DOENGES MOORHOUSE MURR
Guidelines for Individualizing
Client Care Across the Life Span
lOTH EDITION
, INDEX OF DISEASES/DISORDERS
Acid-base imbalances DavisPlus Gastrectomy/gastroplasty (see DavisPlus)
Acquired immunodeficiency syndrome (AIDS), 800 Gastric bypass, 442
Acute coronary syndrome (ACS), 54 Glaucoma DavisPlus
Acute kidney injury (acute renal failure), 595 Graves’ disease, 471
Adult leukemias, 569
Alcohol: acute withdrawal, 919 Heart failure: chronic, 38
Alzheimer’s disease, 851 Hemodialysis, 641
Amputation, 718 Hemolytic anemia, 541
Anemia—iron deficiency, anemia of chronic disease, pernicious, Hemothorax, 169
aplastic, hemolytic, 541 Hepatitis, 482
Angina: chronic/stable, 64 Herniated nucleus pulposus (see DavisPlus)
Anorexia nervosa, 413 HIV-positive client, 785
Aplastic anemia, 541 Hospice, 970
Appendectomy, 382 Hypercalcemia (calcium excess) (see DavisPlus)
Asthma, 132 Hyperkalemia (potassium excess) (see DavisPlus)
Hypermagnesemia (magnesium excess) (see DavisPlus)
Bariatric surgery, 442 Hypernatremia (sodium excess) (see DavisPlus)
Benign prostatic hyperplasia (BPH), 686 Hypertension: severe, 26
Brain infections: meningitis and encephalitis, 267 Hyperthyroidism (Graves’ disease, thyrotoxicosis, thyroid storm), 471
Bulimia nervosa, 413 Hypervolemia (extracellular fluid volume excess) (see DavisPlus)
Burns: thermal, chemical, and electrical—acute and convalescent Hypocalcemia (calcium deficit) (see DavisPlus)
phases, 740 Hypokalemia (potassium deficit) (see DavisPlus)
Hypomagnesemia (magnesium deficit) (see DavisPlus)
Cancer, general considerations, 945 Hyponatremia (sodium deficit) (see DavisPlus)
Cardiac dysrhythmias, 85, 86 Hypovolemia (extracellular fluid volume deficit) (see DavisPlus)
Cardiac surgery: postoperative care, 98 Hysterectomy, 666
Cardiomyoplasty, 46
Cerebrovascular accident/stroke, 247 Ileostomy, 368
Chemical burns, 741 Inflammatory bowel disease: ulcerative colitis, Crohn’s disease, 352
Cholecystectomy DavisPlus Iron-deficiency anemia, 541
Cholecystitis with cholelithiasis, 399
Cholelithiasis, 399 Laminectomy (see Spinal Surgery), 276
Chronic obstructive pulmonary disease (COPD) and asthma, 132 Laryngectomy (see DavisPlus)
Cirrhosis of the liver, 494 Lewy body disease, 851
Colostomy, 368 Leukemias, 569
Coronary artery bypass graft (CABG), 98 Lung cancer: postoperative care, 159
Craniocerebral trauma—acute rehabilitative phase, 226 Lymphomas, 582
Crohn’s disease, 352
Mastectomy, 675
Dementia: Alzheimer’s type/vascular dementia/, Lewy body disease, Meningitis, 267
frontotemporal dementia, 851 Metabolic acid-base imbalances (see DavisPlus)
Deep vein thrombosis (DVT), 120 Metabolic acidosis—primary base bicarbonate deficiency
Diabetes mellitus, 454 (see DavisPlus)
Diabetic ketoacidosis, 454 Metabolic alkalosis—primary base bicarbonate excess
Dialysis: hemodialysis (HD), 641 (see DavisPlus)
Dialysis: peritoneal (PD), 635 Minimally invasive direct coronary artery bypass (MIDCAB), 98
Disaster considerations, 980 Multiple sclerosis, 311
Disc surgery (now called Spinal Surgery), 276 Myocardial infarction, 72
Dysrhythmias, 85, 86
Obesity, 430
Eating disorders: anorexia nervosa/bulimia nervosa, 413
Electrolyte imbalances DavisPlus Bariatric surgery, 442
Electrical burns, 740
Encephalitis, 267 Pancreatitis, 511
End-stage renal disease, 607 Parkinson’s disease, 330
Enteral feeding, 525 Parenteral feeding, 525
Esophageal bleeding, 347 Pediatric considerations, 993
Extended care, 896 Peritoneal dialysis, 635
Peritonitis, 389
Fecal diversions: postoperative care of ileostomy and colostomy, 368 Pernicious anemia, 541
Fluid and electrolyte imbalances, DavisPlus Pneumonia, 147
Fractures, 702 Pneumothorax, 169
i
598-74555_ch00_4P.indd i 12/18/18 1
, Primary base bicarbonate deficiency (see DavisPlus) Stroke, 247
Primary base bicarbonate excess (see DavisPlus) Substance use disorders (SUDs), 929
Primary carbonic acid deficit (see DavisPlus) Surgical interventions, 873
Primary carbonic acid excess (see DavisPlus)
Prostatectomy, 694 Thermal burns, 740
Psychosocial aspects of care, 835 Thrombophlebitis: venous thromboembolism, 120
Pulmonary emboli (PE), 120 Thyroidectomy (see DavisPlus)
Pulmonary tuberculosis (TB), 204 Thyrotoxicosis, 471
Total joint replacement, 729
Radical neck surgery (see DavisPlus) Total nutritional support: parenteral/enteral feeding, 525
Renal calculi, 656 Tuberculosis (TB), pulmonary, 204
Renal dialysis—general considerations, 623
Renal failure: acute, 595 Ulcerative colitis, 352
Renal failure: chronic, 607 Upper gastrointestinal bleeding, 340
Respiratory acid-base imbalances (see DavisPlus) Urinary diversions/urostomy (postoperative care)
Respiratory acidosis (see DavisPlus) Urinary stones (calculi), 656
Respiratory alkalosis (see DavisPlus) Urostomy, 645
Rheumatoid arthritis (RA), 824
Respiratory failure/ventilatory assistance, 187 Valve replacement, 98
Ruptured intervertebral disc (see DavisPlus) Vascular dementia, 851
Venous thromboembolism (VTE) disease, 120
Seizure disorders, 216 Ventilatory assistance (mechanical), 187
Sepsis/Septic Shock, 772
Sickle cell crisis, 552 Wound care: complicated or chronic, 762
Spinal cord injury (acute rehabilitative phase), 288
ii
598-74555_ch00_4P.indd ii 12/18/18 1
, KEY TO ESSENTIAL TERMINOLOGY
CLIENT ASSESSMENT DATABASE When a risk diagnosis is used, the identified risk
Provides an overview of the more commonly occurring eti- factors serve as the “evidenced by” segment of the nursing
ology and coexisting factors associated with a specific med- diagnosis statement, and interventions are provided to pre-
ical and/or surgical diagnosis or health condition as well as vent progression to a problem-focused diagnosis. Further-
the signs and symptoms and corresponding diagnostic find- more, health-promotion diagnoses (readiness for enhanced)
ings. The Database contains the information used to iden- do not contain related factors but do have defining charac-
tify Nursing Diagnoses for planning client care. teristics for the “evidenced by” segment of the client diag-
nostic statement.
NURSING PRIORITIES
Establishes a general ranking of needs and concerns on which DESIRED OUTCOMES/EVALUATION
the Nursing Diagnoses are ordered in constructing the plan of CRITERIA—CLIENT WILL
care. This ranking would be altered according to the individ- These give direction to client care as they identify what the
ual client situation. client or nurse hopes to achieve. They are stated in general
terms to permit the practitioner to modify or individualize
DISCHARGE GOALS them by adding timelines and specific client criteria so they
Identifies generalized statements that could be developed into become “measurable.” For example, “Client will appear re-
short-term and intermediate goals to be achieved by the client laxed and report anxiety is reduced to a manageable level
before being “discharged” from nursing care. They may also within 24 hours.”
provide guidance for creating long-term goals for the client to Nursing Outcomes Classification (NOC) labels are
work on after discharge. also included. The outcome label is selected from a stan-
dardized nursing language and serves as a general header
NURSING DIAGNOSIS for the outcome indicators that follow.
The general need or problem diagnosis is stated without the
distinct cause and signs and symptoms, which would be added ACTIONS/INTERVENTIONS
to create a client diagnostic statement when specific client in- Nursing Interventions Classification (NIC) labels are drawn
formation is available. For example, when a client displays in- from a third standardized nursing language and serve as a
creased tension, apprehension, quivering voice, and focus on general header for the nursing actions that follow.
self, the nursing diagnosis of Anxiety might be stated: se- Nursing actions are divided into independent—those
vere Anxiety related to value conflict, threat to current sta- actions that the nurse performs autonomously— and
tus as evidenced by increase in tension, apprehensiveness; collaborative—those actions that the nurse performs in con-
voice quivering, self-focused. junction with others, such as implementing physician orders.
In addition, diagnoses identified within these guides The interventions in this book are generally ranked from
for planning care as actual, risk, health promotion, or syn- most to least common. When creating the individual plan of
drome can be changed or deleted and new diagnoses added, care, interventions would normally be ranked to reflect the
depending entirely on the specific client situation or avail- client’s specific needs and situation. In addition, the division
able information. of independent and collaborative is arbitrary and is actually
dependent on the individual nurse’s capabilities, agency pro-
MAY BE RELATED TO/POSSIBLY tocols, and professional standards.
EVIDENCED BY
These lists provide the usual or common reasons (etiology) RATIONALE
why a par ticular need or problem may occur with probable Although not commonly appearing in client plans of care,
signs and symptoms, which would be used to create the “re- rationale has been included here to provide a pathophysiolog-
lated to” and “evidenced by” portions of the client diagnos- ical basis to assist the nurse in deciding about the relevance
tic statement when the specific situation is known. of a specific intervention for an individual client situation.
iii
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12/18/18 1
Guidelines for Individualizing
Client Care Across the Life Span
lOTH EDITION
, INDEX OF DISEASES/DISORDERS
Acid-base imbalances DavisPlus Gastrectomy/gastroplasty (see DavisPlus)
Acquired immunodeficiency syndrome (AIDS), 800 Gastric bypass, 442
Acute coronary syndrome (ACS), 54 Glaucoma DavisPlus
Acute kidney injury (acute renal failure), 595 Graves’ disease, 471
Adult leukemias, 569
Alcohol: acute withdrawal, 919 Heart failure: chronic, 38
Alzheimer’s disease, 851 Hemodialysis, 641
Amputation, 718 Hemolytic anemia, 541
Anemia—iron deficiency, anemia of chronic disease, pernicious, Hemothorax, 169
aplastic, hemolytic, 541 Hepatitis, 482
Angina: chronic/stable, 64 Herniated nucleus pulposus (see DavisPlus)
Anorexia nervosa, 413 HIV-positive client, 785
Aplastic anemia, 541 Hospice, 970
Appendectomy, 382 Hypercalcemia (calcium excess) (see DavisPlus)
Asthma, 132 Hyperkalemia (potassium excess) (see DavisPlus)
Hypermagnesemia (magnesium excess) (see DavisPlus)
Bariatric surgery, 442 Hypernatremia (sodium excess) (see DavisPlus)
Benign prostatic hyperplasia (BPH), 686 Hypertension: severe, 26
Brain infections: meningitis and encephalitis, 267 Hyperthyroidism (Graves’ disease, thyrotoxicosis, thyroid storm), 471
Bulimia nervosa, 413 Hypervolemia (extracellular fluid volume excess) (see DavisPlus)
Burns: thermal, chemical, and electrical—acute and convalescent Hypocalcemia (calcium deficit) (see DavisPlus)
phases, 740 Hypokalemia (potassium deficit) (see DavisPlus)
Hypomagnesemia (magnesium deficit) (see DavisPlus)
Cancer, general considerations, 945 Hyponatremia (sodium deficit) (see DavisPlus)
Cardiac dysrhythmias, 85, 86 Hypovolemia (extracellular fluid volume deficit) (see DavisPlus)
Cardiac surgery: postoperative care, 98 Hysterectomy, 666
Cardiomyoplasty, 46
Cerebrovascular accident/stroke, 247 Ileostomy, 368
Chemical burns, 741 Inflammatory bowel disease: ulcerative colitis, Crohn’s disease, 352
Cholecystectomy DavisPlus Iron-deficiency anemia, 541
Cholecystitis with cholelithiasis, 399
Cholelithiasis, 399 Laminectomy (see Spinal Surgery), 276
Chronic obstructive pulmonary disease (COPD) and asthma, 132 Laryngectomy (see DavisPlus)
Cirrhosis of the liver, 494 Lewy body disease, 851
Colostomy, 368 Leukemias, 569
Coronary artery bypass graft (CABG), 98 Lung cancer: postoperative care, 159
Craniocerebral trauma—acute rehabilitative phase, 226 Lymphomas, 582
Crohn’s disease, 352
Mastectomy, 675
Dementia: Alzheimer’s type/vascular dementia/, Lewy body disease, Meningitis, 267
frontotemporal dementia, 851 Metabolic acid-base imbalances (see DavisPlus)
Deep vein thrombosis (DVT), 120 Metabolic acidosis—primary base bicarbonate deficiency
Diabetes mellitus, 454 (see DavisPlus)
Diabetic ketoacidosis, 454 Metabolic alkalosis—primary base bicarbonate excess
Dialysis: hemodialysis (HD), 641 (see DavisPlus)
Dialysis: peritoneal (PD), 635 Minimally invasive direct coronary artery bypass (MIDCAB), 98
Disaster considerations, 980 Multiple sclerosis, 311
Disc surgery (now called Spinal Surgery), 276 Myocardial infarction, 72
Dysrhythmias, 85, 86
Obesity, 430
Eating disorders: anorexia nervosa/bulimia nervosa, 413
Electrolyte imbalances DavisPlus Bariatric surgery, 442
Electrical burns, 740
Encephalitis, 267 Pancreatitis, 511
End-stage renal disease, 607 Parkinson’s disease, 330
Enteral feeding, 525 Parenteral feeding, 525
Esophageal bleeding, 347 Pediatric considerations, 993
Extended care, 896 Peritoneal dialysis, 635
Peritonitis, 389
Fecal diversions: postoperative care of ileostomy and colostomy, 368 Pernicious anemia, 541
Fluid and electrolyte imbalances, DavisPlus Pneumonia, 147
Fractures, 702 Pneumothorax, 169
i
598-74555_ch00_4P.indd i 12/18/18 1
, Primary base bicarbonate deficiency (see DavisPlus) Stroke, 247
Primary base bicarbonate excess (see DavisPlus) Substance use disorders (SUDs), 929
Primary carbonic acid deficit (see DavisPlus) Surgical interventions, 873
Primary carbonic acid excess (see DavisPlus)
Prostatectomy, 694 Thermal burns, 740
Psychosocial aspects of care, 835 Thrombophlebitis: venous thromboembolism, 120
Pulmonary emboli (PE), 120 Thyroidectomy (see DavisPlus)
Pulmonary tuberculosis (TB), 204 Thyrotoxicosis, 471
Total joint replacement, 729
Radical neck surgery (see DavisPlus) Total nutritional support: parenteral/enteral feeding, 525
Renal calculi, 656 Tuberculosis (TB), pulmonary, 204
Renal dialysis—general considerations, 623
Renal failure: acute, 595 Ulcerative colitis, 352
Renal failure: chronic, 607 Upper gastrointestinal bleeding, 340
Respiratory acid-base imbalances (see DavisPlus) Urinary diversions/urostomy (postoperative care)
Respiratory acidosis (see DavisPlus) Urinary stones (calculi), 656
Respiratory alkalosis (see DavisPlus) Urostomy, 645
Rheumatoid arthritis (RA), 824
Respiratory failure/ventilatory assistance, 187 Valve replacement, 98
Ruptured intervertebral disc (see DavisPlus) Vascular dementia, 851
Venous thromboembolism (VTE) disease, 120
Seizure disorders, 216 Ventilatory assistance (mechanical), 187
Sepsis/Septic Shock, 772
Sickle cell crisis, 552 Wound care: complicated or chronic, 762
Spinal cord injury (acute rehabilitative phase), 288
ii
598-74555_ch00_4P.indd ii 12/18/18 1
, KEY TO ESSENTIAL TERMINOLOGY
CLIENT ASSESSMENT DATABASE When a risk diagnosis is used, the identified risk
Provides an overview of the more commonly occurring eti- factors serve as the “evidenced by” segment of the nursing
ology and coexisting factors associated with a specific med- diagnosis statement, and interventions are provided to pre-
ical and/or surgical diagnosis or health condition as well as vent progression to a problem-focused diagnosis. Further-
the signs and symptoms and corresponding diagnostic find- more, health-promotion diagnoses (readiness for enhanced)
ings. The Database contains the information used to iden- do not contain related factors but do have defining charac-
tify Nursing Diagnoses for planning client care. teristics for the “evidenced by” segment of the client diag-
nostic statement.
NURSING PRIORITIES
Establishes a general ranking of needs and concerns on which DESIRED OUTCOMES/EVALUATION
the Nursing Diagnoses are ordered in constructing the plan of CRITERIA—CLIENT WILL
care. This ranking would be altered according to the individ- These give direction to client care as they identify what the
ual client situation. client or nurse hopes to achieve. They are stated in general
terms to permit the practitioner to modify or individualize
DISCHARGE GOALS them by adding timelines and specific client criteria so they
Identifies generalized statements that could be developed into become “measurable.” For example, “Client will appear re-
short-term and intermediate goals to be achieved by the client laxed and report anxiety is reduced to a manageable level
before being “discharged” from nursing care. They may also within 24 hours.”
provide guidance for creating long-term goals for the client to Nursing Outcomes Classification (NOC) labels are
work on after discharge. also included. The outcome label is selected from a stan-
dardized nursing language and serves as a general header
NURSING DIAGNOSIS for the outcome indicators that follow.
The general need or problem diagnosis is stated without the
distinct cause and signs and symptoms, which would be added ACTIONS/INTERVENTIONS
to create a client diagnostic statement when specific client in- Nursing Interventions Classification (NIC) labels are drawn
formation is available. For example, when a client displays in- from a third standardized nursing language and serve as a
creased tension, apprehension, quivering voice, and focus on general header for the nursing actions that follow.
self, the nursing diagnosis of Anxiety might be stated: se- Nursing actions are divided into independent—those
vere Anxiety related to value conflict, threat to current sta- actions that the nurse performs autonomously— and
tus as evidenced by increase in tension, apprehensiveness; collaborative—those actions that the nurse performs in con-
voice quivering, self-focused. junction with others, such as implementing physician orders.
In addition, diagnoses identified within these guides The interventions in this book are generally ranked from
for planning care as actual, risk, health promotion, or syn- most to least common. When creating the individual plan of
drome can be changed or deleted and new diagnoses added, care, interventions would normally be ranked to reflect the
depending entirely on the specific client situation or avail- client’s specific needs and situation. In addition, the division
able information. of independent and collaborative is arbitrary and is actually
dependent on the individual nurse’s capabilities, agency pro-
MAY BE RELATED TO/POSSIBLY tocols, and professional standards.
EVIDENCED BY
These lists provide the usual or common reasons (etiology) RATIONALE
why a par ticular need or problem may occur with probable Although not commonly appearing in client plans of care,
signs and symptoms, which would be used to create the “re- rationale has been included here to provide a pathophysiolog-
lated to” and “evidenced by” portions of the client diagnos- ical basis to assist the nurse in deciding about the relevance
tic statement when the specific situation is known. of a specific intervention for an individual client situation.
iii
598-74555_ch00_4P.indd iii
12/18/18 1
