Nurse's Pocket Guide

More documents

Recommendations

Info

diMaria-Ghalili, RA, and Amelia, E: Nutrition in older adults: Interventions and assessment can help curb the growing threat of malnutrition. AJN 105(3):40–50, 2005. Dionne, M: This bed is just right. Rehab Management 18(1):32–9, 2005. Dossey, BM: Holistic modalities and healing moments. Am J Nurs 98(6):44, 1998. Dossey, BM, and Dossey, L: Body-Mind-Spirit: Attending to holistic care. Am J Nurs 98(8):35, 1998. Drugs that bring erections down. Sex & Health Institute, p. 5, May 1998. Ducharme, S: Autonomic dysreflexia (sexuality and SCI). Paraplegia News, November 1, 2006. Dunn, D: Age-smart care: Preventing perioperative complications in older adults. Nursing 4(3):30–9, 2006. Dunn, D: Preventing perioperative complicatons in special populations. Nursing 35(11):36–43, 2005. Dunne, D: Common questions about ileoanal reservoirs. Am J Nurs 97(11):67, 1997. Durston, S: What you need to know about viral hepatitis. Nursing 35(8):36–41, 2005. Dworak, PA, and Levy, A: Strolling along. Rehab Management 18(9):26–31, 2005. Edmond, M: Combating infection: Tackling disease transmission. Nursing 27(7):65, 1997. Edwards-Beckett, J, and King, H: The impact of spinal pathology on bowel control in children. Rehabil Nurs 21(6):292, 1996. Eisenhauer, C: Media review: The new glucose revolution: The authoritative guide to the glycemic index—the dietary solution for lifelong health. Family & Community Health 30(1):86, 2007. Elgart, HN, Johnson, KL, and Munro, N: Assessment of fluids and electrolytes. AACN Advanced Critical Care 15(4):607–21, 2004. Elpern, EH, Covert, B, and Kleinpell, R: Moral distress of staff nurses in a medical intensive care unit. Am J of Critical Care 14:523–539, 2005. Epps, CK: The delicate business of ostomy care. RN 5(11):32, 1996. Epstein, CD, and Peerless, JR: Weaning readiness and fluid balance in older critcially ill surgical patients. Am J of Crit Care 15(1):54–64, 2006. Erickson, EH: Reflections on the dissent of contemporary youth. International Journal of Psychoanalysis 51:11–22, 1970. Faries, J: Easing your patient’s postoperative pain. Nursing 28(6):58, 1998. Feldman, R, Eidelman, AI, Sirota, L, and Weller, A: Comparison of skinto-skin (Kangaroo) and traditional care: Parenting outcomes and preterm infant development. Pediatrics 110(1):16–26, 2002. Ferrin, MS: Restoring electrolyte balance: Magnesium. RN 59(5):31, 1996. Fish, KB: Suicide awareness at the elementary school level. J Psychosoc Nurs Ment Health Serv 38(7):20, 2000. Fishman, TD, Freedline, AD, and Kahn, D: Putting the best foot forward. Nursing 26(1):58, 1996. Flannery, J: Using the levels of cognitive functioning assessment scale with traumatic brain injury in an acute care setting. Rehab Nurs 23(2):88, 1998. Focazio, B: Clinical snapshot: Mucositis. Am J Nurs 97(12):48, 1997. BIBLIOGRAPHY 923
Frost, KL, and Topp, R: A physical activity RX for the hypertensive patient. The Nurse Practitioner: The American J of Primary Health Care 31(4):29–37, 2006. Fry, VS: The creative approach to nursing. Am J Nurs 53:301, 1953. Galea, S, Nandi, A, and Vlahov, D: The epidemiology of post-traumatic stress disorders after disasters. Epidemiologic Reviews 27(1):78–91, 2005. Gance-Cleveland, B: Motivational interviewing as a strategy to increase families’ adherence to treatment regimens. Journal for Specialists in Pediatric Nursing 10(3):151–155, 2005. Garnett, LR: Is obesity all in the genes? Harv Health Lett 21(6):1, 1996. Giasson, M, and Bouchard, L: Effect of therapeutic touch on the wellbeing of persons with terminal cancer. J of Holistic Nursing 16(3): 383–98, 1998. Gibbons, S, Lauder, W, and Ludwick, R: Self-neglect: A proposed new NANDA diagnosis. International J Nursing Terminologies and Classifications 17(1):10–18, 2006. Goertz, S: Eye of diagnostics: Gauging fluid balance with osmolality. Nursing 36(10):70–1, 2006. Goldrich, G: Understanding the 12–lead ECG, part I. Nursing 36(11):36–41, 2006. Goldrick, BA, and Goetz, AM: ‘Tis the season for influenza. The Nurse Practitioner 31(12):24–33. Goldstein, LB: Cough and aspiration of food and liquids due to oralpharyngeal dysphagia: AACP evidence-based clinical practice guidelines. Chest, January 1, 2006. Good, KK, Verble, JA, Secrest, J, et al: Postoperative hypothermia—The chilling consequences. AORN 83(5):1055–66, 2006. Goshorn, J: Clinical snapshot: Kidney stones. Am J Nurs 96(9):40, 1996. Graf, C: Functional decline in hospitalized older adults. AJN 106(1): 58–67, 2006. Grandjean, CK, and Gibbons, SW: Assessing ambulatory geriatric sleep complaints. Nurse Pract 25(9):25, 2000. Gray, M: Assessment and management of urinary incontinence. The Nurse Pract 30(7):32–43, 2005. Gray, M: Overactive bladder: An overview. Journal of Wound, Ostomy and Continence Nursing 32(3) Suppl: 1–5, 2005. Gray, M, Bliss, DZ, Doughty, DB, et al: Incontinence-associated dermatitis: A consensus. J Wound, Ostomy and Continence Nursing 34(1):45–54, 2007. Gregory, CM: Caring for caregivers: Proactive planning eases burdens on caregivers. Lifelines 1(2):51, 1997. Greifzu, S: Fighting cancer fatigue. RN 61(8):41, 1998. Gritter, M: The latex threat. Am J Nurs 98(9):26, 1998. Grzankowski, JA: Altered thought processes related to traumatic brain injury and their nursing implications. Rehabil Nurs 22(1):24, 1997. Hahn, J: Cueing in to client language. Reflections 25(1):8–11, 1999. Halpin-Landry, JE, and Goldsmith, S: Feet first: Diabetes care. Am J Nurs 99(2):26, 1999. Hankins, J: The role of albumin in fluid and electrolyte balance. J of Infusion Nursing 29(5):260–5, 2006. Hanley, C: Delirium in the acute care setting: Med Surg Nurs 13(4):217–25, 2004. 924 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 58 and 59:
EXCERPT FROM PRENATAL ASSESSMENT TO
Page 60 and 61:
EXCERPT FROM INTRAPARTAL ASSESSMENT
Page 62 and 63:
SECTION 2 DIAGNOSTIC DIVISIONS: NUR
Page 64 and 65:
Spiritual Distress, risk for Spirit
Page 66 and 67:
Death Syndrome, risk for sudden inf
Page 68 and 69:
SECTION 3 CLIENT SITUATION AND PROT
Page 70 and 71:
Nailbeds: pink Conjunctiva and scle
Page 72 and 73:
Eyes: Vision loss, farsighted, “S
Page 74 and 75:
Extended family: 1 daughter lives i
Page 76 and 77:
PLAN OF CARE FOR CLIENT WITH DIABET
Page 78 and 79:
ACTIONS/INTERVENTIONS RATIONALE deh
Page 80 and 81:
ACTIONS/INTERVENTIONS RATIONALE vas
Page 82 and 83:
ACTIONS/INTERVENTIONS RATIONALE and
Page 84 and 85:
ANOTHER APPROACH TO PLANNING CLIENT
Page 86 and 87:
SECTION 4 DOCUMENTATION TECHNIQUES:
Page 88 and 89:
Example 1. SAMPLE SOAP/IER CHARTING
Page 90 and 91:
Example 2. SAMPLE OF FOCUS CHARTING
Page 92 and 93:
Functional Level Classification (Go
Page 94 and 95:
• Plan for maximal activity withi
Page 96 and 97:
• Identify conditions/symptoms th
Page 98 and 99:
ineffective Airway Clearance Taxono
Page 100 and 101:
diaphragm and enhancing drainage of
Page 102 and 103:
treatment of obstructive sleep apne
Page 104 and 105:
kiwi, papya, peach, nectarine), pri
Page 106 and 107:
• Type/extent of symptomatology.
Page 108 and 109:
• Obtain lists of latex-free prod
Page 110 and 111:
Affective Regretful; scared; rattle
Page 112 and 113:
Voice quivers or changes pitch Trem
Page 114 and 115:
NURSING PRIORITY NO. 3. To promote
Page 116 and 117:
Negative thoughts related to death
Page 118 and 119:
• Refer to community agencies/res
Page 120 and 121:
as listed in Risk Factors, to deter
Page 122 and 123:
• Provide information about the e
Page 124 and 125:
• Ascertain availability/use of r
Page 126 and 127:
Autonomic Dysreflexia Taxonomy II:
Page 128 and 129:
urine flow if blocked; remove bowel
Page 130 and 131:
MUSCULOSKELETAL—INTEGUMENTARY STI
Page 132 and 133:
goosebumps; bradycardia; cardiac ir
Page 134 and 135:
• Explore the expressions of emot
Page 136 and 137:
IMPLEMENTATION/EVALUATION • Clien
Page 138 and 139:
• Acknowledge self as an individu
Page 140 and 141:
• Assume all individuals are sens
Page 142 and 143:
Risk Factors Extremes of age/weight
Page 144 and 145:
medication regimen with physician t
Page 146 and 147:
impacted stool; severe diarrhea; de
Page 148 and 149:
DISCHARGE PLANNING • Identified l
Page 150 and 151:
• Encourage skin-to-skin contact.
Page 152 and 153:
Related Factors Prematurity; infant
Page 154 and 155:
for more than 15 minutes on each si
Page 156 and 157:
• Provide practice times at breas
Page 158 and 159:
Maternal desire to maintain breastf
Page 160 and 161:
3 hours while awake as indicated to
Page 162 and 163:
Related Factors Neuromuscular dysfu
Page 164 and 165:
• Deal with fear/anxiety that may
Page 166 and 167:
decreased Cardiac Output Taxonomy I
Page 168 and 169:
of extremities, and progressive sho
Page 170 and 171:
• Refer to NDs ineffective Tissue
Page 172 and 173:
DISCHARGE PLANNING • Discharge co
Page 174 and 175:
Defining Characteristics SUBJECTIVE
Page 176 and 177:
• Identify relationship of caregi
Page 178 and 179:
importance of self-nurturing (e.g.,
Page 180 and 181:
Desired Outcomes/Evaluation Criteri
Page 182 and 183:
Documentation Focus ASSESSMENT/REAS
Page 184 and 185:
• Determine influence of cultural
Page 186 and 187:
owl/aquarium, to stimulate observat
Page 188 and 189:
Anatomical deficit (e.g., cleft pal
Page 190 and 191:
NURSING PRIORITY NO. 2.To assist cl
Page 192 and 193:
Page 194 and 195:
professional interpreter who transl
Page 196 and 197:
• Associate words with objects—
Page 198 and 199:
OBJECTIVE Vacillation between alter
Page 200 and 201:
• Promote opportunities for using
Page 202 and 203:
• Demonstrate appropriate behavio
Page 204 and 205:
DISCHARGE PLANNING • Long-term ne
Page 206 and 207:
• Evaluate for exacerbation of ps
Page 208 and 209:
Page 210 and 211:
client. If the history reveals an i
Page 212 and 213:
PLANNING • Plan of care and who i
Page 214 and 215:
NURSING PRIORITY NO 2. To reduce/co
Page 216 and 217:
Insufficient physical activity; abd
Page 218 and 219:
• Determine laxative/enema use. N
Page 220 and 221:
PLANNING • Plan of care/intervent
Page 222 and 223:
IMPLEMENTATION/EVALUATION • Clien
Page 224 and 225:
• Discuss usual elimination patte
Page 226 and 227:
Related Factors EXTERNAL Chemical c
Page 228 and 229:
Actions/Interventions In reviewing
Page 230 and 231:
• Obtain/assist with diagnostic s
Page 232 and 233:
• Recommend periodic inspection o
Page 234 and 235:
Lack of breakdown of contaminants o
Page 236 and 237:
• Recommend periodic inspection o
Page 238 and 239:
• Specific actions and changes th
Page 240 and 241:
• Assess information available to
Page 242 and 243:
Rationalizes failures [Refuses or r
Page 244 and 245:
• Promote involvement in activiti
Page 246 and 247:
Actions/Interventions NURSING PRIOR
Page 248 and 249:
DISCHARGE PLANNING • Ongoing need
Page 250 and 251:
• Assess current functional capac
Page 252 and 253:
• Discuss/review anticipated proc
Page 254 and 255:
Page 256 and 257:
Page 258 and 259:
involvement with caring for others/
Page 260 and 261:
Page 262 and 263:
Adaptive tasks effectively addresse
Page 264 and 265:
• Attainment/progress toward desi
Page 266 and 267:
fewer infants die of SIDS when they
Page 268 and 269:
SAMPLE NURSING OUTCOMES & INTERVENT
Page 270 and 271:
• Refer to other resources, as ne
Page 272 and 273:
• Note client’s comments about
Page 274 and 275:
Page 276 and 277:
• Recommend that client (of any a
Page 278 and 279:
CAREGIVER Mental retardation; sever
Page 280 and 281:
children’s services, medical equi
Page 282 and 283:
laxatives]; and enteral tube feedin
Page 284 and 285:
• Discuss possible change in infa
Page 286 and 287:
especially during times of stress,
Page 288 and 289:
Related Factors Conflict among deci
Page 290 and 291:
• Provide time for nonjudgmental
Page 292 and 293:
• Be free of signs/symptoms of in
Page 294 and 295:
VASCULAR (TISSUE PERFUSION) • Mon
Page 296 and 297:
• Provide/review information abou
Page 298 and 299:
• Assess/review client’s physic
Page 300 and 301:
Page 302 and 303:
• Identify areas of imbalance or
Page 304 and 305:
impaired Environmental Interpretati
Page 306 and 307:
• Use touch judiciously. Tell cli
Page 308 and 309:
IMPLEMENTATION/EVALUATION • Respo
Page 310 and 311:
• Determine client’s medical, c
Page 312 and 313:
Page 314 and 315:
• Observe individual’s general
Page 316 and 317:
counseling, home care, sources for
Page 318 and 319:
OBJECTIVE Feelings Repressed emotio
Page 320 and 321:
• Provide information regarding e
Page 322 and 323:
assigned tasks; stress-reduction be
Page 324 and 325:
• Provide educational materials a
Page 326 and 327:
today, such as biological, nuclear,
Page 328 and 329:
• Refer to classes/support groups
Page 330 and 331:
Page 332 and 333:
• Encourage use of assistive devi
Page 334 and 335:
Related Factors Innate origin (e.g.
Page 336 and 337:
• Modify procedures, if possible
Page 338 and 339:
Related Factors To be developed Def
Page 340 and 341:
(such as prevention of hyperglycemi
Page 342 and 343:
Page 344 and 345:
Page 346 and 347:
• Verbalize understanding of caus
Page 348 and 349:
Page 350 and 351:
• Note amount/rate of fluid intak
Page 352 and 353:
Page 354 and 355:
Offer fluids between meals and regu
Page 356 and 357:
moist mucous membranes; individual
Page 358 and 359:
• Results of laboratory test/diag
Page 360 and 361:
NURSING PRIORITY NO.2.To evaluate d
Page 362 and 363:
• Identify specific supplier for
Page 364 and 365:
• Assess family/SO(s) support of
Page 366 and 367:
Page 368 and 369:
NURSING PRIORITY NO.2.To determine
Page 370 and 371:
• Support community efforts to st
Page 372 and 373:
elated to socially sensitive issue
Page 374 and 375:
choice to have another child or to
Page 376 and 377:
• Assess status of relationships/
Page 378 and 379:
Congenital/genetic disorders [e.g.,
Page 380 and 381:
• Determine if child’s growth i
Page 382 and 383:
delayed Growth and Development Taxo
Page 384 and 385:
• Note chronological age, familia
Page 386 and 387:
• Determine reasonable expectatio
Page 388 and 389:
Inability to make appropriate judgm
Page 390 and 391:
• Encourage socialization and per
Page 392 and 393:
Expressed concern about current env
Page 394 and 395:
• Pertinent cultural/religious be
Page 396 and 397:
• Assess client/SO’s level of c
Page 398 and 399:
Page 400 and 401:
Page 402 and 403:
• Identify cultural/spiritual val
Page 404 and 405:
• Refer to other resources for as
Page 406 and 407:
abdominal temperature monitoring ma
Page 408 and 409:
onmental heat (e.g., proper clothin
Page 410 and 411:
• Identify underlying cause/contr
Page 412 and 413:
• Keep client quiet; handle gentl
Page 414 and 415:
Immunization status Identification
Page 416 and 417:
still exist and can be passed on to
Page 418 and 419:
Defining Characteristics OBJECTIVE
Page 420 and 421:
• Avoid aversive oral stimulation
Page 422 and 423:
VESTIBULAR • Move and handle the
Page 424 and 425:
Defining Characteristics OBJECTIVE
Page 426 and 427:
Page 428 and 429:
• Demonstrate appropriate weight
Page 430 and 431:
• Caregiver’s involvement in in
Page 432 and 433:
• Provide for isolation, as indic
Page 434 and 435:
measures to prevent pneumonia, woun
Page 436 and 437:
• Demonstrate behaviors, lifestyl
Page 438 and 439:
using smokeless tobacco, occurrence
Page 440 and 441:
Risk Factors Disorientation; sensor
Page 442 and 443:
• Assist with therapies/nursing a
Page 444 and 445:
disorders, dementia, obesity, pregn
Page 446 and 447:
• Encourage routine use of contin
Page 448 and 449:
decreased Intracranial Adaptive Cap
Page 450 and 451:
carina. Administer lidocaine intrat
Page 452 and 453:
[Illnesses/trauma affecting body im
Page 454 and 455:
• Assist client and SO(s) to ackn
Page 456 and 457:
• Be alert to signs of avoidance.
Page 458 and 459:
complex. Can arouse interest/limit
Page 460 and 461:
• Determine motivation/expectatio
Page 462 and 463:
Related Factors Lack of interest/mo
Page 464 and 465:
improve balance and coordination ca
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Parent/Caregiver Will: • Provide
Page 472 and 473:
Page 474 and 475:
State Examination [MMSE]), to compl
Page 476 and 477:
Related Factors Neuromuscular/muscu
Page 478 and 479:
• Involve client/SO(s) in determi
Page 480 and 481:
Page 482 and 483:
maintaining appliances/equipment. P
Page 484 and 485:
vision deficits) are treated/being
Page 486 and 487:
BIOPHYSICAL Biochemical disorders (
Page 488 and 489:
• Encourage client to begin with
Page 490 and 491:
Page 492 and 493:
• Assess ability to distinguish b
Page 494 and 495:
maximize independence, allow client
Page 496 and 497:
Page 498 and 499:
• Establish graduated goals or mo
Page 500 and 501:
[Abnormal laboratory studies (e.g.,
Page 502 and 503:
Appetite stimulants (e.g., wine), i
Page 504 and 505:
• Caloric intake. • Individual
Page 506 and 507:
• Discuss client’s view of self
Page 508 and 509:
• Encourage buying personal items
Page 510 and 511:
Page 512 and 513:
Page 514 and 515:
• Discuss use of non-food rewards
Page 516 and 517:
Page 518 and 519:
Assist with/provide denture care wh
Page 520 and 521:
Related Factors Injuring agents (bi
Page 522 and 523:
• Note cultural and developmental
Page 524 and 525:
Page 526 and 527:
• Evaluate emotional/physical com
Page 528 and 529:
for all persons, encouraging client
Page 530 and 531:
KNOWLEDGE Deficient knowledge about
Page 532 and 533:
Parents with significant impairment
Page 534 and 535:
Page 536 and 537:
voice, are indicative of attachment
Page 538 and 539:
DISCHARGE PLANNING • Long-range n
Page 540 and 541:
• Participate in activities, clas
Page 542 and 543:
• Assess capillary return, skin c
Page 544 and 545:
Page 546 and 547:
• Review results of laboratory te
Page 548 and 549:
Page 550 and 551:
• Demonstrate ability to deal wit
Page 552 and 553:
• 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
Page 562 and 563:
Moderate Dependence on others that
Page 564 and 565:
• Develop contract with client sp
Page 566 and 567:
Inadequate coping patterns Absence
Page 568 and 569:
• Cultural values/religious belie
Page 570 and 571:
DRUG THERAPIES, TREATMENTS, AND DIS
Page 572 and 573:
[C] SILENT REACTION—(00141) Defin
Page 574 and 575:
• Provide environment in which cl
Page 576 and 577:
Page 578 and 579:
Difficulty adhering to prescribed r
Page 580 and 581:
Page 582 and 583:
and practices, these influences wil
Page 584 and 585:
NOTE: A risk diagnosis is not evide
Page 586 and 587:
• Modifications to plan of care.
Page 588 and 589:
(e.g., stomach aches, headaches, ba
Page 590 and 591:
Page 592 and 593:
• Support self-responsibility and
Page 594 and 595:
• Determine client role in family
Page 596 and 597:
Self-Care Deficit: bathing/hygiene,
Page 598 and 599:
• Note concomitant medical proble
Page 600 and 601:
• Support client in making health
Page 602 and 603:
Page 604 and 605:
Page 606 and 607:
nonverbal expressions is culturally
Page 608 and 609:
Page 610 and 611:
• Develop therapeutic relationshi
Page 612 and 613:
Page 614 and 615:
• Note nonverbal body language. I
Page 616 and 617:
isk for situational low Self-Esteem
Page 618 and 619:
Page 620 and 621:
often is an attempt to establish in
Page 622 and 623:
Page 624 and 625:
allow feelings to be expressed, ind
Page 626 and 627:
Page 628 and 629:
Page 630 and 631:
• Ambulate with assistance/device
Page 632 and 633:
Related Factors Ineffectual/absent
Page 634 and 635:
cause such as diabetes, vascular pr
Page 636 and 637:
Page 638 and 639:
• Determine client’s interpreta
Page 640 and 641:
impaired Skin Integrity Taxonomy II
Page 642 and 643:
• Palpate skin lesions for size,
Page 644 and 645:
daily maintenance. Enhances commitm
Page 646 and 647:
Page 648 and 649:
• Advise regular use of sunscreen
Page 650 and 651:
NURSING PRIORITY NO.2.To assist cli
Page 652 and 653:
Sustained inadequate sleep hygiene;
Page 654 and 655:
• Encourage client to develop pla
Page 656 and 657:
impaired Social Interaction Taxonom
Page 658 and 659:
• Evaluate possibility of client
Page 660 and 661:
• Cultural/religious beliefs and
Page 662 and 663:
• Identify blocks to social conta
Page 664 and 665:
Page 666 and 667:
• Acknowledge reality of feelings
Page 668 and 669:
Page 670 and 671:
• Encourage client/family to ask
Page 672 and 673:
• Physical/emotional responses to
Page 674 and 675:
• Ascertain substance use/abuse.
Page 676 and 677:
eadiness for enhanced Spiritual Wel
Page 678 and 679:
• Clarify reality/appropriateness
Page 680 and 681:
Page 682 and 683:
• Allow client to react in own wa
Page 684 and 685:
Risk Factors INTERNAL Reduced olfac
Page 686 and 687:
• Develop plan with client/caregi
Page 688 and 689:
Guilt Gay or lesbian youth DEMOGRAP
Page 690 and 691:
it will help individual to resolve
Page 692 and 693:
Related Factors Extensive/prolonged
Page 694 and 695:
• Collaborate in treatment of com
Page 696 and 697:
Page 698 and 699:
• Identify individually appropria
Page 700 and 701:
• Instruct to chew food on unaffe
Page 702 and 703:
[Added demands made on individual o
Page 704 and 705:
Page 706 and 707:
• Use client’s locus of control
Page 708 and 709:
OBJECTIVE Deficits in advocates for
Page 710 and 711:
ineffective family Therapeutic Regi
Page 712 and 713:
Page 714 and 715:
• Incorporate client’s cultural
Page 716 and 717:
Page 718 and 719:
Distractibility; [altered attention
Page 720 and 721:
NURSING PRIORITY NO. 4.To create th
Page 722 and 723:
impaired Tissue Integrity Taxonomy
Page 724 and 725:
Record size (depth, width), color,
Page 726 and 727:
Mobility; disturbed visual Sensory
Page 728 and 729:
Gastrointestinal Hypoactive/absent
Page 730 and 731:
• Evaluate vital signs, noting ch
Page 732 and 733:
• Administer medications (e.g., a
Page 734 and 735:
• Provide preoperative teaching a
Page 736 and 737:
Page 738 and 739:
Risk Factors INTERNAL Weakness; bal
Page 740 and 741:
• Ascertain knowledge of safety n
Page 742 and 743:
Page 744 and 745:
elieved by voiding and often recurs
Page 746 and 747:
chronic urinary urge incontinence,
Page 748 and 749:
Related Factors To be developed Def
Page 750 and 751:
• Review with client/SO(s) the si
Page 752 and 753:
• Determine if client is voluntar
Page 754 and 755:
Related Factors Bladder outlet obst
Page 756 and 757:
• Instruct client/SO(s) in clean
Page 758 and 759:
• Measure amount of each voiding
Page 760 and 761:
Risk Factors Effects of medications
Page 762 and 763:
Page 764 and 765:
Practice timed voidings (e.g., ever
Page 766 and 767:
Page 768 and 769:
Use condom catheter or other extern
Page 770 and 771:
Page 772 and 773:
Recommend consciously delaying void
Page 774 and 775:
Page 776 and 777:
• Assess for effects of psychotro
Page 778 and 779:
Page 780 and 781:
• Promote maximal ventilation of
Page 782 and 783:
• Discuss impact of specific acti
Page 784 and 785:
Defining Characteristics MILD Subje
Page 786 and 787:
determine if client can assume the
Page 788 and 789:
Risk Factors/[Indicators]* HISTORY
Page 790 and 791:
• Identify precipitating factors.
Page 792 and 793:
NURSING PRIORITY NO.3.To assist cli
Page 794 and 795:
that help client to engage in posit
Page 796 and 797:
Page 798 and 799:
Page 800 and 801:
• Provide a structured daily rout
Page 802 and 803:
CHAPTER 5 Health Conditions and Cli
Page 804 and 805:
isk for ineffective Sexuality Patte
Page 806 and 807:
disturbed Body Image may be related
Page 808 and 809:
of others, destructive behaviors, i
Page 810 and 811:
focus, alteration in muscle tone, p
Page 812 and 813:
isk for Injury/Trauma: risk factors
Page 814 and 815:
Anaphylaxis CH (Also refer to Shock
Page 816 and 817:
isk for sedentary Lifestyle: risk f
Page 818 and 819:
impaired Social Interaction/Social
Page 820 and 821:
y limited range of motion, impaired
Page 822 and 823:
Autistic disorder PED/PSY impaired
Page 824 and 825:
are refuted or wishes denied, manic
Page 826 and 827:
isk for deficient Fluid Volume: ris
Page 828 and 829:
evidenced by expressions of boredom
Page 830 and 831:
deficient Fluid Volume [isotonic] m
Page 832 and 833:
impaired verbal [and/or written] Co
Page 834 and 835:
(wasting), aversion to eating, repo
Page 836 and 837:
fluid intake, possibly evidenced by
Page 838 and 839:
aggressive feelings, lacking a sens
Page 840 and 841:
feeling of abdominal/rectal fullnes
Page 842 and 843:
abnormal breath sounds, ineffective
Page 844 and 845:
taste sensation, lack of interest i
Page 846 and 847:
personal resources, decreased energ
Page 848 and 849:
y verbal expression of distress/unr
Page 850 and 851:
Anxiety [specify level] may be rela
Page 852 and 853:
and ineffective sucking/swallowing
Page 854 and 855:
impaired Gas Exchange may be relate
Page 856 and 857:
situational low Self-Esteem may be
Page 858 and 859:
impaired physical Mobility may be r
Page 860 and 861:
moving in direction of health-promo
Page 862 and 863:
Guillain-Barré syndrome (acute pol
Page 864 and 865:
Hemorrhoidectomy MS/CH acute Pain m
Page 866 and 867:
ehaviors, narrowed focus, and auton
Page 868 and 869:
Hyperactivity disorder PED/PSY defe
Page 870 and 871:
isk for unstable blood Glucose: ris
Page 872 and 873:
secondary defenses (e.g., decreased
Page 874 and 875:
isk for Poisoning: risk factors may
Page 876 and 877:
equired voice rest, possibly eviden
Page 878 and 879:
alance, presence of multiple diseas
Page 880 and 881:
Mastitis OB/GYN acute Pain may be r
Page 882 and 883:
imbalanced Nutrition: risk for more
Page 884 and 885:
Powerlessness/Hopelessness may be r
Page 886 and 887:
acute Pain may be related to ischem
Page 888 and 889:
isk for disorganized Infant Behavio
Page 890 and 891:
Hyperthermia may be related to incr
Page 892 and 893:
disturbed kinesthetic/tactile Senso
Page 894 and 895: negative self-appraisal in response
Page 896 and 897: ehaviors, self-focus, and autonomic
Page 898 and 899: evidenced by frequency, dysuria, ur
Page 900 and 901: ineffective Breathing Pattern may b
Page 902 and 903: decreased Cardiac Output may be rel
Page 904 and 905: changes (atelectasis, airway/alveol
Page 906 and 907: coping methods, multiple stressors
Page 908 and 909: increased metabolic rate, restlessn
Page 910 and 911: isk for deficient Fluid Volume: ris
Page 912 and 913: minimizes health status change, fai
Page 914 and 915: eadings, jugular vein distention, c
Page 916 and 917: Sprain of ankle or foot CH acute Pa
Page 918 and 919: distraction behaviors, self-focus,
Page 920 and 921: isk for Injury [tetany]: risk facto
Page 922 and 923: impaired Skin/Tissue Integrity may
Page 924 and 925: possibly evidenced by reports of he
Page 926 and 927: Anxiety [specify level] may be rela
Page 928: isk for Infection: risk factors may
Page 931 and 932: Domain 4 Activity/Rest: The product
Page 933 and 934: Domain 13 Growth/Development: Age-a
Page 935 and 936: Enhanced: Improved in quality, valu
Page 937 and 938: 916 Books Bibliography Aacovou, I:
Page 939 and 940: Lampe, S: Focus Charting, 7th ed. C
Page 941 and 942: AORN latex guideline: 2004 standard
Page 943: Carroll, P: Preventing nosocomial p
Page 947 and 948: Jirovec, MM, Wyman, JF, and Wells,
Page 949 and 950: McClave, SA, Lukan, JK, Lowen, JA,
Page 951 and 952: Perry, A: Quality of life. Rehab Ma
Page 953 and 954: Sommer, KD, and Sommer, NW: When yo
Page 955 and 956: Adams, L: Working together: Paying
Page 957 and 958: Cheshire, Jr., WP: Grey matters whe
Page 959 and 960: Gardner, BM. (2002). Current approa
Page 961 and 962: Keim, SM, and Kent, M: Nausea and v
Page 963 and 964: National Coalition for Cancer Survi
Page 965 and 966: Planned Parenthood: Sexual health-s
Page 967 and 968: Von Wager, K: Identity crisis—The
Page 969 and 970: ADD. See Attention deficit disorder
Page 971 and 972: Breast (Continued) mastitis, 134 so
Page 973 and 974: Compromised family (Continued) inef
Page 975 and 976: E Eating disorders, 832 Eclampsia,
Page 977 and 978: Hemothorax, 843 Hepatitis, acute vi
Page 979 and 980: Infectious mononucleosis, 862 Infla
Page 981 and 982: Myasthenia gravis, 864 Myeloma, mul
Page 983 and 984: Postpartal cesarean birth, 811-812
Page 985 and 986: Risk for delayed development, 256-2
Page 987 and 988: Social isolation, 639-643 Social Po
Page 989: Urolithiasis, 904 Uterine bleeding,
show all

Nurse's Pocket Guide

Create successful ePaper yourself

Delete template?

Save as template?