Nursing Care Planning Guides - E-Book

1. Nursing Care Planning Guides: Prioritization, Delegation, and Clinical Reasoning - p. i 2. Cover image - p. i 3. Title page - p. ii 4. Table of Contents - p. iii 5. Inside front cover - p. iii 6. Copyright - p. iv 7. Dedication - p. v 8. About the authors - p. vi 9. Preface - p. vii 10. List of Illustrations - p. x 11. 1.  Prioritization, delegation, clinical reasoning, and clinical judgment in patient management - p. 1 12. 2.  Patient problems care plans - p. 7 13. 3.  Nurse-sensitive indicators - p. 67 14. 4.  Nursing care of the patient having surgery - p. 80 15. 5.  The patient with alterations in respiratory function - p. 111 16. 6.  The patient with alterations in cardiovascular function - p. 199 17. Abdominal aortic aneurysm - p. 199 18. Preoperative: Use in conjunction with the standardized preoperative care plan - p. 199 19. Patient Problem Changes in fluid and electrolyte balance - p. 199 20. Patient Problem Potential for shock - p. 201 21. Patient Problem Potential for venous thromboembolism - p. 203 22. Patient Problem Altered cardiac outcome - p. 204 23. Changes in sexual functioning - p. 207 24. Angina pectoris - p. 208 25. Patient Problem Altered cardiac output - p. 208 26. Patient Problem Acute chest pain - p. 210 27. Patient Problem Potential for cardiac dysrhythmias - p. 211 28. Patient Problem Potential for myocardial infarction - p. 213 29. Cardiac dysrhythmias - p. 216 30. Patient Problem Potential for changes in cardiac output - p. 217 31. Patient Problem Decreased activity tolerance - p. 218 32. Patient Problem Potential for falls - p. 219 33. Patient Problem Risk for systemic arterial embolism - p. 220 34. Patient Problem Potential for sudden cardiac death - p. 222 35. Carotid endarterectomy - p. 225 36. Patient Problem Potential for ineffective cerebral tissue perfusion - p. 225 37. Patient Problem Potential for ineffective cerebral tissue perfusion - p. 227 38. Patient Problem Potential for respiratory distress - p. 228 39. Patient Problem Potential for cranial nerve damage (facial, hypoglossal, glossopharyngeal, vagus, and/or accessory nerves) - p. 229 40. Deep vein thrombosis - p. 232 41. Patient Problem Changes in peripheral tissue perfusion - p. 233 42. Patient Problem Pain (affected extremity) - p. 234 43. Patient Problem Altered tissue integrity - p. 235 44. Patient Problem Potential for pulmonary embolus - p. 236 45. Patient Problem Potential for bleeding - p. 237 46. Femoropopliteal bypass - p. 240 47. Patient Problem Altered peripheral tissue perfusion - p. 241 48. Patient Problem Pain (intermittent claudication and rest pain) - p. 242 49. Patient Problem Potential for altered peripheral tissue perfusion - p. 243 50. Patient Problem Risk for compartment syndrome - p. 245 51. Patient Problem Risk for saphenous nerve damage - p. 245 52. Heart failure - p. 248 53. Patient Problem Altered cardiac output - p. 249 54. Patient Problem Altered respiratory function - p. 251 55. Patient Problem Altered fluid and electrolyte balance - p. 253 56. Patient Problem Potential for renal insufficiency - p. 255 57. Patient Problem Risk for cardiac dysrhythmias - p. 256 58. Patient Problem Risk for acute pulmonary edema - p. 257 59. Patient Problem Potential for thrombosis - p. 258 60. Patient Problem Risk for cardiogenic shock - p. 258 61. Heart surgery: Coronary artery bypass grafting or valve replacement - p. 262 62. Patient Problem Altered cardiac output - p. 263 63. Patient Problem Risk for altered respiratory function - p. 265 64. Patient Problem Imbalance of fluid and electrolytes - p. 267 65. Patient Problem Potential for infection - p. 268 66. Patient Problem Potential for cardiac dysrhythmias - p. 269 67. Patient Problem Risk for cardiac tamponade - p. 270 68. Patient Problem Potential for bleeding - p. 272 69. Patient Problem Risk for neurologic dysfunction - p. 273 70. Patient Problem Potential for impaired renal function - p. 274 71. Patient Problem Risk for pneumothorax - p. 274 72. Hypertension - p. 279 73. Patient Problem Changes in tissue perfusion - p. 280 74. Patient Problem Headache - p. 281 75. Patient Problem Risk for cerebrovascular accident/hypertensive encephalopathy - p. 282 76. Patient Problem Risk for impaired renal function - p. 284 77. Patient Problem Risk for aortic dissection - p. 284 78. Patient Problem Ineffective management of chronic health condition - p. 285 79. Discharge planning - p. 287 80. Additional patient problems - p. 289 81. Implantable cardiac devices - p. 289 82. Patient Problem Altered cardiac output - p. 290 83. Patient Problem Risk for pacemaker/implantable cardioverter-defibrillator malfunction - p. 291 84. Patient Problem Risk for cardiac tamponade - p. 292 85. Patient Problem Risk for pneumothorax - p. 294 86. Patient Problem Risk for undesired stimulation of the heart and/or certain nerves and muscles - p. 294 87. Myocardial infarction - p. 297 88. Outcome/discharge criteria - p. 298 89. Patient Problem Altered cardiac output - p. 298 90. Patient Problem Chest pain - p. 300 91. Patient Problem Potential for activity intolerance - p. 301 92. Patient Problem Risk for cardiac dysrhythmias - p. 303 93. Patient Problem Potential for venous thromboembolism - p. 303 94. Patient Problem Risk for rupture of a portion of the heart (e.g., ventricular free wall, interventricular septum, papillary muscle) - p. 304 95. Patient Problem Risk for pericarditis - p. 305 96. Patient Problem Risk for infarction extension or recurrence - p. 306 97. Patient Problem Risk for cardiogenic shock - p. 307 98. 7.  The patient with alterations in neurologic function - p. 313 99. 8.  The patient with alterations in hematologic and immune function - p. 380 100. 9.  The patient with alterations in metabolic function - p. 422 101. 10.  The patient with alterations in the gastrointestinal tract - p. 459 102. Abdominal trauma - p. 459 103. Patient Problem Altered breathing pattern - p. 459 104. Patient Problem Potential for altered fluid volume (hypovolemia) and electrolyte balance - p. 461 105. Patient Problem Potential for infection—peritonitis - p. 463 106. Patient Problem Potential for septic shock - p. 464 107. Patient Problem Potential for organ ischemia/dysfunction (multiple organ dysfunction syndrome) - p. 465 108. Appendicitis/appendectomy - p. 466 109. Patient Problem Potential for altered fluid volume (hypovolemia) and electrolyte balance - p. 467 110. Patient Problem Nausea and vomiting - p. 468 111. Patient Problem Hyperthermia - p. 469 112. Patient Problem Risk for abscess formation - p. 470 113. Bowel diversion: Ileostomy - p. 470 114. Patient Problem Lack of knowledge - p. 471 115. Patient Problem Potential for alterations in fluid volume and electrolyte and acid-base balance - p. 473 116. Patient Problem Potential for altered tissue integrity - p. 474 117. Patient Problem Risk for local infection (e.g., peritonitis and systemic infection) - p. 477 118. Patient Problem Risk for stomal changes - p. 479 119. Patient Problem Risk for stomal obstruction - p. 480 120. Patient Problem Changes in sexuality pattern - p. 481 121. Patient Problem Altered body image - p. 483 122. Enteral nutrition - p. 488 123. Patient Problem Potential for aspiration - p. 488 124. Patient Problem Weight loss - p. 489 125. Patient Problem Potential for inadequate fluid intake - p. 491 126. Gastrectomy - p. 493 127. Patient Problem Inadequate gas exchange - p. 493 128. Patient Problem Weight loss and inadequate nutritional intake - p. 495 129. Patient Problem Diarrhea - p. 497 130. Patient Problem Risk for hypovolemic shock - p. 498 131. Patient Problem Risk for afferent loop syndrome - p. 499 132. Patient Problem Risk for early and late dumping syndrome (postprandial hypoglycemia) - p. 500 133. Bariatric surgery - p. 502 134. Patient Problem Potential for altered breathing and gas exchange - p. 503 135. Patient Problem Potential for overdistention of the gastric pouch - p. 504 136. Patient Problem Potential for venous thromboembolism - p. 505 137. Gastrointestinal bleed, acute - p. 509 138. Patient Problem Potential for shock - p. 509 139. Patient Problem Potential for altered electrolyte balance - p. 510 140. Patient Problem Potential for aspiration - p. 511 141. Patient Problem Potential for fatigue - p. 512 142. Inflammatory bowel disease: Ulcerative colitis and crohn disease - p. 515 143. Patient Problem Potential for altered fluid and electrolyte and acid-base balance - p. 515 144. Patient Problem Nutrition-associated weight loss - p. 517 145. Patient Problem Pain - p. 519 146. Patient Problem Potential for infection - p. 521 147. Patient Problem Potential for renal calculi - p. 524 148. Patient Problem Risk for perirectal, rectovaginal, enterovesical, and enteroenteric abscesses and fistulas - p. 525 149. Patient Problem Risk for toxic megacolon - p. 525 150. Intestinal obstruction and bowel resection - p. 527 151. Patient Problem Potential for altered fluid, electrolyte, and acid-base balance - p. 528 152. Patient Problem Nausea and vomiting - p. 530 153. Patient Problem Risk for intestinal strangulation or infarction - p. 531 154. Patient Problem Altered gas exchange - p. 532 155. Patient Problem Altered airway clearance - p. 533 156. Patient Problem Risk for atelectasis - p. 535 157. Patient Problem Risk for paralytic ileus - p. 536 158. Patient Problem Risk for dehiscence - p. 536 159. Parenteral nutrition - p. 537 160. Patient problems variability in blood glucose levels - p. 538 161. Patient Problem Potential for infection - p. 539 162. Peptic ulcer - p. 542 163. Patient Problem Pain - p. 542 164. Patient Problem Potential for hypovolemia - p. 543 165. 11.  Nursing care of the patient with disturbances of the liver, biliary tract, and pancreas - p. 546 166. 12.  The patient with alterations in the kidney and urinary tract - p. 586 167. 13.  The patient with alterations in musculoskeletal function - p. 625 168. 14.  The patient with alterations in the breast and reproductive system - p. 658 169. 15.  The patient receiving treatment for neoplastic disorders - p. 690 170. 16.  Nursing care of the older adult patient - p. 731 171. 17.  End-of-life nursing care - p. 760 172. 18.  Discharge planning - p. 773 173. Bibliography - p. 779 174. Index - p. 789 175. Inside back cover - p. IBC