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 Nurse's Pocket
Guide, 15e:
Diagnoses,
Prioritized
Interventions and
Rationales

Marilynn E. Doenges
Mary F. Moorhouse
Alice C. Murr
 CONTRIBUTORS TO PREVIOUS EDITIONS

Sheila Marquez
Formerly Executive Director
Vice President/Chief Operating Officer
The Colorado SIDS Program, Inc.
Denver, Colorado

Cayrn F. Demaree, RN, BSN, IBCLC

Lactation Specialist
Denver Health Medical Center
Denver, Colorado

Mary Katherine Blackwell

Research Assistant
Mississippi State University
Columbus, Mississippi

7644_FM_pi-xiv.indd v 18/12/18 10:54 AM

7644_FM_pi-xiv.indd vi 18/12/18 10:54 AM
 ACKNOWLEDGMENTS

A special acknowledgment to Marilynn’s friend, the late

Diane Camillone, who provoked an awareness of the role of
the patient and continues to influence our thoughts about the
importance of quality nursing care, and to our late colleague,
Mary Jeffries, who started us on this journey and introduced us
to nursing diagnoses.
To our colleagues in NANDA International, who continue to
formulate and refine nursing diagnoses to provide nursing with
the tools to enhance and promote the growth of the profession.

Marilynn E. Doenges
Mary Frances Moorhouse
Alice C. Murr

vii

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7644_FM_pi-xiv.indd viii 18/12/18 10:54 AM
 CONTENTS

H ealth Conditions and Client Concerns with Associated

Nursing Diagnoses appear on pages 978–1118.

How to Use the Nurse’s Pocket Guide xi

CHAPTER 1
The Nursing Process and Planning Client Care 1

CHAPTER 2
Nursing Diagnoses in Alphabetical Order 4
For each nursing diagnosis, the following information is provided:
Diagnostic Division
Definition
Related/Risk Factors
Defining Characteristics: Subjective/Objective
Desired Outcomes/Evaluation Criteria
Actions/Interventions
Nursing Priorities
Documentation Focus
Sample Nursing Outcomes & Nursing Interventions
Classifications (NOC/NIC)

CHAPTER 3
Health Conditions and Client Concerns With
Associated Nursing Diagnoses 978
APPENDIX 1
Tools for Choosing Nursing Diagnoses 1119
SECTION 1
Adult Medical/Surgical Assessment Tool 1120
SECTION 2
Diagnostic Divisions: Nursing Diagnoses Organized
According to a Nursing Focus 1132

APPENDIX 2

SECTION 1
Client Situation and Prototype Plan of Care 1140
Plan of Care for Client with Diabetes Mellitus 1148
SECTION 2
Another Approach to Planning Client Care—
Mind or Concept Mapping 1156
Bibliography (See DavisPlus)
Index 1158
ix

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7644_FM_pi-xiv.indd x 18/12/18 10:54 AM
 HOW TO USE THE NURSE’S
POCKET GUIDE

T he American Nurses Association (ANA) Social Policy

Statement of 1980 was the first to define nursing as the diag-
nosis and treatment of human responses to actual and potential
health problems. This definition, when combined with the ANA
Standards of Practice, provided impetus and support for the use
of nursing diagnosis. Defining nursing and its effect on client
care supports the growing awareness that nursing care is a key
factor in client survival and in the maintenance, rehabilitative,
and preventive aspects of healthcare. Changes and new devel-
opments in healthcare delivery in the past 40 years have given
rise to the need for a common framework of communication to
ensure continuity of care for the client moving between mul-
tiple healthcare settings and providers. Evaluation and docu-
mentation of care are important parts of this process.
This book is designed to aid the practitioner and student
nurse in identifying interventions commonly associated with
specific nursing diagnoses as proposed by NANDA Interna-
tional (NANDA-I). These interventions are the activities needed
to implement and document care provided to the individual cli-
ent and can be used in varied settings from acute to community/
home care.
Chapter 1 presents a brief discussion of the nursing process,
data collection, and care plan construction. Appendix 1 contains
tools for choosing nursing diagnoses—an Adult Assessment
Tool and the Diagnostic Divisions list. Appendix 2 puts theory
into practice with a sample assessment database and a corre-
sponding plan of care. A mind or concept map is also provided.
For more in-depth information and inclusive plans of care
related to specific medical or psychiatric conditions and mater-
nal/newborn care (with rationale and the application of the
diagnoses), the nurse is referred to the larger work, published
by the F. A. Davis Company: Nursing Care Plans: Guidelines
for Individualizing Client Care Across the Life Span, ed. 10
(Doenges, Moorhouse, & Murr, 2019), including access to
psychiatric and maternal/newborn plans of care. For nursing
diagnoses and interventions with evidence-based citations, refer
to the more in-depth work published by the F. A. Davis Com-
pany: Nursing Diagnosis Manual: Planning, Individualizing,
and Documenting Client Care, ed. 6 (Doenges, Moorhouse, &
Murr, 2019).
Nursing diagnoses are listed alphabetically in Chapter 2 for
ease of reference and include the diagnoses accepted for use by

xi

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 NANDA-I through 2018–2020. Each diagnosis approved for
testing includes its definition and information divided into the
NANDA-I categories of Related or Risk Factors and Defining
Characteristics. Related/Risk Factors information reflects caus-
ative or contributing factors that can be useful for determining
whether the diagnosis is applicable to a particular client. Defin-
ing Characteristics (signs and symptoms or cues) are listed as
subjective and/or objective and are used to confirm problem-
focused diagnoses or readiness for enhanced diagnoses, aid in
formulating outcomes, and provide additional data for choos-
ing appropriate interventions. The authors have not deleted or
altered NANDA-I’s listings; however, on occasion, they have
added to their definitions or suggested additional criteria to
provide clarification and direction. These additions are denoted
with brackets [ ].
The ANA, in conjunction with NANDA-I, proposed that
specific nursing diagnoses currently approved and structured
according to Taxonomy I Revised be included in the Inter-
national Classification of Diseases (ICD) within the section
“Family of Health-Related Classifications.” Although the World
Health Organization did not accept this initial proposal because
of lack of documentation of the usefulness of nursing diagnoses
at the international level, the NANDA-I list has been accepted
by SNOMED (Systemized Nomenclature of Medicine) for
inclusion in its international coding system and is included in
the Unified Medical Language System of the National Library
of Medicine. Today, nurse researchers from around the world
have submitted new nursing diagnoses and are validating cur-
rent diagnoses in support for resubmission and acceptance of
the NANDA-I list in future editions of the ICD.
The authors have chosen to categorize the list of nursing
diagnoses approved for clinical use and testing into Diagnos-
tic Divisions, which is the framework for an assessment tool
(Appendix 1) designed to assist the nurse to readily identify
an appropriate nursing diagnosis from data collected during
the assessment process. The Diagnostic Division label is listed
under each nursing diagnosis heading.
Desired Outcomes/Evaluation Criteria are identified to
assist the nurse in formulating individual client outcomes and
to support the evaluation process.
Interventions in this pocket guide are primarily directed to
adult care settings (although general age-span considerations
are included) and are listed according to nursing priorities.
Some interventions require collaborative or interdependent
orders (e.g., medical, psychiatric), and the nurse will need to
determine when this is necessary and take appropriate action.
The inclusion of Documentation Focus suggestions is to
remind the nurse of the importance and necessity of recording
the steps of the nursing process.
xii Nurse’s Pocket Guide

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 Finally, in recognition of the ongoing work of numerous
researchers over the past 35 years, the authors have referenced
the Nursing Interventions and Outcomes labels developed by
the Iowa Intervention Projects (Bulechek, Butcher, & Dochter-
man; Moorhead, Johnson, Mass, & Swanson). These groups
have been classifying nursing interventions and outcomes to
predict resource requirements and measure outcomes, thereby
meeting the needs of a standardized language that can be coded
for computer and reimbursement purposes. As an introduction
to this work in progress, sample NIC and NOC labels have
been included under the heading Sample Nursing Interventions
& Outcomes Classifications at the conclusion of each nursing
diagnosis section. The reader is referred to the various publica-
tions by Joanne C. Dochterman and Marion Johnson for more
in-depth information.
Chapter 3 presents 460 disorders/health conditions reflect-
ing all specialty areas, with associated nursing diagnoses writ-
ten as client diagnostic statements that include the “related to”
and “evidenced by” components as appropriate. This section
will facilitate and help validate the assessment and problem or
need identification steps of the nursing process.
As noted, with few exceptions, we have presented NANDA-I’s
recommendations as formulated. We support the belief that
practicing nurses and researchers need to study, use, and evalu-
ate the diagnoses as presented. Nurses can be creative as they
use the standardized language, redefining and sharing informa-
tion as the diagnoses are used with individual clients. As new
nursing diagnoses are developed, it is important that the data
they encompass are added to assessment tools and current
databases. As part of the process by clinicians, educators, and
researchers across practice specialties and academic settings
to define, test, and refine nursing diagnosis, nurses are encour-
aged to share insights and ideas with NANDA-I online at http://
www.nanda.org or at the following address: NANDA Interna-
tional, PO Box 157, Kaukauna, WI 54130–0157.

How to Use the Nurse’s Pocket Guide xiii

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7644_FM_pi-xiv.indd xiv 18/12/18 10:54 AM
 CHAPTER 1
The Nursing Process and
Planning Client Care

The Nursing Process

Nursing is both a science and an art concerned with the physi-
cal, psychological, sociological, cultural, and spiritual concerns
of the individual receiving care. The science of nursing is based
on a broad theoretical framework; its art depends on the caring
skills and abilities of the individual nurse.
The nursing profession continues work to formally define
what nurses do and what makes nursing unique, leading to a
body of professional knowledge distinctive to nursing prac-
tice. A significant portion of defining the work of nursing has
involved the establishment of a commonality of terminology or
standardization of nursing language. Although several standard-
ized nursing languages have been developed, the nursing diag-
noses most commonly used today are the NANDA-I nursing
diagnoses (see inside cover).
In 1980, the American Nurses Association (ANA) defined
nursing as “the diagnosis and treatment of human responses to
actual or potential health problems.” As the nursing profession
has evolved, the definition of nursing has been expanded to
reflect that growth—“nursing is the protection, promotion, and
optimization of health and abilities, prevention of illness and
injury, alleviation of suffering through the diagnosis and treat-
ment of human responses, and advocacy in the care of individu-
als, families, communities, and populations” (Nursing’s Social
Policy Statement, ANA, 2003, p. 6).
Nursing process is patterned after the scientific method of
observing, measuring, gathering data, and analyzing findings.
This process incorporates an interactive and interpersonal
approach with a problem-solving and decision-making pro-
cess (Peplau, 1952; King, 1971; Yura & Walsh, 1988). Shore
(1988) described the nursing process as “combining the most
desirable elements of the art of nursing with the most relevant
elements of systems theory, using the scientific method.” It can
be applied in any healthcare or educational setting, in any theo-
retical or conceptual framework, and within the context of any
nursing theory. Therefore, because nursing process is the basis
of all nursing action, we believe that it is the essence of nursing.

7644_Ch01_p1-3.indd 1 18/12/18 10:00 AM

 The five steps of the nursing process are (1) assessment—
systematically gathering data, sorting and organizing the col-
lected data, and documenting the data in a retrievable format;
(2) diagnosis—analyzing collected data to identify the client’s
needs or problems; (3) planning—setting priorities, establish-
ing goals, identifying desired client outcomes, and determining
specific nursing interventions; (4) implementation—putting the
plan of care into action and performing the planned interven-
tions; and (5) evaluation—determining the client’s progress
toward attaining the identified outcomes and monitoring the
client’s response to and effectiveness of the selected nursing
interventions.

Planning Care
The identification of client needs is the cornerstone for the plan
of care. We support that healthcare providers have a respon-
sibility for planning care along with the client with the goal
toward the eventual outcome of an optimal state of wellness
or a dignified death. Client-centered care engages the client in
responsibility for his or her own care while helping to ensure
that nursing interventions are timely and appropriate.
Creating a plan of care begins with the collection of data
(assessment). The database consists of subjective and objec-
tive client information. Analysis of the collected data leads to
the identification (diagnosis) of problems or areas of concern
(including health promotion) specific to the client. These prob-
lems or needs are expressed as nursing diagnoses (NDs). To
facilitate the diagnosis process, the authors have divided the
NDs into Diagnostic Divisions (Appendix 1), and a sample
assessment tool is also provided, designed to assist the nurse to
identify appropriate NDs as the data are collected.
When the needs are identified, nursing diagnoses are catego-
rized as (1) problem-focused NDs; (2) risk NDs, which could
develop due to specific vulnerabilities of the client; (3) health
promotion NDs, which reflect a client’s desire to improve his
or her well-being; and (4) syndrome NDs, which reflect a spe-
cific cluster of NDs that occur together and are best addressed
together and through similar interventions.
Setting goals and choosing appropriate nursing interven-
tions are also essential to the construction of a plan of care and
the delivery of quality nursing care. Desired outcomes are the
incremental steps formulated to give direction to and evaluate
effectiveness of the care provided in achieving broader goals.
Interventions are those activities that the nurse, client, and/or
significant others perform to promote the client’s movement
toward achieving the desired outcomes.
An individualized client diagnostic statement can be for-
mulated using the problem, etiology, and signs and symptoms

2 Nurse’s Pocket Guide

7644_Ch01_p1-3.indd 2 18/12/18 10:00 AM

 (PES) format by combining the ND label (problem) with the
individual’s specific related factors (etiology) and defining char-
acteristics (signs/symptoms), or risk factors when present. The
resulting client diagnostic statement accurately represents the
client’s current situation, providing direction for nursing care.
Once the plan of care is put into action, changes in client
needs must be continually monitored, because care is pro-
vided in a dynamic environment and flexibility is required to
allow changing circumstances. Periodic review of the client’s
responses to nursing interventions and progress toward attain-
ing desired outcomes help determine effectiveness of the plan
of care. Based on findings, the plan may need to be modified,
referrals to other resources may be required, or the client may
be ready for discharge from the care setting.
Properly written and applied plans of care can save time by
providing direction for continuity of care and by facilitating
communication among nurses and other caregivers. The format
for recording the plan of care is determined by agency policy;
it may be handwritten or computer-generated and may utilize
standardized forms as with clinical pathways.
Ongoing changes in healthcare delivery and computeriza-
tion of client records require a commonality of communication
across clinical settings. By way of example, whereas a medical
diagnosis of diabetes mellitus is the same label used for all
individuals with this condition, the nursing diagnostic statement
is individualized to reflect a specific client need or response. We
use the NANDA-I nursing diagnoses labels to define the client’s
responses to diabetes. For example, the diagnostic statement
may read, “risk for unstable Blood Glucose Level as evidenced
by inadequate blood glucose monitoring, ineffective medication
management.”
The plan of care is not only the end product of the nursing
process, but it also documents client care in areas of account-
ability, quality assurance, and liability. It not only guides the
nurse actively caring for the client (determining client’s needs
[NDs], goals/outcomes, and actions to be taken) but also sub-
stantiates the care provided for review by third-party payers,
legal entities, and accreditation agencies. Therefore, the plan of
care is a critical and permanent part of the client’s healthcare
record.
In Appendix 2, a sample scenario provides an opportunity
to review a client assessment, the plan of care, and Mind Map
created based on the data collected.

The Nursing Process and Planning Client Care 3

7644_Ch01_p1-3.indd 3 18/12/18 10:00 AM

 CHAPTER 2
Nursing Diagnoses
in Alphabetical Order

ACTIVITY INTOLERANCE and risk for ACTIVITY

INTOLERANCE
[Diagnostic Division: Activity/Rest]
Definition: Activity Intolerance: Insufficient physiological
or psychological energy to endure or complete required or
desired daily activities.
Definition: risk for Activity Intolerance: Susceptible to expe-
riencing insufficient physiological or psychological energy to
endure or complete required or desired daily activities, which
may compromise health.

Related Factors (Activity Intolerance)

Physical deconditioning
Sedentary lifestyle
Immobility
Imbalance between oxygen supply and demand
Risk Factors (risk for Activity Intolerance)
Imbalance between oxygen supply/demand
Immobility, physical deconditioning; sedentary lifestyle
Inexperience with an activity
At Risk Population: History of previous activity intolerance

Defining Characteristics
(Activity Intolerance)
Subjective
Fatigue, generalized weakness
Exertional discomfort; dyspnea
Objective
Abnormal heart rate or blood pressure response to activity

Information that appears in brackets has been added by the authors to clarify
and enhance the use of nursing diagnoses.

4 Acute Care Collaborative Community/Home Care Cultural

7644_Ch02_A_p4-57.indd 4 18/12/18 10:28 AM

 ECG change [e.g., arrhythmia, conduction abnormality,

ACTIVITY INTOLERANCE and risk for ACTIVITY INTOLERANCE

ischemia]

Functional Level Classification

(Gordon, 2010):
Level I: Walk, regular pace, on level indefinitely; climb one
flight or more but more short of breath than normal
Level II: Walk one city block [or] 500 ft on level; climb one
flight slowly without stopping
Level III: Walk no more than 50 ft on level without stopping;
unable to climb one flight of stairs without stopping
Level IV: Dyspnea and fatigue at rest

Desired Outcomes/Evaluation Criteria—

Client Will (Activity Intolerance):
• Identify negative factors affecting activity tolerance and
eliminate or reduce their effects when possible.
• Use identified techniques to enhance activity tolerance.
• Participate willingly in necessary/desired activities.
• Report measurable increase in activity tolerance.
• Demonstrate a decrease in physiological signs of intolerance
(e.g., pulse, respirations, and blood pressure remain within
client’s normal range).

Desired Outcomes/Evaluation Criteria—

Client Will (risk for Activity Intolerance):
• Verbalize understanding of potential loss of ability in relation
to existing condition.
• Participate in conditioning/rehabilitation program to enhance
ability to perform.
• Identify alternative ways to maintain desired activity level
(e.g., walking in a shopping mall if weather is bad).
• Identify conditions or symptoms that require medical
reevaluation.

Actions/Interventions
Nursing Priority No. 1.
To identify causative/precipitating or risk factors:
• Note presence of acute or chronic illness, such as heart fail-
ure, pulmonary disorders, hypothyroidism, diabetes mellitus,
AIDS, anemias, cancers, pregnancy-induced hypertension,
and acute and chronic pain. Many factors can cause or
contribute to fatigue, having potential to interfere with

Information that appears in brackets has been added by the authors to clarify
and enhance the use of nursing diagnoses.

Diagnostic Studies Medications Pediatric/Geriatric/Lifespan 5

7644_Ch02_A_p4-57.indd 5 18/12/18 10:28 AM

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