Nursing Maternity Care plan

INDEX OF DISEASES/DISORDERS Acid-base imbalances respiratory, 195 metabolic, 483 AIDS, 709 Alcohol: acute withdrawal, 819 Alzheimer’s disease, 764 Amputation, 646 Anemia–iron deficiency, anemia of chronic disease, pernicious, aplastic, hemolytic, 493 Angina (coronary artery disease, acute coronary syndrome), 64 Anorexia nervosa, 369 Aplastic anemia, 493 Appendectomy, 344 Asthma, 120 Bariatric surgery, 396 Benign prostatic hyperplasia, 588 Bulimia nervosa, 369 Burns: thermal, chemical, and electrical—acute and convalescent phases, 667 Cancer, 846 Cardiac surgery: postoperative care, 100 Cardiomyoplasty, 100 Cerebrovascular accident/stroke, 238 Chemical burns, 667 Cholecystectomy, 364 Cholecystitis with cholelithiasis, 357 Cholelithiasis, 357 Chronic obstructive pulmonary disease, 120 Cirrhosis of the liver, 445 Colostomy, 334 Coronary artery bypass graft, 100 Coronary artery disease, 64 Craniocerebral trauma–acute rehabilitative phase, 220 Crohn’s disease, 321 Deep vein thrombosis, 111 Dementia (Alzheimer’s type or vascular), 764 Diabetes mellitus/diabetic ketoacidosis, 405 Diabetic ketoacidosis, 405 Disaster considerations, 876 Disc surgery, 262 Dysrthymias , 88 Eating disorders: anorexia nervosa/bulimia nervosa, 369 Eating disorders: obesity, 387 Electrical burns, 667 End-of-life care/hospice, 866 Enteral feeding, 469 Esophageal bleeding, 306 Extended care, 801 Fecal diversions: postoperative care of ileostomy and colostomy, 334 Fluid and electrolyte imbalances, 903 Fluid and electrolyte imbalances, 903 Fractures, 632 Gastrectomy/gastric resection, 317 Gastric bypass, 396 Gastric partitioning, 396 Gastroplasty, 396 Glaucoma, 204 Graves’ disease, 419 Heart failure: chronic, 48 Hemodialysis, 575 Hemolytic anemia, 493 Hemothorax, 154 Hepatitis, 434 Herniated nucleus pulposus (ruptured invertebral disc), 254 HIV-positive client, 697 Hospice, 866 Hypercalcemia (calcium excess), 927 Hyperkalemia (potassium excess), 921 Hypermagnesemia (magnesium excess), 932 Hypernatremia (sodium excess), 915 Hypertension: severe, 37 Hyperthyroidism (Graves’ disease, thyrotoxicosis), 419 Hypervolemia (extracellular fluid volume excess), 905 Hypocalcemia (calcium deficit), 924 Hypokalemia (potassium deficit), 918 Hypomagnesemia (magnesium deficit), 930 Hyponatremia (sodium deficit), 914 Hypovolemia (extracellular fluid volume deficit), 908 Hysterectomy, 611 Ileostomy, 334 Inflammatory bowel disease: ulcerative colitis, Crohn’s disease, 321 Iron deficiency anemia, 493 Laminectomy, 262 Laryngectomy (postoperative care), 160 Leukemias, 516 Lung cancer: postoperative care, 144 Lymphomas, 525 Mastectomy, 619 Metabolic acid-base imbalances, 483 Metabolic acidosis—primary base bicarbonate deficiency, 483 Metabolic alkalosis—primary base bicarbonate excess, 488 Minimally invasive direct coronary artery bypass, 100 Multiple sclerosis, 290 Myocardial infarction, 74 Obesity, 387 Obesity: bariatric surgery–gastric partitioning/ gastroplasty, gastric bypass, 396 Pancreatitis, 458 Parenteral feeding, 469 Pediatric considerations, 890 Peritoneal dialysis, 570 Peritonitis, 349 Pernicious anemia, 493 Pneumonia, 131 Pneumothorax, 154 Primary base bicarbonate deficiency, 483 Primary base bicarbonate excess, 488 Primary carbonic acid deficit, 200 Primary carbonic acid excess, 195 Prostatectomy, 596 Psychosocial aspects of care, 749 Pulmonary emboli considerations, 111 Pulmonary tuberculosis, 186 Radical neck surgery: laryngectomy (postoperative care), 160 Renal calculi, 603 Renal dialysis, 560 Renal failure: acute, 536 Renal failure: chronic, 548 Respiratory acid-base imbalances, 195 Respiratory acidosis (primary carbonic acid excess), 195 Respiratory alkalosis (primary carbonic acid deficit), 200 Rheumatoid arthritis, 729 Ruptured invertebral disc, 254 Seizure disorders, 210 Sepsis, 686 Septicemia, 686 Sickle cell crisis, 503 Spinal cord injury (acute rehabilitative phase), 271 Stroke, 238 Substance dependence/abuse rehabilitation, 835 Surgical intervention, 782 Thermal burns, 667 Thrombophlebitis: deep vein thrombosis (including pulmonary emboli considerations), 111 Thyroidectomy, 429 Thyrotoxicosis, 419 Total joint replacement, 655 Total nutritional support: parenteral/enteral feeding, 469 Transplantation considerations—postoperative and lifelong, 739 Tuberculosis, pulmonary, 186 Ulcerative colitis, 321 Upper gastrointestinal/esophageal bleeding, 306 Urinary diversions/urostomy (postoperative care), 578 Urolithiasis (renal calculi), 603 Urostomy, 578 Valve replacement, 100 Vascular dementia, 764 Ventilatory assistance (mechanical), 173

KEY TO ESSENTIAL TERMINOLOGY Client Assessment Database Provides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical and/or surgical diagnosis as well as the signs and symptoms and corresponding diagnostic findings. Nursing Priorities Establishes a general ranking of needs and 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 need or problem (diagnosis) is stated without the distinct cause and signs and symptoms, which would be added to create 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 related to unconscious conflict, threat to self-concept as evidenced by statements of increased tension, apprehension; observations 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 or common reasons (etiology) why a particular need or problem may occur with probable signs and 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 and 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 or individualize them by adding time lines and specific 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 nursing language and serves as a general header for the outcome indicators that follow. Actions/Interventions Nursing Interventions Classification (NIC) 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. The interventions in this book are generally ranked from most to least common. When creating the individual plan of care, interventions would normally be ranked to reflect the client’s specific needs and situation. In addition, the division of independent and collaborative is arbitrary and is actually dependent on the individual nurse’s capabilities and hospital and community standards. Rationale Although not commonly appearing in client plans of care, rationale has been included here to provide a pathophysiological basis 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- or 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. NURSING DIAGNOSES ACCEPTED FOR USE AND RESEARCH FOR 2009–2011 Activity Intolerance [specify level] Activity Intolerance, risk for Activity Planning, ineffective Airway Clearance, ineffective Allergy Response, latex Allergy Response, risk for latex Anxiety [specify level] Anxiety, death Aspiration, risk for Attachment, risk for impaired Autonomic Dysreflexia Autonomic Dysreflexia, risk for Behavior, risk-prone health Bleeding, risk for Body Image, disturbed Body Temperature, risk for imbalanced Bowel Incontinence Breastfeeding, effective Breastfeeding, ineffective Breastfeeding, interrupted Breathing Pattern, ineffective Cardiac Output, decreased Caregiver Role Strain Caregiver Role Strain, risk for Childbearing Process, readiness for enhanced Comfort, impaired Comfort, readiness for enhanced Communication, impaired verbal Communication, readiness for enhanced Conflict, decisional Conflict, parental role Confusion, acute Confusion, risk for acute Confusion, chronic Constipation Constipation, perceived Constipation, risk for Contamination Contamination, risk for Coping, defensive Coping, ineffective Coping, readiness for enhanced Coping, ineffective community Coping, readiness for enhanced community Coping, compromised family Coping, disabled family Coping, readiness for enhanced family Death Syndrome, risk for sudden infant Decision-Making, readiness for enhanced Denial, ineffective Dentition, impaired Development, risk for delayed Diarrhea Dignity, risk for compromised human Distress, moral Disuse Syndrome, risk for Diversional Activity, deficient Electrolyte Imbalance, risk for Energy Field, disturbed Environmental Interpretation Syndrome, impaired Failure to Thrive, adult Falls, risk for Family Processes, dysfunctional Family Processes, interrupted Family Processes, readiness for enhanced Fatigue Fear Feeding Pattern, ineffective infant Fluid Balance, readiness for enhanced [Fluid Volume, deficient hyper/hypotonic] Fluid Volume, deficient [isotonic] Fluid Volume, excess Fluid Volume, risk for deficient Fluid Volume, risk for imbalanced Gas Exchange, impaired Glucose Level, risk for unstable blood Grieving Grieving, complicated Grieving, risk for complicated Growth, risk for disproportionate Growth and Development, delayed Health Maintenance, ineffective Health Management, ineffective self [formerly Therapeutic Regimen Management, ineffective] Health Management, readiness for enhanced self [formerly Therapeutic Regimen Management, readiness for enhanced] Home Maintenance, impaired Hope, readiness for enhanced Hopelessness Hyperthermia Hypothermia Identity, disturbed personal Immunization Status, readiness for enhanced Infant Behavior, disorganized Infant Behavior, readiness for enhanced organized Infant Behavior, risk for disorganized Infection, risk for Injury, risk for Injury, risk for perioperative positioning Insomnia Intracranial Adaptive Capacity, decreased Jaundice, neonatal Knowledge, deficient [Learning Need] [specify] Knowledge [specify], readiness for enhanced Lifestyle, sedentary Liver Function, risk for impaired Loneliness, risk for Maternal/Fetal Dyad, risk for disturbed Memory, impaired Mobility, impaired bed Mobility, impaired physical Mobility, impaired wheelchair Motility, dysfunctional gastointestinal Motility, risk for dysfunctional gastointestinal Nausea Neglect, self Neglect, unilateral Noncompliance [Adherence, ineffective] [specify] 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 Pain, acute Pain, chronic Parenting, impaired Parenting, readiness for enhanced Parenting, risk for impaired Perfusion, ineffective peripheral tissue Perfusion, risk for decreased cardiac tissue Perfusion, risk for ineffective cerebral tisse Perfusion, risk for ineffective gastrointestinal Perfusion, risk for ineffective renal Peripheral Neurovascular Dysfunction, risk for Poisoning, risk for Post-Trauma Syndrome [specify stage] Post-Trauma Syndrome, risk for Power, readiness for enhanced Powerlessness [specify level] Powerlessness, risk for Protection, ineffective Rape-Trauma Syndrome (Rape-Trauma Syndrome: compound reaction— retired 2009) (Rape-Trauma Syndrome: silent reaction—retired 2009) Relationship, readiness for enhanced Religiosity, impaired Religiosity, risk for impaired Religiosity, readiness for enhanced Relocation Stress Syndrome Relocation Stress Syndrome, risk for Resilience, impaired individual Resilience, readiness for enhanced Resilience, risk for compromised Role Performance, ineffective Self-Care, readiness for enhanced Self-Care Deficit: bathing Self-Care Deficit: dressing Self-Care Deficit: feeding Self-Care Deficit: toileting Self-Concept, readiness for enhanced Self-Esteem, chronic low Self-Esteem, situational low Self-Esteem, risk for situational low Self-Mutilation Self-Mutilation, risk for Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)

Sexual Dysfunction Sexuality Pattern, ineffective Shock, risk for Skin Integrity, impaired Skin Integrity, risk for impaired Sleep, readiness for enhanced Sleep Deprivation Sleep Pattern, disturbed Social Interaction, impaired Social Isolation Sorrow, chronic Spiritual Distress Spiritual Distress, risk for Spiritual Well-Being, readiness for enhanced Stress Overload Suffocation, risk for Suicide, risk for Surgical Recovery, delayed Swallowing, impaired (Therapeutic Regimen Management, effective— retired 2009) (Therapeutic Regimen Management, ineffective community—retired 2009) Therapeutic Regimen Management, ineffective family Thermoregulation, ineffective (Thought Processes, disturbed—retired 2009) Tissue Integrity, impaired Transfer Ability, impaired Trauma, risk for Trauma, risk for vascular Urinary Elimination, impaired Urinary Elimination, readiness for enhanced Urinary Incontinence, functional Urinary Incontinence, overflow Urinary Incontinence, reflex Urinary Incontinence, stress (Urinary Incontinence, total—retired 2009) Urinary Incontinence, urge Urinary Incontinence, risk for urge Urinary Retention [acute/chronic] Ventilation, impaired spontaneous Ventilatory Weaning Response, dysfunctional Violence, [actual/]risk for other-directed Violence, [actual/]risk for self-directed Walking, impaired Wandering [specify sporadic or continual] [ ] author recommendations Nursing Diagnoses—Definitions and Classification 2009–2011 © 2009, 2007, 2005, 2003, 2001, 1998, 1996, 1994 NANDA International. Nursing Maternity Care plan

Used by arrangement with Wiley-Blackwell Publishing, a company of John Wiley & Sons, Inc. In order to make safe and effective judgments using NANDA-I nursing diagnoses, it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work. Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span EDITION 8 Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span 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 Mar y 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 Macon, Mississippi EDITION 8 F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2010 by F. A. Davis Company Copyright © 1984, 1989, 1993, 1997, 2000, 2002, and 2006 by F. A. Davis Company. All rights reserved. This book is protected by copyright. Nursing Maternity Care plan

No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Joanne Patzek DaCunha, RN, MSN Director of Content Development: Darlene Pederson, MSN, APRN, BC Project Editor: Kim DePaul Mackey Design and Illustrations Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application  of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Nursing Maternity Care plan

Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Doenges, Marilynn E., 1922– Nursing care plans : guidelines for individualizing client care across the life span / Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr.—Ed. 8. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-2210-4 ISBN-10: 0-8036-2210-4 1. Nursing care plans—Handbooks, manuals, etc. I. Moorhouse, Mary Frances, 1947– II. Murr, Alice C., 1946– III. Title. [DNLM: 1. Patient Care Planning—Handbooks. 2. Nursing Process—Handbooks. WY 49 D651na 2010] RT49.D64 2010 610.73—dc22 2009014629 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. Nursing Maternity Care plan

The fee code for users of the Transactional Reporting Service is: 8036-1169-2/04 0 + $.25. To our spouses, children, parents, and friends, who much of the time have had to manage without us while we work as well as having to cope with our struggles and frustrations. The Doenges families: the late Dean, whose support and encouragement is sorely missed; Jim; Barbara and Bob Lanza; David, Monita, Matthew, and Tyler; John, Holly, Nicole, and Kelsey; and the Daigle families, Nancy, Jim, Jennifer, Brandon, Anna, Will, and Henry Smith-Daigle, and Jonathan, Kim, and Mandalyn JoAn. The Moorhouse family: Jan, Paul; Jason, Thenderlyn, Alexa, and Mary Isabella. To Mary and Marilynn, I couldn’t have done it without you. In loving memory of my parents, who … Nursing Maternity Care plan