Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care is a convenient reference to help the practicing nurse or nursing student make a nursing diagnosis and write a care plan with ease and confidence. This handbook helps nurses correlate nursing diagnoses with known information about clients on the basis of assessment findings; established medical, surgical, or psychiatric diagnoses; and the current treatment plan.
Making a nursing diagnosis and planning care are complex processes that involve diagnostic reasoning and critical thinking skills. Nursing students and practicing nurses cannot possibly memorize the extensive list of defining characteristics, related factors, and risk factors for the 216 diagnoses approved by NANDA-International. This book correlates suggested nursing diagnoses with what nurses know about clients and offers a care plan for each nursing diagnosis.
Section I, Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing, is divided into two parts. Part A includes an overview of the nursing process. This section provides information on how to make a nursing diagnosis and directions on how to plan nursing care. It also includes information on using clinical reasoning skills and eliciting the “client’s story.” Part B includes advanced nursing concepts: Concept mapping; QSEN (Quality and Safety Education for Nurses); Evidence-based nursing care; Quality nursing care; Patient-centered care; Safety; Informatics in nursing; Team/collaborative work with multidisciplinary team; and Root cause thinking.
In Section II, Guide to Nursing Diagnoses, the nurse can look up symptoms and problems and their suggested nursing diagnoses for more than 1450 client symptoms; medical, surgical, and psychiatric diagnoses; diagnostic procedures; surgical interventions; and clinical states.
InSection III, Guide to Planning Care, the nurse can find care plans for all nursing diagnoses suggested in Section II. We have included the suggested nursing outcomes from the Nursing Outcomes Classification (NOC) and interventions from the Nursing Interventions Classification (NIC) by the Iowa Intervention Project. We believe this work is a significant addition to the nursing process to further define nursing practice with standardized language.
Scientific rationales based on research are included for most of the interventions. This is done to make the evidence base of nursing practice apparent to the nursing student and practicing nurse.
New special features of the tenth edition of Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care include the following:
• Root Cause Thinking, an exciting addition to the nursing process to help nurses work with clients to determine the underlying cause(s) of disease
• Labeling of classic older research studies that are still relevant as Classic Evidence Based (CEB)
• Sixteen new nursing diagnoses recently approved by NANDA-I, along with retiring one nursing diagnosis: Disturbed Sensory Perception (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory)
• Ten revisions of nursing diagnoses made by NANDA-I in existing nursing diagnoses
• Further addition of pediatric and critical care interventions to appropriate care plans
• An associated Evolve Online Course Management System that includes appendixes, additional care plans, a care plan constructor, critical thinking case studies, Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) labels, PowerPoint slides, root cause thinking worksheets, and review questions for the NCLEX-RN® exam
The following features of Nursing Diagnosis Handbook: A Guide to Planning Care are also available:
• Suggested nursing diagnoses for more than 1300 clinical entities including signs and symptoms, medical diagnoses, surgeries, maternal-child disorders, mental health disorders, and geriatric disorders
• Labeling of nursing research as EBN (Evidence-Based Nursing) and clinical research as EB (Evidence-Based) to identify the source of evidence-based rationales
• An Evolve Online Courseware System with the Ackley-Ladwig Care Plan Constructor that helps the student or nurse write a nursing care plan
• Rationales for nursing interventions that are for the most part based on nursing research
• Nursing references identified for each care plan
• A complete list of NOC outcomes on the Evolve website
• A complete list of NIC interventions on the Evolve website
• Nursing care plans that contain many holistic interventions
• Care plans written by leading national nursing experts from throughout the United States, along with international contributors, who together represent all of the major nursing specialties and have extensive experience with nursing diagnoses and the nursing process. Care plans written by experts include:
• Caregiver role strain and Fatigue by Dr. Barbara A. Given and Dr. Paula Sherwood
• Constipation by Dr. Marilee Schmelzer
• Contamination and Risk for Contamination by Dr. Laura V. Polk
• Care plans for Spirituality by Dr. Lisa Burkhart
• Care plans for Religiosity by Dr. Lisa Burkhart
• Care plans for Skin integrity by Sharon Baranoski
• Impaired Memory by Dr. Graham J. McDougall, Jr.
• Care plans for Incontinence by Dr. Mikel Gray
• Insomnia and Sleep deprivation by Dr. Judith A. Floyd
• Decreased Intracranial adaptive capacity by Dr. Laura H. Mcilvoy
• Latex Allergy response by Dr. Leslie H. Nicoll and DeLancey Nicoll
• Unilateral Neglect by Dr. Lori M. Rhudy
• Disturbed Energy field by Dr. Diane Wardell
• Anxiety, Death Anxiety, and Fear by Dr. Ruth McCaffrey
• Impaired Comfort by Dr. Katharine Kolcaba
• Moral Distress by Dr. Lisa Burkhart and Dr. Beverly Kopala
• Risk for Infection and Ineffective Protection by Ruth Curchoe
• Readiness for enhanced Communication and Impaired verbal Communication by Dr. Stacey Carroll
• Sexual dysfunction and Ineffective Sexuality pattern by Dr. Elaine E. Steinke
• Defensive Coping revised by Dr. Michelangelo Juvenale and Dr. Patricia Ferreira
• A format that facilitates analyzing signs and symptoms by the process already known by nurses, which involves using defining characteristics of nursing diagnoses to make a diagnosis
• Use of NANDA-I terminology and approved diagnoses
• An alphabetical format for Sections II and III, which allows rapid access to information
• Nursing care plans for all nursing diagnoses listed in Section II
• Specific geriatric interventions in appropriate plans of care
• Specific client/family teaching interventions in each plan of care
• Information on culturally competent nursing care included where appropriate
• Inclusion of commonly used abbreviations (e.g., AIDS, MI, CHF) and cross-references to the complete term in Section II
We acknowledge the work of NANDA-I, which is used extensively throughout this text. In some rare cases, the authors and contributors have modified the NANDA-I work to increase ease of use. The original NANDA-I work can be found in NANDA-I Nursing Diagnoses: Definitions & Classification 2012-2014. Several contributors are the original submitters/authors of the nursing diagnoses established by NANDA-I. These contributors include the following:
Impaired Religiosity; Risk for impaired Religiosity; Readiness for enhanced Religiosity; Spiritual distress; Readiness for enhanced Spiritual well-being
Contamination; Risk for Contamination
Risk for disturbed Maternal/Fetal dyad
Dysfunctional Gastrointestinal Mobility; Risk for Dysfunctional Gastrointestinal Motility
Risk for ineffective renal Perfusion
Risk for compromised Resilience; Impaired individual Resilience; Readiness for enhanced Resilience
We would also like to thank Carole S. Homewood for her English translation from French for the care plan Ineffective Activity planning.
We and the consultants and contributors trust that nurses will find this tenth edition of Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care a valuable tool that simplifies the process of identifying appropriate nursing diagnoses for clients and planning for their care, thus allowing nurses more time to provide evidence-based care that speeds each client’s recovery.