- Page 2 and 3: ACTIVITY/REST—Ability to engage i
- Page 6: Nurse’s Pocket Guide Diagnoses, P
- Page 9 and 10: F. A. Davis Company 1915 Arch Stree
- Page 12: CONTRIBUTOR Sheila Marquez Executiv
- Page 16 and 17: Health Conditions and Client Concer
- Page 18 and 19: How to Use the Nurse’s Pocket Gui
- Page 20 and 21: Medicine. Today, researchers from a
- Page 22 and 23: CHAPTER 1 The Nursing Process Nursi
- Page 24 and 25: her own care and the achievement of
- Page 26 and 27: and psychology. A sense of caring,
- Page 28 and 29: CHAPTER 2 Application of the Nursin
- Page 30 and 31: Table 2-1. (Continued) Death Syndro
- Page 32 and 33: Table 2-1. (Continued) Rape-Trauma
- Page 34 and 35: could be used by nurses throughout
- Page 36 and 37: from the diagnostic statement and a
- Page 38 and 39: CHAPTER 3 Putting Theory into Pract
- Page 40 and 41: documentation of the planning proce
- Page 42 and 43: ADULT MEDICAL/SURGICAL ASSESSMENT T
- Page 44 and 45: Heart sounds (auscultation): Rate:
- Page 46 and 47: Last meal consumed/content: _______
- Page 48 and 49: Cooperative: _____ Agitated/Restles
- Page 50 and 51: Uses seat belt regularly: _______ B
- Page 52 and 53: Social Interactions SUBJECTIVE (REP
- Page 54 and 55:
Areas that may require alteration/a
- Page 56 and 57:
Consistency of behavior: Verbal ___
- Page 58 and 59:
EXCERPT FROM PRENATAL ASSESSMENT TO
- Page 60 and 61:
EXCERPT FROM INTRAPARTAL ASSESSMENT
- Page 62 and 63:
SECTION 2 DIAGNOSTIC DIVISIONS: NUR
- Page 64 and 65:
Spiritual Distress, risk for Spirit
- Page 66 and 67:
Death Syndrome, risk for sudden inf
- Page 68 and 69:
SECTION 3 CLIENT SITUATION AND PROT
- Page 70 and 71:
Nailbeds: pink Conjunctiva and scle
- Page 72 and 73:
Eyes: Vision loss, farsighted, “S
- Page 74 and 75:
Extended family: 1 daughter lives i
- Page 76 and 77:
PLAN OF CARE FOR CLIENT WITH DIABET
- Page 78 and 79:
ACTIONS/INTERVENTIONS RATIONALE deh
- Page 80 and 81:
ACTIONS/INTERVENTIONS RATIONALE vas
- Page 82 and 83:
ACTIONS/INTERVENTIONS RATIONALE and
- Page 84 and 85:
ANOTHER APPROACH TO PLANNING CLIENT
- Page 86 and 87:
SECTION 4 DOCUMENTATION TECHNIQUES:
- Page 88 and 89:
Example 1. SAMPLE SOAP/IER CHARTING
- Page 90 and 91:
Example 2. SAMPLE OF FOCUS CHARTING
- Page 92 and 93:
Functional Level Classification (Go
- Page 94 and 95:
• Plan for maximal activity withi
- Page 96 and 97:
• Identify conditions/symptoms th
- Page 98 and 99:
ineffective Airway Clearance Taxono
- Page 100 and 101:
diaphragm and enhancing drainage of
- Page 102 and 103:
treatment of obstructive sleep apne
- Page 104 and 105:
kiwi, papya, peach, nectarine), pri
- Page 106 and 107:
• Type/extent of symptomatology.
- Page 108 and 109:
• Obtain lists of latex-free prod
- Page 110 and 111:
Affective Regretful; scared; rattle
- Page 112 and 113:
Voice quivers or changes pitch Trem
- Page 114 and 115:
NURSING PRIORITY NO. 3. To promote
- Page 116 and 117:
Negative thoughts related to death
- Page 118 and 119:
• Refer to community agencies/res
- Page 120 and 121:
as listed in Risk Factors, to deter
- Page 122 and 123:
• Provide information about the e
- Page 124 and 125:
• Ascertain availability/use of r
- Page 126 and 127:
Autonomic Dysreflexia Taxonomy II:
- Page 128 and 129:
urine flow if blocked; remove bowel
- Page 130 and 131:
MUSCULOSKELETAL—INTEGUMENTARY STI
- Page 132 and 133:
goosebumps; bradycardia; cardiac ir
- Page 134 and 135:
• Explore the expressions of emot
- Page 136 and 137:
IMPLEMENTATION/EVALUATION • Clien
- Page 138 and 139:
• Acknowledge self as an individu
- Page 140 and 141:
• Assume all individuals are sens
- Page 142 and 143:
Risk Factors Extremes of age/weight
- Page 144 and 145:
medication regimen with physician t
- Page 146 and 147:
impacted stool; severe diarrhea; de
- Page 148 and 149:
DISCHARGE PLANNING • Identified l
- Page 150 and 151:
• Encourage skin-to-skin contact.
- Page 152 and 153:
Related Factors Prematurity; infant
- Page 154 and 155:
for more than 15 minutes on each si
- Page 156 and 157:
• Provide practice times at breas
- Page 158 and 159:
Maternal desire to maintain breastf
- Page 160 and 161:
3 hours while awake as indicated to
- Page 162 and 163:
Related Factors Neuromuscular dysfu
- Page 164 and 165:
• Deal with fear/anxiety that may
- Page 166 and 167:
decreased Cardiac Output Taxonomy I
- Page 168 and 169:
of extremities, and progressive sho
- Page 170 and 171:
• Refer to NDs ineffective Tissue
- Page 172 and 173:
DISCHARGE PLANNING • Discharge co
- Page 174 and 175:
Defining Characteristics SUBJECTIVE
- Page 176 and 177:
• Identify relationship of caregi
- Page 178 and 179:
importance of self-nurturing (e.g.,
- Page 180 and 181:
Desired Outcomes/Evaluation Criteri
- Page 182 and 183:
Documentation Focus ASSESSMENT/REAS
- Page 184 and 185:
• Determine influence of cultural
- Page 186 and 187:
owl/aquarium, to stimulate observat
- Page 188 and 189:
Anatomical deficit (e.g., cleft pal
- Page 190 and 191:
NURSING PRIORITY NO. 2.To assist cl
- Page 192 and 193:
Documentation Focus ASSESSMENT/REAS
- Page 194 and 195:
professional interpreter who transl
- Page 196 and 197:
• Associate words with objects—
- Page 198 and 199:
OBJECTIVE Vacillation between alter
- Page 200 and 201:
• Promote opportunities for using
- Page 202 and 203:
• Demonstrate appropriate behavio
- Page 204 and 205:
DISCHARGE PLANNING • Long-term ne
- Page 206 and 207:
• Evaluate for exacerbation of ps
- Page 208 and 209:
Documentation Focus ASSESSMENT/REAS
- Page 210 and 211:
client. If the history reveals an i
- Page 212 and 213:
PLANNING • Plan of care and who i
- Page 214 and 215:
NURSING PRIORITY NO 2. To reduce/co
- Page 216 and 217:
Insufficient physical activity; abd
- Page 218 and 219:
• Determine laxative/enema use. N
- Page 220 and 221:
PLANNING • Plan of care/intervent
- Page 222 and 223:
IMPLEMENTATION/EVALUATION • Clien
- Page 224 and 225:
• Discuss usual elimination patte
- Page 226 and 227:
Related Factors EXTERNAL Chemical c
- Page 228 and 229:
Actions/Interventions In reviewing
- Page 230 and 231:
• Obtain/assist with diagnostic s
- Page 232 and 233:
• Recommend periodic inspection o
- Page 234 and 235:
Lack of breakdown of contaminants o
- Page 236 and 237:
• Recommend periodic inspection o
- Page 238 and 239:
• Specific actions and changes th
- Page 240 and 241:
• Assess information available to
- Page 242 and 243:
Rationalizes failures [Refuses or r
- Page 244 and 245:
• Promote involvement in activiti
- Page 246 and 247:
Actions/Interventions NURSING PRIOR
- Page 248 and 249:
DISCHARGE PLANNING • Ongoing need
- Page 250 and 251:
• Assess current functional capac
- Page 252 and 253:
• Discuss/review anticipated proc
- Page 254 and 255:
Actions/Interventions NURSING PRIOR
- Page 256 and 257:
Defining Characteristics SUBJECTIVE
- Page 258 and 259:
involvement with caring for others/
- Page 260 and 261:
Actions/Interventions NURSING PRIOR
- Page 262 and 263:
Adaptive tasks effectively addresse
- Page 264 and 265:
• Attainment/progress toward desi
- Page 266 and 267:
fewer infants die of SIDS when they
- Page 268 and 269:
SAMPLE NURSING OUTCOMES & INTERVENT
- Page 270 and 271:
• Refer to other resources, as ne
- Page 272 and 273:
• 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
- Page 286 and 287:
especially during times of stress,
- 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
- Page 298 and 299:
• Assess/review client’s physic
- Page 300 and 301:
PLANNING • Plan of care/intervent
- Page 302 and 303:
• Identify areas of imbalance or
- Page 304 and 305:
impaired Environmental Interpretati
- Page 306 and 307:
• Use touch judiciously. Tell cli
- Page 308 and 309:
IMPLEMENTATION/EVALUATION • Respo
- Page 310 and 311:
• Determine client’s medical, c
- Page 312 and 313:
• Attainment/progress toward desi
- Page 314 and 315:
• Observe individual’s general
- Page 316 and 317:
counseling, home care, sources for
- Page 318 and 319:
OBJECTIVE Feelings Repressed emotio
- Page 320 and 321:
• Provide information regarding e
- Page 322 and 323:
assigned tasks; stress-reduction be
- Page 324 and 325:
• Provide educational materials a
- Page 326 and 327:
today, such as biological, nuclear,
- 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
- Page 334 and 335:
Related Factors Innate origin (e.g.
- Page 336 and 337:
• Modify procedures, if possible
- Page 338 and 339:
Related Factors To be developed Def
- Page 340 and 341:
(such as prevention of hyperglycemi
- Page 342 and 343:
Desired Outcomes/Evaluation Criteri
- Page 344 and 345:
NURSING PRIORITY NO. 5. To promote
- Page 346 and 347:
• Verbalize understanding of caus
- Page 348 and 349:
Documentation Focus ASSESSMENT/REAS
- Page 350 and 351:
• Note amount/rate of fluid intak
- Page 352 and 353:
PLANNING • Plan of care and who i
- Page 354 and 355:
Offer fluids between meals and regu
- Page 356 and 357:
moist mucous membranes; individual
- Page 358 and 359:
• Results of laboratory test/diag
- Page 360 and 361:
NURSING PRIORITY NO.2.To evaluate d
- Page 362 and 363:
• Identify specific supplier for
- 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
- Page 370 and 371:
• Support community efforts to st
- Page 372 and 373:
elated to socially sensitive issue
- Page 374 and 375:
choice to have another child or to
- Page 376 and 377:
• Assess status of relationships/
- Page 378 and 379:
Congenital/genetic disorders [e.g.,
- Page 380 and 381:
• Determine if child’s growth i
- Page 382 and 383:
delayed Growth and Development Taxo
- Page 384 and 385:
• Note chronological age, familia
- Page 386 and 387:
• Determine reasonable expectatio
- Page 388 and 389:
Inability to make appropriate judgm
- Page 390 and 391:
• Encourage socialization and per
- Page 392 and 393:
Expressed concern about current env
- Page 394 and 395:
• Pertinent cultural/religious be
- Page 396 and 397:
• Assess client/SO’s level of c
- Page 398 and 399:
Desired Outcomes/Evaluation Criteri
- Page 400 and 401:
Documentation Focus ASSESSMENT/REAS
- Page 402 and 403:
• Identify cultural/spiritual val
- Page 404 and 405:
• Refer to other resources for as
- Page 406 and 407:
abdominal temperature monitoring ma
- Page 408 and 409:
onmental heat (e.g., proper clothin
- Page 410 and 411:
• Identify underlying cause/contr
- Page 412 and 413:
• Keep client quiet; handle gentl
- Page 414 and 415:
Immunization status Identification
- Page 416 and 417:
still exist and can be passed on to
- Page 418 and 419:
Defining Characteristics OBJECTIVE
- Page 420 and 421:
• Avoid aversive oral stimulation
- Page 422 and 423:
VESTIBULAR • Move and handle the
- Page 424 and 425:
Defining Characteristics OBJECTIVE
- Page 426 and 427:
SAMPLE NURSING OUTCOMES & INTERVENT
- Page 428 and 429:
• Demonstrate appropriate weight
- Page 430 and 431:
• Caregiver’s involvement in in
- Page 432 and 433:
• Provide for isolation, as indic
- Page 434 and 435:
measures to prevent pneumonia, woun
- Page 436 and 437:
• Demonstrate behaviors, lifestyl
- Page 438 and 439:
using smokeless tobacco, occurrence
- Page 440 and 441:
Risk Factors Disorientation; sensor
- Page 442 and 443:
• Assist with therapies/nursing a
- Page 444 and 445:
disorders, dementia, obesity, pregn
- Page 446 and 447:
• Encourage routine use of contin
- Page 448 and 449:
decreased Intracranial Adaptive Cap
- Page 450 and 451:
carina. Administer lidocaine intrat
- Page 452 and 453:
[Illnesses/trauma affecting body im
- Page 454 and 455:
• Assist client and SO(s) to ackn
- Page 456 and 457:
• Be alert to signs of avoidance.
- Page 458 and 459:
complex. Can arouse interest/limit
- Page 460 and 461:
• Determine motivation/expectatio
- Page 462 and 463:
Related Factors Lack of interest/mo
- Page 464 and 465:
improve balance and coordination ca
- Page 466 and 467:
SAMPLE NURSING OUTCOMES & INTERVENT
- Page 468 and 469:
NURSING PRIORITY NO. 3. To promote
- Page 470 and 471:
Parent/Caregiver Will: • Provide
- Page 472 and 473:
Documentation Focus ASSESSMENT/REAS
- Page 474 and 475:
State Examination [MMSE]), to compl
- Page 476 and 477:
Related Factors Neuromuscular/muscu
- Page 478 and 479:
• Involve client/SO(s) in determi
- Page 480 and 481:
Desired Outcomes/Evaluation Criteri
- Page 482 and 483:
maintaining appliances/equipment. P
- Page 484 and 485:
vision deficits) are treated/being
- Page 486 and 487:
BIOPHYSICAL Biochemical disorders (
- Page 488 and 489:
• Encourage client to begin with
- Page 490 and 491:
IMPLEMENTATION/EVALUATION • Respo
- Page 492 and 493:
• Assess ability to distinguish b
- Page 494 and 495:
maximize independence, allow client
- Page 496 and 497:
Desired Outcomes/Evaluation Criteri
- Page 498 and 499:
• Establish graduated goals or mo
- Page 500 and 501:
[Abnormal laboratory studies (e.g.,
- Page 502 and 503:
Appetite stimulants (e.g., wine), i
- Page 504 and 505:
• Caloric intake. • Individual
- Page 506 and 507:
• Discuss client’s view of self
- Page 508 and 509:
• Encourage buying personal items
- Page 510 and 511:
Actions/Interventions NURSING PRIOR
- Page 512 and 513:
SAMPLE NURSING OUTCOMES & INTERVENT
- Page 514 and 515:
• Discuss use of non-food rewards
- Page 516 and 517:
Defining Characteristics SUBJECTIVE
- Page 518 and 519:
Assist with/provide denture care wh
- Page 520 and 521:
Related Factors Injuring agents (bi
- Page 522 and 523:
• Note cultural and developmental
- Page 524 and 525:
PLANNING • Plan of care and who i
- Page 526 and 527:
• Evaluate emotional/physical com
- Page 528 and 529:
for all persons, encouraging client
- Page 530 and 531:
KNOWLEDGE Deficient knowledge about
- Page 532 and 533:
Parents with significant impairment
- Page 534 and 535:
PLANNING • Plan of care and who i
- Page 536 and 537:
voice, are indicative of attachment
- Page 538 and 539:
DISCHARGE PLANNING • Long-range n
- Page 540 and 541:
• Participate in activities, clas
- Page 542 and 543:
• Assess capillary return, skin c
- Page 544 and 545:
DISCHARGE PLANNING • Long-term ne
- Page 546 and 547:
• Review results of laboratory te
- Page 548 and 549:
Documentation Focus ASSESSMENT/REAS
- Page 550 and 551:
• Demonstrate ability to deal wit
- Page 552 and 553:
• Help child to express feelings
- Page 554 and 555:
Documentation Focus ASSESSMENT/REAS
- Page 556 and 557:
ack to get her”; “Don’t call
- Page 558 and 559:
SAMPLE NURSING OUTCOMES & INTERVENT
- Page 560 and 561:
• Assist client to set realistic
- Page 562 and 563:
Moderate Dependence on others that
- Page 564 and 565:
• Develop contract with client sp
- Page 566 and 567:
Inadequate coping patterns Absence
- Page 568 and 569:
• Cultural values/religious belie
- Page 570 and 571:
DRUG THERAPIES, TREATMENTS, AND DIS
- Page 572 and 573:
[C] SILENT REACTION—(00141) Defin
- Page 574 and 575:
• Provide environment in which cl
- Page 576 and 577:
Documentation Focus ASSESSMENT/REAS
- Page 578 and 579:
Difficulty adhering to prescribed r
- Page 580 and 581:
• Attainment/progress toward desi
- Page 582 and 583:
and practices, these influences wil
- Page 584 and 585:
NOTE: A risk diagnosis is not evide
- Page 586 and 587:
• Modifications to plan of care.
- Page 588 and 589:
(e.g., stomach aches, headaches, ba
- Page 590 and 591:
• Attainment/progress toward desi
- Page 592 and 593:
• Support self-responsibility and
- Page 594 and 595:
• Determine client role in family
- Page 596 and 597:
Self-Care Deficit: bathing/hygiene,
- Page 598 and 599:
• Note concomitant medical proble
- Page 600 and 601:
• Support client in making health
- Page 602 and 603:
Defining Characteristics SUBJECTIVE
- Page 604 and 605:
PLANNING • Plan of care/intervent
- Page 606 and 607:
nonverbal expressions is culturally
- Page 608 and 609:
• Attainment/progress toward desi
- Page 610 and 611:
• Develop therapeutic relationshi
- Page 612 and 613:
PLANNING • Plan of care and who i
- Page 614 and 615:
• Note nonverbal body language. I
- Page 616 and 617:
isk for situational low Self-Esteem
- Page 618 and 619:
DISCHARGE PLANNING • Long-term ne
- Page 620 and 621:
often is an attempt to establish in
- Page 622 and 623:
IMPLEMENTATION/EVALUATION • Respo
- Page 624 and 625:
allow feelings to be expressed, ind
- Page 626 and 627:
Documentation Focus ASSESSMENT/REAS
- Page 628 and 629:
Actions/Interventions NURSING PRIOR
- Page 630 and 631:
• Ambulate with assistance/device
- Page 632 and 633:
Related Factors Ineffectual/absent
- Page 634 and 635:
cause such as diabetes, vascular pr
- Page 636 and 637:
DISCHARGE PLANNING • Long-term ne
- Page 638 and 639:
• Determine client’s interpreta
- Page 640 and 641:
impaired Skin Integrity Taxonomy II
- Page 642 and 643:
• Palpate skin lesions for size,
- Page 644 and 645:
daily maintenance. Enhances commitm
- Page 646 and 647:
Desired Outcomes/Evaluation Criteri
- Page 648 and 649:
• Advise regular use of sunscreen
- Page 650 and 651:
NURSING PRIORITY NO.2.To assist cli
- Page 652 and 653:
Sustained inadequate sleep hygiene;
- Page 654 and 655:
• Encourage client to develop pla
- Page 656 and 657:
impaired Social Interaction Taxonom
- Page 658 and 659:
• Evaluate possibility of client
- Page 660 and 661:
• Cultural/religious beliefs and
- Page 662 and 663:
• Identify blocks to social conta
- Page 664 and 665:
IMPLEMENTATION/EVALUATION • Respo
- Page 666 and 667:
• Acknowledge reality of feelings
- Page 668 and 669:
Defining Characteristics SUBJECTIVE
- Page 670 and 671:
• Encourage client/family to ask
- Page 672 and 673:
• Physical/emotional responses to
- Page 674 and 675:
• Ascertain substance use/abuse.
- Page 676 and 677:
eadiness for enhanced Spiritual Wel
- Page 678 and 679:
• Clarify reality/appropriateness
- Page 680 and 681:
Defining Characteristics SUBJECTIVE
- Page 682 and 683:
• Allow client to react in own wa
- Page 684 and 685:
Risk Factors INTERNAL Reduced olfac
- Page 686 and 687:
• Develop plan with client/caregi
- Page 688 and 689:
Guilt Gay or lesbian youth DEMOGRAP
- Page 690 and 691:
it will help individual to resolve
- Page 692 and 693:
Related Factors Extensive/prolonged
- Page 694 and 695:
• Collaborate in treatment of com
- Page 696 and 697:
SAMPLE NURSING OUTCOMES & INTERVENT
- Page 698 and 699:
• Identify individually appropria
- Page 700 and 701:
• Instruct to chew food on unaffe
- Page 702 and 703:
[Added demands made on individual o
- Page 704 and 705:
SAMPLE NURSING OUTCOMES & INTERVENT
- Page 706 and 707:
• Use client’s locus of control
- Page 708 and 709:
OBJECTIVE Deficits in advocates for
- Page 710 and 711:
ineffective family Therapeutic Regi
- Page 712 and 713:
Documentation Focus ASSESSMENT/REAS
- Page 714 and 715:
• Incorporate client’s cultural
- Page 716 and 717:
Actions/Interventions NURSING PRIOR
- Page 718 and 719:
Distractibility; [altered attention
- Page 720 and 721:
NURSING PRIORITY NO. 4.To create th
- Page 722 and 723:
impaired Tissue Integrity Taxonomy
- Page 724 and 725:
Record size (depth, width), color,
- Page 726 and 727:
Mobility; disturbed visual Sensory
- Page 728 and 729:
Gastrointestinal Hypoactive/absent
- Page 730 and 731:
• Evaluate vital signs, noting ch
- Page 732 and 733:
• Administer medications (e.g., a
- Page 734 and 735:
• Provide preoperative teaching a
- Page 736 and 737:
Actions/Interventions NURSING PRIOR
- Page 738 and 739:
Risk Factors INTERNAL Weakness; bal
- Page 740 and 741:
• Ascertain knowledge of safety n
- Page 742 and 743:
Documentation Focus ASSESSMENT/REAS
- Page 744 and 745:
elieved by voiding and often recurs
- Page 746 and 747:
chronic urinary urge incontinence,
- Page 748 and 749:
Related Factors To be developed Def
- Page 750 and 751:
• Review with client/SO(s) the si
- Page 752 and 753:
• Determine if client is voluntar
- Page 754 and 755:
Related Factors Bladder outlet obst
- Page 756 and 757:
• Instruct client/SO(s) in clean
- Page 758 and 759:
• Measure amount of each voiding
- Page 760 and 761:
Risk Factors Effects of medications
- Page 762 and 763:
IMPLEMENTATION/EVALUATION • Respo
- Page 764 and 765:
Practice timed voidings (e.g., ever
- Page 766 and 767:
Defining Characteristics SUBJECTIVE
- Page 768 and 769:
Use condom catheter or other extern
- Page 770 and 771:
Desired Outcomes/Evaluation Criteri
- Page 772 and 773:
Recommend consciously delaying void
- Page 774 and 775:
Desired Outcomes/Evaluation Criteri
- Page 776 and 777:
• Assess for effects of psychotro
- Page 778 and 779:
Defining Characteristics SUBJECTIVE
- Page 780 and 781:
• Promote maximal ventilation of
- Page 782 and 783:
• Discuss impact of specific acti
- Page 784 and 785:
Defining Characteristics MILD Subje
- Page 786 and 787:
determine if client can assume the
- Page 788 and 789:
Risk Factors/[Indicators]* HISTORY
- Page 790 and 791:
• Identify precipitating factors.
- Page 792 and 793:
NURSING PRIORITY NO.3.To assist cli
- Page 794 and 795:
that help client to engage in posit
- Page 796 and 797:
Actions/Interventions NURSING PRIOR
- Page 798 and 799:
SAMPLE NURSING OUTCOMES & INTERVENT
- Page 800 and 801:
• Provide a structured daily rout
- Page 802 and 803:
CHAPTER 5 Health Conditions and Cli
- Page 804 and 805:
isk for ineffective Sexuality Patte
- Page 806 and 807:
disturbed Body Image may be related
- Page 808 and 809:
of others, destructive behaviors, i
- Page 810 and 811:
focus, alteration in muscle tone, p
- Page 812 and 813:
isk for Injury/Trauma: risk factors
- Page 814 and 815:
Anaphylaxis CH (Also refer to Shock
- Page 816 and 817:
isk for sedentary Lifestyle: risk f
- Page 818 and 819:
impaired Social Interaction/Social
- Page 820 and 821:
y limited range of motion, impaired
- Page 822 and 823:
Autistic disorder PED/PSY impaired
- Page 824 and 825:
are refuted or wishes denied, manic
- Page 826 and 827:
isk for deficient Fluid Volume: ris
- Page 828 and 829:
evidenced by expressions of boredom
- Page 830 and 831:
deficient Fluid Volume [isotonic] m
- Page 832 and 833:
impaired verbal [and/or written] Co
- Page 834 and 835:
(wasting), aversion to eating, repo
- Page 836 and 837:
fluid intake, possibly evidenced by
- Page 838 and 839:
aggressive feelings, lacking a sens
- Page 840 and 841:
feeling of abdominal/rectal fullnes
- Page 842 and 843:
abnormal breath sounds, ineffective
- Page 844 and 845:
taste sensation, lack of interest i
- Page 846 and 847:
personal resources, decreased energ
- Page 848 and 849:
y verbal expression of distress/unr
- Page 850 and 851:
Anxiety [specify level] may be rela
- Page 852 and 853:
and ineffective sucking/swallowing
- Page 854 and 855:
impaired Gas Exchange may be relate
- Page 856 and 857:
situational low Self-Esteem may be
- Page 858 and 859:
impaired physical Mobility may be r
- Page 860 and 861:
moving in direction of health-promo
- Page 862 and 863:
Guillain-Barré syndrome (acute pol
- Page 864 and 865:
Hemorrhoidectomy MS/CH acute Pain m
- Page 866 and 867:
ehaviors, narrowed focus, and auton
- Page 868 and 869:
Hyperactivity disorder PED/PSY defe
- Page 870 and 871:
isk for unstable blood Glucose: ris
- Page 872 and 873:
secondary defenses (e.g., decreased
- Page 874 and 875:
isk for Poisoning: risk factors may
- Page 876 and 877:
equired voice rest, possibly eviden
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alance, presence of multiple diseas
- Page 880 and 881:
Mastitis OB/GYN acute Pain may be r
- Page 882 and 883:
imbalanced Nutrition: risk for more
- Page 884 and 885:
Powerlessness/Hopelessness may be r
- Page 886 and 887:
acute Pain may be related to ischem
- Page 888 and 889:
isk for disorganized Infant Behavio
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Hyperthermia may be related to incr
- Page 892 and 893:
disturbed kinesthetic/tactile Senso
- Page 894 and 895:
negative self-appraisal in response
- Page 896 and 897:
ehaviors, self-focus, and autonomic
- Page 898 and 899:
evidenced by frequency, dysuria, ur
- Page 900 and 901:
ineffective Breathing Pattern may b
- Page 902 and 903:
decreased Cardiac Output may be rel
- Page 904 and 905:
changes (atelectasis, airway/alveol
- Page 906 and 907:
coping methods, multiple stressors
- Page 908 and 909:
increased metabolic rate, restlessn
- Page 910 and 911:
isk for deficient Fluid Volume: ris
- Page 912 and 913:
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,