Nurse's Pocket Guide

isk for DISUSE SYNDROME
• Limit/monitor closely the use of restraints and immobilize
client as little as possible. Remove restraints periodically and
assist with ROM exercises.
• Refer to NDs Activity Intolerance; risk for Falls; impaired
physical Mobility; acute or chronic Pain.
SENSORY-PERCEPTION
• Orient client as necessary to time, place, person, and situation.
Provide cues for orientation (e.g., clock, calendar).
• Provide appropriate level of environmental stimulation (e.g.,
music, TV/radio, personal possessions, visitors).
• Encourage participation in recreational/diversional activities
and regular exercise program (as tolerated).
• Suggest use of sleep aids/usual presleep rituals to promote
normal sleep/rest.
• Refer to NDs chronic Confusion; disturbed Sensory Perception;
Insomnia; Social Isolation; deficient Diversional
Activity.
SELF-ESTEEM, POWERLESSNESS
• Explain/review all care procedures.
• Provide for/assist with mutual goal setting, involving SO(s).
Promotes sense of control and enhances commitment to
goals.
• Provide consistency in caregivers whenever possible.
• Ascertain that client can communicate needs adequately
(e.g., call light, writing tablet, picture/letter board, interpreter).
• Encourage verbalization of feelings/questions.
• Refer to NDs Powerlessness; impaired verbal Communication;
Self-Esteem [specify]; ineffective Role Performance.
BODY IMAGE
• Orient to body changes through verbal description, written
information; encourage looking at and discussing changes to
promote acceptance.
• Promote interactions with peers and normalization of activities
within individual abilities.
• Refer to NDs disturbed Body Image; situational low Self-
Esteem; Social Isolation; disturbed Personal Identity.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/
Discharge Considerations):
• Promote self-care and SO-supported activities to gain/maintain
independence.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
274 Cultural Collaborative Community/Home Care