Nurse's Pocket Guide

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• Provide educational materials and information to assist family members in resolution of current crisis. • Refer to classes (e.g., parent effectiveness, specific disease/disability support groups, self-help groups, clergy, psychological counseling/family therapy), as indicated. • Assist family to identify situations that may lead to fear/anxiety. (Refer to NDs Fear; Anxiety.) • Involve family in planning for future and mutual goal setting. Promotes commitment to goals/continuation of plan. • Identify community agencies (e.g., Meals on Wheels, visiting nurse, trauma support group, American Cancer Society, Veterans Administration) for both immediate and long-term support. Documentation Focus ASSESSMENT/REASSESSMENT • Assessment findings, including family composition, developmental stage of family, and role expectations. • Family communication patterns. PLANNING • Plan of care/interventions and who is involved in planning. • Teaching plan. IMPLEMENTATION/EVALUATION • Each individual’s response to interventions/teaching and actions performed. • Attainment/progress toward desired outcome(s). • Modifications to plan of care. DISCHARGE PLANNING • Long-range needs, noting who is responsible for actions to be taken. • Specific referrals made. SAMPLE NURSING OUTCOMES & INTERVENTIONS CLASSIFICATIONS (NOC/NIC) NOC—Family Functioning NIC—Family Process Maintenance Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 303 interrupted FAMILY PROCESSES
eadiness for enhanced FAMILY PROCESSES readiness for enhanced Family Processes Taxonomy II: Role Relationships—Class 2 Family Relationships (00159) [Diagnostic Division: Social Interaction] Submitted 2002 Definition: A pattern of family functioning that is sufficient to support the well-being of family members and can be strengthened Defining Characteristics SUBJECTIVE Expresses willingness to enhance family dynamics Communication is adequate Relationships are generally positive; interdependent with community; family tasks are accomplished Energy level of family supports activities of daily living Family adapts to change OBJECTIVE Family functioning meets needs of family members Activities support the safety/growth of family members Family roles are appropriate/flexible for developmental stages Family resilience is evident Respect for family members is evident Boundaries of family members are maintained Balance exists between autonomy and cohesiveness Desired Outcomes/Evaluation Criteria—Client Will: • Express feelings freely and appropriately. • Verbalize understanding of desire for enhanced family dynamics. • Demonstrate individual involvement in problem solving to improve family communications. • Acknowledge awareness of and respect for boundaries of family members. Actions/Interventions NURSING PRIORITY NO.1.To determine status of family: • Determine family composition: parent(s), children, male/ female, extended family. Many family forms exist in society Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. 304 Cultural Collaborative Community/Home Care
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ACTIVITY/REST—Ability to engage i
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GORDON’S FUNCTIONAL HEALTH PATTER
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Nurse’s Pocket Guide Diagnoses, P
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F. A. Davis Company 1915 Arch Stree
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CONTRIBUTOR Sheila Marquez Executiv
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Health Conditions and Client Concer
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How to Use the Nurse’s Pocket Gui
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Medicine. Today, researchers from a
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CHAPTER 1 The Nursing Process Nursi
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her own care and the achievement of
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and psychology. A sense of caring,
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CHAPTER 2 Application of the Nursin
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Table 2-1. (Continued) Death Syndro
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Table 2-1. (Continued) Rape-Trauma
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could be used by nurses throughout
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from the diagnostic statement and a
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CHAPTER 3 Putting Theory into Pract
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documentation of the planning proce
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ADULT MEDICAL/SURGICAL ASSESSMENT T
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Heart sounds (auscultation): Rate:
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Last meal consumed/content: _______
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Cooperative: _____ Agitated/Restles
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Uses seat belt regularly: _______ B
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Social Interactions SUBJECTIVE (REP
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Areas that may require alteration/a
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Consistency of behavior: Verbal ___
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EXCERPT FROM PRENATAL ASSESSMENT TO
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EXCERPT FROM INTRAPARTAL ASSESSMENT
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SECTION 2 DIAGNOSTIC DIVISIONS: NUR
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Spiritual Distress, risk for Spirit
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Death Syndrome, risk for sudden inf
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SECTION 3 CLIENT SITUATION AND PROT
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Nailbeds: pink Conjunctiva and scle
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Eyes: Vision loss, farsighted, “S
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Extended family: 1 daughter lives i
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PLAN OF CARE FOR CLIENT WITH DIABET
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ACTIONS/INTERVENTIONS RATIONALE deh
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ACTIONS/INTERVENTIONS RATIONALE vas
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ACTIONS/INTERVENTIONS RATIONALE and
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ANOTHER APPROACH TO PLANNING CLIENT
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SECTION 4 DOCUMENTATION TECHNIQUES:
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Example 1. SAMPLE SOAP/IER CHARTING
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Example 2. SAMPLE OF FOCUS CHARTING
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Functional Level Classification (Go
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• Plan for maximal activity withi
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• Identify conditions/symptoms th
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ineffective Airway Clearance Taxono
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diaphragm and enhancing drainage of
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treatment of obstructive sleep apne
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kiwi, papya, peach, nectarine), pri
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• Type/extent of symptomatology.
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• Obtain lists of latex-free prod
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Affective Regretful; scared; rattle
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Voice quivers or changes pitch Trem
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NURSING PRIORITY NO. 3. To promote
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Negative thoughts related to death
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• Refer to community agencies/res
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as listed in Risk Factors, to deter
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• Provide information about the e
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• Ascertain availability/use of r
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Autonomic Dysreflexia Taxonomy II:
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urine flow if blocked; remove bowel
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MUSCULOSKELETAL—INTEGUMENTARY STI
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goosebumps; bradycardia; cardiac ir
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• Explore the expressions of emot
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IMPLEMENTATION/EVALUATION • Clien
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• Acknowledge self as an individu
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• Assume all individuals are sens
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Risk Factors Extremes of age/weight
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medication regimen with physician t
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impacted stool; severe diarrhea; de
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DISCHARGE PLANNING • Identified l
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• Encourage skin-to-skin contact.
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Related Factors Prematurity; infant
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for more than 15 minutes on each si
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• Provide practice times at breas
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Maternal desire to maintain breastf
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3 hours while awake as indicated to
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Related Factors Neuromuscular dysfu
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• Deal with fear/anxiety that may
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decreased Cardiac Output Taxonomy I
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of extremities, and progressive sho
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• Refer to NDs ineffective Tissue
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DISCHARGE PLANNING • Discharge co
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Defining Characteristics SUBJECTIVE
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• Identify relationship of caregi
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importance of self-nurturing (e.g.,
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Desired Outcomes/Evaluation Criteri
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Documentation Focus ASSESSMENT/REAS
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• Determine influence of cultural
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owl/aquarium, to stimulate observat
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Anatomical deficit (e.g., cleft pal
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NURSING PRIORITY NO. 2.To assist cl
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professional interpreter who transl
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• Associate words with objects—
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OBJECTIVE Vacillation between alter
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• Promote opportunities for using
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• Demonstrate appropriate behavio
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DISCHARGE PLANNING • Long-term ne
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• Evaluate for exacerbation of ps
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client. If the history reveals an i
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PLANNING • Plan of care and who i
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NURSING PRIORITY NO 2. To reduce/co
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Insufficient physical activity; abd
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• Determine laxative/enema use. N
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PLANNING • Plan of care/intervent
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IMPLEMENTATION/EVALUATION • Clien
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• Discuss usual elimination patte
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Related Factors EXTERNAL Chemical c
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Actions/Interventions In reviewing
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• Obtain/assist with diagnostic s
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• Recommend periodic inspection o
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Lack of breakdown of contaminants o
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• Recommend periodic inspection o
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• Specific actions and changes th
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• Assess information available to
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Rationalizes failures [Refuses or r
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• Promote involvement in activiti
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Actions/Interventions NURSING PRIOR
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DISCHARGE PLANNING • Ongoing need
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• Assess current functional capac
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• Discuss/review anticipated proc
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involvement with caring for others/
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Adaptive tasks effectively addresse
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• Attainment/progress toward desi
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fewer infants die of SIDS when they
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SAMPLE NURSING OUTCOMES & INTERVENT
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• Refer to other resources, as ne
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• Note client’s comments about
Page 274 and 275: Defining Characteristics SUBJECTIVE
Page 276 and 277: • Recommend that client (of any a
Page 278 and 279: CAREGIVER Mental retardation; sever
Page 280 and 281: children’s services, medical equi
Page 282 and 283: laxatives]; and enteral tube feedin
Page 284 and 285: • Discuss possible change in infa
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Page 288 and 289: Related Factors Conflict among deci
Page 290 and 291: • Provide time for nonjudgmental
Page 292 and 293: • Be free of signs/symptoms of in
Page 294 and 295: VASCULAR (TISSUE PERFUSION) • Mon
Page 296 and 297: • Provide/review information abou
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Page 300 and 301: PLANNING • Plan of care/intervent
Page 302 and 303: • Identify areas of imbalance or
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Page 306 and 307: • Use touch judiciously. Tell cli
Page 308 and 309: IMPLEMENTATION/EVALUATION • Respo
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Page 312 and 313: • Attainment/progress toward desi
Page 314 and 315: • Observe individual’s general
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Page 318 and 319: OBJECTIVE Feelings Repressed emotio
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Page 322 and 323: assigned tasks; stress-reduction be
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Page 328 and 329: • Refer to classes/support groups
Page 330 and 331: Actions/Interventions NURSING PRIOR
Page 332 and 333: • Encourage use of assistive devi
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Page 336 and 337: • Modify procedures, if possible
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Page 342 and 343: Desired Outcomes/Evaluation Criteri
Page 344 and 345: NURSING PRIORITY NO. 5. To promote
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Page 348 and 349: Documentation Focus ASSESSMENT/REAS
Page 350 and 351: • Note amount/rate of fluid intak
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Page 354 and 355: Offer fluids between meals and regu
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Page 358 and 359: • Results of laboratory test/diag
Page 360 and 361: NURSING PRIORITY NO.2.To evaluate d
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Page 364 and 365: • Assess family/SO(s) support of
Page 366 and 367: PLANNING • Plan of care and who i
Page 368 and 369: NURSING PRIORITY NO.2.To determine
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choice to have another child or to
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• Assess status of relationships/
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Congenital/genetic disorders [e.g.,
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• Determine if child’s growth i
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delayed Growth and Development Taxo
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• Note chronological age, familia
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• Determine reasonable expectatio
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Inability to make appropriate judgm
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• Encourage socialization and per
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Expressed concern about current env
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• Pertinent cultural/religious be
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• Assess client/SO’s level of c
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• Identify cultural/spiritual val
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• Refer to other resources for as
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abdominal temperature monitoring ma
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onmental heat (e.g., proper clothin
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• Identify underlying cause/contr
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• Keep client quiet; handle gentl
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Immunization status Identification
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still exist and can be passed on to
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Defining Characteristics OBJECTIVE
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• Avoid aversive oral stimulation
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VESTIBULAR • Move and handle the
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Defining Characteristics OBJECTIVE
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• Demonstrate appropriate weight
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• Caregiver’s involvement in in
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• Provide for isolation, as indic
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measures to prevent pneumonia, woun
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• Demonstrate behaviors, lifestyl
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using smokeless tobacco, occurrence
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Risk Factors Disorientation; sensor
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• Assist with therapies/nursing a
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disorders, dementia, obesity, pregn
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• Encourage routine use of contin
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decreased Intracranial Adaptive Cap
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carina. Administer lidocaine intrat
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[Illnesses/trauma affecting body im
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• Assist client and SO(s) to ackn
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• Be alert to signs of avoidance.
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complex. Can arouse interest/limit
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• Determine motivation/expectatio
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Related Factors Lack of interest/mo
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improve balance and coordination ca
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NURSING PRIORITY NO. 3. To promote
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Parent/Caregiver Will: • Provide
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State Examination [MMSE]), to compl
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Related Factors Neuromuscular/muscu
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• Involve client/SO(s) in determi
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maintaining appliances/equipment. P
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vision deficits) are treated/being
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BIOPHYSICAL Biochemical disorders (
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• Encourage client to begin with
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IMPLEMENTATION/EVALUATION • Respo
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• Assess ability to distinguish b
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maximize independence, allow client
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• Establish graduated goals or mo
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[Abnormal laboratory studies (e.g.,
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Appetite stimulants (e.g., wine), i
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• Caloric intake. • Individual
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• Discuss client’s view of self
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• Encourage buying personal items
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• Discuss use of non-food rewards
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Assist with/provide denture care wh
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Related Factors Injuring agents (bi
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• Note cultural and developmental
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• Evaluate emotional/physical com
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for all persons, encouraging client
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KNOWLEDGE Deficient knowledge about
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Parents with significant impairment
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voice, are indicative of attachment
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DISCHARGE PLANNING • Long-range n
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• Participate in activities, clas
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• Assess capillary return, skin c
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• Review results of laboratory te
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• Demonstrate ability to deal wit
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• Help child to express feelings
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ack to get her”; “Don’t call
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• Assist client to set realistic
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Moderate Dependence on others that
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• Develop contract with client sp
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Inadequate coping patterns Absence
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• Cultural values/religious belie
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DRUG THERAPIES, TREATMENTS, AND DIS
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[C] SILENT REACTION—(00141) Defin
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• Provide environment in which cl
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Difficulty adhering to prescribed r
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and practices, these influences wil
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NOTE: A risk diagnosis is not evide
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• Modifications to plan of care.
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(e.g., stomach aches, headaches, ba
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• Support self-responsibility and
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• Determine client role in family
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Self-Care Deficit: bathing/hygiene,
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• Note concomitant medical proble
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• Support client in making health
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PLANNING • Plan of care/intervent
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nonverbal expressions is culturally
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• Develop therapeutic relationshi
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• Note nonverbal body language. I
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isk for situational low Self-Esteem
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often is an attempt to establish in
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allow feelings to be expressed, ind
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• Ambulate with assistance/device
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Related Factors Ineffectual/absent
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cause such as diabetes, vascular pr
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• Determine client’s interpreta
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impaired Skin Integrity Taxonomy II
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• Palpate skin lesions for size,
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daily maintenance. Enhances commitm
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• Advise regular use of sunscreen
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NURSING PRIORITY NO.2.To assist cli
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Sustained inadequate sleep hygiene;
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• Encourage client to develop pla
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impaired Social Interaction Taxonom
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• Evaluate possibility of client
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• Cultural/religious beliefs and
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• Identify blocks to social conta
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• Acknowledge reality of feelings
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• Encourage client/family to ask
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• Physical/emotional responses to
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• Ascertain substance use/abuse.
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eadiness for enhanced Spiritual Wel
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• Clarify reality/appropriateness
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• Allow client to react in own wa
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Risk Factors INTERNAL Reduced olfac
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• Develop plan with client/caregi
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Guilt Gay or lesbian youth DEMOGRAP
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it will help individual to resolve
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Related Factors Extensive/prolonged
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• Collaborate in treatment of com
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• Identify individually appropria
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• Instruct to chew food on unaffe
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[Added demands made on individual o
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• Use client’s locus of control
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OBJECTIVE Deficits in advocates for
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ineffective family Therapeutic Regi
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• Incorporate client’s cultural
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Distractibility; [altered attention
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NURSING PRIORITY NO. 4.To create th
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impaired Tissue Integrity Taxonomy
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Record size (depth, width), color,
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Mobility; disturbed visual Sensory
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Gastrointestinal Hypoactive/absent
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• Evaluate vital signs, noting ch
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• Administer medications (e.g., a
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• Provide preoperative teaching a
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Risk Factors INTERNAL Weakness; bal
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• Ascertain knowledge of safety n
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elieved by voiding and often recurs
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chronic urinary urge incontinence,
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Related Factors To be developed Def
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• Review with client/SO(s) the si
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• Determine if client is voluntar
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Related Factors Bladder outlet obst
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• Instruct client/SO(s) in clean
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• Measure amount of each voiding
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Risk Factors Effects of medications
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Practice timed voidings (e.g., ever
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Use condom catheter or other extern
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Recommend consciously delaying void
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• Assess for effects of psychotro
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• Promote maximal ventilation of
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• Discuss impact of specific acti
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Defining Characteristics MILD Subje
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determine if client can assume the
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Risk Factors/[Indicators]* HISTORY
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• Identify precipitating factors.
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NURSING PRIORITY NO.3.To assist cli
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that help client to engage in posit
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• Provide a structured daily rout
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CHAPTER 5 Health Conditions and Cli
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isk for ineffective Sexuality Patte
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disturbed Body Image may be related
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of others, destructive behaviors, i
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focus, alteration in muscle tone, p
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isk for Injury/Trauma: risk factors
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Anaphylaxis CH (Also refer to Shock
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isk for sedentary Lifestyle: risk f
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impaired Social Interaction/Social
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y limited range of motion, impaired
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Autistic disorder PED/PSY impaired
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are refuted or wishes denied, manic
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isk for deficient Fluid Volume: ris
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evidenced by expressions of boredom
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deficient Fluid Volume [isotonic] m
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impaired verbal [and/or written] Co
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(wasting), aversion to eating, repo
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fluid intake, possibly evidenced by
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aggressive feelings, lacking a sens
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feeling of abdominal/rectal fullnes
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abnormal breath sounds, ineffective
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taste sensation, lack of interest i
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personal resources, decreased energ
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y verbal expression of distress/unr
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Anxiety [specify level] may be rela
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and ineffective sucking/swallowing
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impaired Gas Exchange may be relate
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situational low Self-Esteem may be
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impaired physical Mobility may be r
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moving in direction of health-promo
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Guillain-Barré syndrome (acute pol
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Hemorrhoidectomy MS/CH acute Pain m
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ehaviors, narrowed focus, and auton
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Hyperactivity disorder PED/PSY defe
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isk for unstable blood Glucose: ris
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secondary defenses (e.g., decreased
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isk for Poisoning: risk factors may
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equired voice rest, possibly eviden
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alance, presence of multiple diseas
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Mastitis OB/GYN acute Pain may be r
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imbalanced Nutrition: risk for more
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Powerlessness/Hopelessness may be r
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acute Pain may be related to ischem
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isk for disorganized Infant Behavio
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Hyperthermia may be related to incr
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disturbed kinesthetic/tactile Senso
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negative self-appraisal in response
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ehaviors, self-focus, and autonomic
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evidenced by frequency, dysuria, ur
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ineffective Breathing Pattern may b
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decreased Cardiac Output may be rel
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changes (atelectasis, airway/alveol
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coping methods, multiple stressors
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increased metabolic rate, restlessn
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isk for deficient Fluid Volume: ris
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minimizes health status change, fai
Page 914 and 915:
eadings, jugular vein distention, c
Page 916 and 917:
Sprain of ankle or foot CH acute Pa
Page 918 and 919:
distraction behaviors, self-focus,
Page 920 and 921:
isk for Injury [tetany]: risk facto
Page 922 and 923:
impaired Skin/Tissue Integrity may
Page 924 and 925:
possibly evidenced by reports of he
Page 926 and 927:
Anxiety [specify level] may be rela
Page 928:
isk for Infection: risk factors may
Page 931 and 932:
Domain 4 Activity/Rest: The product
Page 933 and 934:
Domain 13 Growth/Development: Age-a
Page 935 and 936:
Enhanced: Improved in quality, valu
Page 937 and 938:
916 Books Bibliography Aacovou, I:
Page 939 and 940:
Lampe, S: Focus Charting, 7th ed. C
Page 941 and 942:
AORN latex guideline: 2004 standard
Page 943 and 944:
Carroll, P: Preventing nosocomial p
Page 945 and 946:
Frost, KL, and Topp, R: A physical
Page 947 and 948:
Jirovec, MM, Wyman, JF, and Wells,
Page 949 and 950:
McClave, SA, Lukan, JK, Lowen, JA,
Page 951 and 952:
Perry, A: Quality of life. Rehab Ma
Page 953 and 954:
Sommer, KD, and Sommer, NW: When yo
Page 955 and 956:
Adams, L: Working together: Paying
Page 957 and 958:
Cheshire, Jr., WP: Grey matters whe
Page 959 and 960:
Gardner, BM. (2002). Current approa
Page 961 and 962:
Keim, SM, and Kent, M: Nausea and v
Page 963 and 964:
National Coalition for Cancer Survi
Page 965 and 966:
Planned Parenthood: Sexual health-s
Page 967 and 968:
Von Wager, K: Identity crisis—The
Page 969 and 970:
ADD. See Attention deficit disorder
Page 971 and 972:
Breast (Continued) mastitis, 134 so
Page 973 and 974:
Compromised family (Continued) inef
Page 975 and 976:
E Eating disorders, 832 Eclampsia,
Page 977 and 978:
Hemothorax, 843 Hepatitis, acute vi
Page 979 and 980:
Infectious mononucleosis, 862 Infla
Page 981 and 982:
Myasthenia gravis, 864 Myeloma, mul
Page 983 and 984:
Postpartal cesarean birth, 811-812
Page 985 and 986:
Risk for delayed development, 256-2
Page 987 and 988:
Social isolation, 639-643 Social Po
Page 989:
Urolithiasis, 904 Uterine bleeding,
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