,Tenth Edition
Pearson Nursing Diagnosis
Handbook With NIC
Interventions and NOC
Outcomes
Judith M. Wilkinson, PhD, ARNP, RN
Nurse Educator, Consultant
Shawnee, Kansas
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Nursing Diagnoses in this text are taken from Nursing Diagnoses –
Definitions and Classification 2012–2014. Copyright © 2012, 1994–2012 by
NANDA International. Used by arrangement with John Wiley & Sons Limited.
Copyright © 2014, 2009, and 2005 by Pearson Education, Inc. All rights
reserved. Printed in the United States of America. This publication is
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Notice: Care has been taken to confirm the accuracy of information
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however, cannot accept any responsibility for errors or omissions or for
consequences from application of the information in this book and make
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drug selections and dosages set forth in this text are in accord with
current recommendations and practice at time of publication. However,
in view of ongoing research, changes in government regulations, and the
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change in indications of dosage and for added warnings and precautions.
This is particularly important when the recommended agent is a new and/
or infrequently employed drug.
Library of Congress Control Number:
2012954283
1 2 3 4 5 6 7 8 9 10—CRW—17 16 15 14 13
ISBN-13: 978-0-13-313904-4
ISBN-10: 0-13-313904-2
,Contents
Preface v
New to this Edition v
Features v
Other Features vi
Audience vii
Reviewers viii
SECTION I: Introduction 1
Introduction 3
Background 3
Nursing Process in Relation to Nursing Diagnosis 3
Standards of Care in Relation to Nursing Diagnosis 4
Case Management and Critical Paths 4
Case Management 4
Critical Paths and Managed care 4
Managed Care 4
Nursing Diagnosis Incorporated Into Critical Path 5
Nursing Diagnosis Used to Name Variance 5
Components of Nursing Diagnosis Care Plans 6
Plans of Care 6
Nursing Diagnosis 6
Definition 6
Defining Characteristics 6
Related Factors 7
Risk Factors 7
Suggestions for Use 7
Suggested Alternative Diagnoses 7
NOC Outcomes 7
Goals/Evaluation Criteria 8
NIC Interventions 8
Nursing Activities 9
Clinical Conditions Guide to Nursing Diagnoses and Collaborative
Problems 10
Nursing Diagnoses 10
Multidisciplinary (Collaborative) Problems 11
How to Create a Nursing Diagnosis Care Plan 11
Assessment 12
Diagnosis 12
NOC Outcomes 12
Goals/Evaluation Criteria 13
,iv Contents
Nursing Interventions and Activities 13
Creating a Critical Path 14
Section II: Nursing Diagnoses with Outcomes
and Interventions 17
Plans of Care in Alphabetical Order 19–848
Each plan of care contains the following information:
Taxonomy number
Definition
Defining Characteristics
Related Factors
Risk Factors
Suggestions for Use
Suggested Alternative Diagnoses
NOC Outcomes
Goals/Evaluation Criteria (Examples of NOC and Other)
NIC Interventions
Nursing Activities (NIC and Other)
SECTION III: Clinical Conditions Guide to Nursing
Diagnoses and Collaborative Problems 849
Clinical Conditions Guide to Nursing Diagnoses and
Collaborative Problems 851
Medical Conditions 852
Surgical Conditions 886
Psychiatric Conditions 901
Antepartum and Postpartum Conditions 912
Newborn Conditions 922
Pediatric Conditions 934
Bibliography 951
Appendix A 2012–2014 NANDA International-Approved Nursing
Diagnoses. Grouped by Gordon’s Functional Health Patterns 1134
Appendix B NANDA International-Approved Nursing Diagnoses
(2012–2014), Taxonomy II: Domains, Classes, and Diagnoses 1140
Appendix C Selected NANDA International Axis Descriptors 1149
Appendix D Multidisciplinary (Collaborative) Problems Associated with
Diseases and Other Physiologic Disorders 1151
Appendix E Multidisciplinary (Collaborative) Problems Associated With
Tests and Treatments 1161
Appendix F Multidisciplinary (Collaborative) Problems Associated With
Surgical Treatments 1162
Credits 1164
Index 1165
,Preface
Nursing Diagnosis Handbook with NIC Interventions and NOC Outcomes,
10th edition, is designed to help nurses and students develop individual-
ized patient care plans. The new edition has been expanded to include
all nursing diagnoses approved by the North American Nursing Diagnosis
Association (NANDA International) for 2012–2014, as well as linkages
to current Nursing Outcomes Classification (NOC) and Nursing
Interventions Classification (NIC) research-based outcomes and
interventions. NANDA International, NOC, and NIC standardized
terminology is generally used under those designated headings;
exceptions are enclosed in brackets [].
New to This Edition
• 16 new NANDA-I diagnoses
• 7 deleted NANDA-I diagnoses (retired)
• Thoroughly updated for revised NANDA-I diagnoses
• Thoroughly updated bibliography for each diagnosis
• Thoroughly updated NIC intervention
• Thoroughly updated NOC intervention
Features
NOC Suggested Outcomes
To facilitate use of a unified nursing language and computerized pa-
tient records, each nursing diagnosis lists the outcomes found in NANDA,
NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, & Interventions (3rd
ed.) (Johnson, Moorhead, Bulechek, Butcher, Maas, & Swanson, 2012).
Other “Suggested Outcomes” for the diagnosis can be found in NOC Out-
comes Classification (NOC) (2008). NOC outcomes are nurse-sensitive;
that is, they may be influenced by the nursing care given for a particu-
lar NANDA International diagnosis. This text also demonstrates ways to
use NOC outcomes, outcome indicators, and measuring scales to state
patient goals.
Updated NIC Interventions
NIC interventions have been updated to reflect the continuing work of
the Iowa Interventions Project. The interventions given and defined for
each nursing diagnosis are the “major interventions” associated with
the outcomes listed for that nursing diagnosis in NANDA, NOC, and NIC
Linkages: Nursing Diagnoses, Outcomes, & Interventions (3rd ed.) (Johnson,
Moorhead, Bulechek, Butcher, Maas, & Swanson, 2012). In this text,
we have highlighted the NIC interventions that are ”suggested” rather
,vi Preface
than “major” interventions. We do not list all “suggested interventions.”
NIC interventions were developed and linked to the NANDA International
categories by a research team using a multimethod process that included
the judgments of experts in nursing practice and research.
Inclusion of NIC Nursing Activities
In an effort to further promote use of standardized language, some
of the Nursing Activities for each nursing diagnosis are written in NIC
language. This helps to illustrate how the NIC activities, as well as the
broader NIC interventions, can be used in care planning.
Inclusion of Family, Community, and Collaborative Content
More family- and community-oriented goals have also been included in
the Goals/Evaluation Criteria Examples section. More collaborative, fam-
ily, and community nursing interventions and activities have also been
included.
Enhanced Gerontology and Home Care Content
Recognizing that the majority of patients are older adults, we have
included a section to each care plan for nursing activities that focus on
older adults.
Because a great deal of nursing care is now given in the patient’s
home, and because self-care has become increasingly important,
we also include in each care plan a section on Home Care.
Collaborative Problems
In the Clinical Conditions Guide to Nursing Diagnoses and Collabora-
tive Problems section, each disease or medical condition includes the
associated multidisciplinary (collaborative) problems. Appendices D, E,
and F contain the most comprehensive listing of multidisciplinary prob-
lems available, organized for (a) diseases/pathophysiology, (b) tests and
treatments, and (c) surgical treatments.
Other Features
Organized for Easy Use
The book is divided into three main parts: (a) An introduction to the
use of nursing diagnoses; (b) complete plans of care for each NANDA
International nursing diagnosis; and (c) a list of medical, surgical, psy-
chiatric, perinatal, and pediatric conditions, each accompanied by
nursing diagnoses and collaborative problems commonly associated
with those conditions. This organization allows the nurse to begin the
care planning process with either a medical condition or a nursing
diagnosis.
, Preface vii
Suggestions for Using NANDA International Diagnoses
Author suggestions help to clarify the nursing diagnosis labels and to
advise how they can best be used.
Organization of Defining Characteristics
These cues have been alphabetized and categorized as subjective or
objective. NANDA International no longer designates major, minor, and
critical defining characteristics.
Easy to Individualize
Each plan of care is comprehensive and allows nurses to select specific
content according to the patient’s condition and situation. Each nursing
diagnosis includes related factors or risk factors that make it easy to in-
dividualize the care plan to the specific patient situation. Creative nurses
will tailor standardized outcomes, interventions, and related and risk fac-
tors to meet the needs of each individual patient.
Assessment, Teaching, and Collaborative Nursing Activities
Nursing activities are grouped under the headings: Assessments,
atient/Family Teaching, Collaborative Activities, and Other. This makes
P
it easier to locate a particular activity and helps assure that the nurse
considers each type of activity.
Critical Paths
An up-to-date discussion of nursing diagnosis and critical paths is fea-
tured, along with an example of a format for a multidisciplinary care plan
(critical path).
Care Planning Checklist
A checklist (see perforated flap on back cover) is provided to assist
the practitioner in evaluating the finished care plan for completeness and
suitability for the client.
Audience
This pocket guide is intended to facilitate care planning for nursing stu-
dents, staff nurses in a variety of settings, clinical nurse specialists, and
staff development instructors.
,Reviewers
Becky Bunn, MSN, RNC
University of Mary Hardin-Baylor
Belton, TX
Jayne Hansche Lobert, MS, RN, ACNS-BC, NP
Oakland Community College
Waterford, MI
Nancy J. Cooley, MSN, APRN
University of Maine at Augusta
Augusta, ME
Laurie D. Fishel, RN, MSN
Kent State University
New Philadelphia, OH
, Section I
Introduction
