Nurse's Pocket Guide

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DISCHARGE PLANNING • Long-range needs and who is responsible for actions to be taken. • Modification to plan. SAMPLE NURSING OUTCOMES & INTERVENTIONS CLASSIFICATIONS (NOC/NIC) NOC—Parenting NIC—Parenting Education: Childbearing Family risk for impaired Parenting Taxonomy II: Role Relationships—Class 1 Caregiving Roles (00057) [Diagnostic Division: Social Interaction] Submitted 1978; Nursing Diagnosis Extension and Classification (NDEC) Revision 1998 Definition: Risk for inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child [NOTE: It is important to reaffirm that adjustment to parenting in general is a normal maturational process that elicits nursing behaviors to prevent potential problems and to promote health.] Risk Factors INFANT OR CHILD Altered perceptual abilities; attention deficit hyperactivity disorder Difficult temperament; temperament conflicts with parental expectation Premature birth; mulitple births; not gender desired Handicapping condition; developmental delay Illness; prolonged separation from parent KNOWLEDGE Unrealistic expectations of child; deficient knowledge about child development/health maintenance, parenting skills Low educational level or attainment; lack of cognitive readiness for parenthood; low cognitive functioning Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 517 risk for impaired PARENTING
isk for impaired PARENTING Poor communication skills Inability to respond to infant cues Preference for physical punishment PHYSIOLOGICAL Physical illness PSYCHOLOGICAL Young parental age Closely spaced pregnancies; high number of pregnancies; difficult birthing process Sleep disruption/deprivation Depression; history of mental illness/substance abuse Disability SOCIAL Stress; job problems; unemployment; financial difficulties; poor home environment; relocation Situational/chronic low self-esteem Lack of family cohesiveness; marital conflict; change in family unit; inadequate childcare arrangements Role strain; single parent; father/mother of child not involved; parent-child separation Poor/lack of parental role model; lack of valuing of parenthood Unplanned/unwanted pregnancy; late/lack of prenatal care Low socioeconomic class; poverty; lack of resources/access to resources; lack of transportation Poor problem-solving skills; maladaptive coping strategies Lack of social support network; social isolation History of being abused/being abusive; legal difficulties NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention. Desired Outcomes/Evaluation Criteria—Parents Will: • Verbalize awareness of individual risk factors. • Identify own strengths, individual needs, and methods/ resources to meet them. • Demonstrate behavior/lifestyle changes to reduce potential for development of problem or reduce/eliminate effects of risk factors. Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. 518 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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• 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
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Related Factors Lack of interest/mo
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improve balance and coordination ca
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Parent/Caregiver Will: • Provide
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State Examination [MMSE]), to compl
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Related Factors Neuromuscular/muscu
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• Involve client/SO(s) in determi
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maintaining appliances/equipment. P
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vision deficits) are treated/being
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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
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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
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Page 530 and 531: KNOWLEDGE Deficient knowledge about
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Page 534 and 535: PLANNING • Plan of care and who i
Page 536 and 537: voice, are indicative of attachment
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
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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 578 and 579: Difficulty adhering to prescribed r
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Page 584 and 585: NOTE: A risk diagnosis is not evide
Page 586 and 587: • 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
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negative self-appraisal in response
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ehaviors, self-focus, and autonomic
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evidenced by frequency, dysuria, ur
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ineffective Breathing Pattern may b
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decreased Cardiac Output may be rel
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changes (atelectasis, airway/alveol
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coping methods, multiple stressors
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increased metabolic rate, restlessn
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isk for deficient Fluid Volume: ris
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minimizes health status change, fai
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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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