rencana keperawatan untuk merawat dan menolong nyawa pasien (In_English).

1. Copyright © 2006 by F. A. Davis.

2. Copyright © 2006 by F. A. Davis.
INDEX OF DISEASES/DISORDERS
AIDS, 726 Heart failure: chronic, 47 Pneumonia, 128
Alcohol: acute withdrawal, 831 Hemodialysis, 581 Primary base bicarbonate deficiency, 492
Alzheimer’s disease, 945 Hemolytic anemia, 499 Primary base bicarbonate excess, 495
Amputation, 657 Hepatitis, 443 Primary carbonic acid deficit, 198
Anemias (iron deficiency, pernicious, Herniated nucleus pulposus (ruptured Primary carbonic acid excess, 194
aplastic, hemolytic), 499 intervertebral disc), 252 Prostatectomy, 604
Angina (coronary artery disease), 62 HIV-positive client, 712 Psychosocial aspects of care, 770
Anorexia nervosa, 376 Hospice care, 880 Pulmonary embolus, 108
Aplastic anemia, 499 Hypercalcemia (calcium excess), 938 Pulmonary tuberculosis, 184
Appendectomy, 350 Hyperkalemia (potassium excess), 933
Asthma, 117 Hypermagnesemia (magnesium excess), 943 Radical neck surgery: laryngectomy
Hypernatremia (sodium excess), 928 (postoperative care), 157
Benign prostatic hyperplasia, 596 Hypertension: severe, 35 Regional enteritis, 324
Bulimia nervosa, 376 Hyperthyroidism (thyrotoxicosis, Graves’ Renal calculi, 613
Burns: thermal/chemical/electrical (acute disease), 426 Renal dialysis, 564
and convalescent phases), 680 Hypervolemia (extracellular fluid volume Renal dialysis: peritoneal, 575
excess), 919 Renal failure: acute, 541
Cancer, 857 Hypocalcemia (calcium deficit), 936 Renal failure: chronic, 553
Cardiac surgery: postoperative care, 96 Hypokalemia (potassium deficit), 931 Respiratory acid-base imbalances, 194
Cardiomyoplasty, 96 Hypomagnesemia (magnesium deficit), 941 Respiratory acidosis (primary carbonic acid
Cerebrovascular accident/stroke, 236 Hyponatremia (sodium deficit), 925 excess), 194
Chemical burns, 680 Hypovolemia (extracellular fluid volume Respiratory alkalosis (primary carbonic acid
Cholecystectomy, 371 deficit), 922 deficit), 194
Cholecystitis with cholelithiasis, 364 Hysterectomy, 621 Rheumatoid arthritis, 750
Cholelithiasis, 364 Ruptured intervertebral disc, 252
Chronic obstructive pulmonary disease, 117 Ileocolitis, 324
Cirrhosis of liver, 453 Ileostomy, 338 Seizure disorders, 208
Colostomy, 338 Inflammatory bowel disease: ulcerative Sepsis/septicemia, 701
Coronary artery bypass graft, 96 colitis, regional enteritis (Crohn’s disease, Septicemia, 701
Coronary artery disease, 62 ileocolitis), 324 Sickle cell crisis, 509
Craniocerebral trauma (acute rehabilitative Iron deficiency anemia, 499 Spinal cord injury (acute rehabilitative
phase), 218 phase), 271
Crohn’s disease, 324 Laryngectomy (postoperative care), 157 Stroke, 236
Leukemias, 523 Substance dependence/abuse rehabilitation,
Deep vein thrombosis, 108 Lung cancer (postoperative care), 141 843
Diabetes mellitus/diabetic ketoacidosis, 412 Lymphomas, 532 Subtotal gastrectomy/gastric resection, 320
Diabetic ketoacidosis, 412 Surgical interventions, 788
Disaster considerations, 890 Mastectomy, 630
Disc surgery, 260 Metabolic acid-base imbalances, 491 Thermal burns, 680
Dysrhythmias (including digitalis toxicity), Metabolic acidosis (primary base Thrombophlebitis: deep vein thrombosis
85 bicarbonate deficit), 492 (including pulmonary emboli
Metabolic alkalosis (primary base considerations), 108
Eating disorders: anorexia nervosa/bulimia bicarbonate excess), 495 Thyroidectomy, 437
nervosa, 376 Minimally invasive direct coronary artery Thyrotoxicosis, 426
Eating disorders: obesity, 393 bypass, 96 Total joint replacement, 667
Electrical burns, 680 Multiple sclerosis, 291 Total nutritional support: parenteral/enteral
End of life/hospice care, 880 Myocardial infarction, 72 feeding, 478
Enteral feeding, 478 Transplantation (postoperative and
Esophageal bleeding, 309 Neurological/sensory disorders, 202 lifelong), 761
Extended care, 810
Obesity, 393 Ulcerative colitis, 324
Fecal diversions: postoperative care of Obesity: surgical interventions (gastric Upper gastrointestinal/esophageal
ileostomy and colostomy, 338 partitioning/gastroplasty, gastric bleeding, 309
Fluid and electrolyte imbalances, 919 bypass), 402 Urinary diversions/urostomy
Fluid balance, 919 (postoperative care), 585
Fractures, 642 Pancreatitis, 467 Urolithiasis (renal calculi), 613
Parenteral feeding, 478 Urostomy, 585
Gastric bypass, 402 Pediatric considerations, 905
Gastric partitioning, 402 Peritonitis, 355 Valve replacement, 96
Gastroplasty, 402 Pernicious anemia, 499 Ventilatory assistance (mechanical), 170
Glaucoma, 202
Graves’ disease, 426

3. Copyright © 2006 by F. A. Davis.
KEY TO ESSENTIAL TERMINOLOGY
CLIENT ASSESSMENT DATABASE
Provides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical/sur-
gical diagnosis as well as the signs/symptoms and corresponding diagnostic findings.
NURSING PRIORITIES
Establishes a general ranking of needs/concerns on which the Nursing Diagnoses are ordered in constructing the plan of care.
This ranking would be altered according to the individual client situation.
DISCHARGE GOALS
Identifies generalized statements that could be developed into short-term and intermediate goals to be achieved by the client
before being “discharged” from nursing care. They may also provide guidance for creating long-term goals for the client to
work on after discharge.
NURSING DIAGNOSIS
The general problem/need (diagnosis) is stated without the distinct cause and signs/symptoms, which would be added to cre-
ate a client diagnostic statement when specific client information is available. For example, when a client displays increased
tension, apprehension, quivering voice, and focus on self, the nursing diagnosis of Anxiety might be stated: severe Anxiety, re-
lated to unconscious conflict, threat to self-concept as evidenced by statements of increased tension, apprehension; observa-
tions of quivering voice, focus on self.
In addition, diagnoses identified within these guides for planning care as actual or risk can be changed or deleted and new
diagnoses added, depending entirely on the specific client information.
MAY BE RELATED TO/POSSIBLY EVIDENCED BY
These lists provide the usual/common reasons (etiology) why a particular problem may occur with probable signs/symptoms,
which would be used to create the “related to” and “evidenced by” portions of the client diagnostic statement when the specific
situation is known.
When a risk diagnosis has been identified, signs/symptoms have not yet developed and therefore are not included in the
nursing diagnosis statement. However, interventions are provided to prevent progression to an actual problem. The exception
to this occurs in the nursing diagnosis risk for Violence, which has possible indicators that reflect the client’s risk status.
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL
These give direction to client care as they identify what the client or nurse hopes to achieve. They are stated in general terms
to permit the practitioner to modify/individualize them by adding time lines and individual client criteria so they become
“measurable.” For example, “Client will appear relaxed and report anxiety is reduced to a manageable level within 24 hours.”
Nursing Outcomes Classification (NOC) labels are also included. The outcome label is selected from a standardized nurs-
ing language and serves as a general header for the outcome indicators that follow.
ACTIONS/INTERVENTIONS
NIC (Nursing Interventions Classification) intervention labels are drawn from a standardized nursing language and serve as
a general header for the nursing actions that follow.
Nursing actions are divided into independent (those actions that the nurse performs autonomously) and collaborative
(those actions that the nurse performs in conjunction with others, such as implementing physician orders) and are ranked in
this book from most to least common. When creating the individual plan of care, interventions would normally be ranked to
reflect the client’s specific needs/situation. In addition, the division of independent/collaborative is arbitrary and is actually
dependent on the individual nurse’s capabilities and hospital/community standards.
RATIONALE
Although not commonly appearing in client plans of care, rationale has been included here to provide a pathophysiologic ba-
sis to assist the nurse in deciding about the relevance of a specific intervention for an individual client situation.
CLINICAL PATHWAY
This abbreviated plan of care or care map is event (task) oriented and provides outcome-based guidelines for goal achievement
within a designated length of stay. Several samples have been included to demonstrate alternative planning formats.

4. Copyright © 2006 by F. A. Davis.
NURSING DIAGNOSES ACCEPTED FOR
USE AND RESEARCH THROUGH 2006
Activity Intolerance [specify level] Gas Exchange, impaired Role Performance, ineffective
Activity Intolerance, risk for Grieving, anticipatory Self-Care Deficit: bathing/hygiene
Adjustment, impaired Grieving, dysfunctional Self-Care Deficit: dressing/grooming
Airway Clearance, ineffective Grieving, risk for dysfunctional Self-Care Deficit: feeding
Allergy Response, latex Growth & Development, delayed Self-Care Deficit: toileting
Allergy response, risk for latex Growth, risk for disproportionate Self-Concept, readiness for enhanced
Anxiety [specify level] Health Maintenance, ineffective Self-Esteem, chronic low
Anxiety, death Health-Seeking Behaviors (specify) Self-Esteem, situational low
Aspiration, risk for Home Maintenance, impaired Self-Esteem, risk for situational low
Attachment, risk for impaired Hopelessness Self-Mutilation
parent/infant/child Hyperthermia Self-Mutilation, risk for
Autonomic Dysreflexia Hypothermia Sensory Perception, disturbed: (specify: visual,
Autonomic Dysreflexia, risk for Identity, disturbed personal auditory, kinesthetic, gustatory, tactile,
Body Image, disturbed Infant Behavior, disorganized olfactory)
Body Temperature, risk for imbalanced Infant Behavior, readiness for enhanced Sexual Dysfunction
Bowel Incontinence organized Sexuality Pattern, ineffective
Breastfeeding, effective Infant Behavior, risk for disorganized Skin Integrity, impaired
Breastfeeding, ineffective Infant Feeding Pattern, ineffective Skin Integrity, risk for impaired
Breastfeeding, interrupted Infection, risk for Sleep Deprivation
Breathing Pattern, ineffective Injury, risk for Sleep, readiness for enhanced
Cardiac Output, decreased Injury, risk for perioperative positioning Sleep Pattern, disturbed
Caregiver Role Strain Intracranial Adaptive Capacity, decreased Social Interaction, impaired
Caregiver Role Strain, risk for Knowledge, deficient [Learning Need] Social Isolation
Communication, impaired verbal [specify] Sorrow, chronic
Communication, readiness for enhanced Knowledge [specify], readiness for enhanced Spiritual Distress
Conflict, decisional (specify) Lifestyle, sedentary Spiritual Distress, risk for
Conflict, parental role Loneliness, risk for Spiritual Well-Being, readiness for enhanced
Confusion, acute Memory, impaired Suffocation, risk for
Confusion, chronic Mobility, impaired bed Suicide, risk for
Constipation Mobility, impaired physical Surgical Recovery, delayed
Constipation, perceived Mobility, impaired wheelchair Swallowing, impaired
Constipation, risk for Nausea Therapeutic Regimen Management, effective
Coping, defensive Neglect, unilateral Therapeutic Regimen Management, ineffective
Coping, ineffective Noncompliance, [Adherence, ineffective] Therapeutic Regimen Management, ineffective
Coping, readiness for enhanced [specify] community
Coping, ineffective community Nutrition: less than body requirements, Therapeutic Regimen Management, ineffective
Coping, readiness for enhanced community imbalanced family
Coping, compromised family Nutrition: more than body requirements, Therapeutic Regimen Management, readiness
Coping, disabled family imbalanced for enhanced
Coping, readiness for enhanced family Nutrition, readiness for enhanced Thermoregulation, ineffective
Death syndrome, risk for sudden infant Nutrition: more than body requirements, Thought Processes, disturbed
Denial, ineffective risk for imbalanced Tissue Integrity, impaired
Dentition, impaired Oral Mucous Membrane, impaired Tissue Perfusion, ineffective (specify type:
Development, risk for delayed Pain, acute cerebral, cardiopulmonary, renal,
Diarrhea Pain, chronic gastrointestinal, peripheral)
Disuse Syndrome, risk for Parenting, impaired Transfer Ability, impaired
Diversional Activity, deficient Parenting, readiness for enhanced Trauma, risk for
Energy Field disturbed Parenting, risk for impaired Urinary Elimination, impaired
Environmental Interpretation Syndrome, Peripheral Neurovascular Dysfunction, risk for Urinary Elimination, readiness for enhanced
impaired Poisoning, risk for Urinary Incontinence, functional
Failure to Thrive, adult Post-Trauma Syndrome [specify stage] Urinary Incontinence, reflex
Falls, risk for Post-Trauma Syndrome, risk for Urinary Incontinence, stress
Family Processes: alcoholism, dysfunctional Powerlessness [specify level] Urinary Incontinence, total
Family Processes, interrupted Powerlessness, risk for Urinary Incontinence, urge
Family Processes, readiness for enhanced Protection, ineffective Urinary Incontinence, risk for urge
Fatigue Rape-Trauma Syndrome Urinary Retention [acute/chronic]
Fear Rape-Trauma Syndrome: compound reaction Ventilation, impaired spontaneous
Fluid Balance, readiness for enhanced Rape-Trauma Syndrome: silent reaction Ventilatory Weaning Response, dysfunctional
[Fluid Volume, deficient hyper/hypotonic] Religiosity, impaired Violence, [actual/] risk for other-directed
Fluid Volume, deficient [isotonic] Religiosity, risk for impaired Violence, [actual/] risk for self-directed
Fluid Volume, excess Religiosity, readiness for enhanced Walking, impaired
Fluid Volume, risk for deficient Relocation Stress Syndrome Wandering [specify sporadic or continual]
Fluid Volume risk for imbalanced Relocation Stress Syndrome, risk for [ ] author recommendations
Used with permission from NANDA International: Definitions and Classification, 2005–-2006. NANDA, Philadelphia, 2005.

5. Copyright © 2006 by F. A. Davis.
NURSING CARE PLANS
GUIDELINES FOR INDIVIDUALIZING
CLIENT CARE ACROSS THE LIFE SPAN
EDITION 7
Marilynn E. Doenges, APRN, BC-Retired
Clinical Specialist, Adult Psychiatric/Mental Health Nursing, Retired
Adjunct Faculty
Beth-El College of Nursing and Health Sciences, UCCS
Colorado Springs, Colorado
Mary Frances Moorhouse, RN, MSN, CRRN, LNC
Adjunct Faculty/Clinical Instructor
Pikes Peak Community College
Nurse Consultant/TNT-RN Enterprises
Colorado Springs, Colorado
Alice C. Murr, RN, BSN, LNC
Legal Nurse Consultant
Telephone Triage Nurse
Jackson, Mississippi
F. A. DAVIS COMPANY • Philadelphia