Nurse's Pocket Guide

• Identify specific supplier for supplemental oxygen/necessary
respiratory devices, as well as other individually appropriate
resources, such as home care agencies, Meals on Wheels, and
so on, to facilitate independence.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings, including respiratory rate, character of
breath sounds; frequency, amount, and appearance of secretions;
presence of cyanosis; laboratory findings; and mentation
level.
• Conditions that may interfere with oxygen supply.
PLANNING
• Plan of care/interventions and who is involved in the planning.
• Ventilator settings, liters of supplemental oxygen.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to treatment/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-range needs, identifying who is responsible for actions
to be taken.
• Community resources for equipment/supplies post-discharge.
• Specific referrals made.
SAMPLE NURSING OUTCOMES & INTERVENTIONS
CLASSIFICATIONS (NOC/NIC)
NOC—Respiratory Status: Gas Exchange
NIC—Respiratory Monitoring
risk for unstable blood Glucose
Taxonomy II: Nutrition—Class 4 Metabolism (00179)
[Diagnostic Division: Food/Fluid]
Submitted 2006
Definition: Risk for variation of blood glucose/sugar
levels from the normal range
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 341
risk for unstable blood GLUCOSE