Assist
- Page 313 and 314:
isk for FALLS Impaired balance; dif
- Page 315 and 316:
isk for FALLS • Note socioeconomi
- Page 317 and 318:
dysfunctional FAMILY PROCESSES: alc
- Page 319 and 320:
dysfunctional FAMILY PROCESSES: alc
- Page 321 and 322:
interrupted FAMILY PROCESSES PLANNI
- Page 323 and 324:
interrupted FAMILY PROCESSES Answer
- Page 325 and 326:
eadiness for enhanced FAMILY PROCES
- Page 327 and 328:
eadiness for enhanced FAMILY PROCES
- Page 329 and 330:
FATIGUE Related Factors PSYCHOLOGIC
- Page 331 and 332:
FATIGUE • Discuss lifestyle chang
- Page 333 and 334:
FEAR • Assist client to identify
- Page 335 and 336:
FEAR • Ascertain client’s/SO’
- Page 337 and 338:
eadiness for enhanced FLUID BALANCE
- Page 339 and 340:
eadiness for enhanced FLUID BALANCE
- Page 341 and 342:
[deficient FLUID VOLUME: hyper/hypo
- Page 343 and 344:
[deficient FLUID VOLUME: hyper/hypo
- Page 345 and 346:
deficient FLUID VOLUME deficient Fl
- Page 347 and 348:
deficient FLUID VOLUME • Establis
- Page 349 and 350:
excess FLUID VOLUME Excess fluid in
- Page 351 and 352:
excess FLUID VOLUME • Administer
- Page 353 and 354:
isk for deficient FLUID VOLUME •
- Page 355 and 356:
isk for imbalanced FLUID VOLUME PLA
- Page 357 and 358:
isk for imbalanced FLUID VOLUME •
- Page 359 and 360:
impaired GAS EXCHANGE obstructive l
- Page 361 and 362:
impaired GAS EXCHANGE • Provide p
- Page 363 and 364:
isk for unstable blood GLUCOSE Risk
- Page 365 and 366:
isk for unstable blood GLUCOSE when
- Page 367 and 368:
GRIEVING Making meaning of the loss
- Page 369 and 370:
GRIEVING • Provide hope within pa
- Page 371 and 372:
complicated GRIEVING Related Factor
- Page 373 and 374:
complicated GRIEVING NURSING PRIORI
- Page 375 and 376:
isk for complicated GRIEVING Risk F
- Page 377 and 378:
isk for disproportionate GROWTH Doc
- Page 379 and 380:
isk for disproportionate GROWTH mat
- Page 381 and 382:
isk for disproportionate GROWTH •
- Page 383 and 384:
delayed GROWTH AND DEVELOPMENT Pare
- Page 385 and 386:
delayed GROWTH AND DEVELOPMENT occu
- Page 387 and 388:
ineffective HEALTH MAINTENANCE PLAN
- Page 389 and 390:
ineffective HEALTH MAINTENANCE •
- Page 391 and 392:
HEALTH-SEEKING BEHAVIORS (specify)
- Page 393 and 394:
HEALTH-SEEKING BEHAVIORS (specify)
- Page 395 and 396:
impaired HOME MAINTENANCE Defining
- Page 397 and 398:
eadiness for enhanced HOPE PLANNING
- Page 399 and 400:
eadiness for enhanced HOPE that may
- Page 401 and 402:
HOPELESSNESS Defining Characteristi
- Page 403 and 404:
HOPELESSNESS • Express hope to cl
- Page 405 and 406:
HYPERTHERMIA Decreased perspiration
- Page 407 and 408:
HYPERTHERMIA (heat loss by convecti
- Page 409 and 410:
HYPOTHERMIA Hypothermia Taxonomy II
- Page 411 and 412:
HYPOTHERMIA • Monitor heart rate
- Page 413 and 414:
eadiness for enhanced IMMUNIZATIONS
- Page 415 and 416:
eadiness for enhanced IMMUNIZATIONS
- Page 417 and 418:
disorganized INFANT BEHAVIOR • Sh
- Page 419 and 420:
disorganized INFANT BEHAVIOR • Ob
- Page 421 and 422:
disorganized INFANT BEHAVIOR LIGHT/
- Page 423 and 424:
eadiness for enhanced organized INF
- Page 425 and 426:
eadiness for enhanced organized INF
- Page 427 and 428:
ineffective INFANT FEEDING PATTERN
- Page 429 and 430:
ineffective INFANT FEEDING PATTERN
- Page 431 and 432:
isk for INFECTION Desired Outcomes/
- Page 433 and 434:
isk for INFECTION • Maintain adeq
- Page 435 and 436:
isk for INJURY risk for Injury Taxo
- Page 437 and 438:
isk for INJURY • Evaluate individ
- Page 439 and 440:
isk for perioperative positioning I
- Page 441 and 442:
isk for perioperative positioning I
- Page 443 and 444:
INSOMNIA Related Factors Intake of
- Page 445 and 446:
INSOMNIA • Investigate whether cl
- Page 447 and 448:
INSOMNIA • Investigate use of aid
- Page 449 and 450:
decreased INTRACRANIAL ADAPTIVE CAP
- Page 451 and 452:
disturbed personal IDENTITY Documen
- Page 453 and 454:
disturbed personal IDENTITY • Not
- Page 455 and 456:
deficient KNOWLEDGE Related Factors
- Page 457 and 458:
deficient KNOWLEDGE • Identify in
- Page 459 and 460:
eadiness for enhanced KNOWLEDGE SAM
- Page 461 and 462:
sedentary LIFESTYLE Ability to appl
- Page 463 and 464:
sedentary LIFESTYLE body and hopele
- Page 465 and 466:
sedentary LIFESTYLE age-related com
- Page 467 and 468:
isk for impaired LIVER FUNCTION •
- Page 469 and 470:
isk for LONELINESS IMPLEMENTATION/E
- Page 471 and 472:
isk for LONELINESS • Support expr
- Page 473 and 474:
impaired MEMORY [Substance use/abus
- Page 475 and 476:
impaired bed MOBILITY tasks on a da
- Page 477 and 478:
impaired bed MOBILITY NURSING PRIOR
- Page 479 and 480:
impaired physical MOBILITY Related
- Page 481 and 482:
impaired physical MOBILITY • Inst
- Page 483 and 484:
impaired wheelchair MOBILITY Insuff
- Page 485 and 486:
NAUSEA Documentation Focus ASSESSME
- Page 487 and 488:
NAUSEA • Assess for presence of c
- Page 489 and 490:
NAUSEA manage own care. Some indivi
- Page 491 and 492:
unilateral NEGLECT Failure to move
- Page 493 and 494:
unilateral NEGLECT • Collaborate
- Page 495 and 496:
NONCOMPLIANCE NOTE: When the plan o
- Page 497 and 498:
NONCOMPLIANCE school/workplace issu
- Page 499 and 500:
imbalanced NUTRITION: less than bod
- Page 501 and 502:
imbalanced NUTRITION: less than bod
- Page 503 and 504:
imbalanced NUTRITION: less than bod
- Page 505 and 506:
imbalanced NUTRITION: more than bod
- Page 507 and 508:
imbalanced NUTRITION: more than bod
- Page 509 and 510:
imbalanced NUTRITION: risk for more
- Page 511 and 512:
imbalanced NUTRITION: risk for more
- Page 513 and 514:
eadiness for enhanced NUTRITION •
- Page 515 and 516:
impaired ORAL MUCOUS MEMBRANE PLANN
- Page 517 and 518:
impaired ORAL MUCOUS MEMBRANE • N
- Page 519 and 520:
acute PAIN • Recommend regular de
- Page 521 and 522:
acute PAIN trauma/fractures; surger
- Page 523 and 524:
acute PAIN • Work with client to
- Page 525 and 526:
chronic PAIN Defining Characteristi
- Page 527 and 528:
chronic PAIN NURSING PRIORITY NO.3.
- Page 529 and 530:
impaired PARENTING PLANNING • Pla
- Page 531 and 532:
impaired PARENTING Negative stateme
- Page 533 and 534:
impaired PARENTING • Emphasize pa
- Page 535 and 536:
eadiness for enhanced PARENTING Nee
- Page 537 and 538:
eadiness for enhanced PARENTING NUR
- Page 539 and 540:
isk for impaired PARENTING Poor com
- Page 541 and 542:
isk for PERIPHERAL NEUROVASCULAR DY
- Page 543 and 544:
isk for PERIPHERAL NEUROVASCULAR DY
- Page 545 and 546:
isk for POISONING [Therapeutic marg
- Page 547 and 548:
isk for POISONING Do not take medic
- Page 549 and 550:
POST-TRAUMA SYNDROME Disasters; sud
- Page 551 and 552:
POST-TRAUMA SYNDROME • Be aware o
- Page 553 and 554:
POST-TRAUMA SYNDROME intellectualiz
- Page 555 and 556:
isk for POST-TRAUMA SYNDROME Percep
- Page 557 and 558:
isk for POST-TRAUMA SYNDROME NURSIN
- Page 559 and 560:
eadiness for enhanced POWER Actions
- Page 561 and 562:
POWERLESSNESS SAMPLE NURSING OUTCOM
- Page 563 and 564:
POWERLESSNESS • Note availability
- Page 565 and 566:
isk for POWERLESSNESS • Specific
- Page 567 and 568:
isk for POWERLESSNESS • Be alert
- Page 569 and 570:
ineffective PROTECTION Defining Cha
- Page 571 and 572:
RAPE-TRAUMA SYNDROME Defining Chara
- Page 573 and 574:
RAPE-TRAUMA SYNDROME • Observe fo
- Page 575 and 576:
RAPE-TRAUMA SYNDROME • Acknowledg
- Page 577 and 578:
impaired RELIGIOSITY impaired Relig
- Page 579 and 580:
impaired RELIGIOSITY • Discuss di
- Page 581 and 582:
eadiness for enhanced RELIGIOSITY R
- Page 583 and 584:
isk for impaired RELIGIOSITY SAMPLE
- Page 585 and 586:
isk for impaired RELIGIOSITY • Us
- Page 587 and 588:
RELOCATION STRESS SYNDROME Pessimis
- Page 589 and 590:
RELOCATION STRESS SYNDROME • Coll
- Page 591 and 592:
isk for RELOCATION STRESS SYNDROME
- Page 593 and 594:
ineffective ROLE PERFORMANCE Young
- Page 595 and 596:
ineffective ROLE PERFORMANCE • Us
- Page 597 and 598:
SELF-CARE DEFICIT: bathing/hygiene,
- Page 599 and 600:
SELF-CARE DEFICIT: bathing/hygiene,
- Page 601 and 602:
eadiness for enhanced SELF-CARE IMP
- Page 603 and 604:
eadiness for enhanced SELF-CARE •
- Page 605 and 606:
eadiness for enhanced SELF-CONCEPT
- Page 607 and 608:
eadiness for enhanced SELF-CONCEPT
- Page 609 and 610:
chronic low SELF-ESTEEM Overly conf
- Page 611 and 612:
chronic low SELF-ESTEEM • Involve
- Page 613 and 614:
situational low SELF-ESTEEM Express
- Page 615 and 616:
situational low SELF-ESTEEM • Sup
- Page 617 and 618:
isk for situational low SELF-ESTEEM
- Page 619 and 620:
SELF-MUTILATION Living in nontradit
- Page 621 and 622:
SELF-MUTILATION • Assist client t
- Page 623 and 624:
isk for SELF-MUTILATION Family alco
- Page 625 and 626:
isk for SELF-MUTILATION • Assist
- Page 627 and 628:
disturbed SENSORY PERCEPTION confin
- Page 629 and 630:
disturbed SENSORY PERCEPTION • Ex
- Page 631 and 632:
SEXUAL DYSFUNCTION IMPLEMENTATION/E
- Page 633 and 634:
SEXUAL DYSFUNCTION level of desire.
- Page 635 and 636:
SEXUAL DYSFUNCTION clinical nurse s
- Page 637 and 638:
ineffective SEXUALITY PATTERN • V
- Page 639 and 640:
ineffective SEXUALITY PATTERN NURSI
- Page 641 and 642:
impaired SKIN INTEGRITY • Partici
- Page 643 and 644:
impaired SKIN INTEGRITY open/draini
- Page 645 and 646:
isk for impaired SKIN INTEGRITY SAM
- Page 647 and 648:
isk for impaired SKIN INTEGRITY •
- Page 649 and 650:
eadiness for enhanced SLEEP Related
- Page 651 and 652:
SLEEP DEPRIVATION Documentation Foc
- Page 653 and 654:
SLEEP DEPRIVATION • Note medical
- Page 655 and 656:
SLEEP DEPRIVATION when sleep apnea
- Page 657 and 658:
impaired SOCIAL INTERACTION Actions
- Page 659 and 660:
impaired SOCIAL INTERACTION become
- Page 661 and 662:
SOCIAL ISOLATION Defining Character
- Page 663 and 664:
SOCIAL ISOLATION • Assist client
- Page 665 and 666:
chronic SORROW Expresses feelings o
- Page 667 and 668:
SPIRITUAL DISTRESS PLANNING • Pla
- Page 669 and 670:
SPIRITUAL DISTRESS practices/restri
- Page 671 and 672:
SPIRITUAL DISTRESS • Encourage/fa
- Page 673 and 674:
isk for SPIRITUAL DISTRESS DEVELOPM
- Page 675 and 676:
isk for SPIRITUAL DISTRESS • Role
- Page 677 and 678:
eadiness for enhanced SPIRITUAL WEL
- Page 679 and 680:
STRESS OVERLOAD for later reference
- Page 681 and 682:
STRESS OVERLOAD with Navajo parents
- Page 683 and 684:
isk for SUFFOCATION • Review prop
- Page 685 and 686:
isk for SUFFOCATION • Determine c
- Page 687 and 688:
isk for SUICIDE DISCHARGE PLANNING
- Page 689 and 690:
isk for SUICIDE • Ask directly if
- Page 691 and 692:
delayed SURGICAL RECOVERY • Invol
- Page 693 and 694:
delayed SURGICAL RECOVERY • Ascer
- Page 695 and 696:
delayed SURGICAL RECOVERY • Ident
- Page 697 and 698:
impaired SWALLOWING Heartburn; epig
- Page 699 and 700:
impaired SWALLOWING NURSING PRIORIT
- Page 701 and 702:
effective THERAPEUTIC REGIMEN MANAG
- Page 703 and 704:
effective THERAPEUTIC REGIMEN MANAG
- Page 705 and 706:
ineffective THERAPEUTIC REGIMEN MAN
- Page 707 and 708:
ineffective community THERAPEUTIC R
- Page 709 and 710:
ineffective community THERAPEUTIC R
- Page 711 and 712:
ineffective family THERAPEUTIC REGI
- Page 713 and 714:
eadiness for enhanced THERAPEUTIC R
- Page 715 and 716:
ineffective THERMOREGULATION SAMPLE
- Page 717 and 718:
disturbed THOUGHT PROCESSES • Att
- Page 719 and 720:
disturbed THOUGHT PROCESSES • Not
- Page 721 and 722:
disturbed THOUGHT PROCESSES • Hel
- Page 723 and 724:
impaired TISSUE INTEGRITY elderly;
- Page 725 and 726:
impaired TISSUE INTEGRITY • Provi
- Page 727 and 728:
ineffective TISSUE PERFUSION Relate
- Page 729 and 730:
ineffective TISSUE PERFUSION change
- Page 731 and 732:
ineffective TISSUE PERFUSION • Ch
- Page 733 and 734:
ineffective TISSUE PERFUSION improv
- Page 735 and 736:
impaired TRANSFER ABILITY PERIPHERA
- Page 737 and 738:
isk for TRAUMA transfer, locking wh
- Page 739 and 740:
isk for TRAUMA Driving a mechanical
- Page 741 and 742:
isk for TRAUMA musculoskeletal func
- Page 743 and 744:
impaired URINARY ELIMINATION Dysuri
- Page 745 and 746:
impaired URINARY ELIMINATION incont
- Page 747 and 748:
eadiness for enhanced URINARY ELIMI
- Page 749 and 750:
eadiness for enhanced URINARY ELIMI
- Page 751 and 752:
functional URINARY INCONTINENCE Psy
- Page 753 and 754:
overflow URINARY INCONTINENCE • D
- Page 755 and 756:
overflow URINARY INCONTINENCE agent
- Page 757 and 758:
eflex URINARY INCONTINENCE Neurolog
- Page 759 and 760:
isk for urge URINARY INCONTINENCE
- Page 761 and 762:
isk for urge URINARY INCONTINENCE
- Page 763 and 764:
stress URINARY INCONTINENCE Desired
- Page 765 and 766:
total URINARY INCONTINENCE Document
- Page 767 and 768:
total URINARY INCONTINENCE • Chec
- Page 769 and 770:
urge URINARY INCONTINENCE IMPLEMENT
- Page 771 and 772:
urge URINARY INCONTINENCE NURSING P
- Page 773 and 774:
[acute/chronic] URINARY RETENTION D
- Page 775 and 776:
[acute/chronic] URINARY RETENTION
- Page 777 and 778:
impaired spontaneous VENTILATION
- Page 779 and 780:
impaired spontaneous VENTILATION fo
- Page 781 and 782:
impaired spontaneous VENTILATION
- Page 783 and 784:
dysfunctional VENTILATORY WEANING R
- Page 785 and 786:
dysfunctional VENTILATORY WEANING R
- Page 787 and 788:
[actual/] risk for other-directed V
- Page 789 and 790:
[actual/] risk for self-directed VI
- Page 791 and 792:
[actual/] risk for VIOLENCE • Ide
- Page 793 and 794:
[actual/] risk for VIOLENCE • Not
- Page 795 and 796:
impaired WALKING SAMPLE NURSING OUT
- Page 797 and 798:
impaired WALKING • Provide assist
- Page 799 and 800:
WANDERING Inability to locate signi
- Page 801 and 802:
WANDERING • Register client with
- Page 803 and 804:
A Abdominal perineal resection MS (
- Page 805 and 806:
A Achalasia (cardiac sphincter) MS
- Page 807 and 808:
A CH Fatigue may be related to decr
- Page 809 and 810:
A Adrenal insufficiency CH (Refer t
- Page 811 and 812:
A possibly evidenced by deficient i
- Page 813 and 814:
A Amputation MS risk for ineffectiv
- Page 815 and 816:
A abdominal/back pain, guarding and
- Page 817 and 818:
A problems/conflicts, inappropriate
- Page 819 and 820:
A Aplastic anemia CH (Also refer to
- Page 821 and 822:
A ineffective Airway Clearance may
- Page 823 and 824:
B risk for Trauma: risk factors may
- Page 825 and 826:
B abuse of alcohol/other drugs, tra
- Page 827 and 828:
B Bulimia nervosa PSY/MS (Also refe
- Page 829 and 830:
C acute/chronic Pain may be related
- Page 831 and 832:
C Casts CH/MS (Also refer to Fractu
- Page 833 and 834:
C risk for situational low Self-Est
- Page 835 and 836:
C ineffective Airway Clearance may
- Page 837 and 838:
C disturbed Sensory Perception (spe
- Page 839 and 840:
C Conduct disorder (childhood, PSY/
- Page 841 and 842:
C Croup PED/CH ineffective Airway C
- Page 843 and 844:
D possibly evidenced by poor/delaye
- Page 845 and 846:
D risk for sedentary Lifestyle: ris
- Page 847 and 848:
D risk for disturbed Sensory Percep
- Page 849 and 850:
D risk for ineffective Breathing Pa
- Page 851 and 852:
D fragmentation of the personality)
- Page 853 and 854:
E Dysrhythmia, cardiac MS risk for
- Page 855 and 856:
E Anxiety [specify level] may be re
- Page 857 and 858:
F risk for impaired Parenting: risk
- Page 859 and 860:
G risk for deficient Fluid Volume [
- Page 861 and 862:
G distraction behaviors, and autono
- Page 863 and 864:
H lifestyle, possibly evidenced by
- Page 865 and 866:
H risk for impaired Home Management
- Page 867 and 868:
H acute Pain/[Discomfort] may be re
- Page 869 and 870:
H and misconceptions, inaccurate fo
- Page 871 and 872:
I Hysterectomy GYN/MS acute Pain ma
- Page 873 and 874:
L Kawasaki disease PED Hyperthermia
- Page 875 and 876:
L risk for Fatigue: risk factors ma
- Page 877 and 878:
L disturbed Thought Processes may b
- Page 879 and 880:
M Fatigue may be related to increas
- Page 881 and 882:
M risk for ineffective cerebral Tis
- Page 883 and 884:
M Mononucleosis, infectious CH Fati
- Page 885 and 886:
M Myasthenia gravis MS ineffective
- Page 887 and 888:
N Neglect/Abuse CH/PSY (Refer to Ab
- Page 889 and 890:
O Neuritis CH acute/chronic Pain ma
- Page 891 and 892:
P nerve plexus, possibly evidenced
- Page 893 and 894:
P Caregiver Role Strain may be rela
- Page 895 and 896:
P apprehension, shakiness, restless
- Page 897 and 898:
P Postoperative recovery period MS
- Page 899 and 900:
P Pregnancy (prenatal period) 1st t
- Page 901 and 902:
P disturbed Body Image/situational/
- Page 903 and 904:
P dysuria, frequency, dribbling, in
- Page 905 and 906:
R impaired Urinary Elimination may
- Page 907 and 908:
R gain, edema/anasarca, intake grea
- Page 909 and 910:
S fatigue, exertional discomfort, a
- Page 911 and 912:
S psychomotor activity), and side e
- Page 913 and 914:
S microemboli) and hypovolemia, pos
- Page 915 and 916:
S ineffective community Coping may
- Page 917 and 918:
S impotence/decreased sperm counts
- Page 919 and 920:
T [family] Powerlessness may be rel
- Page 921 and 922:
T distraction behaviors, reluctance
- Page 923 and 924:
T changes in respiratory depth, tac
- Page 925 and 926:
U risk for Infection: risk factors
- Page 927 and 928:
W Ventricular fibrillation MS (Refe
- Page 930 and 931:
APPENDIX 1 NANDA-I’s Taxonomy II
- Page 932 and 933:
Class 1 Sexual Identity: The state
- Page 934 and 935:
APPENDIX 2 Definitions of Taxonomy
- Page 936 and 937:
Risk: Vulnerability, especially as
- Page 938 and 939:
and Home Health Considerations, 4th
- Page 940 and 941:
Health and Human Services, Public H
- Page 942 and 943:
Boesch, C, Myers, J, Habersaat, A,
- Page 944 and 945:
diMaria-Ghalili, RA, and Amelia, E:
- Page 946 and 947:
Hanneman, SK, and Gusick, M: Freque
- Page 948 and 949:
Lai, SC, and Cohen, MN: Promoting l
- Page 950 and 951:
Newman, DK: Assessment of the patie
- Page 952 and 953:
Samarel, N, Fawcett, J, Davis, MM,
- Page 954 and 955:
Weeks, SM: Caring for patients with
- Page 956 and 957:
Boyles, S. (2005). Hope for people
- Page 958 and 959:
Dire, DJ. (2005). Biological warfar
- Page 960 and 961:
Homeir, BP. (2004). Household safet
- Page 962 and 963:
at http://www.guideline.gov/summary
- Page 964 and 965:
(WHO). Retrieved March 2007, at htt
- Page 966 and 967:
Scott-Conner, CEH, and Ballinger, B
- Page 968 and 969:
A Abdominal aortic aneurysm, 794, 7
- Page 970 and 971:
Aortic stenosis, 797 Aplastic anemi
- Page 972 and 973:
Chronic obstructive lung disease, 8
- Page 974 and 975:
Depression, 824-825 Depressive diso
- Page 976 and 977:
hyper/hypotonic, 320-323 isotonic,
- Page 978 and 979:
Impaired gas exchange, 337-341 Impa
- Page 980 and 981:
Lead poisoning acute, 855 chronic,
- Page 982 and 983:
P Pain, 27, 39, 44, 51 acute, 57, 4
- Page 984 and 985:
Readiness for enhanced decision mak
- Page 986 and 987:
Scleroderma, 890 Scoliosis, 890-891
- Page 988 and 989:
Thyrotoxicosis, 899 TIA. See Transi
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