Nurse's Pocket Guide

eadiness for enhanced FLUID BALANCE
• Encourage regular physical activity. Assist client/refer to physical
therapist to develop exercise program (within limits of
ability). Provides a healthy outlet for energy generated by
fearful feelings and promotes relaxation.
• Provide for/deal with sensory deficits in appropriate manner
(e.g., speak clearly and distinctly, use touch carefully, as indicated
by situation).
• Refer to support groups, community agencies/organizations, as
indicated. Provides ongoing assistance for individual needs.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings, noting individual factors contributing to
current situation, source of fear.
• Manifestations of fear.
PLANNING
• Plan of care and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to treatment plan/interventions and
actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be taken.
• Specific referrals made.
SAMPLE NURSING OUTCOMES & INTERVENTIONS
CLASSIFICATIONS (NOC/NIC)
NOC—Fear Self-Control
NIC—Anxiety Reduction
readiness for enhanced Fluid Balance
Taxonomy II: Nutrition—Class 5 Hydration (00160)
[Diagnostic Division: Food/Fluid]
Submitted 2002
Definition: A pattern of equilibrium between fluid volume
and chemical composition of body fluids that is sufficient
for meeting physical needs and can be strengthened
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
316 Cultural Collaborative Community/Home Care