Nurse's Pocket Guide

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Documentation Focus ASSESSMENT/REASSESSMENT • Individual findings, including risk factors present, underlying dynamics, prior episodes. • Cultural/religious practices. • Laboratory test results. • Substance use/abuse. PLANNING • Plan of care and who is involved in planning. • Teaching plan. IMPLEMENTATION/EVALUATION • Response to interventions/teaching and actions performed. • Attainment/progress toward desired outcome(s). • Modifications to plan of care. DISCHARGE PLANNING • Long-range needs and who is responsible for actions to be taken. • Community resources, referrals made. SAMPLE NURSING OUTCOMES & INTERVENTIONS CLASSIFICATIONS (NOC/NIC) NOC—Self-Mutilation Restraint NIC—Behavior Management: Self-Harm disturbed Sensory Perception (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) Taxonomy II: Perception/Cognition—Class 3 Sensation/Perception (00122) [Diagnostic Division: Neurosensory] Submitted 1978; Revised 1980, 1998 (by small group work 1996) Definition: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli Related Factors Insufficient environmental stimuli: [therapeutically restricted environments (e.g., isolation, intensive care, bedrest, traction, Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 605 disturbed SENSORY PERCEPTION
disturbed SENSORY PERCEPTION confining illnesses, incubator); socially restricted environment (e.g., institutionalization, homebound, aging, chronic/ terminal illness, infant deprivation); stigmatized (e.g., mentally ill/developmentally delayed/handicapped)] Excessive environmental stimuli: [excessive noise level, such as work environment, client’s immediate environment (ICU with support machinery and the like)] Altered sensory reception/transmission/integration: [neurological disease, trauma, or deficit; altered status of sense organs] Biochemical imbalances [e.g., elevated BUN, elevated ammonia, hypoxia]; electrolyte imbalance; [drugs, e.g., stimulants or depressants, mind-altering drugs] Psychological stress; [sleep deprivation] Defining Characteristics SUBJECTIVE [Reported] change in sensory acuity [e.g., photosensitivity, hypoesthesias/hyperesthesias, diminished/altered sense of taste, inability to tell position of body parts (proprioception)] Sensory distortions OBJECTIVE [Measured] change in sensory acuity Change in usual response to stimuli [e.g., rapid mood swings, exaggerated emotional responses, anxiety/panic state] Change in behavior pattern; restlessness; irritability Change in problem-solving abilities; poor concentration Disorientation; hallucinations; [illusions]; [bizarre thinking] Impaired communication [Motor incoordination, altered sense of balance/falls (e.g., Ménière’s syndrome)] Desired Outcomes/Evaluation Criteria—Client Will: • Regain/maintain usual level of cognition. • Recognize and correct/compensate for sensory impairments. • Verbalize awareness of sensory needs and presence of overload and/or deprivation. • Identify/modify external factors that contribute to alterations in sensory/perceptual abilities. • Use resources effectively and appropriately. • Be free of injury. Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. 606 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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PLANNING • Plan of care/intervent
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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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• Attainment/progress toward desi
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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 (
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• Encourage client to begin with
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• Assess ability to distinguish b
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maximize independence, allow client
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• Establish graduated goals or mo
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[Abnormal laboratory studies (e.g.,
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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
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• Discuss use of non-food rewards
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Assist with/provide denture care wh
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Related Factors Injuring agents (bi
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• Note cultural and developmental
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• 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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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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DISCHARGE PLANNING • Long-term ne
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• Review results of laboratory te
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• Demonstrate ability to deal wit
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• Help child to express feelings
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ack to get her”; “Don’t call
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• Assist client to set realistic
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Moderate Dependence on others that
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• Develop contract with client sp
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Inadequate coping patterns Absence
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• Cultural values/religious belie
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DRUG THERAPIES, TREATMENTS, AND DIS
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[C] SILENT REACTION—(00141) Defin
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• Provide environment in which cl
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Page 584 and 585: NOTE: A risk diagnosis is not evide
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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
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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
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Page 644 and 645: daily maintenance. Enhances commitm
Page 646 and 647: Desired Outcomes/Evaluation Criteri
Page 648 and 649: • Advise regular use of sunscreen
Page 650 and 651: NURSING PRIORITY NO.2.To assist cli
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Page 654 and 655: • Encourage client to develop pla
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Page 658 and 659: • Evaluate possibility of client
Page 660 and 661: • Cultural/religious beliefs and
Page 662 and 663: • Identify blocks to social conta
Page 664 and 665: IMPLEMENTATION/EVALUATION • Respo
Page 666 and 667: • Acknowledge reality of feelings
Page 668 and 669: Defining Characteristics SUBJECTIVE
Page 670 and 671: • Encourage client/family to ask
Page 672 and 673: • Physical/emotional responses to
Page 674 and 675: • Ascertain substance use/abuse.
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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
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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