Nursing Care Planning (Easy)

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[DNLM: 1. Nursing Process—Examination
Questions. 2. Nursing Process—Handbooks.
3. Patient Care Planning—Examination Questions.
4. Patient Care Planning—Handbooks. WY49]
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ii
Advis ory bo ard
Susan Barnason, PhD, RN, CEN, CCRN, CS Stephen Gilliam, PhD, FNP, APRN-BC J anice J . Hoffman, PhD, RN, CCRN
Associate Professor Assistant Professor Assistant Professor and Vice Chair
University of Nebraska Medical Medical College of Georgia Organizational Systems and Adult
Center School of Nursing Health
College of Nursing Athens, Ga. University of Maryland School of
Lincoln, Neb. Nursing
Margaret Mary Hansen, EdD, MSN, RN, Baltimore, Md.
Michael A. Carter, DNSc, FAAN, APRN-BC NI Certificate
University Distinguished Professor Associate Professor Linda Honan Pellico, PhD, MSN, APRN
University of Tennessee Health University of San Francisco Assistant Professor
Science Center San Francisco, Calif. Yale University
College of Nursing School of Nursing
Memphis, Tenn. Kathy Henley Haugh, PhD, RN New Haven, Conn.
Assistant Professor
Caroline Dorsen, MSN, APRN, BC, FNP University of Virginia Susan L. Woods, PhD, RN, FAAN, FAHA
Clinical Instructor and Coordinator, School of Nursing Professor and Associate Dean for
Adult Nurse Practitioner Program Charlottesville, Va. Academic Programs
New York University University of Washington
College of Nursing Seattle, Wash.
New York, N.Y.
iv
Co ntributo rs and c o ns ultants
Louise A. Aurilio, PhD, RN-BC, NE-BC Susan B. Dickey, PhD, RN Marilyn K. Miller, MSN, RN
Associate Professor Associate Professor Professor of Nursing
Youngstown State University Temple University, Department of St. Charles Community College
Youngstown, Ohio Nursing Cottleville, Mo.
College of Health Professions & Social
Carol Blakeman, MSN, ARNP Work J ill Morsbach, RN, MSN
Professor Philadelphia, Pa. Staff Nurse
College of Central Florida St. J oseph Medical Center
Ocala, Fla. Gloria F. Donnelly, PhD, RN, FAAN Kansas City, Mo.
Dean, College of Nursing and Health
Cheryl Brady, RN, MSN Professions J udith A. Murphy, BSN, RN
Assistant Professor of Nursing Drexel University Staff Nurse
Kent State University Philadelphia, Pa. Cambridge Health Alliance
Salem, Ohio Medford, Mass.
Valerie J . Flattes, MS, APRN, ANP-BC
Natalie C. Burkhalter, RN, MSN, FNP, Instructor, Clinical Holly Myers, MSN, RN
ACNP, CCRN University of Utah College of Nursing Faculty
Associate Professor, Family NP, Acute Salt Lake City, Utah Firelands Regional Medical Center
Care NP, CNS-Med/Surg School of Nursing
Texas A&M International University Leslie Holmes, RN, MSN Sandusky, Ohio
Laredo, Tex. Instructor
Emery University Mary L. Nesbitt, BSN, MAN, RNC
Anita L. Caroll, EdD, MSN, RN Nell Hogson Woodruff School of Assistant Professor
Independent Nursing Consultant Nursing William Carey University
Palmer, Tex. Atlanta, Ga. Biloxi, Miss.
Karen Demzien Connors, MSN, CNE Karla R. J ones, MS, RN Kristie S. Nix, EdD, RN
Director Nursing Programs Associate Professor of Nursing Associate Professor
Central New Mexico Community College University of Alaska The University of Tulsa
Albuquerque, N. Mex. Anchorage, Alaska Tulsa, Okla.
Linda Carman Copel, PhD, RN, PMHCNS, Marilyn Little, APRN, CNS, ANCC Tracy Stephens Patil, MSN, RN
BC, CNE, NCC, FAPA Professor Assistant Professor of Nursing
Professor Salt Lake Community College Lincoln Memorial University
College of Nursing APRN, Prescriber Harrogate, Tenn.
Villanova University Valley Mental Health
Villanova, Pa. Theresa Petersen, MSN, APRN
Salt Lake City, Utah
Assistant Professor
Patricia D. Coyne, RNC-MNN, MS, MPA Kay Luft, RN, MN, CNE, CCRN Montana State University – Northern
Nursing Instructor Assistant Professor Havre, Mont.
Cochran School of Nursing Saint Luke’s College
Yonkers, N.Y. Kansas City, Mo.
v
CONTRIBUTORS AND CONS ULTANTS
vi
Ellen Pfadt, PhD(C), RN N. Darlene Rainwater, RN, MSN Marilyn D. Sellers, MS, FNP-BC
Associate Professor, Nursing Associate Professor Family Nurse Practitioner
Edinboro University of Pennsylvania St. Elizabeth School of Nursing and St. Hampton VAMC
Edinboro, Pa. J oseph’s College Hampton, Va.
Lafayette, Ind.
Noel C. Piano, RN, MS Michele Woodbeck, MS, RN
Coordinator/Instructor Darlene Samuelson, RN, BS, MEd, MSN Professor, Nursing
Lafayette School of Practice Nursing Associate Professor Hudson Valley Community College
Adjunct Professor Northern Kentucky University Troy, N.Y.
Thomas Nelson Community College Highland Heights, Ky.
Williamsburg, Va. Denise R. York, RNC, CNS, MS, MEd
Patricia J . Sands, RN, MSN-PNP, CPNP- Nursing Professor
Deborah A. Raines, PhD, RN, ANEF PC, CEN Columbus State Community College
Director of the Scholarship of Emergency Transport Team Intake Columbus, Ohio
Teaching & Professor Coordinator
Florida Atlantic University The Children’s Hospital of Philadelphia
Boca Raton, Fla. Philadelphia, Pa.
Fore wo rd
The 2010 Institute of Medicine (IOM) Report, “The Future of Nursing,” clearly articulates
the need for our profession to lead change and advance the health of all populations. This
position paper states that the nursing education system must be improved to ensure the safe
delivery of patient-centered care across life’s transitions, from conception to death. To assure
this professional mandate, the IOM Report stresses that nurses must be prepared to practice
to the full extent of their education and training. Furthermore, nurses should be full partners
with physicians and other health care professionals in redesigning the health care delivery
system.
Nursing’s unique contribution to this partnership and to patient care and outcomes is the
individualized nursing plan of care. This second edition of Nu r si n g Ca r e Pla n n i n g Ma de
In cr edi bly Easy offers novice nurses and students an updated global positioning–oriented
navigation system for how to articulate and demonstrate the va lu e that nursing practice
brings to patient outcomes. This book describes the importance of the nursing process and
of mastering a concept map framework to better implement the nursing process. The subse-
quent plan of care evolves naturally as an extension of this process, and the use of electronic
medical records and other technological advancements helps ensure that all members of the
nursing team have access to the same information to address patient and family needs when
delivering care.
In Part I, you’ll find a discussion of three classification systems, which have been updated
for this edition: NANDA-I , which defines standardized nursing diagnoses; NOC, which identi-
fies patient outcomes; and NI C, which lists nursing care interventions that align with
NANDA-I and NOC. In Part II, you’ll see how specific nursing diagnoses relate to common
medical-surgical, psychiatric, maternal-neonatal, and pediatric medical diagnoses. Additionally,
you’ll have online access to 166 customizable care plans covering every nursing specialty,
including new plans for gastric bypass, preterm labor, and cerebral palsy.
As you read through this text, look for these eye-catching logos to focus your attention on
essential information:
Un der con str u cti on offers sample concept maps and care plan components, plus tips for
making care plans specific and individualized
Wei ghi n g the evi den ce provides information on the latest evidence-based standards of care
used in the sample care plans
Tea cher kn ows best imparts important reminders from Instructor Joy to help you understand
how to apply content
Mem or y jogger mnemonic devices help you to remember key concepts and content.
vii
FOREWORD
viii
Although computerized care plans are becoming more common in practice, keep in mind
that they are only a t ool and a g u id e to help you think critically about the individualized care
needed by your patients and their families. Take the time to learn and understand NANDA
diagnoses, NOC, and NIC, as these standards will surely become mainstays in our practice
for providing quality, cost-saving outcomes. And remember, the basis of a successful nursing
practice begins with you, the nurse, and your understanding that each patient is an individual
with unique needs. When caring for each patient, begin by building a concept map and us-
ing the nursing process to develop a nursing diagnosis, realistic and achievable outcomes,
and individualized interventions; then, assess and reassess as you provide care. Follow this
approach throughout your budding career, and the vision of the “Future of Nursing” will be
your reality.
Vict or ia L. Rich , P h D, RN, F AAN

Chief Nurse Executive
Hospital of the University of Pennsylvania
Philadelphia, Pa.
Part I Care planning us ing the
nurs ing proces s
1 Introduc tion to care planning 3
2 As s e s s me nt 23
3 Nurs ing diagnos is 57
4 Planning 83
5 Impleme ntation 115
6 Evaluatio n 137
7 Putting it all tog ether 153

1
Introduction to care planning
J us t t he fact s
In this chapter, you’ll learn:
♦ the benefits of using the nursing process
♦ the role of the nursing process in planning patient care
♦ ways in which the nursing process promotes critical
thinking
♦ fundamentals of concept mapping and its uses in care
planning.
A lo ok a t c a re p la n n in g
A crucial component of nursing care, a care plan (also known as a
pla n of ca r e) serves as a road map that guides all health care team
members involved in a patient’s care. Care planning allows a nurse
to identify a patient’s problems and select interventions that will
help solve or minimize these problems.
The great communicat or

The care plan also communicates vital patient information to
the entire health care team. It contains detailed instructions for Think of a care plan
achieving the goals established for the patient. as a map t hat helps
t he healt h care t eam
st ay on course
when it comes t o
Un d e rs t a n d in g th e n u rs in g pat ient care.
p roc e s s
Effective care planning results from the nursing process—a
deliberate, systematic process that takes a problem-solving
approach to nursing care. Development and acceptance
of the nursing process is one of the key advances in
nursing over the past few decades.
INTRODUCTION TO CARE P LANNING
4
Analyze, addres s , implement , evaluat e

The cornerstone of clinical nursing, the nursing process gives you
a structure for applying your knowledge and skills in an organized,
goal-oriented way. It helps you think critically, solve problems,
and make care decisions tailored to each patient’s individual needs.
The nursing process requires you to systematically analyze
patient data, make inferences, draw conclusions about patient
problems, devise a care plan to address those problems, imple-
ment the plan, evaluate the plan’s effectiveness, and revise the
plan if necessary.
Oh, t he humanit y
The nursing process is holistic and humanistic. It addresses the
human response to medical conditions—how these conditions
affect the patient’s life. To use it correctly, you must consider not
just the patient’s physical, mental, and emotional status but also
his interests, values, beliefs, and ethnic, religious, and cultural
background.
Advantag e s of the nurs ing pro ce s s

When used effectively, the nursing process offers many
advantages:
• It’s patient centered, helping to ensure that your patient’s health
problems and his response to them are the focus of care.
• It enables you to individualize care for each patient.
• It promotes the patient’s participation in his care, encourages
independence and compliance, and gives the patient a greater
sense of control—important factors in a positive health outcome.
(See Pu tti n g the “P” i n pla n n i n g.)
Teacher knows best
Putting the “P” in planning

Always remember to include the “P”—the patient—in planning. Ask for your patient’s
input when identifying his problems, establishing outcomes, and formulating interven-
tions. Doing this validates his importance as an individual and motivates him to partici-
pate in his health care and adhere to the care plan. It also gives him a greater sense
of control, which promotes personal responsibility and strengthens his commitment to
working toward the established goals.
UNDERS TANDING THE NURS ING P ROCES S
5
• It improves communication by providing you and other nurses

with a common list of the patient’s recognized health problems.
• It promotes accountability for nursing activities based on evalu-
ation, which in turn promotes quality assurance.
• It promotes critical thinking, decision making, and problem
solving.
• It’s outcome-focused and encourages the evaluation of results.
• It minimizes errors and omissions in care planning. Picking out shoes
is s cient ific? I knew
t here was a good
Bas is for the nurs ing proc e s s reason it t ook me s o
long—I jus t always
The nursing process is based on the scientific method of problem t hought it was all of
solving, which involves: t he shoes.
• stating the problem you observed
• forming a hypothesis about the solution to the problem
(“if…then” statements)
• developing a method to test the hypothesis
• collecting the test data
• analyzing the data
• drawing conclusions about the hypothesis.
A s cient ific fact

Most people use the scientific method instinc-
tively, without being aware they’re doing it.
Simply picking out which pair of shoes best com-
plements your favorite outfit is an exercise in the
scientific method. So if you’re familiar with the scientific process,
the nursing process probably seems familiar.
Nurs ing proc e s s s te ps

The nursing process encompasses five steps:
assessment
nursing diagnosis
planning
implementation
evaluation.
Following these steps systematically in this order enables you to
organize and prioritize patient care—especially critical for the
novice nursing student. It also helps ensure that you don’t skip
or overlook important information. (See J u st how m a n y steps
a r e ther e?, page 6.)
6
Jus t how many s teps are there?

Nurses are accountable for maintaining national practice standards, such as those set
by the American Nurses Association (ANA). These standards state that “the nursing
process encompasses all significant actions taken by registered nurses and forms the
foundation for decision-making.” However, the number of nursing process steps into
which this definition translates varies.
The initial definition of the nursing process from the 1950s listed only three steps:
assessment, planning, and evaluation. However, the ANA cites six steps in the nursing
process:
• assessment
• nursing diagnosis
• outcome identification
• planning
• implementation
• evaluation.
Many authors and instructors have found it useful to combine outcome identification
into the planning step because it’s so closely allied to the choice of appropriate nursing
interventions.
Remember that the nursing process guides all the nurse’s actions and decisions,
regardless of the number of steps cited.
When used correctly, the nursing process ensures that the care
plan is revised when new problems arise or patient outcomes re-
main unmet. It also allows the care plan to be discontinued when
patient outcomes have been met.
Domino effect
Although the five nursing process steps are sequential, they also
are continuous and overlapping. For instance, when perform-
ing an intervention, such as changing your patient’s dressing,
you should also be assessing his skin. (See The n u r si n g pr ocess:
An u n br oken ci r cle.)
What’s more, these steps are interrelated, with each one influ-
encing all the subsequent steps. For instance:
• Your assessment must be thorough and accurate so that you
formulate the appropriate nursing diagnosis.
• The nursing diagnosis you formulate must be appropriate to en-
sure that you choose reasonable outcomes.
• The outcomes you identify must be appropriate so that you out-
line correct interventions.
• The interventions you choose must be appropriate so that your
patient will make progress toward the outcomes you’ve established.
7
The nurs ing proces s : An unbroken circle

The nursing process is a progression of actions that continually recycle as patient problems and priorities change or
resolve. In any specific task you do, more than one step may be involved.
Take for example…

When you initially assess a new patient’s lungs, you begin the process of determining if the patient has any actual or
potential problems related to respiratory function. In addition to assessing respiratory function, you can assess the skin
integrity on the patient’s chest and back.
The next time you assess his lungs, you can evaluate whether an intervention teaching him to use an incentive
spirometer was effective in keeping his lungs clear. When you do this, however, you notice that his apical heart beat is
rapid and irregular—a change from your initial assessment. Now you quickly:
• conclude that the spi-
rometry has been effec-
tive so far (evaluation)
• identify that the
patient is at risk for
decreased cardiac tis-
sue perfusion (nursing
diagnosis)
• identify that the
patient’s heart rate
should return to less
than 100 beats/minute
with a regular rhythm
(planning expected
outcomes)
• determine that you
should ask the patient
how he’s feeling to
identify associated
symptoms, check the
patient’s pulse oximetry
to assess the need for
supportive oxygen,
obtain an immediate 12-
lead electrocardiogram,
and notify the practi-
tioner of the change
(planning interventions)
• put your devised plan
into action (implemen-
tation).
8
Under construction
Actual vs . Ris k for nurs ing diagnos es

When formulating your patient’s nursing diagnoses, you need to specify whether your
patient has each problem or is at risk for developing it. Here’s the distinction:
• If the patient has identifiable signs and symptoms that appear in all or most patients
with the disorder, you should label the problem with an actual nursing diagnosis.
• If the patient has risk factors for a problem but doesn’t have signs or symptoms,
you should label the problem with a Risk for diagnosis.
Take impaired skin integrity, for example. If the patient has erythema or an open skin
area, he has actual impaired skin integrity and his diagnosis would be Impaired skin
integrity. If he has no signs of skin breakdown but is bedbound and has bowel and blad-
der incontinence, he has predisposing factors that place him at risk for impaired skin
integrity; therefore, his nursing diagnosis would be Risk for impaired skin integrity.
If you go astray during any step—say, by misinterpreting the

assessment data—you can get back on track by reassessing the
patient, evaluating his care plan, and revising the plan if necessary.
As s es s ment
The first step in the nursing process, assessment involves the sys-
tematic collection of patient data. A comprehensive assessment
Alt hough bot h are
gives you a wide-angle view of your patient’s health problems, aid-
import ant part s of
ing in crucial decisions about patient care. pat ient care, medi-
cal diagnoses and
nursing diagnos es are
Nurs ing diagnos is different .
The second step requires you to use your assessment data to for-
mulate nursing diagnoses—clinical judgments about the patient’s
response to an actual or potential health problem that
nurses are legally permitted to manage. (See Actual vs.
Risk for n u r si n g di a gn oses.) Remember, nursing diag-
noses are different from medical diagnoses. (See How
n u r si n g a n d m edi ca l di a gn oses di ffer .)
After the patient’s problems or responses have
been identified and reframed as nursing diagnoses, a
quick review of the assessment findings and diagnoses
can help you to correctly prioritize the most urgent
needs of the patient.
9
How nurs ing and medical diagnos es differ

Practitioners such as doctors, nurse practitioners, and physician assistants diagnose
and treat medical conditions related to anatomy, physiology, disease, or trauma.
They formulate medical diagnoses that center on these medical diseases and conditions.
Nurses aren’t licensed to diagnose medical diseases and conditions. Instead, they
formulate nursing diagnoses that focus on how the patient responds to the medical dis-
ease or condition. Unlike medical diagnoses, nursing diagnoses are patient-centered.
This case study will help you understand the difference between medical and
nursing diagnoses.
Point, counterpoint he has always been the breadwinner
Mr. Mills is a 52-year-old man who was of his family, and he’s worried that if he
hospitalized after falling on a patch of ice needs to be off work for a long time, he
and injuring his right hip. He’s married and won’t have the money to pay his son’s col-
has two children, one of whom attends lege tuition. The initial nursing diagnoses
college. Mr. Mills works as a construction for Mr. Mills are Acute pain related to right
foreman; his wife is unemployed. hip fracture; Impaired urinary elimination
related to inability to stand, pain, and vol-
The practitioner’s viewpoint untary retention; Anxiety related to finan-
Here’s how the practitioner sees the situ- cial concerns; and Risk for situational low
ation: Mr. Mills presents with pain in the self-esteem related to anticipated loss of
right hip, a shortened right leg, and exter- roles as employee and family provider.
nal rotation of the right hip after sustain-
ing a fall on a patch of ice. The hip X-ray The differences
shows a well-defined intertrochanteric The nurse focuses on Mr. Mills and his
fracture of the right hip. The medical diag- responses to the hip fracture. She isn’t
nosis is a right hip fracture. The medical licensed to treat the patient’s hip fracture
plan is to proceed with open reduction independently but can address problems
and internal fixation of the hip. stemming from his responses to the fracture,
such as pain and discomfort, concern with
The nurse’s perspective urination, and the expected role change.
Here’s how the nurse views the same The nursing care plan should address
patient information: Mr. Mills has pain in Mr. Mills’ pain management needs as well
his right hip. He expresses an immediate as include education about the indwelling
concern about the need to urinate. He’s urinary catheter that the nurse will place, a
also concerned about his job and lack of social service consult to address Mr. Mills’
income during the recuperation period, financial concerns, and assistance in work-
when he won’t be able to work. He says ing through his expected role changes.
Three’s company
Each nursing diagnosis has three components:
• label—an actual or potential problem that nursing care can affect
10
• related factors—factors that may precede, contribute to, or be

associated with the human response
• evidence—signs and symptoms that point to the nursing
diagnosis.
Suppose, for instance, that your patient has constipation re-
sulting from use of opioid analgesics for pain. You would formu-
late a nursing diagnosis of Con sti pa ti on r ela ted to u se of opi oi d
a n a lgesi cs a s evi den ced by pa ssa ge of ha r d, for m ed stools.
One t hing leads t o anot her

Correctly identifying the problem and its cause is crucial to the
next steps of the nursing process—planning and implementation.
Planning
During the planning stage of the nursing process, you:
• identify expected patient outcomes, or goals
• select nursing interventions designed to achieve these outcomes
• document the care plan, which becomes a permanent part of
the patient’s record and communicates the patient’s needs to all
health care providers who use the plan.
Here come t he out comes

For every nursing diagnosis, you must identify expected out-
comes—measurable, patient-focused, time-specific goals the
patient should reach as a result of the nursing interventions you’ve
planned. Don’t forget
Outcomes derive from the nursing diagnosis. You must state document at ion.
them in terms of the patient’s behavior. For example, if the patient It ’s an import ant
has a nursing diagnosis of Defi ci en t kn owledge ( i n ci si on ca r e) , part of t he proces s.
one reasonable outcome might be “Patient will verbalize precau-
tions to take to prevent incision infection until healed.”
Next in line—t he int ervent ions

Once you’ve identified the patient’s problem or response and
determined a reasonable outcome measurement, you can begin
to list the steps that must be taken to reach that goal. Interven-
tions are brief descriptions of specific actions. They should be
based on the best evidence available documenting effectiveness
and validity for achieving the desired outcome, and they should
conform to appropriate standards of care.
Don’t forget t o document

Always document the care plan so it’s accessible to other staff
members. Doing this provides crucial patient information to
other health care team members, promoting continuity of care.
11
Impleme ntation
Teacher
The next step in the nursing process is implementation, when you knows best
perform the actual interventions to help your patient reach the
expected outcomes. But before carrying out these interventions, be
sure to quickly reassess the patient to make sure that the interven- Be pliable about
tions you’ve planned are still necessary. Patient situations can change care plans
rapidly, making some interventions inappropriate or unnecessary.
The nursing care plan
Throughout your nursing care, you’ll need to evaluate the ef-
isn’t set in stone. It must
fectiveness of your interventions and make changes as needed. If
be updated as your
you continue to implement ineffective interventions, you and your
patient will lose valuable time. (See Be pli a ble a bou t ca r e pla n s.) patient’s problems,
needs, and priorities
change. Be sure to
Evaluatio n review the care plan
During the evaluation step of the nursing process, you: often and modify it when
• reassess the patient necessary.
• compare your findings with the outcome criteria you estab-
lished during the planning step
• determine the extent of outcome achievement—whether the
outcome was fully met, partially met, or not met at all
• write evaluation statements
• revise the care plan as needed.
Although technically the last step of the nursing process,
evaluation is an ongoing process that occurs each time you see
the patient. You must continually evaluate the patient’s response
to interventions. (See The focu s fa ctor , page 12.)
A change of plans
If desired outcomes have been achieved, the care plan may be dis-
continued. If an outcome has been partially met, the plan may be
continued with an extended time line.
If a desired outcome hasn’t been met, you must reexamine
the care plan and make necessary changes. To change the plan,
you may need to review the new assessment data, formulate new
diagnoses, establish new outcomes, and select new interventions.
Then update the written care plan accordingly.
How the nurs ing proc es s pro mo tes critic al thinking

To use the nursing process, you must be able to think critically.
Critical thinking is a disciplined mental process of analyzing prob-
lems or phenomena that have been gathered from observation,
experience, reflection, reasoning, or communication.
Deliberate, purposeful, and conscious, critical think-
ing requires reasonable, rational interpretation and evalua-
tion of information. It leads you to reasonable solutions to a
12
Teacher knows best
The focus factor

Stay focused during all interactions with your patient. To do this, you’ll need to use active
listening skills and turn off other thoughts going through your head, including “What should I
make for dinner?” and “What time is my dentist appointment tomorrow?” Most patients are
aware of the amount of focus and interest you bring to an exchange and will respond in kind.
problem and helps you choose among these possible solutions

to make a decision.
Hallmarks of critical thinking

The hallmarks of critical thinking are:
• clear, careful, and precise thinking
• objective analysis of the evidence
• use of logical reasoning to reach a discriminating decision
• elimination of stereotypical thinking, bias, preconceptions, and
emotionally charged thinking.
A model proces s
The nursing process is a model of critical thinking because each
step is purposeful, deliberate, and designed to attain a certain
goal. (See Cr i ti ca l thi n ki n g: An essen ti a l ski ll.)
For instance, when evaluating the assessment data you’ve Memory
gathered, you must think critically to determine which questions jogger
to ask your patient next. If he says he occasionally experiences Crit ical
chest pain, the critically thinking nurse doesn’t simply record this t hinking is
statement and move on to the next topic. Instead, she asks ques- a life s kill as well as
tions designed to elicit details about the chest pain, such as: a nurs ing es s ent ial.
• When does the pain occur? Do you experience it after strenuous To remember t he
physical activity? Does it occur after meals? While resting? charact eris t ics of
crit ical-t ype t hought ,
• How severe is the pain on a scale of 0 to 10? t hink of CLOUD:
• Do you have other problems along with the pain?
• Does the pain radiate to other parts of your body? Clear
Logical
Ris ky fact ors Object ive
Thinking critically during assessment enables you to recognize
factors that place your patient at increased risk for developing a Unbias ed
problem. If you detect such a potential, you’ll know the care plan Dis pas sionat e (not
should include a Ri sk for nursing diagnosis and appropriate inter- emot ion-driven).
ventions to prevent the problem.
13
Critical thinking: An es s ential s kill

In the complex, rapidly changing health care environment, safe and effective nursing
care demands critical thinking. Taking basic problem solving one step further, critical
thinking considers all related factors, including the patient’s unique needs and individ-
ual differences. Critical-thinking skills allow the nurse to step outside the situation and
look at the whole picture more objectively.
Truth seekers
To obtain this complete picture, critical thinkers seek the truth and actively pursue
answers to questions. They’re also open-minded and creative and can draw from past
clinical experience to come up with all possible alternatives and then zero in on the
best solution for the patient.
Practice for your practice

Books, articles, and online courses are available to hone nurses’ critical-thinking skills.
When nurses engage in critical thinking, their patients have the best chances for success.
Likewise, critical thinking helps you write outcomes in a way

that promotes easier evaluation and makes the need for any revi-
sions readily apparent.
Novices need it , t oo
Critical thinking skills are essential for nurses at every level. As a
novice nurse, you’ll encounter situations you didn’t see or learn about
during your student clinical rotation—complex problems that require
sound decision-making skills. You’ll be expected to make important
patient-care decisions and take actions based on those decisions.
As technology grows more advanced, such decisions and
actions are becoming increasingly complex. What’s more, they
require you to analyze many patient variables, including social,
cultural, emotional, physical, financial, and spiritual issues.
Us ing the nurs ing proc e s s afte r graduation

No matter how thoroughly you’re oriented in your first nursing
job, you’ll confront many new and unfamiliar situations through-
out your career. You’ll need to make many on-the-spot decisions—
some of which will be crucial. Using the nursing process and
critical thinking skills will help you succeed no matter what your
responsibilities are. As you become more familiar with the nursing
process, gain experience writing care plans, and hone your criti-
cal-thinking skills, your clinical judgment and ability to make good
decisions undoubtedly will improve.
14
Roll wit h t he changes

I’m gonna was h
Because the patient’s status is dynamic and can change quickly, t hat diagnosis right
the nursing process is dynamic as well. As your patient’s condition out t a my hair!
changes, you must assess these changes quickly and adjust the
care plan appropriately. Use the nursing process as a road map
and critical thinking as the vehicle to take you and your patient to
the destination—the desired patient outcome.
Rins e and repeat

As you gain experience, you’ll see that the nursing process shows
you when and how to stop a nursing intervention—namely, when
the desired outcomes are met. Or, if the outcomes remain unmet,
the nursing process will lead you to reassess the situation and, if
necessary, repeat the entire process.
Unde rs ta nding NANDA-I, NOC, a nd NIC

Using standard terminology in the care plan helps ensure that all
members of the nursing team have the same understanding of the
patient’s needs. Technology and the increasing use of electronic
medical records have increased the need for standardized nursing
language.
Speaking t he s ame language

Several standardized classification systems exist for nursing diag-
noses, outcomes, and interventions. With these systems, you can
use a single term to describe what otherwise would require sev-
eral words.
NANDA-I diagnos e s
Most nurses use the diagnoses identified by NANDA International
(NANDA-I; formerly the North American Nursing Diagnosis Asso-
ciation). NANDA-I develops standardized nursing diagnosis termi-
nology for nurses at all levels and in all practice areas.
NANDA-I was founded in 1973 during a conference held to
establish a classification system for nursing diagnoses. In 1987,
the American Nurses Association authorized NANDA-I as the gov-
erning organization for development of a nursing diagnosis classi-
fication system. NANDA-I meets periodically to review and accept
new diagnoses or, when necessary, to revise previously accepted
diagnoses. It then publishes the updated, revised list of approved
diagnoses.
UNDERS TANDING NANDA-I, NOC, AND NIC
15
Other c las s ific ation s ys te ms

The Nursing Outcomes Classification (NOC) system, developed at
the University of Iowa School of Nursing, is a standardized clas-
sification system for patient outcomes that helps nurses evaluate
the effects of nursing interventions.
NOC is no laughing mat t er

NOC outcomes can be used in all settings across the care
continuum to follow patient outcomes throughout an illness
episode or over an extended time. The NOC system consists of
385 outcomes organized into 31 classes and 7 domains. Each
outcome has a definition and a list of measurable indicators.
(See Don ’t kn ock NOC!)
NIC follows NOC

The Nursing Interventions Classification (NIC) system is a compre-
hensive, research-based standardized classification system for inter-
ventions that nurses perform. Like the NOC system, it was developed
at the University of Iowa School of Nursing. NIC addresses both the
physiological and psychosocial aspects of nursing care and includes
independent and collaborative interventions. The NIC system
includes 542 interventions organized into 30 classes and 7 domains.
Research conducted and used in formulating NIC helps ensure
that nursing interventions are based on the best evidence—not
guesswork. Evidence-based interventions promote the best
patient outcomes and take the guesswork out of planning care.
(See NIC a n d n u r ses, page 16.)
Weighing the evidence
Don’t knock NOC!

Classification of nursing outcomes was initiated in the 1970s in response to a need to identify and measure outcomes of
patient care that were responsive to nursing practices. To establish appropriate reimbursement and determine reason-
able staffing coverage, health care organizations, insurers, and regulators wanted to measure how the nursing care
provided affected the patient’s health status. Nurses themselves wanted a language that demonstrated the uniqueness
of their profession and provided a framework for further nursing research.
The nursing outcomes listed by the Iowa Outcomes Project 2004 Nursing Outcomes Classification (NOC) are
research based and have been evaluated for reliability, validity, and sensitivity. Therefore, NOC outcomes provide an
excellent guideline in the preparation of standardized or individualized care plans, paving the way for evidence-based
nursing practice.
16
NIC and nurs es

Research for a classification of nursing interventions began in 1987. Nurses needed a clear, concise, and measurable
list of nursing actions to ease documentation time, aid interdisciplinary communication, assess productivity and compe-
tency, foster nursing research, and teach nursing students. These nursing actions were grouped together into broader
categories of interventions specific to particular patient outcomes.
For example, the intervention “Cardiac Care” contains a list of specific nursing activities that partially includes evalu-
ation of chest pain, assessment of peripheral circulation, documentation of cardiac arrhythmia, and promotion of stress
reduction. The specific nursing activities listed are based on research and standards of care from relevant professional
organizations, and each intervention includes a definition and selected references.
The interventions listed on an individual care plan are ultimately based on the clinical judgment of the nurse respon-
sible for the patient’s care. Nursing activities cited must be modified to reflect unique actions required to help that
patient meet his desired outcomes. Actions that don’t apply to the patient should be omitted. This feature of NIC is what
guarantees that nurses remain patient focused and in control of the nursing process.
Language link-ups
Over the past several years, members of the research teams
responsible for NANDA, NIC, and NOC have consulted to develop
linkages (terminology that links one classification system to the
others). Together, the three classifications provide the basics for a
complete care plan. This gives all nurses a common understanding
of nursing care.
Knock-
knock.
NOC out comes
t hat are going t o
Who’s
help me evaluat e t he
t here?
effect ivenes s of my
nurs ing int ervent ions!
CONCEP T MAP P ING
17
Con c e p t m a p p in g
A common tool to assist you in critical thinking is a concept map
(sometimes called a m i n d m a p). A concept map is a diagram that
shows relationships among various concepts. Concept mapping is
a tool for visualizing how concepts relate to one another. It helps
you understand your patient’s problems and care needs—and see
how these items interact with each other.
A concept map helps you organize your thinking and see the
big clinical picture. Each concept is enclosed in a box or circle,
with lines between related concepts. Concept maps are especially
helpful if you’re a visual learner.
Concept mapping is
Comparing c onc e pt mapping and care planning similar t o t he brain’s
Concept mapping and traditional nursing care planning both have neural net work. Each
concept has long
a problem-solving focus. However, concept mapping doesn’t fibers t hat reach out
require linear design, which can hinder the free flow of ideas. It and connect t o ot her
lets you view information in different ways and from different concept s.
viewpoints because concepts aren’t locked into specific positions.
(See Qu i ck com pa r i son , page 18.)
Advantages of conce pt mapping

Concept mapping also has these other advantages over the
traditional care plan:
• It makes the seemingly intangible concepts of patient
problems, causes, and effects more manageable.
• It clearly defines the central concept (the patient problem)
by positioning it in the center of the page. This ensures that
the patient—not the medical diagnosis—is the focus.
• It shows the relative importance of each concept.
• It helps you identify relationships between important
concepts.
• It requires much less time to write than a care plan.
• It encourages creative and innovative ideas.
• It provides all the basic information on one page.
• It allows new information to be easily added.
• It enables you to see contradictions and gaps in the material or
its interpretation, which provides a foundation for questioning,
discovery, and creativity.
Dis advantages of c onc ept mapping

Despite its advantages, concept mapping can have certain
drawbacks:
18
Quick comparis on
Here’s a quick comparison of concept mapping and nursing care plans.
Concept map Nursing care plan
• Visually organized • Linearly organized
• Assessment data clearly linked to • Assessment data usually in separate

nursing problems (diagnoses) area or different form
• Good for quick identification and outline • Good for quick communication of priority
of multiple patient problems problems, outcomes, and interventions
• Getting the map just right can be time-consuming. You may

have to redraw it several times until you’re satisfied.
• It may become complex and cluttered, hindering your ability to
see the big picture.
• It doesn’t easily lend itself to standardized formats for everyday
use in the clinical setting.
Cre ating a c onc ept map Acute pain

• Verbalized
To develop a concept map for your patient, start with incisional pain
a clean sheet of unlined paper. (If you must use lined • Rates pain as
9 on pain scale
paper, turn it so the lines are vertical.) To promote cre-
ative thinking, you may want to use colored pencils or
pens. Then follow these steps:
B.R.
• After you’ve assessed your patient, place a circle repre- B.R.
Chief complaint
• RLQ pain senting the patient in the middle of the paper. In this cir- Chief complaint
• Nausea, vomiting cle, write the patient’s name or initials, chief complaint, • RLQ pain
• Fever and medical diagnosis. (See example at left.) By placing • Nausea, vomiting
• Fever
Medical diagnosis the patient in the center of the page, your focus is clearly
Appendicitis patient centered. Remember, be brief! Medical diagnosis
Appendicitis
• Write the patient’s major problems or nursing diagno-
ses in boxes surrounding the patient, along with pertinent
supporting data.
• Use lines to connect the central circle—the patient—to Constipation
the nursing diagnoses boxes. You may also draw lines be- • Distended
tween related nursing diagnoses. For example, for a post- abdomen
• Inability to
operative patient experiencing constipation caused by use pass stool
of opioid analgesics, you would draw a line between the
nursing diagnoses of Acute pa i n and Constipa ti on to show
that you understand they’re related. (See example at right.)
CONCEP T MAP P ING
19
• Write expected outcomes for each nursing diagnosis; place each

outcome in its own box because corresponding interventions will
differ for each outcome. Connect these boxes with lines to the
appropriate nursing diagnosis.
• In the same way, write interventions in a box for each outcome,
followed by evaluations. Draw lines between each part of the
nursing process to link related concepts. (See Con cept m a ppi n g
wi thou t tea r s.)
Pat t erns , s ymbols , and not es

To help clarify your concept map, try using patterns and symbols
to help organize types of information, such as:
• branches, to show how a concept can branches into ideas that
are either closely or distantly related
• arrows, to join ideas from different branches
• circled groupings, to combine several branches of related ideas.
You may also include explanatory notes—such as a few words,
phrases, or sentences—to explain, question, or comment on a par-
ticular point.
Us ing your c once pt map

Concept maps are such useful tools that they can be used for
multiple purposes. For example, you can use a concept map to
analyze a case study for class or to guide your patient care during
Teacher knows best
Concept mapping without tears

These guidelines can help you to learn how to quickly and easily create concept maps:
• Work quickly without pausing. Try to keep up with the flow of ideas. Don’t stop to de-
cide where something should go or to organize the material. Just get it down on paper.
Ordering and analyzing are linear activities that can disrupt the mapping process.
• Write down everything you can think of without judging or editing—these activities
can also disrupt the flow of concept mapping.
• If you come to a standstill, look over what you’ve done to see if you’ve left anything out.
• Confine the map to one page so it’s easier to use.
• Print in capital letters for greater legibility. This also encourages you to keep the
points brief.
• Initially, you may want to use color coding to group sections of the map. As you gain
experience, you’ll probably find that color coding isn’t necessary.
20
clinical rotations. During clinicals, you can carry your concept

map in your pocket or place it on your clipboard so you can refer
to it often and update or revise it as necessary.
On t he cas e
Cas e s tudy bac kground

Mr. Jones is a 58-year-old male who was admitted to the medical-
surgical floor with cholecystitis. The patient complains of pain in
his epigastric area, nausea, and vomiting. His vital signs are as fol-
lows: heart rate 102 beats/minute, blood pressure 142/88 mm Hg,
oral temperature 100.4° F, and respiratory rate 22 breaths/minute.
The patient rates his pain as an 8 on a scale of 0 to 10, with 10
being the most severe pain possible and 0 being the absence of
pain. A nasogastric (NG) tube has been placed and is connected to
low, intermittent wall suction, and an IV line with dextrose 5% in
normal saline solution has been started at 75 mL/hour. Mr. Jones
is scheduled for a laparoscopic cholecystectomy tomorrow.
Conc e pt m a ppin g e xe rc is e
Follow the steps outlined here to create a rough concept map for the
care of Mr. Jones. Don’t worry if you can’t complete the entire care
plan. This is just your first try. The answers can be found on page 21.
Steps
1. Assess the patient to collect clinical data.

2. Write the patient’s name or initials, medical diagnosis, and
chief complaint in the middle of a sheet of paper.
3. Write appropriate nursing diagnoses in boxes around the
central box that contains the patient’s name or initials and chief
complaint. (Hi n t: One of the diagnoses should be Acu te pa i n .)
4. Categorize assessment data under the appropriate nursing
diagnoses.
5. Analyze the relationships among nursing diagnoses and draw
lines to indicate these relationships.
6. On another piece of paper, identify patient goals, expected out-
comes, and nursing interventions for the nursing diagnosis Acute
pain. Or, instead of using another piece of paper, you can create
additional boxes on your concept map for the goals, outcomes, and in-
terventions and then link these boxes to the related nursing diagnoses.
ON THE CAS E
21
Ans wer key

Ste ps 1, 2, 3, 4, and 5
This concept map is one example of many possibilities for this
patient. If you couldn’t complete this concept map, don’t worry.
The remaining chapters in this book will walk you step-by-step
through the process of creating a concept map that incorporates
each stage of the nursing process.
Acute pain
• Verbalizes Deficient fluid volume
epigastric pain • Nausea and vomiting
• Rates pain an 8 on • T = 100.4º F
the pain scale • NG tube to low,
• Elevated heart rate intermittent wall suction
and blood pressure • NPO
M.J.
Impaired physical Hyperthermia
Chief complaint
mobility • Epigastric pain • T = 100.4º F
• Pain • Nausea, vomiting
• NG tube • Low-grade fever
connected to Medical diagnosis
intermittent wall suction Cholecystitis
• IVpole and tubing
Deficient knowledge Imbalanced nutrition:

• Diagnosis Less than body
• Pain management requirements
• Cholecystectomy • NPO
• Postoperative care • NG tube
• Dietary management • IV therapy
• NG tube • Nausea and vomiting
22
Ste p 6
Here’s an example of a goal, expected outcomes, and nursing
interventions for the nursing diagnosis Acu te pa i n :
• Nu r si n g di a gn osi s: Acute pain related to inflammation of the
gallbladder as evidenced by the patient reporting pain rating as an
8 on a 0-to-10 scale
– Nu r si n g pr i or i ty: Pain control
• Expected ou tcom e: Patient’s self-reported pain level is reduced
to 3 on a 0-to-10 scale within 2 hours of initiation of prescribed
analgesics.
Nursing interventions Evaluation
Assess pain using pain scale. This section will

include the patient’s
Medicate patient for pain, according to the practitioner’s orders. responses to the
interventions on
Instruct patient on use of patient-controlled analgesia, if appropriate. the left.
Position patient for comfort.
Use techniques of relaxation, meditation, or guided imagery.

2
As s es s ment
J us t t he fact s
♦ the components of a complete health assessment
♦ techniques and formats for gathering and organizing
assessment data
♦ tips for reviewing a patient’s chart for assessment data
♦ the steps for creating a concept map using assessment
information.
A lo ok a t a s s e s s m e n t
The first step in the nursing process, assessment involves data
collection to identify the patient’s actual and potential health
problems and needs. The goal is to gather as much information Think of t he nursing
about your patient as possible. Using these data, you’ll identify his ass essment as a
needs, formulate nursing diagnoses, establish expected outcomes, fact -finding mission.
and identify interventions to help achieve those expected out-
comes. You’ll also set objective criteria to evaluate the effective-
ness of your interventions.
Can I read t hat back t o you?

Be sure to double-check, clarify, or restate the information you’ve
collected to make sure that it’s accurate and complete. Validating
the data helps you avoid misinterpretation. Remember, if your
assessment is incorrect or incomplete, the nursing diagnoses you
formulate are likely to be incorrect as well or you may overlook a
problem and neglect to formulate a diagnosis for it.
Also, to make sure that the data you’ve gathered accurately re-
flect the patient’s life experiences and living patterns, maintain an
objective, nonjudgmental approach during assessment.
AS S ES S MENT
24
Comple te vs . fo c us ed as s es s ment What did t he

Depending on the situation and time constraints, your assessment care plan s ay t o t he
ass essment findings?
may be complete or focused. You complet e me!
You complet e me
A com plete assessment provides comprehensive baseline infor-
mation. Typically, it’s conducted when the patient is admitted.
Student nurses are generally expected to perform a complete
assessment as part of their learning experience.
Hocus focus
A focu sed assessment generally is problem- or need-oriented. Dur-
ing this assessment, focus on evaluating for specific problems or
concerns that have already been identified and are being tracked
by the health care team until they’re resolved.
Typically, you’ll perform a focused assessment after the patient
has been admitted and undergone a complete assessment—for
example, during initial shift assessment or change of assignment,
whenever the patient has a new complaint or a change in condi-
tion, or when you’re evaluating the results of an intervention.
Com p on e n t s of a c om p le t e h e a lt h
assessment
A complete health assessment includes the:
• nursing history
• physical assessment
• review of laboratory and diagnostic test results
• review of other available health information.
Firs t impres s ions

Assessment begins as soon as you meet your patient. Perhaps
without even being aware of it, you’re already noting such aspects
as his skin color, speech patterns, and body position. Your educa-
tion as a nurse gives you the ability to organize and interpret these
data. As you move on to conduct the formal nursing assessment,
you’ll collect data in a more structured way. The findings you col-
lect from your assessment may be subjective or objective. (See
Su bjecti ve vs. objecti ve fi n di n gs.)
Group dynamics
When evaluating the assessment data, you’ll start to recognize
significant points and ask pertinent questions. You’ll probably find
COMP ONENTS OF A COMP LETE HEALTH AS S ES S MENT
25
Teacher knows best
Subjective vs . objective findings

Keep in mind that assessment findings fall into two broad categories: subjective and objective.
Subjective data
Subjective assessment data represents the perception or reality experienced by the person reporting the information.
It may come directly from the patient or indirectly from family members, caregivers, or other health care providers.
For example, when you ask a patient to rate his pain on a scale of 0 to 10, you’re asking him to quantify his personal
perception of the severity of his pain. Even indirect data can provide clues that could prove vital to your patient’s care.
In some cases—for instance, if your patient is physically or mentally incapable of answering questions or providing
information—such third-party sources are crucial to your assessment.
Objective data
Objective data come from the physical examination through inspection, percussion, palpation, and auscultation. Use
physical findings to verify the subjective findings you’ve gathered from the patient’s health history. For example, dimin-
ished breath sounds heard on auscultation of the lower lobes of the lungs (objective data) support the patient’s report of
“having trouble breathing” (subjective data).
yourself starting to group related bits of significant assessment

data into clusters that give you clues about your patient’s problem
and prompt additional questions. For instance, if the data suggest
a pattern of poor nutrition, you should ask questions that will help
elicit the cause, such as:
• Do you have a poor appetite?
• Do you eat most meals alone?
• Do you have enough money to buy food?
On the other hand, if the patient reports frequent nausea, you
should suspect that this may be the cause of his poor nutrition.
Therefore, you’d ask questions to elicit more information about
this symptom, such as:
• Do you feel nauseated after meals? Before meals?
• Do any of your medications upset your stomach?
His tory
The nursing history requires you to collect information about the
patient’s:
• biographic data
• current physical and emotional complaints
• past medical history
• past and current ability to perform activities of daily living (ADLs)
AS S ES S MENT
26
• availability of support systems, effectiveness of past coping pat-

terns, and perceived stressors
• socioeconomic factors affecting preventive health practices and
compliance with medical recommendations
• spiritual and cultural practices, wishes, or concerns
• family patterns of illness.
Biographic data
Begin your history by obtaining biographic data from the patient.
Do this before you begin gathering details about his health. Ask the
patient his name, address, telephone number, birth date, age, marital
status, religion, and nationality. Find out who the patient lives with
and get the name and number of a person to contact in case of an
emergency. Also ask the patient about his health care, including the
name of his primary practitioner and his mode of transportation to
practitioner visits. Finally, ask the patient if he has an advance direc-
tive and, if not, if he wants more information on advance directives.
If the patient can’t furnish accurate information, ask him for
the name of a friend or relative who can. Always document the
source of the information you collect as well as whether an inter-
preter was necessary.
Recording your
Current c omplaints pat ient ’s complaint s
To explore the patient’s current complaints, ask the patient why in his own words
he’s seeking health care. Patient complaints provide valuable data is good nursing
immediately. When you explore these initial complaints, you may pract ice. You can
uncover crucial additional information. quot e me on t hat !
Digging in t he dirt
Record the patient’s complaints in his own words. Ask him to
describe the problem in detail, including any suspected cause.
Keep in mind that, in many cases, presenting signs and symptoms
are the tip of the iceberg. You must use your skills and knowledge
to uncover facts about what’s really going on. Obtaining a thor-
ough patient history is one way to do this.
Pas t me dic al his to ry

Ask the patient about past and current medical problems. Typical
questions include:
• Have you ever been hospitalized? If so, when and why?
• Did you have any childhood illnesses?
• Are you currently being treated for any problem, such as hy-
pertension or diabetes? If so, for what problem and who is your
practitioner?
• Have you ever had surgery? If so, when and why?
27
• Are you allergic to anything in the environment or to any drugs

or foods? If so, what kind of allergic reaction do you have?
• Are you taking medications, including over-the-counter (OTC) prep-
arations, such as aspirin, vitamins, or cough syrup? If so, how much
do you take and how often do you take it? Do you use home remedies
such as homemade ointments? Do you use herbal preparations or
take dietary supplements? Do you use other alternative or comple-
mentary therapies, such as acupuncture, massage, or chiropractic?
• Do you have any pain? If so, how would you rate your pain on
a 0-to-10 pain scale? What aggravates or relieves your pain? How
long have you had it?
Activities of daily living

Find out about your patient’s ability to perform ADLs by asking
him to describe his typical day. The types of information you seek
should include:
• appetite, special diets, food allergies, and meal preparation
• urinary and bowel elimination habits
• exercise and sleep habits and any aids required for sleep
• work and leisure activities
• use of tobacco, alcohol, and other drugs.
Also be sure to elicit the patient’s view of how the present ill-
ness has affected his usual performance of ADLs.
Suppo rt s ys te ms and s tre s s o rs

Because illness doesn’t occur in isolation, you also need to ask
about other aspects of your patient’s life, including the availability
of support systems and perceived stressors, when you collect your
history data. These other life factors can enhance or complicate a
patient’s condition or affect his recovery.
Thank you for being a friend

For instance, lack of social support can affect a patient’s physical
well-being and influence patient outcomes. In addition to family
members, a patient’s social support system may include friends,
coworkers, community agencies, avocational groups, and clergy
who provide assistance in times of anxiety or crisis.
You can begin your evaluation of your patient’s support system
by asking the patient, “Who’s with you today?” or “How did you
get here today?” Other questions that elicit information about the
patient’s support system include:
• Do you live alone?
• Is anyone available to assist you at home, if needed?
• Is the emotional support you receive from family and friends
adequate?
AS S ES S MENT
28
More intimate details of the patient’s social support system are

usually best obtained in ongoing interactions during caregiving ac-
tivities or as you and the patient begin to discuss discharge plans.
As appropriate, weave the information you obtain about your pa-
tient’s support system into the care plan.
St res s marks
Emotional, social, and physical demands on the body cause stress.
The amount of stress a patient experiences can affect his physi-
ological and psychological health. To elicit information about your
patient’s stress level and methods of coping with stress, ask:
• what situations he finds stressful
• how he responds physically to stress
• what he does when he feels stress
• whether stress affects his family relationships
• if he thinks stress affects his health.
Also, inquire about potential stressors, such as recent losses or
setbacks, spiritual concerns, difficulties with self-care or normal
ADLs, and exposure to abuse (see Aski n g a bou t a bu se). These
may be important clues that help you formulate a care plan.
So c io ec o no mic fac to rs
The patient’s socioeconomic status can directly affect health behav-
iors by determining the financial resources available for health
care and a healthful lifestyle, including adequate housing, clothing,
As king about abus e

A history of abuse is an important aspect of a patient’s psychosocial history. Remember that anyone can be a victim of
abuse, including a boyfriend or girlfriend, a spouse, an elderly person, a child, or a parent. In addition, abuse can occur in
many forms, including physical, psychological, emotional, and sexual abuse.
When taking a health history, you should ask two questions to explore abuse:
• When do you feel safe at home?
• When do you not feel safe at home?
Reaction time
Even when you don’t immediately suspect an abusive situation, be aware of how your patient reacts to open-ended
questions. Is the patient defensive, hostile, confused, or frightened? Assess how the patient interacts with you and oth-
ers. Does he seem withdrawn or frightened or show other inappropriate behavior? Keep his reactions in mind when you
perform your physical assessment.
Remember to report
Remember, if the patient tells you about any type of abuse, you’re obligated to report it. Inform the patient that you must
report the incident to local authorities.
29
and nutrition. For example, a patient whose insurance plan doesn’t

reimburse routine health screening and physical examinations usu-
ally seeks health care only for illness. Similarly, a patient whose
financial resources barely meet basic needs is less likely to use ser-
vices or products designed to promote or maintain health.
Ins urance plan

To assess health-related socioeconomic factors, find out if your
patient has health insurance and, if so, whether insurance pays for
a routine physical examination or other screening procedures. Also
find out whether the patient is receiving financial aid and whether
his income is sufficient to pay for housing, food, and clothing.
Spiritual and c ultural influe nce s

Some patients attach great importance to their spiritual and reli-
gious beliefs. Spirituality (one’s personal definition of the purpose
and meaning of life and the world) may assign meaning to individual When as sess ing
and community life, guide daily behavior and lifestyle, define accept- your pat ient ’s
spirit ual beliefs , don’t
able health care, and influence attitudes toward illness and death. let your own beliefs
color your at t it ude.
Divine t hing Remember t o remain
Religion is the component of spirituality that includes particular nonjudgment al.
practices related to a belief in a divine power. A religious system
usually embraces more specific beliefs, including prescribed
behaviors, rituals, or practices. A patient’s health beliefs and prac-
tices may be linked closely to religion.
Cult ure club

A patient’s cultural background can also profoundly influence his
views of life and death, health beliefs, health and dietary habits,
roles, relationships, and family dynamics. For example, patients
from some cultures avoid seeking health care or taking responsi-
bility for changing unhealthful behaviors because they feel power-
less to control their illness, which they may consider punishment
for some wrongdoing. To find out about your patient’s spiritual
and cultural influences, ask these questions:
• Do you have religious or cultural beliefs that affect your diet or
health practices?
• Would you like me to contact any religious affiliation for you?
Assessing cultural influences can bring health-related factors
to light and identify culturally related strengths, such as a strong
support system.
Los t in t rans lat ion?

If the patient has a language barrier, talk with your manager or
the family to assist you in finding an interpreter. When you first
AS S ES S MENT
30
interact with the patient with an interpreter present, explain the

facility’s basic routines and establish a functional method of com-
municating about important health issues, such as pain, constipa-
tion, nausea, or other common symptoms. This is also a good time
to verify that the patient understands use of the call light and any
treatments or restrictions ordered.
Show a lit t le res pect

Being observant, open, and interested are commonly the best ways
to learn about other people’s spiritual and cultural viewpoints.
Whether you’re asking questions or responding to patient queries,
be careful to avoid making assumptions about people who might
be ethnically or culturally different from you. A simple question
opener such as, “Would you be comfortable if I…?” can demon-
strate your respect for the patient’s feelings and your willingness
to adapt your care to the patient’s needs.
Family his to ry
Questioning the patient about his family’s health is a good way to uncover
his risk of having certain illnesses. (See All in the family history.)
Phys ic al e xamination
During the physical examination, you obtain data using four of
your five senses—sight, hearing, touch, and smell. A complete
examination includes a general survey, measurement of vital
signs, height and weight measurements, and assessment of all
organs and body systems. (See Exa m i n i n g the goa ls of a physi -
ca l exa m i n a ti on .) This type of examination is appropriate for
All in the family his tory

Being aware of patterns of illness in families can help you understand genetic risk factors, determine the influence of
these events on the attitudes of your patient, and plan effective interventions. For example, a 49-year-old male with a
family history of several male deaths from heart attack before age 50 who experiences chest pain may be significantly
more afraid or hopeless than a peer with a similar complaint but no early male cardiac deaths in his family.
In some clinical settings, you may not have access to a family medical history because it’s obtained by the
practitioner but isn’t immediately available to you. In this case, obtain a brief history of relevant illness in the patient’s
parents, siblings and, when indicated, grandparents. Typical questions include:
• Are your mother, father, and siblings living?
• If not, how old were they when they died? What were the causes of their deaths?
• If they’re alive, do they have diabetes, high blood pressure, heart disease, asthma, cancer, sickle cell anemia, hemo-
philia, cataracts, glaucoma, or other illnesses?
31
Teacher knows best
Examining the goals of a phys ical examination

During the physical examination, keep in mind that your goal as a nurse is to identify signs, symptoms, and problems for
which the patient needs nursing interventions. In other words, the data you collect should lead you to formulate a nurs-
ing diagnosis—not a medical diagnosis. The nurse’s focus is always on patient processes.
Medical practitioners (such as doctors, nurse practitioners, and physician assistants), on the other hand, use a
method called differential diagnosis to arrive at a medical diagnosis. After identifying signs and symptoms, they system-
atically eliminate related diagnoses until they identify and substantiate a precise diagnosis by objective means, such as
radiologic or laboratory findings. The practitioner’s focus is the disease processes.
Meaningful collaboration among practitioners and nurses leads to health care that maximizes the patient’s health
and quality of life or preserves his comfort and dignity in death.
periodic health checks. Of course, in many cases, you won’t have

time for a complete examination and will need to focus on par-
ticular complaints or health problems.
Ge neral s urvey
The general survey provides vital information about the patient’s
behavior and health status. During your first contact with the
patient, expect to receive a steady stream of impressions—most
of which are visual. The patient’s gender, race, and approximate
age will generally be obvious. Because some health concerns may
relate to these factors, be sure to note them.
Also note less-obvious factors that can contribute to an overall
impression, including:
• signs of distress
• facial characteristics
• body type, posture, and movements
• speech
• dress
• grooming and personal hygiene
• style of interacting with others.
Summarize
When you’ve completed the survey, document your initial impres-
sions of the patient in a one-paragraph statement—a summary that
gives an overall picture to guide your subsequent examination.
Phys ical e xaminatio n te chnique s

To perform the physical examination, you’ll use four basic
techniques—inspection, palpation, percussion, and auscultation.
AS S ES S MENT
32
All eyes on ins pect ion

Inspection, or critical observation, is the most frequently used
assessment technique. Performed correctly, it also reveals more
than the other techniques. But incomplete or hasty inspection may
neglect important details or yield false or misleading findings. Don’t forget t hat
To ensure accurate, useful information, approach inspection in inspect ion is an
a careful, unhurried manner. Pay close attention to details as you import ant part of
assess each body system, observing for color, size, location, move- t he phys ical exam.
ment, texture, symmetry, odors, and sounds. Try to draw logical
conclusions from the findings.
Palpat ion point s

During palpation, you touch the patient’s body with your hands,
using various degrees of pressure to feel pulsations and vibra-
tions, locate body structures, and assess such characteristics as
size, texture, warmth, mobility, and tenderness. Palpation allows
you to detect a pulse, muscle rigidity, enlarged lymph nodes, skin
dryness, organ tenderness, or breast lumps as well as measure
chest expansion and contraction during respiration.
Percus s ion dis cus s ion

During percussion, you tap your fingers or hands quickly and
sharply against body surfaces (usually the chest and abdomen) to
produce sounds, detect tenderness, or assess reflexes. Percussion
for sound (the most common goal) helps locate organ borders,
identify organ shape and position, and determine if an organ is
solid or filled with fluid or gas.
Lis t en clos ely

Auscultation involves listening to body sounds—especially those
produced by the heart, lungs, blood vessels, stomach, and intes-
tines. For all but the most pronounced body sounds, you’ll need a
stethoscope to auscultate.
Diagno s tic te s ting data

Make sure that you know how to access the patient’s laboratory
and other diagnostic test results. In most record-keeping systems,
laboratory results are printed or electronically formatted on forms
that specify what laboratory performed the test, the normal range
of values for that test, the patient’s test value, and where that
value lies in relation to the normal range. Remember that “normal”
values for many tests vary somewhat between different laborato-
ries, depending on the specific equipment or testing techniques
they use. In a student nursing care plan, always cite the range
listed for the laboratory performing the test.
33
Other test results may be filed by type or located by date of

service. Radiology, nuclear scanning, computed tomography,
magnetic resonance imaging, and ultrasound results commonly
are kept together. Endoscopic and biopsy reports may be filed
separately, with the report containing a section on the procedure
process as well as the specific findings. Electrocardiograms are
commonly kept together for ease of comparison.
Support ing role

Nurses not only need to be aware of what tests the patient has
had and the results, but should have an understanding of the dis-
ease process and what these results may mean. Patients may be
understandably anxious about the details of preparing for or going
through a particular test, how soon results will be available, and
what these results mean. The nurse is responsible for teaching and
preparing the patient and then identifying and responding to post-
test complications or reactions. The practitioner is responsible for
conveying test results and implications to the patient, but nurses
are commonly asked to review and clarify the information pro-
vided as the patient thinks through what he has been told.
Other he alth information in the patient’s c hart

The patient’s chart is an excellent source of assessment data. Always
review it carefully, including assessments made by other health
care team members, such as emergency department (ED) staff, the
admitting practitioner, consulting medical specialists, other nurs-
ing staff and advanced practice consultants, dietitians, physical or
other specialty therapy personnel, pharmacy consultants, social
service workers, and discharge planners. The practitioner’s history Get t o know your
and physical examination findings can guide your questioning dur- pat ient ’s medicat ion
ing assessment. If appropriate, you should attempt to corroborate list inside and out . It
these findings during the nursing assessment. If your assessment may affect your care
findings differ, report your findings as appropriate. plan. Get t ing t o
know you…
Medic atio n us e
Be sure to review your patient’s current medication use. Ask
about prescription drugs, OTC drugs, and herbal remedies. List
these medications on the patient’s chart when he’s admitted to the
facility. Medications that are prescribed during hospitalization are
listed on a medication administration record (MAR). Look closely
at the details of each drug order.
Look before you leap

Before your clinical rotation or first patient contact, check your
patient’s list of prescribed drugs and their dosages and make sure
AS S ES S MENT
34
that you know what adverse reactions and interactions these drugs
could cause. Also find out if the patient understands the purpose
of each drug; this will help determine if he needs additional teach-
ing during hospitalization or at discharge. If appropriate, ask about
the patient’s previous medication use as well, find out if he experi-
enced adverse reactions, and ask about recreational drug use.
If you question a drug, dosage, or route listed on the MAR,
double-check the original order in the medical record first, and
then call the pharmacy or practitioner as appropriate. In the home
care setting, check the labels on the patient’s prescriptions and
call the pharmacy or the practitioner to validate discrepancies
between the labels, the patient’s statements, and the physician
orders in the nursing record.
Medic al pro ce dure data

Review the medical procedures scheduled for your patient. Know-
ing which procedures the patient is scheduled for can help you
anticipate potential problems and alert you to postprocedure signs
and symptoms to watch for.
For example…
If the patient is scheduled for myelography, you would expect
to verify the allergy history, looking particularly for an allergy to
iodine or other contrast materials, and notify the referring practi-
tioner and radiologist of new information. You would also expect
to explain to the patient what’s going to happen before, during, and
after the procedure, including transfer to the radiology suite, and
instruct him about procedure restrictions, including the need to:
• withhold solid foods and certain medications before the test
• void right before the test
• remove any jewelry
• maintain a side-lying, fetal-type position during injection of
the contrast medium into the spinal canal by the radiologist just
before the test.
Similarly, if the patient has just undergone a procedure involv-
ing anesthetics or other medications, you would know to assess
for adverse reactions to these agents.
Admitting medic al diagnos is

You should also review the patient’s medical diagnosis. Deter-
mine if your patient’s current complaints and assessment findings
match his admitting diagnosis. If you uncover new information,
report it to the practitioner because these new findings may affect
the treatment plan. Make sure you understand the meaning and
implications of your patient’s medical diagnosis—including its
DATA COLLECTION AND ORGANIZATION
35
pathophysiology, signs and symptoms, required diagnostic tests,

treatments, complications, preparation for procedures, and post-
procedure care. This information helps you focus your assessment.
Special cons iderat ion

If your patient is diagnosed with ulcerative colitis, for instance,
you would realize that he’s more prone to develop anemia due to
internal bleeding. Consequently, you would be sure to monitor his
hematology reports, check his vital signs frequently, and observe
elimination patterns and changes. On the other hand, for a patient
admitted with diabetes mellitus, you would stay alert for signs and
symptoms of hypoglycemia or hyperglycemia.
Da t a c o lle c t ion a n d orga n iza t ion

Every nurse must know how to collect and organize patient data
in a meaningful format. Doing this helps you formulate correct
nursing diagnoses and allows other health care team members to The dat a you
readily understand the data you’ve documented. collect on your
In your educational process, you are often asked to organize pat ient can be
your information by functional health patterns. In the clinical set- overwhelming. Good
ting, many different types of integrated or specialty assessment t hing t hat t here
database formats may be used, according to the regulations and are s yst ems for
organizing all t hese
specific requirements for that facility. dat a.
Go rdon’s func tio nal he alth patte rns

To organize and analyze the patient data you collect, you may
want to use the functional health patterns and rating scale pro-
posed in 1987 by Marjory Gordon. Gordon’s functional health cat-
egories include:
• health perception and management
• nutrition and metabolism
• elimination
• activity and exercise
• cognition and perception
• sleep and rest
• self-perception and self-concept
• sexuality and reproduction
• roles and relationships
• coping and stress management
• values and beliefs.
These 11 categories provide a framework for a systematic, stan-
dardized approach to data collection.
AS S ES S MENT
36
You can use Gordon’s functional health patterns to obtain a

nursing history from the patient’s perspective through a series of
specific questions. These patterns are flexible and adaptable and
can be used for patients in various states of health, from different
age-groups, and in different clinical settings. Gordon’s functional
health patterns have also become an integral part of many nursing
database documentation systems.
Deciphering code
To document your patient’s functional health patterns, you’ll
assign a code based on a five-point scale that rates the ability of the
patient to function independently. (See Assi gni ng fun cti on a l level
codes.) By focusing on each health pattern in turn, you can better
evaluate your patient’s overall level of health and well-being.
Health perc eption and manageme nt

To obtain data about the health perception and management pat-
tern, ask questions that help determine the patient’s:
• perception of his level of health
• detrimental habits, such as smoking or excessive alcohol use
• actual or potential problems related to safety and health manage-
ment or the need for home modifications or continued care at home.
Gordon s ays
Activity and exe rcis e t hat nut rit ion and
When evaluating the patient’s activity and exercise pattern, assess: met abolis m are one
• the patient’s ability to manage normal ADLs that require energy of t he 11 funct ional
expenditure, including self-care, exercise, and leisure time healt h cat egories .
• major body systems involved with activity and exercise (respira-
tory, cardiovascular, and musculoskeletal systems).
Nutrition and me tabolis m

To assess nutrition and metabolism, ask the patient questions about:
• food and fluid consumption relative to metabolic needs
• adequacy of nourishment
• dietary habits and preferences
• problems related to fluid balance, tissue integrity, adequate nu-
trition, and immunologic defenses
• GI problems.
Elimination
To assess your patient’s elimination pattern, ask questions related
to his excretory patterns (bowel, bladder, and skin) and check for
such problems as incontinence, constipation, diarrhea, and urine
retention.
37
As s igning functional
level codes
Dependent
Some facilities require nurses and
unable t o
to assign codes during patient part icipat e
assessment to describe the
patient’s functional level accord-
ing to Gordon’s functional health
patterns (as shown at right). This
type of scale has been adapted Requires
as s is t ance
to many settings and uses, or
particularly in long-term care s upervis ion
from
assessments of activities of daily anot her
pers on and
living. As a student, your instruc- us e of
equipment
tor may also require you to grade or device
the patient’s functional level.
Grading system
If you’re asked to assign func-
tional level codes, you’ll grade Requires
as s is t ance
the functional level of the patient or
s upervis ion
on a scale of 0 to 4 in each of the from
11 categories described in the anot her
pers on
text. You’ll also assign a code
that most closely describes the
patient’s overall functional level.
Code name “Outcomes”
Functional levels can also be
Requires
incorporated into your expected us e of
equipment
outcomes. To do this, you would or
device
include a reference to the func-
tional level you expect the patient
to attain as a result of your nurs-
ing interventions and other col-
laborative care. Say, for example,
a patient is receiving rehabilita-
tion after a hip fracture repair.
Based on your initial assessment,
you rate his functional mobility
level as 3 because he requires
supervision to stand up and walk
safely with a walker. Your expected outcome statement might read: “Attains functional mobility level of 1 as demonstrated
by standing up and walking 15′ with a cane, unassisted, by discharge.” You’ll read more about writing outcome statements
in chapter 4, Planning.
AS S ES S MENT
38
Slee p and res t

When assessing the patient’s sleep and rest pattern, inquire about:
• sleep, rest, and relaxation practices
• dysfunctional sleep patterns, fatigue, and responses to sleep
deprivation.
Cognition and perce ption

To assess cognition and perception, evaluate the patient’s:
• ability to comprehend and use information
• sensory and neurologic functions
• sensory experiences, such as pain and altered sensory input.
Se lf-pe rce ptio n and s elf-co nc ept

To assess your patient’s self-perception and self-concept, evaluate:
• attitudes toward self, including identity, body image, self-worth,
and self-esteem
• response to threats to self-concept.
Se xuality and repro ductio n

To assess the patient’s sexuality and reproduction pattern, evaluate:
• satisfaction or dissatisfaction with sexuality patterns and repro-
ductive functions
• sexuality concerns.
Roles and relations hips

To assess your patient’s roles and relationships, evaluate:
• roles in the world and relationships with others
• satisfaction with roles
• role strain
• dysfunctional relationships.
Coping and s tres s manage me nt

Explore your patient’s coping and stress management pattern by
asking questions about his:
• perception of stress and coping strategies
• support systems
• symptoms of stress
• effectiveness of coping strategies in terms of stress tolerance.
Value s and belie fs

To assess the patient’s values and beliefs, evaluate:
• religious or spiritual orientation
• goals and values that guide decisions.
39
Integ rate d and s pe c ialty databas e formats Memory

jogger
For consistency, most health care facilities require that staff docu-
ment assessment findings using standardized formats. Typically, To re-
history and physical findings are on the same form. The purpose of member
Gordon’s
using a standardized format is to provide a comprehensive, consis- funct ional pat t erns ,
tent, understandable framework for nursing data. (See The J oi n t t hink of t he s logan
Com m i ssi on sta nda r ds for i n i ti a l a ssessm ents.) Standardized “Hey Nurs e! Every
formats enhance information exchange and communication among Act ion Can St art ,
staff members and, when necessary, among health care facilities. St imulat e, St op, or
However, when a standardized format is used, nurses typically Revers e your Care
adapt their assessment techniques to the flow of the form. Because
Vict ory!”
most facilities use computerized documentation, nurses typically Healt h percept ion
enter their assessment findings directly into a computer. (See and management
In tegr a ted a dm i ssi on da ta ba se for m , pages 40 to 43.) Nut rit ion and
met abolis m
Cus t om or generic? Eliminat ion
Some facilities use assessment forms customized for their particu-
Act ivit y and
lar needs; others use more generic forms developed by outside exercis e
vendors. These forms can be downloaded from the vendor either
free or for a fee, depending on the vendor. Some standardized Cognit ion and
forms are designed to promote closer monitoring and evaluation
percept ion
of patient status trends, patterns, and longitudinal observations Sleep and res t
and changes. They’re especially useful in critical care areas, where Self-percept ion
the patient’s status can change in mere moments. and s elf-concept
( Text con ti n u es on pa ge 44.) Sexualit y and
reproduct ion
Roles and
relat ions hips
Coping and s t res s
management
The Joint Commis s ion s tandards for initial
Values and beliefs
as s es s ments
The Joint Commission has developed standards for the initial nursing assessment of
patients. The commission determines its standards by examining the criteria of nurs-
ing professional organizations and relevant research. The Joint Commission standards
state that the following items should be considered in an initial assessment:
• physical factors
• psychological, social, and cultural factors
• environmental factors
• self-care capabilities
• learning needs
• discharge planning needs
• input from the patient’s family and friends, when appropriate.
AS S ES S MENT
40
Integrated admis s ion databas e form

Most health care facilities use a multidisciplinary admission form. The sample form below has spaces that can be filled in
by the nurse, physician, and other health care providers.
MR# 12345678 Holly Smith ABC Hospital

Visit: 1234567891011 Female 12 West
Age: 36 (03/17/1976)
General Information
• Language assistance needed? No
• Source of information Patient
• Arrived from Home
• Valuables? Yes
• Type of valuables Cell phone, earrings, rings, tongue and lip rings
• Disposition of valuables With patient
Advance Directive
• Advance directive (medical health care) in place? No
• Advance directive information given to patient Living will brochure; patient will notify staff if assistance is needed
• Durable power of attorney in place? No
• Is there anybody you would like to make medical decisions on your Nancy
behalf in the event that you are unable to?
• Relationship to patient Mother
Spiritual Concerns and Care
• Are you part of a spiritual or religious community/congregation? No
• Do you have any spiritual, religious issues/concerns? No
• Do you consent to have your name appear on the spiritual care No, patient does not want spiritual or religious preference published
visitation listing? or listed
Allergies
• Fish Reaction: Unknown
• Vancomycin Reaction: Itching
• Doxycycline Reaction: Undefined
Health and Illness
Current health and illness:
• Expected length of hospitalization Unsure
• Primary care physician Dr. Josephine Smith
• Services anticipated at discharge None
• Anticipated discharge disposition Home
Health and illness history:
• Previous general health Average
• Previous healing pattern Average
• Healing facilitated by Rest
• Factors that prevent following health advice None
• Health maintenance behaviors Adequate sleep
• Previous reaction to anesthesia None
Height and Weight
• Actual height (ft): 5’
• Actual height (in): 3”
• Actual height (cm): 160 cm
• Actual weight (lbs): 141 lb
• Actual weight (kg): 64 kg
• Actual body surface area: 1.66 m2
• Actual body mass index: 24.9 kg/m2
• Actual weight 1 year ago: 154 lb
Nutrition and Metabolism
• Diet before admission (any restrictions, preferences) Regular
• Current appetite Fair
41
Integrated admis s ion databas e form (continued)
• Does patient have access to food? Yes

• Who prepares meals? Self
• Nutrition support None
• History of eating disorder None
Nutrition questions:
• Has patient lost more than 10 lb in the last 2 months No
without trying?
• Has patient been eating poorly over the last month, No
resulting in weight loss?
• Does patient have large or nonhealing wounds or No
pressure ulcers on admission?
Medication Information
• Medications brought to health care facility? Yes
• Medication disposition Sent home with family/friend
Roles and Relationships
• Significant relationships Significant other
• Employment status Currently employed
• Does patient provide primary care for anyone? Children
• Limitations on visitors and phone calls None
Living Environment
• Lives with Significant other
• Living arrangements Apartment
• Home accessibility concerns None
• Financial concerns None
• Available transportation Car
Substance and Tobacco Use
Substance use:
• Substance use Current: Alcohol use
Past: Street drug/inhalant/medication abuse
• Alcohol type Liquor
• Last alcohol use 2/14/12
• Duration of alcohol use (mo/yr) Unsure
• Alcohol frequency Monthly or less
• Alcohol amount 1-2 drinks
• Problems related to alcohol use? No
Tobacco use:
• Tobacco use Quit less than 1 year ago
• Date quit 6/23/11
• Tobacco form 10 menthol cigarettes/day x 14 years
• Exposure to secondhand smoke Consistent exposure at home, in car, or at work
• Consistent exposure Less than daily
• Tobacco cessation information Patient education folder provided; seen by smoking-cessation
counselor
• Date seen 4/12/12
Systems Review
Neurologic:
• Neurologic conditions/symptoms None
General pain information:
• Preferred pain scale Numerical (0-10)
• Chronic pain? No
Sleep and relaxation:
• Normal sleep/rest schedule 6-8 hr/night
• Patient feels rested upon awakening? Yes
• Any problem sleeping? No
• Equipment/aids/routines for sleep Watching television
(continued)
AS S ES S MENT
42
Head, eye, ear, nose, and throat (HEENT):

• Dental care Receives routine dental care
• Dental/oral status Teeth intact, good condition
• Dentures? No
Cardiac:
• Cardiac conditions/symptoms None
Peripheral/neurovascular:
• Peripheral/neurovascular conditions/symptoms None
Respiratory:
• Respiratory conditions/symptoms Chest tube
Gastrointestinal:
• Gastrointestinal conditions/symptoms None
Genitourinary:
• Genitourinary conditions/symptoms None
Reproductive, female:
• Reproductive conditions/symptoms None
Musculoskeletal:
• Musculoskeletal conditions/symptoms Left rib fracture
Mobility/activity:
• Ambulation: supervision/device needed Independent
• Communication: issues/assistive device needed None
• New or unaddressed problems None
Home equipment:
• Any equipment used at home? No
Previous level of functioning:
• Ambulation (0) Independent
• Eating (0) Independent
• Transferring (0) Independent
• Toileting (0) Independent
• Bathing (0) Independent
• Dressing (0) Independent
• Communication (0) Understands/communicates without difficulty
• Swallowing (0) Swallows foods and liquids without difficulty
Current level of functioning (if patient scored 2 or higher for any item, consult Rehab Services):
• Ambulation (0) Independent
• Eating (0) Independent
• Transferring (2) Requires assistance
• Toileting (1) Requires assistive equipment
• Bathing (2) Requires assistance
• Dressing (2) Requires assistance
• Communication (0) Understands/communicates without difficulty
• Swallowing (0) Swallows foods and liquids without difficulty
Skin:
• Skin conditions/symptoms Piercing, tattoo
• Location of piercing(s) Lip
• Location of tattoo Lower back
Endocrine:
• Endocrine conditions/symptoms None
Hematologic:
• Hematologic conditions/symptoms None
43
Oncology:
• Oncology conditions/symptoms None
Mental health:
• Mental health conditions/symptoms Depression
Operations and procedures:
• Operation/procedure Breast augmentation (2007)
• Operation/procedure Computed tomography (7/10/10)
• Operation/procedure Tonsillectomy (2005)
Self-Perception, Coping, and Stress Tolerance
Suicide risk:
• Is patient identified as a suicide risk? No
Abuse screen:
• Have you ever been in a relationship where you have been threatened Yes: emotional and physical
or abused physically, emotionally, or sexually?
• Are you currently in a relationship where you are threatened or No
abused physically, emotionally, or sexually?
• Do you feel unsafe going back to the place where you live? No
• Would you like to speak with a social worker/counselor? No
Learning Assessment
Patient:
• Education level Completed high school
• Barriers influencing readiness to learn Acuteness of illness
• Factors impacting ability to learn None
• Learning preferences Individual instruction, verbal instruction
• Cultural considerations None
• Developmental considerations None
• Religious considerations None
• Other learners Significant other
Other learner:
• Learner Significant other
• Education level Quit high school after 10th grade
• Factors influencing readiness to learn Acuteness of illness
• Factors impacting ability to learn None
• Learning preferences Individual instruction, verbal instruction, skill demonstration
• Cultural considerations None
• Developmental considerations None
• Religious considerations None
Mutuality/Individual Preferences
• Do you have any anxiety, fears, or concerns about your health or care? No
• Do you have any questions about your health care? No
• Is there any information you can provide to help us give you more No
personalized care?
• Verification: Mutuality statement reviewed and discussed with patient, significant
other, or family as appropriate to ensure understanding
• What (if any) limitations would patient like on visitors, television, or None
phone calls?
Admissions Folder
• Admission folder given to patient and/or family, as appropriate Yes, reviewed with patient and/or family
• Instruction review code (2) Meets goals/outcomes
• National Patient Safety Goals reviewed Hand and respiratory hygiene, fall precautions
• Instruction review code (2) Meets goals/outcomes
Electronic signatures: Stephanie Stellato, RN (Signed 4/15/12 0800)

AS S ES S MENT
44
Digit al age
Most health care providers use computerized charting to collect
and organize real-time (or near real-time) patient information from
various monitors. As a nursing student, you’re probably familiar
with these devices in other settings, but expect to need time to
adapt to integrating usage of these devices into your patient care.
Fancy format s
Narrative documentation used to be the primary means of recording
data. But recently, newer formats, such as SOAP charting (subjective
data, objective data, assessment data, and plan), problem-oriented
charting, and flowsheets, have become more common.
Except ional chart ing
Computerized documentation often uses charting by exception.
This type of charting calls for the nurse to record notes only on
abnormal systems or issues. Each facility defines the guidelines
to charting, which may include checklists, definitions of “normal,”
and the necessity for narrative supplements. Follow the guidelines
set by your facility to correctly document nursing care and
assessments.
Specialt y as s es s ment s
Your patient’s age and health status may require you to perform a
more specialized examination. Specialty assessment tools include
the Glasgow Coma Scale, pain rating scales, Mini-Mental Status
Examination, and Dubowitz Gestational Age Assessment. The most
common special assessments are those used for special popula-
tions, such as pediatric, elderly, maternal, and psychiatric patients.
You—t he indis pens able t ool
Although standardized formats, specialty forms, and computerized
data collection enhance and promote information collection and
health care delivery, you—the nurse—are the primary collector of
patient data. No matter what format your facility uses, data gather-
ing and interpretation remain largely nursing responsibilities.
As a nurse, you’re the ultimate—and indispensable—assess-
ment tool. Not even the most sophisticated data collection tool or
device can replace assessment by a skilled nurse.
Id e n t ifyin g growt h a n d d e ve lop m e n t

s ta ge
As children grow, they develop intellectually, morally, emo-
tionally, sexually, socially, and spiritually. They learn to think
IDENTIFYING GROWTH AND DEVELOP MENT S TAGE
45
abstractly and logically, use language, and explore the world

around them. However, some theorists posit that growth and
development don’t end with childhood.
Erik H. Erikson is one of several theorists who explained
how growth and development occur across the life span. As part
of your assessment documentation, your instructors may ask
you to identify which developmental stage your patient’s growth
represents. Although Erikson specifies an age range for each
stage, don’t be afraid to question whether your patient actually
resembles a person facing the issues described. Some individu-
als may be mature beyond their years, while others may never
have resolved the main crisis of a previous stage. Remember that
you must be able to state why you believe your patient is moving
through a particular stage. However, you aren’t expected to be an
expert in this area because you’re still building your observation,
listening, and communication techniques. Becoming familiar with
Erikson’s theory though will help you identify and better under-
stand your patient’s psychosocial needs and may be helpful in
planning a teaching strategy.
Eight is enough
According to Erikson, psychosocial development occurs in eight
distinct stages, which he calls “the eight stages of man.” During
each stage, a specific conflict occurs that the person must resolve.
To resolve the conflict, the person undergoes a personality
change, which gives him the strength to deal with the next devel-
opmental stage. If he can’t resolve a conflict at a particular stage,
he’ll confront it later in life.
Did you My
know t hat as s es s ment
Stage 1: Trus t vs . mis trus t t he human is t hat
During the first stage, which occurs from birth to about head weighs you’re wis e
8 lb? beyond your
age 1, children develop trust if their needs are met. If
years .
their needs aren’t met—or are met unpredictably—they
become mistrustful.
Stage 2: Autonomy vs . s hame and do ubt

The second stage occurs between ages 1 and 3, when
children learn to control their body functions and
become increasingly independent. During this stage,
they prefer to do things themselves and learn autonomy
largely by imitating others. If they aren’t allowed to
be independent or are belittled for their efforts, they
develop a sense of shame and self-doubt.
AS S ES S MENT
46
Stage 3: Initiative vs . g uilt

During stage 3, which occurs between ages 3 and 6, children learn
about the world through play and learn to cooperate with others.
They develop a conscience and learn to balance their sense of
initiative against the guilt they experience for doing something
against their parents’ wishes. If they fail this developmental
stage, as adults they may be immo bilized by guilt and continue to
depend unduly on others.
Stage 4: Indus try vs . infe riority

During stage 4, which occurs between ages 6 and 12, children
enjoy working on projects and working with others. They tend to
follow rules and become competitive. Social relationships take on
great importance. If unrealistic expectations (or what they per-
ceive as unrealistic expectations) are placed on them, they may
develop feelings of inferiority. However, if they develop a sense of
industry, they’ll feel competent to meet life’s expectations.
Stage 5: Ide ntity vs . role co nfus io n

From ages 12 to 18, adolescents experience rapid changes in their
bodies. During this stage, they’re preoccupied with how they
look and how others view them. While trying to meet their peers’
expectations, they also try to establish their own identity. If they
fail to accomplish these tasks, they can suffer role confusion.
If they navigate this stage successfully, they become confident
adults who feel comfortable with who they are.
Stage 6: Intimac y vs . is o latio n

During this stage, young adults (ages 18 through 40) seek mutually
satisfying relationships, including friends and marital partners.
Many of them start families. Those who negotiate this stage suc-
cessfully can experience intimacy on a deep level. Those who fail
to do so become isolated and distant from others. Eventually, they
may withdraw socially.
Stage 7: Ge ne rativity vs . s e lf-abs orptio n

During middle adulthood (ages 35 to 65), work and family take on
great importance. People tend to be occupied with meaningful and
creative work. They strive to contribute to the betterment of soci-
ety and community, to transmit cultural values through the family,
INTEGRATING AS S ES S MENT INTO CAREGIVING TAS KS
47
and to establish a stable environment. As their children leave the

home or their relationships or goals change, major life changes
may occur and they struggle to find new meanings and purposes
(commonly referred to as a m i dli fe cr i si s). Failure to negotiate
this stage successfully can lead to self-absorption and stagnation.
Stage 8: Inte grity vs . de s pair

During late adulthood (ages 65 to death), people look back on
their lives and accomplishments. If they have found a meaningful
role in life, have a positive self-concept, and can be intimate with-
out strain, guilt, or regret, they have a feeling of integrity. On the
other hand, those who despair at their experiences and perceived
failure may fear death as they struggle to find purpose in their lives.
In t e gra t in g a s s e s s m e n t in t o
c a re g ivin g ta s ks
The key to accomplishing multiple responsibilities in a short time
is to view all patient care tasks as opportunities to uncover criti-
cal information. Every contact you have with a patient gives you
an opportunity for assessment. Crucial information may come to
light even during seemingly insignificant interactions. Answering
the call light, assisting with bathing, helping with range-of-motion
exercises, even making casual conversation during treatments and
medication administration—these are all chances to observe the Remember t hat
rout ine caregiving
patient and gather valuable information. t asks provide an
opport une t ime
Example t o collect valuable
assess ment dat a.
Suppose, for example, that you’re beginning your shift assignment.
One of your patients is a 45-year-old woman who was admitted
for cholecystectomy. The nurse presenting the change-of-shift
report notes that the patient has been demanding and
has been continually pressing the call light. The patient’s
chart indicates that her vital signs have been stable, she
has reported good pain control, and she shows no signs
of postoperative complications.
Dig deeper
Instead of simply accepting the “demanding” label used
by the exasperated nurse on the previous shift, you
decide to investigate the patient’s condition and seek
more information, suspecting that the patient’s behavior
AS S ES S MENT
48
could signal something deeper. Instead of waiting for the patient

to press the call light, you take the initiative to check on her fre-
quently. Over the next 2 hours, the patient appears to become
more relaxed.
You decide to use the opportunity of morning care to spend a lit-
tle extra time with the patient and assess her emotional and psycho-
logical status. As the patient washes her face and upper body, you
stand quietly by her side. After a few moments, you ask her how she
feels about her recent surgery and her recovery so far. She confides
that she’s been upset with her care in the hospital and also doesn’t
know how she’ll manage at home. She begins to talk about all the
problems she’s had since the gallbladder attack just before admis-
sion. You listen carefully as the patient finishes washing, interjecting
occasionally to show her that you’re paying attention. As you begin
massaging her back with lotion at the end of the bath, the patient
tearfully reveals that her husband passed away several weeks ago—
important information about the patient that you didn’t previously
know. During the seemingly routine chore of bathing, you have ob-
tained information that could prove crucial to the patient’s recovery
and follow-up care—information that could help you to create a
more appropriate care plan for this frightened, grief-stricken patient.
Dat a uncovered
As you can see from the previous example, taking time to assess
the patient as you perform other caregiving tasks can help you to
build rapport and uncover important patient information that may
be crucial to your care plan.
S t a rt in g a c on c e p t m a p b a s e d on
a s s e s s m e n t d a ta
In nursing school, you gain a tremendous amount of knowledge.
But do you wonder how to put this theoretical knowledge into
practice, especially when you have to care for more than one or
two patients? Do you wonder how to start a care plan from your
assessment data? Let’s look at a possible scenario.
Example
You’re a senior nursing student in your final rotation at a small
community hospital. You’re assigned to three patients on the
medical-surgical unit. But before you can take vital signs on your
patients, you learn you’ll be receiving a pediatric patient from the
ED because the pediatric unit is full. You look at your clinical
instructor, hoping that she’ll step in to change your assignment.
S TARTING A CONCEP T MAP BAS ED ON AS S ES S MENT DATA
49
Instead, she explains that the acuity level in the hospital has
changed and that this will be a good opportunity for you to
explore your clinical skills. Two of your other three patients are
reassigned to other nurses.
The pediatric patient from the ED, John Scott, arrives within
minutes. You observe that he’s anxious, crying, and clinging to his
mother, Christine Scott. The ED nurse gives the following report:
The pa ti en t i s a n 8-yea r -old m a le who ha s ha d a hi gh fever
a n d sever e stom a ch pa i n for the la st 8 hou r s; a bdom i n a l gu a r d-
i n g i s pr esen t. Vi ta l si gn s i n clu de tem per a tu r e, 101.6° F, hea r t
r a te 124 bea ts/m i n u te, r espi r a tor y r a te 28 br ea ths/m i n u te, a n d
blood pr essu r e 132/80 m m Hg. Com plete blood cou n t a n d blood
chem i str y sa m ples ha ve been sen t to the la bor a tor y, a lon g wi th
a u r i n e speci m en for u r i n a lysi s. The pa ti en t i s schedu led for a n
em er gen cy explor a tor y la pa r oscopy wi thi n the hou r to r u le ou t a
r u ptu r ed a ppen di x.
You note that the boy’s mother seems shaken and holds her
child closely. Before leaving, the ED nurse takes you aside and
tells you the mother is worried about the financial impact of this
unexpected surgery. She hands you the patient’s chart and leaves.
Don’t pus h t he panic but t on!

You’re already running behind with your other patient. How can
you possibly fulfill your nursing responsibilities to her and to your
new pediatric patient? You need to admit the pediatric patient,
introduce him to the hospital environment, assemble his chart, When asked t o
a panic part y, t urn
carry out the practitioner’s admitting orders, verify that the neces- down t he invit at ion!
sary consents have been signed, make sure that the laboratory test
results are back, and prepare the child (and his mother) for sur-
gery. What’s more, you need to perform an initial nursing assess-
ment and then organize and document your findings before the
boy goes to surgery so you can begin to develop a care plan.
That’s a tall order for a nursing student—or for a n y nurse. How
would you handle it?
Chances are, you would feel overwhelmed, and your mind
would race with frantic thoughts, such as: “Yikes! I have way too
much to do and not nearly enough time to do it! So much is expect-
ed of me—and so fast. How can I meet all these demands and still
make sure that my other patient is safe and receives good care?”
Serenit y now
Remember not to panic. You’re only human and can’t possibly do
everything at once. Before you can attend to your duties, you must
attend to yourself, so take time to calm down and collect yourself.
One way to do this is to stop, look, and listen. As a child, you were
probably taught to stop, look, and listen before crossing a street.
AS S ES S MENT
50
The same procedure can help you focus when you find yourself
in a stressful patient care situation. In this case, you stop first and
then analyze what you’ve already looked at and listened to.
St op, hey,
St op s ign what ’s t hat sound?
Everybody look what ’s
STOP stands for:
goin’ down.
• Slow down—Anxiety causes the release of adrenaline, a natural
stimulant. (More stimulation is the last thing you need now!)
• Take some deep breaths—However many it takes to calm down.
• Objectify your feelings—That is, treat them impersonally; you
don’t have to deny them, but you can choose to not let them con-
trol your actions.
• Prepare a plan and proceed professionally.
After you accomplish the first three steps, the last one will be
much easier. A plan gives you structure and direction and can be
especially reassuring when you’re feeling stressed out.
You know more t han you know

Once you “stop” as described above, you’ll find you feel less anx-
ious, more in charge, and better able to think like a professional.
Now, you’re ready to analyze and organize the information you’ve
already looked at and listened to—namely, the impressions you
started to form from the time you met the patient and his mother
and heard the ED nurse’s report. That’s right—you’ve been gath-
ering assessment information without really being aware of it.
Let’s look at what you know so far:
• The patient is 8 years old.
• He has a high fever and is in pain.
• He has just been introduced to the strange sights, sounds, smells,
and people in the hospital and has just heard people talking about
him rather than to him.
• He’s old enough to understand what surgery is.
• He’s emotionally upset, and his mother is upset as well.
As you begin your structured nursing assessment, you’ll build
on the developmental, emotional, physical, and social information
you’ve already collected.
Taking t ime for a concept map—what a concept !

Even in a hectic situation such as this, you might quickly sketch a
concept map for yourself to help you focus on what you know and
what you need to know. Utilizing just the data you’ve been given
and what you’ve observed, you can rough out a concept map. (See
Getti n g sta r ted).
After you’ve gathered the patient assessment data, you’re ready
to move to the next step of the nursing process—formulating nurs-
ing diagnoses. As you learned in chapter 1, creating a concept map
helps you organize your thinking and see the big clinical picture.
S TARTING A CONCEP T MAP BAS ED ON AS S ES S MENT DATA
51
Under construction
Getting s tarted
Begin your concept map for the pediatric patient described in text by placing a circle in the center of the page. In that
circle, include the patient’s name, age, and medical diagnosis. Also note that his mother is present, and include her
name.
When you have little information but you need a plan quickly, don’t try to formulate nursing diagnoses for your con-
cept map right off the bat. Instead, jot down main categories of problems as you think of them. For example, you might
start by labeling a box “GI symptoms” because you don’t have enough information to get a handle on which nursing
diagnoses are most appropriate. Include in this box any assessment findings that you collected from your observations
and the shift report. Feel free to use abbreviations in your concept map (as shown below) to save time. Also, leave the
boxes open so that you can add more information as you assess the patient and get his test results. You might not even
want to draw connecting lines right away, but try to visualize the interrelationships in your mind.
Fever Pain
• TPR: 101.6-124-28
• Stomach, severe > 8 hrs
• CBC: pending
• Crying, clings to Mom
• Chem: pending
• BP: 132/80
• U/A: pending
J.S.
Age 8
Dx: R/O ruptured
appendix
Mother (Christine)
present
Anxiety – pt GI symptoms
• Been in ED • Stomach pain
• In pain • Abdominal guarding
• Face anxious • Exploratory
• Crying, clinging laparoscopy scheduled
to Mom
• Told needs emergency
surgery Anxiety – mother
• Face anxious,
shaken
• Holds child tightly
• Financial worries
• Told child needs
emergency surgery
AS S ES S MENT
52
On t he cas e

Benny Hayes, a 38-year-old male, was brought to the emergency
department (ED) after being involved in a boating accident.
According to friends, he suffered a brief loss of consciousness at
the scene. They report that he has a history of asthma. On admis-
sion, Mr. Hayes was groggy but easily aroused, scoring a 13 on
the Glasgow Coma Scale. He complained of blurred vision but
his pupils were equal and reactive to light and accommodation.
Vital signs were stable. He presented with a 3.5-cm hematoma on
his left, posterior temporal area and a deep laceration on his left
forearm. A computed tomography (CT) scan with contrast of the
head and X-ray of the left forearm were normal. His laceration
was sutured and he was given 1 g IV cefazolin via a saline lock, as
ordered. An indwelling urinary catheter was also inserted.
When you start your shift, you are assigned to Mr. Hayes. The
night shift nurse reports that Mr. Hayes was admitted with a con-
cussion. His Glasgow Coma Scale score is now 15, his speech is
normal, and his pupils are equal and reactive to light and accom-
modation. He received 1,000 mg of acetaminophen for a headache
at 6:10 a.m. His left forearm dressing is dry and intact.
As you are organizing yourself to start your care, the charge
nurse tells you that Mr. Hayes’ doctor has ordered removal of the
indwelling urinary catheter and discontinuation of the saline lock
in preparation for discharge. You decide to proceed with your
morning assessment and complete the discharge paperwork be-
fore checking and carrying out these orders.
Critic a l-thin king e xe rc is e #1

When questioned by your instructor, you give three reasons why
you decided to keep the urinary catheter and saline lock in place
until just before discharge. They are:
1.
2.
3.
You review the chart and jot notes in concept map form, while
starting to fill in the discharge sheet you’ll be giving to Mr. Hayes.
ON THE CAS E
53
Complete the concept map below, including the problem labels
(titles for the various boxes), by integrating all of the assessment
information you have so far on Mr. Hayes. Note that information
from the chart review is already added for you.
Infection risk
•
•
• Amoxicillin 500 mg PO
q 12 hr (12 p.m.–12 a.m.)
• Had cefazolin
(Allergy: NKDA)
•
• Night: urine clear, cath
intact
I/O: 360/300
• At scene:
• prn albuterol, last
used 3 days ago w/relief • In ED:
• Lungs clear in ED and •
on floor • Vision blurred; pupils equal
• No c/o dyspnea, and reactive
wheeze •
•
B.H. •
Age 38
• q 2 hr neuro ’s
Dx: Concussion
Laceration L
forearm
Hx asthma
Laceration L forearm
•
• X-ray:
•
• Dsg change q shift:
cleanse with 1/2-str
hydrogen peroxide, rinse
w/sterile saline. Apply
nonadherent layer, one
gauze 4” 8”, gauze
wrap. • Head @ hematoma: annoying,
• Elevate achy, 4/10 (10-point verbal scale)
6 a.m.
• L forearm: (No fractures) stinging,
sharp at times, heavy ache always,
tender to touch or movement, 5/10
6 a.m.
•
• Pain sites same at 6:50 a.m. but
rated 1/10, 3/10
AS S ES S MENT
54
You return to Mr. Hayes’ room to finish your assessment and

redress the laceration on his left forearm. He’s sitting up in a chair
and you notice that he’s sleepy and his speech is slower and less
clear than it had been. Nonetheless, he reports, “I feel fine. I’m just
waiting for breakfast.”
Critic a l thin king e xe rc is e #2

1. The difference in Mr. Hayes’ level of consciousness (LOC) may
reflect:
a. early morning hunger.
b. beginning infection from the indwelling urinary catheter or
arm wound.
c. an increase in intracranial pressure (ICP).
d. a normal variant in some individuals.
2. Your first action after seeing the change in Mr. Hayes is to:
a. call the IV team to obtain a blood sample to send for a chem-
istry profile and complete blood count, while you obtain a urine
sample for urinalysis with culture and sensitivity.
b. take his vital signs; measure his pupils; check the remainder
of his neurologic signs; and assist him into bed with the rails up.
c. put up the bed rails, give him his call light, tell him to stay in
bed, and then leave to find his primary nurse or your instructor
to ask for assistance.
d. apply oxygen and then call the practitioner immediately and
request a repeat CT of the brain or magnetic resonance imaging
of the brain because of a probable subdural hematoma.
Ans wer key

1. If Mr. Hayes’ condition suddenly changed before discharge, an
IV line might be needed for new medications.
2. If an untoward event occurs, the indwelling urinary catheter
will be necessary to assess the patient’s fluid balance.
3. You’re responsible for fully assessing the patient so you can
complete your portion of the discharge plan.
ON THE CAS E
55
Infection risk
• Laceration: prophylactic
antibiotics
• Amoxicillin 500 mg P.O.
q 12 hr (12 p.m.–12 a.m.)
• Had cefazolin
(Allergy: NKDA)
• Urinary cath
• Night: urine clear, cath
intact
I/O: 360/300 Change in LOC
Asthma • At scene: Brief loss of
• prn albuterol, last consciousness
used 3 days ago w/relief • In ED: Groggy, easily aroused
• Lungs clear in ED and • Glasgow: 13/15
on floor • Vision blurred; pupils equal
• No c/o dyspnea, and reactive
wheeze • Hematoma L posterior
temporal area, 3.5 cm diameter
• CT contrast, head: WNL
B.H. • Night: Glasgow 15/15, speech
Age 38 normal, pupils equal and
Dx: Concussion reactive
Laceration L • q 2 hr neuro ’s
forearm
Hx asthma
Laceration L forearm
• Sutured in ED; given 1 g
Ancef IV
• X-ray: WNL
• Night: Dsg dry & intact
• Dsg change q shift:
cleanse with 1/2-str
hydrogen peroxide, rinse
w/sterile saline. Apply
nonadherent layer, one
gauze 4” 8”, gauze Pain
wrap. • Head @ hematoma: annoying,
• Elevate achy, 4/10 (10 point verbal scale)
6 a.m.
• L forearm: (No fractures) stinging,
sharp at times, heavy ache always,
tender to touch or movement, 5/10
6 a.m.
• Had acetaminophen 1,000 mg P.O.
6:10 a.m., allowed q 4 hrs p.r.n.
• Pain sites same at 6:50 a.m. but
rated 1/10, 3/10
AS S ES S MENT
56

1. C. A change in LOC is an early indicator of increased ICP. Hun-
ger and early infection don’t produce this sign. A subtle change in
LOC is suspicious and may be the only early sign of increased ICP
in a patient with a head injury. Pupillary changes are a later sign
of increased ICP.
2. B. Because Mr. Hayes isn’t in acute distress, your first action
would be to assist him to a safer position in case of further deteri-
oration; then you would complete your neurologic check and vital
signs assessment so you can give objective, useful information to
the primary nurse or your instructor. Ordering laboratory work is
out of the scope of practice of the nurse. Making the patient safe
is only a portion of your responsibility when a patient’s status
changes; a focused assessment of the new findings must also be
completed unless the change is severe and beyond your skill level.
There’s no indication in the data given that the patient is in respi-
ratory distress and may need immediate oxygen therapy. Inde-
pendently calling a practitioner for orders is outside the scope of
practice for a student.
3
Nurs ing diagnos is
J us t t he fact s
♦ parts of a nursing diagnosis
♦ types of nursing diagnoses
♦ tips for identifying nursing diagnoses from concept
map data.
A lo ok a t n u rs in g d ia gn o s is Confused by
NANDA's definit ion
Nursing diagnosis is the second step of the nursing process. After of a nursing
you’ve assessed the patient and clustered the findings into related diagnosis ? You’re
areas, you must analyze these clusters to identify the patient prob- not alone. At first
lems that nursing care can address. Next, you’ll create specific glance, it can be a
lot t o s wallow. But
labels—nursing diagnoses—for each of your patient’s problems. break it down int o
bit e-size pieces , and
A definit ion for t he diagnos is it goes down easy!
NANDA International (also called NANDA-I or NANDA, and for-
merly known as the North American Nursing Diagnosis Associa-
tion) defines a nursing diagnosis as a “clinical judgment about an
individual, family, or community response to actual or poten-
tial health problems or life processes which provides the
basis for definitive therapy toward achievement of outcomes
for which a nurse is accountable.”
So what does this really mean? Let’s break down this
definition into digestible parts:
• A health problem is a circumstance such as illness, injury,
or surgery or a lack of knowledge about a health issue.
Examples of life processes include divorce, pregnancy, or
the death of a loved one.
• The problem must be responsive to evidence-based, clearly
outlined interventions.
NURS ING DIAGNOS IS
58
• The nursing diagnosis must reflect a problem for which the

nurse:
– is legally permitted to intervene independently
– can be held accountable for the outcomes.
Gimme t hree s t eps , mis t er

To formulate nursing diagnoses, follow these three steps:
Identify the patient’s problems—using a concept map, if

necessary.
Write a nursing diagnosis for each problem.
Validate the diagnosis. Do you like my new

Suppose your patient reports shortness of breath while walk- work? I call her t he
ing short distances; your assessment reveals nasal flaring, a “Crit ical t hinker.”
rapid respiratory rate, and pursed-lip breathing. When clustering She’s a favorit e
among nursing
these data, you would see that these findings suggest a respira- inst ruct ors .
tory problem. Based on this, you would formulate an appropriate
nursing diagnosis. Usually, your clustered data will lead you to
establish several nursing diagnoses for each patient. You’ll then
arrange these diagnoses based on priority to ensure that you
address the most crucial problems first.
Can’t do wit hout crit ical t hinking

You’ll need all your critical thinking skills to determine which
nursing diagnoses are appropriate and to write diagnostic
statements correctly. For example, understanding anatomy
and physiology of the respiratory system and the way in
which various lung disorders can alter respiratory func-
tion is critical to choosing between the nursing diagnoses
Im pa i r ed ga s excha n ge, In effecti ve a i r wa y clea r a n ce, and
In effecti ve br ea thi n g pa tter n . If you select an inappropriate
diagnosis, you’re likely to choose ineffective nursing inter-
ventions, and your care plan will not only reflect your lack of
understanding but will also fail to help the patient.
P a rts of a n u rs in g d ia gn os is
A nursing diagnosis is commonly referred to as a di a gn osti c
sta tem en t because its format includes all the information that
a nurse would need to quickly understand the factors affecting
a particular patient and the specific symptoms of his problem.
An experienced nurse who’s pressed for time could, therefore,
provide appropriate care for the patient without even reading the
expected outcomes and interventions listed on the care plan.
TYP ES OF NURS ING DIAGNOS ES
59
Nursing diagnoses can have three parts:

Memory
The first part is simply a labe l—for instance, Rea di n ess for jogger
en ha n ced pa r en ti n g. It describes an actual or potential patient When t hink-
problem that nursing care can influence. This part is usually writing about
ten in NANDA-I–approved terminology. t he t hree
part s of a nurs ing
Part two is the e tiology, the related factors that precede, diagnos is , remember
contribute to, or are associated with the patient’s problem. t hat LESS is more.
Examples of related factors include diseases, injuries, birth A nurs ing diagnos is
t hat includes all
defects, inherited patterns, medical conditions, medical proce-
t hree part s , (Label,
dures, psychosocial factors, developmental phases, lifestyle, and Et iology, and Signs
situational or environmental factors. In the diagnosis, the etiology and Sympt oms )
should be preceded by the words “related to,” as in Self-ca r e provides t he mos t in-
defi ci t ( ba thi n g/hygi en e) r ela ted to wea kn ess. format ion about t he
pat ient ’s condit ion.
The third part of a nursing diagnosis is a list of the signs and
symptoms that support the diagnosis. This part is preceded by the
phrase “as evidenced by.” For example, a three-part diagnosis for a
psychiatric patient might read In effecti ve r ole per for m a n ce ( wor k)
r ela ted to depr essi on a s evi den ced by decr ea sed con cen tr a ti on ,
i n cr ea sed da i ly sleep pa tter n , a n d fr equ en t cr yi n g whi le a wa ke.
When t o us e which part s

You may notice that nursing textbooks, journals, and research
papers sometimes refer to only one part of a nursing diagnosis (the
diagnostic label) when defining patient problems. In some cases,
the other two parts may be too specific for the discussion and are,
therefore, unnecessary. In other cases, however, more detail is
required and the diagnosis may include the etiology as well.
The care plans that you write for school or in practice must
include at least the first two parts of the diagnostic statement.
Furthermore, if you’re writing about a patient’s existing problem,
all three parts of the statement would be necessary for another
nurse to understand the patient’s situation. If the patient has the
potential to develop a particular problem but has no current signs
and symptoms, then the correctly written nursing diagnosis would
contain just the first two parts of a diagnostic statement.
Typ e s of n u rs in g d ia gn os e s
NANDA-I recognizes four types of nursing diagnoses:
• actual
• risk
• syndrome
• wellness.
NURS ING DIAGNOS IS
60
Actual diagno s is
An actual nursing diagnosis describes an existing problem—a
human response (individual, family, or community) to a health
condition or life process that’s validated by the presence of major
defining signs and symptoms that cluster in patterns.
Everyt hing’s included

All three parts of a diagnostic statement are required for this type
of diagnosis because:
• a NANDA-I label for the response or problem can be readily
identified: In effecti ve i n fa n t feedi n g pa tter n …
• the etiology can be specified: …r ela ted to cleft pa la te…
Under construction
Adding evidence to the diagnos is

Writing a three-part nursing diagnosis is easy if you take it step by step. After writing the diagnostic label and the
“related to” portion of the nursing diagnosis, add defining characteristics—assessment findings that support the diag-
nostic label you’ve chosen. Precede these findings with the words “as evidenced by.” Defining characteristics can be
either subjective (such as the patient statement “I feel dizzy”) or objective (such as vital signs or physical findings).
For example
For an otherwise healthy patient with an open arm fracture, you collect the following assessment findings:
• vital signs—temperature 98.9° F, pulse 104 beats/minute, respirations 20 breaths/minute, and blood pressure 124/76 mm Hg
• displacement of the humerus of the left arm, 6″ above the elbow
• ragged-edged wound at the site of the injury with localized bruising, swelling, and sanguineous oozing
• displaced fracture of the left humerus on X-ray
• facial grimacing and tearfulness
• pain rating of 6 on a 0-to-10 scale
• constant twitching and movement of the legs
• tight gripping of the side rail by the right hand
• patient statement, “I’m afraid of being put under for surgery. My aunt just died that way” (when told by the orthopedic
surgeon that open reduction and internal fixation of the fracture is the best treatment for this injury).
Given the patient’s statement regarding surgery, one of the nursing diagnoses you should choose is Anxiety; you add
the etiology statement related to fear of anesthesia. Then you should add the statement “as evidenced by” and choose
only those assessment findings most pertinent to this particular diagnosis. Your list should include enough information
to validate your choice of diagnosis but need not include every large and small piece of evidence you collected. In this
example, you would complete your three-part diagnosis with as evidenced by muscle twitching and tension and patient
statement regarding anesthesia for surgery.
TYP ES OF NURS ING DIAGNOS ES
61
• the patient exhibits qualifiable or quantifiable signs and symp-

toms of the response: …a s evi den ced by the i n a bi li ty to for m a
m ou th sea l a n d a bdom i n a l di sten ti on fr om swa llowed a i r .
(See Addi n g evi den ce to the di a gn osi s.)
Risk diagnoses
are easy t o ident ify;
Ris k diag nos is t hey begin wit h t he
words “Ris k for.”
A risk diagnosis describes a potential problem that the patient is
Now t hat ’s ris ky
at risk for developing. This type of diagnosis must: business!
• describe a problem or situation that could be prevented with
proper planning and implementation of appropriate interventions
• be supported by risk factors (assessment findings) that make
the patient more vulnerable to the particular problem.
Ris ky bus ines s

The diagnostic label for a risk diagnosis always begins with
the words Ri sk for . In addition, these diagnoses always
contain only the first two parts of a diagnostic statement.
Because the patient is just at risk for the problem, no signs
and symptoms of the diagnosis are present (and therefore,
you can’t include an “as evidenced by” statement); you’re
simply developing a plan to prevent the problem from occurring.
Say, for example, your patient has a fractured femur, is restricted
to bed rest, and is obese. Based on these assessment findings,
you might formulate a nursing diagnosis of Ri sk for i n ju r y
( thr om bolyti c even t or blood clot) r ela ted to obesi ty, decr ea sed
m obi li ty, a n d bon e fr a ctu r e.
Although the list of NANDA-I–approved diagnoses includes
several risk diagnoses, you may also occasionally need to restate
an actual diagnosis as a risk diagnosis if no other label appears
appropriate.
Syndrome diagno s is
A syndrome diagnosis is a NANDA-I label specifically designed to
serve as a shortcut in special diagnostic situations. A syndrome
itself represents a pattern of signs and symptoms that, when
found together, form a distinct clinical disorder. In medicine,
many such syndromes have been identified—for example, Cush-
ing’s syndrome, acquired immunodeficiency syndrome, and fetal
alcohol syndrome. In nursing, a syndrome diagnosis is used
when a cluster of assessment findings or nursing diagnoses occur
together, showing a specific clinical pattern. Syndrome diagnoses
can be actual or risk diagnoses.
NURS ING DIAGNOS IS
62
Six degrees of s yndrome

Syndrome nursing diagnoses include a label, an etiology, and a
group of signs and symptoms or nursing diagnoses. They always
contain the word “syndrome” in the label. NANDA-I has approved
six syndrome diagnoses:
• disuse syndrome
• impaired environmental interpretation syndrome
• posttrauma syndrome
• relocation stress syndrome
• rape-trauma syndrome
• sudden infant death syndrome.
For example…
An individual with a nursing diagnosis of Ra pe-tr a u m a syn dr om e
might appropriately be given multiple nursing diagnoses, such as
Acu te con fu si on , Acu te pa i n , An xi ety, Di stu r bed body i m a ge,
Im ba la n ced n u tr i ti on : Less tha n body r equ i r em en ts, In som n i a ,
Power lessn ess, and Sexu a l dysfu n cti on . However, a syndrome
diagnosis can be used instead to provide a concise statement
about the correlation among these factors and the rape event.
We llne s s diag nos is Even healt hy people

can be assigned
A wellness diagnosis describes a patient’s response to a level of nurs ing diagnoses.
wellness. Typically, these diagnoses are used for patients who Thes e diagnoses
are already healthy but want to maintain or improve their well- are called wellnes s
ness levels. These diagnoses are more commonly seen in clinics diagnos es .
and other outpatient health care settings but can be used in any
setting.
For example…
Suppose a 57-year-old male patient of normal height and weight
with no history of medical problems wants to optimize his well-
ness by improving his diet and starting an exercise regimen.
An appropriate wellness diagnosis might be Rea di n ess for
en ha n ced self-hea lth m a n a gem en t r ela ted to kn owledge
a bou t a r egu la r exer ci se pr ogr a m . Supporting data would
include an existing wellness level and an expressed desire
for optimal fitness and enhanced wellness.
CREATING NURS ING DIAGNOS ES FROM A CONCEP T MAP
63
Cre a t in g n u rs in g d ia gn os e s from
a c on c e p t m a p
If you used a concept map to plot out your patient’s assessment
data, as described in chapter 2, you can then use that map to help
you define the best nursing diagnoses for your patient.
Example
As an example, let’s expand on the case scenario used in chapter
2 (page 56). You’ve settled the child and his mother into a hospital
room and oriented them to the call light system and telephone
usage. The patient’s and his mother’s responses to your questions
help you realize that they don’t know what’s involved in getting
ready for surgery, what to expect after the surgery, or how long
the surgery might last. The child is focused on his discomfort and
points to the face labeled 8 on a 10-point faces pain rating card.
He lies in the bed holding his abdomen, occasionally moaning, and
complains of increasing nausea and head pounding. His skin is hot
and dry, his color is pale, and he won’t let you touch or listen to
his abdomen. He hasn’t experienced vomiting or diarrhea so far,
and his last bowel movement was yesterday. His blood pressure
is 126/74 mm Hg, temperature 102.4° F, pulse 120 beats/minute,
and respirations 28 breaths/minute. His lungs are clear and all his
peripheral pulses are intact.
Per the surgeon’s orders, you initiate an IV line and start
infusing dextrose 5% in normal saline solution. As you work, you
explain to the patient and mother what you’re doing and why.
You also explain that the surgeon wants the patient to have a
computed tomography (CT) scan of the abdomen before the pro-
cedure. You explain as simply as possible what a CT scan is. You
also explain that the surgeon hasn’t approved any pain medica-
tion because of the impending surgery (pain medication can mask
important symptoms). When the patient is transported to the CT
scan department, you provide more information to the mother on
the surgical process and care after the procedure. The pharmacy
sends up the ordered dose of IV antibiotics preoperatively and you
verify with the mother that the child has no known drug or latex
allergies. You’ve already informed the surgeon of the mother’s
concerns about finances and obtained a referral for the social
worker to visit. Per the mother’s wishes, you’ve also notified the
chaplain that she would like a visit as soon as possible.
With the above data in hand, you update your concept map,
including the laboratory results that have returned. (See Con cept
m a ppi n g for di a gn osi s, page 64.)
NURS ING DIAGNOS IS
64
Concept mapping for diagnos is

Now that you have more information, you can update your concept map by adding all the assessment data you’ve
collected (as shown here in color) or just adding a few reminders based on the health assessment form you completed
for admission.
Fever
TPR: 10 1.6 -124-28 ; 10 2.4-120 -28
CBC: pending; WBC 17,0 0 0 Pain
Chem: pending; WNL St omach, severe; st ill, moans soft ly;
U/A: pending; WNL faces scale 8 /10
Skin: hot , dry, color pale > 8 hr
C/o headache Crying, clings t o Mom; lies st ill, holds
IV: D5 NSS abd, refuses exam
ABT ordered IVpres urgery BP: 132/8 0 ; 126 /74
J.S.
Age 8
Dx: R/O rupt ured appendix
Mot her (Christ ine)
present
GI s ymptoms
St omach pain; ent ire abd now
Anxiety – pt Abdominal guarding; refuses
Been in ED Anxiety – mother exam
In pain—cont inues; doesn’t underst and Face anxious, shaken Explorat ory laparoscopy sched;
why not t reat ed CT abd preop
Holds child t ight ly; hand on
Face anxious Increasing nausea
child cont inuously
Crying, clinging t o Mom—st opped now Financial worries; ref t o
Told needs emergency surgery social worker
Told child needs emergency
surgery
Ref t o chaplain
Spiritual dis tres s
Want s chaplain
65
Cre ating a pro ble m lis t

When you develop a nursing diagnosis, you’re translating the
patient’s history data, physical findings, and laboratory data into
a statement about his clinical status, responses to treatment, and
nursing care needs. A good way to start is to use the assessment
information you’ve gathered to develop a problem list, which
describes the patient’s problems or needs. To help generate the
list, you might want to use a conceptual model, such as Gordon’s
functional health patterns or a concept map.
Problem child
In the problem list, identify your patient’s problems and needs
with simple phrases, such as “high fever” or “GI distress.” Then
look at the assessment data categories, such as activity-exercise
pattern or health maintenance pattern. For each category, deter-
mine if your patient is having a problem or is at risk for develop-
ing one. Then formulate a tentative nursing diagnosis for each
problem or potential problem. (See Pr oblem s, pr oblem s li st.)
Problems , problems lis t

Once all of your assessment data are updated on your concept map, you can analyze
these data to create a problem list. Find a corner on the map and list the problems
you’ve noted. Then begin to rough out the nursing diagnoses you believe
might match those problems. For example, a problem list for the
patient concept map at left might include the fol-
lowing problems and potential diagnoses.
PROBLEMS
• F e ve r , WBCs: H yp e r t he r m ia, De f icie n t f lu id vo lu m e ,
Risk f o r in f e ct io n
• GI sx: I n e f f e ct ive p r o t e ct io n ; Risk f o r in j u r y;
N au se a; Risk f o r in e f f e ct ive gast r o in t e st in al t issu e
p e r f u sio n
• Pain : Acu t e p ain
• An xie t y, m o t he r : An xie t y, Sp ir it u al d ist r e ss, St r e ss
o ve r lo ad , Co m p r o m ise d f am ily co p in g
NURS ING DIAGNOS IS
66
Writing a diag nos tic s tate me nt

As previously mentioned, the primary nursing language used in
schools of nursing today, as well as in most health care facilities
and agencies, is that of NANDA-I. Using NANDA-I–approved nurs-
ing diagnoses advances a standard nursing language, promotes
reimbursement of medical costs, and supports electronic
documentation of patient care.
NANDA-I diagnoses, definitions, related factors, and defining
characteristics, as well as the taxonomy derived from them, are
constantly changing to reflect newly identified needs and the lat-
est research. NANDA-I meets every 2 years to review and revise
existing nursing diagnoses and approve new ones. However,
debate still continues on specific wording issues, appropriate-
ness of certain words across cultures and nations, and whether
the language is truly adequate to express the close collaboration
between nurses and practitioners in managing and preventing
disease complications.
Tale of t he t axonomy
In 2000, NANDA-I changed its nursing diagnosis classification
system from the original alphabetical listing, called Taxonomy
I, to a conceptual system called Taxonomy II. The new system
is based largely on Gordon’s functional health patterns, but with
some adjustments to reduce misclassifications and redundancies.
(For more information on Gordon’s functional health patterns, see
page 35.)
Taxonomy II has three levels:
• domains
• classes
• nursing diagnoses.
Each domain includes several classes. For instance, the
self-perception domain has three classes—self-concept, self-
esteem, and body image. (See Di ffer en ti a ti n g the dom a i n s.)
Each class, in turn, has numerous approved nursing diagnoses.
The self-esteem class of the self-perception domain, for instance,
has three nursing diagnoses—chronic low self-esteem, situational
low self-esteem, and risk for situational low self-esteem.
As of 2012, NANDA-I has approved a total of 216 nursing
diagnoses. (See Wa n ted: New n u r si n g di a gn oses, page 68.)
Dazed and confus ed

Some nurses have trouble writing nursing diagnoses because they
find NANDA-I’s terminology complex and the taxonomy confus-
ing. Rather than listing diagnostic labels strictly alphabetically,
NANDA-I lists the labels alphabetically “by diagnostic concept.”
67
Differentiating the domains

NANDA International divides its 216 nursing diagnoses into 13 broad
categories called domains (or spheres of activity):
• Health promotion
• Nutrition
• Elimination and exchange
• Activity/rest
• Perception/cognition
• Self-perception
• Role relationships
• Sexuality
• Coping/stress tolerance
• Life principles
• Safety/protection
• Comfort
• Growth/development.
Dividing the domains

Each domain has up to six subdivisions called classes. The domain of
Health promotion, for instance, has two classes—health awareness
and health management. On the other hand, the Safety/protection
domain has six classes—infection, physical injury, violence, environ-
mental hazards, defensive processes, and thermoregulation. A total of
47 classes exist among the 13 domains.
Adapted from NANDA International, Nursing Diagnoses: Definitions and Classifi-

cation, 2012-2014. NANDA International, 2012.
However, nurses who aren’t familiar with the concepts contained

in the list can spend time searching for a label. For example, if a
patient has bowel and bladder incontinence, you might reason-
ably think the major concept is incontinence and go to the letter I.
However, “bowel” and “urinary” (not “bladder”) are the diagnostic
concepts that NANDA-I links to incontinence.
Another reason that NANDA-I can be difficult to use is that not
all the problems you identify on your concept map can be readily
found in NANDA-I terminology. Remember the boy with
GI symptoms from chapter 2? You might start looking for nursing
diagnoses for this patient under the letter “G” (for gastrointes-
tinal), figuring that diagnoses related to stomach pain would be
listed there. But you find none! Now what? Here’s where critical
thinking can be helpful.
NURS ING DIAGNOS IS
68
Wanted: New nurs ing diagnos es

NANDA International (NANDA-I) is seeking new nursing diagnoses to
include in its taxonomy. Registered nurses are invited to submit new diag-
noses they believe would be useful to their practice to NANDA-I’s Diag-
nosis Development Committee (Diagnosis Review Committee). For details
about submitting new diagnoses, visit www.nlinks.org or www.nanda.org.
Crit ically acclaimed

You apply your critical thinking skills by proposing these two
questions to yourself and then answering them:
1. What type of physiology has been disrupted when severe
abdominal pain and guarding and nausea are present? (An swer :
Function of the GI tract)
2. At the simplest level, what patterns of function (NANDA-
I domains) are presently most disrupted by this dysfunction
within the GI tract? (An swer : Nutrition, activity and rest, coping
69
and stress tolerance, safety and protection, and comfort).

(See the appendix NANDA-I nursing diagnoses by domain,
pages 272–274.)
St airway t o labels
Next, follow these six steps to identify the NANDA-I terminology
that best describes your patient’s problems:
1. Look over the diagnoses listed under “Nutrition.”—You decide
there isn’t enough evidence to support any of these diagnoses at
this time.
2. Move on to the “Activity and rest” domain.—The diagnosis Inef-
fecti ve ti ssu e per fu si on (ga stroi n testi n al) catches your eye and
you realize that this is your patient’s underlying problem, regardless
of the exact medical cause. You write this diagnostic label down on
a corner of your concept map or on a second sheet of paper.
3. Check the “Coping and stress tolerance” list.—The diagnosis
An xi ety heads this list, and your concept map shows that the
child and mother are anxious at this time, although for different
reasons. You jot down this label under the previous one.
4. Scan the “Safety and protection” section.—You quickly find
the diagnosis Ri sk for i n fecti on , which fits with the patient’s
elevated temperature, respiratory rate, and white blood cell count.
You add this diagnosis to your list of labels. However, you realize
you’re unsure of the meanings of In effecti ve pr otecti on and Ri sk
for i n ju r y, two other diagnoses in this section.
5. Look up the NANDA-I definitions for these diagnoses and find
the following definitions:
– In effecti ve pr otecti on : “Decrease in the ability to guard self
from internal or external threats such as illness or injury”
– Ri sk for i n ju r y: “At risk of injury as a result of environmental
conditions interacting with the individual’s adaptive and defen-
sive resources.”
Then read the related factors and defining characteristics for the
protection diagnosis and the risk factors for the injury diagnosis,
which help you decide that neither of these diagnoses fit the pres-
ent situation.
6. Finish your search with the “Comfort” domain.—You quickly real-
ize that this domain yields two possible diagnoses: Acute pain and
Nausea. You add them to your growing list of diagnostic labels.
Whole lot t a diagnos es

Now that you’ve chosen the diagnostic labels that best represent
your assessment of the patient’s problems, you must complete the
diagnostic statements. This means returning to your label list and
filling in the second and third parts of each statement, as appropri-
ate. For additional tips on writing nursing diagnoses the right way,
follow the guidelines outlined in The do’s a n d don ’ts of n u r si n g
di a gn oses, pages 70 and 71.
NURS ING DIAGNOS IS
70
Under construction
The do’s and don’ts of nurs ing diagnos es

Many nurses have trouble writing nursing diagnoses using NANDA International (NANDA-I) terminology. Some find the
language complex, abstract, vague, wordy, or clinically not useful. The following do’s and don’ts may help you to muddle
through the mass of NANDA-I’s diagnoses to determine appropriate diagnoses for your patients.
Do conception despite the recommendation for abortion to

• Write diagnoses for problems that nurses are licensed save the patient’s life
to treat and that nursing interventions can resolve. – CORRECT: Moral distress related to high risk of patient’s
– INCORRECT: Uncontrolled blood pressure and recur- death unless fetus is aborted as evidenced by patient’s
rent gastroesophageal disease (daughter) related to statements of belief in the sanctity of life at conception
mother’s dependency on adult child for personal care as • Include only the diagnostic label and cause in all po-
evidenced by mother’s inability to be safe when alone tential (Risk for) nursing diagnoses.
and impaired functional capacity for personal hygiene – INCORRECT: Risk for infection related to
– CORRECT: Caregiver role strain (daughter) related to chemotherapeutic immune
mother’s dependency on adult child for personal care system suppression as evi-
and nurture as evidenced by mother’s inability to be denced by probable drug nadir
safe when alone and impaired functional capacity for in 10 days
personal hygiene – CORRECT: Risk for infection
• List the diagnostic label first and the medical cause (eti- related to chemotherapeutic
ology) second. immune system suppression
– INCORRECT: Inadequate problem solving related to
Don’t
ineffective coping
• Write a diagnosis that focuses
– CORRECT: Ineffective coping related to inadequate
on a medical problem. (Nurses
problem solving
are only licensed to treat nursing
• Make the diagnosis clear and precise.
problems.)
– INCORRECT: Ineffective community coping related
– INCORRECT: Heart failure
to fear of their children catching meningitis from other
related to acute myocardial in-
school children who were close to the two girls who
farction and atrial arrhythmia
have meningitis as evidenced by the parents frequently
– CORRECT: Decreased car-
keeping their children home from school and calling the
diac output related to cardiac
practitioner to beg for antibiotics
muscle death from a blood clot
– CORRECT: Ineffective community coping related to
and atrial arrhythmia
acute meningitis outbreak as evidenced by decreased
• Write a diagnosis that focuses
school attendance and markedly increased calls and
on a nursing goal.
visits to local health care providers
– INCORRECT: Promote early
• Include the diagnostic label, etiology, and signs and
postoperative ambulation re-
symptoms in all actual nursing diagnosis statements.
lated to risk of prolonged im-
• – INCORRECT: Moral distress as evidenced by pa-
mobility
tient’s statements of belief in the sanctity of life from
71
The do’s and don’ts of nurs ing diagnos es (continued)
– CORRECT: Ineffective peripheral tissue perfusion related to risk of decreased tissue perfusion
related to prolonged postoperative immobility (respiratory)
• Write a diagnosis that focuses on difficulty accomplish- – CORRECT: Risk for decreased cardiac tissue perfusion
ing a nursing intervention. related to postoperative immobility and minute thrombo-
– INCORRECT: Difficulty administering tube feedings emboli seen on ventilation-perfusion scan
related to gastrostomy feeding tube insertion as evi- • Say the same thing twice.
denced by kinking of feeding tube – INCORRECT: Total urinary incontinence related to un-
– CORRECT: Imbalanced nutrition: Less than body re- predictable urine loss
quirements related to difficulty swallowing and initiation – CORRECT: Total urinary incontinence related to spinal
of feeding by gastrostomy tube cord injury as evidenced by inability to sense or contract
• Create a diagnosis for a treatment or diagnostic test. the urinary sphincter
– INCORRECT: Ventilation-perfusion scan and com-
puted tomography scan of the lungs with contrast
Collaborative c are
Not all nursing diagnoses can be managed solely by the nurse.
To meet desired patient outcomes, some diagnoses require
collaborative management by the nurse with a doctor, a nurse
practitioner, a physician’s assistant, a pharmacist, a dietitian, a
social worker, a physical therapist, a clergyperson, or another
health care professional. (See Con cer n s a bou t colla bor a ti ve ca r e,
page 72.)
Elaborat ion on collaborat ion

Collaborative care is care for which:
• the practitioner is responsible for ordering definitive treatments
or tests
• the nurse is responsible for implementing medical orders, acting
under medically approved protocols, monitoring the patient, and
taking measures to prevent complications, as needed
• the nurse may coordinate care with another health care profes-
sional under the direction of a practitioner.
Most collaborative care is tied to physiological complications
that a nurse must monitor to detect their onset or manage
changes in patient status. Examples of proposed collaborative
care diagnoses might include:
• Ri sk of hypovolem i c shock r ela ted to blood loss
• Ri sk of postoper a ti ve com pli ca ti on s
• Ri sk of a r r hythm i a r ela ted to per m a n en t pa cem a ker
m a lfu n cti on .
NURS ING DIAGNOS IS
72
Concerns about collaborative care

Educational institutions, health care agencies, nursing professionals, and specialists
on the language of nursing incorporate documentation of collaborative care within the
nursing care plan in various ways.
Collaborative problem list

Lynda Juall Carpenito-Moyet, an expert on nursing diagnoses, has long advocated for
care plans to include a “Collaborative Problem” category that describes physiological
complications for which practitioners prescribe treatments but nurses monitor and
carry out the medical and any related nursing interventions. She recommends that
these problems be listed with the nursing diagnoses at the beginning of a nursing care
plan and be preceded by the letters “PC,” meaning “potential complication.” Examples
could include:
• PC: Bleeding
• PC: Pneumonia.
Nursing intervention labels

Other specialists in nursing language indicate that the collaborative nature of patient
care is best reflected in the nursing interventions. Thus, they list interventions as
“independent” or “collaborative.” Independent interventions are those that a nurse can
prescribe for a human response or condition that she’s legally permitted to treat.
For example, a patient who’s experiencing hard stools while hospitalized may be
assigned a nursing diagnosis of Risk for constipation. For this diagnosis, standards of
nursing care would recommend such nursing interventions as providing the patient
with adequate oral fluids, assisting the patient to ambulate in the hall twice per day,
and teaching the patient the importance of choosing foods high in fiber. However, if the
patient reports that he regularly used a stool softener at home, collaborative interven-
tions would include reporting these findings to the practitioner and administering a daily
stool softener as prescribed.
To complicat e mat t ers …

However, not all physiological complications call for collaborative
diagnoses. Suppose your patient is developing a contracture, has
a stage 1 break in skin integrity, or is at risk for an infection from
an external source. In this case, the nurse can initiate and imple-
ment preventive measures or order definitive treatment. Thus, the
problem is considered a nursing care issue for which a nursing
diagnosis is appropriate.
Creat e your own

NANDA-I acknowledges that not all potential nursing diagnoses,
including some that relate to collaborative care, have yet been
73
proposed or validated through their governing body. Therefore,

most educational institutions allow students to include properly
worded but non-NANDA-approved nursing diagnoses in their care
plans. Some facilities label these diagnoses as “collaborative prob-
lems”; others handle these diagnoses in different ways.
The documentation of collaborative care concerns, as with
other non-NANDA-I–approved diagnoses, remains at the discre-
tion of the clinical or educational institution involved. This book
focuses on the correct format of a nursing diagnosis and how
to choose an appropriate NANDA-I nursing diagnosis. The issue
of collaborative care is discussed again in the next chapter as
it relates to expected outcomes and nursing interventions. (See
Choosi n g a NANDA-I di a gn osi s, page 74.)
Remember, nurs es
Comparing nurs ing diagno s e s and t reat t he pat ient ,
not t he disease.
medic al diagnos e s That import ant
Once you become familiar with nursing diagnoses, you’ll clearly dist inct ion is
reflect ed in nursing
see how nursing practice and medical practice differ. Both nurses
diagnos es .
and doctors identify patient problems, but they use different types
of diagnoses and different treatment approaches.
An int eres t ing dis t inct ion

The main difference is that doctors are licensed to diagnose
and treat a medical disease or condition, whereas nurses are
licensed to diagnose and treat a patient’s r espon se to a disease
or condition. So a nursing diagnosis describes a r espon se to a
disease—not the disease itself.
However, nursing diagnoses aren’t limited to patients’
responses to diseases. Nurses also can diagnose the need for:
• patient education
• comfort and counseling
• care until the patient is physically and emotionally capable
of providing self-care.
Anot her not able difference

Another way in which nursing diagnoses differ from medical
diagnoses is that nursing diagnoses may change frequently dur-
ing a patient’s hospital stay or during the recovery process. As a
patient progresses through the stages of illness toward problem
resolution, the nursing diagnoses you formulate for him are likely
to change correspondingly. (See Ada pti n g to cha n ges, pages 75
and 76.)
( Text con ti n u es on pa ge 76.)

NURS ING DIAGNOS IS
74
Teacher knows best
Choos ing a NANDA-I diagnos is

What should you do if you can’t easily identify a NANDA International (NANDA-I) diagnosis that applies to the patient
problem you’ve identified? Use the algorithm below to help you.
If you have reanalyzed the data and are still convinced that no NANDA-I diagnosis is appropriate, consult with your
instructor about using a non-NANDA-approved nursing diagnosis or a collaborative diagnosis.
Reanalyze pat ient

assessment dat a.
Can’t see what a nurs e

Ident ify t he pat ient ’s basic or funct ional could do t o resolve t he
problem t hat nursing int ervent ions can resolve. problem? Ask yourself:
• Did I pick a medical
problem?
• Did I det ermine what
Can’t figure out t he domain?
Det ermine which NANDA I need t o do (nurs ing
As k yours elf:
domain t his problem falls under. goal or int ervent ion)?
• Do I underst and t he
• Did I s elect a t reat -
definit ions of t he different
ment or t est ?
domains correct ly?
• Did I review t he
• Am I t hinking out side t he
anat omy and phys iolo-
box?
gy or pat hophys iology
For example:
of t he problem s o t hat
Readines s for enhanced Find t he diagnosis whose definit ion
I unders t and t he un-
nut rit ionis under “Healt h most closely mat ches t he pat ient
derlying is sues ?
promot ion” NOT “Nut ri- problem you ident ified or assessed.
t ion.”
Impaired gas exchange
is under “Eliminat ion/
exchange” NOT “Act ivit y/
res t ,” as are ot her
res pirat ory-relat ed Look at t he pat ient
diagnos es . Complet e part s t wo and assessment dat a and
t hree of t he diagnost ic rewrit e a problem t hat
st at ement , as appropriat e. nursing care can impact .
Validat e t he diagnosis.
(See t he algorit hm on
page 77.)
75
Adapting to changes
To illustrate the variability of nursing diagnoses vs. the relative stability of medical diagnoses, consider the case of J.D.,
a 69-year-old retired carpenter with a medical history of hypertension and hyperlipidemia. He takes olmesartan and
hydrochlorothia zide (Benicar HCT) 40/25 mg and simvastatin (Zocor) 20 mg daily. He’s married to 64-year-old N.D., who
works 40 to 50 hours per week and is the primary housekeeper, cook, and grocery shopper for the family. Follow his
diagnoses through the course of an acute illness.
Course of the illness Medical diagnoses Nursing diagnoses
While his wife is at work, J.D. develops sudden, se- Rule out: • Risk for ineffective cerebral tis-
vere weakness in his right (dominant) arm and right • Stroke sue perfusion related to hyperten-
lower lip, with milder weakness in the right leg. He • Hypertension sion and possible stroke
calls 911 but can’t relay to the responders what hap- • Hyperlipidemia • Risk for injury related to confu-
pened or a medical or drug history. He’s confused to sion and right-sided weakness
time and place and says anxiously, “I don’t want to • Fear related to sudden body
die.” He’s taken to the hospital, where a computed changes and risk of death
tomography scan shows no signs of cerebral hemor-
rhage or clotting, but his blood pressure is 192/108
mm Hg. J .D. is admitted.
N.D. arrives at the hospital 5 hours later but stays for Rule out: • Risk for ineffective cerebral tis-
only 2 hours. Within these first few hours of admis- • Stroke sue perfusion related to hyperten-
sion, J.D. complains to the nurse about an inability to • Hypertension sion and possible stroke
urinate. A bladder ultrasound shows 600 mLof urine • Hyperlipidemia • Risk for injury related to confu-
in the bladder, and the nurse inserts an indwelling • Urinary tract infection sion and right-sided weakness
urinary catheter. J.D.’s urine culture is positive for (UTI) • Death anxiety related to sudden
infection, and antibiotic treatment is ordered. J .D.’s body changes and risk of death
weakness and confusion don’t progress, and his lip • Urinary retention related to UTI
drooping disappears. His blood pressure decreases
to 186/96 mm Hg. J.D. still expresses fear that “this is
the end.”
Gradually, all of J.D.’s neurologic symptoms disap- • Transient ischemic • Deficient knowledge (patient):
pear, except for some residual disorientation to time. attack (TIA) Medication regimen related to new
J.D. verbalizes understanding that his condition is • Hypertension antihypertensive and anticlotting
treatable. After 3 days, J.D. and N.D. are informed • Hyperlipidemia medications
that discharge is imminent, and the nurse assesses • UTI • Deficient knowledge (patient and
their ongoing care and learning needs. N.D. has vis- wife): Low-salt, low-fat diet related
ited J.D. only briefly each day and states she has little to new diet orders
time to learn a new diet; J.D. says he can’t remember • Risk for injury related to possible
it all. J.D. is discharged from the hospital with a refer- recurrence of TIA or stroke
ral for home care services due to ongoing concerns
for home safety and health maintenance and the
need for more teaching regarding blood pressure
management.
(continued)
NURS ING DIAGNOS IS
76
Adapting to changes (continued )
Course of the illness Medical diagnoses Nursing diagnoses
The home care nurse visits J.D. the following • TIA • Deficient knowledge (patient and wife):
evening and completes an assessment. N.D. • Hypertension Low-salt, low-fat diet related to new diet orders
is present for the visit and expresses minimal • Hyperlipidemia • Deficient knowledge (patient): Medication
willingness to learn about recommended regimen and risk factors for stroke related to
dietary adjustments. She states: “I’m just too inadequate time for teaching due to patient’s
busy; I can’t do it all. He needs to do more for learning style (repetition and demonstration
himself and the house. He’s gotten so lazy.” required)
J.D. also admits to not taking his medications • Ineffective family therapeutic regimen man-
regularly before the hospital admission. agement related to interspousal conflict over
roles and skills
• Risk for injury related to deconditioning dur-
ing hospitalization, hypertension, and risk of
stroke or TIA
During the course of J.D.’s care, the home care • TIA • Deficient knowledge (patient and wife):
nurse reports to the practitioner that the patient • Hypertension Multi-infarct dementia
shows difficulty with short-term memory and • Hyperlipidemia • Deficient knowledge (patient and wife):
has a Mini-Mental Status Examination score • Multi-infarct Low-salt, low-fat diet related to new diet
of 26 (indicative of early dementia). The practi- dementia orders
tioner orders a magnetic resonance image of • Impaired memory related to cerebral injury
the brain, which shows signs of multiple small • Risk for injury related to deconditioning dur-
infarctions. N.D. verbalizes more acceptance ing hospitalization, hypertension, and risk for
of J.D.’s care giving needs and willingness to stroke or TIA
learn new skills when the testing shows he
isn’t deliberately refusing to be responsible.
Va lid a t in g n u rs in g d ia gn os e s
After you have finished developing all of the patient’s nursing
diagnoses, you must go back and check each of the statements
again to validate them. Start by determining the correctness of
each diagnostic label, reviewing its definition and defining char-
acteristics or risk factors and comparing them with the patient
assessment data. Then critically analyze your information from
the assessment data and your knowledge of the associated medi-
cal disorders, verifying that you accurately listed the etiology and
stated the specific signs and symptoms that validate the diagno-
sis. This process of review and validation might help you find
mistakes in interpretation of a definition or in placement of the
parts of the statement. (See Va li da ti n g a di a gn osi s.)
VALIDATING NURS ING DIAGNOS ES
77
Teacher knows best
Validating a diagnos is
You’ve completed all your nursing diagnoses statements. What’s next? Validation of the diagnoses. Follow the rest of the
algorithm on your path to understanding the trick to successful nursing diagnosis.
Validat e each diagnosis when complet e.

To do t his, ask yourself: Nursing diagnosis doesn’t
• Do t he label and NANDA Int ernat ional pass validat ion t est ?
(NANDA-I) definit ion mat ch t he pat ient ’s • Recheck t he pat ient as-
problem? sessment dat a for new
• Does t he et iology logically support t he ideas.
label per NANDA-I definit ion? • Check possible movement
• Do t he signs and sympt oms conclusive- of some dat a int o different
ly support t he label and relat ed fact ors clust ers.
(not used for a risk diagnosis)? • Check your definit ion of
t he pat ient ’s basic or func-
t ional problem.
To validat e
St ill can’t validat e? a risk diag-
Priorit ize all diagnoses. There may be no appropriat e NANDA-I nosis , verify
diagnosis for t his pat ient problem. t hat t he
To validat e an act ual pat ient has
nursing diagnos is, verify relevant ris k
t hat t he pat ient has fact ors.
relevant major s igns and
sympt oms . Consult your inst ruct or about :
– obt aining help in using and writ ing
NANDA-I–approved nursing diagnoses
– using a non-NANDA-I–approved
diagnosis
– using a collaborat ive problem diagnosis.
NURS ING DIAGNOS IS
78
Searching for s upport

If most of the patient’s assessment data aren’t consistent with or
don’t support the nursing diagnosis, you can either:
• reassess the patient for additional assessment data that do sup-
port the diagnosis
• revise the diagnosis so it’s consistent with the assessment data.
Don’t initiate the care plan until you’ve validated the diagno-
ses. If you write a care plan based on invalid nursing diagnoses,
you’ll waste time implementing it—and you could jeopardize your
patient’s well-being.
P rioritizin g n u rs in g d ia gn os e s
Usually, you won’t have time to address all—or even most—of the
nursing diagnoses you’ve formulated for your patient. You’ll need
to focus on the most important ones, which means that you’ll have
to be able to prioritize them. Then, when you plan your care, you
address the highest-priority diagnoses first.
High, low, and in bet ween

You can prioritize diagnoses into high, intermediate, and low
priority:
• Hi gh-pr i or i ty nursing diagnoses involve emergency or
immediate physical care needs.
• In ter m edi a te-pr i or i ty diagnoses involve nonemergency needs.
• Low-pr i or i ty diagnoses involve needs that don’t directly relate
to the patient’s illness or prognosis.
For example, for an acute-care patient in a nonpsychiatric
setting, high-priority nursing diagnoses typically relate to air-
way, breathing, and circulation (for example, Decr ea sed ca r di a c
ou tpu t r ela ted to ca r di a c ta m pon a de). Intermediate-priority
diagnoses relate to problems whose resolution can impact the
patient’s speed or degree of recovery but aren’t life-threatening
(for example, Ri sk for i n fecti on r ela ted to i n dwelli n g u r i n a r y
ca theter ). Low-priority diagnoses commonly address anxiety, fear,
self-esteem, or a preexisting chronic problem to which the patient
has adapted (for example, In som n i a r ela ted to va r i a ble shi ft
wor k schedu le a s evi den ced by sleepi n g du r i n g the da y, a wa ke a t
n i ght si n ce hospi ta li zed).
P RIORITIZING NURS ING DIAGNOS ES
79
Priorit izing props

The pyramids have
You can use the problem list you created to help you prioritize myst ical powers.
nursing diagnoses, or you can refer to Maslow’s hierarchy of Mas low’s has t he
needs. This hierarchy classifies human needs based on the power t o help you
concept that physiological needs must be met before more priorit ize nursing
abstract needs can be addressed. (See The power of Ma slow’s diagnos es .
pyr a m i d.)
Out of t ime
You might need to provide a referral to the patient at discharge
to help him manage ongoing recovery or long-term impairment,
problems that a nurse in an acute-care setting can’t fully address.
If you are working in a rehabilitation facility, skilled-nursing
facility, inpatient psychiatric center, or home health care agency,
your care plan should address the long-term needs and concerns
of the patient.
The power of Mas low’s pyramid

Maslow’s pyramid can help you prioritize a patient’s nursing diagnoses. Physiological needs—represented by the base
of the pyramid in the diagram below—must be met first.
Self-actualization
Recognition and realization of one’s potential, growth, health, and autonomy
Self-esteem
Sense of self-worth, self-respect, independence, dignity, privacy,
self-reliance
Love and belonging

Affiliation, affection, intimacy, support, reassurance
Safety and security

Safety from physiological and psychological threat,
protection,
continuity, stability, lack of danger
Physiological needs
Oxygen, food, elimination, temperature control,
sex, movement, rest, comfort
NURS ING DIAGNOS IS
80
On t he cas e
Your patient, Harriet Zoose, has a medical diagnosis of Acu te
exa cer ba ti on of u lcer a ti ve coli ti s. When you obtain her health
history, she tells you that she’s currently experiencing painful
abdominal cramps and has had very frequent bowel movements
containing blood and pus for the past few days. She rates her
discomfort level at a 7 on a 10-point scale. She also states she has
recently had trouble sleeping and feels extremely fatigued. She
says the colitis has drastically decreased her sex drive, which is
causing tension within her marriage.
On physical examination, you assess:
• hypotension
• low-grade fever
• hypoactive bowel sounds
• abdominal distention and tenderness
• pallor.
When you review her diagnostic data, you note that she has
a moderately elevated white blood cell count; slightly elevated
blood urea nitrogen (BUN) level; decreased hemoglobin level,
hematocrit, and total protein level; and a prolonged bleeding time.
An upper GI series performed the previous day found scarred
and stenotic bowel segments, which are obstructing the intestinal
flow.
ON THE CAS E
81
Critic a l thin king e xe rc is e

Together, the nursing and medical diagnoses—and the care plan
overall—should describe the complete nursing care the patient
needs. For this patient, the care plan should include nursing diag-
noses that address her r espon se to her medical diagnoses. List
four three-part nursing diagnoses for this patient. (Note that there
are more than four correct answers.)
1.
2.
3.
4.
NURS ING DIAGNOS IS
82
Ans wer key

Here are some examples of nursing diagnoses that could be
appropriate for this patient:
1. Ri sk for i n fecti on r ela ted to poten ti a l bowel per for a ti on
a n d gen er a l debi li ta ti on
2. Chr on i c pa i n r ela ted to a bdom i n a l cr a m pi n g a n d di sten ti on
a s evi den ced by pa i n sca le r a ti n g a n d pa ti en t sta tem en ts
3. In som n i a r ela ted to a n xi ety a n d u n com for ta ble sen sa ti on s
a s evi den ced by pa ti en t sta tem en ts
4. In effecti ve sexu a li ty pa tter n r ela ted to decr ea sed physi -
ca l en er gy a n d chr on i c, u n com for ta ble physi ca l sym ptom s a s
evi den ced by decr ea sed sexu a l i n ter est per pa ti en t sta tem en ts
5. Defi ci en t flu i d volu m e r ela ted to a cu te di a r r hea a n d blood
loss a s evi den ced by decr ea sed hem oglobi n level a n d hem a tocr i t,
i n cr ea sed BUN level, a n d decr ea sed blood pr essu r e
6. Fa ti gu e r ela ted to decr ea sed hem oglobi n level a n d hem a to-
cr i t, pa i n , a n d exa cer ba ti on of coli ti s a s evi den ced by pa ti en t
sta tem en ts a n d decr ea sed hou r s of sleep
7. In ter r u pted fa m i ly pr ocesses r ela ted to i n cr ea sed sym p-
tom s of u lcer a ti ve coli ti s a s evi den ced by pa ti en t com pla i n ts of
decr ea sed li bi do a n d r esu lta n t m a r i ta l ten si on
4
Planning
J us t t he fact s
♦ skills for developing and writing measurable, achievable
patient outcomes
♦ factors that influence behavior and contribute to patient
compliance
♦ classifications of nursing interventions
♦ guidelines for developing and writing effective nursing Writ ing t he care
interventions plan for a pat ient
really st art s wit h
♦ the relevance of evidenced-based practice in planning planning achievable
care. goals wit h t he pat ient
and deciding t he
best ways t o reach
t hem. Gat hering
Ca re p la n c om p on e n t s ass essment dat a

and developing
nursing diagnoses
After you establish and prioritize a patient’s nursing diagnoses, form t he basis for
you’re ready to identify patient outcomes and develop a written t his plan.
care plan. Recall that the nursing care plan is a written plan of
action designed to help you deliver quality patient care. It’s based
on the problems identified during the patient’s admission inter-
view and includes these three major components:
• nursing diagnoses
• expected outcomes
• nursing interventions.
One s ize does n’t always fit all

Care plans may be traditional (plans that are created from
scratch) or standardized (preprinted plans that can be tailored
to a patient’s individual needs). As a student, you’ll most likely
use some form of traditional care plan format designed by your
faculty until you’ve gained more experience in critical thinking.
You may be instructed to use this care plan in conjunction with
concept mapping. During your clinical rotations, you’ll consult the
P LANNING
84
care plan tool used by the individual facility. Keep in mind that a
patient’s problems and needs can change, so you’ll need to review Tailoring a
the care plan often and modify it as necessary. st andardized care
plan t o each pat ient
Take t hree giant s t eps guarant ees t he best
fit .
Writing an initial care plan involves these three steps:
reviewing the established diagnoses and assessment data if

needed
identifying expected patient outcomes and specific nursing

interventions to attain those outcomes
documenting the nursing diagnoses, expected outcomes, and

nursing interventions in a clear, consistent format.
The first step above was covered in detail in the previous chap-
ters. It’s included here as a reminder that you should know your
patient’s established diagnoses and current status before you be-
gin planning his specific care needs.
Id e n t ifyin g e xp e c t e d p a tie n t
ou tc o m e s
During outcome identification, you must focus on determining
appropriate goals, or expected outcomes, for a patient based on Make sure t hat
the nursing diagnoses you’ve already formulated for him. Remem- t he out comes in
ber, the ultimate goal of your nursing care is to help the patient your nurs ing care
reach his highest functional level with minimal risk and problems plan focus on t he
by the time of discharge. If the patient can’t recover completely, pat ient —not on
your care should help him to cope physically and emotionally with act ions you must
his impaired or declining health. perform.
Keeping it real
With these long-range goals in mind, you need to
identify realistic, measurable expected outcomes
and corresponding target dates for your patient.
Expected outcomes are goals the patient should
reach as a result of planned nursing interventions.
Sometimes, a nursing diagnosis requires more than
one expected outcome.
Outcomes are always geared toward the patient’s
performance—not the nurse’s actions. An out-
come can specify an improvement in the patient’s
IDENTIFYING EXP ECTED P ATIENT OUTCOMES
85
ability to function—for example, an increase in the distance he

can walk—or it can specify the correction of a problem such as Memory
a reduction in pain. In either case, each outcome calls for the
jogger
maximum realistic improvement for a particular patient. To
remember
t he
four neces s ary
The outc ome s tateme nt component s of an
All outcomes must be patient-oriented and expressed in the form effect ive out come
of a statement, called the ou tcom e sta tem en t. For instance, a s t at ement , t hink,
“Be More Careful,
patient with a nursing diagnosis of Im pa i r ed ga s excha n ge r ela ted Timmy”:
to ven ti la ti on per fu si on i m ba la n ce fr om pu lm on a r y em bolu s
might have an expected outcome of “Show decreased work of Behavior
breathing and restlessness and increased oxygen saturation within Meas ure
24 hours of heparin infusion initiation.” Condit ions
Time frame.
Parts o f an o utc o me s tatement
An outcome statement consists of four components:
a specific behavior that shows the patient has reached his goal
criteria for measuring that behavior
the conditions under which the behavior should occur
a time frame for when the behavior should occur. (See I object t o
Un der sta n di n g ou tcom e sta tem en ts, page 86.) s ubject ive out come
st at ement s. Make
s ure t hat your
Be ha vior nursing out comes
A beha vi or is generally defined as an action or response to stimu- focus on behaviors
lation that can be observed or heard. In terms of outcome identifi- t hat can be
cation, it’s something (an action) you would expect to see or hear object ively observed
the patient do as a result of your nursing interventions. or measured.
Object ively s peaking

Always begin your outcome statement with an action
verb that focuses on a behavior you can objectively
observe and measure. Examples of verbs that can be eas-
ily measured by sight or sound include:
• movements (for example, a m bu la te, ba the, cli m b,
gi ve, m ove, per for m , poi n t, u se)
P LANNING
86
Unders tanding outcome s tatements

An outcome statement consists of four elements: behavior, measure, condition, and time frame.
Behavior Measure Conditions Time frame

A desired behavior for the Criteria for measuring the The conditions under When the behavior
patient; must be observ- behavior; specifies how which the behavior should occur
able much, how long, how far, should occur
and so on
Me asu r e s e ach t im e be f o r e e xe r cisin g by 2 / 2 1/ 12

r ad ial p u lse
Am bu lat e o n e f light o f u n assist e d by 2 / 2 1/ 12

st air s
• speech (for example, descr i be, expr ess, r epor t, sta te, ver ba li ze)
• other actions (for example, a r r a n ge, a voi d, dem on str a te,
exhi bi t, i den ti fy, m a i n ta i n , m odi fy, pa r ti ci pa te, seek, set).
Sounds s ubject ive t o me

Although it’s important to consider the patient’s thoughts and
feelings when planning care, these can’t be readily observed or
measured. Avoid beginning an outcome statement with a verb
that’s too subjective to evaluate, such as a ccept, kn ow, a ppr eci -
a te, or u n der sta n d. After all, how can you objectively observe
a patient’s a ppr eci a ti on ? Even when working with a psychiat-
ric patient, you’ll write outcomes based on behaviors—not the
thoughts or feelings that might be influencing the behaviors. For
example, instead of including the outcome “Patient will state that
he feels less depressed,” you might include the outcome “Patient
will obtain a score of XX on the Beck Depression Scale”; this
outcome is a measurable improvement in a patient’s mood.
87
Me a s u re
Memory
Explaining precisely what’s being measured and how it’s being jogger
measured helps gauge your patient’s progress toward achieving
his goal. It also enables you and other team members to work To
different iat e
within consistent parameters, ensuring the systematic evaluation
object ive
of nursing interventions. from s ubject ive
pat ient behavior,
Specifics , pleas e t hink in t erms of
Make sure your outcome statement indicates the criteria needed what you need t o do
to measure the behavior, such as: t o int erpret it :
• how much Object ive—Obs erve
• how long direct ly t hrough
• how far s ight or s ound.
• using what scale. Subject ive—Sens e
what t he pat ient is
Condition s t hinking or feeling.
Stipulate in the outcome statement, as necessary, the conditions
under which the behavior should occur. For instance, tell when
during the day the behavior should occur, how frequently it should
occur, and whether the patient requires any assistance in com-
pleting the action. For example, the outcome statement, “Patient
will drink 360 mL of noncaffeinated fluids on day shift, 240 mL
on evening shift, and 120 mL on night shift,” gives more direction
to staff and sets a clearer goal for the patient than the statement
“Patient will drink 720 mL of noncaffeinated fluids per day.”
Don’t s et t he bar t oo high

Keep in mind your patient’s overall condition, ability to perform
the behavior, and agreement with the proposed target. Make sure
the conditions can be realistically met.
For example, you’re caring for a patient who has had an acute
exacerbation of moderate chronic obstructive lung disease and
now requires oxygen therapy for exertion and sleep. The patient’s
nursing diagnoses include Defi ci en t kn owledge ( m ea su r es to
m a i n ta i n m a xi m u m pu lm on a r y fu n cti on ) r ela ted to m i scon -
cepti on s a bou t the di sea se pr ocess a n d oxygen ther a py a s evi -
den ced by ver ba l sta tem en ts r ega r di n g the di sea se and Acti vi ty
i n toler a n ce r ela ted to di sea se pr ocess a s evi den ced by exer ti on a l
dyspn ea . You’re aware that mild but regular exercise, such as
performing self-bathing and grooming activities, can help the pa-
tient maintain his residual pulmonary function, so you establish
P LANNING
88
an expected outcome of “Bathe independently except for back

and lower legs daily within 2 weeks.” However, this outcome may
not be realistic unless the patient responds to your teaching plan
for Defi ci en t kn owledge. If the patient doesn’t understand the
basis for your outcome statement or doesn’t agree that the goal
is achievable, the expected outcome isn’t realistic. In this situa- Keep t ime in
tion, your outcome timing for the Defi ci en t kn owledge diagnosis mind. Remember t o
must be set before the target date on the bathing outcome, and include a t ime frame
you must be prepared to adjust the bathing outcome statement de- for complet ing each
pending on the patient’s response to the knowledge teaching plan. out come.
Time fra me
Although one of your primary responsibilities as a nurse is
to help your patient achieve the highest level of functioning
or wellness before discharge, you need some way of moni-
toring his progress along the way. All patient outcomes
must provide a realistic time frame for completing the
desired behavior. For example, in a student care plan for a
home care patient you’ll be seeing once a week, you might
have a new outcome statement for each visit, as you assist
the patient to learn to manage his disease process. At some
point in his care, you may then be able to write a longer
outcome target as he gradually integrates new information
and techniques into his daily routine.
The long and s hort of goals

Long-term goals commonly require weeks or months to
achieve. Short-term goals, on the other hand, take much less
time to achieve; these are typically the goals (or outcomes) you’ll
address in your student outcome statement. (See Docu m en ti n g
lon g-ter m goa ls.)
Writing o utc ome s tateme nts

When writing outcome statements, always start with a specific
action verb that focuses on your patient’s behavior. By telling how
your patient should look, walk, eat, turn, cough, speak, or stand,
for example, you give a clear picture of how to evaluate progress.
Choos e wis ely

Be careful about your verb choice, though. Such verbs as “allow,”
“let,” and “enable” focus attention on your own and other health
care team member’s behavior—not the patient’s behavior. In many
cases, you can easily turn around outcome statements that focus
on your behavior so that they focus on the patient. For example,
89
Documenting long-term goals

As a student, the expected outcomes you write will gener- To each his own
ally reflect short-term goals. Your instructors focus your As a practicing nurse, your agency or facility may have a
care plans on outcomes that might be achievable by you different system of handling short-term and long-term out-
during your clinical time with a specific patient. However, comes in its care plans. Some examples are listed here:
to demonstrate that you’re aware of the larger issues • Acute-care settings: Factors affecting discharge plan-
involved in caring for a patient, you’ll also probably be ning are documented on the initial assessment. The
asked to document discharge planning. This is where nursing care plan lists outcomes expected by discharge.
you’ll express the patient’s long-term goals. Some of the Teaching flow sheets and discharge instruction sheets
items you may be asked to include are: are used to document learning need outcomes and patient
• discharge outcomes—specify the outcomes expected status and medical orders plus any referrals or follow-
by the time of discharge up care on discharge. Patients are given a copy of their
• learning needs—list the topics that the patient and fam- discharge instructions.
ily should demonstrate an understanding of by discharge • Rehabilitative, home care, long-term-care settings: The
• referrals—explain possible referrals needed to assist nursing or interdisciplinary care plan lists short-term and
the patient and his family in reaching long-term optimum long-term goals for each diagnosis and specifies dates for
health outcomes reevaluation of each. Discharge planning begins when the
• documentation issues—identify the results of outcome patient has been appropriately reevaluated or requests
evaluation that must be documented. discharge. Preparations for discharge are then listed as a
goal on the updated care plan, as are any continuing care
needs and referrals. A discharge summary is completed
on the day of discharge and a copy is given to the patient.
Find out and follow the documentation procedures at
your facility.
“Medication brings chest pain relief” doesn’t say anything about

the patient’s behavior, but “Expresses relief from chest pain
within 5 minutes of receiving medication” does.
Include t he nit t y-grit t y

Also be sure to make your statements specific. For example, the
statement “Understands relaxation techniques” doesn’t tell you
much. (How do you observe a patient’s understanding?) Instead,
you should write: “Practices progressive muscle relaxation tech-
niques unassisted for 15 minutes daily by hospital day 5.” This
statement tells you exactly what to look for when assessing the
patient’s progress. Choose your words carefully and be clear and
concise. (See Ti ps for keepi n g sta tem en ts con ci se, page 90.)
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90
Teacher knows best
Tips for keeping s tatements concis e

These tips will help you write clear, precise outcome statements:
• Avoid unnecessary words. For example, with many documentation
formats, you won’t need to include the phrase “The patient will…” with
each expected outcome statement. In most cases, it’s obvious that
you’re talking about the patient. However, you’ll have to specify which
person the goals refer to when family, friends, or others are involved.
• Use accepted abbreviations. Refer to The Joint Commission’s and
your facility’s list of approved abbreviations. If your facility’s list de-
scribes patient stays in day-long intervals, use abbreviations such as
“HD1” for hospital day 1 or “POD 2” for postoperative day 2.
• Use a standardized list of patient outcomes, such as the Nursing Out-
comes Classification or the classification system used in your facility. Alt hough your
out come st at ement s
s hould be det ailed,
t ry t o keep t hem
clear and concise.
For your cons iderat ion
When writing outcome statements, consider the patient’s medi-
cal orders. The outcome statements you write shouldn’t ignore or
contradict those medical orders. For example, before including
the outcome statement, “Ambulate 10′ unassisted twice per day by
postoperative day 3,” make sure that the medical orders don’t call
for more restricted activity.
Also, adapt the outcome to the specific circumstances. Consid-
er such health-related factors as the patient’s coping ability, age,
education, cultural influences, family support, living conditions,
socioeconomic status, and anticipated length of stay. Also con-
sider the health care setting. For example, the outcome statement,
“Ambulate outdoors with assistance for 20 minutes t.i.d. by admis-
sion day 5,” might be unrealistic in a facility located within a large
city. (See Fa ctor s a ffecti n g hea lth.)
Pat ient part icipat ion

One way to help ensure the effectiveness of outcome statements
is to encourage the patient to participate in formulating them.
A patient who helps write his outcome statements is more motivated
to achieve his goals. His input, along with family member input, can
also help you set realistic goals. (See Eliciting the patient’s help and
How to obtain better pati en t complian ce, page 92.)
91
Factors affecting health

Various factors can affect your patient’s overall health and ability to achieve wellness.
Keep these factors in mind when developing or modifying his care plan.
Up for a challenge?
Not all outcome statements will be as straightforward to formu-
late as the examples previously presented. In such cases, remem-
bering the four components and identifying each component
separately can help you formulate outcome statements. (See
Fi n di n g the r i ght wor ds i n di ffi cu lt si tu a ti on s, pages 93 and 94.)
Nurs ing Outc ome s Clas s ific ation

As described in chapter 1, the Nursing Outcomes Classifica-
tion (NOC) is a nursing-sensitive, standardized categorization of
patient outcomes that helps nurses evaluate the effects of nursing
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92
Eliciting the patient’s help Weighing

the
Discussing the care plan with the patient and keeping him informed about his progress evidence
and needed changes can be mutually beneficial. The patient remains informed and How to obtain
actively involved in health care decisions, and you elicit his compliance with achiev-
ing the outcomes stipulated in the care plan. Remember to keep the following points in
better patient
mind: compliance
• Discuss the care plan with the patient, and keep him informed whenever the plan In a 2004 article in the
changes. Journal of Nursing
• Assess the patient’s knowledge about his condition or problem. Care Quality, authors
• Explain procedures and review laboratory findings. Maramba, Richards,
• Respect the patient’s wishes in the decision-making process. Myers, and Larrabee
• Begin discussing discharge plans at the earliest appropriate time, keeping the patient reported their literature
apprised of necessary changes to the plan. review research on the
• Seek the patient’s permission to discuss his progress and needs with his family, discharge planning pro-
particularly when planning ahead toward discharge. cess. One of the com-
ponents investigated
was patient satisfaction
interventions. Experience has shown, however, that the outcomes with the care provided.
listed can be useful for other disciplines as well. The authors stated that
“Two studies identi-
Jus t s o we unders t and each ot her… fied patient and family
In order to correlate patient outcomes with specific interventions understanding of the
and evaluate their effectiveness in a way that’s meaningful and patient’s condition, feel-
useful, health care providers must agree on standardized defini- ing prepared to manage
tions of the words used when talking about patient care. Such care after discharge,
standardization serves four main purposes: and being involved in
• It ensures consistent measurement and comparison of patient decisions related to
outcomes. discharge planning as
• It helps validate the effectiveness of nursing care as a compo- predictors of patient
nent of quality, cost-effective health care. satisfaction.” Other
• It further legitimizes the profession of nursing in the health research has shown that
care arena. when patients are more
• It aids in adapting nursing care planning into the electronic satisfied with their care,
health system database.
they’re more likely to
The creators of NOC have done extensive research with prac-
follow the care plan on
ticing nurses and nurse-educators in various settings to determine
discharge.
which words nurses regularly use in discussing the outcomes of
their patient care and which tasks they perform to impact these
outcomes. NOC research is ongoing to validate each outcome and
indicator as well as to add new outcomes.
93
Finding the right words in difficult s ituations

Some of the most difficult nursing diagnoses to work with are those that reflect the patient’s perceptions and feelings
and those that refer to normal human processes such as birth. Let’s look at and work through two examples.
Example diagnosis 1 for example, “immediately,” “within 5 minutes,” “within

In some ways, the diagnosis Risk for disorganized infant 2 hours,” or whatever time you believe is realistic consid-
behavior related to potential intrapartum complications ering the situation.
appears to have a simple outcome: the fetus will be deliv- • Last, state the time frame within which you would expect
ered without experiencing any alteration in normal fetal to accomplish the stated outcomes. In this situation, the
signs indicative of intrapartum complications resulting in time frame can be the period ending with the birth of the
disorganized infant behavior. But how do you word the infant or, for the amniotic fluid, the time after the amniotic
behavior, measure, condition, and time frame in the out- sac has broken.
come statement for this generalized outcome?
Putting it together
One step at a time For this diagnosis, you could make two clear outcome
Here are four steps for constructing an outcome statement statements using the guidelines above:
for this diagnosis: • Maintain fetal heart rate within 120 to 160 beats/minute
• Consider what actual fetal signs you can measure while throughout the intrapartum period until birth.
the infant is in the process of being delivered (the mother • Detect meconium staining of the amniotic fluid by pres-
is in labor). Examples might include fetal heart rate, varia- ence of dark green color of the fluid within 5 minutes of
tions in electronic fetal monitoring patterns, the presence rupture of the amniotic sac.
of meconium staining of the amniotic fluid when the sac As you can probably see, several other possibilities for
has broken, and fetal position or presenting part. Then specific outcome statements exist for this diagnosis. As a
think of an action verb to describe the behavior (sign) you student, you would choose only those for which you could
want to see. Examples might include “Maintain fetal heart be accountable during your clinical time with the patient.
rate” or “Detect meconium staining of the amniotic fluid.” Example diagnosis 2
• Determine the limits for the behavior—in other words, Let’s look at another example with a different type of diag-
the way in which you would measure the success or fail- nosis: Ineffective denial related to new diagnosis of pul-
ure of your outcome. For “Maintain fetal heart rate,” you monary hypertension as evidenced by patient statements,
would want to specify the normal fetal heart rate range “I feel better already. You just let me go home, and I’ll get
during labor, which is 120 to 160 beats/minute. For “Detect back to work in no time” and “I think I was just working too
meconium staining of amniotic fluid,” you would expect much overtime and got exhausted. I just needed a break.”
the amniotic fluid to be clear or have a yellow or green The first tendency would be to write the outcome state-
tinge on rupture of the amniotic sac, not marked by the ment: “Patient will accept his new diagnosis of pulmonary
dark green color of meconium. If staining were present, hypertension by discharge.” However, because “accept”
the infant would be at risk for aspiration of meconium dur- is a subjective verb, this outcome is hard to measure.
ing the intrapartum period. Taking one component at a time, let’s see how to word a
• Outline the conditions under which you would expect reasonable outcome for this patient:
to find the two behaviors listed above. In normal labor, • Objective desired behaviors might include “Describes
the fetal heart rate would remain within the cited limits pulmonary hypertension as the source of changes in
throughout the delivery process. But detection of the color functional capacity,” “Expresses interest in learning more
of the amniotic fluid (the indicator for the risk of aspiration about the disease,” “States understanding of the chronic
of meconium) must be stated more specifically, by saying,
(continued)
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94
Finding the right words in difficult s ituations (continued)
and progressive nature of the disease,” and “Questions hypertension, not overwork or exhaustion, as the source
staff about how the disease may affect his ability to return of symptoms.”
to work after hospital discharge.” • The conditions under which you might reasonably
• Let’s assume that your interactions with the patient expect the patient to demonstrate this desired behavior
have led you to choose “Describes pulmonary hyperten- might be “daily, when queried by nurse.”
sion as the source of changes in functional capacity” as • “Within 3 days of diagnosis” is a clear time frame for the
an attainable behavioral outcome. Possible measure- expected behavior, although a specific date would be
ment of that behavior might be “by citing pulmonary more helpful to other staff nurses.
What NOC is not

Perhaps the most confusing thing about using NOC is under-
standing that a NOC outcome i sn ’t the same as a nursing goal or Don’t be afraid
expected outcome. By definition, it’s an individual patient’s state of NOC. There are
several advant ages
or behavior, including perceptions or subjective states. In fact,
t o us ing t he st an-
NOC outcomes are deliberately designed to be variable, not goal dardized language
specific. What does this mean? It means that a NOC outcome: t hat NOC offers.
• defines a patient’s state at a specific time, which can represent
an improvement or a decline from that patient’s state at an earlier
assessment
• becomes an “outcome” only if it’s assessed after a nursing inter-
vention (thus, a patient’s mobility status on an admission assess-
ment is information, not an outcome)
• is measured along a continuum from negative to positive
• has an associated group of specific state, behavior, or percep-
tion descriptions (called i n di ca tor s) that give examples of the
various components of the outcome
• can apply to any discipline if it uses indicators representative of
the discipline instead of the nursing indicators listed in NOC
• can be reformatted into a nursing goal (outcome statement or
expected outcome) when used with its indicators and in conjunc-
tion with an expected completion date.
How the taxonomy works

NOC is a five-component classification system that’s categorized
according to:
• health domain
• outcome class
• outcome labels
• indicators of the outcomes
• measures of the outcomes and indicators.
95
The big breakdown

Seven different domains and 31 classes are identified in NOC. The
domains are:
• functional health
• physiological health
• psychosocial health
• health knowledge and behavior
• perceived health
• family health
• community health.
NOC around t he clock

NOC currently includes 385 outcomes, each with its own four-digit
taxonomy number, standardized definition, and list of indicators
(behavioral criteria by which the more general outcome can be
evaluated). To assist in quantifying the behaviors listed, a five-
point Likert-type scale is identified for each outcome. (See Get to
kn ow Li ker t sca les—Li ker t or n ot, page 96.) Users of the system
are encouraged, though not mandated, to use the scales provided
in order to maintain reliability and validity of outcome measure-
ment. The system also provides a space for the nurse to document
an outcome target rating for the patient. (See An a tom y of a NOC
ou tcom e, page 97.)
Pract ice your s cales

The Likert scales in the NOC system allow nurses (and other
members of the health care team) to evaluate the patient’s status
from most negative to most positive over time. Examples of scales
commonly used to track outcomes include:
Extremely Substantially Moderately Mildly Not

compromised compromised compromised compromised compromised
1 2 3 4 5
Never Rarely Sometimes Often Consistently

demonstrated demonstrated demonstrated demonstrated demonstrated
1 2 3 4 5
None Limited Moderate Substantial Extensive

1 2 3 4 5
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96
Ice cream?
I st rongly
Get to know Likert s cales —Likert or not agree!
A Likert scale, named after Rensis Likert, is a type of psychometric
response scale commonly used in questionnaires. Traditionally,
this scale has been used to gauge a participant’s level of agree-
ment with a particular statement. For example, a participant might
be asked to rate his level of agreement with the statement, “I like
ice cream,” using a five-point scale that includes “Strongly
agree,” “Agree,” “Neither agree nor disagree,” “Disagree,”
and “Strongly disagree.” Each of the categories is assigned
a number (for example, “Strongly agree” = 4; “Agree” = 3;
“Neither agree nor disagree” = 2, “Disagree” = 1; and
“Strongly disagree” = 0) that allows the scale to be
scored. Scores for several items are usually combined
to provide an overall rating. Likert scales can have more
or less than five points; however, five are commonly
used. If Likert scales seem familiar to you, you might have
encountered them on a course evaluation form.
Us ing NOC to write e xpe cte d outc omes

Although NOC outcomes aren’t the same as expected outcomes,
you can use NOC to write outcome statements. Here’s how:
• Go to the “NANDA International–NOC Linkages” section of
the NOC text and find each of the nursing diagnoses you’ve
selected for your patient. Below each one you’ll see the NANDA
International (NANDA-I) definition of the diagnosis and then
lists of suggested outcomes and associated outcomes. (See
Spea ki n g the la n gu a ge, page 98.)
• Choose outcomes from the lists that seem like they might apply
to your patient.
• Find each of the potential outcomes in the alphabetical listing
in the NOC text, and read the outcome definition and indicators to
determine whether the outcome is appropriate for your patient.
• For each appropriate outcome, choose the indicators that apply
to your patient.
• Assign baseline ratings for each indicator as well as an overall
baseline rating.
97
Anatomy of a NOC outcome

Becoming familiar with the organization and components of an individual NOC outcome Outcome Taxonomy
can help you to use NOC to write specific outcome statements for your patients. Below label number
is a sample outcome.
Domain Nutritional Status: Food & Fluid Intake (1008) Patient’s

and class Domain-Physiological Health (II) Care Recipient: name
Class-Nutrition (K) Data Source:
Scale(s)-Not adequate to Totally adequate (f)
Type Source of
of scale Definition: Amount of food and fluid taken into the body over a 24-hour period assessment
used data, such
Outcome Target Rating: Maintain at Increase to as the
patient, his
Nutritional status: Not Slightly Moderately Substantially Totally
Specific family, or
Food & Fluid Intake adequate adequate adequate adequate adequate
meaning his medical
Overall rating 1 2 3 4 5
of the record
outcome Indicators:
label 100801 Oral food intake 1 2 3 4 5 NA
100802 Tube feeding intake 1 2 3 4 5 NA
100803 Oral fluid intake 1 2 3 4 5 NA
Total 100804 Intravenous fluid intake 1 2 3 4 5 NA
rating 100805 Parenteral nutrition intake 1 2 3 4 5 NA
based on References
selected 1st edition 1997; Revised 3rd edition 2004 to support
indicators the
Outcome Content References:
indicators
Champagne, M.T., & Ashley, M.L. (1989). Nutritional support in the critically ill elderly patient. Critical
and
Taxonomy Care Nursing Quarterly, 12(1), 15-25.
outcome
number Coyle, E.F. (2004). Fluid and fuel intake during exercise. Journal of Sports Sciences, 22, 39-55.
for each Duggal, A., & Lawrence, R.M. (2001). Aspects of food refusal in the elderly: The “hunger strike.”
indicator International Journal of Eating Disorders, 30(2), 213-216.
(based on the Gianino, S., & St. John, R.E. (1993). Nutritional assessment of the patient in the intensive care unit.
number of Critical Care Nursing Clinics of North America, 5(1), 1-16.
the specific Keithley, J.K., & Kohn, C.L. (1990). Managing nutritional problems in people with AIDS. Oncology
outcome) Nursing Forum, 17(1), 23-27.
Used with permission from Moorhead, S., et al. (2008). Nursing outcomes classification (NOC) (4th ed.), p. 530.
St. Louis: Mosby.
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98
Speaking the language

Once you start working with the Nursing Outcomes Classification
(NOC), you’ll quickly realize that the NOC domains are different from the
domains listed in NANDA International (NANDA-I) taxonomy. As you’ll
see later on, both of these domains also differ from the domains in the
Nursing Interventions Classification (NIC). The reason for this is that
each language is trying to codify a different aspect of nursing care. To
successfully incorporate each of these taxonomies into your care plans,
be prepared to look at NANDA, NOC, and NIC Linkages: Nursing Diag-
noses, Outcomes, and Interventions (Johnson, et al, 2006).
Improving for the greater good

In 2000, representatives from NANDA-I, NIC, and NOC created the NNN
Alliance, a virtual organization aimed at fostering a working relationship
among the three organizations. One goal of this alliance has been to
develop a more universal language that can be used not only for these
taxonomies but also for other nursing languages.
• Allocate an overall target rating for the patient and a time frame
for achieving the goal based on the patient’s assessment data,
current condition, and personal goals. (See NOC ou tcom es.)
De ve lop in g n u rs in g in t e rve n t ion s

Once you’ve developed expected outcomes for a patient, it’s time
to start planning specific interventions to achieve them. As with
patient outcomes, nursing interventions must be:
• realistic
• measurable
• achievable within the time frame specified in the patient
outcome.
DEVELOP ING NURS ING INTERVENTIONS
99
Under construction
NOC outcomes
Like all expected outcomes, the outcomes you develop based on the Nursing Outcomes Classification (NOC) should con-
tain the following elements: behavior, measure, criteria, and time frame. However, the form these elements take is modi-
fied by the structure of the language of NOC. The examples shown here illustrate two ways in which you might record a
NOC expected outcome in your care plan. The actual format you use is determined by your school or facility.
NOC format
This format records the outcome statement in the chart form given in the NOC text. Fill in the patient’s
target goal rating
here. Note that this
Circle goal can be either a
the Nutritional Status: Food & Fluid Intake (1008) maintenance goal or an
patient’s improvement goal.
Domain-Physiological Health (II) Care Recipient: Su san Wo n g
baseline
Class-Nutrition (K) Data Source: Pat ie n t , char t
ratings Scale(s)-Not adequate to Totally adequate (f)
for the Circle
indicators Definition: Amount of food and fluid taken into the body over a 24-hour period the
that you patient’s
select here. Outcome Target Rating: Maintain at ________ Increase to 4 wit hin 7 d ays
overall
Nutritional status: Not Slightly Moderately Substantially Totally baseline
Food & Fluid Intake adequate adequate adequate adequate adequate rating
Overall rating 1 2 3 4 5 here.
Indicators:
100801 Oral food intake 1 2 3 4 5 NA
100802 Tube feeding intake 1 2 3 4 5 NA
100803 Oral fluid intake 1 2 3 4 5 NA
100804 Intravenous fluid intake 1 2 3 4 5 NA
100805 Parenteral nutrition intake 1 2 3 4 5 NA
1st edition 1997; Revised 3rd edition 2004

If a
copy of the
Champagne, M.T., & Ashley, M.L. (1989). Nutritional support in the critically ill elderly patient. Critical
outcome is
Care Nursing Quarterly, 12(1), 15-25. Circle “NA”
included in
Coyle, E. F. (2004). Fluid and fuel intake during exercise. Journal of Sports Sciences, 22, 39-55. for any
the medical
Duggal, A., & Lawrence, R.M. (2001). Aspects of food refusal in the elderly: The “hunger strike.”
record, sign indicators
International Journal of Eating Disorders, 30(2), 213-216.
the outcome that you
Gianino, S., & St. John, R.E. (1993). Nutritional assessment of the patient in the intensive care unit.
and include haven’t
Critical Care Nursing Clinics of North America, 5(1), 1-16.
the date
Keithley, J.K., & Kohn, C.L. (1990). Managing nutritional problems in people with AIDS. Oncology chosen for
of the
Nursing Forum, 17(1), 23-27. your patient.
assessment.
J o an Cu n n in gh am , RN
3 / 14 / 12
(continued)
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100
NOC outcomes (continued)
NOC format
This example condenses the information from NOC into a simpler format that is commonly used in schools.
Code or label Definition and indicators Measure Time frame

10 0 8 N u t r it io n al St at u s: F o o d & F lu id I n t ake
T h e am o u n t o f f o o d an d f lu id t ake n
in t o t h e bo d y o ve r a 2 4 - h o u r p e r io d
10 0 8 0 1 Or al f o o d in t ake at a le ve l o f 4 wit hin 7 d ays
(su bst an t ially ad e qu at e )
10 0 8 0 3 Or al f lu id in t ake at a le ve l o f 4 wit hin 7 d ays
(su bst an t ially ad e qu at e )
Remember that you shouldn’t change the NOC outcome label and definition; however, you can add new indicators or
modify existing ones to make them more specific to your patient. For example, you could redefine the measurement of
indicator 100801 of the Nutritional Status: Food and Fluid Intake NOC outcome (Oral food intake) to make it more specific
(for instance, by defining 1 = No intake, 2 = 25% of food available per meal, 3 = 50% of food available per meal, 4 = 75% of
food available per meal, and 5 = 100% of food available per meal).
Independent
int ervent ions don’t
Type s o f interve ntio ns require any direct ion
Interventions are grouped into two general categories: or supervision from a
• independent pract it ioner.
• collaborative (or interdependent).
Inde pe ndent interventio ns

An independent intervention is one that falls within the scope
of nursing practice. It doesn’t require a practitioner’s direc-
tion or supervision, so you can initiate the action on your
own.
You’re on your own, kid

Many of the interventions you’ll incorporate into the care
plan are independent nursing interventions. They address
aspects of care that you can do to promote change and facili-
tate wellness. These interventions cover such topics as:
• performing activities of daily living
• promoting safety and comfort
• patient teaching.
101
Independent interventions involve working directly with a

patient, such as teaching him how to perform his own insulin Collaborat ive
injections. However, they also include the indirect activities you int ervent ions are
ones t hat you
pursue to help him reach his goal, such as gathering resource ma-
perform based on t he
terials about diabetes and insulin self-injection. inst ruct ions from
anot her member of
Collaborative inte rve ntions t he healt h care t eam.
A collaborative intervention is one that’s based on instructions

(oral or written) provided by a practitioner or one that you’ll do in
consultation with another member of the health
care team, such as a dietitian, social worker, or
physical therapist. Collaborative interventions fall
outside the realm of nursing practice, meaning
that you can’t initiate them on your own.
Hey, let ’s work t oget her

Examples of collaborative interventions include:
• administering prescribed medications or fluids
• obtaining specimens for laboratory analysis
• inserting catheters.
(See Com pa r i n g i n depen den t a n d colla bor a ti ve n u r si n g
i n ter ven ti on s, page 102.)
Writing nurs ing interve ntio ns

All nursing interventions are based on the goals stated in the
patient outcomes and are intended to alter the etiology, defining
characteristics, or risk factors for a specific nursing diagnosis.
The number of interventions can vary for each outcome. What’s
most important is that the care plan is comprehensive enough to
ensure that the patient can meet the outcomes. You’ll usually list
several interventions covering various aspects of care, all aimed at
correcting the problem identified in the nursing diagnosis.
Each intervention you “prescribe” must be written so that a
caregiver (you or another nurse) has a clear picture of what to
do to promote a positive change in the patient. As a student, your
care plans are generally completed for your instructor, not for the
agency or facility where you gain your clinical experience. (See
Ti ps for wr i ti n g effecti ve i n ter ven ti on s, page 103.)
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Comparing independent and collaborative nurs ing interventions

Differentiating independent nursing interventions from collaborative interventions can be difficult. Some interventions
can be classified as either independent or collaborative, depending on the wording used for the intervention and the
nurse’s understanding of her scope of practice. One way to differentiate is to consider whether the action is nurse pre-
scribed or practitioner prescribed.
This chart demonstrates a chain of related independent and collaborative nursing actions related to a practitioner
order for bed rest.
Practitioner order
Bed rest
Independent nursing action

Passive range of motion
Independent nursing action Practitioner order Practitioner order

Consult with practitioner to increase Physical therapy consultation Bathroom privileges
activity per patient assessment and
patient request
Physical therapist Independent

consultation order Collaborative
nursing action nursing action
Nursing staff to assist patient to Teach patient
Practitioner order walk in hallway 20′ each evening Assist patient
Up as tolerated to bathroom to dangle
legs from the
side of the
bed before
Independent Collaborative standing
Collaborative Independent nursing action nursing action
nursing action nursing action Ask spouse Assist patient
Check vital Teach patient to bring socks to walk in
signs, vasomotor to call nurse and shoes hallway after
response, before or nonslip dinner 20′, as Remember, even if a
strength, attempting to slippers to tolerated pract it ioner has given orders for
balance, and get out of bed patient pat ient care, you mus t use your
safety when for the first
nursing judgment t o det ermine
assisting the time
patient out of whet her an order is appropriat e
bed initially and before implement ing it .
as needed
103
Teacher knows best
Tips for writing effective interventions

To write interventions clearly and cor- For instance, before teaching a patient
rectly, follow these guidelines: how to self-administer medication, make
• Keep your interventions simple and to the sure he’s physically able to do it and that
point, and make sure they’re aimed at helping he can remember and follow the regimen.
your patient achieve the desired outcome. • Follow your facility’s rules. For example,
• Clearly state the necessary action. Note if your facility allows only nurses to admin-
how and when to perform the intervention, ister medications, don’t write an interven-
and include special instructions if neces- tion calling for the patient to administer
sary. For example, “Promote comfort” hemorrhoidal suppositories as needed.
doesn’t tell you what specific action to • Consider other health care activities.
take, but “Administer ordered analgesic Adjust your interventions when other ac-
30 minutes before dressing change” spec- tivities interfere with them. For example,
ifies exactly what to do and when to do it. you might want your patient to get plenty
• Make sure your interventions fit the of rest on a day when he has several di-
patient. Consider the patient’s age, condi- agnostic tests scheduled.
tion, developmental level, environment, • Use available resources. If your patient
and values. For instance, if the patient is needs to learn about his cardiac problem, Unlike out comes ,
a vegetarian, don’t write an intervention use your facility’s education department, which are
that requires him to eat lean meat to gain literature from the American Heart As- pat ient focus ed,
extra pounds for healing. sociation, and local support groups. Write int ervent ions focus
on t he act ions t hat
• Keep the patient’s safety in mind. Con- your intervention to reflect the use of
you, t he nurs e, will
sider his physical and mental limitations. these resources. t ake.
Ident ify t he act ivit y

Keep in mind that all interventions are actions that you (not the
patient) will do. Therefore, they should always begin with an
action verb, for example:
• Offer fluids every 4 hours.
• Monitor temperature, blood pressure, and pulse.
• Assess pedal pulses.
• Discuss with patient how to perform regular self-breast exams.
Make it s pecific
Include as many qualifiers as needed to know:
• how, when, and where to do the activity
• how frequently it needs to be done
• special equipment needed
• additional instructions.
P LANNING
104
Wat ch t he t ime
Remember that all of the interventions developed for a particular
patient outcome must be achievable within the same time frame.
This doesn’t mean, however, that a particular intervention can’t
be used again to meet a new progressive outcome related to the
original diagnosis.
Keep in mind
When planning interventions, give some thought to:
• likelihood of success, taking into account the timing, interven-
tions by other team members, amount of time required, and cost
factors
• resources available to you and your patient
• your ability to perform the intervention
• scientific rationale behind the actions
• the patient’s ability and willingness to comply
• prior interventions that you or your patient have successfully
used
• interventions from standardized care plans, nursing textbooks,
or nursing journals. (See Pla n to su cceed.)
Nurs ing Inte rventions Clas s ific ation

The Nursing Interventions Classification (NIC) is a systematized
classification of research-based nursing interventions. NIC inter-
ventions cover such areas as illness prevention, illness treatment,
and health promotion. Most are designed for individual patients,
but some are geared toward families and communities. Covering a
broad range of nursing care, NIC may be used in any practice set-
ting and any specialty across the entire health care continuum—
from intensive care to primary care, home care, and hospice. Like
NOC, NIC is designed so that even nonnurse health care providers
can use the interventions in their treatment of patients. The most
difficult aspect of using NIC for nurses new to the language is that
instead of listing the specific actions the nurse will take, NIC uses
labels that group several actions (called a cti vi ti es) together.
Clas s act
NIC consists of 542 interventions (both physiological and psycho-
social labels) that are grouped into 30 classes and 7 domains. The
7 domains are unique to NIC and don’t correlate directly with the
NANDA-I or NOC domains. They are:
• Physiological: Basic—supports physical functioning
• Physiological: Complex—supports homeostatic regulation
• Behavioral—supports social function and lifestyle changes
105
Teacher knows best
Plan to s ucceed
Always consider your intervention options carefully, and then weigh
their potential for success. Determine if you can obtain the necessary
equipment and resources. If not, take steps to get what you need or
change the intervention accordingly. Also, observe the patient’s willing-
ness and functional ability to participate in the various interventions,
and be prepared to postpone or modify them if necessary. For example,
don’t plan extensive verbal teaching with a patient who has significant
hearing loss.
• Safety—supports protection against harm

• Family—supports the family unit
• Health system—supports use of the health care system
• Community—supports health of the community.
Each intervention in the classification includes a taxonomic
code, a label name, a definition, and a list of activities to carry
out the intervention. Nurses can select specific activities based
on patient need and circumstances. (See An a tom y of a NIC
i n ter ven ti on , page 106.)
Us ing NIC to write inte rve ntions

Just as you may be asked to use NOC to create your expected
outcome statements, you may be asked to choose interventions
from a standardized interventions classification, such as NIC. You
can find the information in the Nu r si n g In ter ven ti on s Cla ssi fi -
ca ti on book in two ways. First, you can look in the alphabetical
listing for the intervention you’re interested in. If you find the list
daunting or you’ve looked up what you believe to be key words or
concepts for an intervention and haven’t found what you wanted,
you can search for interventions using NANDA-I nursing diagno-
ses. Nu r si n g In ter ven ti on s Cla ssi fi ca ti on includes charts that
list NANDA-I nursing diagnoses alphabetically, with the diagnosis
definition and suggested and optional nursing interventions for
each diagnosis.
Pers onalizat ion

Remember that NIC includes a definition for each class of interven-
tions that shouldn’t be changed. However, NIC is designed to be
Anatomy of a NIC intervention
Becoming familiar with the organization and components of an individual Nursing Interventions Classification (NIC) interven-
tion can help you to use NIC to write nursing interventions specific to your patients. Below is a sample intervention and its
corresponding activities.
Intervention Taxonomic
label code
Definition
Feeding 1050
of label Definition: Providing nutritional intake for patient who is unable to feed self
Activities
Identify prescribed diet
Set food tray and table attractively
Create a pleasant environment during mealtime (e.g., put bedpans, urinals, and suctioning
equipment out of sight)
Provide for adequate pain relief before meals, as appropriate
Provide for oral hygiene before meals Specific
Identify presence of swallowing reflex, if necessary activities
Sit down while feeding to convey pleasure and relaxation (suggested
Offer opportunity to smell foods to stimulate appetite activities)
Ask patient reference for order of eating
Fix foods as patient prefers
Maintain patient in an upright position, with head and neck flexed slightly forward during feeding
Place food in the unaffected side of the mouth, as appropriate
Place food in the person’s vision if he or she has a visual-field defect
Choose different-colored dishes to help distinguish item, if perceptual deficit
Follow feedings with water, if needed
Protect with a bib, as appropriate
Ask the patient to indicate when finished, as appropriate
Record intake, if appropriate
Avoid disguising drugs in food
Avoid presenting drink or bite up to mouth while still chewing
Provide a drinking straw, as needed or desired
Provide finger foods, as appropriate
Provide foods at most appetizing temperature
Avoid distracting patient during swallowing
Feed unhurriedly/slowly
Maintain attention to patient during feeding
Postpone feeding, if patient is fatigued
Check mouth for residue at end of meal
References
Wash face and hands after meal
to support the
Encourage parents/family to feed patient
activities
1st edition 1992; Revised 5th edition 2008
Background Readings
Evans-Stoner, N.J. (1999). Feeding. In G.M. Bulechek & J.C. McCloskey (Eds.), Nursing interventions:
Effective nursing treatments (3rd ed.) (pp. 31-46). Philadelphia: W.B. Saunders.
Harkreader, H.C. (2004). Fundamentals of nursing: Caring and clinical judgment. Philadelphia: W.B.
Saunders.
Pelletier, C.A. (2004). What do certified nurse assistants actually know about dysphagia and feeding
nursing home residents? American Journal of Speech-Language Pathology, 13, 99-113.
Styker, R. (1977). Rehabilitative aspects of acute and chronic nursing care. Philadelphia: W.B. Saunders.
Used with permission from Bulechek, G., et al. (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis: Mosby.
107
Under construction
Getting the knack of NIC

To better understand NIC, consider this example: You’re caring for an elderly man who
has Alzheimer’s disease. The patient needs assistance with feeding but has no difficulty
swallowing.
Using NIC
To determine interventions for this patient using NIC, take a step-by-step approach:
• Determine that the Nursing Outcomes Classfication (NOC) entry Nutritional Status:
Food & Fluid Intake is appropriate for your patient and use this NOC outcome to set
outcome goals.
• Look up the corresponding NANDA International diagnosis, Self-care deficit: Feeding,
in the Nursing Interventions Classification book.
• Read through each of the suggested NIC classes that might apply to your patient and
choose activities that most closely represent the actions you would need to take, based
on your knowledge and research. For example:
– Environmental management
– Feeding
– Nutrition management
– Nutritional monitoring
– Positioning
Note: “Bottle feeding” isn’t relevant for your patient because he’s an adult and “Swallow-
ing therapy” isn’t relevant to your patient because he isn’t having difficulty swallowing.
• Modify or add to the listed activities as needed. For example:
– Of the 30 activities, you eliminate seven as not being applicable to your patient.
– You modify “Protect with a bib, as appropriate” to read “Protect with a cloth nap-
kin” because you know the patient’s spouse has brought napkins and this activity
conserves the patient’s self-esteem.
– You modify “Record intake, if appropriate” to read “Record fluid intake on I&O
sheet; record percentage of food eaten for each meal as 25%, 50%, 75%, or 100%.”
– You add interventions to “Weigh patient weekly,” “Monitor trends in weight loss and
gain,” “Monitor albumin, total protein, and hemoglobin levels and hematocrit as or-
dered,” and “Consult dietitian if patient doesn’t respond to interventions by target date.”
dynamic and flexible, allowing nurses to modify the activities to

reflect the unique needs of the patient and his family. Interven-
tions from more than one class may be needed to help the patient
achieve his expected outcomes. Nurses can also add activities as
appropriate for the patient’s particular situation. (See Getti ng the
knack of NIC.)
P LANNING
108
Us in g e vid e n c e -b a s e d p ra c t ic e
Evidence-based practice can be defined as the systematic and
judicious use of the current best evidence to make decisions
about patient care. When applied to nursing, the term evi den ce-
ba sed pr a cti ce is used to describe the care that nurses provide
based on research and identified standards.
Shift ing s ands

Because of the vast amount of available clinical research and
accessibility to research findings, there has been a steady shift
away from traditional, intuitive-oriented nursing toward evidence-
based nursing. Nurses are following the growing trend among all
health care fields of using well-designed and well-executed scien-
tific studies to guide their clinical decision making and clinical care.
Putting evide nc e into prac tic e

For your student care plans, your instructor may require you to
write rationales for the interventions you’ve planned or com- Alt hough t radit ion
pleted. In some cases, students are also required to provide a com- has it s t ime and
place, evidence-bas ed
plete reference list by intervention, or a bibliography.
pract ice ens ures t hat
When planning care, you should use evidence-based research nurses keep up wit h
and your critical thinking skills to ascertain why certain actions t he t imes by us ing
or practices are being performed. Asking pertinent questions can clinically sound bes t
help you determine whether you’re taking the right course of ac- pract ices .
tion and whether the interventions you’ve chosen will improve
your patient’s outcome.
Don’t be afraid t o as k
Questions to ask yourself as you plan interventions include:
• Who determined the basis for this treatment?
• What’s the rationale for this decision?
• What are the clinical ramifications of this practice?
• Is this the only way of doing this procedure?
• Could this treatment be done better, more efficiently, or more
cost-effectively?
• Is this the highest achievable outcome for my patient?
Evaluating s o urce s o f informatio n

Truly evaluating the reliability and validity of the findings of a
research study requires knowledge of statistics and research prin-
ciples. However, keeping the following basic principles in mind
ON THE CAS E
109
can help you to identify valid sources of information that can be

used to support evidence-based care—and avoid those that don’t:
• Check medical resources for guidelines or standards of clinical
practice related to your patient’s medical diagnosis or the proce-
dures or treatments he may be undergoing.
• Use resources written within the past 3 to 5 years, depending on
your faculty’s preference.
• Use reputable, well-known journals and textbooks.
• Be wary of research that utilizes small sample sizes because the
conclusions from this research may be too narrow to generalize to
a larger population.
On t he cas e

You’re caring for Johanna Keller, a patient with Parkinson’s dis-
ease. After a recent medication adjustment, the patient’s symp-
toms include mild, bilateral upper extremity tremors that improve
with use of the arms and slowed ability to initiate and sustain
gross motor movements (such as rising from a bed or chair and
walking). The patient is highly motivated to remain as active as
possible for as long as possible. Based on her assessment data,
you establish the following nursing diagnosis: Im pa i r ed physi ca l
m obi li ty r ela ted to decr ea sed dopa m i n e n eu r otr a n sm i tter a va i l-
a bi li ty ( Pa r ki n son ’s di sea se) a s evi den ced by u pper extr em i ty
tr em or s a n d decr ea sed a bi li ty to i n i ti a te a n d su sta i n gr oss
m otor m ovem en ts.

1. Based on the definition in the NOC text, you determine that
NOC outcome 0208 Mobility (shown on page 110) is appropriate
for your patient. Use this NOC outcome to document an outcome
statement for this patient.
P LANNING
110
Mobility (0208)
Domain-Functional Health (I) Care Recipient:
Class-Mobility (C) Data Source:
Scale(s)-Not adequate to Not compromised (a)
Definition: Ability to move purposefully in own environment independently with or

without assistive device
Outcome Target Rating: Maintain at ________ Increase to ________
Severely Substantially Moderately Mildly Not
Mobility compromised compromised compromised compromised compromised
Overall Rating 1 2 3 4 5
Indicators:
020801 Balance 1 2 3 4 5 NA
020809 Coordination 1 2 3 4 5 NA
020810 Gait 1 2 3 4 5 NA
020803 Muscle movement 1 2 3 4 5 NA
020804 Joint movement 1 2 3 4 5 NA
020802 Body positioning 1 2 3 4 5 NA
performance
020805 Transfer performance 1 2 3 4 5 NA
020811 Running 1 2 3 4 5 NA
020812 Jumping 1 2 3 4 5 NA
020813 Crawling 1 2 3 4 5 NA
020806 Walking 1 2 3 4 5 NA
020814 Moves with ease 1 2 3 4 5 NA

Maas, M.L., & Specht, J.P. (2001). Impaired physical mobility. In M. Maas, K. Buckwalter, M. Hardy, T.
Tripp-Reimer, M. Titler, & J. Specht (Eds.), Nursing care of older adults: Diagnoses, outcomes &
interventions (pp. 337-365). St. Louis: Mosby.
Podsiadlo, D., & Richardson, S. (1991). The timed “Up & Go”: A test of basic functional mobility for frail
elderly persons. Journal of American Geriatrics Society, 39(2), 142-148.
Rukenstein, L.Z., Wieland, D., & Bernakei, R. (Eds.) (1995). Geriatric assessment technology: The state
of the art. New York: Springer.
Used with permission from Moorhead, S., et al. (2008). Nursing outcomes classification (NOC) (4th ed.), p. 530. St. Louis: Mosby.
2. Now review NIC intervention 0226, Exercise Therapy: Muscle

Control (shown on page 111). Select at least five nursing activi-
ties from this NIC intervention that would be appropriate for this
patient.
1.
2.
3.
4.
5.
ON THE CAS E
111
Exercise Therapy: Muscle Control 0226

Definition: Use of specific activity or exercise protocols to enhance or restore
controlled body movement
Activities
Determine patient’s readiness to engage in activity or exercise protocol
Collaborate with physical, occupational, and recreational therapists in developing and executing
exercise program, as appropriate
Consult physical therapy to determine optimal position for patient during exercise and number of
repetitions for each movement pattern
Evaluate sensory functions (e.g., vision, hearing, and proprioception)
Explain rationale for type of exercise and protocol to patient/family
Provide patient privacy for exercising, if desired
Adjust lighting, room temperature, and noise level to enhance patient’s ability to concentrate on the
exercise activity
Sequence daily care activities to enhance effects of specific exercise therapy
Initiate pain control measures before beginning exercise/activity
Dress patient in nonrestrictive clothing
Assist to maintain trunk and/or proximal joint stability during motor activity
Apply splints to achieve stability of proximal joints involved with fine motor skills, as prescribed
Reevalutate need for assistive devices at regular intervals in collaboration with PT, OT, or RT
Assist to sitting/standing position for exercise protocol, as appropriate
Reinforce instructions provided to patient about the proper way to perform exercises to minimize injury
and maximize effectiveness
Determine accuracy of body image
Reorient patient to body awareness
Reorient patient to movement functions of the body
Coach patient to visually scan affected side of body when performing ADLs or exercises, if indicated
Provide step-by-step cueing for each motor activity during exercise or ADLs
Instruct patient to “recite” each movement as it is being performed
Use visual aids to facilitate learning how to perform ADLs or exercise movements, as appropriate
Provide restful environment for patient after periods of exercise
Assist patient to develop exercise protocol for strength, endurance, and flexibility
Assist patient to formulate realistic, measurable goals
Use motor activities that require attention to and use of both sides of the body
Incorporate ADLs into exercise protocol, if appropriate
Encourage patient to practice exercises independently, as indicated
Assist patient with/encourage patient to use warm-up and cool-down activities before and after
exercise protocol
Use tactile (and/or tapping) stimuli to minimize muscle spasm
Assist patient to prepare and maintain a progress graph/chart to motivate adherence to exercise protocol
Monitor patient’s emotional, cardiovascular, and functional responses to exercise protocol
(continued)
P LANNING
112
Activities:—cont’d
Monitor patient’s self-exercise for correct performance
Evaluate patient’s progress toward enhancement/restoration of body movement and function
Provide positive reinforcement for patient’s efforts in exercise and physical activity
Collaborate with home caregivers regarding exercise protocol and ADLs
Assist patient/caregiver to make prescribed revisions in home exercise plan, as indicated
Background Readings
Donohue, K., Miller, C., & Craig, B. (1988). Chronic alterations in mobility. In P.H. Mitchell (Ed.), AANN’s
neuroscience nursing: Phenomena and practice (pp. 319-343). Norwalk, CT: Appleton & Lange.
Glick, O.J. (1992). Interventions related to activity and movement. In G.M. Bulechek & J.C. McCloskey
(Eds.), Symposium on nursing interventions. Nursing Clinics of North America, 27(2), 541-568.
Hickey, J. (1992). The clinical practice of neurological and neurosurgical nursing (3rd ed.).
Philadelphia: J.B. Lippincott.
Hogue, C. (1985). Mobility. In E.G. Schneider (Ed.), The teaching nursing home. New York: Raven Press.
Lewis, C.B. (1989). Improving mobility in older persons. Rockville, MD: Aspen.
Lubkin, I. (1990). Chronic illness: Impact and intervention (2nd ed.). Boston: Jones & Bartlett.
McFarland, G.K., & McFarlane, E.A. (1997). Nursing diagnosis and intervention (3rd ed.).
St. Louis: Mosby.
Moorhouse, M., Geissler, A., & Doenges, M. (1987). Critical care plans, guidelines for patient care.
Philadelphia: F.A. Davis.
Pender, N.J. (1987). Health promotion nursing practice (2nd ed.). Norwalk, CT: Appleton & Lange.
Sullivan, P., & Markos, P. (1993). Clinical procedures in therapeutic exercise. Norwalk, CT:
Appleton & Lange.
Vogt, G., Miller, M., & Esluer, M. (1985). Mosby’s manual of neurological care. St. Louis: Mosby.
Used with permission from Bulechek, G., et al. (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis: Mosby.
Ou t o r in ?
Read each statement. On the blank line provided, write “O” if the
statement is an outcome or write “I” if it’s an intervention.
1. Assist with ambulation, as needed.
2. Demonstrate proper use of ambulation with quad cane
within 4 days of discharge.
3. Administer oral analgesics three times per day, as prescribed.
4. Monitor vital signs every 4 hours until stable.
5. Offer sips of water and ice chips, as tolerated, followed
by soft diet by HD 2 postop.
6. Maintain acceptable body weight throughout length of stay.
7. Provide environmental cues (clock, calendar, pictures)
to assist with orientation.
8. Encourage participation in daily self-care.
9. Avoid straining when having a bowel movement
throughout hospitalization.
10. Verbalize decreased pain as evidenced by lower score
on pain-rating scale within 1 week.
ON THE CAS E
113
Ans wer key

1. The NOC outcome statement for this patient might look like this:
Mobility (0208)
Domain-Functional Health (I) Care Recipient: J o h an n a Ke lle r
Class-Mobility (C) Data Source: P at ie n t , ch ar t
Scale(s)-Not adequate to Not compromised (a)
Definition: Ability to move purposefully in own environment independently with or

without assistive device
Outcome Target Rating: Maintain at ________ Increase to 4 wit hin 3 d ays
Severely Substantially Moderately Mildly Not

Mobility compromised compromised compromised compromised compromised
Overall Rating 1 2 3 4 5
Indicators:
020801 Balance 1 2 3 4 5 NA
020809 Coordination 1 2 3 4 5 NA
020810 Gait 1 2 3 4 5 NA
020803 Muscle movement 1 2 3 4 5 NA
020804 Joint movement 1 2 3 4 5 NA
020802 Body positioning 1 2 3 4 5 NA
performance
020805 Transfer performance 1 2 3 4 5 NA
020811 Running 1 2 3 4 5 NA
020812 Jumping 1 2 3 4 5 NA
020813 Crawling 1 2 3 4 5 NA
020806 Walking 1 2 3 4 5 NA
020814 Moves with ease 1 2 3 4 5 NA

Maas, M.L., & Specht, J.P. (2001). Impaired physical mobility. In M. Maas, K. Buckwalter, M. Hardy, T.
Tripp-Reimer, M. Titler, & J. Specht (Eds.), Nursing care of older adults: Diagnoses, outcomes &
interventions (pp. 337-365). St. Louis: Mosby.
Podsiadlo, D., & Richardson, S. (1991). The timed “Up & Go”: A test of basic functional mobility for frail
elderly persons. Journal of American Geriatrics Society, 39(2), 142-148.
Rukenstein, L.Z., Wieland, D., & Bernakei, R. (Eds.) (1995). Geriatric assessment technology: The state
of the art. New York: Springer.
Used with permission from Moorhead, S., et al. (2008). Nursing outcomes classification (NOC) (4th ed.), p. 530.
St. Louis: Mosby.
P LANNING
114
2. Examples of nursing activities that would be appropriate for

this patient include:
• Determine patient’s readiness to engage in activity or exercise
protocol
• Collaborate with physical, occupational, and recreational thera-
pists in developing and executing exercise program, as appropriate
• Consult physical therapy to determine optimal position for pa-
tient during exercise and number of repetitions for each movement
pattern
• Explain rationale for type of exercise and protocol to patient/
family
• Sequence daily care activities to enhance effects of specific exer-
cise therapy
• Reevalutate need for assistive devices at regular intervals in col-
laboration with PT, OT, or RT
• Reorient patient to movement functions of the body
• Assist patient to develop exercise protocol for strength, endur-
ance, and flexibility
• Incorporate ADLs into exercise protocol, if appropriate
• Evaluate patient’s progress toward enhancement/restoration of
body movement and function
Note that other nursing activities may also be appropriate.
Ou t o r in ?
1. Intervention
2. Outcome
3. Intervention
4. Intervention
5. Intervention
6. Outcome
7. Intervention
8. Intervention
9. Outcome
10. Outcome
5
Implementation
J us t t he fact s
♦ responsibilities associated with implementation of a care
plan
♦ strategies for gathering and organizing patient information
♦ methods for integrating care activities
♦ the importance of communicating with the interdisciplin-
ary team
♦ two commonly used documentation methods.
Im p le m e n t a t ion ove rvie w Less t alk,

more act ion.
Implement at ion is
Once you’ve written a care plan—including the nursing diagno- t he t ime t o put your
ses, patient outcomes, and interventions needed to achieve those care plan int o act ion.
outcomes—you’re ready to put the care plan into action.
Let ’s get hands -on

Implementation, the fourth step in the nursing process, is the step
during which you’ll have hands-on involvement with your patient.
It encompasses:
• employing planned interventions
• using your critical thinking skills to solve problems and set
priorities
• continually reassessing the patient’s response to your
interventions
• communicating effectively with other members of the health
care team
• documenting all of the care you provide.
IMP LEMENTATION
116
All in a day’s work

To implement a care plan, expect to perform some or all of the fol- Don’t be afraid t o
lowing types of interventions: ask. If you need help,
• conducting routine assessment and monitoring of the patient cons ult wit h ot her
• performing therapeutic interventions, such as administering healt h care t eam
medications or obtaining ordered specimens members before
• offering comfort measures you perform an
int ervent ion.
• providing nourishment
• helping with activities of daily living
• supporting respiratory and elimination functions
• providing skin care
• offering emotional support
• providing patient teaching and counseling
• communicating with interdisciplinary team members.
Somebody point me in t he right direct ion!

It’s normal to feel slightly overwhelmed and even frightened
when you begin implementing your nursing care plan, especially
if you’re a nursing student or are just beginning your nursing
career. However, this lack of confidence will dissipate with time
and ongoing experience. Remember, the care plan is a road map
to helping your patient achieve wellness. It will point you in the
direction toward achieving that goal, but it’s your responsibility to
determine if you need additional information or need to collabo-
rate with other health care team members before implementing an
intervention.
Le ve ls o f res po ns ibility
Your role in preparing and implementing a nursing care plan will
vary with your level of nursing experience.
St udent body
As a nursing student, your goal is to work from a care plan that
you develop based on your assessment of the patient. In reality,
you might not have access to your patient or his medical record
until shortly before you become responsible for providing his
care. In this situation, you need to review the care plan already
in place as a blueprint for implementation. As you complete your
own patient assessment, you become responsible for modifying
the established care plan to reflect any changes and implement-
ing your new interventions. The care plan you later write for your
instructor may include diagnoses and interventions you actually
had no time to initiate in the confines of your clinical time with
the patient.
GETTING S TARTED
117
Graduat e fellows hip

Even aft er you
As a practicing nurse, you’ll initially follow a care plan developed graduat e from
by another nurse, and you may not know much about the patient s t udent nurs e t o
before you actually meet him and begin providing care. Your game pract icing nurs e,
plan remains the same as when you were a student, though— your game plan
modify the care plan as needed as you develop your own assess- should st ay t he
ment data. As you’re given new patients to admit to the unit, you’ll same: Modify t he
care plan as needed
have opportunities to develop complete care plans for them.
as you develop your
Regardless of your place in the nursing hierarchy, it’s up to own as sess ment
you to learn as much as you can about your patient and his cur- dat a.
rent condition before implementing care. You’re even responsible
for making sure that a practitioner’s orders are appropriate for a
patient before you implement them.
Ge t t in g s t a rt e d
Start your implementation of the care plan by assessing the
patient’s current situation. Then gather the supplies you’ll need to
complete the planned interventions.
As s e s s ing the s ituation

Even if this is your first encounter with this patient, a great deal
of information about the patient is available to you from various
sources. For example, you can gather plenty of useful information by:
• listening to the report of the departing nurse at the start of your
shift
• reading the patient’s chart, including information obtained
during the initial history and physical examination
• talking with other staff, including your clinical instructor, the
patient’s primary nurse, and other members of the health care
team
• talking with the patient and family members
• directly observing and assessing the patient
• reviewing laboratory and other test results.
Shift ing gears

Begin your shift by listening to the previous shift nurse’s report
about the patient. (See Electr on i c cha n ge-of-shi ft r epor t a t the
bedsi de, page 118.) On a worksheet, computer, or bedside worksta-
tion, write or enter any pertinent information about the patient’s
vital signs, activities, intake and output, frequency of treatment,
any medications given on an “as needed” basis and the patient’s
response, and special instructions, per the facility’s guidelines.
IMP LEMENTATION
118
Electronic change-of-s hift report at the beds ide

The change-of-shift report is a time for nurses to communicate information about their
patients to oncoming nurses for the next shift. They share such information as a patient’s
condition, status, signs and symptoms, medications, tests and test results, and response
to medical interventions. Change of shift is also a time when nurses can plan patient care.
A study on a GI surgical oncology unit at the University of Texas MD Anderson Cancer
Center describes a staff-driven quality improvement initiative to develop a template for
bedside shift reports that saves time and money and improves information quality.
Source: Nelson, B.A., & Massey, R. (2010). Implementing an electronic change-of-shift report using
transforming care at the bedside processes and methods, JONA: Journal of Nursing Administra-
tion 40(4),162-168.
If you work in a setting that has an electronic health record

system, you may be able to print a patient-specific report of all
orders and test results from the system. Some systems also con-
tain the nursing care plans. (See Sa m ple electr on i c shi ft r epor t.)
Take not e of t his

After listening to the report, you should review the patient’s chart
for any new orders that may have been written. Note any changes
in the patient’s treatment or care regimen on both the care plan It ’s a good
and your worksheet. Also review the medication and IV fluid idea t o highlight
administration record, and make notes (on your worksheet) of the medicat ion and IV
times that medications, IV fluids, and other IV drugs are scheduled. administ rat ion t imes
on your worksheet .
Note the frequency of treatments, vital signs, dressing changes
(and type), and blood glucose monitoring. This will help you to
organize and integrate your planned independent nursing interven-
tions with the collaborative interventions listed in the care plan.
Making cont act

Next, assess the patient. After entering the patient’s room, intro-
duce yourself, wash your hands, and then check the patient’s
identification. Remember to use two patient identifiers, such as
his name, birth date, or assigned identification number. Whenever
possible, ask the patient to tell you his name instead of calling him
by his name. (See Na ti on a l Pa ti en t Sa fety Goa ls, page 122.)
Perform your initial assessment and make notes of your find-
ings; these notes will provide the basis for your initial nurse’s note

GETTING S TARTED
119
Sample electronic s hift report

Many electronic health record systems are programmed to send practitioners’ medical orders directly to the staff who will be
implementing them. For example, new medication orders are sent to the pharmacy-specific section of the record system as
well as to the nursing-specific section. Staff members in these departments can print out information they need to know from
the records and use it to plan their work. Nurses usually obtain a printout (or electronic shift report) on each of their assigned
patients at the start of their shifts. They might also regularly check the computer for new orders throughout their shift.
Although electronic shift reports are valuable, they shouldn’t be used in place of verbal shift reports because the data
they provide about a patient’s current status are limited. For example, electronic reports don’t tell you how your patient
is doing, what issues are most important for follow-up, or what the previous assessment revealed. The electronic shift
report printout is a good place to make notes about information obtained during the verbal shift report.
Here’s a sample electronic nursing shift report.
This section
includes the
patient’s medical
information and
other essential This information
data. is critical in
emergencies.
This section
indicates
that medical
consultations
were requested;
you should
verify their
completion.
This is the care

plan. Look up the
protocols if you’re
unsure what
they entail.
(continued)
IMP LEMENTATION
120
Sample electronic s hift report (continued )
The current
medical orders
are broken down
into categories. In
shift report, note
the status of each
order and the
latest assessment
results. Leave
space for your
assessments.
GETTING S TARTED
121
Sample electronic s hift report (continued )
For diagnost ic
and laborat ory
t est s, verify t hat
t he report s are
in t he chart and
check t he res ult s.
in the patient’s medical record. You can also use this opportunity
to talk briefly with the patient (and any family members who may
be present if the patient gives permission) and gather additional
information about the patient’s:
• perception of his current illness and his overall health and
well-being
• ability to perform the interventions to meet the outcomes
specified in the care plan
• available resources and support system.
IMP LEMENTATION
122
National Patient Safety Goals

Since July 2002, The Joint Commission has annually published National Patient Safety
Goals that they require an organization to meet before it can be accredited. These
standards, or goals, are developed based on safety statistics, research, and input from
numerous health care professionals and consumers. The validity of the goals is so well
recognized that many institutions follow them even if they aren’t seeking accreditation.
A few of the important safety goals you might need to implement in your clinical
settings are:
• using at least two forms of patient identification before initiating any care, service, or
treatment
• engaging in a pause before the start of any invasive procedure (called a time out or a
preverification process) in which all staff actively confirm that the right patient is present,
the right procedure is scheduled, and that the right site for the procedure has been marked
• eliminating all nonstandardized abbreviations and symbols in medical communications
• complying with your facility’s standardized system for giving and receiving shift
report, which includes the opportunity for questions and answers
• labeling all medications and medication containers
• labeling all laboratory specimens in the presence of the patient
• reconciling the patient’s medication list with the admission list before admission
and then communicating his current medication list on discharge to all health care
providers involved in his aftercare and, in writing, to the patient himself
• assessing each patient’s risk of falls and implementing a program to reduce this risk
• assessing each patient’s risk of health care–associated pressure ulcers and
implementing a program to reduce this risk
• assessing each patient’s inherent risks, such as a patient with an emotional or a
behavioral disorder being regularly assessed for suicide or a home care patient on
oxygen therapy being assessed for the risk of fire
• following proven guidelines to prevent blood infection from central lines
• following hand hygiene guidelines from the Centers for Disease Control and
Prevention or the World Health Organization.
Source: The Joint Commission. “National Patient Safety Goals.” Available at www.joint
commission.org/PatientSafety/NationalPatientSafetyGoals/.
St udent report
If you’re a student, provide a brief verbal report of your findings
to the patient’s assigned nurse and your clinical instructor, alert-
ing them immediately to any abnormal findings. Ask them to
P ROVIDING CARE
123
Teacher knows best
Nurs es as res ources

Experienced nurses can be invaluable resources. They’ve amassed a wealth of
information through practical experience in providing bedside care. They can teach
you organizational skills and strategies for thinking through situations that you may
encounter in the clinical setting. Tapping into their knowledge can help you to fine-tune
your assessment and care techniques in your quest to become a registered nurse.
clarify anything you’re unsure about or ask your clinical instruc-

tor to check on the patient to verify your findings. (See Nu r ses
a s r esou r ces.)
Gathe ring s upplie s

After you’ve performed your initial assessment, you’ll gather and
assemble the appropriate equipment and supplies for other interven-
tions you’ll need to perform. Once you’ve properly prepared your-
self and the necessary supplies, it’s time to implement your care.
P rovid in g c a re I see medicat ion

administ rat ion in
Now you’re ready to begin tackling specific interventions. Being your fut ure. Make
prepared and developing a system that integrates various activi- sure t hat you have
t he right drug, dose,
ties can save you time and benefit your patient by reducing inter-
pat ient , t ime, and
ruptions to his rest. rout e.
Bas ic impleme ntation s te ps

Although the specific care activities that you’ll perform will
depend on the patient’s condition, some general practices apply to
all patients. The timing of meals, therapies, tests, and procedures
the patient is scheduled to receive will determine which of the
other interventions specified in the care plan you’ll initiate next.
Meet Mr. Med

When your patient is due to receive a medication, locate and
prepare the medications under the supervision of your nursing
instructor or the patient’s primary nurse. (See Sa fe dr u g a dm i n -
i str a ti on gu i deli n es, page 124.) Follow a tried-and-true set of
IMP LEMENTATION
124
Teacher knows best
Safe drug adminis tration guidelines

When administering a drug, be sure to adhere to best practices to avoid potential problems and manage those that do
occur. You can help prevent drug errors by following these guidelines as well as facility policy.
Drug orders • If your facility uses a bar code administration system, fol-
• Don’t rely on the pharmacy computer system to detect all low the manufacturer’s and your facility’s policies for use.
unsafe orders. Before you give a drug, understand the cor- Never bypass safety protocols.
rect dosage, indications, and adverse effects.
Avoiding common problems
• Be aware of the drugs your patient takes regularly, and
Calculation errors
question any deviation from his regular routine. As with
• Writing the milligrams per kilogram (mg/kg) or milligrams
any drug, take your time and read the label carefully.
per meter squared (mg/m2) dose and the calculated dose
• Before you give drugs that are ordered in units, such as in-
provides a safeguard against calculation errors. When-
sulin and heparin, always check the prescriber’s written order
ever a prescriber provides the calculation, double-check it
against the provided dose. Never abbreviate the word “units.”
and document that the dose was verified.
• To prevent an acetaminophen overdose from combined
• Don’t assume that liquid drugs are less likely to cause
analgesics, note the amount of acetaminophen in each
harm than other forms. Pediatric and geriatric patients
drug. Beware of substitutions by the pharmacy because
commonly receive liquid drugs and may be especially sen-
the amount of acetaminophen may vary.
sitive to the effects of an inaccurate dose. If a unit-dose
Drug preparation and administration form isn’t available, calculate carefully and double-check
• Always check the expiration date before administering your math and the drug label.
a drug. • Have another nurse verify your calculations, especially
• If a familiar drug has an unfamiliar appearance, find out insulin and heparin dosages and calculations.
why. If the pharmacist cites a manufacturing change, ask • Read the label on every drug you prepare and never
him to double-check whether he has received verification administer any drug that isn’t labeled.
from the manufacturer. Document the appearance dis-
Air bubbles in pump tubing
crepancy, your actions, and the pharmacist’s response in
• To clear bubbles from IVtubing, never increase the
the patient record.
pump’s flow rate to flush the line. Instead, remove the tub-
• Use two patient identifiers, such as the patient’s name and
ing from the pump, disconnect it from the patient, and use
assigned identification number, to identify the patient before
the flow-control clamp to establish gravity flow.
administering any drug or treatment. Teach the patient to offer
• When the bubbles have been removed, return the tubing
his identification bracelet for inspection when anyone arrives
to the pump, restart the infusion, and recheck the flow rate.
with drugs and to insist on having it replaced if it’s removed.
• Ask the patient to verify his allergy history before admin- Incorrect administration route
istering an antibiotic. • When a patient has multiple IVlines, label the distal end
• Ask the patient about his use of alternative therapies, of each line.
including herbs, and record your findings in his medical • Never use a parenteral syringe to prepare oral liquid
record. Monitor the patient carefully and report unusual drugs (this increases the chance for error because the
events. Ask the patient to keep a diary of all therapies he syringe tip fits easily into IVports). To safely give an oral
uses and to take the diary for review each time he visits a drug through a feeding tube, use a dose prepared by the
health care professional. pharmacy and a syringe with the appropriate tip.
P ROVIDING CARE
125
safeguards known as the “five rights” to help you avoid the most
basic and common medication errors. Each time you administer a Memory
medication, confirm that you have the:
jogger
• right drug Before you
• right dose adminis t er
• right patient a drug,
remember your nurs -
• right time ing res pons ibilit ies
• right route. for t his int erven-
t ion. To remember
Room s ervice t he s equence of t he
At meal times, raise the head of the bed so that the patient can sit act ions you mus t
upright. Adjust his tray, and assess his need for fresh water. Ask t ake, t hink “Unt il
Clear, Ask Many
about any special requests, such as the desire for juice or other
Times ”:
food items. Place the call light within the patient’s reach, and
instruct him to call you with any additional needs or concerns. Unders t and t he
drug and how it
Before you leave works .
Each time you prepare to exit the patient’s room, look over Clarify t he drug
your care plan and worksheet. Identify the interventions you’ve order as needed.
completed, and make note of any changes to the care plan that Administ er t he
need to be made. Also note any changes in the patient’s status, drug.
his response to treatment and care, and his refusal of care, treat- Monit or t he pat ient
ments, or regimens (all of which require nursing note entries in for t herapeut ic re-
the patient’s medical record). s pons e t o t he drug
and for advers e
St at us report effect s .
Report any abnormal findings, patient or family concerns, changes Teach t he pat ient
in the patient’s condition, or uncertainty or concern about findings about t he drug as
to your clinical instructor and the patient’s primary care nurse. needed.
Also report your completion of ordered treatments and regimens.
Integ rating ac tivitie s

Although you could approach each intervention separately when
providing care, systematically checking off each intervention in
the care plan, this approach isn’t the most practical use of your
time and energy. A more effective approach is to try completing
as many interventions as possible during each visit to the patient’s
room. Coordinating and integrating your nursing care between
or with activities of daily living, medication administration, vital
signs assessments, treatments, and other collaborative and inter-
dependent care has several benefits:
• It saves time.
• It enhances your coordination skills.
• It allows you to provide efficient and timely care.
IMP LEMENTATION
126
When taking an integrated approach, remember to review your

care plan and notes carefully because you’ll be attempting to com-
plete several interventions during a single visit.
Imple me ntatio n e xample

Because the care that you provide is specific to each patient, a
sample scenario might help you to better understand ways in
which you can successfully integrate routine activities to imple-
ment efficient patient care. Suppose you’re working the morning
shift (7 a.m. to 3 p.m.) in a hospital and you’re assigned a patient
with a neuromuscular impairment. After report, you review the
care plan, which included the nursing diagnoses:
• Ba thi n g self-ca r e defi ci t r ela ted to n eu r om u scu la r i m pa i r -
m en t a n d gen er a li zed debi li ty a s evi den ced by i n a bi li ty to wa sh
body a n d obta i n ba th su ppli es
• Ri sk for i m pa i r ed ski n i n tegr i ty r ela ted to decr ea sed m obi li ty
a n d poor n u tr i ti on a l i n ta ke
Your nursing care plan for this patient might look like the one
shown in Un der sta n di n g i m plem en ta ti on : Sa m ple ca r e pla n .
Based on the care plan, interventions for this patient may
include:
• taking vital signs
• assisting with morning hygiene (such as bathing, oral care,
toileting, and grooming) Mealt imes are
• assessing skin, diet, fluid intake, musculoskeletal strength, and anot her good
opport unit y t o
mobility
ass ess your
• positioning the patient pat ient ’s s t at us and
• providing nutritious meals. his needs.
You’ll also need to incorporate other assessments, such as
assessment of cardiopulmonary status, bowel elimination, and
pain, into your care to gain a full picture of the patient’s status.
Making t he mos t of your t ime

Remember, to provide the most effective care possible, you may
need to integrate several interventions. Here are some ways
in which you can integrate the nursing tasks that you need to
perform:
• If the patient’s ability allows, ask him to wash his face while
you’re setting up supplies for his bed bath. Observe the patient’s
reaction and the action taken in response to this request. Assess
the patient’s interest in self-care, ability to understand and follow
instructions, functional use and range of motion (ROM) of upper
extremities, and any signs of discomfort.
P ROVIDING CARE
127
Under construction
Unders tanding implementation: Sample care plan

This sample care plan was developed for a patient who has problems with bathing and hygiene and who’s at risk for skin
breakdown because of his chronic illness and current hospitalization.
Date Nursing Patient Interventions Outcome evaluation

diagnosis outcomes (initials and date)
5 / 8 / 12 Bat hin g se lf - • T he p at ie n t • Asse ss t he p at ie n t ’s f u n ct io n al

car e d e f icit will wash his le ve l e ve r y shif t , an d d o cu m e n t
r e lat e d t o f ace , ar m s, f in d in gs.
n e u r o m u scu - f r o n t al t r u n k, • Assist wit h o r p e r f o r m bat hin g
lar im p air - an d p e r i- d aily while p r o m o t in g p at ie n t in -
m e n t an d n e al ar e a o n d e p e n d e n ce in bat hin g t he p ar t s
ge n e r alize d m o r n in g shif t o f his bo d y wit hin his r e ach an d
d e bilit y as by d ischar ge . his m axim al f u n ct io n al abilit y.
e vid e n ce d by • T he f am ily • Chan ge lin e n s d aily an d as
in abilit y t o will d e m o n - n eed ed .
wash bo d y an d st r at e saf e • Asse ss t he f am ily’s kn o wle d ge
o bt ain bat h an d e f f e ct ive o f p r o p e r bat h an d lin e n ch an ge
su p p lie s assist an ce wit h p r o ce d u r e s, saf e t y m e asu r e s, an d
p at ie n t ’s bat h r at io n ale f o r p e r so n al hygie n e
an d hygie n e in o r d e r t o m e e t t he p at ie n t ’s
o n m o r n in g bat hin g an d hygie n e n e e d s o n d is-
shif t by d ischar ge .
char ge . • I n st r u ct t he f am ily as n e e d e d
o n saf e t e chn iqu e s f o r p r o vid in g
bat hin g an d hygie n e n e e d s.
• Obse r ve f am ily m e m be r s d e m -
o n st r at e saf e an d e f f e ct ive assis-
t an ce wit h t he p at ie n t ’s p e r so n al
car e .
• Asse ss t he f am ily’s n e e d f o r
ho m e car e assist an ce t o p r o vid e
t he p at ie n t ’s bat hin g an d hygie n e
n e e d s f o r saf e t y o r r e sp it e issu e s.
REVIEW DATES
Date Signature Initials
5 / 8 / 12 J ackie Mille r , RN J M
(continued)
IMP LEMENTATION
128
Unders tanding implementation: Sample care plan (continued )
Date Nursing Patient Interventions Outcome evaluation

5 / 8 / 12 Risk f o r • T he p at ie n t • Asse ss skin in t e gr it y e ve r y shif t

im p air e d will r e m ain an d as n e e d e d .
skin in t e gr it y f r ee f r om • Asse ss d ie t ar y an d f lu id p r e f e r -
r e lat e d t o skin br e ak- e n ce s o n ad m issio n .
d e cr e ase d d o wn d u r in g • Asse ss d ie t ar y in t ake an d f lu id
m o bilit y an d t he ho sp it al in t ake an d o u t p u t e ve r y shif t .
p o o r n u t r i- st ay. • Asse ss t he f am ily’s kn o wle d ge o f
t io n al in t ake • T he p at ie n t p r in cip le s an d p r act ice s o f skin
will co n su m e car e an d t he ir n e e d f o r sp e cial-
8 0 % o f all ize d e qu ip m e n t t o p r o m o t e go o d
m e als d u r in g car e at ho m e .
ho sp it al st ay. • Ke e p skin an d lin e n s cle an an d
• T he f am ily d r y, an d ke e p lin e n s wr in kle - f r e e .
will d e m o n - • T u r n an d r e p o sit io n t he p at ie n t
st r at e p r o p e r e ve r y 2 ho u r s an d as n e e d e d .
u se an d • Ap p ly lo t io n t o d r y skin ar e as
u n d e r st an d - af t e r bat hin g, at be d t im e , an d as
in g o f ho m e d e sir e d by t he p at ie n t .
m e asu r e s t o • Pr o vid e f o o d s an d f lu id s o f
p r e ve n t skin cho ice t hat ar e n u t r it io n ally ap -
br e akd o wn by p r o p r iat e f o r t he p at ie n t ’s d ie t
d ischar ge . an d m e d ical r e gim e n .
• Pr omo t e p at ie n t in t ake o f at
le ast 1 L o f n o n caf f e in at e d liqu id s
p e r d ay.
• T e ach t he f amily as n e e d e d abo u t
skin car e an d o bse r vat io n t e ch-
n iqu e s, p o sit io n chan ge r e qu ir e -
me n t s, an d n u t r it io n al an d f lu id
n e e d s t o p r e ve n t skin br e akd o wn .
• Obse r ve t he f am ily d e m o n st r at e
an d ve r balize u n d e r st an d in g o f all
in st r u ct io n s give n .
REVIEW DATES
5 / 8 / 12 J ackie Mille r , RN J M
P ROVIDING CARE
129
• While the patient washes himself, ask about pain or discomfort

with movement, level of fatigue, usual activity level before this
hospitalization, the availability of people to assist him at home,
and any preferences for skin care.
• While helping the patient shave, assess endurance and fine
motor skills and ROM of the hands and arms.
• When applying lotion to the patient’s hands, assess bilateral
grip strength, radial pulses, capillary refill, and gross sensory
disturbances.
• While washing the patient’s lower extremities, assess strength
and ROM of legs and feet, endurance, skin integrity, distal pulses,
capillary refill, toenails, and gross sensory disturbances.
• While helping the patient wash his perineal area, discuss bowel
and bladder status or problems and observe skin integrity of the
abdomen and groin.
• While assisting with oral hygiene, assess the teeth, gums,
tongue, and oral mucosa and encourage the patient to drink
sufficient amounts of water. Teach the importance of adequate
fluid intake to maintain healthy skin and bowel and bladder
function.
Working with the inte rdis c iplinary te am

Nurses aren’t the only health care professionals involved in
patient care. As you implement care, you’ll need to collaborate
with an interdisciplinary team to meet the diverse needs of your
patients.
Share and s hare alike

The focus of an interdisciplinary team is on the patient and patient
outcomes. Each team member shares responsibility for achieving Remember, pat ient
these outcomes. To provide more effective and comprehensive care is a t eam s port .
care, you need to understand each team member’s role. (See Meet
the i n ter di sci pli n a r y tea m , page 130.)
Pas s ing not es is permit t ed

When you’re reviewing the patient’s chart, be
sure to read the progress notes written by other
members of the health care team. Those notes
will provide you with important information about
your patient’s treatment and progress toward
outcomes.
If you have questions about the patient’s condi-
tion or treatment, contact the appropriate team
members for more information. For example, a
IMP LEMENTATION
130
Meet the interdis ciplinary team

Members of the interdisciplinary health care team—and their roles—include:
• physician, physician’s assistant, nurse practitioner, and consultant specialty
physicians—who assess, monitor, and provide treatment guidelines for the patient’s
medical conditions
• primary nurse, advanced practice or clinical nurse specialist, and nurse-manager—
who assess, monitor, teach, and intervene to help the patient meet his expected
outcomes by discharge
• registered dietitian—who assesses and monitors nutritional needs
• social worker—who provides support and counseling to patients and their families and
helps with financial difficulties
• occupational therapist—who assists the patient in performing activities of daily living,
participating in recreation, and working to the highest functional level
• physical therapist—who assists the patient to improve or restore physical functioning
and prevent deconditioning
• respiratory therapist—who monitors and provides airway management and
oxygenation
• pastoral care specialist—who provides religious and spiritual support to patients and
their families
• pharmacist—who reviews, prepares, and dispenses the patient’s medications; provides
information and guidance in the preparation and administration of medications; and pro-
vides patient education (in an outpatient setting)
• discharge planner—who coordinates access to ongoing services after discharge, such
as transfer to another facility, arrangement for medical equipment in the home, or referral
for home health services.
Hospice or palliative care

In a hospice or palliative care setting, the interdisciplinary team would also include:
• volunteer—who provides emotional and diversional support and respite to the patient
and family
• bereavement counselor—who supports and counsels the family for 1 year after the
death of the patient.
Important reminder
And don’t forget the most important members of the team: the patient and his family.
No interventions can occur and no goals can be met unless the patient permits the care
and is committed to the outcome.
DOCUMENTING INTERVENTIONS
131
pharmacist can tell you how to space medications to eliminate

drug or food interactions, whereas a physical therapist can pro-
vide you with written instructions on the patient’s prescribed
exercises.
Play well wit h ot hers

You’ll also need to coordinate care with other team members.
For example, medicating your postoperative patient before respi-
ratory exercises helps the patient cough and deep breathe more
effectively with the respiratory therapist. When working with
other team members, remember to use good communication
skills. Above all, treat all team members with respect, and they’ll
respect you in turn!
Doc u m e n t in g in t e rve n t ion s

Documentation is an important component of implementation.
As previously mentioned, you should take notes after each inter-
vention you perform, including the nature of the intervention,
the time you performed it, and the patient’s response as well as
interventions you performed based on the patient’s response and
the reasons you performed them. Each intervention should also
be documented in the patient’s medical record. You should record
interventions whenever you:
• give routine care
• give emergency care
• observe changes in the patient’s condition
• administer medications
• perform procedures or interventions.
Tailor-fit t o hous e s t yle

Where do you document your interventions? That depends on
your facility’s policy. You can document them on graphic records,
on a patient care flow sheet that integrates all nurses’ notes for a
1-day period, on integrated or separate nurses’ progress notes, and
on other specialized documentation forms (such as the medica-
tion administration record). Your facility’s policies also dictate the
style and format of the documentation.
Focus ed document at ion

Your documentation should be patient-centered and outcome-
oriented. Stating the patient’s response to your nursing interven-
tions help to make your documentation patient-centered. Linking
your interventions and responses to the nursing diagnoses and
goal statements makes it outcome-oriented as well.
IMP LEMENTATION
132
Doc umentation formats

Various types of nursing note formats are used in the clinical
setting. They may be done by hand or in a computerized charting
system. Two of the most commonly used formats for documenting
interventions are discussed here.
PIE s ys tem
The problem-intervention-evaluation (PIE) system organizes infor-
mation according to patient problems and was devised to simplify
the documentation process. This system requires you to keep a
daily patient assessment flow sheet and to write structured prog-
ress notes.
Piecing PIE t oget her

Each piece of PIE has it’s own purpose:
• The problem category is used to identify the nursing diagnosis
requiring the interventions.
• The intervention category describes the actions you took and
any assessment data related to the interventions.
• The evaluation section describes the results of your interventions
and any additional information regarding attaining your outcomes.
(See Usi n g PIE docu m en ta ti on .)
SOAP fo rmat
SOAP is an acronym for subjective data, objective data, assess-
ment, and planning. The SOAP system, which is used in problem-
oriented medical record charting, allows all health care team
members to record their findings using narrative progress notes.
This system allows readers to readily distinguish between the
subjective and objective data so the correct plan of care can be
chosen, and you can show that your interventions addressed the
patient’s documented needs. It also specifies the follow-up care
that’s planned.
The dirt on SOAP

To use the SOAP format, document the following information for
each problem:
• Subjective data: Information the patient or family members tell
you, such as the chief complaint
• Objective data: Factual, measurable data you gather during
assessment, such as vital signs and laboratory test results
DOCUMENTING INTERVENTIONS
133
Us ing PIE documentation

For the nursing diagnosis Bathing self-care deficit, you would document your
care using the PIE format in this way:
P—Bat h in g se lf - car e d e f icit

I —Assist e d p t . wit h bat h; he was able t o wash his o wn han d s an d
u p p e r ch e st slo wly wit ho u t d isco m f o r t . Pt . u n able t o lif t ar m s abo ve
che st ; m u scle st r e n gt h gr ad e 3 / 6 u p p e r an d lo we r e xt r e m it ie s.
Re m ain s o n p r act it io n e r - o r d e r e d be d r e st . Chan ge d lin e n s an d r e -
p o sit io n e d p t . o n t o le f t sid e af t e r ap p lyin g o il- base d lo t io n t o skin .
E—Co n t in u e s t o r e qu ir e m aj o r assist an ce wit h p e r so n al car e . P lan t o
asse ss t he f am ily’s abilit y t o m e e t t he p t .’s bat hin g an d h ygie n e n e e d s
whe n t he y visit in t h e af t e r n o o n .
For the nursing diagnosis Risk for impaired skin integrity, you would document your
care using the PIE format in this way:
P—Risk f o r im p air e d skin in t e gr it y

I —Pt . asse ssm e n t r e ve ale d war m , d r y skin t hat ’s p ap e r y o n t he
lo we r le gs wit h so m e f lakin g. Sacr al ar e a is r e d d e n e d f r o m lyin g
su p in e , bu t co lo r cle ar s wh e n t h e p at ie n t is r e p o sit io n e d o n t o le f t
sid e . N o o t h e r ar e as o f r e d n e ss o r an y o t h e r d e f e ct s p r e se n t .
Rad ial, d o r salis p e d is, an d p o st e r io r t ibial p u lse s +2 an d e qu al bilat -
e r ally; all n ail be d s sho w br isk cap illar y r e f ill. Ap p lie d lo t io n af t e r
bat h. Pt . at e 5 0 % o f br e akf ast ; st at e s "I d o n ’t ge t t o o hu n gr y an y-
m o r e . I like a ho t br e akf ast bu t "I d o n ’t car e f o r baco n o r sau sage ,
j u st e ggs o r o at m e al". I n st r u ct e d p t . t hat d ie t it ian can visit an d
he lp him cho o se m e als he like s as we ll as f in d ways t o ke e p u p h is
p r o t e in an d calo r ie s so his skin r e m ain s he alt hy. Pt . agr e e able bu t
r e qu e st s visit in t h e af t e r n o o n s, wh e n h is wif e is h e r e . Also t au gh t
p t . im p o r t an ce o f d r in kin g 4 t o 6 cu p s o f n o n caf f e in at e d f lu id s
p e r d ay f o r skin , bo we l, an d blad d e r he alt h an d ap p lyin g lo t io n t o
d r y e xt r e m it ie s, p ar t icu lar ly t he lo we r le gs, at le ast t wice d aily.
E—Pt . ve r balize d u n d e r st an d in g o f all in st r u ct io n s bu t p r e f e r s t o
have wif e he ar in f o r m at io n as we ll; p t . st at e s "she ke e p s t r ack o f
e ve r yt hin g n o w." Pt . o f f e r s t o ask h e r t o r u b lo t io n o n his le gs an d
ar m s d u r in g he r af t e r n o o n visit s. Re f e r r al m ad e t o d ie t it ian .
IMP LEMENTATION
134
• Assessment data: Conclusions based on the collected subjective

and objective data and formulated as patient problems and nurs-
ing diagnoses; these conclusions are dynamic, changing as more
or different data become known
• Plan: Your strategy for relieving the patient’s problem, including
both short- and long-term measures.
(See Usi n g SOAP n otes.)
Us ing SOAP notes

For the patient problem Bathing self-care deficit, you would document your care
using the SOAP format in this way:
S—"I can ’t ge t t o m y bat h su p p lie s be cau se m y st r e n gt h is go n e .

I can ’t e ve n m o ve m yse lf ."
O—Pt . u n able t o lif t ar m s abo ve che st . Washe d o wn han d s an d u p p e r
che st slo wly. Mu scle st r e n gt h gr ad e 3 / 6 u p p e r an d lo we r e xt r e m i-
t ie s. P t . r e m ain s o n p r act it io n e r - o r d e r e d be d r e st .
A—Bat hin g se lf - car e d e f icit
P —Co n t in u e t o p r o vid e f o r p t .’s bat hin g an d hygie n e n e e d s. Asse ss
an d in st r u ct f am ily r e gar d in g alt e r n at e m e t ho d s f o r m e e t in g
bat h in g an d hygie n e n e e d s.
For the patient problem Risk for impaired skin integrity, you would document your
care using the SOAP format in this way:
S—"I ’m f e e lin g so m e p r e ssu r e an d p ain in m y lo we r back."

O—Pap e r y d r y skin o n t he lo we r le gs wit h so m e f lakin g; sacr al ar e a
r e d d e n e d f r o m lyin g su p in e .
A—Risk f o r im p air e d skin in t e gr it y
P —Co n t in u e t o chan ge p o sit io n f r e qu e n t ly. Ap p ly lo t io n t o d r y ar e as.
ON THE CAS E
135
On t he cas e
For your first clinical rotation on a medical-surgical unit,
you’re assigned to care for two patients. Your first patient is
Shirley Trotter, a 75-year-old who was admitted yesterday with
pneumonia and severe shortness of breath. Your second patient
is Carl Conrad, a 46-year-old admitted 3 days ago for an abdominal
cholecystectomy.

To help prepare for your clinical experience, place these steps in
proper sequence by numbering them from 1 to 9:
A. Assess Shirley Trotter.
B. Document your care and the patients’ responses to your
interventions.
C. Receive the shift report from your patients’ previous
nurse.
D. Greet your patients, introduce yourself to them, and
verify their identities per protocol.
E. Check in with your instructor and prepare the patients’
morning medications, gathering any other supplies needed.
F. Receive your patient assignment, research the medi-
cal diagnoses and existing care plans, and establish preliminary
priorities of care.
G. Assess Carl Conrad.
H. Review medication and IV fluid administration records.
I. Complete as many interventions as possible during each
visit to each patient’s room.
J. Administer your patients’ morning medications.
IMP LEMENTATION
136
Ans wer key

1. F, 2. C, 3. H, 4. D, 5. A, 6. G, 7. E, 8. J, 9. I, 10. B
6
Evaluation
J us t t he fact s
♦ the importance of continually reassessing the patient’s
condition during all phases of care
♦ criteria for evaluating care
♦ the process for evaluating whether a care plan must
be revised and the way in which revisions should be
implemented.
A lo ok a t e va lu a t ion
Although designated as the fifth phase of the nursing process,
evaluation is really an ongoing practice that occurs with every Don’t be nervous
patient encounter. It encompasses: about being
• reassessing the patient evaluat ed. Evaluat ion
• comparing your findings with the outcome criteria established is an ongoing and
crit ical part of
in the care plan
pat ient care.
• determining the extent of the patient’s progress, or outcome
achievement (whether an outcome goal was met, partially met,
or not met)
• writing evaluation statements
• revising the care plan, including nursing diagnoses,
outcomes, and interventions, as needed
• documenting your evaluation.
The value of evaluat ion

Each evaluation you make depends primarily on your
ability to form an opinion or judgment about the data
you collect. As a nurse, you’ll use your evaluation
findings to:
• determine if the original assessment findings still
apply to the patient’s condition
• uncover complications
EVALUATION
138
• assess and analyze trends or patterns in the patient’s response

to all aspects of his care, including medications, changes in diet or
activity, procedures, unusual incidents or problems, and teaching
• determine how closely your care conforms to established
standards
• assess the results of care provided by other health care team
members
• identify opportunities to improve the quality of care.
Re a s s e s s in g a p a t ie n t
Reassessment is a necessary part of evaluation. After all, how else
can you determine whether your patient’s condition is improving,
your interventions are working, or your patient is making suffi-
cient progress toward achieving his outcome goals? Reas sess ment is a
necess ary part of
The pat ient and t he proces s evaluat ion.
It’s important to note that reassessment includes not only periodi-

cally rechecking your patient’s status throughout his care but also
reexamining all phases of the nursing process in relation to the
patient. This involves reviewing all the nursing diagnoses, patient
outcomes, and specific interventions written into the care plan.
(See Eva lu a ti on thr ou ghou t the n u r si n g pr ocess.)
Comparing patie nt data

In order to evaluate care, you must first compare your patient’s
prior assessment data with your follow-up assessment data to see
whether his condition has changed. This comparison allows you
to make inferences about the patient’s condition and to alter the
care plan accordingly.
Dat a déjà vu
When comparing data, remember to review all the patient’s find-
ings, including:
• his baseline level of functioning at the time of admission
• his most recent assessment findings
• any other pertinent data collected within the past 24 hours.
Your comparison should include a careful review of the
patient’s functional level, vital signs, and general overall status.
Begging t he ques t ion

Next, you should compare the patient’s current condition with his
condition prior to the initiation of care to determine his response
REAS S ES S ING A P ATIENT
139
Evaluation throughout the nurs ing proces s

Assessment, or more correctly reassessment, takes place at all phases of the nursing
process. Examples of the types of questions you can ask as you move through the stages
of the nursing process are shown below. Remember that any change in the patient’s
condition that’s outside of the expected findings requires you to notify the practitioner.
Nursing process step Questions
Assessment Have the patient’s vital signs changed?

What’s the patient’s current pain scale rating?
Nursing diagnosis Is this diagnosis still relevant?

Do the current signs and symptoms point to any new
diagnoses?
Planning Are the outcomes still realistic in the time allotted?

Do the interventions still match the patient’s expected
outcomes?
Implementation Did I observe a response when I implemented the

interventions?
Was the patient comfortable with the interventions?
Evaluation How do the reassessment findings compare with the

original findings?
Can I document the nursing diagnostic goal as met?
to your interventions (independent and collaborative). Ask your-

self these two key questions:
How is my patient responding to care?
What’s his current condition (is he stable, improving, or

worsening)?
Your answers to these questions will help guide your decisions
about follow-up care. (For an example of how to evaluate patient
data, see Is m y pa ti en t i m pr ovi n g?, page 140.)
Report , record, react

The follow-up care you’ll perform will be determined by the
results of your reassessment evaluation. If the patient’s condition
is stable or improved, your next step is documentation of your
findings. If, however, you believe that the patient’s condition is
EVALUATION
140
Is my patient improving?
You’ve been working with an elderly, bedbound, terminally ill patient. One of the major
nursing considerations for this patient is his comfort level, which includes keeping him
free from painful skin breakdown.
Initial assessment
The patient’s initial assessment showed:
• very dry, flaking skin on the lower legs and feet
• buildup of dead skin on the soles
• deep-red heels that are continuously tender
• present and equal dorsalis pedis and posterior tibial pulses bilaterally
• absence of edema
• sluggish capillary refill.
A nursing diagnosis of Impaired skin integrity related to immobility, decreased nutrition,
and skin effects of aging was identified on the patient’s care plan, which also included
the following expected outcomes:
• The skin on the patient’s lower extremities will be pink, dry, and intact by discharge.
• The patient’s skin will be free from additional areas of impaired skin integrity through-
out hospitalization.
Your assessment
Your assessment on day 3 of admission reveals:
• soft skin on the lower legs and feet
• slight flaking of the skin on the ankles and feet
• decrease of 50% in residual dead skin buildup
• deep-red heels that are tender to touch
• unchanged pulses, edema, and capillary refill.
Comparing assessments
When you compare the new data you collected with the initial patient data, you deter-
mine that the patient’s condition is improving and your plan is to continue to implement
the nursing interventions identified on the care plan and to continue to monitor the
patient. If your assessment had revealed that the patient’s condition was unstable or
worsening, in addition to continuing with established interventions you may add new
interventions, such as consulting the practitioner and wound care specialist for addi-
tional treatments or requesting an order for a specialty bed.
remaining static or deteriorating, be prepared to suggest the next

appropriate actions and give your rationales for them. Then pro-
ceed with further interventions as appropriate. Keep in mind that
you’ll need to document your findings and the care plan revisions.
As a student nurse, you’ll also need to report your assessment
data to the primary nurse and your instructor.
141
Teacher knows best
Keeping track of interventions

One suggestion for keeping track of the interventions you perform is to check off the
interventions after you perform them, and then write down data that suggest the patient
is making progress toward achieving the goal. Also remember to evaluate and docu-
ment in your notes how the patient tolerates the interventions you perform and any
unexpected effects related to the intervention.
Evaluating inte rve ntions and g oals

At some point, you’ll need to conduct a systematic review of all
your interventions to gauge your patient’s progress toward achiev-
ing the expected outcomes. When you do this, you’ll ask yourself
many additional questions, such as:
• Do the reassessment findings show that the interventions are
working?
• Are some interventions no longer necessary?
• Have any or all of the patient’s short-term goals been met? Have
long-term goals been met?
Complet e or communicat e
As a student, you might not be able to perform all of the interven-
tions included in a patient’s care plan. However, you’re responsi-
ble for communicating to your instructor and the patient’s primary
care nurse which interventions you did and did not complete. (See
Keepi n g tr a ck of i n ter ven ti on s.) This communication ensures
that the patient’s primary care nurse knows what interventions
still need to be completed so that the patient receives all of the
planned nursing interventions.
Achie ving expec te d outc ome s

On evaluation, you may determine, based on the patient’s
response to treatment and care, that the patient has met his short-
term goals. For example, you may have successfully employed all
of the interventions needed to return your patient’s assessment
findings to within normal limits. Hence, your evaluation would
lead you to assume that the expected outcome has been met.
To help clarify this concept, consider a practical real-life
example, such as buying a new pair of shoes. (See The blu e shoe
blu es, page 142.)
EVALUATION
142
The blue s hoe blues

Here’s a practical example of how to evaluate whether expected outcomes have been met: Imagine that you’ve been
invited to a party to celebrate your completion of nursing school. You have a beautiful, new blue dress at home that you’ve
been saving for just such an occasion. However, you assess your shoe wardrobe and are sad to discover that you have
no blue shoes to match the dress. Your nursing diagnosis (note that this one isn’t NANDA International approved) is Shoe
deficit, blue. Your short-term goal is to buy a new pair of blue shoes right away that are comfortable and reasonably
priced. You remember that the shoe store down the street is having a sale, and you drive there to search for shoes that are
just the right color, size, and price. You make your purchase—a new pair of blue suede shoes—and drive home happy.
So, from a nursing perspective, how would you evaluate what you’ve just done? In this example, the best approach is to
compare the diagnosis with the goal to determine what you’ve accomplished. The flowchart below takes you through this
process step by step.
As s e s s me
n
findings t
Have brown, tan, red, white, and black shoes appropriate for every outfit.
Lack fancy blue shoes appropriate to wear with cocktail dress.
Dia gnos is Expe c te d

outc ome
Shoe deficit, blue

Today I will buy a pair of reasonably
priced blue shoes that are comfortable
and match my dress.
Inte rve nti
ons
• Drive to the shoe store down the street.

• Find various shades and styles of blue shoes in my size.
• Compare shades of blue, comfortableness, and prices of all blue shoes in my size.
• Purchase the pair that meets the established outcome criteria.
Eva lua tio

n
Today I purchased a pair of comfortable

blue shoes.
143
Whe n e xpec ted o utco me s are n’t me t

Achieving expected outcomes indicates progress in your patient’s
care. However, suppose that you perform all of the interventions
in the care plan and your patient’s condition doesn’t improve or,
worse yet, his condition has deteriorated. These findings indicate
that the expected outcomes haven’t been achieved. So, what do
you do? At this point, you must reassess the situation.
Posit ive out comes
A cas e of int olerable int ervent ions ? indicat e progres s!
You’re caring for a 78-year-old patient with a nursing diagnosis
of Toi leti n g self-ca r e defi ci t r ela ted to wea kn ess a s evi den ced
by m u scle str en gth 4/6 i n lower extr em i ti es, a pr i or or der for
bed r est, a n d loss of m u scle m a ss du e to a gi n g. This patient’s
expected outcome is that he will ambulate to the bathroom with
assistance the third day after admission. You begin performing
the following interventions, as mentioned in the care plan:
• Assess the patient’s functional level and strength before getting
him out of bed.
• Dangle the patient’s feet at the side of the bed before assisting
him to a standing position.
• Assist the patient out of bed to the bathroom when needed.
• Instruct the patient to call for assistance with toileting before
an urgent need, and explain planned interventions to achieve the
expected outcome.
As soon as you begin assisting the patient to sit on the side
of the bed to dangle his legs, you hear him state that he feels
dizzy. You immediately help him to lie back down in bed and
take these vital signs: blood pressure 80/58 mm Hg, pulse 110
beats/minute, and oxygen saturation per pulse oximetry 97%
on room air. You check these measurements and find that the
patient’s morning vital signs were blood pressure 110/64 mm Hg,
pulse 88 beats/minute, and oxygen saturation per pulse oxim-
etry 97% on room air. These vital sign changes and the patient’s
complaint of dizziness lead you to conclude that the patient’s
condition has changed. Given the circumstances, he’s unable
to carry out the intervention and, therefore, can’t meet his
expected outcome.
Reassess the patient’s condition to determine whether the in-
tervention you performed (assisting the patient to dangle his legs
before standing) caused the response (dizziness, tachycardia, and
hypotension) or whether the response is a sign or symptom of a
worsening condition or a complication. Ask yourself the following
questions:
• Is this response a continuation or exacerbation of an existing
problem or condition?
EVALUATION
144
• Is this response due to something that has changed in the

patient’s condition?
• Is this a new problem that needs to be addressed by a revision
of the care plan?
Subt le s igns
During evaluation, always pay attention to even slight changes in
assessment findings. Sometimes, a mild physiological adaptation,
such as a response to a position change, can mimic a subtle change
in condition. Because of a relative lack of clinical experience, stu-
dent nurses commonly have difficulty making such distinctions,
which can affect the care plans they create for patients. Remem-
ber, when you’re in doubt, you and your patient will benefit most
if you ask for help from another nurse or from your instructor.
The power of reas s es s ment

When evaluation reveals changes in a patient’s condition or
expected outcomes that haven’t been achieved by the nursing inter-
ventions set out in the care plan or when your interventions create
an unexpected patient response that leads to new symptoms or a
worsening of the patient’s condition, you must reassess not only
the patient but also your expectations for the patient (expected
outcome). In some cases, the care plan will need to be revised to
reflect a different patient outcome and a new set of interventions.
Doc umenting c hang es

Remember to write a nurse’s note (electronic or handwritten) Short -t erm goals
that describes the patient’s changed condition. Use the format are t hose t hat can
preferred by your facility for this note. Also document any calls be accomplis hed
that you make to the practitioner to inform him of changes in the during t he pat ient ’s
patient’s condition, including the time the call was made. hospit al st ay, usually
wit hin a week.
Writ in g e va lu a t io n s t a t e m e n t s
Part of the evaluation process involves writing a statement that
describes whether the patient has achieved the expected outcome
(short- or long-term goal) as it was written into the care plan.
Revis it ing goals

As you may recall, short-term goals are those that can be accom-
plished during the patient’s hospital stay (usually within 1 week or
less), whereas long-term goals are those that can be accomplished
over an extended time (usually more than 1 week).
WRITING EVALUATION S TATEMENTS
145
May I opine?
Your evaluation statement should indicate whether the expected
outcome was achieved. However, your documentation just prior
to the evaluation statement should list the evidence supporting
this conclusion. This evidence is the information you obtained in
your reassessment and evaluation. These conclusions can state
that an outcome has been fully met, partially met, or not met.
Writ e right
In your actual charting, your evaluation should contain three types
of information:
• results of your reassessment
• results of your comparison of the reassessment data with the
patient’s baseline data or normal findings
• evaluation statement that specifies the patient’s status toward
achieving his expected outcomes.
Evaluating s hort-te rm goals

Your evaluation of a short-term goal should occur within the time
frame established in the patient outcome statement. You should
determine the patient’s progress toward achieving the goal within
the time frame and revise the care plan if needed. Keep in mind
that your patient may have more than one short-term goal for each
nursing diagnosis.
Let ’s walk t hrough it t oget her

For example, if a patient outcome states that “The patient will Long-t erm goals
ambulate in the hallway two times with minimal assistance on the t ake more t ime
t o accomplis h—
evening shift on 6/22/12,” you must evaluate the patient’s progress
somet imes weeks or
toward accomplishing that goal by the end of your shift on that mont hs.
day. If the patient fails to achieve the goal by the end of your shift,
you must document this in your nursing notes in the form of an
evaluation statement, such as “Patient was unable to tolerate sec-
ond attempt at ambulating in hallway with assistance; expected
outcome not met.” Of course, your reassessment data supporting
this evaluation would be documented in the chart according to the
format used in the facility.
Evaluating long -term go als

Your patient’s long-term goal may be the desired end result of
nursing care or, in some cases, a goal that extends beyond the
usual time frame of his hospital stay. Such conditions as stroke,
myocardial infarction, traumatic brain injury, neurologic or spinal
EVALUATION
146
injury, hip fracture, and Alzheimer’s disease commonly require

long-term goals that extend over a continuum of care. Typically,
patients with these conditions are discharged from the hospital
to a long-term care facility or home health agency for continued
nursing treatment and care.
Taking t he long road home

For example, the patient with a nursing diagnosis of Toi leti n g
self-ca r e defi ci t r ela ted to wea kn ess a s evi den ced by m u scle
str en gth 4/6 i n lower extr em i ti es, a pr i or or der for bed r est,
a n d loss of m u scle m a ss du e to a gi n g may have the following
expected outcome: “Ambulate to bathroom with minimal assis-
tance within 1 month after discharge to nursing rehabilitation
center.”
Such a goal establishes a clear timeline for evaluating the
outcome (within 1 month) and sets the criteria (with assistance,
after discharge from the hospital or transfer to the rehabilitation
center).
Eva lu a tin g th e c a re p la n
In addition to periodically evaluating the patient’s status and
progress toward achieving outcomes, you’ll need to evaluate the
care plan in its entirety. This means going through each section of
the plan to determine whether the patient’s problems have been
Reevaluat ing t he
resolved, outcomes have been achieved, and interventions are still care plan is just as
appropriate and current. import ant as
reevaluat ing t he
pat ient .
Reviewing the plan
Your reassessment of the care plan will yield much information
about what you and the patient have accomplished and what care
still needs to be done. Ask yourself the following questions, taking
each section in turn.
Look at t he nurs ing diagnos es

• Does the patient still have the same problems (nursing
diagnoses)? If so, has the focus of any of the problems changed
in a way that would warrant rewriting the diagnosis?
• Were the diagnoses confirmed or ruled out?
• Does the patient have any new needs? If so, should any
additional diagnoses be added to the care plan?
• Are all of the diagnoses prioritized?
EVALUATING THE CARE P LAN
147
Check pat ient out comes

• Has the patient achieved the short- and long-term outcomes for
each nursing diagnosis?
• Is each goal still valid and achievable within its given time
frame?
• Should the care plan include any additional criteria for
achieving the outcomes?
• Does the patient agree with the stated outcomes?
• If the patient didn’t achieve the outcomes, do you know why?
Review t he int ervent ions

• Do the interventions address the patient’s specific needs?
• Are they achievable within the designated time frames?
• Are they clearly written so that other team members can follow
them?
• Should any interventions be discontinued or rewritten?
Evaluating the plan

Once you’ve reviewed the care plan, you can provide a written
evaluation (on the care plan itself or in your progress notes)
of each care plan section. Be sure to base your evaluation on
information gathered from all sources, including your own
observations and findings, the patient’s medical record, the
patient himself, the patient’s family, and other members of the
health care team.
Record your evaluation using standard terminology that all
team members can easily understand and follow. For example,
use the following words:
• Con ti n u e: No change in diagnosis, patient outcomes, or
interventions is needed at this time, and the diagnosis hasn’t
yet been resolved.
• Revi sed: No change in diagnosis is needed, but the patient’s
expected outcomes and the associated interventions have been
updated to reflect the patient’s current status.
• Di scon ti n u ed: A change in diagnosis is needed because
additional data collection has shown that the diagnosis is no
longer appropriate for the patient.
• Achi eved: All expected outcomes have been met and the
diagnosis is no longer appropriate for the patient, or one
expected outcome has been met and, therefore, that portion of
the care plan is marked “achieved” while the other outcomes are
ongoing.
• Rei n sta te: A previous diagnosis whose outcomes had all been
achieved requires renewal because the problem has recurred.
EVALUATION
148
Updating the care plan Memory

jogger
In some cases, you’ll need to make modifications to the patient’s
care plan as a result of your evaluation. Updating typically begins If you know
with determining whether the patient has achieved the outcomes. you need t o
revis e your
If the outcomes haven’t been fully met but your assessment shows
pat ient ’s care plan
that the problem is resolved or was inappropriately identified, but can’t remember
the plan can be discontinued. If the problem persists, continue where t o s t art , t hink
the plan with new outcome target dates until the desired status REDO:
is achieved. If the outcomes are partially met or unmet, identify Reas s ess t he
interfering factors, such as misinterpreted information or a change pat ient .
in the patient’s status, and revise the outcomes and interventions
Evaluat e your
accordingly. findings.
When plan A does n’t work… Decide on a cours e
of act ion.
Updating may involve:
• clarifying or amending the database to reflect new information Organize t he care
• reexamining and correcting nursing diagnoses plan accordingly.
• establishing outcome criteria that reflect new information and
new or amended nursing strategies
• adding the revised nursing care plan to the original document
• recording the rationale for the revision in the progress notes.
…go t o plan B…
For instance, in the case of the patient who couldn’t tolerate
getting out of bed to use the bathroom, even with assistance
(see page 149), you could change the nursing diagnosis, patient
outcome, and interventions based on the inferences you made
when comparing the baseline patient data with his reassessment
findings. (See Upda ti n g a ca r e pla n .)
…or plan C
In the event that the patient can’t tolerate the activities associ-
ated with sitting on the side of the bed and, therefore, can’t meet
the outcome goal, revise the care plan again, beginning with your
reassessment. Other nursing diagnoses that can be established
based on the given findings and reassessment data may include:
• Defi ci en t flu i d volu m e
• Ri sk for i n ju r y.
Keeping priorit ies s t raight

Be sure to reprioritize the nursing diagnoses when updating your
care plan. This is especially important when the patient experi-
ences unexpected changes in his condition or possibly untoward
reactions as a result of his treatment or care.
EVALUATING THE CARE P LAN
149
Updating a care plan

After your 78-year-old patient’s experience with attempting to dangle and stand upright before walking into the
bathroom, you reevaluate the established care plan. After careful reassessment, you update his care plan to include
an additional nursing diagnosis and expected outcomes. One possible update is presented below:
Date Nursing Expected Interventions Outcome evaluation

4 / 1/ 12
Act ivit y T he p at ie n t • Asse ss f u n ct io n al le ve l e ve r y
in t o le r an ce will t o le r at e shif t as n e e d e d .
r e lat e d t o sit t in g u p at • Obt ain p osit ion al vit al sign s,
agin g p r o - t h e sid e o f oxyge n sat u r at ion le ve l, an d p ain
ce ss an d t h e be d wit h le ve l be f or e st ar t in g an y act ivit y
hyp o vo le m ia assist an ce f o r an d comp ar e t he se f in d in gs wit h
as e vid e n ce d 10 m in u t e s, mor n in g base lin e d at a.
by we akn e ss, t wice p e r d ay • Asse ss p at ie n t in t ake an d o u t -
d izzin e ss, an d o n 7 - 3 sh if t . p u t o ve r t he p ast 2 4 ho u r s.
in cr e ase d • Mon it or f or sign s of f at igu e an d
p u lse r at e avoid act ivit y d u r in g t his p er iod .
d u r in g • Main t ain t he p at ie n t ’s saf e t y.
act ivit y • Raise t he he ad o f t he be d in -
cr e m e n t ally t o r e d u ce d izzin e ss.
• H e lp t he p at ie n t sit o n t he
sid e o f t he be d wit h t he assis-
t an ce o f t wo su p p o r t p e r so n n e l.
• Re m ain wit h t he p at ie n t t he
e n t ir e t im e he ’s sit t in g u p r ight ,
an d asse ss f o r chan ge s in co n d i-
t io n o r act ivit y in t o le r an ce .
• Re p o r t sign if ican t chan ge s in
t he p at ie n t ’s co n d it io n o r act ivit y
in t o le r an ce t o t he p r act it io n e r .
REVIEW DATES
4 / 1/ 12 Am an d a T r o t t e r AT
When reprioritizing diagnoses, ask yourself these questions:

• Will the patient’s progress be hindered if the problem isn’t
managed now?
• Will the patient lose functional status if the problem isn’t
managed now?
• Will the patient be harmed in any way that will produce a
detrimental outcome if the problem isn’t managed now?
EVALUATION
150
A new out come

If you’re changing the nursing diagnoses, follow through by updat-
ing the expected patient outcomes (remember to include realistic,
measurable goals) and specific interventions needed to achieve
them. Also, make sure your interventions address any new treat-
ments or required care (independent or collaborative) resulting
from the patient’s changed condition.
Las t but not leas t

Document all of your evaluations and, as a student nurse, commu-
nicate your findings to your instructor and the patient’s primary
care nurse. Be sure to follow the facility’s procedure for recording
nurses’ notes and updating nursing care plans.
On t he cas e

You’re assigned to care for Ella Racer, a 70-year-old admitted
3 days ago with dehydration. In reviewing the admission assess-
ment data, you note that admission vital signs were blood pres-
sure 90/50 mm Hg, heart rate 110 beats/minute, and respiratory
rate 18 breaths/minute. Her skin color was pale and skin turgor
was poor. Her weight is 145 lb (usual weight 151 lb). Initial labora-
tory studies indicated an elevated serum sodium level and serum
osmolarity. Her care plan includes the nursing diagnosis Defi ci en t
flu i d volu m e r ela ted to a cti ve loss thr ou gh di a r r hea a n d i n a d-
equ a te i n ta ke. Her expected outcomes are:
• The patient’s fluid volume will return to normal and remain
normal as evidenced by stable vital signs and a urine output at the
volume established for the patient by day 3 of hospitalization.
• The patient’s electrolyte values will stay within a normal range
by discharge.
• The patient will express and identify three ways to prevent
dehydration by discharge.
Nursing interventions for this patient include:
• Monitor and record vital signs every 2 hours.
• Measure and record intake and output every hour. Report a
urine output less than 30 mL/hour.
• Administer fluids as ordered and monitor and record effective-
ness of therapy.
ON THE CAS E
151
• Administer antidiarrheal medication as ordered.

• Weigh the patient daily at the same time.
• Monitor electrolyte levels and report abnormal values.
• Explain reasons for fluid loss and teach the patient how to
avoid further episodes.
Your reassessment on day 3 reveals the following vital signs:
blood pressure 110/60 mm Hg, heart rate 75 beats/minute, and
respiratory rate 16 breaths/minute. Urine output is greater than
30 mL/hour. Dextrose 5% in water is infusing IV at 50 mL/hour.
Skin color is pink and skin turgor is normal. The patient has
experienced no further episodes of diarrhea and is tolerating oral
fluids and solids. Electrolyte levels are within normal limits. The
patient states, “I don’t know how I can prevent this from happen-
ing again.”

1. What reassessment findings show that the interventions are
working?
2. Which interventions may no longer be necessary or could be

altered?
3. Which of the patient’s short-term goals hasn’t been met?

EVALUATION
152
Ans wer key

1. Reassessment findings that show that interventions are
working include vital signs that have returned to within normal
limits (blood pressure 110/60 mm Hg, heart rate 75 beats/minute,
and respiratory rate 16 breaths/minute); urine output greater
than 30 mL/hour; normal skin turgor; oral fluid toleration; and
electrolyte levels within normal limits.
2. Because the patient is now stable, vital signs no longer need to
be taken every 2 hours. Monitoring every 4 hours or 8 hours would
be adequate. Urine output could also now be measured every
4 to 8 hours.
3. Because the patient stated “I don’t know how I can prevent this
from happening again,” the goal of “The patient will express and
identify three ways to prevent dehydration by discharge” hasn’t
been met.
7
Putting it all together
J us t t he fact s
♦ techniques for using traditional and standardized care
plans
♦ the role of computers in generating care plans
♦ components of and uses for a critical pathway
♦ types of care plans used in different health care settings.
An ot h e r loo k a t t h e n u rs in g c a re p la n
By now, you’re probably fairly well versed in the nursing process
and its relationship to the nursing care plan. You know the five
steps of the nursing process—assessment, nursing diagnosis, plan-
ning, implementation, and evaluation—and understand that each
This chapt er will
step builds on the previous one and that all the steps interconnect, help you put t oget her
forming the basis of a care plan. t he pieces of t he care
But how does it all come together? How do you gather all the planning process.
necessary information about a patient and document it correctly?
And where do you, as a nursing student, fit in?
Why yo u ne ed a c are plan

The nursing care plan is the core of your nursing practice—a vital
source of information about your patient’s problems, needs, and
goals and the quintessential blueprint to direct your treatment
and care. When well-executed, this document can lead you step-
by-step through your busy workday and help put your patient
squarely on the road to wellness.
Flexible, but permanent record

Until 1991, a care plan wasn’t a required part of a patient’s per-
manent record. It may have been used by the nursing staff but, in
P UTTING IT ALL TOGETHER
154
When did The Joint Commis s ion become

“The Bos s ”?
The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare
Organizations [JCAHO]) is often cited as the authority on standards of practice within
health care organizations. However, The Joint Commission itself doesn’t claim to
originate standards of practice. By incorporating them into the accreditation process,
The Joint Commission promotes compliance with those standards that the members of
a profession have deemed essential for best practice within their specialty. This can
mean engineering standards for building safety or nursing standards for excellence
in provision of nursing care. The American Nurses Association and related specialty
nursing organizations have determined that the nursing process, as embodied in an
individualized patient care plan, is the standard of care expected of a nurse.
some facilities, it was discarded when a patient was discharged.

Now, The Joint Commission mandates that the nursing care plan
be permanently integrated into the medical record by paper or
electronic means. (See When di d The J oi n t Com m i ssi on becom e
“The Boss”?)
Joint Commission policy changes have also led to greater flex-
ibility when writing care plans. The commission no longer speci-
fies the format for documenting patient care, so new methods
have emerged that can make planning faster and easier.
By nurs es , but not jus t for nurs es

Nursing is a unique patient-focused profession that’s different from
medicine and other health care fields, having its own set of diagno-
ses and outcomes and interventions that can be customized to meet
each patient’s needs. However, nurses don’t work in a vacuum; they
work in collaboration with other team members to promote patient
health and wellness. Consequently, although nursing care plans are
developed by nurses, they may be used as a springboard to a team
plan by the entire interdisciplinary team, including:
• nurses (clinical nurse specialists, registered nurses, licensed
practical nurses, and nursing students)
• practitioners (physicians, physician’s assistants, nurse practition-
ers, and midwives)
• physical and occupational therapists
• speech-language pathologists
• dietitians
ANOTHER LOOK AT THE NURS ING CARE P LAN
155
The expanding world of care planning

The nursing profession isn’t the only profession concerned with demon-
strating the unique and crucial nature of their skills in the health care
setting. Like nurses, other health care providers are seeking ways to
show that their actions reflect professional accountability and repre-
sent reimbursable services from insurance companies.
Respiratory, physical, and occupational therapists; registered
dietitians; speech-language pathologists; and nutritional specialists all
assess patients, analyze their findings, develop treatment plans, imple-
ment their plans, and reassess the effectiveness of their plans. The
standards of practice for these professionals make it clear that these
are mandated functions.
In many long-term care facilities, assisted-living facilities, inpatient
psychiatric centers, and home care and hospice agencies, these
professionals are active members of an interdisciplinary team that
develops an overall care plan for each patient. As such, a dietitian might
collaborate with nursing staff to include specific interventions in the
nursing care plan that promote certain outcomes—for example, obtain-
ing optimal nutrition or skin integrity. A physical or occupational thera-
pist might be involved in developing some of the nursing interventions
for a patient with a diagnosis of Impaired physical mobility. Depending
on the facility, these specialists may document their assessment find-
ings and care on an interdisciplinary form or their own standard forms.
• respiratory therapists
• social workers and discharge planners
• pharmacists
• clergy.
All on t he s ame t eam

Each member of the interdisciplinary team may have some input in
developing the care plan, but the registered nurse is responsible for
making sure that it’s carried out on a daily basis and documented
according to the facility’s policies. Other team members can also
document their interventions on the care plan under their specified
column or box. (See The expa n di n g wor ld of ca r e pla n n i n g.)
Students ’ role in c are planning

As a student, you should read and be knowledgeable about your
patient’s care plan at the hospital, nursing home, or agency
where you perform clinical rounds. Each facility and department
156
Teacher knows best
Paper trail
As you proceed through your clinical rotations, the type of paperwork you’re required to
complete might change. An early focus may be on the nursing assessment and corre-
lating those findings with the medical history and diagnosis. Later, you may be required
to complete medication worksheets that focus on helping you learn about hundreds of
drugs and what to teach the patients taking them. Finally come the nursing care plans
themselves, in various formats and detail. All of these tools serve one essential pur-
pose: to widen your knowledge base and sharpen your thinking skills so you can make
decisions logically and quickly as you care for patients.
operates differently, so it’s your responsibility to become familiar

with the system used.
RN recording right s
Keep in mind that only registered nurses can create and update a
nursing care plan. In some institutions, licensed practical nurses
can assist with writing the care plan, but they’re only permitted to
do so under the supervision of a registered nurse. The registered
nurse remains the one accountable for the correctness, implemen-
tation, and evaluation of the plan and is the only team member
permitted to change the nursing portions of the plan.
St udent ’s right t o writ e

As a student, you may use and follow the established care plan,
but you can’t document on it. You’ll document your patient find-
ings, nursing care, and observations directly on the medication
records, flow sheets, treatment plans, and progress notes. How-
ever, you’re expected to create your own care plan or concept
map to use during clinical rotations. Even when you don’t have to
turn in a written care plan to your instructor, you’re accountable
for having developed a care plan for the day and being able to ver-
balize it to your instructor when asked. (See Pa per tr a i l.)
Typ e s of c a re p la n s
Care plans are usually written in one of two styles: traditional or
standardized. As a student or a newly graduated nurse, you’re more
likely to see and use standardized care plans; in most cases, they’re
TYP ES OF CARE P LANS
157
easier to use and they’re more common than traditional plans.

Another issue is the increasing use of electronic health records
systems that include a care planning function. These systems are
a variation on standardized care plans but require some special
mention. Regardless of which type you use, your care plan should
cover all aspects of nursing care, from admission to discharge.
Traditional c are plans

Also called an i n di vi du a lly developed pla n , a traditional care
plan is written to your patient’s specific problems and causative
factors. After you analyze your assessment data for a patient, you
either write the plan by hand or enter it into a computer. (See
Tr a di ti on a l, bu t hi ghly per son a li zed, page 158.)
Home-baked from s crat ch

The basic form for the traditional care plan varies, depending on
the function of this important document in your facility or depart- Tradit ional
ment. Most forms have four main columns: care plans can
be writ t en by
nursing diagnoses hand or ent ered
int o a comput er.
expected outcomes
interventions
outcome evaluations.
The form may also have columns for the date when you initiated
the care plan, target dates for expected outcomes, and the dates for
review, revisions, and resolutions. Most forms also have a place for
you to sign or initial whenever you make an entry or revision.
Looking t oward an out come

The information that you should include on a traditional care plan
form varies, too. Because shorter hospital stays are more common
today, in some facilities, you’re expected to write only short-term
outcomes that the patient can reach by the time he’s discharged.
However, other facilities—especially long-term care facilities—
may also want you to chart long-term outcomes for the patient’s
maximum functioning level. These facilities commonly provide
forms with separate spaces for short-term and long-term outcomes.
Pers onal, vis ual, clear

The traditional method has several advantages:
• It provides a personalized plan for each patient.
• The format allows health care team members and the patient to
easily visualize the plan.
• Columns for outcome evaluations are clearly delineated.
158
Under construction
Traditional, but highly pers onalized

Here’s an example of a traditional care plan. It shows how these forms are typically organized. Remember that a tradi-
tional plan is written from scratch for each patient. These types of plans are becoming less common with the advent of
electronic products containing modifiable standardized care plans.
Date Nursing Expected Interventions Outcome evaluation

6 / 2 7 / 12 I n e f f e ct ive T he p at ie n t • Asse ss an d r e co r d r e sp ir at o r y
br e at hin g will m ain t ain st at u s, in clu d in g p u lse o xim e t r y q4 h Nursing diagnoses,
p at t e r n r e sp ir at o r y at 12 - 4 - 8 . expected outcomes,
R/ T p ain as r at e o f 16 t o • Asse ss f o r p ain q3 h an d 1 ho u r interventions, and
e vid e n ce d 2 0 br e at hs/ af t e r e ach d o sage o f p ain m e d ica- outcome evaluations
by p at ie n t min u t e wit h t io n q4 h at 12 - 4 - 8 . are key elements
r ep or t n o r mal d e p t h • Give p ain m e d icat io n as o r d e r e d of traditional care
o f p ain while awake p .r .n . plans.
wit h d e e p wit hin 8 ho u r s. • Assist p at ie n t t o co m f o r t able
br e at hs o r p o sit io n q2 h while awake o n e ve n
co u ghin g T he p at ie n t ho u r s.
an d shallo w will r at e p ain • T e ach p at ie n t ho w, whe n , an d why
r e sp ir at io n s as 3 o r le ss t o u se in ce n t ive sp ir o m e t e r .
at 2 2 t o o n a 0 - t o - 10 • De m o n st r at e t o p at ie n t ho w t o
2 6 br e at hs/ scale while u s- sp lin t che st while co u ghin g.
m in u t e in g an in ce n - • En co u r age p at ie n t t o u se sp ir o m -
t ive sp ir o m - e t e r 10 t im e s/ ho u r while awake as
e t e r 10 t im e s lo n g as be d r e st is m ain t ain e d .
ho u r ly wh ile • Pr o vid e r e st p e r io d s be t we e n car e
awake wit hin act ivit ie s.
4 ho u r s an d • I n it iat e o xyge n t he r ap y as o r -
o n go in g. d e r e d p e r give n p ar am e t e r s.
REVIEW DATES
6 / 2 8 / 12 C. Plan n e r , RN CP
Time is n’t on it s s ide

The main disadvantage of a traditional plan is that it’s time-
consuming to read and write because it requires lengthy
docu mentation.
159
Standardized c are plans

Standardized care plans are more commonly used. They eliminate
the problems associated with traditional plans by using preprinted
information. This saves documentation time. (See Sta n da r di zed
sa ves ti m e, page 160.)
Some standardized plans are classified by medical diagnoses
or diagnosis-related groups (DRGs); others, by nursing diagnoses.
The preprinted information included in a standardized care plan
includes interventions for patients with similar diagnoses and,
usually, root outcome statements.
Ins is t on individualit y
Early versions of standardized care plans didn’t allow for differ-
ences in patients’ needs. However, current versions require you to
explain how you have individualized the plan for each patient by
adding the following information:
• “related to” (R/T) statements and signs and symptoms for a
nursing diagnosis—If the form provides a root diagnosis, such as
“Acute pain R/T ,” you might fill in i n fla m m a ti on , a s ex-
hi bi ted by gr i m a ci n g a n d other expr essi on s of pa i n .
• time limits for the outcomes—To a root statement of the goal
Per for m postu r a l dr a i n a ge wi thou t a ssi sta n ce, you might add St andardized care
for 15 m i n u tes i m m edi a tely on a wa ken i n g i n the m or n i n g by plans are commonly
complet ed on a
11/12. comput er.
• frequency of interventions—To an intervention such as Per for m
pa ssi ve r a n ge-of-m oti on exer ci ses, you might add twi ce per da y:
i n the m or n i n g a n d i n the even i n g.
• specific instruction for interventions—For the standard inter-
vention Eleva te the pa ti en t’s hea d, you might specify befor e sleep,
on thr ee pi llows.
Comput ers make combos les s cumbers ome

When a patient has more than one diagnosis, you must use all the
standardized care plans, which can make records long and cum-
bersome. However, if your facility uses computerized standard-
ized care plans, you may be able to extract only the parts you
need for each plan and then combine them to make one manage-
able plan. Some computer programs provide a checklist of inter-
ventions from which you can select to build your own plans.
Although standardized plans usually include only essential
information, most provide space for you to write additional ex-
pected outcomes, interventions, and outcome evaluations.
160
Standardized s aves time

A standardized care plan can save you valuable time. The plan below is for a patient with a nursing diagnosis of Impaired
tissue integrity. To customize this standardized care plan to one of your patients, you would complete the diagnosis—
including signs and symptoms—and fill in the expected outcomes.
Date 4 / 15 / 12 Nursing diagnosis

Impaired tissue integrity Re lat e d t o ar t e r ial in su f f icie n cy as
e vid e n ce d by p ain in calve s an d p r e ssu r e ar e a wit h walkin g, st age
2 u lce r o n R f o u r t h t o e , bilat e r al +1 n o n p it t in g e d e m a, co o l
t e m p e r at u r e , an d slu ggish cap illar y cir cu lat io n in r ight f o o t
Target date Expected outcomes

4 / 17 / 12 Attains relief from immediate symptoms: Pain an d e d e m a will r e so lve
4 / 17 / 12 Voices intent to change tissue-aggravating behavior: Will st o p sm o kin g
im m e d iat e ly
4 / 17 / 12 Maintains collateral circulation: P alp able p e r ip he r al p u lse s in lo we r
e xt r e m it ie s, e xt r e m it ie s war m
4 / 19 / 12 Voices intent to follow specific management routines after discharge: F oot
car e gu id e lin e s, e xe r cise r e gim e n as sp e cif ie d by p hysical t he r ap ist
Date 4 / 15 / 12 Interventions
• Provide foot and ulcer care. Administer and monitor treatments according to
facility protocols.
• Encourage adherence to an exercise regimen as tolerated.
• Educate the patient about risk factors and injury prevention measures. Refer the
patient to a stop-smoking program on discharge.
• Maintain adequate hydration. Monitor I/O: q8 h o u r s
• Elevate the head of bed: 6 " t o 8 "
• Additional interventions: I n sp e ct skin in t e gr it y q6 h; asse ss p e r ip he r al
p u lse s, skin t e m p e r at u r e an d co lo r , an d cap illar y r e f ill q8 h;
ad m in ist e r an alge sics be f o r e u lce r car e an d p hysical t he r ap y as
o r d e r e d p .r .n .
Date Outcome evaluation

4 / 17 / 12 Attained relief of immediate symptoms: P ain an d e d e m a r e so lve d , st age
2 u lce r co n t in u e s; o u t co m e p ar t ially m e t , e xt e n d e xp e ct e d o u t co m e
t o 4 / 19 / 12 o r d ischar ge if e ar lie r
4 / 17 / 12 Voiced intent to change tissue-aggravating behavior: H asn ’t sm o ke d sin ce
ad m issio n , ve r balize s d e sir e t o r e m ain n o n sm o kin g af t e r d ischar ge
wit h he lp o f n ico t in e p at ch o r gu m if n e e d e d ; o u t co m e m e t
4 / 17 / 12 Maintained collateral circulation: Palp able p e r ip he r al p u lse s bilat e r ally,
r igh t d im in ish e d co m p ar e d t o le f t ; r igh t lo we r e xt r e m it y co o le r t o
t o u ch t han le f t ; cap illar y r e f ill slu ggish bu t e qu al bilat e r ally; o u t co m e
p ar t ially m e t , e xt e n d e xp e ct e d o u t co m e t o 4 / 19 / 12 o r d ischar ge if
e ar lie r
4 / 17 / 12 Voiced intent to follow specific management routines after discharge: Ve r balizes
u n d e r st an d in g of f oot car e an d e xe r cise gu id elin e s give n , an d willin gn ess
t o con t in u e r e gimen af t e r d ischar ge ; ou t come me t
161
The pros
Standardized care plans offer many advantages because they:
• require far less writing than traditional plans
• are more legible
• are easier to duplicate
• make compliance with a facility’s policy easier for all members
of the health care team, including experts, novices, and ancillary
staff
• guide you in creating the plan and allow you the freedom to
adapt it to your patient.
The cons (t here’s always at leas t one)

This method has one main drawback: If you simply check off
items on a list or fill in the blanks, you might not individualize the
patient’s care or document your findings adequately.
Compute rize d c are plans

In the health care industry, the first area of extensive conver-
sion to electronics was institutional accounting. However, in the
past 10 years, the push has been toward integrating accounting
systems with a complete electronic health record (EHR). Today,
you’re increasingly likely to encounter computerized care plans
during your clinical rotations.
Different s t rokes for different folks

Various types of software are available for different facility needs.
Some systems are programmed to generate a list of nursing diag-
noses after the patient’s assessment data is entered. You can mod-
ify the selected items as needed. Others require you to choose the
diagnoses yourself from a master list. The system then adds these
diagnoses to the patient’s EHR.
EHRs also offer different styles of care planning. Some sys-
tems rely on generalized care plans written to a patient problem
or profile, not to a specific nursing diagnosis. For example, in the
sample electronic shift report shown on pages 119 to 121, note
that the patient’s care plan was called “General care of the adult”
and included two nursing protocols (Falls prevention and Skin
breakdown [prevention]), plus a clinical guideline (CVA). A very
general goal is listed: “Patient will tolerate a progressive increase
in activity level.” However, some EHR products are moving to-
ward integrating the taxonomies of NANDA International, Nursing
Interventions Classification, and Nursing Outcomes Classification
into the process.
162
RN input
Like traditional and standardized plans, a computerized care plan
must be reviewed by a registered nurse every 24 hours. Remem-
ber that despite their efficiency and ability to access information
quickly, computer software systems can’t replace a nurse’s critical
thinking and decision-making skills. Nurses still have to decide
which diagnoses and interventions are most appropriate for any
given patient and must evaluate when changes to the care plan are
needed.
Ca re p la n s in d iffe re n t s e t tin gs
As you begin your clinical rotations, you’ll notice that different
units and care settings sometimes use different care plan formats.
For example, acute-care units, including psychiatric centers, com-
monly use standardized care plans or critical pathways. Same-day
surgery units often use a problem-list format rather than an actual
care plan, but it serves the same purpose.
Have diagnos is , will t ravel

The standardized care plans available on each unit are usually
selected to fit the type of patient medical diagnoses common to
the unit. For example, a medical-surgical unit might have differ- Not e t hat different
care s et t ings us e
ent standard plans than the maternity or psychiatric unit. How- different t ypes of
ever, a resource containing all plans should be available to all care plans .
staff because patients may have more than one diagnosis, some
of which may not be included in the standardized plans for the
patient’s assigned unit. For example, a patient on a psychiatric
unit may have coexisting nursing diagnoses related to an ongoing
medical diagnosis, such as diabetes or gastroesophageal reflux
disease. Conversely, a patient with schizophrenia may be admit-
ted to an oncology unit for treatment of cancer. Holistic patient
care requires attention to all diagnoses because each impacts the
patient’s healing capacity.
Acute-c are hos pital units

On most acute-care units, care plans are separate documents
that are formulated at the time of a patient’s admission (typically
within the first 8 hours). Although nursing interventions begin
immediately with a patient’s admission, the care plan takes careful
planning and collaborative input and serves as a legal document
of the care being given.
CARE P LANS IN DIFFERENT S ETTINGS
163
Most facilities require that care plans be reviewed and updated

by a registered nurse at least every 24 hours, beginning with the
time of admission. Accreditation organizations, such as The Joint
Commission, perform spot checks of individual patient charts to
see whether a care plan is present and if it was reviewed within
the established time frame.
Fill in t he blanks …
Some units use preprinted plans on which the nursing diagnosis
is already written; the nurse fills in a “related to” clause as well
as individualized interventions, making the care plan specific to
the patient. For example, for a patient with a nursing diagnosis of
Acu te pa i n , the nurse might fill in r ela ted to su r gi ca l pr ocedu r e,
depending on the reason for the pain. The interventions, of course,
would be filled in based on the patient’s needs and circumstances.
…or check ‘em off

Other units use preprinted care plans that include a comprehen-
sive list of interventions. In this case, the nurse simply checks off
the interventions applicable to her patient’s problem.
Mult iple problems

Usually, patients on medical-surgical units have multiple nurs-
ing diagnoses that must be addressed. All of the diagnoses for
one patient are considered one care plan. For example, a patient
admitted with a fractured left tibia might have the following diag-
noses:
• Acu te pa i n r ela ted to com pou n d fr a ctu r e of ti bi a
• Ri sk for i n fecti on r ela ted to m u lti ple br ea ks i n ski n i n tegr i ty
of left leg
• Im pa i r ed physi ca l m obi li ty r ela ted to fr a ctu r ed left ti bi a a s
evi den ced by i n a bi li ty to bea r wei ght on left leg a n d X-r a ys
showi n g com pou n d fr a ctu r e.
Keeping priorit ies s t raight

Within the care plan, the nursing diagnoses must be prioritized
according to the level of importance for the patient. For example,
suppose you’ve assessed a patient admitted with acute heart fail-
ure and have identified these diagnoses:
• Excess flu i d volu m e r ela ted to sodi u m a n d wa ter r eten ti on
• Acti vi ty i n toler a n ce r ela ted to shor tn ess of br ea th a n d fa ti gu e
• Decr ea sed ca r di a c ou tpu t r ela ted to i m pa i r ed con tr a cti li ty
• Im pa i r ed u r i n a r y eli m i n a ti on ( hesi ta n cy) r ela ted to ben i gn
pr osta te en la r gem en t
• In effecti ve per i pher a l ti ssu e per fu si on r ela ted to decr ea sed
ca r di a c ou tpu t
164
• An xi ety r ela ted to a cu te i n cr ea se i n shor tn ess of br ea th.

You might prioritize these nursing diagnoses as follows:
• Decr ea sed ca r di a c ou tpu t
• Excess flu i d volu m e
• In effecti ve ti ssu e per fu si on
• An xi ety
• Im pa i r ed u r i n a r y eli m i n a ti on Think of a
• Acti vi ty i n toler a n ce. crit ical pat hway as
a predet ermined
Take t he crit ical pat hway checklist t hat
describes t he st eps
A critical pathway is a special type of care plan that’s used by the you and t he pat ient
interdisciplinary team, not just nurses, so it’s more collaborative in mus t t ake.
nature. It includes assessment criteria, interventions, treatments,
and outcomes for specific conditions according to a timeline that’s
based on an average patient’s expected length of stay. Actual time
frames can be modified to meet each patient’s needs.
Complet e coverage
Think of a critical pathway as a predetermined checklist describ-
ing the tasks you and the patient must accomplish. Unlike a
nursing care plan, its focus is interdisciplinary, covering all of
the patient’s problems, not just those identified during a nursing
assessment. For example, it may include specific interventions
for physical assessment, lab work and procedures, consultations,
medication administration, nutrition, elimination, activity and
therapy, patient teaching, and discharge planning. (See Usi n g a
cr i ti ca l pa thwa y, pages 166 and 167.)
Same-day s urg ery unit

On a same-day surgery unit, nurses may follow an abbreviated
standardized plan that addresses the patient’s specific type of
surgery or procedure. Additional medical diagnoses are listed and
interventions are added related to those diagnoses if needed. The
nurse typically reviews the problem list before and after the sur-
gery or procedure. If the patient requires admittance to the hospi-
tal, a full nursing care plan is developed, using the problem list as
a starting point.
Exte nde d-c are fac ilities

Nursing homes and other extended-care facilities have a different
system for formulating care plans. Most of these facilities provide
services for individuals who qualify for Medicare or Medicaid
insurance benefits due to their age or severe disability. Medicare
CARE P LANS IN DIFFERENT S ETTINGS
165
regulations have become the standard of care for extended-care

facilities so that even private insurers look for verification that a
facility meets these standards. Part of these standards requires the
completion of the Minimum Data Set (MDS) form, which docu-
ments patient assessment and care screening and guides reimburse-
ment levels. Each facility employs a registered nurse as the RN
Assessment Coordinator (RNAC). This person is responsible for
completing and submitting the MDS and other required forms and
running the weekly interdisciplinary team meetings at which care
plans are finalized and reviewed for each resident. The RNAC meets
with residents and their families, communicates with all staff mem-
bers involved in the resident’s care, and reviews all documentation
to verify that required information has been completed.
Mirror, mirror on t he wall

If you have a chance to do a clinical rotation in an extended-care
facility, you may find that this setting most closely mirrors the use
of the nursing process and nursing and interdisciplinary care plan-
ning as you have been taught in school. Because residents have
chronic conditions requiring 24-hour care, nursing diagnoses may
be relevant for long periods. Expected outcomes tend to focus
less on healing and resumption of prior function than on maintain-
ing the present level of function and developing skills to adapt to
limitations in function. However, always be alert for those situ-
ations in which a rehabilitative goal is appropriate, such as frac-
tured bones, episodic lung or urinary tract infections, situational
depression or anxiety disorders, or new urinary incontinence
issues.
Don’t break t he rules

An RNAC has up to 7 days to complete the MDS and 14 days to
develop an individualized care plan for each new resident. In the
meantime, a generic care plan must be initiated within 24 hours.
Common nursing diagnoses in extended-care facilities include:
• Chr on i c pa i n
• Ri sk for i n ju r y
• Acti vi ty i n toler a n ce
• Ri sk for i n fecti on
• Ri sk for i m pa i r ed ski n i n tegr i ty
• Im pa i r ed en vi r on m en ta l i n ter pr eta ti on syn dr om e.
Each resident must have a complete reassessment yearly, includ-
ing a complete physical examination by a physician. Guidelines
have been set for frequency of documentation by each discipline,
review of the medical orders, and evaluation and updating of the
interdisciplinary care plan.
Us ing a critical pathway
At any point in a patient’s treatment, a glance at the critical pathway allows you to compare the patient’s progress and your
performance as a caregiver with the usual course of care and progress for other patients with the same diagnosis. Critical
pathways are based on analytical studies as well as the standards of care established by the professional group most
closely allied with treatment of the disorder.
Example
The standard critical pathway below outlines care for a patient with a colon resection.
CRITICAL PATHWAY: COLON RESECTION WITHOUT COLOSTOMY

Patient visit Presurgery day 1 Day 0 O.R. day Postoperative day 1
Assessments History and physical with breast, Nursing admission Nursing admission assess- Review of systems
rectal, and pelvic examinations assessment ment on TBA patients in hold- assessment*
Nursing assessment ing area
Postoperative review of sys-
tems assessment*
Consults Social service consult Notify referring doctor of
Physical therapy consult impending admission The pathway
designates a
Labs and diagnostics Complete blood count (CBC) Type and screen for Type and screen for patients CBC
PT/PTT patients with Hg level in holding area with Hg level specific time frame
Electrocardiogram less than 10 less than 10 for patient care
Chest X-ray (CXR) activities.
Chemistry profile
CT scan ABD w/wo contrast
CT scan pelvis
Urinalysis
Barium enema and flexible sig-
moidoscopy or colonoscopy
Biopsy report
Interventions Many or all of the above labs and Admit by 0800 Shave and prepare in operat- NG tube maintenance*
diagnostics will have already Check for bowel preparation ing room I/O*
been done. Check all results and orders NG tube maintenance* VS per routine*
fax to the surgeon’s office. I/O Foley care*
Bowel preparation* VS per routine* Incentive spirometry*
The pathway is organized Antiembolism stockings Foley care* Ankle exercises*
Incentive spirometry Incentive spirometry* IVsite care*
into categories based on the Ankle exercises* Ankle exercises* HOB 30°*
patient’s medical diagnosis. IVaccess* IVsite care* Safety measures*
Routine VS* HOB 30° Wound care*
Pneumatic inflation boots Safety measures* Mouth care*
Wound care* Antiembolism
Mouth care* stockings
IVs IVfluids, D51/2 NSS IVfluids, D5LR I.V. fluids, D5LR
The pathway lists
Medication Prescribe GoLYTELYor NuLYTELY GoLYTELYor NuLYTELY Preoperative ABXin holding PCAtasks
(basalthat
rate the patient
0.5 mg)
1000-1400 1000-1400 area S.C. and
heparin
caregivers need
Neomycin at 1400, 1500, and 2200 Erythromycin at 1400, 1500, Postoperative ABX 2 doses
Erythromycin at 1400, 1500, and 2200 and 2200 PCA (basal rate 0.5 mg) to accomplish.
Neomycin at 1400, 1500, and 2200 subQ heparin
Diet/GI Clear liquids presurgery day Clear liquids presurgery NPO/NG tube
NPO after midnight day
NPO after midnight
Activity 4 hours after surgery ambulate Ambulate t.i.d. with
with abdominal binder* abdominal binder*
D/C pneumatic inflation boots May shower
after patient ambulates Physical therapy b.i.d.
KEY: * = NSG Activities 1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2. 3.

V= Variance V V V V V V V V V V V V
N = No Variance
O
N N N O O O
N N N O O O
N N N O O O
N N N
Signatures: 1. C. Mo llo y, RN 1. M Co n n e l, RN 1. L. Sin ge r , RN 1. L. Sin ge r , RN

2. 2. J . Sm it h, RN 2. J . Sm it h , RN 2. J . Sm it h , RN
3. 3. P . J o se p h, RN 3. P . J o se p h , RN 3. P . J o se p h, RN
167
CRITICAL PATHWAY: COLON RESECTION WITHOUT COLOSTOMY

Postoperative day 2 Postoperative day 3 Postoperative day 4 Postoperative day 5
Assessments Review of systems assessment* Review of systems Review of systems Review of systems
assessment* assessment* assessment*
Consults Dietary consult Oncology consult if indi-
cated (Dukes B2 or C or
high-risk lesion) (or to be
done as outpatient)
Labs and diagnostics Electrolyte 7 (EL-7) CBC Pathology results on chart CBC
CXR EL-7 EL-7
Interventions Discontinue NG tube if possible* I/O* I/O* Consider staple removal
(per guidelines) VS per routine* VS per routine* Replace with Steri-Strips
I/O* Incentive spirometry* Incentive spirometry* Assess that patient has
VS per routine* Ankle exercises* Ankle exercises* met discharge criteria*
Discontinue Foley* IVsite care* IVsite care* Discontinue saline lock
Ambulating* Safety measures* Safety measures*
Incentive spirometry* Wound care* Wound care*
Ankle exercises* Antiembolism stockings Antiembolism stockings
IVsite care*
HOB 30°*
Safety measures* The pathway
Wound care*
Mouth care* lists key events that
Antiembolism stockings must occur before the
patient’s discharge date.
IVs IVfluids D51/2 NSS+ MVI IVconvert to saline lock Continue saline lock Discontinue saline lock
Medication PCA (0.5 mg basal rate) Discontinue PCA PO analgesia PO analgesia
PO analgesia Preoperative meds Preoperative meds
Resume routine home meds
Diet/GI Discontinue NG tube per guide- Clear liquids if+bm/flatus House House
lines: (Clamp tube at 8 a.m. if Advance to postop-
no N/Vand residual less than erative diet if tolerating
200 mL, D/C tube at 1200)* clears (at least one
(Check with doctor first) tray of clear liquids)
Activity Ambulate four times/day with Ambulate at least four Ambulate at least four
abdominal binder* times/day with abdomi- times/day with abdominal
May shower nal binder* binder*
Physical therapy b.i.d. May shower May shower
Physical therapy b.i.d. Physical therapy b.i.d.
Teaching Reinforce preoperative Reinforce preoperative Reinforce preoperative Review all discharge
teaching* teaching* teaching* instructions and Rx
Patient and family education Patient and family edu- Patient and family educa- including:*
p.r.n.* cation p.r.n.* tion p.r.n.* follow-up appointments:
Re: family screening Re: family screening Discharge teaching re: re- with surgeon within
Begin discharge teaching portable s/s, follow-up, and 3 weeks
wound care* with oncologist within
1 month if indicated
KEY: * = NSG Activities 1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2. 3.

V= Variance V V V V V V V V V V V V
N = No Var.
O O O
N N N O O O
N N N O O O
N N N O O
N N N
Signatures: 1. A. M cCar t h y, RN 1. A. M cCar t hy, RN 1. L. Sin ge r , RN 1. L. Sin ge r , RN

2. R. M aye r , Rn 2. R. M aye r , Rn 2. J . Sm it h , RN 2. J . Sm it h , RN
3. L. Wat e r s, RN 3. L. Wat e r s, RN 3. P . J o se p h , RN 3.
168
Hos pic e c are

Hospice programs also use care plans for their patients. In this
setting, the care plan is prepared by an interdisciplinary team
comprising nurses, certified nursing assistants, physicians,
therapists, clergy, volunteers, bereavement counselors, and social
workers. It’s reviewed daily and updated every 2 weeks. (For in-
patient hospice patients, care plans may be reviewed on a weekly
basis.) All hospice programs, regardless of the setting, must fol-
low Medicare rules and regulations if they want to accept patients
under the Medicare hospice benefit program.
Cre a t in g c a re p la n s : A s u m m a ry
As previously discussed, everything you do as a nurse focuses on
the nursing process, and care plans are a natural extension of that
process. Your patient’s care plan is a summary of his problems,
his goals, and the care he receives. It’s also your key to helping
him achieve wellness.
Revis iting the nurs ing proc e s s

You’ll start developing your care plan beginning with
your patient’s initial assessment. This is when you’ll
talk with the patient and his family members to
gather subjective and objective data, perform a
physical examination, and obtain the medical history.
Taking it s t ep by s t ep
From all this information, you’ll develop your
nursing diagnoses, collaborate with the patient to
identify his outcome goals, and begin planning inter-
ventions to achieve those goals. The plan you come
up with—the nursing care plan—directs your patient
care from that moment forward.
Why you do what you do

As a student, remember to include a rationale (reason) and cite
the reference source, as appropriate, for each intervention. The
rationale is the “why” behind the “what.”
Why is it necessary to ambulate a surgical patient on the first
postoperative day? Why should you assess lung sounds every
4 hours if your patient has heart failure? Right now, you’re learn-
ing the answers to these and other questions in your classroom
setting and by researching journals and other textbooks. With
S AMP LE CARE P LANS AND CONCEP T MAP S
169
each new patient, you’ll acquire more and more knowledge and
hone your critical thinking skills. Soon such questions, and their
corresponding rationales, will become second nature to you.
As a practicing nurse, you won’t include rationales in the pa-
tient’s care plan. But don’t think this lets you off the hook! Nursing
is continually evolving, just like medicine in general. Long-trusted
techniques and standards of care may be rejected as research
shows better ways to accomplish the same tasks. Throughout
your career, you’ll need to stay up-to-date with the latest evidence-
based practice and standards of care. In fact, many states require
registered nurses to have several continuing-education credits to
renew their nursing licenses.
Evaluat ing and reas s es s ing at every t urn

Keep in mind that, as you perform each intervention, you’ll need
to evaluate your patient’s condition and response to the interven-
tion. In some cases, these responses will require you to change
the care plan accordingly. For example, your patient may not be
able to walk the distance specified in his care plan or his pneu-
monia may be clearing up and you won’t need to assess his breath
sounds as frequently as specified in the care plan. Such changes
mean reexamining the interventions and expected outcome and
making necessary modifications if the patient hasn’t yet achieved
his outcome goal.
S a m p le c a re p la n s a n d c on c e p t m a p s
During your rotations, you’ll probably care for patients in mater-
nity, pediatric, psychiatric, and medical-surgical settings. On
the pages that follow, you’ll find sample patient scenarios, with
corresponding concept maps and care plans, for some of these
settings. These care plans and concept maps are included to help
you analyze how a care plan comes together. As you review these
sample plans, try to think of other possible diagnoses, outcomes,
and interventions that might be appropriate for these patients.
Welcome, Baby!
An 18-year-old female, Patricia Thomas, just gave birth to an 8-lb,
2-oz baby boy via cesarean delivery. She isn’t married, but her boy-
friend is present. Her parents are also present but are visibly tense.
The patient’s vital signs are stable, but she’s in pain. She states that
she wants to breast-feed the baby, so you assist her in turning on
her side and you position the baby beside her. You show her how
to get the baby to latch on, but the young mother is having diffi-
culty and becomes frustrated. “Don’t give up,” says the boyfriend.
170
This patient’s care plan focuses on the nursing diagnoses

Defi ci en t kn owledge ( br ea st-feedi n g) and Acu te pa i n . The con-
cept map for this patient might look like this:
P.T.
Age 18
First child
Boyfriend and parents
present
Dx: Cesarean birth
Deficient knowledge– Acute pain: Abdominal

Breast-feeding incision
• Pt. wants to breast-feed • Pt. complains of pain
• Frustrated with first • C-section
attempt
• C-section • Determine pain severity:
• Instruct on : Pain scale
– Proper latch-on • Administer analgesic
– Proper position • Instruct on:
– Pain control – Relaxation techniques
– Fluid intake – Proper body movement
– Proper nutrition
• Obtain lactation nurse
consult
See Sa m ple m a ter n a l-n eon a ta l ca r e pla n to see what the care
plan might look like.
171
Sample maternal-neonatal care plan

Here’s an example of what the care plan might look like for the maternal patient described in the text.
Nursing diagnosis 1
Deficient knowledge (breast-feeding) related to unfamiliarity as evidenced by being a first-time mother who’s new to
breast-feeding
Outcome
The mother will demonstrate proper latching on technique and nursing positions before discharge. The baby will have a
good suck reflex and audible swallowing.
Interventions Rationale
1. Teach the mother proper latch-on technique. 1. Proper latch-on ensures proper sucking by infant,
which in turn affects milk supply.
2. Instruct the mother on the different nursing positions, es- 2. Positioning to decrease strain on the incision and
pecially the side-lying and football-hold positions, which are increase neonatal comfort and safety is conducive to
best for post-cesarean-delivery patients. let-down.
3. Offer and administer pain medications as needed. 3. Being pain-free helps the mother relax and pro-
motes the let-down reflex.
4. Encourage the mother to drink at least 8 glasses of fluid 4. Good hydration is essential for a healthy milk supply.
per day.
5. Encourage the mother to increase her caloric intake. 5. Breast-feeding mothers need to consume 500
calories more per day than they did when they were
pregnant to help with milk production.
6. Obtain an order for a lactation nurse if needed. 6. Lactation nurses specialize in dealing with breast-
feeding problems and offering correct information.
(continued)
172
Sample maternal-neonatal care plan (continued)
Nursing diagnosis 2
Acute pain related to abdominal incision from cesarean delivery as evidenced by verbalization of pain and slowed move-
ments in and out of bed
Outcome
The mother will verbalize decreased pain each day and minimal pain by discharge.
1. Assess and document severity of pain every shift and as 1. Knowing the patient’s pain severity assists in pro-
needed, using a 0-to-10 pain scale. viding the correct type and dose of pain medication.
2. Administer pain medication as ordered. 2. Pain medications help alleviate pain and promote rest.
3. Teach the mother not to wait for pain to get severe before 3. Severe pain may require more medication or more
asking for pain medication. time to become alleviated.
4. Teach the mother relaxation techniques. 4. Relaxation techniques help lessen pain perception
and can assist with coping with stress at home.
5. Teach the mother the proper techniques for getting out of 5. Proper movements help minimize discomfort and
a chair and bed. pain when getting up.
173
Feeling t he blues
A 65-year-old female, Julie Blue, is admitted with depression and
inadequate nutrition due to lack of eating. Her husband of 45 years
passed away unexpectedly 1 year ago, and she hasn’t been cop-
ing well with his death. Her daughter brought her to the hospital
because she couldn’t get her mother to eat, bathe, get out of bed,
or brush her hair for 2 weeks.
The patient states, “I just can’t go on without my husband. He
did everything.” The daughter also tells the nurse that the electric
and water have been turned off because her mother keeps forget-
ting to pay the bills.
The concept map for this patient might look like this:
J.B.
Age 65
Widowed 1 year,
married 45 years
Daughter present
Dx: Major depression;
inadequate nutrition
Ineffective coping Complicated grieving

• Decreased self-care • Spouse died 1 year ago
• Decreased appetite • Deteriorating mood and
• S&S depressed mood self-care since loss
• Pt. states: “I can’t cope”
• Not handling finances • Examine factors prolong-
ing grief
• Encourage verbalization of • Encourage verbalization of
feelings feelings
• Use active listening • Identify support systems
• Administer antidepres- • Set realistic goals
sants as ordered
• Promote independence
• Teach problem-solving
tools
• Consult pastoral care and
social services
See Sa m ple psychi a tr i c ca r e pla n , pages 174 and 175, to see what
the care plan might look like.
174
Sample ps ychiatric care plan

Here’s an example of what the care plan might look like for the patient described in the text.
Nursing diagnosis 1
Ineffective coping related to sudden death of spouse 1 year ago as evidenced by lack of self-care and verbalization of
inability to cope
Outcome
The patient will verbalize feelings about the death of her husband and demonstrate new coping mechanisms by
discharge.
1. Encourage the patient to talk about her feelings. 1. Verbalizing feelings makes the patient and others
aware of what the patient is going through.
2. Use active listening and a calm, unhurried manner. 2. This approach conveys to the patient your concern
and willingness to listen.
3. Administer antidepressants as ordered. 3. Medications may be essential to assist the patient

with the mood disorder.
4. Encourage the patient to independently perform at least 4. Self-care helps improve patient outlook, self-worth,
one activity of daily living each day. and independence.
5. Teach the patient problem-solving tools, such as the 5. Knowledge of problem-solving tools assists with
step-by-step approach and weighing advantages and day-to-day activities on discharge.
disadvantages.
6. Allow the patient time to solve at least one simple problem 6. Successful problem solving promotes indepen-
per day on her own (such as what to eat or wear). dence and self-confidence.
7. Assist the patient in identifying problems or issues that 7. Helping the patient realize her limitations decreases
she can’t control or change. stress and feelings of incompetence.
8. Obtain an order for consults with pastoral care and social 8. Spiritual guidance or assistance with other issues may
services, as needed. be helpful as the patient identifies issues of concern.
175
Sample ps ychiatric care plan (continued)
Nursing diagnosis 2
Complicated grieving related to loss of spouse as evidenced by depression, social isolation, inability to cope with ADLs
Outcome
The patient will verbalize feelings of grief and demonstrate use of new coping methods for managing her feelings by
discharge.
1. Assess for factors that are prolonging the grieving 1. Identifying a problem will help to solve it.
process.
2. Encourage the patient to talk about feelings of grief, anger, 2. Acknowledging feelings is first step to finding ways
and depression in individual and group therapy sessions. to deal with them.
3. Assist the patient in identifying her support systems. 3. Support systems can help patient in time of emo-
tional need.
4. Discuss with the patient methods to cope with stresses 4. Planning too far ahead can increase stress as new
such as focusing on living life “one day at a time.” coping skills are developed.
5. Assist the patient in setting realistic goals. 5. Accomplishing short-term goals will help her gain a
sense of control of her life.
Boy, oh boy!
A 10-year-old boy with cystic fibrosis, Bobby Young, is admit-
ted to the hospital with an upper respiratory tract infection and
fever. His oral temperature is 101.6° F. He’s coughing up copious
amounts of yellowish green sputum. He’s talkative but tires eas-
ily. His mother says his symptoms started about 2 days ago; she
noticed that he’d gone to bed earlier because he was tired and that
he appeared to be coughing more in the evening. She gave him an
extra breathing treatment last night, but it didn’t seem to help. The
patient has been drinking his fluids well and taking his medica-
tions without any problems. His lung sounds on admission reveal
rhonchi throughout the lower lobes. He has no acute shortness of
breath and no other problems. His chest X-ray reveals no signifi-
cant findings.
176
The concept map for this patient might look like this:
B.Y.
Age 10
Mother present
Cystic fibrosis
DX: Upper respiratory
tract infection
Ineffective airway Ineffective protection

clearance • Chronic multisystem
•Increased fatigue disorder with lung
• Fever 101.6° F involvement
• Increased sputum
production • Teach hand washing
• Sputum color change to • Instruct to avoid crowds
yellowish green • Maintain good health
habits
• Assess lung sounds
• Monitor sputum
• Check VS
• Give antibiotics
• Teach cleaning of
respiratory equipment
• Advise flu shot
• Instruct to avoid crowds
See Sa m ple pedi a tr i c ca r e pla n to see what the care plan might
look like. Note that this care plan addresses the patient’s present
infection and ongoing infection risk.
And many more…

Throughout your nursing career, you’re likely to create or encoun-
ter plenty of nursing care plans. Using the previous examples, and
everything you’ve learned about care planning in this book, see if
you can create your own care plan for the medical-surgical patient
described in the On the ca se quiz on page 178.
177
Sample pediatric care plan

Here’s an example of what the care plan might look like for the patient described in the text.
Nursing diagnosis 1
Ineffective airway clearance related to acute respiratory infection as evidenced by increased amount of sputum,
yellowish-green sputum color, increased fatigue, and fever
Outcome
The patient will demonstrate clear lung sounds, lack of fever, and return to baseline energy level by discharge.
1. Assess lungs sounds and respiratory pattern every shift 1. Early recognition of worsening condition leads to
and as needed. early treatment and improved patient outcomes.
2. Assess amount, color, and consistency of sputum every 2. Increased amounts, thickening, and continued color
shift. change of sputum can indicate worsening infection.
3. Assess vital signs every shift. Report deteriorating find- 3. Increasing temperature and respirations indicate
ings to the practitioner. poor response to treatment.
4. Administer antibiotics as ordered. 4. Antibiotics help to fight infection.
5. Teach the patient and family proper cleaning of respira- 5. Proper cleaning of respiratory equipment helps to
tory equipment. prevent bacterial growth.
6. Teach the patient the importance of avoiding crowds dur- 6. Cystic fibrosis puts the patient at higher risk for
ing flu season and getting a flu shot. infection. Avoiding crowds limits exposure to the flu.
Getting a flu shot provides additional protection.
Nursing diagnosis 2
Ineffective protection related to chronic medical condition characterized by respiratory infections as evidenced by
ongoing sputum production, enzymatic disorder, and increased risk of infection
Outcome
The patient and family will verbalize understanding of instructions on risk reduction by discharge.
1. Reinforce with the patient and family that proactive hand 1. Hand washing prevents incidental exposure to
washing is a major defense against secondary infection. infection.
2. Teach the patient and family to actively avoid crowded envi- 2. Active attention to environmental risks can de-
ronments during flu season and to avoid people who are ill. crease exposure to infectious agents.
3. Teach the patient to maintain healthy rest, nutrition, and 3. Healthy daily habits promote increased resistance
lung maintenance programs. to infectious agents.
178
On t he cas e

A 56-year-old male is admitted to the medical-surgical unit with
chronic obstructive pulmonary disease (COPD) and pneumonia.
He has shortness of breath and audible wheezes and appears
anxious. He’s unable to answer all of the medical history ques-
tions, so his wife answers for him while he sits, leaning over the
bedside table. She says he has been coughing up more sputum
the past 3 days and that it’s green in color. His vital signs are
oral temperature 99.2° F, pulse 115 beats/minute, respirations
28 breaths/minute and labored with accessory muscle use, and
blood pressure 142/68 mm Hg. During the physical examination,
the nurse notes 2+ edema of both feet and an irregular heartbeat.
His arterial blood gas results in the emergency department (ED)
were pH 7.30, Pa CO2 65 mm Hg, Pa O2 55 mm Hg, HCO3– 30 mEq/L,
and Sa O2 88%. The ED placed the patient on 24% oxygen by
ventimask, IV D5W at 50 mL/hr, methylprednisolone sodium succi-
nate (Solu-Medrol) 40 mg IV q 6 hr, erythromycin 500 mg IV q 6 hr,
breathing treatments q 4 hr, bed rest, and nothing-by-mouth status.

Complete a three-diagnosis care plan, including at least three
interventions and rationales for each diagnosis, for this medical-
surgical patient.
Nursing diagnosis 1
Outcome
1. 1.
2. 2.
3. 3.
ON THE CAS E
179
Nursing diagnosis 2
Outcome
1. 1.
2. 2.
3. 3.
Nursing diagnosis 3
Outcome
1. 1.
2. 2.
3. 3.
Ans wer key

Five potential nursing diagnoses for this patient are given in the
care plan on pages 186 to 188. See how many of your diagnoses,
outcomes, and interventions match. Did you think of a different
diagnosis? You could be right! As long as your care plan was con-
sistent with what you know about COPD and pneumonia, met the
patient’s profile, and was logically thought out, you’ve probably
developed a good care plan.
Nursing diagnosis 1
Impaired gas exchange related to inadequate ventilation and excessive mucus production as evidenced by wheezes and
labored respirations with accessory muscle use
Outcome
The patient will maintain adequate gas exchange as evidenced by return of arterial blood gas (ABG) values back to his
baseline by discharge.
1. Assess and document respiratory rate and pattern, pulse 1. Early recognition of deteriorating respiratory function
oximetry every shift, and ABGs as ordered. Report changes. can improve patient outcomes.
2. Maintain low-flow oxygen therapy as ordered. 2. Oxygen therapy helps to correct hypoxemia. High oxy-
gen saturation levels may diminish a COPD patient’s respi-
ratory drive and cause further retention of carbon dioxide.
3. Administer bronchodilators as ordered. Watch for 3. Bronchodilators relax bronchial smooth muscle,
adverse effects of tachycardia and arrhythmias. improving air flow.
4. Assist the patient to high Fowler’s position as needed. 4. High Fowler’s position promotes fuller lung expansion.
Nursing diagnosis 2
Ineffective airway clearance related to increased sputum production as evidenced by increased sputum, wheezes,
and patient report of shortness of breath
Outcome
The patient will have a patent airway as evidenced by decreased amounts of mucus by discharge.
1. Assess lung sounds and respiratory rate and pattern 1. Rhonchi decrease the airflow patency of large air-
every 4 hours and as needed. ways. Increased respiratory rate and labored breathing
are signs of respiratory distress due to mucus plug or
inadequate airway clearance.
2. Teach the patient effective coughing techniques. 2. Proper coughing techniques loosen mucus and ease
expectoration, helping to conserve patient energy.
3. Teach the patient about adequate hydration (drink- 3. Adequate hydration helps to thin secretions.
ing at least six 8-ounce glasses of fluid per day, unless
contraindicated).
4. Perform chest physiotherapy, if ordered. 4. Chest physiotherapy helps to loosen secretions.
5. Monitor the patient’s performance of incentive spirom- 5. Incentive spirometry helps promote lung expansion.
etry as ordered.
6. Suction the patient to remove mucus from the back of 6. Thick secretions are difficult to cough out and the
the throat and mouth. patient may not have the energy to do so.
ON THE CAS E
181
Nursing diagnosis 3
Activity intolerance related to dyspnea and inadequate oxygenation as evidenced by labored respirations with acces-
sory muscle use and patient report of shortness of breath
Outcome
The patient will perform activities of daily living (ADLs) with minimal assistance by discharge.
1. Monitor the severity of dyspnea and oxygen saturation 1. Activity increases oxygen demand. Assessing these
during patient activity. variables reveals the patient’s tolerance of ADLs.
2. Stop or change any activity that causes worsening 2. Worsening dyspnea with increased heart rate signals
dyspnea with increased heart rate. activity intolerance, which increases the patient’s oxy-
gen demand.
3. Maintain oxygen therapy with activity as needed. 3. Oxygen helps alleviate hypoxemia and helps to
improve activity tolerance.
4. Schedule activities after breathing treatments. 4. Breathing treatments maximize lung function and
improve activity tolerance.
5. Help the patient to gradually increase activities every 5. A gradual, steady increase in activity helps to improve
day. respiratory and cardiac condition.
6. Teach the patient to avoid factors that increase oxy- 6. An increase in oxygen demand increases cardiac
gen demand, such as smoking, temperature extremes, workload.
excess weight, and stress.
7. Teach the patient energy conservation techniques. 7. These techniques allow the patient to accomplish
more with the limited energy he has.
8. Teach the patient pursed-lip and diaphragmatic 8. These breathing techniques maximize lung function.
breathing techniques and explain that he should use
these techniques during activities.
182
Nursing diagnosis 4
Risk for infection related to ineffective clearance of secretions
Outcome
The patient will verbalize methods to reduce risk of infection by discharge.
1. Teach the patient proper hand-washing technique. 1. Good hand washing is the single most important de-
fense against the spread of infection.
2. Teach the patient how to care for and clean respira- 2. Standing water in respiratory equipment can be a
tory equipment at home. source of bacterial growth.
3. Teach the patient and family early signs of infection 3. Early detection leads to early treatment and decreases
(increased sputum, change in sputum color, and in- the risk of complications.
creased dys pnea).
4. Teach the patient about the importance of getting a 4. The flu vaccine provides some immunity from infection.
yearly flu vaccine.
Nursing diagnosis 5
Anxiety related to dyspnea as evidenced by rapid and labored respirations and patient report of shortness of breath
Outcome
The patient will verbalize decreased feelings of anxiety within 48 hours of admission.
1. Stay with the patient during episodes of shortness of 1. Having someone present during these episodes de-
breath and provide reassurance. creases patient anxiety.
2. Encourage the use of breathing techniques during epi- 2. Successful use of breathing techniques helps to re-
sodes of shortness of breath and anxiety. duce anxiety.
3. Maintain a calm environment. 3. A calm environment promotes relaxation.
4. Teach the patient relaxation techniques, such as 4. Relaxation techniques help to reduce anxiety.
guided imagery and visualization.
Part II Nurs ing diagnos es
by medical diagnos is
8 Medic al-s urgical diag nos e s 185
9 Mate rnal-neo natal diagno s e s 243
10 Pe diatric diagno s es 251
11 Ps yc hiatric diag nos e s 263

8
Medical-s urgical diagnos es
J us t t he fact s
♦ nursing diagnoses that correlate with common medical-
surgical medical diagnoses.
A lo ok a t m e d ic a l-s u rgic a l d ia gn os e s
This chapter covers medical-surgical problems that are common
in adult patients. Each entry provides a list of a few of the major
nursing diagnoses and related factors to be considered after your
assessment of a patient with the particular medical diagnosis. Remember
Remember that the nursing diagnoses listed here represent the t hat your nursing
needs most commonly associated with the medical condition; diagnoses should
your patient may have different needs. be specific t o t he
pat ient —not
Abdominal aort ic aneurys m repair necessarily t he
disorder.
• Acute pain related to surgical tissue trauma
• Anxiety related to threat to health status
• Decreased cardiac output related to:
– changes in intravascular volume
– increased systemic vascular resistance
– third-space fluid shift
• Deficient knowledge (preoperative and postoperative care)
related to newly identified need for aortic surgery
• Impaired skin integrity related to surgical incision
• Ineffective breathing pattern related to:
– effects of general anesthesia
– endotracheal intubation
– presence of an abdominal incision
Abdominal injury
• Acute pain related to tissue trauma
• Deficient fluid volume related to active blood loss
• Fear related to unknown diagnosis and prognosis
MEDICAL-S URGICAL DIAGNOS ES
186
• Ineffective breathing pattern related to surgical incision Abdominal injuries

• Risk for adverse reaction to iodinated contrast media related to may be as sociat ed
diagnostic procedure wit h pain or
infect ion. Look
• Risk for infection related to: for signs of t hese
– penetrating wound relat ed problems in
– potential bowel rupture your pat ient .
Acquired immunodeficiency s yndrome

• Deficient fluid volume related to persistent diarrhea associated
with opportunistic infections
• Deficient knowledge (symptoms of disease progression, risk
factors, transmission of disease, home care, and treatment
options) related to lack of exposure to information
• Grieving related to uncertain prognosis and change in health status
• Imbalanced nutrition: Less than body requirements related to:
– anorexia
– diarrhea
– medication adverse effects
– nausea and vomiting
• Impaired gas exchange related to:
– respiratory failure
– ventilation-perfusion imbalance
• Impaired oral mucous membrane related to:
– masses
– opportunistic infections
• Impaired physical mobility related to:
– fatigue and weakness
– hypoxemia
– medication adverse effects
• Ineffective airway clearance related to pneumonia
• Ineffective breathing pattern related to fatigue
• Ineffective therapeutic regimen management related to com-
plexity of therapeutic regimen
• Risk for compromised human dignity related to:
– body image
– social isolation
– societal prejudice
• Risk for impaired skin integrity related to:
– effects of immobility
– medication reactions
– opportunistic disease effects
– poor nutritional status
• Risk for infection related to immunosuppression
• Sexual dysfunction related to:
– depression
– fatigue
A LOOK AT MEDICAL-S URGICAL DIAGNOS ES
187
– fear of disease transmission

– fear of rejection
• Social isolation related to:
– associated societal stigma
– contacts’ fear of being infected
– depression
– fear of infection from social contacts
Acut e alcohol wit hdrawal

• Acute confusion related to chemical imbalances
• Imbalanced nutrition: Less than body requirements related to
lack of food intake
• Risk for injury related to abrupt withdrawal of alcohol
Acut e pos t s t rept ococcal glomerulonephrit is

• Activity intolerance related to inadequate tissue oxygenation
and inadequate nutritional status
• Acute pain related to inflammatory process
• Decreased cardiac output related to decreased preload
• Excess fluid volume related to altered renal function
proteinuria
• Impaired gas exchange related to decreased lung expansion
• Impaired physical mobility related to altered hemodynamic status
• Risk for constipation related to decreased intake of foods high
in fiber and decreased gastrointestinal motility
• Risk for electrolyte imbalance related to inability to excrete fluids
Acut e res pirat ory
• Risk for infection related to altered immune state
dist ress syndrome
• Risk for injury related to alteration in hemodynamic status
can affect everyt hing
Acut e res pirat ory dis t res s s yndrome from gas exchange
and fluid volume t o
• Deficient fluid volume related to active fluid volume loss
s kin int egrit y and
verbal communicat ion.
inability to ingest food due to mechanical ventilation
• Impaired gas exchange related to alveolocapillary membrane
changes
• Impaired skin integrity related to immobility and decreased
nutritional intake
• Impaired spontaneous ventilation related to respiratory muscle
fatigue
• Impaired verbal communication related to physical barriers of
mechanical ventilation
• Ineffective airway clearance related to retained secretions
Acut e res pirat ory failure

• Activity intolerance related to respiratory distress and fatigue
• Anxiety related to sensation of severe shortness of breath
188
• Bathing, dressing, toileting self-care deficits related to:

– fatigue with exertion
– shortness of breath at rest
shortness of breath
• Impaired gas exchange related to ventilation-perfusion imbalance
• Risk for decreased cardiac tissue perfusion related to impaired
transport of oxygen across alveolocapillary membranes
• Risk for suffocation related to respiratory collapse
Adrenal hypofunct ion

• Decreased cardiac output related to altered heart rate
• Deficient fluid volume related to nausea, vomiting, and diarrhea
• Fatigue related to disease process
Alzheimer’s dis eas e

• Bathing, dressing, feeding, toileting self-care deficits related to I can't remember,
cognitive impairment did you already read
• Caregiver role strain related to the complexity and amount of t he nursing diagnoses
t hat are associat ed
caregiving tasks wit h Alzheimer's
• Chronic confusion related to degenerative loss of cerebral tissue dis eas e?
• Constipation related to:
– inadequate diet
– inadequate fluid intake
– memory loss about toileting behavior
– difficulty swallowing
– inadequate food intake
– memory loss
• Impaired memory related to degenerative loss of cerebral tissue
• Impaired verbal communication related to advanced confusion
• Risk for aspiration related to advanced confusion
• Risk for injury related to:
– agnosia
– aphasia
– wandering behavior
• Wandering related to cognitive impairment
Amput at ion
• Acute pain related to postoperative tissue, nerve, and bone trauma
• Disturbed body image related to loss of a body part
• Impaired physical mobility related to loss of a body part
• Impaired skin integrity related to traumatic or surgical tissue
removal
• Risk for injury related to altered mobility
189
Amblyopia
• Anxiety related to sudden onset of impaired vision
• Compromised family coping related to increased health care needs
• Fear related to sudden onset of impaired vision
• Risk for infection related to alteration in eye integrity
• Risk for injury related to sudden alteration in vision
Amyot rophic lat eral s cleros is

• Bowel incontinence related to neuromuscular impairment
• Caregiver role strain related to complexity of care needs
• Death anxiety related to disease prognosis
• Decisional conflict related to decision concerning intubation
• Grieving related to disease prognosis
• Hopelessness related to disease prognosis
• Impaired physical mobility related to muscle atrophy
enervation
• Impaired swallowing related to neuromuscular impairment
• Impaired verbal communication related to neuromuscular
impairment
• Ineffective breathing pattern related to neuromuscular impairment
• Ineffective health maintenance related to lack of gross and fine
motor skills
• Powerlessness related to disease progression
• Risk for aspiration related to neuromuscular impairment
• Risk for suicide related to terminal illness
• Risk for thermal injury related to neuromuscular impairment Fat igue relat ed
t o low hemoglobin
Anaphylaxis level leaves me feeling
• Death anxiety related to acute respiratory distress exhaus t ed!
• Decreased cardiac output related to altered heart rate and
hypotension
• Impaired gas exchange related to edema of upper respiratory tract
• Risk for ineffective cerebral tissue perfusion related to impaired
Anemia
• Activity intolerance related to weakness, fatigue, and shortness
of breath
• Fatigue related to low hemoglobin level
• Hopelessness related to chronic fatigue and activity intolerance
– anorexia
– fatigue
– lack of knowledge of need for specific nutrients (folate, iron,
vitamin B12)
190
• Ineffective protection related to decreased oxygen-carrying

capacity of blood
– decreased mobility and bed rest
– tissue hypoxia
Aneurys m, cerebral
• Acute pain related to aneurysm
• Compromised family coping related to unknown prognosis
• Decreased intracranial adaptive capacity related to increased
intracranial pressure from brain hemorrhage
• Risk for acute confusion related to moderate bleeding of cere-
bral artery into the brain
Aneurys m, femoral and poplit eal

• Acute pain related to:
– compression of nerves
– edema
– ischemia
related to lack of exposure to information
• Ineffective peripheral tissue perfusion related to thrombus
formation and ischemia
Aneurys m, t horacic aort ic

• Acute pain related to thoracic aortic aneurysm
• Risk for decreased cardiac tissue perfusion related to aortic
insufficiency Angina
• Risk for deficient fluid volume related to compromised regula- pect oris can lead
tory mechanisms s ome pat ient s
t o be int olerant
Aneurys m, vent ricular of exercise.
• Death anxiety related to risk of life-threatening rupture
• Decreased cardiac output related to arrhythmias
• Risk for ineffective cerebral tissue perfusion related to heart failure
Angina pect oris

• Activity intolerance related to development of chest pain on
exertion
• Anxiety related to situational crisis and shortness of breath
• Decreased cardiac output related to reduced stroke volume
• Deficient knowledge (cardiac diagnostic procedures) related to
new onset of angina
• Readiness for enhanced management of therapeutic regimen
related to perceived ability to reduce cardiovascular risk factors
191
Ankylos ing s pondylit is

• Activity intolerance related to pain and inflammation of joints
• Chronic pain related to deteriorating bone and cartilage of joints
• Deficient diversional activity related to pain, stiffness, and limi-
tation of spinal motion
Aort ic ins ufficiency

• Activity intolerance related to imbalances between oxygen sup-
ply and demand
• Anxiety related to lack of understanding of medical diagnosis
• Decreased cardiac output related to increased afterload and
preload
• Deficient knowledge related to cardiac disease management
• Excess fluid volume related to decreased excretion of water in
response to decreased cardiac output
• Fatigue related to inadequate periods of rest
• Fear related to lack of understanding of medical diagnosis
• Impaired gas exchange related to increased pulmonary intersti-
tial fluid accumulation
• Impaired physical mobility related to altered hemodynamic status
• Ineffective coping related to fear and anxiety of medical diagnosis
• Risk for decreased cardiac tissue perfusion related to decreased
cardiac output
• Risk for injury related to weakness
Appendicit is
• Acute pain related to inflammatory process
• Nausea related to peritoneal inflammation
• Risk for infection related to:
– possible rupture of appendix
– surgical incision
Art erial occlus ive dis eas e

• Acute pain related to arterial occlusion
• Deficient knowledge (disease and treatment options) related to
lack of exposure to information
• Ineffective peripheral tissue perfusion related to reduced
arterial blood flow
Art eriovenous malformat ion

• Acute pain related to increased intracerebral pressure
• Anxiety related to lack of understanding of diagnosis, tests, and
treatments
• Fear related to lack of understanding of diagnosis, tests, and
treatment
• Ineffective coping related to fear, anxiety, and depression
192
• Risk for deficient fluid volume related to increased fluid loss as a

result of compensatory mechanism to control intracerebral pressure
• Risk for ineffective cerebral tissue perfusion related to de-
creased cerebral blood flow from intracerebral hemorrhage
• Risk for injury related to motor and/or visual impairment
At elect as is
• Anxiety related to shortness of breath
• Impaired gas exchange related to alveolocapillary membrane
changes
• Ineffective airway clearance related to excessive mucus
Bas al cell epit helioma

• Disturbed body image related to cancerous lesion
• Readiness for enhanced knowledge (prevention) related to will-
ingness to learn how to prevent recurrence
(skin care and protective measures) related to willingness to fol-
low necessary medical regimen
Bell’s pals y
• Disturbed body image related to unilateral facial weakness
• Social isolation related to disturbed body image
Benign pros t at ic hyperplas ia

• Impaired urinary elimination related to obstruction by enlarged
prostate
• Risk for deficient fluid volume related to postoperative bleeding
• Sexual dysfunction related to postsurgical recovery time, retro-
grade ejaculation, and anxiety
• Urinary retention related to blockage by enlarged prostate Blas t omycos is
originat es as a
Bladder cancer respirat ory infect ion
• Deficient knowledge (disease and treatment options) related to but can end up
lack of exposure to information affect ing t he s kin
and bones .
• Fear related to unknown prognosis
• Impaired tissue integrity related to radiation or chemotherapy
• Impaired urinary elimination related to bladder irritability and pain
• Risk for adverse reaction to iodinated contrast media related to
diagnostic procedure
• Situational low self-esteem (postoperative) related to self-
consciousness and disturbed self-image after urinary diversion surgery
Blas t omycos is
• Acute pain related to tenderness and swelling of bony lesions
• Hyperthermia related to viral infection of upper respiratory tract
193
• Impaired skin integrity related to macules or papules on

exposed body parts
• Ineffective airway clearance related to respiratory fungal infection
Blepharit is
• Disturbed body image related to inflammation of margins of eyelids
• Ineffective family therapeutic regimen management related to
ability to manage symptoms
• Impaired comfort related to burning and irritation of eyelid
• Impaired skin integrity related to inflammation
Bone t umor
• Acute pain related to pressure from tumor growth
• Anxiety related to change in health status
• Impaired physical mobility related to tumor growth or postop-
erative healing response
• Impaired skin integrity related to surgical incision for tumor removal
Bot ulis m
• Death anxiety related to life-threatening disorder
• Deficient fluid volume related to vomiting and diarrhea
• Ineffective breathing pattern related to respiratory muscle failure
Brain abs ces s

• Acute pain related to edema and necrosis
• Risk for acute confusion related to neurologic impairment
• Risk for ineffective cerebral tissue perfusion related to edema
and necrosis
• Risk for injury related to neurologic impairment
Brain t umor
• Anxiety related to:
Did s omeone say
– deterioration of physical and mental function brain t umor? Now
– risks of treatment options I’m get t ing anxious!
• Decreased intracranial adaptive capacity related to brain tissue
injury
• Impaired verbal communication related to damage to speech center
• Risk for acute confusion related to tissue damage from brain mass
• Risk for ineffective cerebral tissue perfusion related to location
of tumor
• Risk for injury related to increased seizure potential and neuro-
muscular effects of brain tissue damage
Breas t cancer
• Decisional conflict (treatment choice) related to risks and
potential adverse effects of treatment options
• Disturbed body image related to breast surgery
194
• Fatigue related to effects of disease and treatments

• Impaired skin integrity related to incision following breast
surgery
• Ineffective sexuality patterns related to perceived loss of attrac-
tiveness after mastectomy
• Stress overload related to family needs while physically and
emotionally taxed
Bronchiect as is
inadequate food intake due to illness
• Ineffective breathing pattern related to chronic abnormal dila-
tion of bronchi and destruction of bronchial walls
• Risk for infection related to repeated damage to bronchial walls
Bronchiolit is oblit erans wit h organizing pneumonia

• Activity intolerance related to fatigue and shortness of breath
inadequate food intake due to disturbed taste and anorexia
• Ineffective airway clearance related to excess secretions from
infection
• Ineffective breathing pattern related to inflammation of small
airways
Buerger’s dis eas e

• Deficient knowledge (disease causes and risks, treatment
options) related to new diagnosis
• Disturbed body image related to disease
• Ineffective peripheral tissue perfusion related to decreased
blood flow to the feet and legs
• Risk-prone health behavior related to smoking addiction
Burns
• Acute pain related to tissue destruction and exposure of nerves
in partially destroyed tissue
• Compromised family coping related to prolonged disease or
disability
• Contamination related to infective agents at place of injury
• Disturbed body image related to potential scarring
increased metabolic needs of burn healing
• Impaired gas exchange related to airway burns and carbon mon-
oxide inhalation
• Impaired physical mobility related to movement limitations
from scar tissue or burn treatments
195
• Ineffective peripheral tissue perfusion related to:

– circumferential eschar formation on arms and legs
– compartment syndrome
– vascular disruption
• Powerlessness related to illness
• Risk for deficient fluid volume related to active loss through
disrupted skin
• Risk for imbalanced body temperature related to infection
• Risk for impaired skin integrity related to nonadherence of graft
and impaired donor site healing
– decreased perfusion
– exposure to contamination
– impaired immunologic response
– loss of protective integument
• Risk for injury related to continued exposure to heat or chemicals
Cancer Pat ient s wit h

• Activity intolerance related to weakness from: cancer can experience
– altered protein metabolism imbalanced nut rit ion
– cachexia as a result of
– hypoxia anorexia, changes
in t as t e, and
– muscle wasting
s t omat it is . Not hing
• Anxiety related to diagnosis, treatment effects, and prognosis for me right now,
• Chronic pain related to: t hanks.
– chemotherapy adverse effects
– metastasis
– primary disease
– anorexia
– changes in taste sensation
– stomatitis
• Impaired urinary elimination related to hemorrhagic cystitis
from chemotherapy
• Ineffective sexuality patterns related to alterations in body
image
• Readiness for enhanced hope related to decreased signs of
cancer on repeated testing and healthful changes in lifestyle to
decrease risk of recurrence
• Risk for constipation related to opioid use
• Risk for infection related to immunosuppression from chemo-
therapy and malnutrition
• Risk for peripheral neurovascular dysfunction related to periph-
eral neuropathies caused by chemotherapy
196
• Risk for situational low self-esteem related to:

– hair loss
– role changes
– weight loss
• Sleep deprivation related to:
– alterations in patterns of elimination
– anxiety
– fear of dying while sleeping
– other sequelae of cancer
– pain
Candidias is
• Impaired oral mucous membrane related to fungal infection in
mouth
• Impaired skin integrity related to fungal infection
• Ineffective thermoregulation related to systemic infection
• Risk for impaired liver function related to fluconazole (Diflu-
can) or other specific systemic antifungal agents
Cardiac arrhyt hmias

• Activity intolerance related to shortness of breath or chest pain
when dysrhythmic or drug effects
• Decreased cardiac output related to altered contractility of
heart muscle
• Fatigue related to arrhythmias
• Fear related to decreased confidence in health status
• Ineffective coping related to inadequate level of control over ill-
ness recurrence
cardiac cycle and blood oxygenation
Cardiac s urgery
• Acute confusion related to:
– anesthesia
– cerebral ischemia or infarction
– sensory overload from intensive care unit environment
• Deficient fluid volume related to blood loss
• Deficient knowledge (postoperative care) related to complex
therapeutic regimen
• Dysfunctional ventilatory weaning response related to respira-
tory complications postoperatively
– alveolar collapse
– increased pulmonary shunt
197
– increased secretions
– pain
Cardiac t amponade
• Decreased cardiac output related to altered preload
• Fear related to life-threatening disorder
• Ineffective breathing pattern related to cardiac tamponade
Cardiogenic s hock
• Activity intolerance related to:
– diminished cardiovascular reserve
– hypoxemia
– weakness
• Decreased cardiac output related to heart rate abnormalities or
diminished contractility
• Excess fluid volume related to compromised regulatory
mechanisms
Cardiomyopat hy
• Activity intolerance related to cardiopulmonary dysfunction
• Acute pain related to decreased tissue perfusion
– deterioration in health status
– lack of understanding of diagnosis and treatment
– alterations in preload, afterload, heart rate, and contractility
– arrhythmias and ineffective pump action
• Deficient knowledge (disease and treatment) related to changes
in regimen
• Ineffective breathing pattern related to disease process
• Excess fluid volume related to decreased left ventricular
compliance
• Impaired gas exchange related to ventilation-perfusion
imbalance
• Ineffective coping related to fear and anxiety about disease
process
• Risk for ineffective cardiac tissue perfusion related to reduced
myocardial contractility
Carot id endart erect omy

• Deficient knowledge (procedure) related to unfamiliarity with
procedure and hospital protocol
• Impaired gas exchange related to airway obstruction from tra-
cheal compression or aspiration
198
• Risk for ineffective peripheral tissue perfusion related to

decreased blood circulation
• Risk for infection related to surgical incision
Carpal t unnel s yndrome

Dis t urbances in
• Acute pain related to nerve compression audit ory, olfact ory,
• Bathing or hygiene self-care deficit related to pain and visual percept ion
• Risk for peripheral neurovascular dysfunction related to disease can res ult from
process cerebral cont usion.
Cat aract
• Deficient knowledge (disease and treatment options) related
to lack of exposure to information
• Impaired physical mobility related to fear of injury
• Risk for injury related to impaired vision
Cerebral cont us ion

• Acute pain related to headache after trauma
• Risk for acute confusion related to brain injury
• Risk for adverse reaction to iodinated contrast media related
to diagnostic procedure
• Risk for ineffective cerebral tissue perfusion related to bruising
of brain tissue
• Risk for injury related to brain injury
Cervical cancer
• Acute pain related to tumor invasion
• Disturbed body image related to weight loss
• Fatigue related to cancer process and treatment effects
• Sexual dysfunction related to postcoital pain and bleeding
Ches t injury, blunt

• Acute pain related to injury
• Anxiety related to impaired oxygenation
• Impaired spontaneous ventilation related to blunt trauma
• Ineffective breathing pattern related to chest wall injury
Chlamydia
lack of information on sexually transmitted diseases
• Ineffective sexuality patterns related to fear of spreading
infection
• Risk for infection related to untreated partners
199
Cholecys t ect omy

• Acute pain related to gallbladder inflammation
– altered lipid metabolism
– increased nutritional needs during healing
– nasogastric (NG) suction
– postoperative nothing-by-mouth (NPO) status
– preoperative nausea and vomiting
• Impaired oral mucous membrane related to NPO status and pos-
sible NG suction
• Ineffective breathing pattern related to pain from high abdomi-
nal incision
• Risk for infection (postoperative) related to obstruction of
external biliary drainage tube
Cholelit hias is , cholecys t it is

• Acute pain related to gallbladder inflammation or presence of
stones
attacks following meals
• Risk for infection related to complications of disease
Chronic alcoholis m
• Dysfunctional family processes: Alcoholism related to alcohol
abuse
lack of food intake
• Ineffective coping related to:
– anger
– denial
– dependence
• Ineffective therapeutic regimen management related to denial of
problem
• Risk for impaired liver function related to alcohol intake
• Risk for other-directed violence related to:
– disorientation
– impaired judgment
• Risk-prone health behavior related to alcohol abuse
Chronic fat igue and immune dys funct ion s yndrome

• Fatigue related to illness
• Hopelessness related to chronic illness
• Sleep deprivation related to internal factors
200
Chronic obs t ruct ive pulmonary dis eas e

• Activity intolerance related to shortness of breath
• Adult failure to thrive related to fatigue and chronic dyspnea of
severe disease
• Deficient knowledge (disease processes and treatment) related
to complexity of disorder
shortness of breath during and after meals
• Impaired gas exchange related to impaired excretion of carbon
dioxide
• Impaired home maintenance related to inadequate support sys-
tems and inability to do tasks due to disease process
• Ineffective breathing pattern related to fatigue or blunting of
respiratory drive
• Ineffective sexuality patterns related to:
– adverse reactions to medications
– change in body image
– change in relationship with spouse or partner
– deconditioning
– shortness of breath
• Insomnia related to:
– anxiety
– bronchodilator’s stimulant effect
– depression
– shortness of breath
Cirrhos is
• Dysfunctional family processes: Alcoholism related to alcohol
addiction
• Excess fluid volume related to fluid retention
– GI symptoms (anorexia, nausea, vomiting, diarrhea)
– inability to absorb nutrients
imbalance
• Risk for acute confusion related to increasing ammonia levels
• Risk for impaired liver function related to alcohol addiction
• Risk for impaired skin integrity related to edema and pruritus
Clos t ridium difficile infect ion

• Risk for deficient fluid volume related to diarrhea
• Risk for impaired skin integrity related to diarrhea
• Risk for infection related to inadequate defenses
201
Cold injury
• Deficient knowledge (prevention of cold injury) related to inex-
perience with excessive cold
• Hypothermia related to cold injury
• Risk for impaired skin integrity related to frostbite
Colorect al cancer
• Constipation related to GI obstruction
• Diarrhea related to inflammation or malabsorption
• Fatigue related to malnutrition or anemia
inability to absorb nutrients
• Risk for deficient fluid volume related to diarrhea or bleeding
• Risk for spiritual distress related to potential life-threatening
diagnosis
Colos t omy
• Deficient knowledge (care of descending or sigmoid colostomy)
related to unfamiliarity with altered bowel procedures
• Disturbed body image related to loss of control over fecal
elimination
• Risk for impaired skin integrity related to fecal contamination
of skin
• Sexual dysfunction related to change in body image
Concus s ion A pat ient wit h a

concus sion is at ris k
• Nausea related to blow to the head for injuries relat ed
• Risk for injury related to dizziness and lethargy t o dizziness and
let hargy. Now t hat ’s
Conjunct ivit is a blow t o t he head!
• Risk for impaired skin integrity related to eye discharge and tearing
• Risk for infection related to contagious disease and ability to
spread to other eye or other people
• Risk for situational low self-esteem related to hyperemia of eyes
Cor pulmonale
– exertional dyspnea
– tissue hypoxia
• Acute pain related to decreased coronary perfusion
• Anxiety related to lack of understanding of diagnosis and treatment
– decreased stroke volume
– ineffective ventricular pumping
202
• Excess fluid volume related to cardiopulmonary dysfunction

• Fear related to lack of understanding of prognosis
• Grieving related to poor prognosis
– interstitial pulmonary fluid accumulation
– pulmonary capillary destruction
• Ineffective airway clearance related to interstitial pulmonary fluid
accumulation
• Ineffective breathing pattern related to increased respiratory rate
Corneal abras ion

• Acute pain related to eye injury
• Disturbed sensory perception (visual) related to eye injury
• Risk for injury related to poor visual acuity
Corneal ulcer
• Risk for infection related to inadequate primary defenses
• Risk for injury related to visual blurring
Coronary art ery dis eas e

• Anxiety related to angina
• Decreased cardiac output related to diminished coronary blood flow
• Risk for decreased cardiac tissue perfusion related to atherosclerosis
decreased blood circulation.
Craniot omy
• Deficient knowledge (impending craniotomy) related to lack of
exposure to information
• Disturbed body image related to hair loss and possible disrup-
tion of motor function
• Risk for deficient fluid volume related to:
– diuretic therapy
– fluid restriction
– GI suction
– hyperthermia
• Risk for infection related to invasive techniques (surgery, con-
tinuous intracranial monitoring, ventricular drains)
– decreased level of consciousness
– drug therapy
– effect of anesthetics
– seizures
203
Crohn’s dis eas e (irrit able bowel s yndrome)

• Acute pain related to bowel inflammation
• Compromised family coping related to chronic disease
• Diarrhea related to bowel inflammation
• Nausea related to bowel inflammation
• Risk for imbalanced fluid volume related to diarrhea
• Risk for infection related to invasive procedures (surgery, home
infusions)
Cus hing’s s yndrome

• Disturbed body image related to secondary effects of excessive
corticosteroid levels
• Excess fluid volume related to high serum corticosteroid levels
• Risk for impaired skin integrity related to secondary effects of
medications
• Risk for infection related to the immunosuppressive action of
glucocorticoids
• Risk for unstable glucose level related to the anti-insulin proper-
ties of glucocorticoids
Defibrillat ion
• Impaired gas exchange related to cardiopulmonary dysfunction
• Risk for decreased cardiac tissue perfusion related to cardiac
arrhythmias
• Risk for impaired skin integrity related to electric current
• Risk for injury related to electric current
Dermabras ion
• Acute pain related to invasive procedure
• Anxiety related to lack of understanding of procedure
• Deficient knowledge related to lack of understanding of procedure
• Fear related to possible outcomes of procedure
• Impaired tissue integrity related to abrading of skin surface
• Risk for infection related to open areas in abraded skin
Dermat it is
• Chronic low self-esteem related to poor body image
• Impaired skin integrity related to inflammation, itching, or
lesions of the skin
Dermat ophyt os is
• Acute pain related to inflammation
• Impaired skin integrity related to skin infection
related to desire to follow through with treatment regimen
204
Diabet es ins ipidus Wat ch for s igns

• Constipation related to dehydration of dehydrat ion
• Deficient fluid volume related to active fluid loss in a pat ient wit h
• Impaired oral mucous membrane related to dehydration diabet es insipidus.
Fluid volume can be
Diabet es mellit us difficult t o balance.
• Compromised family coping related to prolonged disease
• Deficient knowledge (self-care) related to complex chronic
disease
• Ineffective therapeutic regimen management related to:
– ineffective coping with chronic disorder
– lack of material resources
– lack of support
• Risk for imbalanced nutrition: More than body requirements
related to excessive calorie intake
• Risk for ineffective renal perfusion related to complications of
disease
• Risk for thermal injury related to neuromuscular impairment
• Risk for unstable glucose level related to:
– inadequate endogenous insulin (type 1)
– inadequate endogenous insulin and insulin resistance (type 2)
Diabet ic ket oacidos is

• Deficient fluid volume related to osmotic diuresis or vomiting
• Deficient knowledge (self-care) related to lack of exposure to
complex disease and therapy information
– acidosis
– cerebral dehydration
– hypoxemia
• Risk for unstable glucose level related to decreased cellular glu-
cose uptake and use
Dis locat ion and s ubluxat ion

• Acute pain related to damage to tissue
• Anxiety related to pain and treatment
• Impaired physical mobility related to joint injury and pain
Dis s eminat ed int ravas cular coagulat ion

– bleeding into organ or joint capsules
– hematomas
– tissue ischemia
205
• Deficient fluid volume related to hemorrhage

• Fear related to unfamiliarity with hospital environment
• Impaired gas exchange related to hypoxemia
• Impaired skin integrity related to capillary fragility
Divert iculit is
– bowel infection or perforation
– inflammation
• Constipation related to lack of roughage in diet
• Deficient fluid volume related to active loss and poor intake
• Diarrhea related to inflammation and infection
Drug overdos e
• Hopelessness related to:
– emotional disorganization
– inadequate resources
– low self-esteem
• Ineffective airway clearance related to:
– decreased or absent gag reflex
– lavage procedures
– obstruction by tongue
– reduced alertness
– vomiting
• Risk-prone health behavior related to drug addiction
Duodenal ulcer
• Chronic pain related to:
– excessive motility of upper GI tract
– increased hydrochloric acid secretion
– increased spasm
– inflammation of the duodenum
– intragastric pressure
– dysphagia
– mouth soreness
– diarrhea
– GI hemorrhage
– vomiting
Ebola virus infect ion

• Diarrhea related to viral infection
• Fear related to poor prognosis
• Grieving related to probable death from disease
206
• Hyperthermia related to infection

• Impaired skin integrity related to diarrhea
• Risk for deficient fluid volume related to diarrhea and hemorrhage
Encephalit is
• Acute pain related to increased intracranial pressure
• Impaired physical mobility related to possible coma
Endocardit is
• Activity intolerance related to fatigue and weakness
• Decreased cardiac output related to bacterial or fungal invasion
of heart
Endomet rios is
• Acute pain related to inflammation and adhesions of endome-
trial tissue
• Sexual dysfunction related to pain
Epididymit is
• Acute pain related to infection
• Sexual dysfunction related to pain, swelling, and tenderness of
groin area
Epileps y
• Deficient knowledge (disease) related to lack of exposure to
information
• Fatigue related to antiseizure medication adverse effect
related to desire to follow treatment
• Risk for caregiver role strain related to worry and fear about
diagnosis
• Risk for compromised human dignity related to seizures
• Risk for falls related to seizures
Es cherichia coli and ot her Ent erobact eriaceae

infect ions
• Acute pain related to crampy diarrhea
• Deficient fluid volume related to loss through diarrhea and
vomiting
• Diarrhea related to infection
207
Es ophageal cancer
– fistula
– surgery
– tumor
• Fatigue related to cachexia
dysphagia
• Risk for aspiration related to dysphagia
Es ophageal divert icula

dysphagia and regurgitation
• Impaired swallowing related to dysphagia
• Risk for aspiration related to dysphagia and regurgitation
Ext raocular mot or nerve pals y

• Anxiety related to chronic disease
• Bathing/hygiene or feeding self-care deficit related to vision
impairment
• Deficient diversional activity related to vision impairment
Fat t y liver Pat ient s wit h

• Acute pain related to large, tender liver fat t y liver are at
• Deficient knowledge (proper diet) related to lack of exposure to ris k for impaired
liver funct ion from
information
t oo much fat
• Imbalanced nutrition: Less than body requirements related to accumulat ing in t he
anorexia and liver inflammation liver. Maybe I s hould
• Imbalanced nutrition: More than body requirements related to go on a diet …
excess fat and calorie consumption
• Risk for impaired liver function related to excess fat accumula-
tion in the liver
Femoral poplit eal bypas s

• Acute pain related to surgical incision
• Impaired physical mobility related to surgery and
preexisting disability
• Impaired skin integrity related to surgical incision and
preexisting stasis ulcers
• Ineffective peripheral tissue perfusion related to arterial
insufficiency
(broken skin)
208
Fibromyalgia s yndrome
• Activity intolerance related to pain
• Chronic pain related to illness
• Fatigue related to musculoskeletal pain and sleep disturbance
• Insomnia related to pain
Gas t ric cancer

• Deficient fluid volume related to vomiting and decreased fluid
intake
• Delayed surgical recovery related to decreased nutrition and
primary defenses
– dyspepsia
– epigastric discomfort
– feeling of fullness after eating
• Risk for spiritual distress related to cancer diagnosis and
p rognosis
Gas t rit is
• Deficient knowledge (prevention and treatment) related to lack
of exposure to information about smoking or dietary factors and
to medication use
• Nausea related to gastric irritation
• Readiness for enhanced nutrition related to willingness to ingest
nonirritating foods
Gas t roent erit is

• Acute pain related to intestinal flu
• Nausea related to bacteria, parasites, and virus in intestine
• Risk for deficient fluid volume related to nausea and vomiting
Gas t roes ophageal reflux

• Chronic pain related to reflux of gastric and duodenal contents
into esophagus
• Deficient knowledge (treatment options) related to lack of
• Risk for aspiration related to reflux
Gas t roint es t inal hemorrhage

• Deficient fluid volume related to active bleeding
• Deficient knowledge (potential recurrent bleeding) related to
unfamiliarity with disorder
209
• Fear related to sight of blood and distressing physical symptoms

– accumulation of toxins
– electrolyte imbalance
– inadequate organ perfusion
– ulcer perforation
– undetected bleeding
Glaucoma
• Anxiety related to progression of disease
• Deficient knowledge (eyedrops administration procedures)
related to lack of previous experience
• Risk for injury related to loss of peripheral vision
Glomerulonephrit is
• Excess fluid volume related to oliguria
anorexia
• Risk for ineffective renal perfusion related to disease process
• Risk for infection related to inadequate defenses
Goit er
• Disturbed body image related to neck distention
• Impaired swallowing related to swelling and distention of neck
• Ineffective breathing pattern related to compression of trachea
Gonorrhea
• Ineffective sexuality patterns related to fear of spreading infec-
tion
• Risk for infection related to inadequate primary resources
• Risk for situational low self-esteem related to infection
Gout
• Activity intolerance related to painful joints
• Acute pain related to urate deposits in joints
• Disturbed body image related to joint deformity
• Risk for dry eye related to reduced quantity or quality of tears to
moisten eye
Graft reject ion s yndrome

• Grieving related to loss of graft
• Ineffective tissue perfusion (peripheral, cardiopulmonary,
renal) related to stimulation of the complement cascade with
resultant thrombosis and tissue infarction
• Powerlessness related to loss of graft
210
Granulocyt openia, lymphocyt openia

• Fatigue related to low white blood cell (WBC) count
• Risk for infection related to low WBC count
Guillain-Barré s yndrome
• Bathing, feeding, toileting self-care deficit related to muscle
weakness and paralysis
• Fear related to sudden onset of illness
• Impaired spontaneous ventilation related to muscle weakness
and paralysis
• Ineffective airway clearance related to neuromuscular dysfunction
• Risk for urge urinary incontinence related to muscle weakness
Hant avirus pulmonary s yndrome

• Impaired gas exchange related to respiratory failure and
ventilation-perfusion imbalance
Your pat ient ’s
• Ineffective breathing pattern related to pulmonary infiltrates hearing los s can
with respiratory compromise affect his abilit y t o
hear danger signals
Headache in t he environment ,
• Acute pain related to vascular or muscle contraction put t ing him at ris k
• Fatigue related to headache for injury.
• Ineffective coping related to recurrence of headaches
Hearing los s
• Readiness for enhanced communication related to ability to
learn ways to communicate without adequate hearing
• Risk for injury related to not hearing danger signs in environment
Heart failure
– altered heart rhythm
– decreased contractility
– fluid volume overload
– increased afterload
• Deficient knowledge (treatment regimen) related to lack of
• Excess fluid volume related to:
– decreased myocardial contractility
– decreased renal perfusion
– increased sodium and water retention
211

decreased appetite and unpalatability of low-sodium diet
• Ineffective therapeutic regimen management related to:
– complexity of regimen
– health beliefs
– negative relationship with caregivers
• Powerlessness related to illness
Heart valve commis s urot omy

• Acute pain related to surgical procedure
– alterations in afterload
– alterations in contractility
– alterations in heart rate or rhythm or both
– alterations in preload
• Deficient fluid volume related to hypovolemia
• Deficient knowledge related to lack of understanding of proce-
dure and postprocedure care
• Impaired gas exchange related to atelectasis
• Risk for bleeding related to use of anticoagulants
• Risk for infection related to invasive procedure
Heat s yndrome
• Deficient knowledge (management of syndrome) related to lack
of exposure to information
• Deficient knowledge (prevention) related to language barrier,
impaired literacy, or lack of exposure to information
• Hyperthermia related to environmental heat conditions
Hemophilia
• Anxiety related to risk of acute bleeding
• Ineffective protection related to abnormal blood profile
• Risk for injury related to lack of awareness of environmental
dangers
• Risk for trauma related to external factors
Hemorrhoids
• Acute pain related to inflammation of hemorrhoidal veins
• Constipation related to pain
• Deficient knowledge (activities that increase intravenous
pressure) related to lack of exposure to information
212
Hemot horax
• Acute pain related to blood in pleural cavity
• Anxiety related to acute shortness of breath
• Fear related to sudden onset of injury
• Ineffective breathing pattern related to blood in pleural cavity
Hepat ic encephalopat hy
• Deficient fluid volume related to active loss
• Risk for impaired liver function related to alcohol abuse
Hepat it is
• Acute pain related to inflammation of the liver
• Deficient knowledge (home care, disease process, prevention of
recurrence) related to lack of exposure to information
anorexia, diarrhea, nausea, or vomiting
• Nausea related to GI irritation
• Risk for activity intolerance related to increased fatigue
• Risk for deficient fluid volume related to vomiting and diarrhea
– frequent diarrhea
– prolonged bed rest
– pruritus
Herniat ed dis k
• Acute pain related to impingement on spinal nerve roots
related to ability to follow through with regimen
Herpes s implex
• Acute pain related to cold sores and fever blisters
• Chronic low self-esteem related to skin lesions
• Ineffective sexuality patterns related to fear of spreading infec-
tion to sexual partner
• Sexual dysfunction related to sexually transmitted disease
(herpes simplex 2)
Herpes zos t er
• Acute pain related to inflammation of the dorsal root ganglia
• Chronic pain related to postherpetic neuralgia
• Impaired skin integrity related to localized vesicular skin lesions
213
Hiat al hernia
• Acute pain related to displacement or stretching of the stomach
• Impaired swallowing related to esophagitis, ulcers, or strictures
Hodgkin’s dis eas e

• Fatigue related to weight loss and disease process
• Grieving related to perceived potential for loss of life
• Hyperthermia related to immunosuppression
• Ineffective protection related to Hodgkin’s disease
Hunt ingt on’s dis eas e

• Bathing self-care deficit related to physical deterioration
• Bowel incontinence related to neuromuscular impairment
• Caregiver role strain related to complexity and amount of care-
giving activities
• Impaired physical mobility related to neuromuscular impairment
• Impaired verbal communication related to dysarthria
Hydronephros is
• Acute pain related to physical obstruction of urine flow
• Impaired urinary elimination related to obstruction of urine flow
• Risk for infection related to obstruction of urine flow
Hyperaldos t eronis m
information
• Fatigue related to hypokalemia
• Impaired urinary elimination related to polyuria and polydipsia
• Risk for unstable glucose level related to hypokalemia
Hyperlipidemia
• Deficient knowledge related to lack of understanding of diagno-
sis and treatment
• Fear related to disease prognosis
• Imbalanced nutrition: More than body requirements related to
excessive intake of foods high in fat and cholesterol
• Ineffective peripheral tissue perfusion related to buildup of cho-
lesterol in vascular system
• Noncompliance related to failure to adhere to dietary restric-
tions and medication regimen
• Risk for decreased cardiac tissue perfusion related to narrowing
of coronary arteries
• Risk for injury related to disease process
214
Hyperparat hyroidis m
• Acute pain related to hypercalcemia, which causes bone tender-
ness, pancreatitis, and peptic ulcers
• Hopelessness related to deteriorating condition
nausea and vomiting
Hyperos molar hyperglycemic nonket ot ic s yndrome Pat ient s wit h

• Deficient fluid volume related to osmotic diuresis hypert ension can
• Deficient knowledge (self-care) related to lack of exposure to be noncompliant as
complex disease and management a result of healt h
• Risk for injury related to: beliefs or cult ural
– cerebral dehydration influences .
– cerebral edema during rapid rehydration
– glucose deprivation
– hypoxemia
• Risk for unstable glucose level related to inadequate insulin
secretion or peripheral insulin resistance
Hypert ens ion

• Decreased cardiac output related to decreased stroke volume
mechanisms
• Ineffective therapeutic regimen management related to
deficient knowledge
• Noncompliance (treatment) related to health beliefs and
cultural influences
Hypoglycemia
• Fatigue related to hypoglycemia
• Ineffective therapeutic regimen management related to
complexity of the disease and deficient knowledge
– excessive exercise
– inappropriate exogenous insulin use
– lack of food
Hypoparat hyroidis m
• Decreased cardiac output related to cardiac arrhythmias
inability to ingest foods due to dysphagia
• Ineffective coping related to situational crisis
215
Hypot hyroidis m
• Decreased cardiac output related to cardiac arrhythmias
• Disturbed body image related to periorbital edema and upper
eyelid droop
moisten eye
• Risk for imbalanced body temperature related to decreased
sensitivity of thermoreceptors
Hypovolemic s hock
• Decreased cardiac output related to altered heart rate and rhythm
• Ineffective coping related to threat to life
• Ineffective peripheral tissue perfusion related to hypovolemia
– disease processes
– iatrogenic interventions
– surgical interventions
• Risk for ineffective cerebral tissue perfusion related to
hypovolemia
• Risk for ineffective gastrointestinal perfusion related to
hypovolemia
• Risk for ineffective renal perfusion related to hypovolemia
• Risk for injury related to complications from ischemia
Ileal conduit urinary divers ion

• Deficient knowledge (care of an ileal conduit) related to lack of
• Disturbed body image related to urinary diversion
• Impaired urinary elimination related to creation of an ileal conduit
• Risk for infection related to GI or genitourinary anastomosis
breakdown or leakage
• Sexual dysfunction related to cystectomy and possible ejacula-
tory incompetence with prostatectomy
Infert ilit y
• Complicated grieving related to multiple miscarriages
• Ineffective coping related to uncertainty of future pregnancies
• Situational low self-esteem related to infertility
Inflammat ory bowel dis eas e

• Chronic pain related to abdominal distention
• Deficient fluid volume related to decreased fluid intake and
increased fluid loss through diarrhea
216

– decreased nutrient intake
– increased nutrient loss
– possible decreased bowel absorption
• Impaired skin integrity related to frequent stools and altered
nutritional status
• Ineffective sexuality patterns related to diminished physical
energy and persistence of uncomfortable physical symptoms
• Insomnia related to:
– anxiety related to hospitalization
– nocturnal defecation
– uncomfortable sensations
– bowel perforation
– general debilitation
– immunosuppression
• Social isolation related to dependent behavior
Influenza
• Ineffective community therapeutic regimen management related
to insufficient supply of influenza vaccine
• Risk for imbalanced fluid volume related to fever, cough,
decreased oral intake
• Risk for infection related to inadequate primary and secondary
defenses to prevent secondary bacterial invasion
Inguinal hernia
• Acute pain related to tension on herniated contents
• Risk for ineffective gastrointestinal perfusion related to diver-
sion of bowel through hernia
• Risk for infection related to complete obstruction
Int es t inal obs t ruct ion

• Acute pain related to abdominal distention
• Constipation related to intestinal obstruction
• Risk for deficient fluid volume related to intestinal obstruction
• Risk for dysfunctional gastrointestinal motility
obstruction
Joint replacement
• Acute pain related to surgery
• Impaired physical mobility related to joint surgery
• Risk for infection related to incision
217
Kapos i’s s arcoma

Your pat ient
• Acute pain related to lesions that break down or impinge on may have exces s
nerves and organs fluid volume relat ed
• Grieving related to threat of death in advanced disease and t o t he funct ion of
when associated with human immunodeficiency virus his t ransplant ed
• Impaired skin integrity related to disease process kidney. My pail
• Ineffective breathing pattern related to bronchial blockage and runnet h over…
hypoventilation
Kidney t rans plant at ion

• Acute pain related to frequent invasive procedures and surgery
• Disturbed body image related to effects of steroid therapy
• Excess fluid volume related to function of transplanted kidney
• Ineffective coping related to sensory overload
• Noncompliance (drug regimen) related to adverse drug effects
and complicated multidrug regimen
Laminect omy
– immobility
– muscle spasm
– paresthesia secondary to surgical trauma and postoperative
edema
– blood loss during surgery
– hemorrhage at the incision site
– retroperitoneal hemorrhage
– vascular injury
• Risk for ineffective renal tissue perfusion related to:
– anesthesia
– anxiety
– cord edema
– injury to the spinal nerve roots innervating the bladder
– opioids
– pain
– supine positioning
Laryngeal cancer
• Acute pain related to drinking citrus or hot liquid or tumor
pressure
impaired swallowing
218
• Impaired swallowing related to tumor

• Impaired verbal communication related to laryngectomy
Legionnaires ’ dis eas e

• Fatigue related to infection
• Ineffective airway clearance related to increased mucus production
• Risk for infection related to inadequate immune defenses to
prevent secondary bacterial invasion
Leukemia
– depressed nutritional status
– fatigue secondary to rapid destruction of leukemic cells
– tissue hypoxia secondary to anemia
• Acute pain related to physical, biological, or chemical agents
• Deficient knowledge (therapeutic modality and choice and care of
vascular access device) related to lack of exposure to information
• Fatigue related to rapid destruction of leukemic cells
• Hopelessness related to prognosis
– anorexia
– chemotherapy
– nausea
– taste perception changes
– vomiting
– cytotoxic effects of chemotherapy
– immunosuppression secondary to disease
• Ineffective coping related to uncertain prognosis and multiple
disease- and treatment-induced losses
• Ineffective protection related to severe immunosuppression
associated with bone marrow transplantation or peripheral stem
cell transplantation protocol
• Readiness for enhanced immunization status related to success-
ful bone marrow transplantation
• Risk for deficient fluid volume related to risk of hemorrhage
Liver abs ces s

• Acute pain related to liver abscess
• Impaired gas exchange related to abnormal breathing rate and
rhythm due to pain
219
Liver failure
• Imbalanced nutrition: Less than body requirements related to Remember t hat
every pat ient may
catabolism caused by liver disease have different
• Impaired skin integrity related to: needs . The nursing
– ascites diagnoses lis t ed
– increased bleeding tendencies here are t hose t hat
– jaundice are most commonly
– malnutrition as sociat ed wit h each
medical condit ion.
• Risk for acute confusion related to hepatic encephalopathy
syndrome
• Risk for imbalanced fluid volume related to ascites
• Risk for infection related to liver disease
Liver t rans plant at ion

• Compromised family coping related to prolonged disease
– anorexia
– chronic illness
– initial postoperative nothing-by-mouth status
• Ineffective breathing pattern related to prolonged general anes-
thesia and a large abdominal incision
• Readiness for enhanced hope related to new liver
• Risk for deficient fluid volume related to high-dose steroid
therapy and fluid loss
• Risk for impaired liver function related to surgery and disease
process
• Risk for infection related to surgical incision and immunosup-
pression
Lung abs ces s

• Impaired gas exchange related to altered oxygen supply
• Ineffective airway clearance related to increased secretions
Lung cancer
• Activity intolerance related to imbalance between oxygen
supply and demand
inability to ingest food
• Ineffective airway clearance related to fatigue
• Powerlessness related to perceived mortality
220
Lupus eryt hemat os us

• Decreased cardiac output related to pericarditis, myocarditis, or
endocarditis
• Hyperthermia related to immunosuppression
• Impaired physical mobility related to joint inflammation
• Impaired skin integrity related to rashes
• Risk-prone health behavior related to disability
Lyme dis eas e

• Acute pain related to arthritis
• Anxiety related to long treatment course
• Impaired skin integrity related to rash
Lymphoma, non-Hodgkin’s
• Anxiety related to unknown hospital procedures and threat to
health status
• Deficient knowledge (self-care of vascular access device,
including peripherally or centrally inserted venous catheters or
subcutaneous ports) related to lack of exposure to information
• Disturbed body image related to effects of chemotherapy or
radiation therapy
– altered oral mucous membrane
– anorexia
– fatigue
– taste alterations
• Impaired skin integrity related to effects of radiation therapy
• Ineffective protection related to immunosuppression
– chemotherapy
– leukopenia, lymphopenia from bone marrow involvement
– radiation therapy effects
Macular degenerat ion

• Impaired physical mobility related to vision impairment
• Powerlessness related to illness progression
Malignant melanoma
• Disturbed body image related to skin lesion on head or neck
• Impaired skin integrity related to sore, inflamed, itchy skin lesion
related to understanding treatment protocols
221
Mas t ect omy

• Anxiety related to fear of cancer recurrence
• Disturbed body image related to loss of a body part
• Risk for infection related to incision
Maze procedure for at rial fibrillat ion

• Anxiety related to lack of understanding of surgical procedure
• Decreased cardiac output related to alteration in hemodynamic
status
• Deficient fluid volume related to hypovolemia
• Deficient knowledge related to lack of understanding of procedure
• Fear related to lack of understanding of surgical procedure
Mechanical vent ilat ion

• Bathing self-care deficit related to impaired mobility status and
pain
• Deficient fluid volume related to:
– altered oral intake
– fluid retention
– osmotic diuresis
• Deficient knowledge (peripheral parenteral nutrition [PPN]
catheter care and therapy) related to lack of experience with PPN
• Fear related to inability to speak and dependence on life support
inability to ingest nutrients orally or digest them satisfactorily, or
to increased need
• Impaired bed mobility related to ventilator
• Impaired gas exchange related to insufficient oxygen levels
– increased secretions
– presence of an endotracheal tube
– underlying disease
moisten eye.
• Risk for impaired skin integrity related to physical immobility
• Risk for infection related to central venous catheter
– bypassed safety alarm mechanisms
– complications of PPN catheter insertion
– increased intrathoracic pressure
– mechanical breakdown
– patient deterioration
222
Ménière’s dis eas e

• Deficient knowledge (symptom prevention and control
measures) related to recent onset of disease
• Impaired physical mobility related to vertigo
• Risk for falls related to vertigo
• Sedentary lifestyle related to vertigo
Meningit is
• Acute pain related to headache, joint involvement, muscle aches
from infection
• Risk for ineffective cerebral tissue perfusion related to increased
intracranial pressure
• Risk for injury related to seizures
Met abolic acidos is

• Deficient fluid volume related to active loss from diarrhea and
vomiting
• Ineffective breathing pattern related to fatigue and Kussmaul’s
respirations
• Nausea related to GI distress
Met abolic alkalos is

• Ineffective breathing pattern related to hypoventilation
• Risk for injury related to muscle weakness
Mult iple myeloma

• Acute pain related to neoplasm that infiltrates the bone
• Fatigue related to illness
Mult iple s cleros is

• Compromised family coping related to effects of progressive,
debilitating disease on family members and resultant alteration in
role-related behavior patterns
• Constipation related to decreased peristalsis
• Dressing/grooming self-care deficit related to neuromuscular
impairment
• Fatigue related to weakness and spasticity
• Impaired physical mobility related to demyelinization
• Impaired verbal communication related to dysarthria
• Interrupted family processes related to role disturbance and
uncertain future
223
• Powerlessness related to remissions and exacerbations of

illness
• Readiness for enhanced comfort related to acceptance of care
and support of significant others
• Risk for caregiver role strain related to progressive debilitating
disease
– gait impairment
– vertigo
– vision disturbances
• Sexual dysfunction related to fatigue, decreased sensation,
muscle spasm, or urinary incontinence
• Situational low self-esteem related to progressive, debilitating
effects of disease
• Urinary retention related to sensorimotor deficits
Myas t henia gravis

• Activity intolerance related to muscle fatigue and weakness
• Dressing self-care deficit related to neuromuscular involvement
• Fatigue related to muscle weakness
• Impaired swallowing related to cerebellar dysfunction
• Ineffective airway clearance related to impaired ability to cough Says here t hat
• Ineffective therapeutic regimen management related to insuf- pat ient s can
ficient knowledge of disease experience deat h
• Risk for injury related to vision disturbance and weakness anxiet y relat ed
t o a diagnosis
• Risk for spiritual distress related to chronic illness of myocardial
• Risk for urge urinary incontinence related to neuromuscular infarct ion. Yikes !
involvement
Myocardial infarct ion

• Activity intolerance related to weakness and fatigue
• Acute pain (chest) related to decreased myocardial oxygenation
• Death anxiety related to diagnosis
• Decreased cardiac output related to altered heart rate, rhythm
• Deficient knowledge (diagnostic procedures, therapeutic inter-
ventions, and long-range implications for lifestyle changes) related
to complex diagnosis and therapeutic regimen
imbalance
• Ineffective coping related to fear of death, anxiety, denial, or
depression
• Risk for constipation related to diet, bed rest, or medications
224
• Risk for injury related to myocardial ischemia, injury, necrosis,

inflammation, or arrhythmias
Myocardit is
• Activity intolerance related to weakness and fatigue
Nephrect omy
– anesthesia
– immobility
– location of incision
– pain
– presence of chest tube
• Risk for imbalanced fluid volume related to decreased renal
reserve and third-space fluid shifting immediately after surgery
• Risk for perioperative positioning related to flank positioning
and outermost arm positioning
Nephrot ic s yndrome
high-protein, low-sodium diet
• Risk for imbalanced fluid volume related to disease process
Neurit is , peripheral
• Impaired physical mobility related to muscle weakness
• Risk for injury related to disturbed sensory perception
Neurogenic bladder
• Reflex urinary incontinence related to neuromuscular dysfunc-
tion of the lower urinary tract
• Risk for compromised human dignity related to incontinence
• Risk for infection related to incomplete emptying of bladder
• Risk for urinary incontinence related to neuromuscular
dysfunction
Obes it y
• Activity intolerance related to deconditioned status and exces-
sive energy demands secondary to obesity
• Disturbed body image related to social stigma of obesity
225
• Imbalanced nutrition: More than body requirements related to:

– dysfunctional eating patterns
– energy expenditure imbalance
– excess food intake
– inherited disposition
– sedentary activity level
• Impaired gas exchange related to ventilation-perfusion imbal-
ance
• Impaired physical mobility related to fatigue with minimal exer-
tion, joint or back discomfort, limitation of motion from extra skin
folds
– altered circulation (edema)
– multiple moist skin folds
– nutritional deficit
• Sedentary lifestyle related to weight
• Social isolation related to size too large for standard seating and
body image disturbance
Os t eoart hrit is
• Chronic pain related to deterioration of joint cartilage
• Impaired home maintenance related to inadequate support sys-
tems, decreased range of motion with increased joint pain
Os t eomyelit is
• Deficient knowledge (prolonged treatment regimen for infection
and measures to prevent recurrence) related to new diagnosis
• Impaired physical mobility related to pain
• Risk for disuse syndrome related to prolonged infection, pain,
and immobilization
• Risk for injury related to use of antibiotics with high potential
for toxic effects
Os t eoporos is
• Disturbed body image related to joint deformity
• Ineffective sexuality patterns related to pain
moisten eye
• Risk for trauma related to bone loss
226
Ot os cleros is
information
• Risk for infection related to surgery
Ovarian cancer
• Constipation related to GI obstruction
• Grieving related to potential loss
• Urinary retention related to obstruction
Ovarian cys t
• Acute pain related to complications of ovarian cysts that cause
acute abdominal symptoms
• Anxiety related to laparoscopic surgery
• Ineffective sexuality patterns related to irregular or prolonged
bleeding
Paget ’s dis eas e

• Acute pain related to impingement of abnormal bone on spinal
cord
• Bathing, dressing, toileting self-care deficit related to musculo-
skeletal impairment
• Disturbed body image related to musculoskeletal impairment
• Impaired physical mobility related to asymmetrical bowing of
tibia and femur
Pancreat ic cancer
• Acute pain related to tumor pressure
• Anxiety related to threat of death and disease status
• Caregiver role strain related to illness severity
– impaired digestion
– loss of appetite
– pain
– vomiting
Pancreat it is
– abscess formation or hemorrhaging
– autodigestive processes and necrosis
– edema of the pancreas and surrounding tissues
– peritonitis
227

– gastric suction Wat ch pat ient s
– impaired digestion wit h pancreat it is for
– nothing-by-mouth status signs of imbalanced
– vomiting nut rit ion. I’m feeling
queasy jus t looking
• Nausea related to gastric distention at t his list .
– fluid shifts
– hemorrhage
– hyperglycemia
– vomiting
• Risk for infection related to trauma and chronic disease
– alcoholism
– hypovolemia
– pulmonary insults
Parkins on’s dis eas e

• Activity intolerance related to neuromuscular impairment
• Bathing self-care deficit related to neuromuscular impairment
• Disturbed body image related to tremors
• Impaired home maintenance related to disease effects
• Risk for aspiration related to impaired muscles of swallowing
• Risk for falls related to impaired gait and balance
• Sedentary lifestyle related to neuromuscular impairment
Pelvic inflammat ory dis eas e

• Sexual dysfunction related to malaise and profuse, purulent
vaginal discharge
Pept ic ulcers
• Acute pain related to ulcers
• Deficient knowledge (ulcer prevention and care) related to lack
Percut aneous t rans luminal coronary angioplas t y

• Acute pain related to restrictions on mobility and percutaneous
puncture at groin site
• Anxiety related to known risks associated with the procedure
• Deficient knowledge (postdischarge care) related to lack of
228

• Risk for injury related to break in skin and presence of foreign
body intravascularly
Pericardit is
• Acute pain related to inflammation of pericardium
• Decreased cardiac output related to pericarditis
• Risk for decreased cardiac tissue perfusion related to decreased
cellular exchange
Peripheral vas cular dis eas e

• Impaired physical mobility related to pain and activity intolerance
oxygenation
• Risk for peripheral neurovascular dysfunction related to vascu-
lar obstruction
Perirect al abs ces s and fis t ula

• Acute pain related to abscess and fistula
• Delayed surgical recovery related to inflammation
• Situational low self-esteem related to difficult healing process
Perit onit is
• Nausea related to increased GI pressure
Permanent pacemaker ins ert ion

• Bathing self-care deficit related to bed rest and activity
limitations
• Deficient knowledge (self-care after discharge) related to unfa-
miliar therapeutic intervention
• Disturbed body image related to dependence on pacemaker
• Risk for infection related to surgical disruption of skin barrier
Pit uit ary t umor

• Acute pain related to tumor pressure
• Deficient knowledge (surgical options) related to lack of expo-
sure to information
• Disturbed sensory perception (visual) related to unilateral
blindness
• Risk for injury related to dementia
229
Pleural effus ion and empyema

• Fatigue related to weakness
• Ineffective breathing pattern related to pain and increased work
of breathing
Pleuris y
• Acute pain related to inflammation of visceral and parietal pleurae
• Impaired gas exchange related to altered oxygen supply
• Ineffective breathing pattern related limited movement on
affected side
Pneumocys t is jiroveci (carinii) pneumonia

• Grieving related to poor prognosis
Pneumonia
• Acute pain related to fever and pleuritic irritation
• Bathing/hygiene self-care deficit related to weakness and fatigue
• Risk for infection related to stress and other risk factors
Pneumonect omy
• Deficient knowledge related to lack of understanding of surgical
procedure and prognosis
• Disturbed body image related to change in body function
• Fear related to lack of understanding of diagnosis and treatment
• Impaired gas exchange related to alveolar hypoventilation
• Impaired physical mobility related to pain from surgical procedure
• Ineffective airway clearance related to inadequate pain control
and splinting of surgical site to promote effective coughing and
deep breathing
• Ineffective breathing pattern related to decreased lung expansion
• Risk for infection related to surgical procedure
Pneumot horax
• Acute pain related to air trapped in the intrapleural space
230

• Ineffective tissue perfusion (cardiopulmonary) related to Lack of expos ure
collapsed lung t o informat ion can
lead t o deficient
Polycys t ic kidney dis eas e knowledge about an
illnes s. I t hought
• Acute pain related to kidney mass I might do a lit t le
• Deficient knowledge (illness) related to lack of exposure to reading about
information polycys t ic kidney
• Risk for ineffective renal perfusion related to kidney mass dis eas e.
Polycyt hemia vera

• Acute pain related to headache
• Deficient knowledge (disease and treatment) related to lack of
• Impaired gas exchange related to dyspnea
Pot as s ium imbalance

• Diarrhea related to hypercalcemia and hypocalcemia
Pres s ure ulcers

inability to digest and absorb nutrients
• Impaired physical mobility related to musculoskeletal and neu-
romuscular impairment
• Impaired skin integrity related to:
– altered circulation
– altered sensation
– impaired physical mobility
– mechanical factors
• Risk for infection related to impaired skin integrity
Pros t at ect omy

– bladder spasms
– catheter obstruction
– surgical intervention
– urethral stricture
• Risk for deficient fluid volume related to prostatic or incisional
bleeding after surgery
• Risk for infection (postoperative) related to:
– abdominal drain placement
– preoperative status
– urinary catheter
231
• Risk for situational low self-esteem related to:

– incontinence
– potential impotence
– sexual alterations
• Sexual dysfunction (decreased libido) related to:
– decreased self-esteem
– fear of incontinence
– impotence related to parasympathetic nerve damage (from
radical prostatectomy)
– infertility related to retrograde ejaculation (from transure thral
resection of the prostate and suprapubic prostatectomy)
• Urge urinary incontinence related to:
– decrease in detrusor muscle
– sphincter tone
– trauma to the bladder neck
– urinary catheter removal
• Urinary retention related to urinary catheter obstruction
Pros t at ic cancer
• Acute pain related to physical, biological, or chemical agents
• Sexual dysfunction related to impotence
• Urinary retention related to obstruction
Pros t at it is
• Acute pain related to infection and destruction of tissue
• Impaired urinary elimination related to infection
Ps eudomembranous ent erocolit is

• Diarrhea related to inflammation
• Impaired skin integrity related to severe diarrhea
Ps orias is
• Disturbed body image related to itchy, dry, cracked, and
encrusted lesions on body parts
• Impaired skin integrity related to itchy, dry, cracked, and
encrusted lesions
• Social isolation related to disturbed body image
Pulmonary edema
• Decreased cardiac output related to tachycardia
• Dysfunctional ventilatory weaning response related to anxiety
• Excess fluid volume related to fluid accumulation in extravas-
cular spaces of the lungs
• Ineffective breathing pattern related to diminished lung compliance
232
Pulmonary embolis m and infarct ion

• Activity intolerance related to imbalance between oxygen
supply and demand
• Acute pain related to biological injury
• Compromised family coping related to potentially life-
threatening situation
• Deficient knowledge (treatment regimen) related to complex
disorder and therapy
Pulmonary hypert ens ion

• Bathing self-care deficit related to fatigue
• Ineffective breathing pattern related to hypertrophy of small
pulmonary arteries
Pyelonephrit is
• Excess fluid volume related to compromised regulatory mecha-
nisms
• Impaired urinary elimination related to urgency, burning, or Pat ient s wit h
nocturia Raynaud’s dis ease
• Risk for infection related to inadequate primary and secondary are at risk for
defenses impaired s kin
int egrit y relat ed t o
Radioact ive implant for cervical cancer decreas ed s ensat ion.
Is it cold in here, or is
• Ineffective sexuality patterns related to vaginal tissue changes it jus t me?
or fear of radioactivity
• Risk for disuse syndrome related to imposed bed rest
• Risk for injury related to dislodgment of the implant
Rape-t rauma s yndrome

• Rape-trauma syndrome related to rape or attempted rape
• Situational low self-esteem related to rape
Raynaud’s dis eas e

arterial blood flow
• Risk for impaired skin integrity related to decreased sensation
and ischemia
233
Renal calculi
• Acute pain related to obstruction of ureter or kidney by renal
calculi
information
• Risk for infection related to trauma
• Urinary retention related to ureter obstruction by renal calculi
Renal dialys is
• Acute pain related to hemodialysis treatment
– abdominal distention
– anorexia
– nausea
– stomatitis
• Impaired physical mobility related to lengthy treatment regimen
• Ineffective breathing pattern related to elevation of diaphragm
during peritoneal dialysis exchanges and reduced mobility
• Risk for acute confusion related to consequences of long-term
dialysis treatment
• Risk for fluid imbalance related to dialysis
– bleeding from the area around the vascular access device
– potential for thrombosis, stenosis, or hematoma of vascular
access
• Risk for injury (perforation or ileus) related to catheter inser-
tion or irritation from dialysate
Renal failure, acut e

• Deficient knowledge (acute renal failure and dialysis) related to
lack of exposure to information on complex disease and its man-
agement
• Excess fluid volume related to sodium and water retention
anorexia, nausea and vomiting, and restricted dietary intake
• Impaired urinary elimination related to disease process
• Risk for infection related to decreased immune response and
skin changes secondary to uremia
• Risk for injury related to uremic syndrome
Renal failure, chronic

• Caregiver role strain related to illness chronicity
• Chronic low self-esteem related to chronic disease
234
• Disturbed thought processes related to:

– acidosis
– fluid and electrolyte imbalances
– uremic toxins
• Excess fluid volume related to fluid retention
– altered metabolism of proteins, lipids, and carbohydrates
– anorexia
– diarrhea
– GI inflammation with poor absorption
– restricted dietary intake
• Impaired oral mucous membrane related to accumulation of
urea and ammonia
• Noncompliance (treatment regimen) related to:
– deficient knowledge
– denial
– lack of resources
– lack of social support systems
– abnormal blood clotting
– anemia
– calcium phosphate deposits on the skin
– capillary fragility
– decreased activity of oil and sweat glands
– retention of pigments
– scratching
• Sexual dysfunction related to the effects of uremia on the endo-
crine system and central nervous system and to the psychosocial
impact of chronic renal failure and its treatment
Res pirat ory acidos is

• Impaired gas exchange related to ventilatory-perfusion imbalance
• Ineffective breathing pattern related to hypoventilation
Res pirat ory alkalos is

• Anxiety related to hyperventilation
• Impaired gas exchange related to ventilatory-perfusion imbalance
• Ineffective breathing pattern related to hyperventilation
Ret inal det achment

• Impaired physical mobility related to vision disturbance
• Ineffective coping related to decreased vision and impending
surgery
• Risk for falls related to impaired vision
235
Rheumat oid art hrit is

• Activity intolerance related to pain and swelling of joints
• Chronic pain related to inflammation of joints
• Disturbed body image related to arthritic joints
• Ineffective health maintenance related to lack of mobility
moisten the eye
Rhinoplas t y
• Acute pain related to surgical manipulation and swelling
• Anxiety related to lack of understanding of surgical procedure
• Deficient knowledge related to lack of understanding of what is
involved in surgical procedure
• Disturbed sleep pattern related to pain and edema
• Fear related to surgical procedure
• Impaired skin integrity related to surgical intervention
• Ineffective breathing pattern related to nasal packing
• Risk for infection related to surgical procedure
• Risk for injury related to tissue trauma
Salmonellos is
• Diarrhea related to GI distress
• Risk for deficient fluid volume related to diarrhea
Sarcoidos is
• Ineffective breathing pattern related to pain
Scabies
• Ineffective sexual patterns related to fear of spreading infection
• Social isolation related to fear of spreading infection
Seizure dis order

• Acute confusion related to postictal state
• Deficient knowledge (seizure management) related to lack of
• Impaired memory related to neurologic disturbance
– airway occlusion by tongue or foreign body
– apnea
– excessive secretions
236
– jaw clenching
– loss of consciousness
• Ineffective therapeutic regimen management related to deficient
knowledge of disease, seizure care, and community resources
• Risk for injury related to excessive uncontrolled muscle activity
• Risk for trauma related to internal factors
Sept ic art hrit is

• Acute pain related to inflammation of joints
• Anxiety related to threat to health and roles
• Risk for infection related to inadequate primary and secondary
defenses
Sept ic s hock
• Acute confusion related to decreased cerebral tissue perfusion
• Diarrhea related to GI irritation
inadequate intake and active fluid and nutrient loss
• Impaired gas exchange related to ventilation-perfusion imbal-
ance and diffusion defects
• Ineffective coping related to threat to life
• Risk for injury due to complications related to ischemia or bleeding
Sinus it is
• Acute pain related to inflammation and pressure
Sjögren’s s yndrome
• Impaired oral mucous membrane related to oral dryness
Skin graft s
• Deficient knowledge (home care of donor and graft sites) re-
lated to lack of exposure to information
• Disturbed body image related to wound and potential scarring
increased metabolic needs secondary to tissue healing
• Impaired physical mobility related to position and movement
limitations
• Risk for infection of donor site related to surgical excision
Spinal cord injury

• Bathing self-care deficit related to spinal cord injury
• Constipation related to loss of voluntary bowel control
237
• Decreased cardiac output related to autonomic dysfunction and

immobility Spinal cord
• Deficient diversional activity related to loss of mobility or function injuries can caus e
• Disturbed body image related to physical disability many problems not
t he least of which is
• Imbalanced nutrition: Less than body requirements related to a deficit relat ed t o
acute injury s elf-care. Brus h up
• Impaired gas exchange related to loss of use of phrenic nerve, on t he ones lis t ed
intercostal muscles, or abdominal muscles secondary to the spinal here.
injury
• Impaired home maintenance related to inadequate support systems
• Impaired physical mobility related to muscle paralysis
• Impaired urinary elimination related to interruption of neural
innervation
• Incontinence, bowel and total urinary related to neuromuscular
enervation
• Ineffective airway clearance related to loss of use of intercostal
muscles
• Risk for autonomic dysreflexia related to damage to spinal cord
with another associated stressor
• Risk for infection related to catheterization
Spinal neoplas m
• Impaired physical mobility related to neuromuscular impair-
ment
• Incontinence, bowel and total urinary related to neurologic dys-
function
• Risk for autonomic dysreflexia related to spinal cord injury or
lesion
– altered nutritional status
– altered sensation
– mechanical factors
– moisture from incontinence
– physical immobilization
Squamous cell carcinoma

• Impaired skin integrity related to invasive tumor of skin
• Ineffective therapeutic regimen management related to deficient
knowledge
St omat it is
• Acute pain related to swollen and easily bruised gums and
mucous membranes
presence of oral lesions
238

– chemical irritants
– infection
– malnutrition or vitamin deficiency
– mechanical irritants (ill-fitting dentures, braces)
St roke
• Bathing self-care deficit related to:
– neuromuscular impairment
– perceptual cognitive impairment
– weakness or lack of motivation
• Caregiver role strain related to increased care needs
• Chronic confusion related to cerebral injury
• Deficient knowledge (stroke management) related to lack of ex-
posure to information on self-care
• Impaired physical mobility related to damage to motor cortex or
motor pathways
• Impaired verbal communication related to cerebral injury
• Ineffective airway clearance related to hemiplegic effects of a
stroke
• Risk for disuse syndrome related to neuromuscular impairment
• Risk for ineffective cerebral tissue perfusion related to clot or
hemorrhage
• Unilateral neglect related to cerebral injury
Syphilis
• Ineffective coping related to situational crisis
• Ineffective sexuality patterns related to fear of spreading illness
• Risk for infection related to external factors
Tendinit is and burs it is

• Activity intolerance related to pain and stiffness
• Ineffective role performance related to restricted movement of
joint due to pain
Thoracot omy
• Deficient knowledge (treatment regimen) related to unfamiliar-
ity with thoracotomy
239

– analgesic medications
– atelectasis
– hypoventilation from anesthesia
– pain
– thickened secretions
• Risk for infection related to surgical incision and endotracheal
intubation
Thrombocyt openia
• Decreased cardiac output related to tachycardia
• Risk for injury related to possible bleeding from lack of platelets
Thrombophlebit is
• Acute pain related to vessel obstruction and edema
• Ineffective peripheral tissue perfusion related to interruption of
venous flow
Thyroid cancer
• Impaired swallowing related to pressure of thyroid nodule
• Ineffective breathing pattern related to enlarged thyroid nodule
Toxic s hock s yndrome

Tracheos t omy
• Impaired skin integrity related to humidity, moisture, or mucus
accumulation
• Ineffective breathing pattern related to tracheal tube dislodg-
ment or plugging
• Risk for aspiration related to impaired swallowing and vomiting
• Risk for injury (poor oxygenation) related to suctioning procedure
240
Trans cranial magnet ic s t imulat ion

• Acute pain related to stimulation of cranial nerves
• Deficient knowledge related to lack of understanding of process
or procedure and possible outcomes
• Fear related to lack of understanding of procedure
• Impaired skin integrity related to burns from electrode heating
• Risk for injury related to possible seizure activity
Trauma
– head injury
– pulmonary injury
– shock
• Impaired physical mobility related to orthopedic injury
• Risk for imbalanced fluid volume related to hypovolemia or
cardiac injury
• Risk for injury (complications) related to: Trigeminal
– hypermetabolic state neuralgia can
cause acut e pain.
– impaired immunologic defenses What nerve!
– stress
• Risk for posttrauma syndrome related to perception of event
and sudden, unexpected injury
Trigeminal neuralgia
• Acute pain related to disorder of the fifth cranial nerve
• Anxiety related to threat to health
• Ineffective coping related to inadequate level of perception of
control
Tuberculos is
• Deficient knowledge (disease process) related to lack of expo-
sure to information
• Ineffective airway clearance related to tracheobronchial
obstruction or secretions
• Ineffective breathing pattern related to decreased energy or fatigue
• Risk for infection related to altered primary defenses
• Social isolation related to fear of spreading disease
Ulcerat ive colit is

• Diarrhea related to inflammation of colon
• Fatigue related to loss of fluids and diarrhea
inability to absorb nutrients
• Ineffective role performance related to frequent diarrhea
241
Urinary t ract infect ion

• Acute pain related to inflammation and muscle spasms
• Deficient knowledge (disease process) related to lack of expo-
sure to information
• Impaired urinary elimination related to obstruction
Urolit hias is
– incision
– passage of calculus fragments
– procedural manipulation
• Deficient knowledge (potential causes of calculus formation)
• Impaired urinary elimination: Dysuria, oliguria, pyuria, or fre-
quency related to:
– calculus fragment passage
– hematuria
– infection
– obstruction
Ut erine cancer
• Acute pain related to cancer
• Imbalanced nutrition: Less than body requirements related to cancer
• Spiritual distress related to chronic illness
Ut erine prolaps e
• Disturbed body image related to biophysical factors
• Stress urinary incontinence related to weak pelvic musculature
Valvular heart dis eas e
• Activity intolerance related to fatigue and dyspnea on exertion
• Decreased cardiac output related to mechanical disruption
• Ineffective breathing pattern related to decreased energy and
fatigue
Vas cular ret inopat hy
• Ineffective coping related to chronic illness
• Risk for injury related to loss of vision
Vas culit is
• Disturbed body image related to illness
anorexia of disease process
242
• Ineffective peripheral tissue perfusion related to inflamed

vessels causing impaired blood flow to nearby organs
• Risk for ineffective cerebral tissue perfusion related to inflamed
vessels causing impaired blood flow to nearby organs
inflamed vessels causing impaired blood flow to nearby organs
• Risk for ineffective renal perfusion related to inflamed vessels
causing impaired blood flow to nearby organs
• Risk for infection related to impaired defenses
Vulvovaginit is
• Ineffective sexuality patterns related to vaginal inflammation,
itching, and irritation
Wounds
• Acute pain related to trauma to nerve endings
• Impaired skin integrity related to penetration of skin
• Risk for contamination related to detrimental home environ-
mental factors
• Risk for deficient fluid volume related to active loss from trauma
9
Maternal-neonatal diagnos es
J us t t he fact s
♦ nursing diagnoses that correlate with common maternal-
neonatal medical diagnoses.
A look a t m a te rna l-ne ona ta l dia gnos e s

This chapter covers medical diagnoses that are applicable to preg-
nant patients and their neonates. Maternal-neonatal care can be
complex because both the mother and neonate have many needs.
The diagnoses listed here are just a sampling of the diagnoses that
you might encounter on a maternity unit. Each entry provides a list
of a few of the major nursing diagnoses and related factors to be
considered after your assessment. Remember that the nursing diag-
noses listed here represent the needs most commonly associated
with the medical condition; your patient may have different needs.
Abort ion Mat ernal-neonat al

care mus t addres s
• Anxiety related to situational crisis t he needs of bot h
• Complicated grieving related to loss of pregnancy t he mot her and t he
• Moral distress related to decision and possible guilt neonat e.
• Risk for complicated grieving related to pregnancy loss
• Risk for deficient fluid volume related to bleeding
• Risk for infection related to altered primary defenses
• Situational low self-esteem related to possible guilt
Abrupt io placent ae
• Acute pain related to separation of placenta
• Anxiety related to unknown outcome of pregnancy
• Deficient fluid volume related to bleeding
• Grieving related to potential loss of fetus
• Risk for decreased cardiac tissue perfusion (neonate)
related to decreased cellular exchange
MATERNAL-NEONATAL DIAGNOS ES
244
Acquired immunodeficiency s yndrome

• Fear (parent) related to infant’s future death as a result of
human immunodeficiency virus (HIV) infection
• Risk for disturbed maternal-fetal dyad related to medication-
related adverse effects
– immunosuppression
– perinatal transmission of HIV
Cardiovas cular dis eas e in pregnancy

• Activity intolerance related to heart failure
• Decreased cardiac output related to heart decompensation and
arrhythmias
• Risk for decreased cardiac tissue perfusion related to altered
cardiovascular hemodynamics of pregnancy
• Risk for imbalanced fluid volume related to compromised
regulatory mechanism
Cervical cerclage
• Deficient knowledge related to surgical procedure
• Fear related to possible loss of pregnancy
• Risk for infection related to surgical incision or procedure
Ces arean birt h

– anesthetic administration
– pain
– fatigue
– perceived loss of birthing experience
– surgical intervention
• Readiness for enhanced parenting related to birth of healthy
neonate
• Risk for deficient fluid volume related to bleeding associated
with surgery
– bladder intubation
– IV lines
– repeated vaginal examination
– sequela of anesthetic administration
A LOOK AT MATERNAL-NEONATAL DIAGNOS ES
245
Childbirt h Many pregnant

• Acute pain related to physiological response to childbirth pat ient s experience
• Anxiety related to hospitalization and birth process anxiet y relat ed t o
• Deficient fluid volume related to altered intake during labor hospit alizat ion and
• Deficient knowledge related to lack of information about birth t he birt h proces s.
process
• Impaired skin integrity related to episiotomy
• Impaired urinary elimination related to sensory impairment dur-
ing labor
• Ineffective coping related to uncertainty about labor and birth
• Interrupted family processes related to:
– impending birth
– shift of roles to include new family member
• Readiness for enhanced breast-feeding related to basic breast-
feeding knowledge
• Readiness for enhanced childbearing
• Readiness for enhanced parenting
• Risk for disturbed maternal-fetal dyad
• Risk for infection related to labor and birth
• Risk for injury related to labor
Cleft lip or palat e

• Compromised family coping related to neonatal health problem
• Deficient knowledge (maternal) related to neonatal condition
• Imbalanced nutrition: Less than body requirements (neonate)
related to altered nutritional intake
• Ineffective breast-feeding related to neonate’s inability to latch
onto nipple correctly due to structural anomaly of lip and palate
• Ineffective infant feeding pattern related to condition of lip and
palate
• Risk for aspiration related to structural anomaly of lip and palate
Diabet es mellit us and pregnancy

• Deficient fluid volume related to polyuria
• Deficient knowledge related to lack of information about
disease
inability to use glucose
• Imbalanced nutrition: More than body requirements related to
altered carbohydrate metabolism
• Ineffective breathing pattern related to possible birth trauma in
large-for-gestational-age neonate
• Ineffective breathing pattern related to uterine enlargement and
excessive amniotic fluid
246
• Risk for disproportionate growth related to altered carbohy-

drate metabolism
• Risk for imbalanced nutrition: Less than body requirements (ne-
onate) related to additional nutrients needed to maintain weight
and prevent hypoglycemia
• Risk for impaired parenting related to high-risk status of
neonate
• Risk for ineffective coping related to required change in lifestyle
reduced vascular flow
• Risk for infection related to disease process
• Risk for injury (fetal) related to dependence on maternal glyce-
mic state
• Risk for injury related to birth trauma in large-for-gestational-age
neonate
• Risk for unstable blood glucose level related to altered carbohy-
drate metabolism
Drug addict ion and wit hdrawal

• Deficient knowledge (safe, healthy neonatal care and develop-
ment) related to emotional inadequacy and lack of exposure to
information about infant care
• Imbalanced nutrition: Less than body requirements (neonate)
related to:
– poor or low intake because of lack of coordination in sucking
or swallowing
– vomiting
• Ineffective childbearing process related to deficient knowledge
• Ineffective coping (maternal) related to drug abuse or inability
to care for the infant
• Ineffective infant feeding pattern related to delayed neurologic
development
• Insufficient breast milk related to alcohol intake
• Risk for deficient fluid volume (neonate) related to diarrhea or
vomiting
• Risk for impaired skin integrity (neonate) related to perianal
irritation from diarrhea and rubbing against sheets because of
hyperactivity
• Risk for ineffective childbearing process related to deficient
knowledge
• Risk for injury (neonate) related to withdrawal from drug
exposure
Ect opic pregnancy

• Acute pain related to disruption of pelvic tissue
• Anxiety related to situational crisis
247
• Deficient fluid volume related to bleeding

• Fear related to loss of pregnancy and threat to future fertility
• Risk for imbalanced fluid volume related to concealed hemor-
rhage and blood loss
• Risk for infection related to the trauma of tubal rupture and
peritoneal inflammation
• Situational low self-esteem related to loss of perceived
pregnancy
Fet al alcohol s yndrome

• Deficient knowledge (parental) related to lack of information Fet al alcohol
syndrome can cause
about infant care
delays in growt h and
• Delayed growth and development (neonate) related to neuro- development .
logic and mental deficiency
• Dysfunctional family processes: Alcoholism related to abuse of
alcohol
• Imbalanced nutrition: Less than body requirements (neo-
nate) related to:
– lack of nutritional resources
– poor intake
• Risk for disproportionate growth related to imbalanced
nutrition and poor intake
• Risk for impaired parenting related to:
– lifestyle associated with alcohol abuse
– unrealistic expectations of self and neonate
• Risk for neonatal jaundice related to difficulty in making
the transition to extrauterine life
Hydrocephalus
• Anxiety (parent) related to lack of understanding about the
child’s condition and treatment
• Compromised family coping related to illness of neonate
• Deficient knowledge (maternal) related to health care needs of
child with hydrocephalus
• Delayed growth and development related to disease
feeding difficulties
• Interrupted family processes (maternal) related to impact on
family of neonate’s disorder
• Risk for deficient fluid volume related to altered nutritional status
• Risk for impaired skin integrity related to extra weight and
immobility of child’s head
increased intracranial pressure
• Risk for infection related to surgical placement of shunt
• Risk for injury related to onset of seizures
248
Hyperemes is gravidarum
• Acute pain related to repeated episodes of vomiting
• Deficient fluid volume related to protracted emesis
• Fear related to hospitalization and pregnancy outcome
nausea and vomiting and subsequent inconsistent or insufficient
food intake
Hypert ens ion of pregnancy

• Activity intolerance related to activity restrictions
• Deficient fluid volume related to compromised regulatory
mechanisms
• Deficient knowledge (signs and symptoms of increased blood
pressure) related to lack of exposure to information
mechanisms
• Fear related to unknown outcome of pregnancy
compromised regulatory mechanisms
• Risk for injury (fetal) related to impaired maternal-placental
perfusion
• Urinary retention related to compromised regulatory A dramat ic
mechanisms increase in family
size can lead t o
Meconium as pirat ion s yndrome ineffect ive coping.
Sure, t hese t wo can
• Disabled family coping related to anxiety and guilt be a handful, but
• Impaired gas exchange related to: imagine t rying t o
– impaired alveolocapillary changes juggle quadruplet s .
– ventilation-perfusion imbalance
fatigue
• Ineffective breathing pattern related to meconium aspiration
• Interrupted breast-feeding related to need for ventilatory
support
• Risk for aspiration related to presence of meconium
• Risk for injury related to meconium aspiration
Mult iple ges t at ion

• Deficient knowledge related to unknown outcome of pregnancy
• Impaired parenting related to demands of caring for multiple
neonates
• Ineffective coping related to dramatic increase in family size
• Risk for impaired parenting related to anxiety regarding caring
for multiple neonates
249

– physiological demands of multifetal pregnancy (maternal and
fetal)
– preterm labor and birth (maternal and fetal)
• Stress urinary incontinence related to increased weight of
gravid uterus on bladder
Myelomeningocele
• Delayed growth and development related to hospitalization
• Hypothermia related to heat loss through the sac
surgery
• Impaired skin integrity related to presence of sac and surgical
procedure
• Impaired urinary elimination related to injury of spinal
nerves
• Risk for impaired parenting related to separation from the
neonate at birth
• Risk for impaired skin integrity related to contact with urine or
feces and altered mobility
• Risk for ineffective cerebral tissue perfusion related to hydro-
cephalus and increased intracranial pressure
Necrot izing ent erocolit is

• Diarrhea related to inflammation
• Ineffective infant feeding pattern related to nothing-by-mouth
status
• Interrupted family processes related to shift in health status of
family member
Neural t ube defect s

• Decisional conflict (possible abortion) related to genetic defect
• Interrupted family processes related to change in health status
of family member
• Spiritual distress related to chronic illness
Placent a previa
• Anxiety related to unknown hospital procedures
• Deficient fluid volume related to active loss, bleeding
• Fear related to unknown maternal and fetal outcome
• Risk for injury (fetal) related to uteroplacental insufficiency
Premat ure rupt ure of membranes

• Anxiety related to situational crisis
• Risk for infection related to lack of primary defenses
250
Pret erm labor

• Deficient knowledge related to procedures
• Impaired parenting related to inadequate attachment to high-
risk neonate
• Ineffective breast-feeding related to prematurity of neonate and
insufficient sucking
• Insufficient breast milk related to ineffective sucking
• Risk for disturbed maternal-fetal dyad related to separation
from neonate at birth
• Risk for neonatal jaundice related to prematurity
• Risk for infection related to possible premature rupture of
membranes
• Situational low self-esteem related to guilt about preterm labor
Res pirat ory dis t res s s yndrome

• Decreased cardiac output related to disease
• Disabled family coping related to anxiety, guilt, and separation
from the infant as a result of situational crisis
– decreased gastric motility
– inability to ingest feedings
– withholding of food and water
– alveolar ventilation
– lung perfusion
– reduced lung volume and compliance
• Ineffective airway clearance related to immature respiratory
functioning
• Ineffective breathing pattern related to impaired adjustment to
extrauterine existence
• Ineffective thermoregulation related to immaturity
• Risk for deficient fluid volume related to active fluid losses
• Risk for injury related to medical therapy and treatments
10
Pediatric diagnos es
J us t t he fact s
♦ nursing diagnoses that correlate with common pediatric
medical diagnoses.
A lo ok a t p e d ia t ric d ia gn os e s Alt hough pediat ric

pat ient s can have
t he same diagnoses
This chapter covers medical diagnoses that are common in pediat-
as adult s, t he care
ric patients. Remember that pediatric patients can have the same provided may be
medical and nursing diagnoses as an adult; however, the care pro- different .
vided for these patients may be different. Each entry provides a
list of a few of the major nursing diagnoses and related factors to
be considered after your assessment. Remember that the nursing
diagnoses listed here represent the needs most com-
monly associated with the medical condition in pediat-
ric patients; your pediatric patient may have different
needs.
Acne vulgaris
• Deficient knowledge (care of skin) related to lack
• Situational low self-esteem related to face lesions
• Social isolation related to alteration in physical
appearance
Anorexia nervos a
• Disturbed body image related to psychological effects of the
disorder
fear of obesity
• Impaired social interaction related to low self-esteem
• Interrupted family processes related to illness of family member
• Social isolation related to eating habits
P EDIATRIC DIAGNOS ES
252
Aplas t ic and hypoplas t ic anemias

• Ineffective breathing pattern related to weakness and fatigue
• Ineffective family coping related to altered health status of
family member
• Risk for infection related to destruction of stem cells in bone
marrow
Arm and leg fract ures

• Bathing, dressing, feeding self-care deficit related to immobility
of affected limb
• Impaired walking related to cast or splints
• Risk for injury related to inability to use body part
As t hma
• Activity intolerance related to imbalance between oxygen supply
and demand
• Deficient knowledge (home care procedures) related to new
diagnosis
• Deficient knowledge (treatment regimen) related to complexity
of therapeutic regimen
• Fatigue related to hypoxia
• Impaired gas exchange related to bronchial constriction
• Ineffective airway clearance related to constriction
• Readiness for enhanced self-health management related to
perceived benefits
• Risk for allergy response to iodinized contrast media related to
• Risk for deficient fluid volume related to loss of fluid from the
respiratory tract
At t ent ion deficit hyperact ivit y dis order

• Impaired social interaction related to hyperactivity
family member
• Risk for delayed development related to brain disorder
Aut is m s pect rum dis order

• Impaired social interaction related to brain disorder
• Impaired verbal communication related to stimulus confusion
• Risk for impaired parenting related to 24-hour demands of child
with special needs
• Risk for other-directed or self-directed violence related to
impaired capacity to identify and express feelings
A LOOK AT P EDIATRIC DIAGNOS ES
253
Biliary at res ia
• Deficient fluid volume related to poor absorption of nutrients
diagnosis
• Delayed growth and development related to chronic illness
Bronchiolit is
• Anxiety (child and parent) related to lack of knowledge about
condition
diagnosis
• Fatigue related to respiratory distress
– inability to take oral feeding
– increased metabolic needs
• Impaired gas exchange related to bronchiolar edema and
increased mucus production
• Risk for deficient fluid volume related to increased water loss
through exhalation and decreased fluid intake
Keep in mind t hat
• Social isolation related to isolation precautions
many pediat ric
Bronchopulmonary dys plas ia condit ions caus e
anxiet y in parent s
• Anxiety (parent) related to fear and lack of knowledge about and ot her family
the child’s illness members or
• Delayed growth and development related to chronic illness, caregivers.
prematurity, or prolonged hospitalization
increased metabolic rate and high calorie demands
• Impaired gas exchange related to atelectasis
• Risk for impaired parenting related to chronic illness
• Risk for impaired skin integrity related to irritation from naso-
gastric tube feedings
Bulimia nervos a
• Constipation related to poor eating habits and insufficient fluid
intake
• Disturbed personal identity related to body weight
binge-purge behavior
Cerebral pals y
• Bathing self-care deficit related to involuntary movements and
impaired muscle function
• Caregiver role strain related to complex needs of care recipient
254
• Delayed growth and development related to neuromuscular

impairment
• Impaired physical mobility related to impaired muscle function
• Impaired swallowing related to impaired muscle function
• Risk for aspiration related to impaired motor activity
Child abus e
• Delayed growth and development related to inadequate
care giving
• Impaired parenting related to the abusive parent’s inability to
attach to or bond with the child
• Ineffective family coping related to personal issues that contrib-
ute to child abuse
• Risk for other-directed violence (abusive family member)
related to maladaptive behavior
Cleft lip and cleft palat e

• Disabled family coping related to the stress of hospitalization
(preoperative)
impaired feeding (preoperative)
• Impaired skin integrity related to surgical incision
• Ineffective infant feeding pattern related to deformity
• Risk for aspiration related to ineffective feeding
• Risk for perioperative positioning injury related to surgical repair
Clubfoot
• Compromised family coping related to situational crisis
• Deficient knowledge (treatment protocols) related to lack of
• Impaired physical mobility related to casting or splinting
• Risk for delayed growth and development related to impaired
early ambulation
• Risk for impaired skin integrity related to casting or splinting
• Risk for injury related to failure to provide appropriate care,
leading to complications
• Risk for peripheral neurovascular dysfunction related to casting
of limb
Complement deficiency
• Disabled family coping related to change in health status of
family member
• Risk for infection related to increased susceptibility to infection
255
Congenit al heart defect

• Anxiety (child) related to:
– immobility
– intensive care unit environment
– parental anxiety
– separation from parents
– surgery
• Anxiety (parent) related to child’s congenital heart defect
• Decreased cardiac output related to disease process and
surgical procedure
related to impending surgery
• Risk for infection related to immobility and numerous incisions
– blood loss
– electric current
– positioning
– surgical procedure
Congenit al hip dys plas ia

• Constipation related to immobility
• Deficient diversional activity related to immobility secondary to
traction or spica cast
– immobility
– spica cast
– traction
• Risk for infection related to break in skin integrity secondary to
traction (if pins are used)
• Risk for injury related to possible mechanical malfunctioning of
traction or circulatory compromise
Croup
• Anxiety related to hospitalization and respiratory distress
• Ineffective airway clearance related to laryngeal obstruction
• Ineffective breathing pattern related to upper airway edema and
thickened secretions
• Risk for deficient fluid volume related to decreased oral intake
• Risk for infection related to break in primary defenses
Cys t ic fibros is
• Anxiety (child) related to respiratory distress and hospitalization
• Anxiety (parent) related to lack of knowledge about the child’s
condition
256
• Deficient knowledge (home care procedures) related to

complex disorder
reduced absorption of nutrients
• Impaired gas exchange related to increased mucus production
• Parental role conflict related to child’s hospitalization
• Risk for delayed development related to illness
• Risk for infection related to increased mucus production
Down s yndrome
• Interrupted family processes related to chronic illness
• Risk for delayed development related to chromosomal
abnormality
Epiglot t idit is
• Anxiety (parent) related to lack of knowledge concerning the
child’s condition
• Anxiety and fear (child) related to respiratory distress and
hospitalization
• Disabled family coping related to anxiety and fear
• Impaired swallowing related to inflammation and edema
• Ineffective airway clearance related to inflammation and edema
• Ineffective breathing pattern related to upper airway edema
• Risk for aspiration related to excessive production of oral
secretions
• Risk for deficient fluid volume related to decreased intake
Es ophagit is , corros ive

• Impaired parenting related to:
– deficient knowledge about injury protection
– poor home environment
– presence of stress
• Readiness for enhanced parenting related to willingness to
enhance parenting
• Risk for poisoning related to presence of poison within reach of
child
Fract ure
• Acute pain related to muscle spasm, swelling, or bleeding
• Constipation related to immobility
• Feeding self-care deficit related to limb cast and immobility
• Impaired gas exchange related to complications secondary to
the fracture and immobility
• Ineffective peripheral tissue perfusion related to:
– bleeding
– cast
257
– swelling
– traction
• Risk for activity intolerance related to immobility from cast or
traction
• Risk for impaired skin integrity related to immobility from cast
or traction
• Toileting self-care deficit related to limb cast and immobility
Fragile Xs yndrome
• Delayed growth and development related to X-linked dominant
gene inheritance
• Impaired verbal communication related to mental retardation
family member
• Risk for caregiver role strain related to complex care needs of
care recipient
Glycogen s t orage dis eas e

• Anxiety (parent) related to lack of knowledge concerning the
child’s condition
• Delayed growth and development related to chronic illness
• Readiness for enhanced nutrition related to readiness to
manage disease through diet
Haemophilus influenzae infect ion Traumat ic head

• Deficient fluid volume related to active loss injury can cause
anxiet y for bot h
t he child and t he
• Impaired gas exchange related to ventilation-perfusion imbalance parent . What if my
head never st ops
Head injury spinning?
• Acute pain related to head injury
• Anxiety (child and parent) related to traumatic head injury
• Decreased cardiac output related to hemorrhage
• Decreased intracranial adaptive capacity related to cerebral
edema
diagnosis
• Ineffective breathing pattern (with potential for respiratory fail-
ure) related to increased intracranial pressure (ICP)
• Ineffective peripheral tissue perfusion related to hypotension
secondary to hypovolemic shock
• Risk for deficient fluid volume related to nausea and vomiting
• Risk for impaired skin integrity related to physical immobility
• Risk for infection related to injury
• Risk for injury related to altered level of consciousness second-
ary to head injury or increased ICP (or both)
• Risk for injury secondary to seizures
258
Hemophilia
• Acute pain related to bleeding and swelling
• Chronic low self-esteem related to chronic illness and
hospitalization
• Compromized family coping related to repeated hospitalization
and the child’s chronic illness
• Impaired physical mobility related to decreased range of motion
secondary to bleeding and swelling
• Risk for bleeding related to insufficient functioning of clotting
cascade
• Risk for injury (hemorrhage) related to disease
Hirs chs prung’s dis eas e

• Anxiety (parent) related to lack of knowledge about the disease
and prescribed treatment
• Constipation related to aganglionosis
• Disturbed body image related to colostomy or ileostomy
• Impaired skin integrity related to exposure to stools secondary
to colostomy or ileostomy
– decreased intake
– increased absorptive surface of distended bowel
• Risk for infection of incision related to contamination from
stools
Hypopit uit aris m

• Anxiety related to treatment regimen
• Risk for delayed development related to deficiency of anterior
pituitary hormones
• Risk for disproportionate growth related to deficiency of
anterior pituitary hormones
Hypos padias and epis padias

• Anxiety (child and parent) related to surgical procedure
(urethroplasty)
• Impaired tissue integrity related to surgical repair
• Risk for infection (urinary tract) related to placement of
indwelling catheter
• Risk for injury related to dislodged urinary catheter or urinary
catheter removal
259
Impet igo
• Deficient knowledge (parent, treatment and prevention of recur-
rence of infection) related to new diagnosis
Int ravent ricular hemorrhage

• Deficient knowledge (infant’s condition and potential for home
care) related to the new injury
• Risk for injury related to fragility of the capillary beds in the
cerebrum
Int us s us cept ion

• Acute pain related to bowel strangulation
• Anxiety (parent) related to surgery
• Nausea related to vomiting
• Risk for infection related to gangrenous bowel
Juvenile rheumat oid art hrit is

• Activity intolerance related to severe joint pain and edema
• Chronic pain related to joint inflammation
• Disturbed body image related to the effects of the chronic
illness and the disabling nature of the disease
• Dressing self-care deficit related to severe joint pain and edema
• Impaired physical mobility related to joint inflammation
• Impaired skin integrity related to immobility
• Risk for imbalanced body temperature related to disease process
Kyphos is
• Disturbed body image related to altered physical appearance
related to readiness to follow treatment regimen
• Risk for situational low self-esteem related to altered physical
appearance
Leukemia, acut e
• Delayed growth and development related to treatment regimen
• Fatigue related to pancytopenia
• Hopelessness related to illness
• Impaired oral mucous membrane related to chemotherapy
adverse effects
• Ineffective protection related to immunosuppression
• Risk for infection related to altered primary and secondary defenses
260
Mononucleos is
• Fatigue related to weakness
• Interrupted family processes related to family member becom-
ing temporary full-time caregiver
Mus cular dys t rophy

• Caregiver role strain related to increased care needs
• Dressing self-care deficit related to muscle weakness and
disability
• Impaired physical mobility related to muscle weakness
• Ineffective health maintenance related to inability to care for self
Myringot omy
• Anxiety (child and parent) related to the surgical procedure and
perioperative events
treatment
• Risk for injury (hemorrhage) related to surgery
Some children
Os t eomyelit is wit h ot it is media
• Chronic pain related to inflammation and infection experience acut e
• Compromised family coping related to prolonged hospitalization pain relat ed t o
• Imbalanced nutrition: Less than body requirements related to inflammat ion.
increased metabolic needs for wound healing
• Impaired physical mobility related to infection
• Impaired skin integrity related to infection
• Risk for infection related to wound contamination
Ot it is media
• Acute pain related to inflammation of the middle ear
• Disturbed sensory perception (auditory) related to
complications of otitis media
• Risk for infection related to impaired primary defenses
Pediculos is
• Impaired skin integrity related to itching and redness
• Situational low self-esteem related to lice
• Social isolation related to feelings of embarrassment due to
diagnosis
Phenylket onuria
• Disturbed thought processes related to mental retardation
• Impaired skin integrity related to dry skin lesions
• Risk for delayed development related to accumulation of
phe nylalanine in blood
261
Pyloric s t enos is
• Anxiety (parent) related to lack of understanding about the
disease, diagnostic studies, and treatment
• Deficient fluid volume related to dehydration or shock (or both)
frequent projectile vomiting
• Risk for infection related to surgery
Res pirat ory s yncyt ial virus infect ion
inability to ingest foods
• Ineffective breathing pattern related to decreased energy
• Risk for deficient fluid volume related to active loss and
inflamed mucous membranes of the throat
Rheumat ic fever and rheumat ic heart dis eas e
• Acute pain related to joint pain
• Decreased cardiac output related to carditis
• Impaired gas exchange related to diminished pumping action of heart
Ros eola infant um
• Deficient knowledge (child’s care needs and prognosis) related
to new diagnosis
Rubella
• Deficient knowledge (child’s care needs and prognosis) related
to new diagnosis
Rubeola
• Fatigue related to disease
• Impaired skin integrity related to pruritic rash
Scolios is
• Acute pain related to curvature of spine
• Disturbed body image related to altered body shape
• Risk for impaired skin integrity related to brace
Sickle cell anemia
• Acute pain related to vascular occlusion and tissue hypoxia
• Deficient fluid volume related to decreased fluid intake and the
kidneys’ inability to concentrate urine
262
• Impaired gas exchange related to decreased oxygen-carrying

capacity of blood
• Ineffective peripheral tissue perfusion related to blood vessel
obstruction secondary to sickling of red blood cells
Spinal cord defect s

• Deficient knowledge (spinal cord defects) related to lack of
• Delayed growth and development related to spinal cord defect
• Disabled family coping related to increased caregiving demands
on family with minimal social support
Tay-Sachs dis eas e

• Delayed growth and development related to muscle weakness
• Disabled family coping related to family member with
unexpressed feelings of anxiety
• Grieving related to death of child
Tons illit is
• Acute pain related to throat swelling Tons illit is
• Hyperthermia related to infection can cause pain
and difficult y
• Impaired swallowing related to swelling swallowing.
Luckily, ice cream
Tracheoes ophageal fis t ula slides right
• Anxiety (parent) related to lack of knowledge about the down!
disorder, diagnostic testing, and treatment
• Delayed growth and development related to hospitalization and
deprivation of normal parent-infant interactions and environmental
stimulation
• Ineffective airway clearance related to aspiration of secretions
or feedings or both
• Ineffective breathing pattern related to choking, coughing, and
cyanosis during feeding
Tympanoplas t y
• Anxiety (child and parent) related to surgical procedure and
perioperative events
• Risk for injury (hemorrhage) related to surgery
Varicella
• Acute pain related to rash
• Impaired skin integrity related to pruritic rash
• Interrupted family processes related to family member having to
stay home from work to care for child
11
Ps ychiatric diagnos es
J us t t he fact s
♦ nursing diagnoses that correlate with common psychiat-
ric medical diagnoses.
A lo ok a t p s yc h ia t ric d ia gn os e s
This chapter covers common psychiatric medical diagnoses. Each
entry provides a list of a few of the major nursing diagnoses and
related factors to be considered after your assessment of a patient
with the particular medical diagnosis. Remember that the nursing
diagnoses listed here represent the needs most commonly associ-
ated with the medical condition; your patient may have different
needs.
Abus ive dis orders , s exual or phys ical

• Dysfunctional family processes related to violence
• Ineffective relationship related to history of domestic violence
• Posttrauma syndrome related to:
– abandonment
– interpersonal violence
– physical neglect or abuse
– sexual abuse or assault
• Risk for compromised human dignity related to abuse
P S YCHIATRIC DIAGNOS ES
264
Addict ive dis orders

Alc ohol addic tion and abus e
Alcohol addict ion
• Anxiety related to: and abuse can
– alcohol withdrawal lead t o risk for
– poor self-concept injury relat ed
– real or perceived threats to physical safety t o wit hdrawal,
• Chronic low self-esteem related to: depress ion, seizures ,
and s uicidal ideat ion,
– coping difficulties just t o name a few.
– guilt Anot her reason t o
– shame about alcohol abuse st ay addict ed t o
– unmet expectations wat er. Cheers !
• Dysfunctional family processes: Alcoholism related to role dis-
ruptions caused by the patient’s alcohol-related disorder
– effects of chronic alcohol intake on digestive organs
– interference of alcohol in absorption and metabolism of
nutrients
– poor dietary intake while consuming alcohol
• Insomnia related to alcohol abuse and decreased rapid-eye-
movement sleep cycle
– alcohol withdrawal
– depression
– impaired judgment
– seizures
– sensory deficits
– suicidal ideation
• Risk-prone health behavior related to alcohol abuse
Hallucinoge nic s ubs tanc e abus e

• Insomnia related to hallucinogen abuse or intoxication as evi-
denced by verbal complaints of sleeping inability, nightmares, or
interrupted sleep
– impaired judgment and disorientation
– poisoning by use of adulterated street drugs
• Risk-prone health behavior related to substance abuse
A LOOK AT P S YCHIATRIC DIAGNOS ES
265
Po lys ubs tance abus e

• Chronic low self-esteem related to perceived failures and lack
of positive feedback
• Ineffective coping related to maladaptive reliance on alcohol
and other drugs
• Powerlessness related to lack of control over psychoactive sub-
stance use
Stimulant abus e
• Decreased cardiac output related to stimulant use
• Deficient knowledge (risks of stimulant abuse) related to denial
of need for information
• Fear related to altered thought processes
placing greater importance on drug use than on eating
• Impaired social interaction related to isolation associated with
drug use
• Ineffective health maintenance related to the effects of stimu-
lant dependence on self-esteem
• Insomnia related to stimulant use
• Risk for disturbed personal identity related to use of psychoac-
tive agents
• Risk for imbalanced body temperature related to stimulant use
• Risk for other-directed violence related to:
– difficulty processing and interpreting thoughts
– sensory overload from stimulant use
Subs tance abus e (s edative s , o pio ids )

• Deficient knowledge (risks of substance abuse) related to in-
ability to process or retain information while impaired and in denial
• Ineffective denial related to feelings of low self-esteem
– compromised immunity
– high-risk behaviors
– insufficient knowledge about disease
Adjus t ment dis order

• Complicated grieving related to:
– inhibited grieving
– multiple losses and bereavement processes
266
• Defensive coping related to:

– inadequate support systems
– personal vulnerability
– unmet expectations
– work overload
• Impaired social interaction related to decreased perception of
appropriate social behavior
• Risk-prone health behavior related to:
– disability requiring lifestyle changes
– impaired cognition
– inadequate support systems
– unresolved grieving
Anxiet y dis order

– stresses in home or work environments, close interpersonal
relationships
– threat to self-concept
– unmet needs
• Chronic low self-esteem related to lack of positive feelings and
difficulty concentrating
• Imbalanced nutrition: Less than body requirements related to in-
ability to ingest food due to psychological factors
• Social isolation related to panic state
Bipolar dis order

• Chronic low self-esteem related to depressive state and feelings
of hopelessness, need to continue long-term medications
• Disturbed personal identity related to manic state
• Impaired home maintenance related to difficulty concentrating
and flight of ideas
• Sleep deprivation related to manic state
Delus ional dis order

• Impaired social interaction related to delusional behavior
• Social isolation related to delusional behavior
Depres s ion
• Chronic low self-esteem related to stress or loss
• Deficient diversional activity related to lack of interest
• Imbalanced nutrition: More than/less than body requirements
related to poor eating habits
• Ineffective coping related to obsessive negative thoughts and
feelings
267
• Risk for caregiver role strain related to psychological needs of

care recipient
• Risk for disturbed personal identity related to depressive state
• Risk for loneliness related to self-imposed social isolation
• Risk for self-directed violence related to lack of self-esteem Preoccupat ion
• Social isolation related to inability to engage in satisfying wit h eat ing
behaviors or rit uals
personal relationships can lead t o impaired
s ocial int eract ion.
Dis s ociat ive dis order
• Disturbed personal identity related to underdeveloped ego,
threat to self-concept, or childhood abuse or trauma
• Ineffective coping related to a severe level of repressed anxiety
family member
• Risk for chronic low self-esteem related to perceived lack of
belonging
Eat ing dis orders

• Deficient knowledge (nutrition and eating disorders) related to
lack of interest in learning
• Disturbed body image related to misperceived physical appear-
ance
– excessive physical exercise
– purging activities
– refusal to eat
• Impaired social interaction related to withdrawal from peer
group, fear of rejection, and preoccupation with eating behaviors
or rituals
• Ineffective denial related to a lack of knowledge about real or
potential dangers associated with eating disorders
• Ineffective impulse control related to disturbed body image
• Interrupted family processes related to a perfectionistic, over-
protective, or chaotic family system
Gender ident it y dis order

• Anxiety related to conflict between desires and expected sex
role behavior
• Disturbed personal identity related to conflict between
anatomical sex and gender identity
• Ineffective sexuality pattern related to conflicts with sexual
orientation
• Interrupted family processes related to family confusion and
anxiety about gender of family member
268
Panic dis order

• Anxiety related to feelings of panic
• Chronic low self-esteem related to repeated episodes of appre-
hension and fear
• Posttrauma syndrome related to perception of adverse event or
sudden loss
Pers onalit y dis order—Clus t er A

• Impaired social interaction related to disorganized thinking, odd
or eccentric behaviors, emotional coldness
– inability to trust others
– self-absorption
– unusual perceptions and communication patterns
• Ineffective impulse control related to personality disorder
• Interrupted family processes related to shift in physical or men-
tal health status of family member
Pers onalit y dis order—Clus t er B

• Impaired social interaction related to:
– behaviors that produce hostility in others
– inability to form healthy interpersonal relationships
– low self-esteem
– fear of abandonment
Pers ist ent
– feelings of loneliness, emptiness, boredom irrat ional fear can
– poor frustration tolerance lead t o ineffect ive
– poor impulse control coping. St and back,
• Ineffective impulse control related to personality disorder folks. I’m about t o
• Risk for other-directed or self-directed violence related to dra- drop in for a visit .
matic, emotional, or erratic behavior or low self-esteem
Pers onalit y dis order—Clus t er C

• Anxiety related to preoccupation
– inability to ask for help
– need to always be right and perfect
– need to use rules and routines to maintain a secure
environment
– verbal manipulation
• Interrupted family processes related to rigidity in functions,
roles, and rules
• Powerlessness related to:
– intellectualization or denial of feelings as a means to gain self-
control
– perfectionistic behavior that protects against inferiority feelings
269
• Sleep deprivation related to prolonged psychological discomfort

• Social isolation related to an inability to establish and maintain
relationships
Phobias
• Disturbed personal identity related to inability to control fear
• Fear related to anxiety about an object or a situation
• Ineffective coping related to persistent irrational fear
Pos t t raumat ic s t res s dis order

• Hopelessness related to feelings of helplessness and loss of con-
trol
• Posttrauma syndrome related to traumatic event
• Powerlessness related to uncertainty about the future
Schizophrenia
• Anxiety related to disturbance in thought content
• Bathing self-care deficit related to apathy and delusions
• Caregiver role strain related to chronic illness
Pat ient s wit h
Sleep dis orders sleep disorders can
experience anxiet y
• Anxiety related to inability to sleep relat ed t o inabilit y
• Insomnia related to: t o sleep. At t his
– external factors, such as hospital routines, environmental point , even t he
noise, and changing work shifts sheep have gone t o
– medical illness sleep.
– pain
– psychological stress
• Interrupted family processes related to family member not
being able to fulfill role requirements because of lack of sleep
Somat oform and fact it ious dis orders

• Bathing self-care deficit related to:
– activity intolerance
– neuromuscular or musculoskeletal impairment
– pain or discomfort
– perceptual or cognitive impairment
• Caregiver role strain related to unpredictable illness and con-
flict with care recipient
• Chronic pain related to unmet dependency needs or repressed
anxiety as demonstrated by verbal complaints with no pathophysi-
ological validation
• Deficient knowledge (healthful social interactions) related to:
– denial
– intense repressed anxiety level
– lack of interest in learning
– preoccupation with self and pain
270
• Disabled family coping related to struggle for control and power

• Disturbed body image related to low self-esteem evidenced by
preoccupation with real or imagined altered body structure or
function
– extreme need for approval and acceptance
– inability to manage emotional conflict
– low self-esteem
– unmet dependency needs
• Social isolation related to physical symptoms or disability
Vicarious t raumat izat ion

• Insomnia related to recurrent nightmares or dreams of personal
death and fear of their recurrence
• Posttrauma syndrome related to the subjective experience of
single or multiple traumatic events through repeated exposure to
trauma victims (vicarious traumatization)
• Powerlessness related to:
– inadequate problem-solving and coping skills
– overwhelming anxiety
Appendices and index
NANDA-I nurs ing diagno s es
by domain 272
Se le c te d re fe re nc e s 275
Inde x 277
NANDA-I nurs ing diag no s e s by do main
This list presents the 2012–2014 NANDA Interna- Do main 4: Ac tivity/Re s t
tional (NANDA-I) taxonomy according to their • Activity intolerance
• Bathing self-care deficit
domains. • Decreased cardiac output
Do main 1: He alth pro mo tio n • Disturbed energy field
• Deficient community health • Disturbed sleep pattern
• Deficient diversional activity • Dressing self-care deficit
• Ineffective family therapeutic regimen management • Dysfunctional ventilatory weaning response
• Ineffective health maintenance • Fatigue
• Ineffective protection • Feeding self-care deficit
• Ineffective self-health management • Impaired bed mobility
• Readiness for enhanced immunization status • Impaired home maintenance
• Readiness for enhanced self-health management • Impaired physical mobility
• Risk-prone health behavior • Impaired spontaneous ventilation
• Sedentary lifestyle • Impaired transfer ability
Do main 2: Nutritio n • Impaired walking
• Deficient fluid volume • Impaired wheelchair mobility
• Excess fluid volume • Ineffective breathing pattern
• Imbalanced nutrition: Less than body requirements • Ineffective peripheral tissue perfusion
• Imbalanced nutrition: More than body requirements • Insomnia
• Impaired swallowing • Readiness for enhanced self-care
• Ineffective infant feeding pattern • Readiness for enhanced sleep
• Insufficient breast milk • Risk for activity intolerance
• Neonatal jaundice • Risk for decreased cardiac tissue perfusion
• Readiness for enhanced fluid balance • Risk for disuse syndrome
• Readiness for enhanced nutrition • Risk for ineffective cerebral tissue perfusion
• Risk for deficient fluid volume • Risk for ineffective gastrointestinal perfusion
• Risk for electrolyte imbalance • Risk for ineffective peripheral tissue perfusion
• Risk for imbalanced fluid volume • Risk for ineffective renal perfusion
• Risk for imbalanced nutrition: More than body requirements • Self-neglect
• Risk for impaired liver function • Sleep deprivation
• Risk for neonatal jaundice • Toileting self-care deficit
• Risk for unstable blood glucose level • Wandering
Do main 3: Eliminatio n and e xc hang e Do main 5: Pe rc e ptio n/Co g nitio n
• Bowel incontinence • Acute confusion
• Constipation • Chronic confusion
• Diarrhea • Deficient knowledge
• Dysfunctional gastrointestinal motility • Impaired environmental interpretation syndrome
• Functional urinary incontinence • Impaired memory
• Impaired gas exchange • Impaired verbal communication
• Impaired urinary elimination • Ineffective impulse control
• Overflow urinary incontinence • Readiness for enhanced communication
• Perceived constipation • Readiness for enhanced knowledge
• Readiness for enhanced urinary elimination • Risk for acute confusion
• Reflex urinary incontinence • Unilateral neglect
• Risk for constipation Do main 6: S e lf-pe rc e ptio n
• Risk for dysfunctional gastrointestinal motility • Chronic low self-esteem
• Risk for urge urinary incontinence • Disturbed body image
• Stress urinary incontinence • Disturbed personal identity
• Urge urinary incontinence • Hopelessness
• Urinary retention • Readiness for enhanced self-concept
272
NANDA-I NURS ING DIAGNOS ES BY DOMAIN
273
• Risk for chronic low self-esteem • Readiness for enhanced family coping
• Risk for compromised human dignity • Readiness for enhanced organized infant behavior
• Risk for disturbed personal identity • Readiness for enhanced power
• Risk for loneliness • Readiness for enhanced resilience
• Risk for situational low self-esteem • Relocation stress syndrome
• Situational low self-esteem • Risk for autonomic dysreflexia
Do main 7: Ro le re latio ns hips • Risk for complicated grieving
• Caregiver role strain • Risk for compromised resilience
• Dysfunctional family processes • Risk for disorganized infant behavior
• Impaired parenting • Risk for ineffective activity planning
• Impaired social interaction • Risk for post-trauma syndrome
• Ineffective breast-feeding • Risk for powerlessness
• Ineffective relationship • Risk for relocation stress syndrome
• Ineffective role performance • Stress overload
• Interrupted breast-feeding Do main 10: Life princ iple s
• Interrupted family processes • Decisional conflict
• Parental role conflict • Impaired religiosity
• Readiness for enhanced breast-feeding • Moral distress
• Readiness for enhanced family processes • Noncompliance
• Readiness for enhanced parenting • Readiness for enhanced decision making
• Readiness for enhanced relationship • Readiness for enhanced hope
• Risk for caregiver role strain • Readiness for enhanced religiosity
• Risk for impaired attachment • Readiness for enhanced spiritual well-being
• Risk for impaired parenting • Risk for impaired religiosity
• Risk for ineffective relationship • Risk for spiritual distress
Do main 8: S e xuality • Spiritual distress
• Ineffective childbearing process Do main 11: S afe ty/Pro te c tio n
• Ineffective sexuality pattern • Contamination
• Readiness for enhanced childbearing process • Delayed surgical recovery
• Risk for disturbed maternal/fetal dyad • Hyperthermia
• Risk for ineffective childbearing process • Hypothermia
• Sexual dysfunction • Impaired dentition
Do main 9: Co ping /S tre s s to le ranc e • Impaired oral mucous membrane
• Adult failure to thrive • Impaired skin integrity
• Anxiety • Impaired tissue integrity
• Autonomic dysreflexia • Ineffective airway clearance
• Chronic sorrow • Ineffective thermoregulation
• Complicated grieving • Latex allergy response
• Compromised family coping • Risk for adverse reaction to iodinated contrast media
• Death anxiety • Risk for allergy response
• Decreased intracranial adaptive capacity • Risk for aspiration
• Defensive coping • Risk for bleeding
• Disabled family coping • Risk for contamination
• Disorganized infant behavior • Risk for dry eye
• Fear • Risk for falls
• Grieving • Risk for imbalanced body temperature
• Impaired individual resilience • Risk for impaired skin integrity
• Ineffective activity planning • Risk for infection
• Ineffective community coping • Risk for injury
• Ineffective coping • Risk for latex allergy response
• Ineffective denial • Risk for other-directed violence
• Post-trauma syndrome • Risk for perioperative positioning injury
• Powerlessness • Risk for peripheral neurovascular dysfunction
• Rape-trauma syndrome • Risk for poisoning
• Readiness for enhanced community coping • Risk for self-directed violence
• Readiness for enhanced coping • Risk for self-mutilation
NANDA-I NURS ING DIAGNOS ES BY DOMAIN
274
• Risk for shock • Domain 13: Growth/De ve lopme nt

• Risk for sudden infant death syndrome • Delayed growth and development
• Risk for suffocation • Risk for delayed development
• Risk for suicide • Risk for disproportionate growth
• Risk for thermal injury
• Risk for trauma To make safe and effective judgments using NANDA-I nursing
• Risk for vascular trauma diagnoses, it is essential that nurses refer to the definitions
• Self-mutilation and defining characteristics of the diagnoses listed in Nursing
Diagnoses: Definitions and Classification 2012-2014 © 2012,
Do main 12: Co mfo rt 1994-2012 NANDA International (ISBN 978-0-4706-5482-8).
• Acute pain Copyright NANDA International, www.nanda.org. Nu r si n g
• Chronic pain Di a gn oses: Defi n i ti on s a n d Cla ssi fi ca ti on 2012-2014 © 2012
• Impaired comfort NANDA International. Used by arrangement with Blackwell
• Nausea Publishing Limited, a company of John Wiley & Sons, Inc.
• Readiness for enhanced comfort
• Social isolation
S elec te d re fe re nce s
Baranoski, S., & Ayello, S. E. (2011). edi ti on . Oxford, England: Wiley-Blackwell
Wou n d ca r e essen ti a ls: Pr a cti ce Publishing, a company of John Wiley &
pr i n ci ples (3rd ed.). Philadelphia, Sons, Inc.
PA: Lippincott Williams & Wilkins. Nettina, S. (2009). Li ppi n cott m a n u a l of n u r si n g
Bulechek, G., et al. (2007). Nu r si n g pr a cti ce (9th ed.). Philadelphia, PA: Lippincott
i n ter ven ti on s cla ssi fi ca ti on ( NIC) Williams & Wilkins.
( 5th ed.). St. Louis, MO: Mosby. Pillitteri, A. (2009). Ma ter n a l a n d chi ld hea lth
Fauci, A. S., et al. (2008). Harrison’s n u r si n g: Ca r e of the chi ldbea r i n g a n d
principles of internal medicine chi ldr ea r i n g fa m i ly (6th ed.). Philadelphia,
(17th ed.). New York, NY: McGraw-Hill. PA: Lippincott Williams & Wilkins.
Ignatavicius, D., & Workman, L. Porth, C. M. (2010). Essen ti a ls of pa thophysi ology
(2009). Medi ca l-su r gi ca l n u r si n g: (3rd ed.). Philadelphia, PA: Lippincott Williams
Pa ti en t-cen ter ed colla bor a ti ve ca r e. & Wilkins.
Philadelphia, PA: W. B. Saunders. Smeltzer, S. C., et al. (2009). Br u n n er a n d
Johnson, M., et al. (2011). NOC a n d Su dda r th’s textbook of m edi ca l-su r gi ca l n u r s-
NIC li n ka ges to NANDA-I a n d cli n i ca l i n g (12th ed.). Philadelphia, PA: Lippincott
con di ti on s. St. Louis, MO: Mosby. Williams & Wilkins.
Li ppi n cott’s gu i de to i n fecti ou s di sea ses. (2010). Taylor, C., et al. (2010). Fu n da m en ta ls of n u r si n g:
Philadelphia, PA: Lippincott Williams & Wilkins. The a r t a n d sci en ce of n u r si n g ca r e (7th ed.).
Medi ca l-su r gi ca l n u r si n g m a de i n cr edi bly ea sy! Philadelphia, PA: Lippincott Williams & Wilkins.
(3rd ed.). (2011). Philadelphia, PA: Lippincott Ward, S., & Hisley, S. (2009). Ma ter n a l-chi ld n u r s-
Williams & Wilkins. i n g ca r e: Opti m i zi n g ou tcom es for m other s,
Melnyk, B., & Fineout-Overholt, E. (2010). chi ldr en , a n d fa m i li es. Philadelphia, PA: F. A.
Evi den ce-ba sed pr a cti ce i n n u r si n g Davis Company.
& hea lthca r e: A gu i de to best pr a cti ce. Woods, S. L., et al. (Eds.). (2009). Ca r di a c n u r si n g
Philadelphia, PA: Lippincott Williams & Wilkins. (6th ed.). Philadelphia, PA: Lippincott Williams
Moorhead, S., et al. (2007). Nu r si n g ou tcom es cla s- & Wilkins.
si fi ca ti on ( NOC) . St. Louis, MO: Mosby. Yarbro, C. H., et al. (2010). Ca n cer n u r si n g:
NANDA International. (2012). Nu r si n g di a gn oses, Pr i n ci ples a n d pr a cti ce (7th ed.). Sudbury, MA:
defi n i ti on s a n d cla ssi fi ca ti on s, 2012-2014 Jones & Bartlett Learning.
275
Index
A Care plan (continued )
evaluating, 147
Coping and stress management pattern
assessing, 38
Abuse, asking about, in nursing history, 28
in extended-care facilities, 164–165 Critical observation as examination
Activities of daily living, nursing history
flexibility of, 11 technique, 32
and, 27
in hospice setting, 168 Critical pathway, 164, 166–167i
Activity and exercise pattern, assessing, 36
implementing, 115–135 Critical thinking, 11–13
Actual diagnosis, 60–61
individually developed, 157–158, 158i as essential skill, 13
Acute care hospital unit, care plan in, 162–164
purpose of, 3 hallmarks of, 12–13
Administration route, incorrect, avoiding, 124
reassessment of, 146–147 nursing process and, 12–13
Advanced practice nurse as health care
as required part of patient’s record, 153–155 Cultural influences, nursing history and, 29–30
team member, 130
in same-day surgery unit, 164 Current complaints, nursing history and, 26
Air bubbles in pump tubing, avoiding, 124
sample Current patient situation, assessment of,
American Nurses Association
for maternal-neonatal care, 171–172t as implementation step, 117–118,
NANDA International and, 14
for pediatric care, 177t 119–121i, 121–123
nursing process and, 6
for psychiatric care, 174–175t
Assessment
standardized, 159, 160i, 161
complete, 23
components of, 24–35
traditional, 157, 158i D
updating, 148–150, 149i Data collection
critical thinking and, 12
Care planning. See also Care plan. assessment and, 23
of current patient situation, 117–118,
in health care setting, 155 organization and, 35–36, 37i, 38–39,
119–121i, 121–123
nursing process and, 3–4, 6 40–43i, 44
data collection and, 23
patient input in, 4, 90–91, 92 Developmental stages
focused, 24
students’ role in, 155–156 autonomy vs. shame and doubt, 45
initial, Joint Commission standards for, 39
Clinical nurse specialist as health care team generativity vs. self-absorption, 46–47
integrating, into caregiving tasks, 47–48
member, 130 identity vs. role confusion, 46
as nursing process step, 8, 23–52
Clinical site staff, level of responsibility industry vs. inferiority, 46
Auscultation as examination technique, 31
and, 156 initiative vs. guilt, 46
Autonomy vs. shame and doubt
Cognition and perception, assessing, 38 integrity vs. despair, 47
developmental stage, 45
Collaborative care, 71–73 intimacy vs. isolation, 46
Collaborative interventions, 101, 102i trust vs. mistrust, 45
B Complete assessment, 24
components of, 24–35
Diagnostic statement, 58. See also Nursing
diagnosis.
Bedside shift report, 118
Behavior as element in outcome statement, Concept map, 17. See also Concept mapping. writing, 66–69, 71–73
85–86, 86i creating, 18–19 Diagnostic testing data, assessment and,
Biographic data, nursing history and, 26 based on assessment data, 48–50, 51i, 52 32–33
guidelines for, 19 Differential diagnosis, 31
creating nursing diagnoses from, 63, 64i, 65 Discharge planner as health care team
C sample member, 130
Calculation errors, avoiding, 124 for maternal-neonatal care, 170i Documentation
Caregiving tasks, integrating assessment for pediatric care, 176i of care plan, 10
into, 47–48 for psychiatric care, 173i of changes in patient’s condition, 144
Care plan. See also Care planning. uses for, 19 patient-centered, 130
in acute care hospital unit, 162–164 Concept mapping. See also Concept map. Documentation formats, 131–134, 133i, 134i
changing, 11, 148–150, 149i advantages of, 17 Domains
collaborative care and, 71–73 disadvantages of, 17–18 in NANDA International–approved nursing
components of, 83–84 vs. nursing care plans, 18t diagnoses, 66, 67, 98, 105
computerized, 161–162 Conditions as element in outcome statement, in Nursing Interventions Classification
vs. concept map, 18t 86i, 87–88 system, 105
creating, 168–169 Consultant specialty physician as health care in Nursing Outcomes Classification
documenting, 10 team member, 130 system, 94–95, 98, 105
i refers to an illustration; t refers to a table.
277
INDEX
278
Drug orders, 124

Drug preparation and administration, 124
I Medical diagnoses vs. nursing diagnoses, 9,
73, 75–76t
Identity vs. role confusion as developmental
Medical diagnosis, reviewing, 34–35
stage, 46
Medical procedure data, reviewing, 34
E Implementation
Medical-surgical diagnoses, 185–242
Electronic change-of-shift report, 118 assessment of current situation and,
Medication use, current, reviewing, 33
Electronic health record, 161–162 117–118, 119–121i, 121–123
Mind map. See Concept map.
Electronic shift report, 119–121i basic steps in, 123, 125
Modifications to care plan, 148–150, 149i
Elimination pattern, assessing, 36 as nursing process step, 11, 115–116
Multidisciplinary admission form, 40–43i
Erikson’s stages of development, 45–47 Independent interventions, 100–101, 102i
Etiology as nursing diagnosis part, 59 Industry vs. inferiority developmental
Evaluation stage, 46 N
of care plan, 147 Information sources, evaluating, 108–109 NANDA International, 14, 66. See also
critical thinking and, 12 Initiative vs. guilt developmental stage, 46 NANDA International–approved
Likert scales as tool for, 95, 96 Inspection as examination technique, 32 diagnoses.
of long-term goals, 145–146 Integrated database format, 39, 40–43i submitting new diagnoses to, 68i
as nursing process step, 11, 137 Integrating nursing care, 125–126, 129 NANDA International–approved diagnoses,
reassessment and, 138–144 Integrity vs. despair as developmental 14, 16. See also NANDA International.
of short-term goals, 145 stage, 47 choosing, 74i
value of, 137–138 Interdependent interventions, 101, 102i definition of, 57–58
Evaluation statements, writing, 144–146 Interdisciplinary team diagnostic statements and, 66–69, 71–73
Evidence-based practice, 108–109 care planning and, 155 by domain, 272–274
Extended-care facility working with, 129–131 domains in, 66, 67
care plan in, 164–165 Interventions Taxonomy II for, 66
RN Assessment Coordinator in, 165 care plan and, 10 levels of, 66
correlating, with patient outcomes, 92 National Patient Safety Goals, 122
documenting, 131–134 North American Nursing Diagnosis
F evaluating, 141, 142i, 143–144 Association. See NANDA International.
Family history, nursing history and, 30 keeping track of, 141 Nurse-manager as health care team
Five rights of drug administration, 123, 125 standardized classification system for, 15, 16 member, 130
Focused assessment, 24 types of, 100–101, 102i Nurse practitioner as health care team
Focus factor, patient interactions and, 12 using Nursing Interventions Classification member, 130
Follow-up assessment data, comparing, with to write, 105–107, 106i Nurses as resources, 123
prior, 138–140 writing, 101, 103–104 Nursing diagnoses by medical diagnosis,
Functional levels, assigning codes to, 37i. Intimacy vs. isolation as developmental 183–270
See also Gordon’s functional health stage, 46 maternal-neonatal diagnoses, 243–250
patterns. medical-surgical diagnoses, 185–242
J pediatric diagnoses, 251–262
G Joint Commission
psychiatric diagnoses, 263–270
General survey of patient, 31 Nursing diagnosis
as authority on practice standards, 154
Generativity vs. self-absorption as actual vs. risk for, 8
standards of, for initial assessments, 39
developmental stage, 46–47 classifications system for, 14
Gordon’s functional health patterns, 35–36 collaborative care and, 71–73
assigning codes to levels of, 37i L components of, 9–10
categories included in, 35–36, 38–39 Label as nursing diagnosis part, 59 creating, from concept map, 63, 64i, 65
NANDA International Taxonomy II Language barrier, overcoming, 29 critical thinking and, 12
and, 66 Levels of responsibility, 116–117 developing a problem list for, 65, 65i
Growth and development stages, 44–47 Likert scales as evaluation tool, 95, 97 do’s and don’ts of writing, 70–71
Long-term goals, evaluating, 145 formulating, 58
vs. medical diagnoses, 9, 73, 75–76t
H as nursing process step, 8, 57–79
Health perception and management pattern, M parts of, 58–59, 60
assessing, 36 Maslow’s hierarchy of needs, 79i prioritizing, 78–79
Hospice Maternal-neonatal diagnoses, 243–250 Maslow’s pyramid and, 79i
care plan in, 168 Measure as element in outcome types of, 59–62
interdisciplinary team in, 130 statement, 86i, 87 validating, 76, 77i, 78

INDEX
279
Nursing history, 25–30

Nursing Interventions Classification system,
P Risk diagnosis, 61
RN Assessment Coordinator in
Palliative care, interdisciplinary team in, 130
15, 16, 104–105 extended-care facility, 165
Palpation as examination technique, 32
domains in, 104–105 Roles and relationships, assessing, 38
Past medical history, nursing history and,
using, to write interventions, 105,
26–27
106i, 107
Nursing Outcomes Classification system, 15,
Pastoral care specialist as health care team
member, 130
S
16, 91–92, 94–98 Safe drug administration guidelines, 124
Patient assessment data, comparing prior, Same-day surgery unit, care plan in, 164
anatomy of outcome in, 97i
with follow-up, 138–140 Self-perception and self-concept,
categories in, 94–95
Patient-centered documentation, 131 assessing, 38
definition of outcome in, 94
Patient compliance, improving, 92 Sexuality and reproduction pattern,
role of Likert scales in, 95, 96
Patient goals, 10 assessing, 38
using, to write expected outcomes, 96, 98,
long-term, 88 Shift report
99–100i
documenting, 89 bedside, 118
Nursing process, 3–4
evaluating, 145–146 electronic, 119–121i
advantages of, 4–5
short-term, 88 Short-term goals, evaluating, 145
basis for, 5
evaluating, 145 Signs and symptoms as nursing diagnosis
critical thinking and, 11–13
Patient outcomes. See Outcomes, expected. part, 59
initial definition of, 6
Patient safety goals, 122 Sleep and rest pattern, assessing, 38
postgraduation use of, 13–14
Patient’s chart as data source, 33 SOAP documentation format, 132–134, 134i
reassessment throughout, 139t
Pediatric diagnoses, 251–262 Social worker as health care team member,
steps in, 5–6, 8–11
Percussion as examination technique, 32 130
interrelationship of, 6, 7i, 8
Pharmacist as health care team member, 130 Socioeconomic factors, nursing history and,
Nursing student, level of responsibility and,
Physical examination, 30, 31–32 28, 29
116–117, 155–156
general survey and, 31 Specialty database formats, 39, 44
Nutrition and metabolism pattern,
goals of, 31 Spiritual influences, nursing history and,
assessing, 36
techniques used in, 31–32 29, 30
Physical therapist as health care team Standardized care plans, 159, 160i, 161
member, 130
O Physician as health care team member, 130
advantages of, 161
disadvantage of, 161
Objective data, 25 Physician’s assistant as health care team
Occupational therapist as health care team STOP acronym, 50
member, 130 Stressors, nursing history and, 27, 28
member, 130 Planning as nursing process step, 10
Outcome-oriented documentation, 131 Subjective data, 25
Plan of care. See Care plan. Support systems, nursing history and, 27–28
Outcomes, expected Primary nurse as health care team member,
achieving, 143–144 Syndrome diagnosis, 61–62
130
adapting, to specific circumstances, Prioritizing nursing diagnoses, 78–79
90, 91i
care plan and, 10
Maslow’s pyramid and, 79i T
Problem-intervention-evaluation Time frame as element in outcome
correlating, with specific interventions, 92 documentation system, 132, 133i statement, 86i, 88
critical thinking and, 13 Problem list, developing, 65, 65i Traditional care plan, 157–158, 158i
evaluating, 141, 142i Problem solving as basis for nursing process, 5 advantages of, 157
identifying, 84–91 Psychiatric diagnoses, 263–270 basic form for, 157, 158i
standardized classification system
disadvantage of, 158
for, 15
using Nursing Outcomes Classification to R Trust vs. mistrust developmental stage, 45
write, 96, 98 Reassessment
Outcome statement, 85 of care plan, 146–147
nursing process and, 138, 139t
V
parts of, 85–88, 86i Validating nursing diagnoses, 76, 77i, 78
patient input in, 90–91, 92 of patient, 138–144 Values and beliefs, assessing, 38
specificity and conciseness in, 89–90, 96i Registered dietitian as health care team
writing, 88–91, 93–94 member, 130
Over-the-counter drugs, information Respiratory therapist as health care team W
resources for, 37, 38 member, 130 Wellness diagnosis, 62

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S taff The clinical treatments described and recommended

in this publication are based on research and consulta-

Vict or ia L. Rich , P h D, RN, F AAN

3 Nurs ing diagnos is 57

5 Impleme ntation 115

7 Putting it all tog ether 153

The great communicat or

Analyze, addres s , implement , evaluat e

Advantag e s of the nurs ing pro ce s s

Teacher knows best

Putting the “P” in planning

• It improves communication by providing you and other nurses

A s cient ific fact

Nurs ing proc e s s s te ps

Jus t how many s teps are there?

The nurs ing proces s : An unbroken circle

Take for example…

Actual vs . Ris k for nurs ing diagnos es

If you go astray during any step—say, by misinterpreting the

How nurs ing and medical diagnos es differ

• related factors—factors that may precede, contribute to, or be

One t hing leads t o anot her

Here come t he out comes

Next in line—t he int ervent ions

Don’t forget t o document

How the nurs ing proc es s pro mo tes critic al thinking

Teacher knows best

The focus factor

problem and helps you choose among these possible solutions

Hallmarks of critical thinking

Critical thinking: An es s ential s kill

Practice for your practice

Likewise, critical thinking helps you write outcomes in a way

Us ing the nurs ing proc e s s afte r graduation

Roll wit h t he changes

Rins e and repeat

Unde rs ta nding NANDA-I, NOC, a nd NIC

Speaking t he s ame language

Other c las s ific ation s ys te ms

NOC is no laughing mat t er

NIC follows NOC

Weighing the evidence

Don’t knock NOC!

Weighing the evidence

NIC and nurs es

Advantages of conce pt mapping

Dis advantages of c onc ept mapping

Concept map Nursing care plan

• Visually organized • Linearly organized

• Assessment data clearly linked to • Assessment data usually in separate

• Getting the map just right can be time-consuming. You may

Cre ating a c onc ept map Acute pain

• Write expected outcomes for each nursing diagnosis; place each

Pat t erns , s ymbols , and not es

Us ing your c once pt map

Teacher knows best

Concept mapping without tears

clinical rotations. During clinicals, you can carry your concept