Nurse's Pocket Guide

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EXCERPT FROM PRENATAL ASSESSMENT TOOL Safety SUBJECTIVE (REPORTS) Allergies/sensitivity: __________________________________ Reaction: ________________________________________ Previous alteration of immune system: __________________ Cause: __________________________________________ History of sexually transmitted diseases/gynecologic infections (date/type): ______________________________________ Testing/date: ______________________________________ High-risk behaviors:__________________________________ Blood transfusion/number: ________ When: ______________ Reaction: ________________________________________ Describe: ________________________________________ Childhood diseases: __________________________________ Immunization history/date: Tetanus: __________________ Pneumonia: ______________________________________ Influenza: ________ Hepatitis: ________ MMR: ________ Polio: _____________ HPV: ________________________ Recent exposure to German measles: ____________________ Other viral infections: ______________________________ X-ray/radiation: __________ House pets: ______________ Previous obstetric problems: PIH: ______ Kidney: ________ Hemorrhage: __________ Cardiac: __________________ Diabetes: ___ Infection/UTI: ___ ABO/Rh sensitivity: ___ Uterine surgery: __________________________________ Anemia: ___ Explain “yeses”: ________________________ Length of time since last pregnancy: ____________________ Type of previous delivery: __________________________ History of accidental injuries: Fractures/dislocations: ________ Physical abuse: ____________________________________ Arthritis/unstable joints: ____________________________ Back problems: ____________________________________ Changes in moles: __________ Enlarged nodes: __________ Impaired vision: __________ Hearing: __________________ Prostheses: ________ Ambulatory devices: ________________ OBJECTIVE (EXHIBITS) Temperature: __________ Diaphoresis: __________________ Skin integrity: __________ Scars: ________ Rashes: ________ Ecchymosis: ________ Genital warts/lesions: ____________ General strength: __________ Muscle tone: ______________ Gait: ____________________________________________ ROM: ________ Paresthesia/paralysis: ________ PUTTING THEORY INTO PRACTICE 37 Sample Assessment Tool
Fetal: Heart rate: ____________ Location: ________________ Method of auscultation: _______Fundal height: ________ Estimated gestation (weeks): _______ Movement: ________ Ballottement: ____________________________________ Fetal testing: Date: ________ Test: ________ Result: ________ AFT: ____________________________________________ Screenings: Serology: ___________ Syphilis: ______________ Sickle cell: ___________ Rubella: _____________________ Hepatitis: _________ HIV: __________ AFP: ___________ Results of cultures (cervical/rectal): ______________________ Immune system testing: _____________________________ Blood type: Maternal: __________ Paternal: ______________ Sexuality (Component of Social Interactions) SUBJECTIVE (REPORTS) Sexual concerns: ____________________________________ Menarche: __________ Length of cycle (days): ____________ Duration (days): __________________________________ First day of last menstrual period: _______ Amount: ________ Bleeding/cramping since LMP: _______________________ Vaginal discharge:__________________________________ Client’s belief of when conception occurred: ______________ Estimated date of delivery: ____________________________ Last PAP smear: _____ Practices breast self-examination: ____ Recent contraceptive method: __________________________ OB history (GPTPAL): Gravida: _____ Para: ____ Term: ____ Preterm: ___ Abortions: ___ Living: ___ Multiple births: ___ Delivery history: Year: ________ Place of delivery: __________ Length of gestation (weeks): ________________________ Length of labor (hours): _________ Type of delivery: ____ Born (alive): ____ Weight: ______ Apgar scores: ________ Complications (maternal/fetal): ________________________ OBJECTIVE (EXHIBITS) Pelvic: Vulva: ________ Perineum: ________ Vagina: _______ Cervix: _________ Uterus: _________ Adnexal:__________ Diagonal conjugate: ________________________________ Transverse: _______ Diameter: ______ Outlet (cm): ______ Shape of sacrum: ________ Arch: _______ Coccyx: _______ SS notch: ________________________________________ Ischial spines: ____________________________________ Adequacy of inlet: _______ Mid: _______ Outlet: ________ Prognosis for delivery: ________________________________ Breast exam: ____________ Nipples: ____________________ Pregnancy test: __________ Serology test (date): ___________ PAP smear results: ___________________________________ 38 NURSE’S POCKET GUIDE
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 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.
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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
Page 312 and 313:
Page 314 and 315:
• 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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Page 344 and 345:
Page 346 and 347:
• Verbalize understanding of caus
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Page 350 and 351:
• Note amount/rate of fluid intak
Page 352 and 353:
Page 354 and 355:
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
Page 362 and 363:
• 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
Page 382 and 383:
delayed Growth and Development Taxo
Page 384 and 385:
• Note chronological age, familia
Page 386 and 387:
• Determine reasonable expectatio
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Inability to make appropriate judgm
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• Encourage socialization and per
Page 392 and 393:
Expressed concern about current env
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• Pertinent cultural/religious be
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• Assess client/SO’s level of c
Page 398 and 399:
Page 400 and 401:
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• Identify cultural/spiritual val
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• Refer to other resources for as
Page 406 and 407:
abdominal temperature monitoring ma
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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
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still exist and can be passed on to
Page 418 and 419:
Defining Characteristics OBJECTIVE
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• Avoid aversive oral stimulation
Page 422 and 423:
VESTIBULAR • Move and handle the
Page 424 and 425:
Defining Characteristics OBJECTIVE
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Page 428 and 429:
• Demonstrate appropriate weight
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• Caregiver’s involvement in in
Page 432 and 433:
• Provide for isolation, as indic
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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
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• 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
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• 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 (
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• Encourage client to begin with
Page 490 and 491:
Page 492 and 493:
• Assess ability to distinguish b
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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
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• Caloric intake. • Individual
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• Discuss client’s view of self
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• Encourage buying personal items
Page 510 and 511:
Page 512 and 513:
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• Discuss use of non-food rewards
Page 516 and 517:
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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
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for all persons, encouraging client
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KNOWLEDGE Deficient knowledge about
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Parents with significant impairment
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Page 536 and 537:
voice, are indicative of attachment
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DISCHARGE PLANNING • Long-range n
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• Participate in activities, clas
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• Assess capillary return, skin c
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• Review results of laboratory te
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Page 550 and 551:
• Demonstrate ability to deal wit
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• Help child to express feelings
Page 554 and 555:
Page 556 and 557:
ack to get her”; “Don’t call
Page 558 and 559:
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
Page 566 and 567:
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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Page 578 and 579:
Difficulty adhering to prescribed r
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and practices, these influences wil
Page 584 and 585:
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
Page 622 and 623:
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allow feelings to be expressed, ind
Page 626 and 627:
Page 628 and 629:
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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
Page 646 and 647:
Page 648 and 649:
• 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
Page 656 and 657:
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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Page 714 and 715:
• Incorporate client’s cultural
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Page 718 and 719:
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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Page 738 and 739:
Risk Factors INTERNAL Weakness; bal
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• Ascertain knowledge of safety n
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Page 744 and 745:
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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Page 764 and 765:
Practice timed voidings (e.g., ever
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Use condom catheter or other extern
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Page 772 and 773:
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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Page 798 and 799:
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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
Page 814 and 815:
Anaphylaxis CH (Also refer to Shock
Page 816 and 817:
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
Page 824 and 825:
are refuted or wishes denied, manic
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isk for deficient Fluid Volume: ris
Page 828 and 829:
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
Page 838 and 839:
aggressive feelings, lacking a sens
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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
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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
Page 854 and 855:
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
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
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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
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,
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