Nurse's Pocket Guide

FEAR
• Assist client to identify appropriate coping behaviors. Promotes
sense of control and improves self-esteem.
• Identify support groups/community resources.
• Refer to counseling/psychotherapy, as indicated.
• Identify resources to assist with routine needs (e.g., Meals on
Wheels, homemaker/housekeeper services, yard care).
Documentation Focus
ASSESSMENT/REASSESSMENT
• Manifestations of fatigue and other assessment findings.
• Degree of impairment/effect on lifestyle.
• Expectations of client/SO(s) relative to individual abilities/
specific condition.
PLANNING
• Plan of care/interventions and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge needs/plan, actions to be taken, and who is responsible.
• Specific referrals made.
SAMPLE NURSING OUTCOMES & INTERVENTIONS
CLASSIFICATIONS (NOC/NIC)
NOC—Endurance
NIC—Energy Management
Fear
[Specify Focus]
Taxonomy II: Coping/Stress Tolerance—Class 2 Coping
Responses (00148)
[Diagnostic Division: Ego Integrity]
Submitted 1980; Revised 2000
Definition: Response to perceived threat [real or
imagined] that is consciously recognized as a danger
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
312 Cultural Collaborative Community/Home Care