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NURSE’S POCKET MINDER
Convert Nursing Problem
Statement Into Nursing Diagnosis
Quickly Easily Accurately
THE NURSING REFERENCE
Following is a complete listing of all NANDA Nursing Diagnoses through the 15th conference
ACTIVITY/REST—Ability to engage in Relocation Stress Syndrome 565–569
necessary/desired activities of life (work and Relocation Stress Syndrome, risk for 569–571
leisure) and to obtain adequate sleep/rest Self-Concept, readiness for enhanced 583–587
Activity Intolerance 70–73 Self-Esteem, chronic low 587–591
Activity Intolerance, risk for 74–76 Self-Esteem, situational low 591–594
Disuse Syndrome, risk for 270–275 Self-Esteem, risk for situational low 595–597
Diversional Activity, deficient 276–279 Sorrow, chronic 643–646
Fatigue 307–312 Spiritual Distress 646–651
Insomnia 421–426 Spiritual Distress, risk for 651–654
Lifestyle, sedentary 440–445 Spiritual Well-Being, readiness for enhanced
Mobility, impaired bed 454–457 655–658
Mobility, impaired wheelchair 461–464
Sleep, readiness for enhanced 627–630 ELIMINATION—Ability to excrete waste
Sleep Deprivation 630–634 products
Transfer Ability, impaired 714–716 Bowel Incontinence 123–127
Walking, impaired 774–777 Constipation 194–199
Constipation, perceived 199–201
CIRCULATION—Ability to transport Constipation, risk for 201–204
oxygen and nutrients necessary to meet Diarrhea 259–264
cellular needs Urinary Elimination, impaired 721–726
Autonomic Dysreflexia 105–108 Urinary Elimination, readiness for enhanced
Autonomic Dysreflexia, risk for 108–111 726–729
Cardiac Output, decreased 145–151 Urinary Incontinence, functional 729–732
Intracranial Adaptive Capacity, decreased Urinary Incontinence, overflow 732–735
427–430 Urinary Incontinence, reflex 735–738
Tissue Perfusion, ineffective (specify type: Urinary Incontinence, risk for urge 738–741
renal, cerebral, cardiopulmonary, gastroin- Urinary Incontinence, stress 741–744
testinal, peripheral) 705–714 Urinary Incontinence, total 744–748
Urinary Incontinence, urge 748–752
Urinary Retention [acute/chronic] 752–756
EGO INTEGRITY—Ability to develop and
use skills and behaviors to integrate and
FOOD/FLUID—Ability to maintain intake
manage life experiences
of and utilize nutrients and liquids to meet
Anxiety [specify level] 88–94
Anxiety, death 94–97 physiological needs
Behavior, risk-prone health 111–115 Breastfeeding, effective 127–130
Body Image, disturbed 115–120 Breastfeeding, ineffective 130–136
Conflict, decisional [specify] 176–179 Breastfeeding, interrupted 136–140
Coping, defensive 220–223 Dentition, impaired 252–256
Coping, ineffective 227–231 Failure to Thrive, adult 287–291
Coping, readiness for enhanced 234–237 Fluid Balance, readiness for enhanced 316–320
Decision Making, readiness for enhanced [Fluid Volume, deficient hyper/hypotonic]
247–249 320–323
Denial, ineffective 249–252 Fluid Volume, deficient [isotonic] 324–327
Dignity, risk for compromised human 264–266 Fluid Volume, excess 327–331
Distress, moral 266–270 Fluid Volume, risk for deficient 331–334
Energy Field, disturbed 279–282 Fluid Volume, risk for imbalanced 334–337
Fear 312–316 Glucose, risk for unstable blood 341–345
Grieving 345–349 Infant Feeding Pattern, ineffective 406–409
Grieving, complicated 349–353 Liver Function, risk for impaired 445–448
Grieving, risk for complicated 353–356 Nausea 464–469
Hope, readiness for enhanced 376–379 Nutrition: less than body requirements,
Hopelessness 379–383 imbalanced 478–483
Personal Identity, disturbed 430–433 Nutrition: more than body requirements,
Post-Trauma Syndrome 527–533 imbalanced 483–487
Post-Trauma Syndrome, risk for 533–537 Nutrition: more than body requirements, risk
Power, readiness for enhanced 537–540 for imbalanced 488–491
Powerlessness 540–544 Nutrition, readiness for enhanced 491–494
Powerlessness, risk for 544–547 Oral Mucous Membrane, impaired 494–498
Rape-Trauma Syndrome 549–555 Swallowing, impaired 675–680
Rape-Trauma Syndrome: compound reaction
550 HYGIENE—Ability to perform activities of
Rape-Trauma Syndrome: silent reaction 551 daily living
Religiosity, impaired 556–559 Self-Care, readiness for enhanced 580–583
Religiosity, readiness for enhanced 559–562 Self-Care Deficit, bathing/hygiene 575–580
Religiosity, risk for impaired 562–565 Self-Care Deficit, dressing/grooming 575–580
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Self-Care Deficit, feeding 575–580 Suffocation, risk for 662–666
Self-Care Deficit, toileting 575–580 Suicide, risk for 666–670
Surgical Recovery, delayed 670–674
NEUROSENSORY—Ability to perceive, Thermoregulation, ineffective 694–696
integrate, and respond to internal and external Tissue Integrity, impaired 701–705
cues Trauma, risk for 716–721
Confusion, acute 183–187 Violence, [actual/] risk for other-directed
Confusion, risk for acute 191–194 766–767
Confusion, chronic 187–191 Violence, [actual/] risk for self-directed 768–774
Infant Behavior, disorganized 396–402 Wandering [specify sporadic or continual]
Infant Behavior, readiness for enhanced orga- 777–780
nized 402–405
Infant Behavior, risk for disorganized 405–406 SEXUALITY— [Component of Ego
Memory, impaired 451–454 Integrity and Social Interaction] Ability to
Neglect, unilateral 469–473 meet requirements/characteristics of
Peripheral Neurovascular Dysfunction, risk for male/female role
519–523 Sexual Dysfunction 610–615
Sensory Perception, disturbed (specify: visual, Sexuality Pattern, ineffective 615–618
auditory, kinesthetic, gustatory, tactile,
olfactory) 605–610 SOCIAL INTERACTION—Ability to
Stress Overload 658–662 establish and maintain relationships
Thought Processes, disturbed 696–700
Attachment, risk for impaired parent/child
102–104
PAIN/DISCOMFORT—Ability to control Caregiver Role Strain 151–157
internal/external environment to maintain Caregiver Role Strain, risk for 158–161
comfort Communication, impaired verbal 166–171
Comfort, readiness for enhanced 161–166 Communication, readiness for enhanced
Pain, acute 498–503 171–176
Pain, chronic 503–508 Conflict, parental role 180–183
Coping, ineffective community 232–234
RESPIRATION—Ability to provide and Coping, readiness for enhanced community
use oxygen to meet physiological needs 238–240
Airway Clearance, ineffective 77–81 Coping, compromised family 217–220
Aspiration, risk for 98–101 Coping, disabled family 223–227
Breathing Pattern, ineffective 140–144 Coping, readiness for enhanced family 240–243
Gas Exchange, impaired 337–341 Family Processes: alcoholism, dysfunctional
Ventilation, impaired spontaneous 756–762 296–300
Ventilatory Weaning Response, dysfunctional Family Processes, interrupted 300–303
762–766 Family Processes, readiness for enhanced
304–307
SAFETY—Ability to provide safe, growth- Loneliness, risk for 448–451
promoting environment Parenting, impaired 508–513
Allergy Response, latex 81–85 Parenting, readiness for enhanced 513–517
Allergy Response, risk for latex 85–87 Parenting, risk for impaired 517–519
Body Temperature, risk for imbalanced 120–123 Role Performance, ineffective 571–574
Contamination 204–212 Social Interaction, impaired 635–639
Contamination, risk for 212–217 Social Isolation 639–643
Death Syndrome, risk for sudden infant
243–247 TEACHING/LEARNING—Ability to
Environmental Interpretation Syndrome, incorporate and use information to achieve
impaired 283–287 healthy lifestyle/optimal wellness
Falls, risk for 291–295 Development, risk for delayed 256–259
Health Maintenance, ineffective 366–370 Growth, risk for disproportionate 356–360
Home Maintenance, impaired 373–376 Growth and Development, delayed 361–366
Hyperthermia 383–387 Health-Seeking Behaviors (specify) 370–376
Hypothermia 388–392 Knowledge, deficient (specify) 433–438
Immunization status, readiness for enhanced Knowledge, readiness for enhanced 438–440
392–396 Noncompliance [Adherence, ineffective]
Infection, risk for 409–413 [specify] 473–478
Injury, risk for 414–418 Therapeutic Regimen Management, effective
Injury, risk for perioperative positioning 680–683
418–421 Therapeutic Regimen Management, ineffective
Mobility, impaired physical 457–461 683–686
Poisoning, risk for 523–527 Therapeutic Regimen Management, ineffective
Protection, ineffective 547–549 community 686–688
Self-Mutilation 597–601 Therapeutic Regimen Management, ineffective
Self-Mutilation, risk for 601–605 family 689–691
Skin Integrity, impaired 619–624 Therapeutic Regimen Management, readiness
Skin Integrity, risk for impaired 624–627 for enhanced 691–694
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GORDON’S FUNCTIONAL HEALTH PATTERNS*
HEALTH PERCEPTION-HEALTH Risk for impaired liver function 445–448
MANAGEMENT PATTERN Risk for impaired skin integrity 624–627
Contamination 204–212 Risk for unstable blood glucose 341–345
Disturbed energy field 279–282
Effective therapeutic regimen management ELIMINATION PATTERN
680–683 Bowel incontinence 123–127
Health-seeking behaviors (specify) Constipation 194–199
370–376 Diarrhea 259–264
Ineffective community therapeutic regimen Functional urinary incontinence 729–732
management 686–688 Impaired urinary elimination 721–726
Ineffective family therapeutic regimen Overflow urinary incontinence 732–735
management 689–691 Perceived constipation 199–201
Ineffective health maintenance 366–370 Readiness for enhanced urinary elimination
Ineffective protection 547–549 726–729
Ineffective therapeutic regimen management Reflex urinary incontinence 735–738
683–686 Risk for constipation 201–204
Noncompliance 473–478 Risk for urge urinary incontinence 738–741
Readiness for enhanced immunization status Stress urinary incontinence 741–744
392–396 Total urinary incontinence 744–748
Readiness for enhanced therapeutic regimen Urge urinary incontinence 748–752
management 691–694 Urinary retention 752–756
Risk for contamination 212–217
ACTIVITY-EXERCISE PATTERN
Risk for falls 291–295
Activity intolerance (specify) 70–73
Risk for infection 409–413
Autonomic dysreflexia 105–108
Risk for injury (trauma) 414–418
Decreased cardiac output 145–151
Risk for perioperative positioning injury
Decreased intracranial adaptive capacity
418–421
427–430
Risk for poisoning 523–527
Deficient diversional activity 276–279
Risk for suffocation 662–666
Delayed growth and development 361–366
Delayed surgical recovery 670–674
NUTRITIONAL-METABOLIC PATTERN Disorganized infant behavior 396–402
Adult failure to thrive 287–291 Dysfunctional ventilatory weaning response
Deficient fluid volume 320–327 762–766
Effective breastfeeding 127–130 Fatigue 307–312
Excess fluid volume 327–331 Impaired spontaneous ventilation 756– 762
Hyperthermia 383–387 Impaired bed mobility 454–457
Hypothermia 388–392 Impaired gas exchange 337–341
Imbalanced nutrition: more than body Impaired home maintenance 373–376
requirements 483–487 Impaired physical mobility 457–461
Imbalanced nutrition: less than body Impaired transfer ability 714–716
requirements 478–483 Impaired walking 774–777
Imbalanced nutrition: risk for more than Impaired wheelchair mobility 461–464
body requirements 488–491 Ineffective airway clearance 77–81
Impaired dentition 252–256 Ineffective breathing pattern 140–144
Impaired oral mucous membrane Ineffective tissue perfusion (specify)
494–498 705–714
Impaired skin integrity 619–624 Readiness for enhanced organized infant
Impaired swallowing 675–680 behavior 402–405
Impaired tissue integrity (specify type) Readiness for enhanced self-care 580–583
701–705 Risk for delayed development 256–259
Ineffective breastfeeding 130–136 Risk for disorganized infant behavior
Ineffective infant feeding pattern 406–409 405–406
Ineffective thermoregulation 694–696 Risk for disproportionate growth 356–360
Interrupted breastfeeding 136–140 Risk for activity intolerance 74–76
Latex allergy response 81–85 Risk for autonomic dysreflexia 108–111
Nausea 464–469 Risk for disuse syndrome 270–275
Readiness for enhanced fluid balance Risk for peripheral neurovascular
316–320 dysfunction 519–523
Readiness for enhanced nutrition 491–494 Risk for sudden infant death syndrome
Risk for aspiration 98–101 243–247
Risk for deficient fluid volume 331–334 Sedentary lifestyle 440–445
Risk for imbalanced fluid volume 334–337 Self-care deficit (specify: bathing/hygiene,
Risk for imbalanced body temperature dressing/grooming, feeding, toileting)
120–123 575–580
Risk for latex allergy response 85–87 Wandering 777–780
*Modified by Marjory Gordon, 2007, with permission.
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SLEEP-REST PATTERN Ineffective role performance 571–574
Insomnia 421–426 Interrupted family processes 300–303
Readiness for enhanced sleep 627–630 Parental role conflict 180–183
Sleep deprivation 630–634 Readiness for enhanced communication
171–176
COGNITIVE-PERCEPTUAL PATTERN Readiness for enhanced family processes
Acute confusion 183–187 304–307
Acute pain 498–503 Readiness for enhanced parenting 513–517
Chronic confusion 187–191 Relocation stress syndrome 565–569
Chronic pain 503–508 Risk for caregiver role strain 158–161
Decisional conflict (specify) 176–179 Risk for complicated grieving 353–356
Deficient knowledge (specify) 433–438 Risk for impaired parent/child attachment
Disturbed sensory perception (specify) 102–104
605–610 Risk for impaired parenting 517–519
Disturbed thought processes 696–700 Risk for relocation stress syndrome
Impaired environmental interpretation 569–571
syndrome 283–287 Risk for other-directed violence 766–767
Impaired memory 451–454 Social isolation 639–643
Readiness for enhanced comfort 161–166
Readiness for enhanced decision making SEXUALITY-REPRODUCTIVE
247–249 Ineffective sexuality pattern 615–618
Readiness for enhanced knowledge (specify) Rape-trauma syndrome 549–555
438–440 Rape-trauma syndrome: compound reaction
Risk for acute confusion 191–194 550
Unilateral neglect 469–473 Rape-trauma syndrome: silent reaction 551
Sexual dysfunction 610–615
SELF-PERCEPTION-SELF-CONCEPT
PATTERN COPING-STRESS TOLERANCE
Anxiety 88–94 PATTERN
Chronic low self-esteem 587–591 Compromised family coping 217–220
Death anxiety 94–97 Defensive coping 220–223
Disturbed body image 115–120 Disabled family coping 223–227
Disturbed personal identity 430–433 Ineffective community coping 232–234
Fear 312–316 Ineffective coping 227–231
Hopelessness 379–383 Ineffective denial 249–252
Powerlessness 540–544 Post-trauma syndrome 527–533
Readiness for enhanced hope 376–379 Readiness for enhanced community
Readiness for enhanced power 537–540 coping 238–240
Readiness for enhanced self-concept Readiness for enhanced coping 234–237
583–587 Readiness for enhanced family coping
Risk for compromised human dignity 240–243
264–266 Risk for self-mutilation 601–605
Risk for loneliness 448–451 Risk for suicide 666–670
Risk for self-directed violence 768–774 Risk for post-trauma syndrome 533–537
Risk for powerlessness 544–547 Risk-prone health behaviors 111–115
Risk for situational low self-esteem 595–597 Self-mutilation 597–601
Situational low self-esteem 591–594 Stress overload 658–662
ROLE-RELATIONSHIP PATTERN VALUE-BELIEF PATTERN
Caregiver role strain 151–157 Impaired religiosity 556–559
Chronic sorrow 643–646 Moral distress 266–270
Complicated grieving 349–353 Readiness for enhanced religiosity 559–562
Dysfunctional family processes: alcoholism Readiness for enhanced spiritual well-being
296–300 655–658
Impaired parenting 508–513 Risk for impaired religiosity 562–565
Impaired social interaction 635–639 Risk for spiritual distress 651–654
Impaired verbal communication 166–171 Spiritual distress 646–651
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Nurse’s Pocket Guide
Diagnoses, Prioritized
Interventions, and
Rationales
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Nurse’s Pocket Guide
Diagnoses, Prioritized
Interventions, and
Rationales
EDITION 11
Marilynn E. Doenges, APRN, BC–retired
Clinical Specialist—Adult Psychiatric/Mental Health Nursing
Adjunct Faculty
Beth-El College of Nursing and Health Sciences, UCCS
Colorado Springs, Colorado
Mary Frances Moorhouse, RN, MSN, CRRN,
LNC
Nurse Consultant
TNT-RN Enterprises
Adjunct Faculty
Pikes Peak Community College
Colorado Springs, Colorado
Alice C. Murr, RN, BSN, LNC
Nurse Consultant/Author
Collins, Mississippi
F. A. Davis Company • Philadelphia
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F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2008 by F. A. Davis Company
Copyright © 1985, 1988, 1991, 1993, 1996, 1998, 2000, 2002, 2004, 2006
by F. A. Davis Company. All rights reserved. This book is protected by
copyright. No part of it may be reproduced, stored in a retrieval system,
or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without written permission
from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Publisher, Nursing: Joanne Patzek DaCunha, RN, MSN
Director of Content Development: Darlene D. Pedersen, MSN, APRN, BC
Project Editors: Padraic J. Maroney and Meghan K. Ziegler
Design and Illustration Manager: Carolyn O’Brien
As new scientific information becomes available through basic and clin-
ical research, recommended treatments and drug therapies undergo
changes. The author(s) and publisher have done everything possible to
make this book accurate, up to date, and in accord with accepted stan-
dards at the time of publication. The author(s), editors, and publisher
are not responsible for errors or omissions or for consequences from
application of the book, and make no warranty, expressed or implied, in
regard to the contents of the book. Any practice described in this book
should be applied by the reader in accordance with professional stan-
dards of care used in regard to the unique circumstances that may apply
in each situation. The reader is advised always to check product infor-
mation (package inserts) for changes and new information regarding
dose and contraindications before administering any drug. Caution is
especially urged when using new or infrequently ordered drugs.
ISBN-13: 978-0-8036-1857-2
ISBN-10: 0-8036-1857-3
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Dedication
This book is dedicated to:
Our families, who helped with the mundane activities of
daily living that allowed us to write this book and who provide
us with love and encouragement in all our endeavors.
Our friends, who support us in our writing, put up with our
memory lapses, and love us still.
Bob Martone, Publisher, Nursing, who asks questions that
stimulate thought and discussion, and who maintains good
humor throughout. Joanne DaCunha and Danielle Barsky who
supported us and kept us focused. The F.A. Davis production
staff who coordinated and expedited the project through the
editing and printing processes, meeting unreal deadlines, and
sending pages to us with bated breath.
Robert H. Craven, Jr., and the F.A. Davis family.
And last and most important:
The nurses we are writing for, to those who have found the
previous editions of the Pocket Guide helpful, and to other
nurses who are looking for help to provide quality nursing care
in a period of transition and change, we say, “Nursing Diagno-
sis is the way.”
