Nurse's Pocket Guide

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SAMPLE NURSING OUTCOMES & INTERVENTIONS CLASSIFICATIONS (NOC/NIC) NOC—Weight Control NIC—Weight Management readiness for enhanced Nutrition Taxonomy II: Health Awareness—Class 2 Health Management (00163) [Diagnostic Division: Food/Fluid] Submitted 2002 Definition: A pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened Related Factors To be developed Defining Characteristics SUBJECTIVE Expresses knowledge of healthy food and fluid choices/willingness to enhance nutrition Eats regularly Attitude toward eating/drinking is congruent with health goals OBJECTIVE Consumes adequate food/fluid Follows an appropriate standard for intake (e.g., the food pyramid or American Diabetic Association <strong>Guide</strong>lines) Safe preparation/storage for food/fluids Desired Outcomes/Evaluation Criteria—Client Will: • Demonstrate behaviors to attain/maintain appropriate weight. • Be free of signs of malnutrition. • Be able to safely prepare and store foods. Actions/Interventions NURSING PRIORITY NO.1.To determine current nutritional status and eating patterns: • Review client’s knowledge of current nutritional needs and ways client is meeting these needs. Provides baseline for further teaching and interventions. Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 491 readiness for enhanced NUTRITION
eadiness for enhanced NUTRITION • Assess eating patterns and food/fluid choices in relation to any health-risk factors and health goals. Helps to identify specific strengths and weaknesses that can be addressed. • Verify that age-related and developmental needs are met. These factors are constantly present throughout the lifespan, although differing for each age group. For example, older adults need same nutrients as younger adults, but in smaller amounts, and with attention to certain components, such as calcium, fiber, vitamins, protein, and water. Infants/children require small meals and constant attention to needed nutrients for proper growth/development while dealing with child’s food preferences and eating habits. • Evaluate influence of cultural/religious factors to determine what client considers to be normal dietary practices, as well as to identify food preferences/restrictions, and eating patterns that can be strengthened and/or altered, if indicated. • Assess how client perceives food, food preparation, and the act of eating to determine client’s feeling and emotions regarding food and self-image. • Ascertain occurrence of/potential for negative feedback from SO(s). May reveal control issues that could impact client’s commitment to change. • Determine patterns of hunger and satiety. Helps identify strengths and weaknesses in eating patterns and potential for change (e.g., person predisposed to weight gain may need a different time for a big meal than evening, or need to learn what foods reinforce feelings of satisfaction). • Assess client’s ability to safely store and prepare foods to determine if health information or resources might be needed. NURSING PRIORITY NO.2.To assist client/SO(s) to develop plan to meet individual needs: • Determine motivation/expectation for change. • Assist in obtaining/review results of individual testing (e.g., weight/height, body fat percent, lipids, glucose, complete blood count, total protein, etc.) to determine that client is healthy and/or identify dietary changes that may be helpful in attaining health goals. • Encourage client’s beneficial eating patterns/habits (e.g., controlling portion size, eating regular meals, reducing high-fat or fast-food intake, following specific dietary program, drinking water and healthy beverages). Positive feedback promotes continuation of healthy lifestyle habits and new behaviors. Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. 492 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
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• Recommend that client (of any a
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CAREGIVER Mental retardation; sever
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children’s services, medical equi
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laxatives]; and enteral tube feedin
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• Discuss possible change in infa
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especially during times of stress,
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Related Factors Conflict among deci
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• Provide time for nonjudgmental
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• Be free of signs/symptoms of in
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VASCULAR (TISSUE PERFUSION) • Mon
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• Provide/review information abou
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• Assess/review client’s physic
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• Identify areas of imbalance or
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impaired Environmental Interpretati
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• Use touch judiciously. Tell cli
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IMPLEMENTATION/EVALUATION • Respo
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• Determine client’s medical, c
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• Observe individual’s general
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counseling, home care, sources for
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OBJECTIVE Feelings Repressed emotio
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• Provide information regarding e
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assigned tasks; stress-reduction be
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• Provide educational materials a
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today, such as biological, nuclear,
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• Refer to classes/support groups
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• Encourage use of assistive devi
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Related Factors Innate origin (e.g.
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• Modify procedures, if possible
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Related Factors To be developed Def
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(such as prevention of hyperglycemi
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NURSING PRIORITY NO. 5. To promote
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• Verbalize understanding of caus
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• Note amount/rate of fluid intak
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Offer fluids between meals and regu
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moist mucous membranes; individual
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• Results of laboratory test/diag
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NURSING PRIORITY NO.2.To evaluate d
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• Identify specific supplier for
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• Assess family/SO(s) support of
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NURSING PRIORITY NO.2.To determine
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• Support community efforts to st
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elated to socially sensitive issue
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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
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
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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 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
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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
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Page 534 and 535: PLANNING • Plan of care and who i
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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 550 and 551: • Demonstrate ability to deal wit
Page 552 and 553: • Help child to express feelings
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Page 558 and 559: SAMPLE NURSING OUTCOMES & INTERVENT
Page 560 and 561: • 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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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
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,
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