Nurse's Pocket Guide

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that help client to engage in positive social activities with others. • Discuss reasons for client’s behavior with SO(s). Determine desire/commitment of involved parties to sustain current relationships. • Develop strategies to help parents learn more effective parenting skills (e.g., parenting classes, appropriate ways of dealing with frustrations). Mothering has a powerful effect on helping children to learn impulse control. • Identify support systems (e.g., family/friends, clergy). In addition to the client, those around him or her need to learn how to be positive role models and display a broader array of skills for resolving problems. • Refer to formal resources, as indicated (e.g., individual/group psychotherapy, substance abuse treatment program, social services, safe house facility, parenting classes). • Refer to NDs impaired Parenting; family Coping [specify]; Post-Trauma Syndrome. Documentation Focus ASSESSMENT/REASSESSMENT • Individual findings, including nature of concern (e.g., suicidal/homicidal), behavioral risk factors and level of impulse control, plan of action/means to carry out plan. • Client’s perception of situation, motivation for change. • Family history of violence. • Availability/use of resources. PLANNING • Plan of care and who is involved in the planning. • Details of contract regarding violence to self/others. • Teaching plan. IMPLEMENTATION/EVALUATION • Actions taken to promote safety, including notification of parties at risk. • 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. • Available resources, specific referrals made. Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 773 [actual/] risk for VIOLENCE
impaired WALKING SAMPLE NURSING OUTCOMES & INTERVENTIONS CLASSIFICATIONS (NOC/NIC) NOC—Aggression Control NIC—Anger Control Assistance impaired Walking Taxonomy II: Activity/Rest—Class 2 Activity/Exercise (00088) [Diagnostic Division: Activity/Rest] Submitted 1998 Definition: Limitation of independent movement within the environment on foot Related Factors Insufficient muscle strength; neuromuscular impairment; musculoskeletal impairment (e.g., contractures) Limited endurance; deconditioning Fear of falling; impaired balance Impaired vision Pain Obesity Depressed mood; cognitive impairment Lack of knowledge Environmental constraints (e.g., stairs, inclines, uneven surfaces, unsafe obstacles, distances, lack of assistive devices or persons, restraints) Defining Characteristics SUBJECTIVE OR OBJECTIVE Impaired ability to walk required distances; walk on an incline/ decline; walk on uneven surfaces; to navigate curbs, climb stairs [Specify level of independence—refer to ND impaired physical Mobility, for suggested functional level classification] Desired Outcomes/Evaluation Criteria—Client Will: • Be able to move about within environment as needed/desired within limits of ability or with appropriate adjuncts. • Verbalize understanding of situation/risk factors and safety measures. Information in brackets added by the authors to clarify and enhance the use of nursing diagnoses. 774 Cultural Collaborative Community/Home Care
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ACTIVITY/REST—Ability to engage i
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GORDON’S FUNCTIONAL HEALTH PATTER
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Nurse’s Pocket Guide Diagnoses, P
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F. A. Davis Company 1915 Arch Stree
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CONTRIBUTOR Sheila Marquez Executiv
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Health Conditions and Client Concer
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How to Use the Nurse’s Pocket Gui
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Medicine. Today, researchers from a
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CHAPTER 1 The Nursing Process Nursi
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her own care and the achievement of
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and psychology. A sense of caring,
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CHAPTER 2 Application of the Nursin
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Table 2-1. (Continued) Death Syndro
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Table 2-1. (Continued) Rape-Trauma
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could be used by nurses throughout
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from the diagnostic statement and a
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CHAPTER 3 Putting Theory into Pract
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documentation of the planning proce
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ADULT MEDICAL/SURGICAL ASSESSMENT T
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Heart sounds (auscultation): Rate:
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Last meal consumed/content: _______
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Cooperative: _____ Agitated/Restles
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Uses seat belt regularly: _______ B
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Social Interactions SUBJECTIVE (REP
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Areas that may require alteration/a
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Consistency of behavior: Verbal ___
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EXCERPT FROM PRENATAL ASSESSMENT TO
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EXCERPT FROM INTRAPARTAL ASSESSMENT
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SECTION 2 DIAGNOSTIC DIVISIONS: NUR
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Spiritual Distress, risk for Spirit
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Death Syndrome, risk for sudden inf
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SECTION 3 CLIENT SITUATION AND PROT
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Nailbeds: pink Conjunctiva and scle
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Eyes: Vision loss, farsighted, “S
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Extended family: 1 daughter lives i
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PLAN OF CARE FOR CLIENT WITH DIABET
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ACTIONS/INTERVENTIONS RATIONALE deh
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ACTIONS/INTERVENTIONS RATIONALE vas
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ACTIONS/INTERVENTIONS RATIONALE and
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ANOTHER APPROACH TO PLANNING CLIENT
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SECTION 4 DOCUMENTATION TECHNIQUES:
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Example 1. SAMPLE SOAP/IER CHARTING
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Example 2. SAMPLE OF FOCUS CHARTING
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Functional Level Classification (Go
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• Plan for maximal activity withi
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• Identify conditions/symptoms th
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ineffective Airway Clearance Taxono
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diaphragm and enhancing drainage of
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treatment of obstructive sleep apne
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kiwi, papya, peach, nectarine), pri
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• Type/extent of symptomatology.
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• Obtain lists of latex-free prod
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Affective Regretful; scared; rattle
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Voice quivers or changes pitch Trem
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NURSING PRIORITY NO. 3. To promote
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Negative thoughts related to death
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• Refer to community agencies/res
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as listed in Risk Factors, to deter
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• Provide information about the e
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• Ascertain availability/use of r
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Autonomic Dysreflexia Taxonomy II:
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urine flow if blocked; remove bowel
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MUSCULOSKELETAL—INTEGUMENTARY STI
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goosebumps; bradycardia; cardiac ir
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• Explore the expressions of emot
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IMPLEMENTATION/EVALUATION • Clien
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• Acknowledge self as an individu
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• Assume all individuals are sens
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Risk Factors Extremes of age/weight
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medication regimen with physician t
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impacted stool; severe diarrhea; de
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DISCHARGE PLANNING • Identified l
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• Encourage skin-to-skin contact.
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Related Factors Prematurity; infant
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for more than 15 minutes on each si
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• Provide practice times at breas
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Maternal desire to maintain breastf
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3 hours while awake as indicated to
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Related Factors Neuromuscular dysfu
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• Deal with fear/anxiety that may
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decreased Cardiac Output Taxonomy I
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of extremities, and progressive sho
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• Refer to NDs ineffective Tissue
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DISCHARGE PLANNING • Discharge co
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Defining Characteristics SUBJECTIVE
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• Identify relationship of caregi
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importance of self-nurturing (e.g.,
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Desired Outcomes/Evaluation Criteri
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Documentation Focus ASSESSMENT/REAS
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• Determine influence of cultural
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owl/aquarium, to stimulate observat
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Anatomical deficit (e.g., cleft pal
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NURSING PRIORITY NO. 2.To assist cl
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professional interpreter who transl
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• Associate words with objects—
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OBJECTIVE Vacillation between alter
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• Promote opportunities for using
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• Demonstrate appropriate behavio
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DISCHARGE PLANNING • Long-term ne
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• Evaluate for exacerbation of ps
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client. If the history reveals an i
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PLANNING • Plan of care and who i
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NURSING PRIORITY NO 2. To reduce/co
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Insufficient physical activity; abd
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• Determine laxative/enema use. N
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PLANNING • Plan of care/intervent
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IMPLEMENTATION/EVALUATION • Clien
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• Discuss usual elimination patte
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Related Factors EXTERNAL Chemical c
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Actions/Interventions In reviewing
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• Obtain/assist with diagnostic s
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• Recommend periodic inspection o
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Lack of breakdown of contaminants o
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• Recommend periodic inspection o
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• Specific actions and changes th
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• Assess information available to
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Rationalizes failures [Refuses or r
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• Promote involvement in activiti
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Actions/Interventions NURSING PRIOR
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DISCHARGE PLANNING • Ongoing need
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• Assess current functional capac
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• Discuss/review anticipated proc
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involvement with caring for others/
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Adaptive tasks effectively addresse
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• Attainment/progress toward desi
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fewer infants die of SIDS when they
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SAMPLE NURSING OUTCOMES & INTERVENT
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• Refer to other resources, as ne
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• Note client’s comments about
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• Recommend that client (of any a
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CAREGIVER Mental retardation; sever
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children’s services, medical equi
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laxatives]; and enteral tube feedin
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• Discuss possible change in infa
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especially during times of stress,
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Related Factors Conflict among deci
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• Provide time for nonjudgmental
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• Be free of signs/symptoms of in
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VASCULAR (TISSUE PERFUSION) • Mon
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• Provide/review information abou
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• Assess/review client’s physic
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• Identify areas of imbalance or
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impaired Environmental Interpretati
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• Use touch judiciously. Tell cli
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IMPLEMENTATION/EVALUATION • Respo
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• Determine client’s medical, c
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• Observe individual’s general
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counseling, home care, sources for
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OBJECTIVE Feelings Repressed emotio
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• Provide information regarding e
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assigned tasks; stress-reduction be
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• Provide educational materials a
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today, such as biological, nuclear,
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• Refer to classes/support groups
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• Encourage use of assistive devi
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Related Factors Innate origin (e.g.
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• Modify procedures, if possible
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Related Factors To be developed Def
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(such as prevention of hyperglycemi
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• Verbalize understanding of caus
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• Note amount/rate of fluid intak
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Offer fluids between meals and regu
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moist mucous membranes; individual
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• Results of laboratory test/diag
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NURSING PRIORITY NO.2.To evaluate d
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• Identify specific supplier for
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• Assess family/SO(s) support of
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NURSING PRIORITY NO.2.To determine
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• Support community efforts to st
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elated to socially sensitive issue
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choice to have another child or to
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• Assess status of relationships/
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Congenital/genetic disorders [e.g.,
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• Determine if child’s growth i
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delayed Growth and Development Taxo
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• Note chronological age, familia
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• Determine reasonable expectatio
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Inability to make appropriate judgm
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• Encourage socialization and per
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Expressed concern about current env
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• Pertinent cultural/religious be
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• Assess client/SO’s level of c
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• Identify cultural/spiritual val
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• Refer to other resources for as
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abdominal temperature monitoring ma
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onmental heat (e.g., proper clothin
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• Identify underlying cause/contr
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• Keep client quiet; handle gentl
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Immunization status Identification
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still exist and can be passed on to
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Defining Characteristics OBJECTIVE
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• Avoid aversive oral stimulation
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VESTIBULAR • Move and handle the
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Defining Characteristics OBJECTIVE
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• Demonstrate appropriate weight
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• Caregiver’s involvement in in
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• Provide for isolation, as indic
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measures to prevent pneumonia, woun
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• Demonstrate behaviors, lifestyl
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using smokeless tobacco, occurrence
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Risk Factors Disorientation; sensor
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• Assist with therapies/nursing a
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disorders, dementia, obesity, pregn
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• Encourage routine use of contin
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decreased Intracranial Adaptive Cap
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carina. Administer lidocaine intrat
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[Illnesses/trauma affecting body im
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• Assist client and SO(s) to ackn
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• Be alert to signs of avoidance.
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complex. Can arouse interest/limit
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• Determine motivation/expectatio
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Related Factors Lack of interest/mo
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improve balance and coordination ca
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Parent/Caregiver Will: • Provide
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State Examination [MMSE]), to compl
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Related Factors Neuromuscular/muscu
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• Involve client/SO(s) in determi
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maintaining appliances/equipment. P
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vision deficits) are treated/being
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BIOPHYSICAL Biochemical disorders (
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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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• 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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Difficulty adhering to prescribed r
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and practices, these influences wil
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NOTE: A risk diagnosis is not evide
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• Modifications to plan of care.
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(e.g., stomach aches, headaches, ba
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• Support self-responsibility and
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• Determine client role in family
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Self-Care Deficit: bathing/hygiene,
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• Note concomitant medical proble
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• Support client in making health
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nonverbal expressions is culturally
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• Develop therapeutic relationshi
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• Note nonverbal body language. I
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isk for situational low Self-Esteem
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often is an attempt to establish in
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allow feelings to be expressed, ind
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• Ambulate with assistance/device
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Related Factors Ineffectual/absent
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cause such as diabetes, vascular pr
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• Determine client’s interpreta
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impaired Skin Integrity Taxonomy II
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• Palpate skin lesions for size,
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daily maintenance. Enhances commitm
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• Advise regular use of sunscreen
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NURSING PRIORITY NO.2.To assist cli
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Sustained inadequate sleep hygiene;
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• Encourage client to develop pla
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impaired Social Interaction Taxonom
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• Evaluate possibility of client
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• Cultural/religious beliefs and
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• Identify blocks to social conta
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• Acknowledge reality of feelings
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• Encourage client/family to ask
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• Physical/emotional responses to
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• Ascertain substance use/abuse.
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eadiness for enhanced Spiritual Wel
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• Clarify reality/appropriateness
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• Allow client to react in own wa
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Risk Factors INTERNAL Reduced olfac
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• Develop plan with client/caregi
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Guilt Gay or lesbian youth DEMOGRAP
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it will help individual to resolve
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Related Factors Extensive/prolonged
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• Collaborate in treatment of com
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• Identify individually appropria
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• Instruct to chew food on unaffe
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[Added demands made on individual o
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• Use client’s locus of control
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OBJECTIVE Deficits in advocates for
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ineffective family Therapeutic Regi
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• Incorporate client’s cultural
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Distractibility; [altered attention
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NURSING PRIORITY NO. 4.To create th
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impaired Tissue Integrity Taxonomy
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Record size (depth, width), color,
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Mobility; disturbed visual Sensory
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Gastrointestinal Hypoactive/absent
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• Evaluate vital signs, noting ch
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• Administer medications (e.g., a
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• Provide preoperative teaching a
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Risk Factors INTERNAL Weakness; bal
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• Ascertain knowledge of safety n
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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: IMPLEMENTATION/EVALUATION • Respo
Page 764 and 765: Practice timed voidings (e.g., ever
Page 766 and 767: Defining Characteristics SUBJECTIVE
Page 768 and 769: Use condom catheter or other extern
Page 770 and 771: Desired Outcomes/Evaluation Criteri
Page 772 and 773: Recommend consciously delaying void
Page 774 and 775: Desired Outcomes/Evaluation Criteri
Page 776 and 777: • Assess for effects of psychotro
Page 778 and 779: Defining Characteristics SUBJECTIVE
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 796 and 797: Actions/Interventions NURSING PRIOR
Page 798 and 799: SAMPLE NURSING OUTCOMES & INTERVENT
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
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taste sensation, lack of interest i
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personal resources, decreased energ
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y verbal expression of distress/unr
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Anxiety [specify level] may be rela
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and ineffective sucking/swallowing
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impaired Gas Exchange may be relate
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situational low Self-Esteem may be
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impaired physical Mobility may be r
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moving in direction of health-promo
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Guillain-Barré syndrome (acute pol
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Hemorrhoidectomy MS/CH acute Pain m
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ehaviors, narrowed focus, and auton
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Hyperactivity disorder PED/PSY defe
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isk for unstable blood Glucose: ris
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secondary defenses (e.g., decreased
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isk for Poisoning: risk factors may
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equired voice rest, possibly eviden
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alance, presence of multiple diseas
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Mastitis OB/GYN acute Pain may be r
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imbalanced Nutrition: risk for more
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Powerlessness/Hopelessness may be r
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acute Pain may be related to ischem
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isk for disorganized Infant Behavio
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Hyperthermia may be related to incr
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disturbed kinesthetic/tactile Senso
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negative self-appraisal in response
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ehaviors, self-focus, and autonomic
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evidenced by frequency, dysuria, ur
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ineffective Breathing Pattern may b
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decreased Cardiac Output may be rel
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changes (atelectasis, airway/alveol
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coping methods, multiple stressors
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increased metabolic rate, restlessn
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isk for deficient Fluid Volume: ris
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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