Nurse's Pocket Guide

More documents

Recommendations

Info

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—Client Will: • Express understanding of relation of situation/health status to thoughts and feelings of concern about ability to participate in desired religious activities. • Seek solutions to individual factors that may interfere with reliance on religious beliefs/participation in religious rituals. • Identify and use resources appropriately. Actions/Interventions NURSING PRIORITY NO.1.To assess causative/contributing factors: • Ascertain current situation, e.g., illness, hospitalization, prognosis of death, depression, lack of support systems, financial concerns. Identifies problems client is dealing with in the moment that may be affecting desire to be involved with religious activities. • Note client’s concerns/expressions of anger, belief that illness/condition is result of lack of faith. Individual may blame himself or herself for what has happened and could reject religious beliefs and/or God. • Determine client’s usual religious/spiritual beliefs, past or current involvement in specific church activities. • Identify cultural values/expectations regarding religious beliefs and/or practices. • Note quality of relationships with significant others and friends. Individual may withdraw from others in relation to the stress of illness, pain, and suffering. Others may be encouraging client to rely on religious beliefs at a time when individual is questioning own beliefs in the current situation. • Assess lack of transportation/environmental barriers to participation in desired religious activities. • Ascertain substance use/abuse. Individuals often turn to use of various substances in distress, and this can affect the ability to deal with problems in a positive manner. NURSING PRIORITY NO. 2.To assist client to deal with feelings/ situation: • Develop nurse/client relationship. Individual can express feelings and concerns freely when he or she feels safe to do so. Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 563 risk for impaired RELIGIOSITY
isk for impaired RELIGIOSITY • Use therapeutic communications skills of active-listening, reflection, and I-messages. Helps client to find own solutions to problems and concerns and promotes sense of control. • Have client identify and prioritize current/immediate needs. Dealing with current needs is easier than trying to predict the future. • Provide time for nonjudgmental discussion of individual’s spiritual beliefs and fears about impact of current illness and/or treatment regimen. Helps to clarify thoughts and promote ability to deal with stresses of what is happening. • Review with client past difficulties in life and coping skills that were used at that time. • Encourage client to discuss feelings about death and end-oflife issues when illness/prognosis is grave. NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations): • Have client identify support systems available. • Help client learn relaxation techniques, meditation, guided imagery, and mindfulness/living in the moment and enjoying it. • Take the lead from the client in initiating participation in religious activities, prayer, other activities. Client may be vulnerable in current situation and must be allowed to decide own participation in these actions. • Refer to appropriate resources (e.g., crisis counselor, governmental agencies, spiritual advisor) who has qualifications/ experience dealing with specific problems, such as death/ dying, relationship problems, substance abuse, suicide, hospice, psychotherapy, Alcoholics/Narcotics Anonymous. Documentation Focus ASSESSMENT/REASSESSMENT • Individual findings, including risk factors, nature of current distress. • Physical/emotional response to distress. • Access to/use of resources. PLANNING • Plan of care and who is involved in planning. • Teaching plan. IMPLEMENTATION/EVALUATION • Responses to interventions/teaching and actions performed. • Attainment/progress toward desired outcome(s). Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. 564 Cultural Collaborative Community/Home Care
Page 2 and 3:
ACTIVITY/REST—Ability to engage i
Page 4 and 5:
GORDON’S FUNCTIONAL HEALTH PATTER
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:
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:
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:
Page 256 and 257:
Page 258 and 259:
involvement with caring for others/
Page 260 and 261:
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:
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:
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:
Page 344 and 345:
Page 346 and 347:
• Verbalize understanding of caus
Page 348 and 349:
Page 350 and 351:
• Note amount/rate of fluid intak
Page 352 and 353:
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:
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:
Page 400 and 401:
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:
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:
Page 468 and 469:
Page 470 and 471:
Parent/Caregiver Will: • Provide
Page 472 and 473:
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:
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:
Page 492 and 493:
• Assess ability to distinguish b
Page 494 and 495:
maximize independence, allow client
Page 496 and 497:
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:
Page 512 and 513:
Page 514 and 515:
• Discuss use of non-food rewards
Page 516 and 517:
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:
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 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 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 586 and 587: • Modifications to plan of care.
Page 588 and 589: (e.g., stomach aches, headaches, ba
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 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 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:
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:
Page 666 and 667:
• Acknowledge reality of feelings
Page 668 and 669:
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:
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:
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:
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:
Page 714 and 715:
• Incorporate client’s cultural
Page 716 and 717:
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:
Page 738 and 739:
Risk Factors INTERNAL Weakness; bal
Page 740 and 741:
• Ascertain knowledge of safety n
Page 742 and 743:
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:
Page 764 and 765:
Practice timed voidings (e.g., ever
Page 766 and 767:
Page 768 and 769:
Use condom catheter or other extern
Page 770 and 771:
Page 772 and 773:
Recommend consciously delaying void
Page 774 and 775:
Page 776 and 777:
• Assess for effects of psychotro
Page 778 and 779:
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:
Page 798 and 799:
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
Page 878 and 879:
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
Page 890 and 891:
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,
show all

Nurse's Pocket Guide

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?