Nursing Care Plans & Documentation: Nursing Diagnoses

and Collaborative Problems (Nursing Care Plans and

Documentation)

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Nursing Care Plans

& Documentation
Nursing Diagnoses and Collaborative Problems

Lynda Juall Carpenito-Moyet, R.N., M.S.N., C.R.N.P.

Family Nurse Practitioner
ChesPenn Health Services
Chester, Pennsylvania
Nursing Consultant
Mullica Hill, New Jersey

EDITION5
11075-00_FMrev.qxd 8/7/08 10:28 AM Page iv

Senior Acquisitions Editor: Jean Rodenberger

Managing Editor: Michelle Clarke
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5th Edition

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Copyright © 2004, 1999 by Lippincott Williams and Wilkins. Copyright © 1995, 1991 by J. B. Lippincott
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Library of Congress Cataloging-in-Publication Data

Carpenito-Moyet, Lynda Juall.

Nursing care plans & documentation : nursing diagnoses and collaborative problems /
Lynda Juall Carpenito-Moyet.—5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-7817-7064-4 (alk. paper)
1. Nursing care plans. 2. Nursing assessment. 3. Nursing diagnosis. I. Title. II. Title: Nursing
care plans and documentation.
[DNLM: 1. Patient Care Planning. 2. Nursing Process. 3. Nursing Records. WY 100
C294n 2008]
RT49.C38 2008
610.73—dc22
2008016029

Care has been taken to confirm the accuracy of the information presented and to describe generally
accepted practices. However, the author, editors, and publisher are not responsible for errors or omissions
or for any consequences from application of the information in this book and make no warranty, expressed
or implied, with respect to the currency, completeness, or accuracy of the contents of the publication.
Application of this information in a particular situation remains the professional responsibility of the practi-
tioner; the clinical treatments described and recommended may not be considered absolute and universal
recommendations.

The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set
forth in this text are in accordance with the current recommendations and practice at the time of publica-
tion. However, in view of ongoing research, changes in government regulations, and the constant flow of
information relating to drug therapy and drug reactions, the reader is urged to check the package insert for
each drug for any change in indications and dosage and for added warnings and precautions. This is partic-
ularly important when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
clearance for limited use in restricted research settings. It is the responsibility of the health care provider to
ascertain the FDA status of each drug or device planned for use in his or her clinical practice.

LWW.com
11075-00_FMrev.qxd 8/7/08 10:28 AM Page v

To My Mother: Elizabeth Julia Juall

Every year brings me a new appreciation and admiration for this woman
In her 80s (close to 90) there is not much she does not do
She has role-modeled unconditional love, respect for all, forgiveness, and independence
She is determined she can, and she does!
She is one generation of my family’s Hungarian Woman Warriors, and I proudly walk in
their footprints, carry their swords to battle injustice, and cherish deeply our loved ones.

Love your daughter

Lynda
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Current Contributors

John Dugan, R.N., B.S.N. Tracy Schreiner, R.N., M.S.N., M.B.A.

Manager, Intensive Care Unit President, Schreiner Consulting
Carondelet Health Network Adjunct Faculty
St. Joseph’s Hospital Grand Canyon University
Tucson, Arizona Phoenix, Arizona
(Cardiovascular and Peripheral Vascular Disorders) Chamberlain College of Nursing
Chamberlin, Ohio
Gloria J. Gdovin, R.N., M.S.N., [Respiratory Disorders, Osteoporosis, Osteomyelitis,
C.C.R.N. (Diagnostic and Therapeutic Procedures: Anticoagulant
Clinical Nurse Educator, Critical Care Therapy, Casts, Chemotherapy, Corticosteroid
Carondelet Health Network Therapy, Enteral Nutrition, Long-Term Venous
St. Joseph’s Hospital Access, Pacemaker Insertion, Radiation Therapy,
Tucson, Arizona Total Parenteral Nutrition)]
[Stroke, Multiple Sclerosis, Neurogenic Bladder,
Fractures, Osteomyelitis, Neoplastic Disorders,
Pressure Ulcers, Immobility, HIV-Aids, Systemic
Previous Contributors
Lupus, Glaucoma, (Surgical Procedures: Abdominal Caroline M. Alterman, M.S.N., C.N.S.
Aortic Aneurysm Repair, Amputation, Arterial Bypass, Director, Spinal Cord Injury Program, Lakeshore
Breast Surgery, Carotid Endarectomy, Coronary Rehabilitation Hospital, Birmingham, Alabama
Bypass Graft, Radical Prostatectomy, Thoracic (Spinal Cord Injury, 2nd ed.)
Surgery, Total Joint Replacement, Urostomy)]
Elizabeth Brady-Avis, R.N., M.S.N.,
Susan Laureen Jones, R.N., B.S.N., C.C.R.N.
C.C.R.N. Clinical Nurse Specialist, Thomas Jefferson
Clinical Specialist, Inpatient Neuroscience University Hospital, Philadelphia,
Carondelet Health Network Pennsylvania
St. Joseph’s Hospital
Tucson, Arizona (Mechanical Ventilation, Asthma)

[Cancer End-Stage, Alcohol Withdrawal, Thermal Sharon Buckingham, B.S.N.

Injuries, Spinal Cord Injury, Seizures, Parkinson Staff Nurse, ICU, Huron Valley Hospital,
Disease, Myasthenia Gravis, Guillain-Barré, Milford, Michigan
Inflammatory Joint Disease, Renal and Urinary
Disorders, Peritoneal Dialysis, Hemodialysis, Sexual (Hypertension, Cirrhosis, 2nd ed.)
Assault, (Surgical Procedures: Generic Surgery,
Nephrectomy, Enucleation, Cranial Surgery, Cataract Gerald A. Burns, M.S.N.
Extraction, Laryngectomy, Ileostomy, Fractured Hip Clinical Nurse Specialist/Case Manager, Harper
and Femur, Neck Dissection, Laminectomy, Hospital, Detroit, Michigan
Hysterectomy, Colostomy)] (Human Immunodeficiency Virus/Acquired
Immunodeficiency Syndrome)

vii
11075-00_FMrev.qxd 8/7/08 10:28 AM Page viii

viii Current Contributors

Ann Delengowski, R.N., M.S.N. Amy Ottariano, R.N., M.S.N.

Oncology Clinical Nurse Specialist, Thomas Clinical Nurse Specialist, Intermediate Cardiac
Jefferson University Hospital, Philadelphia, Care Unit, Thomas Jefferson University
Pennsylvania Hospital, Philadelphia, Pennsylvania
(Leukemia, Sickle Cell Anemia, 2nd ed.) (Thoracic Surgery, 2nd ed.)

Mary Ann Ducharme, R.N., M.S.N., Rhonda R. Panfilli, R.N., M.S.N.

C.C.R.N. Coordinator, Case Management, Grace Hospital,
Case Manager/Clinical Nurse Specialist, Harper Detroit Medical Center, Detroit, Michigan
Hospital, Detroit, Michigan (Obesity)
(Hemodynamic Monitoring, Peritoneal Dialysis)
Gayle Vandendool Parker, R.N., B.S.N.
Rita Dundon, R.N., M.S.N., C.S., O.C.N. Nursing Practice Coordinator, London
Clinical Nurse Specialist, Henry Ford Hospital, Psychiatric Hospital, London, Ontario, Canada
Detroit, Michigan (Alcohol Withdrawal)
[Cancer (Initial Diagnosis), Chemotherapy, End-Stage
Cancer, Long-Term Venous Access Devices] Joy Ross, R.N.
London Psychiatric Hospital, London,
Doris R. Fleming, M.S.N., R.N., Ontario, Canada
C.S., C.D.E. (Sexual Assault)
Clinical Nurse Specialist, Harper Hospital,
Detroit, Michigan Rose B. Shaffer, R.N., M.S.N., C.C.R.N.
(Diabetes Mellitus) Clinical Nurse Specialist, Intermediate Cardiac
Care Unit, Thomas Jefferson University
Andrea Sampson Haggood, Hospital, Philadelphia, Pennsylvania
M.S.N., R.N. (Cardiac Catheterization, Pacemaker Insertion)
Clinical Nurse Specialist/Case Manager,
Oncology and Otorhinolaryngology, Harper Ellen Stefanosky, R.N., M.S.N.
Hospital, Detroit, Michigan Transplant Coordinator, Thomas Jefferson
University Hospital, Philadelphia,
(Tracheostomy, Neck Dissection, Laryngectomy, 2nd ed.)
Pennsylvania
Evelyn Howard, R.N., C.N.N. (Renal Transplant, 2nd ed.)
Director, Renal Dialysis, St. Vincent Infirmary
Medical Center, Little Rock, Arkansas Patricia A. Vaccaro, R.N., M.S.N.
Clinical Nurse Facilitator, Burn Center, Lehigh
(Acute Renal Failure, Chronic Renal Failure, 2nd ed.)
Valley Hospital, Allentown, Pennsylvania
Debra J. Lynn-McHale, R.N., M.S.N., (Thermal Injuries, 2nd ed.)
C.S., C.C.R.N.
Clinical Nurse Specialist, Surgical Cardiac Care Donna J. Zazworsky, R.N., M.S.
Unit, Thomas Jefferson University Hospital, Professional Nurse Case Manager, Carondelet St.
Philadelphia, Pennsylvania Mary’s Hospital, Tucson, Arizona

(Coronary Artery Bypass Graft, Percutaneous (Multiple Sclerosis)

Transluminal Coronary Angioplasty)

JoAnn Maklebust, M.S.N., R.N., C.S.

Clinical Nurse Specialist/Wound Care, Case
Manager/General and Reconstructive Surgery,
Harper Hospital, Detroit, Michigan
(Colostomy, Ileostomy, Urostomy, Pressure Ulcers,
Inflammatory Bowel Disease, Neurogenic Bladder)
11075-00_FMrev.qxd 8/7/08 10:28 AM Page ix

Preface

Nursing is primarily assisting individuals, sick or well, in activities that contribute to health or its recovery, or to
a peaceful death, and that they perform unaided when they have the necessary strength, will, or knowledge.
Nursing also helps individuals carry out prescribed therapy and to be independent of assistance as soon as possible
(Henderson, 1960).
Historically, nurses have represented the core of the health care delivery system (including acute,
long-term, and community agencies), but their image continues to be one of individuals whose actions
are dependent on physician supervision. Unfortunately, what Donna Diers wrote over 15 years ago is
still relevant today: “Nursing is exceedingly complicated work since it involves technical skill, a great
deal of formal knowledge, communication ability, use of self, timing, emotional investment, and any
number of other qualities. What it also involves—and what is hidden from the public—is the complex
process of thinking that leads from the knowledge to the skill, from the perception to the action, from
the decision to the touch, from the observation to the diagnosis. Yet it is this process of nursing care, which is
at the center of nursing’s work, that is so little described . . .” (Diers, 1981, p. 1, emphasis supplied).
Physicians regularly and openly explain the measures they plan to the public, especially to clients
and their families. Nurses, however, often fail to consistently explain their plan of care to clients and
family. This book provides both a framework for nurses to provide responsible nursing care and guide-
lines for them to document and communicate that care. These care plans should not be hand-written.
They must be reference documents for practicing nurses. Write or free text the different care the client
needs in addition to the standard.
The focus of Nursing Care Plans and Documentation is independent nursing care—the manage-
ment of client situations that the nurse can treat legally and independently. It will assist students in
transferring their theoretical knowledge to clinical practice; it can help experienced nurses provide
care in a variety of unfamiliar clinical situations. This book also incorporates the findings of a valida-
tion study, a description of which (method, subjects, instrument findings) is presented in the section
titled Validation Project, following the Preface. These findings should be very useful for practicing
nurses, students of nursing, and departments of nursing.
The Bifocal Clinical Practice Model underpins this book and serves to organize the nursing care
plans in Unit II. Chapter 1 describes and discusses the Bifocal Clinical Practice Model, which differen-
tiates nursing diagnoses from other problems that nurses treat. In this chapter, nursing diagnoses and
collaborative problems are explained and differentiated. The relationship of the type of diagnosis to
outcome criteria and nursing interventions is also emphasized.
Efficient and appropriate documentation of nursing care is outlined in Chapter 2. Legal issues,
standards, and regulatory agencies and their effect on nursing documentation are discussed. The chapter
explains a documentation system from admission to discharge. Sample forms are used to emphasize
efficient, professional charting. This chapter also includes a discussion of priority diagnoses and case
management. The elements of critical pathways are explained with examples. Directions on how to
create critical pathways using the care plans in Unit II are discussed and illustrated.
Chapter 3 gives an overview of the 11 steps in care planning and takes the reader through each
phase of this process.
Chapter 4 explores the issues and human responses associated with illness and hospitalization, and
describes the coping strategies of the client and family. A discussion of Bandura’s self-efficacy theory and
its application to management of therapeutic regimens is also presented.
Chapter 5 focuses on the surgical experience and related nursing care to discuss the human
response to the experience. Preoperative assessment and preparation are described for preadmitted
and same-day-admission surgical clients. The nursing responsibilities in the postanesthesia recovery
room are described, and the related documentation forms are included. This chapter also outlines the
integration of the nursing process in caring for same-day surgery clients; again, the corresponding
forms that will help the nurse to do this are included.
New to this edition is Chapter 6. This chapter focuses on Moral Distress in nurses. This new
NANDA nursing diagnosis has the nurse as the focus, not the client. The clinical reality of Moral
ix
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x Preface

Distress in nursing will be explored, and strategies for preventing and reducing Moral Distress will be
presented. Self-Assessment of Health Behaviors will help the nurse with a self-evaluation of his or her
life style. End-of-Life Decisions will be explored and strategies for promoting these decisions in one’s
personal life and with clients will be discussed. A reproducible Living Will document is available for
distribution with instructions on how to use it.
Unit II presents care plans that represent a compilation of the complex work of nursing in caring for
individuals (and their families) experiencing medical disorders or surgical interventions or undergoing
diagnostic or therapeutic procedures. It uses the nursing process to present the type of nursing care that
is expected to be necessary for clients experiencing similar situations. The plans provide the nurse with a
framework for providing initial, or essential, care. This is the nursing care known to be provided when a
certain clinical situation is present—for example, preoperative teaching for clients awaiting surgery or
the management of fatigue in individuals with arthritis. As the nurse intervenes and continues to assess,
additional diagnoses, goals, and interventions can be added to the initial plan. Even though the type of
care that is warranted for clients in certain clinical situations is predictable, the nurse must still assess the
individual for additional responses. The fifth edition features extensive revisions or additions to the
goals/outcome criteria in each care plan and, when possible, research findings or the work of expert
clinicians were incorporated.
The intent of this book is to assist the nurse to identify the responsible care that nurses are account-
able to provide. The incorporation of recent research findings further enhances the applicability of the
care plans. By using the Bifocal Clinical Practice Model, the book clearly defines the scope of indepen-
dent practice. The author invites comments and suggestions from readers. Correspondence can be
directed to the publisher or to the author’s address.

REFERENCES
Diers, D. (1981). Why write? Why publish? Image, 13, 991–997
Henderson, V. & Nite, G. (1960). Principles and practice of nursing (5th ed.). New York: Macmillan, p. 14.
11075-00_FMrev.qxd 8/7/08 10:28 AM Page xi

Validation Project

Background
In 1984, this author published diagnostic clusters under medical and surgical conditions (Carpenito,
1984). These diagnostic clusters represented nursing diagnoses and collaborative problems described in
the literature for a medical or surgical population. After the initial diagnostic clusters were created, they
were reviewed by clinicians who practiced with specific corresponding populations.
Since 1984, numerous other authors (Holloway, 1988; Doenges, 1991; Sparks, 1993; Ulrich,
1994) have generated similar groupings. To date none of the clusters have been studied to determine
their frequency of occurrence. In other words, are some diagnoses in the diagnostic cluster treated
more frequently than others?

Reasons for Study

In the last 10 years, the health care delivery system has experienced numerous changes. Specifically, clients
are in the acute care setting for shorter periods. These client populations all share a high acuity. This acuity
is represented with multiple nursing diagnoses and collaborative problems. However, do all these diagnoses
have the same priority? Which diagnoses necessitate nursing interventions during the length of stay?
Care planning books report a varied number of diagnoses to treat under a specific condition. For
example, in reviewing a care plan for a client with a myocardial infarction, this author found the follow-
ing number of diagnoses reported: Ulrich, 16; Carpenito, 11; Doenges, 7; Holloway, 4. When students
review these references, how helpful are lists ranging from 4 to 16 diagnoses? How many diagnoses can
nurses be accountable for during a client’s length of stay?
The identification of nursing diagnoses and collaborative problems that nurses treat more frequently
than others in certain populations can be very useful data to:
• Assist nurses with decision making
• Determine the cost of nursing services for population sets
• Plan for resources needed
• Describe the specific responsibilities of nursing
Novice nurses and students can use these data to anticipate the initial care needed. They can
benefit from data reported by nurses experienced in caring for clients in specific populations.
These data should not eliminate an assessment of an individual client to evaluate if additional
nursing diagnoses or collaborative problems are present and establish priority for treatment during the
hospital stay. This individual assessment will also provide information to delete or supplement the care
plan found in this book. The researched data will provide a beginning focus for care.
By identifying frequently treated nursing diagnoses and collaborative problems in client populations,
institutions can determine nursing costs based on nursing care provided. Nurse administrators and managers
can plan for effective use of staff and resources. Knowledge of types of nursing diagnoses needing nursing
interventions will also assist with matching the level of preparation of nurses with appropriate diagnoses.
To date, the nursing care of clients with medical conditions or postsurgical procedures has centered
on the physician-prescribed orders. The data from this study would assist departments of nursing to
emphasize the primary reason why clients stay in the acute care setting—for treatment of nursing diagnoses
and collaborative problems. The purpose of this study is to identify which nursing diagnoses and collabora-
tive problems are most frequently treated when a person is hospitalized with a specific condition.

Method
Settings and Subjects
The findings presented are based on data collected from August 1993 to March 1994. The research
population consisted of registered nurses with over 2 years’ experience in health care agencies in the
United States and Canada. A convenience sample of 18 institutions represented five U.S. geographical

xi
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xii Validation Project

regions (Northeast, Southeast, North-Midwest, Northwest, Southwest) and Ontario province in

Canada. The display lists the participating institutions. The target number of R.N. responses was
10 per condition from each institution. The accompanying table illustrates the demographics of the
subjects.

Instrument
A graphic rating scale was developed and pilot-tested to measure self-reported frequencies of interven-
tions provided to clients with a specific condition. Each collaborative problem listed under the condition
was accompanied by the question:
When you care for clients with this condition, how often do you monitor for this problem?
Each nursing diagnosis listed under the condition was accompanied by the question:
When you care for clients with this condition, how often do you provide interventions for this nursing
diagnosis?
The respondent was asked to make an X on a frequency scale of 0% to 100%. Scoring was tabu-
lated by summing the scores for each question and calculating the median.

PARTICIPATING INSTITUTIONS

Allen Memorial Hospital Presbyterian Hospital University of Minnesota Hospital

1825 Logan Avenue 200 Hawthorne Lane 420 Delaware Street, S.E.
Waterloo, Iowa 50703 Charlotte, NC 28233-3549 Minneapolis, MN 55455
Carondelet St. Joseph’s Hospital St. Francis Medical Center University of New Mexico Hospital
350 N. Wilmont Road 211 St. Francis Drive 2211 Lomas Blvd., N.E.
Tucson, AZ 85711-2678 Cape Girardeau, MO 63701 Albuquerque, NM 87131
The Evanston Hospital St. Joseph Hospital Victoria Hospital
Burch Building 601 N. 30th Street 800 Commissioners Road, East
2650 Ridge Avenue Omaha, NE 68131 London, Canada N6A 4G5
Evanston, IL 60201 St. Peter Community Hospital Wills Eye Hospital
Huron Valley Hospital 2475 Broadway 900 Walnut Street
1601 East Commerce Road Helena, MT 39601 Philadelphia, PA 19107
Milford, MI 48382-9900 San Bernardino County Medical Wilmer Ophthalmological Institute
Lehigh Valley Hospital Center Johns Hopkins Hospital
Cedar Crest & I-78 780 E. Gilbert Street Baltimore, MD 21287-9054
Allentown, PA 18105-1556 San Bernardino, CA 92415-0935 Winthrop-University Hospital
Memorial Medical Center of Sioux Valley Hospital 259 First Street
Jacksonville 1100 South Euclid Avenue Mineola, NY 11501
3625 University Blvd., South Sioux Falls, SD 57117-5039
Jacksonville, FL 32216

Data Collection
Prior to data collection, the researcher addressed the requirements for research in the institution. These
requirements varied from a review by the nursing department’s research committee to a review by the
institutional review board (IRB).
After the approval process was completed, each department of nursing was sent a list of the 72
conditions to be studied and asked to select only those conditions that were regularly treated in their
institution. Only those questionnaires were sent to the respective institutions. Study institutions received
a packet for those selected conditions containing 10 questionnaires for each condition. Completed ques-
tionnaires were returned by the nurse respondent to the envelope and the envelope sealed by the desig-
nated distributor. Nurse respondents were given the option of putting their questionnaire in a sealed
envelope prior to placing it in the larger envelope.
Since two of the study institutions did not treat ophthalmic conditions, questionnaires related to
these conditions were sent to two institutions specializing in these conditions.
11075-00_FMrev.qxd 8/7/08 10:28 AM Page xiii

Validation Project xiii

Findings
Of the 19 institutions that agreed to participate, 18 (including the two ophthalmic institutions) returned
the questionnaires. The target return was 160 questionnaires for each condition. The range of return was
29% to 70%, with the average rate of return 52.5%.
Each condition has a set of nursing diagnoses and collaborative problems with its own frequency
score. The diagnoses were grouped into three ranges of frequency: 75% to 100%—frequent; 50% to
74%—often; <50%—infrequent. Each of the 72 conditions included in the study and in this book has
the nursing diagnoses and collaborative problems grouped according to the study findings.

Future Work
This study represents the initial step in the validation of the nursing care predicted to be needed when a
client is hospitalized for a medical or surgical condition. It is important to validate which nursing diag-
noses and collaborative problems necessitate nursing interventions. Future work will include the identifi-
cation of nursing interventions that have priority in treating a diagnosis, clarification of outcomes
realistic for the length of stay, and evaluation and review by national groups of nurses.

DEMOGRAPHICS OF RESPONDENTS
Questionnaires
Sent 9,920
Returned 5,299
% returned 53.4%
Average Age 39
Average Years in Nursing 15

Level of Nursing Preparation

Diploma 22.7%
AD 25.7%
BSN 36.5%
MSN 12.4%
PhD 1.5%
No indication 1.2%

REFERENCES
Carpenito, L. J. (1984). Handbook of nursing diagnosis. Philadelphia: J. B. Lippincott.
Carpenito, L. J. (1991). Nursing care plans and documentation. Philadelphia: J. B. Lippincott.
Doenges, M., & Moorhouse, M. (1991). Nurse’s pocket guide: Nursing diagnoses with interventions. Philadelphia:
F. A. Davis.
Holloway, N. M. (1988). Medical surgical care plans. Springhouse, PA: Springhouse.
Sparks, S. M., & Taylor, C. M. (1993). Nursing diagnoses reference manual. Springhouse, PA: Springhouse.
Ulrich, S., Canale, S., & Wendell, S. (1994). Medical-surgical nursing: Care planning guide. Philadelphia:
W. B. Saunders.
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xiv Validation Project

Acknowledgments
The Validation Project could not have been completed without the support of the following nurses who
coordinated the data collection in their institutions:
Tammy Spier, R.N., M.S.N. Pauline Elliott, R.N., B.S.N.
Department of Nursing Services St. Francis Medical Center
Department of Staff Development Cape Girardeau, Missouri
Allen Memorial Hospital Dena Belfiore, R.N., Ph.D.
Waterloo, Iowa Dianne Hayko, M.S.R.N., C.N.S.
Donna Dickinson, R.N., M.S. St. Joseph Hospital
Carol Mangold, R.N., M.S.N. Omaha, Nebraska
Carondelet St. Joseph’s Hospital Jennie Nemec, R.N., M.S.N.
Tucson, Arizona St. Peter Community Hospital
Kathy Killman, R.N., M.S.N. Helena, Montana
Liz Nelson, R.N., M.S.N. Eleanor Borkowski, R.N.
The Evanston Hospital Tina Buchanan, R.N.
Evanston, Illinois Jill Posadas, R.N.
Margaret Price, R.N., M.S.N. Deanna Stover, R.N.
Lynn Bobel Turbin, R.N., M.S.N. Margie Bracken, R.N.
Nancy DiJanni, R.N., M.S.N. Barbara Upton, R.N.
Huron Valley Hospital Kathleen Powers, R.N.
Milford, Michigan Jeanie Goodwin, R.N.
Pat Vaccaro, R.N., B.S.N., C.C.R.N. San Bernardino County Medical Center
Deborah Stroh, R.N. San Bernardino, California
Mary Jean Potylycki, R.N. Kathy Karpiuk, R.N., M.N.E.
Carolyn Peters, R.N. Monica Mauer, R.N.
Sue DeSanto, R.N. Susan Fey, R.N.
Christine Niznik, R.N. Joan Reisdorfer, R.N.
Carol Saxman, R.N. Cheryl Wilson, Health Unit Coordinator
Kelly Brown, R.N. Gail Sundet, R.N.
Judy Bailey, R.N. Pat Halverson, R.N.
Nancy Root, R.N. Ellie Baker, R.N.
Cheryl Bitting, R.N. Jackie Kisecker, R.N.
Carol Sorrentino, R.N. Cheri Dore-Paulson, R.N.
Lehigh Valley Hospital Kay Gartner, R.N.
Allentown, Pennsylvania Vicki Tigner, R.N.
Loretta Baldwin, R.N., B.S.N. Jan Burnette, R.N.
Karin Prussak, R.N., M.S.N., C.C.R.N. Maggie Scherff, R.N.
Bess Cullen, R.N. Sioux Valley Hospital
Debra Goetz, R.N., M.S.N. Sioux Falls, South Dakota
Susan Goucher, R.N. Keith Hampton, R.N., M.S.N.
Sandra Brackett, R.N., B.S.N. University of Minnesota Hospital
Barbara Johnston, R.N., C.C.R.N. Minneapolis, Minnesota
Lisa Lauderdale, R.N. Eva Adler, R.N., M.S.N.
Randy Shoemaker, R.N., C.C.R.N. Jean Giddens, R.N., M.S.N., C.S.
Memorial Medical Center of Jacksonville Dawn Roseberry, R.N., B.S.N.
Jacksonville, Florida University of New Mexico Hospital
Karen Stiefel, R.N., Ph.D. Albuquerque, New Mexico
Jerre Jones, R.N., M.S.N., C.S.
Lise Heidenreich, R.N., M.S.N., F.N.P., C.S.
Christiana Redwood-Sawyerr, R.N., M.S.N.
Presbyterian Hospital
Charlotte, North Carolina
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Validation Project xv

Fran Tolley, R.N., B.S.N. My gratitude also extends to each of the nurses
Vicky Navarro, R.N., M.A.S. who gave their time to complete the question-
Wilmer Ophthalmological Institute naires.
Johns Hopkins Hospital A sincere thank you to Dr. Ginny
Baltimore, Maryland Arcangelo, Director of the Family Nurse
Heather Boyd-Monk, R.N., M.S.N. Practitioner Program at Thomas Jefferson
Wills Eye Hospital University in Philadelphia, for her work as the
Philadelphia, Pennsylvania methodology consultant to the project.
A study of this magnitude required over
Joan Crosley, R.N., Ph.D. 9000 questionnaires to be produced, duplicated,
Winthrop-University Hospital and distributed. Over 100,000 data entries were
Mineola, New York made, yielding the findings found throughout this
Carol Wong, R.N., M.Sc.N. edition.
Cheryl Simpson, R.N.
Victoria Hospital
London, Canada
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Contents

UNIT I
Introduction to Care Planning 1
Chapter 1 The Bifocal Clinical Practice Model 3
Chapter 2 Documentation of Nursing Care 9
Chapter 3 11 Steps to Care Planning 27
Chapter 4 The Ill Adult: Issues and Responses 32
Chapter 5 Response to the Surgical Experience 38
Chapter 6 Reducing Moral Distress in Nurses 50

UNIT II
Clinical Nursing Care Plans 55

Section 1 ◗ MEDICAL CONDITIONS 61

Generic Medical Care Plan for the Hospitalized Multiple Sclerosis 258
Adult Client 62 Myasthenia Gravis 269
Cardiovascular and Peripheral Vascular Neurogenic Bladder 275
Disorders 83 Parkinson Disease 286
Heart Failure 83 Seizure Disorders 292
Deep Venous Thrombosis 87 Spinal Cord Injury 298
Hypertension 93 Hematologic Disorders 318
Acute Coronary Syndrome 99 Sickle Cell Disease 318
Peripheral Arterial Disease Integumentary Disorders 326
(Atherosclerosis) 110 Pressure Ulcers 326
Respiratory Disorders 118 Thermal Injuries 334
Asthma 118 Musculoskeletal and Connective
Chronic Obstructive Pulmonary Tissue Disorders 354
Disease 125 Fractures 354
Pneumonia 137 Inflammatory Joint Disease (Rheumatoid
Metabolic and Endocrine Disorders 145 Arthritis, Infectious Arthritis, or Septic
Cirrhosis 145 Arthritis) 360
Diabetes Mellitus 152 Osteomyelitis 375
Hepatitis (Viral) 163 Osteoporosis 379
Hypothyroidism 168 Infectious and Immunodeficient Disorders 385
Obesity 174 Human Immunodeficiency Virus/Acquired
Pancreatitis 180 Immunodeficiency Syndrome 385
Gastrointestinal Disorders 190 Systemic Lupus Erythematosus 400
Gastroenterocolitis/Enterocolitis 190 Neoplastic Disorders 407
Inflammatory Bowel Disease 194 Cancer: Initial Diagnosis 407
Peptic Ulcer Disease 206 Cancer: End-Stage 417
Renal and Urinary Tract Disorders 212 Leukemia 433
Acute Kidney Failure 212 Clinical Situations 441
Chronic Kidney Disease 219 Alcohol Withdrawal Syndrome 441
Neurologic Disorders 236 Immobility or Unconsciousness 450
Cerebrovascular Accident (Stroke) 236 Sexual Assault 457
Guillain-Barré Syndrome 251
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xviii Contents

Section 2 ◗ SURGICAL PROCEDURES 463

Generic Care Plan for the Surgical Client 464 Fractured Hip and Femur 572
Abdominal Aortic Aneurysm Resection 480 Hysterectomy 584
Amputation 485 Ileostomy 590
Arterial Bypass Grafting in the Laminectomy 606
Lower Extremity 497 Laryngectomy 612
Breast Surgery (Lumpectomy, Mastectomy) 503 Neck Dissection 614
Carotid Endarterectomy 511 Nephrectomy 624
Cataract Extraction 517 Radical Prostatectomy 629
Colostomy 525 Thoracic Pulmonary Surgery 636
Coronary Artery Bypass Grafting 540 Total Joint Replacement
Cranial Surgery 554 (Hip, Knee, Shoulder) 647
Enucleation 565 Urostomy 655

Section 3 ◗ DIAGNOSTIC AND THERAPEUTIC PROCEDURES 667

Anticoagulant Therapy 668 References/Bibliography 764
Casts 672 Appendix 778
Chemotherapy 678
Corticosteroid Therapy 691
Clinical Situations Index 787
Enteral Nutrition 699 Nursing Diagnoses Index 789
Hemodialysis 707 Collaborative Problems Index 796
Long-Term Venous Access Devices 713 General Index 802
Mechanical Ventilation 719
Pacemaker Insertion (Permanent) 726
Peritoneal Dialysis 736
Radiation Therapy 746
Total Parenteral Nutrition 756
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UNIT

I
Introduction to
Care Planning
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1 THE BIFOCAL CLINICAL

PRACTICE MODEL

The classification activities of the North American Nursing Diagnosis Association International
(NANDA-I) have been instrumental in defining nursing’s unique body of knowledge. This unified system
of terminology
• Provides consistent language for oral, written, and electronic communication
• Stimulates nurses to examine new knowledge
• Establishes a system for automation and reimbursement
• Provides an educational framework
• Allows efficient information retrieval for research and quality assurance
• Provides a consistent structure for literature presentation of nursing knowledge
• Clarifies nursing as an art and a science for its members and society
• Establishes standards to which nurses are held accountable
The inside cover of this text provides a list of nursing diagnoses grouped under conditions that necessitate
nursing care.
Clearly, nursing diagnosis has influenced the nursing profession positively. Integration of nursing diag-
nosis into nursing practice, however, has proved problematic. Although references to nursing diagnosis in the
literature have increased 100-fold since the first meeting in 1973 of the National Group for the Classification
of Nursing Diagnoses (which later became NANDA-I), nurses have not seen efficient and representative appli-
cations. For example, nurses have been directed to use nursing diagnoses exclusively to describe their clinical
focus. Nevertheless, nurses who strongly support nursing diagnosis often become frustrated when they try to
attach a nursing diagnosis label to every facet of nursing practice. Some of the dilemmas that result from the
attempt to label as nursing diagnoses all situations in which nurses intervene are as follows:
1. Using nursing diagnoses without validation. When the nursing diagnoses are the only labels or diagnostic
statements the nurse can use, the nurse is encouraged to “change the data to fit the label.” For exam-
ple, using the Imbalanced Nutrition category for all clients who are given nothing-by-mouth status.
Risk for Injury also frequently serves as a “wastebasket” diagnosis because all potentially injurious situ-
ations (e.g., bleeding) can be captured within a Risk for Injury diagnosis.
2. Renaming medical diagnoses. Clinical nurses know that an important component of their practice is
monitoring for the onset and status of physiologic complications and initiating both nurse-prescribed
and physician-prescribed interventions. Morbidity and mortality are reduced and prevented because
of nursing’s expert management.
If nursing diagnoses are to describe all situations in which nurses intervene, then clearly a vast
number must be developed to describe the situations identified in the International Code of Diseases
(ICD-10). Table 1.1 represents examples of misuse of nursing diagnoses and the renaming of medical
diagnoses. Examination of the substitution of nursing diagnosis terminology for medical diagnoses or
pathophysiology in Table 1.1 gives rise to several questions:
• Should nursing diagnoses describe all situations in which nurses intervene?
• If a situation is not called a nursing diagnosis, is it then less important or scientific?
• How will it serve the profession to rename medical diagnoses as nursing diagnoses?
• Will using the examples in Table 1.1 improve communication and clarify nursing?
3. Omitting problem situations in documentation. If a documentation system requires the use of nursing
diagnosis exclusively, and if the nurse does not choose to “change the data to fit a category” or “to
rename medical diagnoses,” then the nurse has no terminology to describe a critical component of
nursing practice. Failure to describe these situations can seriously jeopardize nursing’s effort to justify
and affirm the need for professional nurses in all health care settings (Carpenito, 1983).

3
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4 Introduction to Care Planning

TABLE 1.1 Diagnostic Errors: Renaming Medical Diagnoses With

Nursing Diagnosis Terminology
Medical Diagnosis Nursing Diagnosis
Myocardial Infarction Decreased Cardiac Output

Shock Decreased Cardiac Output

Adult Respiratory Distress Impaired Gas Exchange

Chronic Obstructive Lung Disease Impaired Gas Exchange

Asthma Impaired Gas Exchange

Alzheimer’s Disease Impaired Cerebral Tissue Perfusion

Increased Intracranial Pressure Impaired Cerebral Tissue Perfusion

Retinal Detachment Disturbed Sensory Perception: Visual

Thermal Burns Impaired Tissue Integrity

Incisions, Lacerations Impaired Skin Integrity

Hemorrhage Deficient Fluid Volume

Congestive Heart Failure Excess Fluid Volume

Bifocal Clinical Practice Model

Nursing’s theoretical knowledge derives from the natural, physical, and behavioral sciences, as well as the
humanities and nursing research. Nurses can use various theories in practice, including family systems, loss,
growth and development, crisis intervention, and general systems theories.
The difference between nursing and the other health care disciplines is nursing’s depth and breadth
of focus. Certainly the nutritionist has more expertise in the field of nutrition and the pharmacist in the
field of therapeutic pharmacology than any nurse. Every nurse, however, brings a knowledge of nutrition
and pharmacology to client interactions. The depth of this knowledge is sufficient for many client situa-
tions; when it is insufficient, consultation is required. No other discipline has this varied knowledge,
explaining why attempts to substitute other disciplines for nursing have proved costly and ultimately unsuc-
cessful. Figure 1.1 illustrates this varied expertise.
The Bifocal Clinical Practice Model (Carpenito, 1983) represents situations that influence persons,
groups, and communities as well as the classification of these responses from a nursing perspective. The
situations are organized into five broad categories: pathophysiologic, treatment-related, personal, environ-
mental, and maturational (Figure 1.2). Without an understanding of such situations, the nurse will be
unable to diagnose responses and intervene appropriately.
Clinically, these situations are important to nurses. Thus, as nursing diagnoses evolved, nurses sought
to substitute nursing terminology for these situations; for example, Impaired Tissue Integrity for burns and
High Risk for Injury for dialysis. Nurses do not prescribe for and treat these situations (e.g., burns and dial-
ysis). Rather, they prescribe for and treat the responses to these situations.
The practice focus for clinical nursing is at the response level, not at the situation level. For example,
a client who has sustained burns may exhibit a wide variety of responses to the burns and the treatments.
Some responses may be predicted, such as High Risk for Infection; others, such as fear of losing a job, may
not be predictable. In the past, nurses focused on the nursing interventions associated with treating burns
rather than on those associated with the client’s responses. This resulted in nurses being described as “doers”
rather than “knowers”; as technicians rather than scientists.

Nursing Diagnoses and Collaborative Problems

The Bifocal Clinical Practice Model describes the two foci of clinical nursing: nursing diagnoses and col-
laborative problems.
A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or poten-
tial health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to
achieve outcomes for which the nurse is accountable (NANDA, 1990). Collaborative problems are certain
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The Bifocal Clinical Practice Model 5

Nutrition Self-Care

Expert Expert

Novice Novice

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Wo cial
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So
ys

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y
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trit

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Signs/Symptoms of Bleeding Pressure Ulcer Prevention

Expert Expert

Novice Novice
rse

an

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ist
Wo cial

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Th sica
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FIGURE 1.1
Th sica
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ici

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Knowledge of multidisciplines of selected
trit

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topics.

physiologic complications that nurses monitor to detect onset or changes of status. Nurses manage collaborative
problems using physician-prescribed and nursing-prescribed interventions to minimize the complications of the
events (Carpenito, 1997). Figure 1.3 illustrates the Bifocal Clinical Practice Model.
The nurse makes independent decisions for both collaborative problems and nursing diagnoses. The
difference is that in nursing diagnoses, nursing prescribes the definitive treatment to achieve the desired
outcome, while in collaborative problems, prescription for definitive treatment comes from both nursing
and medicine. Some physiologic complications (such as High Risk for Infection and Impaired Skin
Integrity) are nursing diagnoses because nurses can order the definitive treatment. In a collaborative prob-
lem, the nurse uses surveillance to monitor for the onset and change in status of physiologic complications,
and manages these changes to prevent morbidity and mortality. These physiologic complications are usually

Pathophysiological Treatment-related

Personal

FIGURE 1.2 Environmental Maturational

Examples of pathophysiologic, treatment-
related, personal, environmental, and
maturational situations.
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6 Introduction to Care Planning

FIGURE 1.3
Bifocal clinical practice model. (© 1987, Lynda
Juall Carpenito.)

related to disease, trauma, treatments, medications, or diagnostic studies. Thus, collaborative problems
can be labeled Potential Complication (specify); for example, Potential Complication: Hemorrhage or
Potential Complication: Renal Failure.
Monitoring, however, is not the sole nursing intervention for collaborative problems. For example, in
addition to monitoring a client with increased intracranial pressure, the nurse also restricts certain activi-
ties, maintains head elevation, implements the medical regimen, and continually addresses the client’s psy-
chosocial and educational needs.
The following are some collaborative problems that commonly apply to certain situations:

Situation Collaborative Problem

Myocardial Infarction Potential Complication (PC): Dysrhythmias

Craniotomy PC: Increased Intracranial Pressure

Hemodialysis PC: Fluid/Electrolyte Imbalance

Surgery PC: Hemorrhage

Cardiac Catheterization PC: Allergic Reaction

If the situation calls for the nurse to monitor for a cluster or group of physiologic complications, the col-
laborative problems may be documented as
PC: Cardiac
or
PC: Post-op: Urinary retention
PC: Hemorrhage
PC: Hypovolemia
PC: Hypoxia
PC: Thrombophlebitis
PC: Renal insufficiency
PC: Paralytic ileus
PC: Evisceration
A list of common collaborative problems grouped under conditions that necessitate nursing care
appears on the inside front and back covers. Not all physiologic complications, however, are collaborative problems.
Nurses themselves can prevent some physiologic complications such as infections from external sources