Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales 15th Edition

Book Preface

This book is dedicated to:

Our families, who helped with the mundane activities of daily living that allowed us to write this book and who provide us with love and encouragement in all our endeavors. Our friends, who support us in our writing, put up with our memory lapses, and love us still.

Bob Martone, former Publisher, Nursing, who germinated the idea for this project so long ago. Jacalyn Sharp and Amy Romano, who have taken on the challenge of providing direct support and keeping us focused. Robert Allen, who has guided us through the XML maze since the book went high tech and is a lifeline we greatly appreciate. The F. A. Davis production staff, who coordinated and expedited the project through the editing and printing processes, meeting unreal deadlines, and sending pages to us with bated breath.

Robert H. Craven, Jr., and the F. A. Davis family.

And last and most important:
The nurses we are writing for, to those who have found the previous editions of the Pocket Guide helpful, and to other nurses who are looking for help to provide quality nursing care in a period of transition and change, we say, “Nursing Diagnosis is the way.”

The American Nurses Association (ANA) Social Policy Statement of 1980 was the fi rst to defi ne nursing as the diagnosis and treatment of human responses to actual and potential health problems. This defi nition, when combined with the ANA Standards of Practice , provided impetus and support for the use of nursing diagnosis. Defi ning nursing and its effect on client care supports the growing awareness that nursing care is a key factor in client survival and in the maintenance, rehabilitative, and preventive aspects of healthcare. Changes and new developments in healthcare delivery in the past 40 years have given rise to the need for a common framework of communication to ensure continuity of care for the client moving between multiple healthcare settings and providers. Evaluation and documentation of care are important parts of this process.

This book is designed to aid the practitioner and student nurse in identifying interventions commonly associated with specific nursing diagnoses as proposed by NANDA International (NANDA-I). These interventions are the activities needed to implement and document care provided to the individual client and can be used in varied settings from acute to community/ home care.

Chapter 1 presents a brief discussion of the nursing process, data collection, and care plan construction. Appendix 1 contains tools for choosing nursing diagnoses—an Adult Assessment Tool and the Diagnostic Divisions list. Appendix 2 puts theory into practice with a sample assessment database and a corresponding plan of care. A mind or concept map is also provided.

For more in-depth information and inclusive plans of care related to specifi c medical or psychiatric conditions and maternal/newborn care (with rationale and the application of the diagnoses), the nurse is referred to the larger work, published by the F. A. Davis Company: Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span , ed. 10 (Doenges, Moorhouse, & Murr, 2019), including access to psychiatric and maternal/newborn plans of care. For nursing diagnoses and interventions with evidence-based citations, refer to the more in-depth work published by the F. A. Davis Company: Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care , ed. 6 (Doenges, Moorhouse, & Murr, 2019).

Nursing diagnoses are listed alphabetically in Chapter 2 for ease of reference and include the diagnoses accepted for use by NANDA-I through 2018–2020. Each diagnosis approved for testing includes its defi nition and information divided into the NANDA-I categories of Related or Risk Factors and Defining Characteristics. Related/Risk Factors information refl ects causative or contributing factors that can be useful for determining whether the diagnosis is applicable to a particular client. Defi ning Characteristics (signs and symptoms or cues) are listed as subjective and/or objective and are used to confi rm problemfocused diagnoses or readiness for enhanced diagnoses, aid in formulating outcomes, and provide additional data for choosing appropriate interventions. The authors have not deleted or altered NANDA-I’s listings; however, on occasion, they have added to their definitions or suggested additional criteria to provide clarifi cation and direction. These additions are denoted with brackets [ ].

The ANA, in conjunction with NANDA-I, proposed that specific nursing diagnoses currently approved and structured according to Taxonomy I Revised be included in the International Classifi cation of Diseases ( ICD ) within the section “Family of Health-Related Classifi cations.” Although the World Health Organization did not accept this initial proposal because of lack of documentation of the usefulness of nursing diagnoses at the international level, the NANDA-I list has been accepted by SNOMED (Systemized Nomenclature of Medicine) for inclusion in its international coding system and is included in the Unifi ed Medical Language System of the National Library of Medicine. Today, nurse researchers from around the world have submitted new nursing diagnoses and are validating current diagnoses in support for resubmission and acceptance of the NANDA-I list in future editions of the ICD .

The authors have chosen to categorize the list of nursing diagnoses approved for clinical use and testing into Diagnostic Divisions, which is the framework for an assessment tool (Appendix 1) designed to assist the nurse to readily identify an appropriate nursing diagnosis from data collected during the assessment process. The Diagnostic Division label is listed under each nursing diagnosis heading. Desired Outcomes/Evaluation Criteria are identified to assist the nurse in formulating individual client outcomes and to support the evaluation process.

Interventions in this pocket guide are primarily directed to adult care settings (although general age-span considerations are included) and are listed according to nursing priorities. Some interventions require collaborative or interdependent orders (e.g., medical, psychiatric), and the nurse will need to determine when this is necessary and take appropriate action. The inclusion of Documentation Focus suggestions is to  remind the nurse of the importance and necessity of recording the steps of the nursing process.

Finally, in recognition of the ongoing work of numerous researchers over the past 35 years, the authors have referenced
the Nursing Interventions and Outcomes labels developed by the Iowa Intervention Projects (Bulechek, Butcher, & Dochterman; Moorhead, Johnson, Mass, & Swanson). These groups have been classifying nursing interventions and outcomes to predict resource requirements and measure outcomes, thereby meeting the needs of a standardized language that can be coded for computer and reimbursement purposes. As an introduction to this work in progress, sample NIC and NOC labels have been included under the heading Sample Nursing Interventions & Outcomes Classifi cations at the conclusion of each nursing diagnosis section. The reader is referred to the various publications by Joanne C. Dochterman and Marion Johnson for more in-depth information.

Chapter 3 presents 460 disorders/health conditions reflecting all specialty areas, with associated nursing diagnoses written as client diagnostic statements that include the “related to” and “evidenced by” components as appropriate. This section will facilitate and help validate the assessment and problem or need identification steps of the nursing process. As noted, with few exceptions, we have presented NANDA-I’s recommendations as formulated. We support the belief that practicing nurses and researchers need to study, use, and evaluate the diagnoses as presented. Nurses can be creative as they use the standardized language, redefining and sharing information as the diagnoses are used with individual clients. As new nursing diagnoses are developed, it is important that the data they encompass are added to assessment tools and current databases. As part of the process by clinicians, educators, and researchers across practice specialties and academic settings to define, test, and refine nursing diagnosis, nurses are encouraged to share insights and ideas with NANDA-I online at http://www.nanda.org or at the following address: NANDA International, PO Box 157, Kaukauna, WI 54130–0157.