Anticipated changes in living situation after discharge: ________
Living facility other than home (specify): ___________________
Referrals (date/source/services): Social Services: _____________
Rehab services: _______ Dietary: ______ Home care: _________
Resp/O2: ______ Equipment: _______________________________
Supplies: ____________________ Other: _____________________
Hospice: _________________________________________________
Box 3.1 Nursing Diagnoses Organized According to Diagnostic Divisions
After data are collected and areas of concern or need identified,the nurse is directed to the Diagnostic Divisions to review the list of nursing diagnoses that fall within the individual cate- gories. This will assist the nurse in choosing the specific diag- nostic label to accurately describe the data. Then, with the addition of etiology or related/risk factors (when known), and signs and symptoms, or cues (defining characteristics), the client diagnostic statement emerges.
Activity/Rest—ability to engage in necessary or desired activities of life (work and leisure) and to obtain adequate sleep and rest
• Activity Intolerance
• Activity Intolerance, risk for
• Activity Planning, ineffective
• Activity Planning, risk for ineffective
• Disuse Syndrome, risk for
• Diversional Activity, deficient
• Fatigue
• Insomnia
• Lifestyle, sedentary
• Mobility, impaired bed
• Mobility, impaired wheelchair
• Sleep, readiness for enhanced
• Sleep Deprivation
• Sleep Pattern, disturbed
• Transfer Ability, impaired
• Walking, impaired
Circulation—ability to transport oxygen and nutrients necessary to meet cellular needs
• Autonomic Dysreflexia
• Autonomic Dysreflexia, risk for
• Bleeding, risk for
• Cardiac Output, decreased
• Gastrointestinal Perfusion, risk for ineffective
• Intracranial Adaptive Capacity, decreased
• Renal Perfusion, risk for ineffective
• Shock, risk for
• Tissue Perfusion, ineffective peripheral
• Tissue Perfusion, risk for decreased cardiac
• Tissue Perfusion, risk for ineffective cerebral
• Tissue Perfusion, risk for ineffective peripheral
Ego Integrity—ability to develop and use skills and behaviors to integrate and manage life experiences
• Anxiety [specify level]
• Body Image, disturbed
• Coping, defensive
• Coping, ineffective Figure 3.1 Adult medical-surgical assessment tool. This is a suggested guide and tool for creating a database reflecting a nursing focus. Although the diagnostic divisions are alphabetized here for ease of presentation, they can be prioritized or rearranged in any manner to meet indi- vidual needs. In addition, this assessment tool can be adapted to meet the needs of specific client populations.
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Box 3.1 Nursing Diagnoses Organized According to Diagnostic Divisions
(continued)• Coping, readiness for enhanced
• Death Anxiety
• Decision-Making, readiness for enhanced
• Decisional Conflict
• Denial, ineffective
• Energy Field, disturbed
• Fear
• Grieving
• Grieving, complicated
• Grieving, risk for complicated
• Health Behavior, risk-prone
• Hope, readiness for enhanced
• Hopelessness
• Human Dignity, risk for compromised
• Impulse Control, ineffective
• Moral Distress
• Personal Identity, disturbed
• Personal Identity, risk for disturbed
• Post-Trauma Syndrome
• Post-Trauma Syndrome, risk for
• Power, readiness for enhanced
• Powerlessness
• Powerlessness, risk for
• Rape-Trauma Syndrome
• Relationships, ineffective
• Relationships, readiness for enhanced
• Relationships, risk for ineffective
• Religiosity, impaired
• Religiosity, readiness for enhanced
• Religiosity, risk for impaired
• Relocation Stress Syndrome
• Relocation Stress Syndrome, risk for
• Resilience, impaired individual
• Resilience, readiness for enhanced
• Resilience, risk for compromised
• Self-Concept, readiness for enhanced
• Self-Esteem, chronic low
• Self-Esteem, risk for chronic low
• Self-Esteem, situational low
• Self-Esteem, risk for situational low
• Sorrow, chronic
• Spiritual Distress
• Spiritual Distress, risk for
• Spiritual Well-Being, readiness for enhanced Elimination—ability to excrete waste products
• Constipation
• Constipation, perceived
• Constipation, risk for
• Diarrhea
• Gastrointestinal Motility, dysfunctional
• Gastrointestinal Motility, risk for dysfunctional
• Incontinence, bowel
• Incontinence, functional urinary
• Incontinence, overflow urinary
• Incontinence, reflex urinary
• Incontinence, stress urinary
• Incontinence, urge urinary
• Incontinence, risk for urge urinary
• Urinary Elimination, impaired
• Urinary Elimination, readiness for enhanced
• Urinary Retention, [acute/chronic]
Food/Fluid—ability to maintain intake of and utilize nutrients and liquids to meet physiological needs
• Blood Glucose Level, risk for unstable
• Breast Milk, insufficient
• Breastfeeding, ineffective
• Breastfeeding, interrupted
• Breastfeeding, readiness for enhanced
• Dentition, impaired
• Electrolyte Imbalance, risk for
• Failure to Thrive, adult
• Feeding Pattern, ineffective infant
• Fluid Balance, readiness for enhanced
• [Fluid Volume, deficient hypertonic or hypotonic]
• Fluid Volume, deficient [isotonic]
• Fluid Volume excess
• Fluid Volume, risk for deficient
• Fluid Volume, risk for imbalanced
• Liver Function, risk for impaired
• Nausea
• Nutrition: less than body requirements, imbalanced
• Nutrition: more than body requirements, imbalanced
• Nutrition: more than body requirements, risk for imbalanced
• Nutrition, readiness for enhanced
• Oral Mucous Membrane, impaired
• Swallowing, impaired
Hygiene—ability to perform activities of daily living
• Self-Care, readiness for enhanced
• Self-Care Deficit: bathing
• Self-Care Deficit: dressing
• Self-Care Deficit: feeding
• Self-Care Deficit: toileting
• Self-Neglect
Neurosensory—ability to perceive, integrate, and respond to internal and external cues
• Behavior, disorganized infant
• Behavior, risk for disorganized infant
• Behavior, readiness for enhanced organized infant
• Confusion, acute
• Confusion, risk for acute
• Confusion, chronic
• Memory, impaired
• Peripheral Neurovascular Dysfunction, risk for
• [Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)]
• Stress Overload
• Unilateral Neglect
Pain/Discomfort—ability to control internal/external environment to maintain comfort
• Comfort, impaired
• Comfort, readiness for enhanced
• Pain, acute
• Pain, chronic
CHAPTER 3CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
Box 3.1 Nursing Diagnoses Organized According to Diagnostic Divisions
(continued)Respiration—ability to provide and use oxygen to meet physiological needs
• Airway Clearance, ineffective
• Aspiration, risk for
• Breathing Pattern, ineffective
• Gas Exchange, impaired
• Ventilation, impaired spontaneous
• Ventilatory Weaning Response, dysfunctional Safety—ability to provide safe, growth-promoting environment
• Adverse Reaction to Iodinated Contrast Media, risk for
• Allergy Response, risk for
• Body Temperature, risk for imbalanced
• Contamination
• Contamination, risk for
• Dry Eye, risk for
• Environmental Interpretation Syndrome, impaired
• Falls, risk for
• Health Maintenance, ineffective
• Home Maintenance, impaired
• Hyperthermia
• Hypothermia
• Immunization Status, readiness for enhanced
• Infection, risk for
• Injury, risk for
• Jaundice, neonatal
• Jaundice, risk for neonatal
• Latex Allergy Response
• Latex Allergy Response, risk for
• Maternal-Fetal Dyad, risk for disturbed
• Mobility, impaired physical
• Perioperative Positioning Injury, risk for
• Poisoning, risk for
• Protection, ineffective
• Self-Mutilation
• Self-Mutilation, risk for
• Skin Integrity, impaired
• Skin Integrity, risk for impaired
• Sudden Infant Death Syndrome, risk for
• Suffocation, risk for
• Suicide, risk for
• Surgical Recovery, delayed
• Thermal Injury, risk for
• Thermoregulation, ineffective
• Tissue Integrity, impaired
• Trauma, risk for
• Vascular Trauma, risk for
• Violence, risk for other-directed
• Violence, risk for self-directed
• Wandering [specify sporadic or continual]
Sexuality[Component of Ego Integrity and Social Interaction]—
ability to meet requirements/characteristics of male or female role
• Childbearing Process, ineffective
• Childbearing Process, readiness for enhanced
• Childbearing Process, risk for ineffective
• Sexual Dysfunction
• Sexuality Pattern, ineffective
Social Interaction—ability to establish and maintain relationships
• Attachment, risk for impaired
• Caregiver Role Strain
• Caregiver Role Strain, risk for
• Communication, impaired verbal
• Communication, readiness for enhanced
• Coping, compromised family
• Coping, disabled family
• Coping, readiness for enhanced community
• Coping, readiness for enhanced family
• Family Processes, dysfunctional
• Family Processes, interrupted
• Family Processes, readiness for enhanced
• Loneliness, risk for
• Parenting, impaired
• Parenting, risk for impaired
• Parenting, readiness for enhanced
• Role Conflict, parental
• Role Performance, ineffective
• Social Interaction, impaired
• Social Isolation
Teaching/Learning—ability to incorporate and use information to achieve healthy lifestyle and optimal wellness
• Development, risk for delayed
• Growth, risk for disproportionate
• Growth and Development, delayed
• Health, deficient community
• Knowledge, deficient [Learning Need] (specify)
• Knowledge (specify), readiness for enhanced
• Noncompliance [Adherence, ineffective] [specify]
• Self-Health Management, ineffective
• Self-Health Management, readiness for enhanced
• Therapeutic Regimen Management, ineffective family
To assist in visualizing this critical thinking process, a prototype client situation (Fig. 3.2) is provided as an ex- ample of data collection and construction of a plan of care.
As the client assessment database is reviewed, the nurse can identify the related or risk factors, and defining char- acteristics (signs and symptoms) if present, that were used to formulate the client diagnostic statements. The addition of timelines to specific client outcomes and goals reflects
the anticipated length of stay and individual client-nurse expectations. Interventions are based on concerns and needs identified by the client and nurse during data collec- tion. In addition, physician and other discipline orders are also considered when identifying interventions. Although not normally included in a plan of care, rationales are in- cluded in this sample for the purpose of explaining or clar- ifying the choice of interventions.
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