Ackley and Ladwig’s Nursing Diagnosis Handbook

Ackley and Ladwig’s Nursing Diagnosis Handbook

Create individualized nursing care plans with ease and confidence! Ackley and Ladwig’s Nursing Diagnosis Handbook, 13th Edition uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Step-by-step instructions show how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking. To make care planning easier, this handbook allows you to look up nursing diagnoses and care plans for more than 1450 client symptoms, as well as interventions from NIC (Nursing Interventions Classification) and outcomes from NOC (Nursing Outcomes Classification). Edited by noted nursing educators Mary Beth Flynn Makic and Marina Reyna Martinez-Kratz, this reference provides everything you need to write nursing care plans in just one book!

Key features Readership

Undergraduate and graduate nursing students

Associate Degree Annual Enrollment: 141,343

Baccalaureate Annual Enrollment: 263,282

RN-to-BSN Annual Enrollment: 119,428

Master’s Degree Annual Enrollment 134,777

Table of contents Cover image Title page Disclaimer Table of Contents NANDA-I Diagnoses Dedication About the Authors Contributors Acknowledgments How to Use Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care Section I. Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing Introduction

Part A: The Nursing Process: Using Clinical Reasoning Skills to Determine Nursing Diagnosis and Plan Care

Part B: Advanced Nursing Concepts

Part A. The Nursing Process: Using Clinical Reasoning Skills to Determine Nursing Diagnoses and Plan Care

The “Patient’s Story” The Nursing Process Step 1: Assessment (ADPIE) Step 2: Nursing Diagnosis (ADPIE) Step 3: Planning (ADPIE) Step 4: Implementation (ADPIE) Step 5: Evaluation (ADPIE) Part B. Advanced Nursing Process Concepts Section II. Guide to Nursing Diagnosis Introduction Abdominal Distention Abdominal Hysterectomy Abdominal Pain Abdominal Surgery Abdominal Trauma Ablation, Radiofrequency Catheter Abortion, Induced Abortion, Spontaneous Abruptio Placentae <36 Weeks Abscess Formation Abuse, Child Abuse, Spouse, Parent, or Significant Other Accessory Muscle Use (to Breathe) Accident Prone Acid-Base Imbalances Acidosis, Metabolic Acidosis, Respiratory Acromegaly Activity Intolerance, Potential to Develop Acute Abdominal Pain Acute Alcohol Intoxication Acute Back Pain Acute Confusion Acute Coronary Syndrome Acute Lymphocytic Leukemia (ALL) Acute Renal Failure Acute Respiratory Distress Syndrome Acute Substance Withdrawal Adams–Stokes Syndrome Addison’s Disease Adenoidectomy Adhesions, Lysis of Adjustment Disorder Adjustment Impairment Adolescent, Pregnant Adoption, Giving Child up for Adrenocortical Insufficiency Advance Directives Affective Disorders Age-Related Macular Degeneration Aggressive Behavior Agoraphobia Agranulocytosis AIDS (Acquired Immunodeficiency Syndrome) AIDS, Child AIDS Dementia Airway Obstruction/Secretions Alcohol Withdrawal Alcoholism Alcoholism, Dysfunctional Family Processes ALL (Acute Lymphocytic Leukemia) ALS (Amyotrophic Lateral Sclerosis) Altered Mental Status Alzheimer’s Disease AMD (Age-Related Macular Degeneration) Amenorrhea AMI (Acute Myocardial Infarction) Amniocentesis Amnionitis Amniotic Membrane Rupture Amputation Amyotrophic Lateral Sclerosis (ALS) Anal Fistula Anaphylactic Shock Anaphylaxis Prevention Anemia, in Pregnancy Anemia, Sickle Cell Anencephaly Aneurysm, Abdominal Aortic Repair Surgery Aneurysm, Cerebral Angiocardiography (Cardiac Catheterization) Angioplasty, Coronary Anomaly, Fetal/Newborn (Parent Dealing with) Anorectal Abscess Anorexia Nervosa Anosmia (Smell, Loss of Ability to) Antepartum Period Anterior Repair, Anterior Colporrhaphy Anticoagulant Therapy Antisocial Personality Disorder Anxiety Disorder Aortic Valvular Stenosis Aplastic Anemia Apnea in Infancy Apneustic Respirations Appendectomy Appendicitis Apprehension ARDS (Acute Respiratory Distress Syndrome) Arrhythmia Arterial Insufficiency Arthrocentesis Arthroplasty (Total Hip Replacement) Arthroscopy Asperger’s Syndrome Asphyxia, Birth Aspiration, Danger of Assault Victim Assaultive Client Atelectasis Atherosclerosis Athlete’s Foot ATN (Acute Tubular Necrosis) Atrial Fibrillation Atrial Septal Defect Attention Deficit Disorder Autonomic Dysreflexia Autonomic Hyperreflexia Bacteremia Balanced Energy Field Barrel Chest Bathing/Hygiene Problems Battered Child Syndrome Battered Person Bedbugs, Infestation Bed Mobility, Impaired Bed Rest, Prolonged Bedwetting Bell’s Palsy Benign Prostatic Hypertrophy Bereavement Biliary Atresia Biliary Calculus Biliary Obstruction Bilirubin Elevation in Neonate Bioterrorism Bipolar Disorder I (Most Recent Episode, Depressed or Manic) Birth Asphyxia Birth Control Bladder Cancer Bladder Distention Bladder Training Bladder Training, Child Bleeding Tendency Blepharoplasty Blood Disorder Blood Glucose Control Blood Pressure Alteration Blood Transfusion Body Dysmorphic Disorder Body Image Change Body Temperature, Altered Bone Marrow Biopsy Borderline Personality Disorder Bowel Incontinence Bowel Obstruction Bowel Resection Bowel Sounds, Absent or Diminished Bowel Sounds, Hyperactive Bowel Training Bowel Training, Child BPH (Benign Prostatic Hypertrophy) Bradycardia Brain Injury Brain Surgery Brain Tumor Braxton Hicks Contractions Breast Biopsy Breast Cancer Breast Examination, Self Breast Lumps Breast Pumping Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Breast Milk Production, Insufficient Breath Sounds, Decreased or Absent Breathing Pattern Alteration Breech Birth Bronchitis Bronchopulmonary Dysplasia Bronchoscopy Bruits, Carotid Bryant’s Traction Buck’s Traction Buerger’s Disease Bunionectomy Bypass Graft CABG (Coronary Artery Bypass Grafting) Calcium Alteration Candidiasis, Oral Capillary Refill Time, Prolonged Carbon Monoxide Poisoning Cardiac Arrest Cardiac Catheterization Cardiac Disorders in Pregnancy Cardiac Dysrhythmia Cardiac Output, Decreased Cardiac Tamponade Cardiogenic Shock Caregiver Role Strain Carious Teeth Carotid Endarterectomy Carpal Tunnel Syndrome Carpopedal Spasm Cataract Extraction Catatonic Schizophrenia Catheterization, Urinary Cavities in Teeth Celiac Disease Cellulitis Cellulitis, Periorbital Central Line Insertion Cerebral Aneurysm Cerebral Palsy Cerebral Perfusion Cerebrovascular Accident (CVA) Cervicitis Cesarean Delivery Chemical Dependence Chemotherapy Chest Pain Chest Tubes Cheyne-Stokes Respiration Chickenpox Child Abuse Childbearing Problems Child Neglect Child with Chronic Condition Childbirth Childhood Obesity Chlamydia Infection Choking or Coughing with Eating Cholecystectomy Cholelithiasis Chorioamnionitis Chronic Confusion Chronic Functional Constipation Chronic Lymphocytic Leukemia Chronic Obstructive Pulmonary Disease (COPD) Chronic Pain Chronic Renal Failure (Chronic Renal Disease) Chvostek’s Sign Circumcision Cleft Lip/Cleft Palate Clotting Disorder Cocaine Baby Codependency Cold, Viral Collagen Disease Colporrhaphy, Anterior Comfort, Loss of

Communicable Diseases, Childhood (e.g., Measles, Mumps, Rubella, Chickenpox, Scabies, Lice, Impetigo)

Communication Communication Problems Community Coping Community Health Problems Companion Animal Compartment Syndrome Compulsion Conduction Disorders (Cardiac) Confusion, Acute Confusion, Chronic Congenital Heart Disease/Cardiac Anomalies Congestive Heart Failure (CHF) Conjunctivitis Consciousness, Altered Level of Constipation Constipation, Chronic Functional Constipation, Perceived Constipation, Risk for Contamination Continent Ileostomy (Kock Pouch) Contraceptive Method Convulsions COPD (Chronic Obstructive Pulmonary Disease) Coping Problems Corneal Injury Corneal Reflex, Absent Corneal Transplant Coronary Artery Bypass Grafting (CABG) Costovertebral Angle Tenderness Cough, Ineffective Crackles in Lungs, Coarse Crackles in Lungs, Fine Craniectomy/Craniotomy Crepitation, Subcutaneous Crohn’s Disease Cryosurgery for Retinal Detachment Cushing’s Syndrome Cuts (Wounds) CVA (Cerebrovascular Accident) Cyanosis, Central with Cyanosis of Oral Mucous Membranes Cyanosis, Peripheral with Cyanosis of Nail Beds Cystic Fibrosis Cystoscopy Death, Oncoming Decisions, Difficulty Making Decubitus Ulcer Deep Vein Thrombosis (DVT) Defensive Behavior Dehiscence, Abdominal Dehydration Delirium Tremens (DT) Denial of Health Status Dental Caries Depression (Major Depressive Disorder) Dermatitis Despondency Destructive Behavior Toward Others Developmental Concerns Diabetes in Pregnancy Diabetes Insipidus Diabetes Mellitus Diabetes Mellitus, Juvenile (Insulin-Dependent Diabetes Mellitus Type 1) Diabetic Coma Diabetic Ketoacidosis Diabetic Neuropathy Diabetic Retinopathy Diaphragmatic Hernia DIC (Disseminated Intravascular Coagulation) Digitalis Toxicity Dignity, Loss of Dilation and Curettage (D&C) Dirty Body (for Prolonged Period) Discharge Planning Discomforts of Pregnancy Dislocation of Joint Dissecting Aneurysm Disseminated Intravascular Coagulation (DIC) Dissociative Identity Disorder (Not Otherwise Specified) Disuse Syndrome, Potential to Develop Diversional Activity Engagement, Lack of Diverticulitis Domestic Violence Down Syndrome Dress Self (Inability to) Dribbling of Urine Dropout from School Drug Abuse Drug Withdrawal DT (Delirium Tremens) DVT (Deep Vein Thrombosis) Dying Client Dysfunctional Eating Pattern Dysfunctional Family Unit Dysfunctional Ventilatory Weaning Dysmenorrhea Dyspareunia Dysrhythmia Dysthymic Disorder Ear Surgery Eating Dynamics, Adolescent Eating Dynamics, Child Eating Dynamics, Infant ECMO (Extracorporeal Membrane Oxygenator) ECT (Electroconvulsive Therapy) Ectopic Pregnancy ED (Erectile Dysfunction) Elder Abuse Electroconvulsive Therapy Electrolyte Imbalance Emaciated Person Emancipated Decision-Making, Impaired Embolectomy Embolism in Leg or Arm Emotional Problems Encephalitis Endocardial Cushion Defect Endocarditis Endometriosis Endometritis Environmental Interpretation Problems Epididymitis Epiglottitis Episiotomy Epstein-Barr Virus Erectile Dysfunction (ED) Escherichia coli Infection Esophageal Varices Esophagitis Evisceration Exhaustion Exposure to Hot or Cold Environment External Fixation Extracorporeal Membrane Oxygenator (ECMO) Eye Discomfort Eye Surgery Failure to Thrive, Child Falls, Risk for Family Problems Family Process Febrile Seizures Fecal Impaction Fecal Incontinence Feeding Dynamics, Infant Feeding Problems, Newborn Female Genital Mutilation Femoral Popliteal Bypass Fetal Alcohol Syndrome Fetal Distress/Nonreassuring Fetal Heart Rate Pattern Fibrocystic Breast Disease Filthy Home Environment Financial Crisis in the Home Environment Fistulectomy Flail Chest Flashbacks Flat Affect Fluid Volume Deficit Fluid Volume Excess Fluid Volume Imbalance, Risk for Food Allergies Foodborne Illness Food Intolerance Foreign Body Aspiration Formula Feeding of Infant Fractured Hip Frail Elderly Syndrome Frequency of Urination Friendship Frothy Sputum Fusion, Lumbar Gag Reflex, Depressed or Absent Gallop Rhythm Gallstones Gang Member Gas Exchange, Impaired Gastric Ulcer Gastroenteritis Gastroenteritis, Child Gastroesophageal Reflux Disease (GERD) Gastroesophageal Reflux, Child Gastrointestinal Bleeding (GI Bleed) Gastrointestinal Hemorrhage Gastrointestinal Surgery Gastroschisis/Omphalocele Gastrostomy Gender Dysphoria Genital Herpes Genital Warts Gestational Diabetes (Diabetes in Pregnancy) GI Bleed (Gastrointestinal Bleeding) Gingivitis Glomerulonephritis Gluten Allergy Grandiosity Grand Mal Seizure Grandparents Raising Grandchildren Graves’ Disease Grieving, Maladaptive Groom Self (Inability to) Growth and Development Lag Guillain-Barré Syndrome Hallucinations Head Injury Health Behavior, Risk-Prone Health Maintenance Problems Health-Seeking Person Hearing Impairment Heart Attack Heart Failure Heart Surgery Heat Stroke Hematemesis Hemianopia Hemiplegia Hemodialysis Hemodynamic Monitoring Hemolytic Uremic Syndrome Hemophilia Hemoptysis Hemorrhage Hemorrhoidectomy Hemorrhoids Hemothorax Herniated Disk Herniorrhaphy Herpes in Pregnancy Herpes Simplex I Herpes Simplex II Herpes Zoster HHNS (Hyperosmolar Hyperglycemic Nonketotic Syndrome) Hiatal Hernia Hip Fracture Hip Replacement Hirschsprung’s Disease Hitting Behavior HIV (Human Immunodeficiency Virus) Hodgkin’s Disease Homelessness Home Maintenance Problems Hopelessness Hospitalized Child Hostile Behavior HTN (Hypertension) Human Energy Field Humiliating Experience Huntington’s Disease Hydrocephalus Hygiene, Inability to Provide Own Hyperactive Syndrome Hyperbilirubinemia, Neonatal Hypercalcemia Hypercapnia Hyperemesis Gravidarum Hyperglycemia Hyperkalemia Hypernatremia Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) Hyperphosphatemia Hypersensitivity to Slight Criticism Hypertension (HTN) Hyperthermia Hyperthyroidism Hyperventilation Hypocalcemia Hypoglycemia Hypokalemia Hypomagnesemia Hyponatremia Hypoplastic Left Lung Hypotension Hypothermia Hypothyroidism Hypovolemic Shock Hysterectomy IBS (Irritable Bowel Syndrome) ICD (Implantable Cardioverter/Defibrillator) IDDM (Insulin-Dependent Diabetes Mellitus) Identity Disturbance/Problems Idiopathic Thrombocytopenic Purpura (ITP) Ileal Conduit Immigration Transition, Risk for Complicated Immobility Immunization Immunosuppression Impaction of Stool Impaired Sitting Impaired Standing Imperforate Anus Implantable Cardioverter/Defibrillator (ICD) Impulsiveness Inactivity Incompetent Cervix Incontinence of Stool Incontinence of Urine Indigestion Induction of Labor Infant Apnea Infant Behavior Infant Care Infant Feeding Dynamic, Ineffective Infant of Diabetic Mother Infant of Substance-Abusing Mother Infantile Polyarteritis Infection, Potential for Infectious Processes Infertility Inflammatory Bowel Disease (Child and Adult) Inguinal Hernia Repair Insulin Shock Intellectual Disability Intermittent Claudication Internal Cardioverter/Defibrillator (ICD) Internal Fixation Interstitial Cystitis Intervertebral Disk Excision Intestinal Obstruction Intestinal Perforation Intoxication Intraaortic Balloon Counterpulsation Intracranial Pressure, Increased Intrauterine Growth Retardation Intravenous Therapy Intubation, Endotracheal or Nasogastric Iodine Reaction with Diagnostic Testing Irregular Pulse Irritable Bowel Syndrome (IBS) ITP (Idiopathic Thrombocytopenic Purpura) Jaundice, Neonatal Jaw Pain and Heart Attacks Jaw Surgery Joint Dislocation Joint Pain Joint Replacement JRA (Juvenile Rheumatoid Arthritis) Kaposi’s Sarcoma Kawasaki Disease Keratoconjunctivitis Sicca (Dry Eye Syndrome) Keratoplasty Ketoacidosis, Alcoholic Ketoacidosis, Diabetic Keyhole Heart Surgery Kidney Disease Screening Kidney Failure Kidney Failure Acute/Chronic, Child Kidney Failure, Nonoliguric Kidney Stone Kidney Transplant Kidney Transplantation, Donor Kidney Transplantation, Recipient Kidney Tumor Kissing Disease Knee Replacement Knowledge, Deficient Kock Pouch Korsakoff’s Syndrome Labor, Induction of Labor, Normal Labor Pain Labyrinthitis Lacerations Lactic Acidosis Lactose Intolerance Laminectomy Language Impairment Laparoscopic Laser Cholecystectomy Laparoscopy Laparotomy Large Bowel Resection Laryngectomy Laser Surgery LASIK Eye Surgery (Laser-Assisted in Situ Keratomileusis) Latex Allergic Reaction Laxative Abuse Lead Poisoning Left Heart Catheterization Legionnaires’ Disease Lens Implant Lethargy/Listlessness Leukopenia Level of Consciousness, Decreased Lifestyle, Sedentary Lightheadedness Limb Reattachment Procedures Liposuction Lithotripsy Liver Biopsy Liver Cancer Liver Disease Liver Function Liver Transplant Living Will Loneliness Loose Stools (Bowel Movements) Loss of Bladder Control Loss of Bowel Control Lou Gehrig’s Disease Low Back Pain Low Blood Glucose Low Blood Pressure Lower GI Bleeding Lumbar Puncture Lumpectomy Lung Cancer Lung Surgery Lupus Erythematosus Lyme Disease Lymphedema Macular Degeneration Magnetic Resonance Imaging (MRI) Major Depressive Disorder Malabsorption Syndrome Maladaptive Behavior Male Infertility Malignancy Malignant Hypertension (Arteriolar Nephrosclerosis) Malignant Hyperthermia Malnutrition Mammography Manic Disorder, Bipolar I Manipulative Behavior Marfan Syndrome Mastectomy Maternal Infection Maturational Issues, Adolescent Maze III Procedure MD (Muscular Dystrophy) Measles (Rubeola) Meconium Aspiration Meconium Delayed Medical Marijuana Memory Deficit Ménière’s Disease Meningitis/Encephalitis Meningocele Menorrhagia Mental Illness Metabolic Acidosis Metabolic Alkalosis Metabolic Imbalance Syndrome Metastasis Methicillin-Resistant Staphylococcus aureus (MRSA) MI (Myocardial Infarction) MIDCAB (Minimally Invasive Direct Coronary Artery Bypass) Midlife Crisis Migraine Headache Military Families, Personnel Milk Intolerance Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Miscarriage Mitral Stenosis Mitral Valve Prolapse Mobility, Impaired Bed Mobility, Impaired Physical Mobility, Impaired Wheelchair Modified Radical Mastectomy Mononucleosis Mood Disorders Moral/Ethical Dilemmas Morning Sickness Motion Sickness Mottling of Peripheral Skin Mouth Lesions MRI (Magnetic Resonance Imaging) MRSA (Methicillin-Resistant Staphylococcus aureus) MS (Multiple Sclerosis) Mucocutaneous Lymph Node Syndrome Mucous Membrane Integrity, Impaired Oral Multi-Infarct Dementia Multiple Gestations Multiple Personality Disorder (Dissociative Identity Disorder) Multiple Sclerosis (MS) Muscular Atrophy/Weakness Muscular Dystrophy (MD) MVC (Motor Vehicle Crash) Myasthenia Gravis Mycoplasma Pneumonia Myelomeningocele Myocardial Infarction (MI) Myocarditis Myringotomy Narcissistic Personality Disorder Narcolepsy Narcotic Use Nasogastric Suction Near-Drowning Nearsightedness Nearsightedness; Corneal Surgery Neck Vein Distention Necrosis, Kidney Tubular; Necrosis, Acute Tubular Necrotizing Enterocolitis Negative Feelings About Self Neglect, Unilateral Neglectful Care of Family Member Neonatal Abstinence Syndrome Neonatal Hyperbilirubinemia Nephrectomy Nephrostomy, Percutaneous Nephrotic Syndrome Neural Tube Defects (Meningocele, Myelomeningocele, Spina Bifida, Anencephaly) Neuritis (Peripheral Neuropathy) Neurogenic Bladder Neurological Disorders Neuropathy, Peripheral Neurosurgery Newborn, Normal Newborn, Postmature Newborn, Small for Gestational Age (SGA) Nicotine Addiction NIDDM (Non–Insulin-Dependent Diabetes Mellitus) Nightmares Nipple Soreness Nocturnal Myoclonus Nocturnal Paroxysmal Dyspnea Non–Insulin-Dependent Diabetes Mellitus (NIDDM) Normal Pressure Hydrocephalus (NPH) NSTEMI (Non–ST-Elevation Myocardial Infarction) Nutrition, Imbalanced OBS (Organic Brain Syndrome) Obsessive-Compulsive Disorder (OCD) Obstruction, Bowel Obstructive Sleep Apnea OCD (Obsessive-Compulsive Disorder) Occupational Injury ODD (Oppositional Defiant Disorder) Older Adult Omphalocele Oophorectomy OPCAB (Off-Pump Coronary Artery Bypass) Open Heart Surgery Open Reduction of Fracture with Internal Fixation (Femur) Opioid Addiction Opioid Use Opportunistic Infection Oppositional Defiant Disorder (ODD) Oral Mucous Membrane Integrity, Impaired Oral Thrush Organic Mental Disorders Orthopedic Traction Orthostatic Hypotension Osteoarthritis Osteomyelitis Osteoporosis Otitis Media Ovarian Carcinoma Paget’s Disease Pain Management, Acute Pain Management, Chronic Painful Breasts, Engorgement Painful Breasts, Sore Nipples Pallor of Extremities Palpitations (Heart Palpitations) Pancreatic Cancer Pancreatitis Panic Disorder (Panic Attacks) Paralytic Ileus Paranoid Personality Disorder Paraplegia Parathyroidectomy Parent Attachment Parental Role Conflict Parenting, Impaired Parenting, Risk for Impaired Paresthesia Parkinson’s Disease Paroxysmal Nocturnal Dyspnea (PND) Patent Ductus Arteriosus (PDA) Patient-Controlled Analgesia (PCA) Patient Education PCA (Patient-Controlled Analgesia) Pectus Excavatum Pediculosis PEG (Percutaneous Endoscopic Gastrostomy) Pelvic Inflammatory Disease (PID) Penile Prosthesis Peptic Ulcer Percutaneous Transluminal Coronary Angioplasty (PTCA) Pericardial Friction Rub Pericarditis Periodontal Disease Perioperative Hypothermia Perioperative Positioning Peripheral Neuropathy Peripheral Neurovascular Dysfunction Peripheral Vascular Disease (PVD) Peritoneal Dialysis Peritonitis Pernicious Anemia Persistent Fetal Circulation Personal Identity Problems Personality Disorder Pertussis (Whooping Cough) Pesticide Contamination Petit Mal Seizure Pharyngitis Phenylketonuria (PKU) Pheochromocytoma Phobia (Specific) Photosensitivity Physical Abuse PID (Pelvic Inflammatory Disease) PIH (Pregnancy-Induced Hypertension/Preeclampsia) Piloerection Pituitary Tumor, Benign PKU (Phenylketonuria) Placenta Abruptio Placenta Previa Plantar Fasciitis Pleural Effusion Pleural Friction Rub Pleural Tap PMS (Premenstrual Syndrome) PND (Paroxysmal Nocturnal Dyspnea) Pneumonectomy Pneumothorax Poisoning, Risk for Poliomyelitis Polydipsia Polyphagia Postoperative Care Postpartum Depression Postpartum Hemorrhage Postpartum, Normal Care Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Posttraumatic Stress Disorder (PTSD) Potassium, Increase/Decrease Power/Powerlessness Preeclampsia Pregnancy, Cardiac Disorders Pregnancy-Induced Hypertension/Preeclampsia (PIH) Pregnancy Loss Pregnancy, Normal Premature Dilation of the Cervix (Incompetent Cervix) Premature Infant (Child) Premature Infant (Parent) Premature Rupture of Membranes Premenstrual Tension Syndrome (PMS) Prenatal Care, Normal Prenatal Testing Preoperative Teaching Pressure Injury Preterm Labor Problem-Solving Dysfunction Projection Prolapsed Umbilical Cord Prostatic Hypertrophy Prostatitis PTCA (Percutaneous Transluminal Coronary Angioplasty) PTSD (Posttraumatic Stress Disorder) Pulmonary Edema Pulmonary Embolism (PE) Pulmonary Stenosis Pulse Deficit Pulse Oximetry Pulse Pressure, Increased Pulse Pressure, Narrowed Pulses, Absent or Diminished Peripheral Pyelonephritis Pyloric Stenosis Pyloromyotomy (Pyloric Stenosis Repair) RA (Rheumatoid Arthritis) Radial Nerve Dysfunction Radiation Therapy (Radiotherapy) Radical Neck Dissection Rape-Trauma Syndrome Rationalization Rats, Rodents in Home Raynaud’s Disease RDS (Respiratory Distress Syndrome) Rectal Fullness Rectal Lump Rectal Pain/Bleeding Rectal Surgery Rectocele Repair Reflex Incontinence Regression Rehabilitation Relationship Relaxation Techniques Religiosity Religious Concerns Relocation Stress Syndrome Renal Failure Renal Failure Acute/Chronic, Child Renal Failure, Nonoliguric Respiratory Acidosis

Respiratory Conditions of the Neonate (Respiratory Distress Syndrome [RDS], Meconium Aspiration, Diaphragmatic Hernia)

Respiratory Distress Respiratory Distress Syndrome (RDS)

Respiratory Infections, Acute Childhood (Croup, Epiglottitis, Pertussis, Pneumonia, Respiratory Syncytial Virus)

Respiratory Syncytial Virus Restless Leg Syndrome Retinal Detachment Retinopathy, Diabetic Retinopathy of Prematurity (ROP) Rh Factor Incompatibility Rhabdomyolysis Rheumatic Fever Rheumatoid Arthritis (RA) Rib Fracture Ridicule of Others Ringworm of Body Ringworm of Nails Ringworm of Scalp Roaches, Invasion of Home with Role Performance, Altered ROP (Retinopathy of Prematurity) RSV (Respiratory Syncytial Virus) Rubor of Extremities Ruptured Disk SAD (Seasonal Affective Disorder) Safety, Childhood Salmonella Salpingectomy Sarcoidosis SBE (Self–Breast Examination) Schizophrenia Sedentary Lifestyle Seizure Disorders, Adult Seizure Disorders, Childhood (Epilepsy, Febrile Seizures, Infantile Spasms) Self–Breast Examination (SBE) Self-Care Deficit, Bathing Self-Care Deficit, Dressing Self-Care Deficit, Feeding Self-Care Deficit, Toileting Self-Concept Self-Destructive Behavior Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Mutilation Senile Dementia Separation Anxiety Sepsis, Child Septicemia Service Animal Severe Acute Respiratory Syndrome (SARS) Sexual Dysfunction Sexual Harassment Victim Sexuality, Adolescent Sexuality Pattern, Ineffective Sexually Transmitted Disease (STD) Shaken Baby Syndrome Shock, Cardiogenic Shock, Hypovolemic Shock, Septic Shoulder Repair Sickle Cell Anemia/Crisis SIDS (Sudden Infant Death Syndrome) Sitting Problems Situational Crisis SJS (Stevens-Johnson Syndrome) Skin Cancer Skin Disorders Skin Turgor, Change in Elasticity Sleep Apnea Sleep Deprivation Sleep Problems Sleep Pattern, Disturbed, Parent/Child Slurring of Speech Small Bowel Resection Smell, Loss of Ability to Smoke Inhalation Smoking Behavior Social Interaction, Impaired Social Isolation Sociopathic Personality Sodium, Decrease/Increase Somatization Disorder Sore Nipples, Breastfeeding Sore Throat Spastic Colon Speech Disorders Spina Bifida Spinal Cord Injury Spinal Fusion Spiritual Distress Spiritual Well-Being Splenectomy Stable Blood Pressure, Risk for Unstable Standing Problems Stapedectomy Stasis Ulcer STD (Sexually Transmitted Disease) STEMI (ST-Elevation Myocardial Infarction) Stent (Coronary Artery Stent) Sterilization Surgery Stertorous Respirations Stevens-Johnson Syndrome (SJS) Stillbirth Stomatitis Stool, Hard/Dry Straining with Defecation Strep Throat Stress Urinary Incontinence Stuttering Subarachnoid Hemorrhage Substance Misuse Substance Misuse, Adolescent Substance Misuse in Pregnancy Substance Withdrawal Sucking Reflex Sudden Infant Death Syndrome (SIDS) Suffocation, Risk for Suicide Attempt Support System, Inadequate Suppression of Labor Surgery, Perioperative Care Surgery, Postoperative Care Surgery, Preoperative Care Surgical Recovery, Delayed Surgical Site Infection Suspected Child Abuse and Neglect (SCAN), Child Suspected Child Abuse and Neglect (SCAN), Parent Swallowing Difficulties Systemic Lupus Erythematosus T & A (Tonsillectomy and Adenoidectomy) Tachycardia Tardive Dyskinesia Taste Abnormality TB (Pulmonary Tuberculosis) TBI (Traumatic Brain Injury) TD (Traveler’s Diarrhea) Technology Addiction Temperature, Decreased Temperature, High Temperature Regulation, Impaired TEN (Toxic Epidermal Necrolysis) TENS Unit (Transcutaneous Electrical Nerve Stimulation) Terminally Ill Adult Terminally Ill Child, Adolescent Terminally Ill Child, Infant/Toddler Terminally Ill Child, Preschool Child Terminally Ill Child, School-Age Child/Preadolescent Terminally Ill Child/Death of Child, Parent Tetralogy of Fallot Tetraplegia Thermoregulation, Ineffective Thoracentesis Thoracotomy Thought Disorders Thrombocytopenic Purpura Thrombophlebitis Thyroidectomy TIA (Transient Ischemic Attack) Tic Disorder Tinea Capitis Tinea Corporis Tinea Cruris Tinea Pedis Tinea Unguium (Onychomycosis) Tissue Damage, Integumentary Tissue Perfusion, Peripheral Toileting Problems Toilet Training Tonsillectomy and Adenoidectomy (T & A) Total Anomalous Pulmonary Venous Return Total Joint Replacement (Total Hip/Total Knee/Shoulder) Total Parenteral Nutrition (TPN) Tourette’s Syndrome (TS) Toxic Epidermal Necrolysis (TEN) (Erythema Multiforme) TPN (Total Parenteral Nutrition) Tracheoesophageal Fistula Tracheostomy Traction and Casts Transfer Ability Transient Ischemic Attack (TIA) Transposition of Great Vessels Transurethral Resection of the Prostate (TURP) Trauma in Pregnancy Trauma, Physical, Risk for Traumatic Brain Injury (TBI) Traumatic Event Traveler’s Diarrhea (TD) Trembling of Hands Tricuspid Atresia Trigeminal Neuralgia Truncus Arteriosus TS (Tourette’s Syndrome) TSE (Testicular Self-Examination) Tubal Ligation Tube Feeding Tuberculosis (TB) TURP (Transurethral Resection of the Prostate) Ulcer, Peptic (Duodenal or Gastric) Ulcerative Colitis Ulcers, Stasis Unilateral Neglect of One Side of Body Unsanitary Living Conditions Upper Respiratory Infection Urgency to Urinate Urinary Catheter Urinary Diversion Urinary Elimination, Impaired Urinary Incontinence Urinary Retention Urinary Tract Infection (UTI) Urolithiasis Uterine Atony in Labor Uterine Atony in Postpartum Uterine Bleeding UTI (Urinary Tract Infection) VAD (Ventricular Assist Device) Vaginal Hysterectomy Value System Conflict Varicose Veins Vascular Dementia (Formerly Called Multi-Infarct Dementia) Venereal Disease Venous Thromboembolism (VTE) Ventilated Client, Mechanically Ventricular Assist Device (VAD) Ventricular Fibrillation Violent Behavior Viral Gastroenteritis Vision Impairment VTE (Venous Thromboembolism) Walking Impairment Weight Gain Weight Loss Wellness-Seeking Behavior Wernicke-Korsakoff Syndrome West Nile Virus Wheelchair Use Problems Wilms’ Tumor Withdrawal from Alcohol Withdrawal from Drugs Wound Debridement Wound Dehiscence, Evisceration Wound Infection Wounds, Open Section III. Guide to Planning Care Introduction Making an Accurate Nursing Diagnosis Writing Outcomes Statements and Nursing Interventions A. Decreased Activity Tolerance Domain 4 Activity/rest Class 2 Activity/exercise A. Risk for Decreased Activity Tolerance Domain 4 Activity/rest Class 2 activity/exercise A. Ineffective Activity Planning Domain 9 Coping/stress tolerance Class 2 Coping responses A. Risk for Ineffective Activity Planning Domain 9 Coping/stress tolerance Class 2 Coping responses A. Ineffective Airway Clearance Domain 11 Safety/protection Class 2 Physical injury A. Risk for Allergy Reaction Domain 11 Safety/protection Class 5 Defensive processes A. Anxiety Domain 9 Coping/stress tolerance Class 2 Coping responses A. Death Anxiety Domain 9 Coping/stress tolerance Class 2 Coping responses A. Risk for Aspiration Domain 11 Safety/protection Class 2 Physical injury A. Risk for Impaired Attachment Domain 7 Role relationship Class 2 Family relationships A. Autonomic Dysreflexia Domain 9 Coping/stress tolerance Class 3 Neurobehavioral stress A. Risk for Autonomic Dysreflexia Domain 9 Coping/stress tolerance Class 3 Neurobehavioral stress B. Risk for Bleeding Domain 11 Safety/projection Class 2 Physical injury

B. Risk for Unstable Blood Pressure Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

B. Disturbed Body Image Domain 6 Self-perception Class 3 Body image B. Insufficient Breast Milk Production Domain 2 Nutrition Class 1 Ingestion B. Ineffective Breastfeeding Domain 2 Nutrition Class 1 Ingestion B. Interrupted Breastfeeding Domain 2 Nutrition Class 1 Ingestion B. Readiness for Enhanced Breastfeeding Domain 2 Nutrition Class 1 Ingestion B. Ineffective Breathing Pattern Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses C. Decreased Cardiac Output Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

C. Risk for Decreased Cardiac Output Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

C. Risk for Decreased Cardiac Tissue Perfusion Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

C. Risk for Impaired Cardiovascular Function Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

C. Caregiver Role Strain Domain 7 Role relationship Class 1 Caregiving roles C. Risk for Caregiver Role Strain Domain 7 Role relationship Class 1 Caregiving roles

C. Risk for Ineffective Cerebral Tissue Perfusion Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

C. Ineffective Childbearing Process Domain 8 Sexuality Class 3 Reproduction C. Readiness for Enhanced Childbearing Process Domain 8 Sexuality Class 3 Reproduction C. Risk for Ineffective Childbearing Process Domain 8 Sexuality Class 3 Reproduction C. Impaired Comfort Domain 12 Comfort Class 1 Physical comfort C. Readiness for Enhanced Comfort Domain 12 Comfort Class 2 Environmental comfort C. Readiness for Enhanced Communication Domain 5 Perception/cognition Class 5 Communication C. Impaired Verbal Communication Domain 5 Perception/cognition Class 5 Communication C. Acute Confusion Domain 5 Perception/cognition Class 4 Cognition C. Chronic Confusion Domain 5 Perception/cognition Class 4 Cognition C. Risk for Acute Confusion Domain 5 Perception/cognition Class 4 Cognition C. Constipation Domain 3 Elimination and exchange Class 2 Gastrointestinal function C. Risk for Constipation Domain 3 Elimination and exchange Class 2 Gastrointestinal function C. Perceived Constipation Domain 3 Elimination and exchange Class 2 Gastrointestinal function

C. Chronic Functional Constipation Domain 3 Elimination and exchange Class 2 Gastrointestinal function

C. Risk for Chronic Functional Constipation Domain 3 Elimination and exchange Class 2 Gastrointestinal function

C. Contamination Domain 11 Safety/protection Class 4 Environmental hazards C. Risk for Contamination Domain 11 Safety/protection Class 4 Environmental hazards C. Impaired Bowel Continence Domain 3 Elimination and exchange Class 2 Gastrointestinal function

C. Risk for Adverse Reaction to Iodinated Contrast Media Domain 11 Safety/protection Class 5 Defensive processes

C. Readiness for Enhanced Community Coping Domain 9 Coping/stress tolerance Class 2 Coping responses C. Defensive Coping Domain 9 Coping/stress tolerance Class 2 Coping responses C. Ineffective Coping Domain 9 Coping/stress tolerance Class 2 Coping responses C. Readiness for Enhanced Coping Domain 9 Coping/stress tolerance Class 2 Coping responses C. Ineffective Community Coping Domain 9 Coping/stress tolerance Class 2 Coping responses C. Compromised Family Coping Domain 9 Coping/stress tolerance Class 2 Coping responses C. Disabled Family Coping Domain 9 Coping/stress tolerance Class 2 Coping responses C. Readiness for Enhanced Family Coping Domain 9 Coping/stress tolerance Class 2 Coping responses

D. Readiness for Enhanced Decision-Making Domain 10 Life principles Class 3 Value/belief/action congruence

D. Decisional Conflict Domain 10 Life principles Class 3 Value/belief/action congruence D. Risk for Elopement Attempt Domain 1 Health promotion Class 2 Health management

D. Impaired Emancipated Decision-Making Domain 10 Life principles Class 3 Value/belief/action congruence

D. Readiness for Enhanced Emancipated Decision-Making Domain 10 Life principles Class 3 Value/belief/action congruence

D. Risk for Impaired Emancipated Decision-Making Domain 10 Life principles Class 3 Value/belief/action congruence

D. Readiness for Enhanced Exercise Engagement Domain 1 Health promotion Class 2 Health management D. Ineffective Denial Domain 9 Coping/stress tolerance Class 2 Coping responses D. Impaired Dentition Domain 11 Safety/protection Class 2 Physical injury D. Delayed Child Development Domain 13 Growth/development Class 2 Development D. Risk for Delayed Child Development Domain 13 Growth/development Class 2 Development D. Delayed Infant Motor Development Domain 13 Growth/development Class 2 Development D. Risk for Delayed Infant Motor Development Domain 13 Growth/development Class 2 Development D. Diarrhea Domain 3 Elimination and exchange Class 2 Gastrointestinal function D. Risk for Disuse Syndrome Domain 4 Activity/rest Class 2 Activity/exercise D. Decreased Diversional Activity Engagement Domain 1 Health promotion Class 1 Health awareness E. Ineffective Adolescent Eating Dynamics Domain 2 Nutrition Class 1 Ingestion E. Ineffective Child Eating Dynamics Domain 2 Nutrition Class 1 Ingestion E. Risk for Electrolyte Imbalance Domain 2 Nutrition Class 5 Hydration E. Labile Emotional Control Domain 5 Perception/cognition Class 4 Cognition E. Imbalanced Energy Field Domain 4 Activity/rest Class 3 Energy balance E. Ineffective Dry Eye Self-Management Domain 11 Safety/protection Class 2 Physical injury E. Risk for Dry Eye Domain 11 Safety/protection Class 2 Physical injury F. Risk for Adult Falls Domain 11 Safety/protection Class 2 Physical injury F. Risk for Child Falls Domain 11 Safety/protection Class 2 Physical injury E. Dysfunctional Family Processes Domain 7 Role relationship Class 2 Family relationships F. Interrupted Family Processes Domain 7 Role relationship Class 2 Family relationships F. Readiness for Enhanced Family Processes Domain 7 Role relationship Class 2 Family relationships F. Fatigue Domain 4 Activity/rest Class 3 Energy balance F. Fear Domain 9 Coping/stress tolerance Class 2 Coping responses F. Ineffective Infant Feeding Dynamics Domain 2 Nutrition Class 1 Ingestion F. Risk for Female Genital Mutilation Domain 11 Safety/protection Class 3 Violence F. Risk for Imbalanced Fluid Volume Domain 2 Nutrition Class 5 Hydration F. Deficient Fluid Volume Domain 2 Nutrition Class 5 Hydration F. Excess Fluid Volume Domain 2 Nutrition Class 5 Hydration F. Risk for Deficient Fluid Volume Domain 2 Nutrition Class 5 Hydration F. Frail Elderly Syndrome Domain Health promotion Class 2 Health management F. Risk for Frail Elderly Syndrome Domain 1 Health promotion Class 2 Health management G. Impaired Gas Exchange Domain 3 Elimination and exchange Class 4 Respiratory function

G. Risk for Dysfunctional Gastrointestinal Motility Domain 3 Elimination and exchange Class 2 Gastrointestinal function

G. Dysfunctional Gastrointestinal Motility Domain 3 Elimination and exchange Class 2 Gastrointestinal function

G. Risk for Unstable Blood Glucose Level Domain 2 Nutrition Class 4 Metabolism G. Maladaptive Grieving Domain 9 Coping/stress response Class 2 Coping responses G. Risk for Maladaptive Grieving Domain 9 Coping/stress tolerance Class 2 Coping responses G. Readiness for Enhanced Grieving Domain 9 Coping/stress tolerance Class 2 Coping responses H. Deficient Community Health Domain 1 Health promotion Class 2 Health management H. Risk-Prone Health Behavior Domain 1 Health promotion Class 2 Health management H. Ineffective Health Self-Management Domain 1 Health promotion Class 2 Health management H. Readiness for Enhanced Health Self-Management Domain 1 Health promotion Class 2 Health management H. Ineffective Family Health Self-Management Domain 1 Health promotion Class 2 Health management H. Ineffective Health Maintenance Behaviors Domain 1 Health promotion Class 2 Health management H. Ineffective Home Maintenance Behaviors Domain 1 Health promotion Class 2 Health management

H. Readiness for Enhanced Home Maintenance Behaviors Domain 1 Health promotion Class 2 Health management

H. Risk for Ineffective Home Maintenance Behaviors Domain 1 Health promotion Class 2 Health management

H. Readiness for Enhanced Hope Domain 6 Self-perception Class 1 Self-concept H. Hopelessness Domain 6 Self-perception Class 1 Self-concept H. Risk for Compromised Human Dignity Domain 6 Self-perception Class 1 Self-concept H. Neonatal Hyperbilirubinemia Domain 2 Nutrition Class 4 Metabolism H. Risk for Neonatal Hyperbilirubinemia Domain 2 Nutrition Class 4 Metabolism H. Hyperthermia Domain 11 Safety/protection Class 6 Thermoregulation H. Hypothermia Domain 11 Safety/protection Class 6 Thermoregulation H. Risk for Hypothermia Domain 11 Safety/protection Class 6 Thermoregulation H. Neonatal Hypothermia Domain 11 Safety/protection Class 6 Thermoregulation H. Risk for Neonatal Hypothermia Domain 11 Safety/protection Class 6 Thermoregulation H. Risk for Perioperative Hypothermia Domain 11 Safety/protection Class 6 Thermoregulation I. Disturbed Family Identity Syndrome Domain 7 Role relationship Class 2 Family relationships

I. Risk for Disturbed Family Identity Syndrome Domain 7 Role relationship Class 2 Family relationships

I. Disturbed Personal Identity Domain 6 Self-perception Class 1 Self-concept I. Risk for Disturbed Personal Identity Domain 6 Self-perception Class 1 Self-concept

I. Risk for Complicated Immigration Transition Domain 9 Coping/stress tolerance Class 1 Post-trauma responses

I. Ineffective Impulse Control Domain 5 Perception/cognition Class 4 Cognition

I. Disability-Associated Urinary Incontinence Domain 3 Elimination and exchange Class 1 Urinary function

I. Mixed Urinary Incontinence Domain 3 Elimination and exchange Class 1 Urinary function I. Stress Urinary Incontinence Domain 3 Elimination and exchange Class 1 Urinary function I. Urge Urinary Incontinence Domain 3 Elimination and exchange Class 1 Urinary function I. Risk for Urge Urinary Incontinence Domain 3 Elimination and exchange Class 1 Urinary function I. Disorganized Infant Behavior Domain 9 Coping/stress tolerance Class 3 Neurobehavioral stress

I. Readiness for Enhanced Organized Infant Behavior Domain 9 Coping/stress tolerance Class 3 Neurobehavioral stress

I. Risk for Disorganized Infant Behavior Domain 9 Coping/stress tolerance Class 3 Neurobehavioral stress

I. Risk for Infection Domain 11 Safety/protection Class 1 Infection I. Risk for Surgical Site Infection Domain 11 Safety/protection Class 1 Infection I. Risk for Injury Domain 11 Safety/protection Class 2 Physical injury I. Risk for Corneal Injury Domain 11 Safety/protection Class 2 Physical injury I. Risk for Occupational Injury Domain 11 Safety/projection Class 4 Environmental hazards I. Nipple-Areolar Complex Injury Domain 11 Safety/protection Class 2 Physical injury I. Risk for Nipple-Areolar Complex Injury Domain 11 Safety/protection Class 2 Physical injury I. Risk for Urinary Tract Injury Domain 11 Safety/protection Class 2 Physical injury I. Insomnia Domain 4 Activity/rest Class 1 Sleep/rest K. Deficient Knowledge Domain 5 Perception/cognition Class 4 Cognition K. Readiness for Enhanced Knowledge Domain 5 Perception/cognition Class 4 Cognition L. Risk for Latex Allergy Reaction Domain 11 Safety/protection Class 5 Defensive processes L. Readiness for Enhanced Health Literacy Domain 1 Health promotion Class 1 Health awareness L. Risk for Impaired Liver Function Domain 2 Nutrition Class 4 Metabolism L. Risk for Loneliness Domain 12 Comfort Class 3 Social comfort

L. Ineffective Lymphedema Self-Management Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

L. Risk for Ineffective Lymphedema Self-Management Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

M. Risk for Disturbed Maternal–Fetal Dyad Domain 8 Sexuality Class 3 Reproduction M. Impaired Memory Domain 5 Perception/cognition Class 4 Cognition M. Risk for Metabolic Syndrome Domain 2 Nutrition Class 4 Metabolism M. Impaired Bed Mobility Domain 4 Activity/rest Class 2 Activity/exercise M. Impaired Physical Mobility Domain 4 Activity/rest Class 2 Activity/exercise M. Impaired Wheelchair Mobility Domain 4 Activity/rest Class 2 Activity/exercise M. Impaired Mood Regulation Domain 9 Coping/stress tolerance Class 2 Coping response M. Moral Distress Domain 10 Life principles Class 3 Value/belief/action congruence M. Risk for Dry Mouth Domain 11 Safety/protection Class 2 Physical injury N. Nausea Domain 12 Comfort Class 1 Physical comfort N. Neonatal Abstinence Syndrome Domain 9 Coping/stress tolerance Class 3 Neurobehavioral stress N. Readiness for Enhanced Nutrition Domain 2 Nutrition Class 1 Ingestion N. Imbalanced Nutrition Less Than Body Requirements Domain 2 Nutrition Class 1 Ingestion O. Impaired Oral Mucous Membrane Integrity Domain 11 Safety/protection Class 2 Physical injury

O. Risk for Impaired Oral Mucous Membrane Integrity Domain 11 Safety/protection Class 2 Physical injury

O. Obesity Domain 2 Nutrition Class 1 Ingestion O. Overweight Domain 2 Nutrition Class 1 Ingestion P. Risk for Overweight Domain 2 Nutrition Class 1 Ingestion P. Acute Pain Domain 12 Comfort Class 1 Physical comfort P. Chronic Pain Domain 12 Comfort Class 1 Physical comfort P. Chronic Pain Syndrome Domain 12 Comfort Class 1 Physical comfort P. Labor Pain Domain 12 Comfort Class 1 Physical comfort P. Impaired Parenting Domain 7 Role relationship Class 1 Caregiving roles P. Readiness for Enhanced Parenting Domain 7 Role relationship Class 1 Caregiving roles P. Risk for Impaired Parenting Domain 7 Role relationship Class 1 Caregiving roles P. Risk for Perioperative Positioning Injury Domain 11 Safety/protection Class 2 Physical injury P. Risk for Peripheral Neurovascular Dysfunction Domain 11 Safety/projection Class 2 Physical injury 201. Risk for Poisoning Domain 11 Safety/protection Class 4 Environmental hazards 202. Post-Trauma Syndrome Domain 9 Coping/stress tolerance Class 1 Post-trauma responses 203. Risk for Post-Trauma Syndrome Domain 9 Coping/stress tolerance Class 1 Post-trauma responses 204. Readiness for Enhanced Power Domain 9 Coping/stress tolerance Class 2 Coping responses 205. Powerlessness Domain 9 Coping/stress tolerance Class 2 Coping responses 206. Risk for Powerlessness Domain 9 Coping/stress tolerance Class 2 Coping responses 207. Adult Pressure Injury Domain 11 Safety/protection Class 2 Physical injury P. Risk for Adult Pressure Injury Domain 11 Safety/protection Class 2 Physical injury P. Child Pressure Injury Domain 11 Safety/protection Class 2 Physical injury P. Risk for Child Pressure Injury Domain 11 Safety/protection Class 2 Physical injury P. Neonatal Pressure Injury Domain 11 Safety/protection Class 2 Physical injury P. Risk for Neonatal Pressure Injury Domain 11 Safety/protection Class 2 Physical injury P. Ineffective Protection Domain 1 Health promotion Class 2 Health management R. Rape-Trauma Syndrome Domain 9 Coping/stress tolerance Class 1 Post-trauma responses R. Ineffective Relationship Domain 7 Role relationship Class 3 Role performance R. Readiness for Enhanced Relationship Domain 7 Role relationship Class 3 Role performance R. Risk for Ineffective Relationship Domain 7 Role relationship Class 3 Role performance R. Impaired Religiosity Domain 10 Life Principles Class 3 Value/belief/action congruence

R. Readiness for Enhanced Religiosity Domain 10 Life principles Class 3 Value/belief/action congruence

R. Risk for Impaired Religiosity Domain 10 Life principles Class 3 Value/belief/action congruence R. Relocation Stress Syndrome Domain 9 Coping/stress tolerance Class 1 Post-trauma responses

R. Risk for Relocation Stress Syndrome Domain 9 Coping/stress tolerance Class 1 Post-trauma responses

R. Impaired Resilience Domain 9 Coping/stress tolerance Class 2 Coping responses R. Readiness for Enhanced Resilience Domain 9 Coping/stress tolerance Class 2 Coping responses R. Risk for Impaired Resilience Domain 9 Coping/stress tolerance Class 2 Coping responses R. Parental Role Conflict Domain 7 Role relationship Class 3 Role performance R. Ineffective Role Performance Domain 7 Role relationship Class 3 Role performance S. Sedentary Lifestyle Domain 1 Health promotion Class 1 Health awareness S. Readiness for Enhanced Self-Care Domain 4 Activity/rest Class 5 Self-care S. Bathing Self-Care Deficit Domain 4 Activity/rest Class 5 Self-care S. Dressing Self-Care Deficit Domain 4 Activity/Rest Class 5 Self-Care S. Feeding Self-Care Deficit Domain 4 Activity/rest Class 5 Self-care S. Toileting Self-Care Deficit Domain 4 Activity/rest Class 5 Self-care S. Readiness for Enhanced Self-Concept Domain 6 Self-perception Class 1 Self-concept S. Chronic Low Self-Esteem Domain 6 Self-perception Class 2 Self-esteem S. Situational Low Self-Esteem Domain 6 Self-perception Class 2 Self-esteem S. Risk for Chronic Low Self-Esteem Domain 6 Self-perception Class 2 Self-esteem S. Risk for Situational Low Self-Esteem Domain 6 Self-perception Class 2 Self-esteem S. Risk for Self-Mutilation Domain 11 Safety/protection Class 3 Violence S. Self-Mutilation Domain 11 Safety/protection Class 3 Violence S. Self-Neglect Domain 4 Activity/rest Class 5 Self-care S. Sexual Dysfunction Domain 8 Sexuality Class 2 Sexual function S. Ineffective Sexuality Pattern Domain 8 Sexuality Class 2 Sexual function S. Risk for Shock Domain 11 Safety/protection Class 2 Physical injury S. Impaired Sitting Domain 4 Activity/rest Class 2 Activity/exercise R. Impaired Skin Integrity Domain 11 Safety/protection Class 2 Physical injury S. Risk for Impaired Skin Integrity Domain 11 Safety/protection Class 2 Physical injury S. Sleep Deprivation Domain 4 Activity/rest Class 1 Sleep/rest R. Readiness for Enhanced Sleep Domain 4 Activity/rest Class 1 Sleep/rest S. Disturbed Sleep Pattern Domain 4 Activity/rest Class 1 Sleep/rest R. Impaired Social Interaction Domain 7 Role relationship Class 3 Role performance S. Social Isolation Domain 12 Comfort Class 3 Social comfort S. Chronic Sorrow Domain 9 Coping/stress tolerance Class 2 Coping responses S. Spiritual Distress Domain 10 Life principles Class 3 Value/belief/action congruence S. Risk for Spiritual Distress Domain 10 Life principles Class 3 Value/belief/action congruence R. Readiness for Enhanced Spiritual Well-Being Domain 10 Life Principles Class 2 Beliefs S. Impaired Standing Domain 4 Activity/rest Class 2 Activity/exercise S. Stress Overload Domain 9 Coping/stress tolerance Class 2 Coping responses

S. Acute Substance Withdrawal Syndrome Domain 9 Coping/stress tolerance Class 3 Neurobehavioral stress

S. Risk for Acute Substance Withdrawal Syndrome Domain 9 Coping/stress tolerance Class 3 Neurobehavioral stress

S. Ineffective Infant Suck-Swallow Response Domain 2 Nutrition Class 1 Ingestion T. Risk for Sudden Infant Death Domain 11 Safety/protection Class 2 Physical injury S. Risk for Suffocation Domain 11 Safety/protection Class 2 Physical injury S. Risk for Suicidal Behavior Domain 11 Safety/protection Class 3 Violence S. Delayed Surgical Recovery Domain 11 Safety/protection Class 2 Physical injury T. Risk for Delayed Surgical Recovery Domain 11 Safety/protection Class 2 Physical injury S. Impaired Swallowing Domain 2 Nutrition Class 1 Ingestion T. Risk for Thermal Injury Domain 11 Safety/protection Class 2 Physical injury T. Ineffective Thermoregulation Domain 11 Safety/protection Class 6 Thermoregulation T. Risk for Ineffective Thermoregulation Domain 11 Safety/protection Class 6 Thermoregulation T. Risk for Thrombosis Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses T. Disturbed Thought Process Domain 5 Perception/cognition Class 4 Cognition T. Impaired Tissue Integrity Domain 11 Safety/protection Class 2 Physical injury T. Risk for Impaired Tissue Integrity Domain 11 Safety/protection Class 2 Physical injury

T. Ineffective Peripheral Tissue Perfusion Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

T. Risk for Ineffective Peripheral Tissue Perfusion Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

T. Impaired Transfer Ability Domain 4 Activity/rest Class 2 Activity/exercise T. Risk for Physical Trauma Domain 11 Safety/protection Class 2 Physical injury U. Unilateral Neglect Domain 5 Perception/cognition Class 1 Attention U. Impaired Urinary Elimination Domain 3 Elimination and exchange Class 1 Urinary function U. Urinary Retention Domain 3 Elimination and exchange Class 1 Urinary function V. Risk for Urinary Retention Domain 3 Elimination and exchange Class 1 Urinary function V. Risk for Vascular Trauma Domain 11 Safety/projection Class 2 Physical injury

V. Impaired Spontaneous Ventilation Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

V. Dysfunctional Adult Ventilatory Weaning Response Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

V. Dysfunctional Ventilatory Weaning Response Domain 4 Activity/rest Class 4 Cardiovascular/pulmonary responses

V. Risk for Other-Directed Violence Domain 11 Safety/protection Class 3 Violence V. Risk for Self-Directed Violence Domain 11 Safety/protection Class 3 Violence W. Impaired Walking Domain 4 Activity/rest Class 2 Activity/exercise W. Wandering Domain 4 Activity/rest Class 3 Energy balance Product details No. of pages : 1088 Language : English Edition : 13 Published : April 14, 2022 Imprint : Mosby Paperback ISBN : 9780323776837 eBook ISBN : 9780323811170 About the editors

Mary Beth Flynn Makic

Mary Beth Flynn Makic has more than 30 years of critical care experience in research, evidence-based practice, and clinical education. She is a Professor at the University of Colorado College of Nursing and Program Director for the Adult-Gerontology Clinical Nurse Specialist graduate program. She is also a Research Scientist at a Level I trauma center in Denver, Colorado. Dr. Makic achieved her BSN from the University of Wisconsin in Madison, Wisconsin. She completed her Masters of Science at the University of Maryland at Baltimore with a focus on trauma patient populations and the advanced practice role of a Clinical Nurse Specialist. Her PhD was conferred in 2007 by the University of Colorado Health Sciences Center in Denver, Colorado. She is active locally and nationally in several professional organizations. She recently served on the Board of Directors for the American Association of Critical-Care Nurses. She also serves on the editorial board of several critical care journals, has published extensively in peer-reviewed journals, and is a successor co-author of two Elsevier books on nursing diagnosis. Dr. Makic is well known for her passion for improving patient outcomes and nursing practice through evidence-based practice.

Affiliations and expertise

Professor, University of Colorado College of Nursing, Aurora, Colorado; Nurse Scientist, Denver Health, Denver, Colorado