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Sparks and Taylor's Nursing Diagnosis Pocket Guide LWBK392-FM_i-xxiv.qxd 11/17/09 8:20 PM Page i Aptara Inc SPARKS AND TAYLOR’S Nursing Diagnosis Pocket Guide Sheila Sparks Ralph, RN, PhD, FAAN Professor, Division of Nursing Shenandoah University Winchester, VA Member of NANDA-I Foundation Philadelphia Cynthia M. Taylor, RN, MS Nurse Consultant Coordinator, Parish Nurse Program St. Michael’s Church Kailua Kona, HI LWBK392-FM_i-xxiv.qxd 11/17/09 8:20 PM Page ii Aptara Inc Acquisitions Editor: Jean Rodenberger Development Editor: Helene T. Caprari Marketing Manager: Laura Meiskey Director of Nursing Production: Helen Ewan Art Director, Design: Joan Wendt Manufacturing Coordinator: Karin Duffield Production Services: Aptara, Inc. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please con- tact Lippincott Williams & Wilkins at 530 Walnut Street, Philadelphia, PA 19106, via e-mail at [email protected], or via Web site at lww.com (products and services). 987654321 Printed in China Library of Congress Cataloging-in-Publication Data Ralph, Sheila Sparks. Sparks and Taylor’s nursing diagnosis pocket guide / Sheila Sparks Ralph, Cynthia M. Taylor. p. ; cm. Includes bibliographical references. ISBN 978-1-58255-733-5 1. Nursing diagnosis—Handbooks, manuals, etc. I. Taylor, Cynthia M. II. Title. III. Title: Nursing diagnosis pocket guide. [DNLM: 1. Nursing Diagnosis—methods—Handbooks. WY 49 R163sa 2011] RT48.6.R35 2011 616.07'5—dc22 2009028540 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current rec- ommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the healthcare provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice. LWW.COM LWBK392-FM_i-xxiv.qxd 11/17/09 8:20 PM Page iii Aptara Inc CONTRIBUTORS Marcia Perkins, MSN, RN Adjunct Clinical Instructor, Division of Nursing Shenandoah University Winchester, VA Helen H. Mautner, MSN, RN Assistant Professor, Division of Nursing Shenandoah University Winchester, VA Anne Z. Cockerham, PhD, CNM Course Coordinator Frontier School of Midwifery and Family Nursing Hyden, KY Jennifer Matthews, PhD, RN Associate Professor, Division of Nursing Shenandoah University Winchester, VA Billinda Tebbenhoff, MSN, RN Adjunct Clinical Instructor, Division of Nursing Shenandoah University Winchester, VA Sherry Rawls-Bryce, MSN, RN Adjunct Assistant Professor, Division of Nursing Shenandoah University Winchester, VA Maryann Valcourt, MSN, CPNP Assistant Professor Trinity University Washington, DC iii LWBK392-FM_i-xxiv.qxd 11/17/09 8:20 PM Page iv Aptara Inc LWBK392-FM_i-xxiv.qxd 11/17/09 8:20 PM Page v Aptara Inc PREFACE For student nurses as well as expert clinicians, Sparks and Taylor’s Nursing Diagnosis Pocket Guide offers a clearly written, authoritative care plan for each of the NANDA International (NANDA-I) approved nursing diagnoses to help meet patients’ healthcare needs. The guide is organized using a unique assessment framework based on the NNN Taxonomy of Nursing Practice: A Common Unifying Structure for Nursing Language (Dochterman & Jones, 2003) and the intervention terms from the International Classification for Nursing Practice (ICNP® Version 1; International Council of Nurses, 2005). This framework provides a comprehensive yet easy-to-use format for writ- ing plans of care for clients. The book also includes the linkages between NANDA-I and the Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) labels. You’ll find the care plans in this book, which are designed for easy use with a left- and right-page sequence, are invaluable in every healthcare setting you encounter throughout your career. GUIDELINES FOR USING SPARKS AND TAYLOR’S NURSING DIAGNOSIS POCKET GUIDE All care plans contain the following sections: I Diagnostic statement. Each diagnostic statement includes a NANDA-I-approved diagnosis. The Sparks and Taylor’s Nursing Diagnosis Pocket Guide contains all the diagnoses approved by NANDA-I through 2009. I Definition. Each diagnosis is explained with a NANDA-I approved definition. I Defining characteristics. This section lists clinical findings that confirm the diagnosis. For diagnoses expressing the possibility of a problem, such as “Risk for Injury,” this section is labeled Risk Factors. I Assessment. This section suggests parameters to use when collect- ing data to ensure an accurate diagnosis. Complete assessment parameters are presented in Appendix A. The parameters are based on the NNN Taxonomy of Nursing Practice and include four domains: functional, physiological, psychosocial, and environmental (see Appendix A). The domains are subdivided v LWBK392-FM_i-xxiv.qxd 11/17/09 8:20 PM Page vi Aptara Inc vi Preface into classes; each class includes key subjective and objective data to be assessed. For each plan, the authors have indicated the parameters that are most necessary for that diagnosis. I Expected outcomes. Here you’ll find realistic goals for resolving or ameliorating the patient’s health problem, written in measura- ble behavioral terms. You should select outcomes that are appro- priate to the condition of your patient. Outcomes are arranged to flow logically from admission to discharge of the patient. Outcomes identified by NOC research are included for your con- sideration. I Interventions and rationales. This section provides specific activities you carry out to help attain expected outcomes. Inter- ventions are organized using the following terms: determine, perform, inform, attend, and manage. These intervention types use the International Classification of Nursing Practice taxonomy that is explained in more detail later in these guide- lines. Each intervention contains a rationale, highlighted in italic. Rationales receive typographic emphasis because they form the premise for every nursing action. You’ll find it helpful to consider rationales before intervening. Understanding the why of your actions can help you see that carrying out repetitive or difficult interventions is an essential element of your nursing practice. More importantly, it can improve critical thinking and help you avoid mistakes. Interventions from NIC research are included for your consideration. I Reference. Each plan concludes with a reference that you may find useful if you need further information about the nursing diagnosis. NURSING PROCESS OVERVIEW The cornerstone of clinical nursing, the nursing process, is a system- atic method for taking independent nursing action. Steps in the nursing process include the following: I assessing the patient’s problems I forming a diagnostic statement I identifying expected outcomes I creating a plan to achieve expected outcomes I implementing the plan or assigning steps for implementation to others I evaluating the plan’s effectiveness These phases of the nursing process—assessment, nursing diagnosis formation, outcome identification, care planning, implementation, and evaluation—are dynamic and flexible; they commonly overlap. LWBK392-FM_i-xxiv.qxd 11/17/09 8:20 PM Page vii Aptara Inc Preface vii Becoming familiar with this process has many benefits. It will allow you to apply your knowledge and skills in an organized, goal- oriented manner. It will also enable you to communicate about pro- fessional topics with colleagues from all clinical specialties and prac- tice settings. Using the nursing process is essential to documenting nursing’s role in the provision of comprehensive, quality patient care. By clearly defining those problems a nurse may treat independently, the nursing process has helped dispel the notion that nursing practice is based solely on carrying out physician’s orders. Nurse researchers and expert practitioners
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