Nurse's Pocket Guide

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Hanneman, SK, and Gusick, M: Frequency of oral care and positioning of patients in critical care: A replication study. Am. J Crit Care 14(5):378–386, 2005. Hanson, MJS: Caring for a patient with COPD. Nursing 27(12):39, 1997. Harvey, C, Dixon, M, and Padberg, N: Support group for families of trauma patients: A unique approach. Crit Care Nurse 15(4):59, 1995. Hayes, DD: Bradycardia. Keeping the current flowing. Nursing 27(6):50, 1997. Hayn, MA, and Fisher, TR: Stroke rehabilitation: Salvaging ability after the storm. Nursing 27(3):40, 1997. Hernandez, D: Microvascular complications of diabetes: Nursing assessment and interventions. Am J Nurs 98(6):16, 1998. Herson, L, Hart, K, Gordon, M, et al: Identifying and overcoming barriers to providing sexuality information in the clinical setting. Rehabil Nurs 24(4):148, 1999. Hess, CT: Caring for a diabetic ulcer. Nursing 29(5):70, 1999. Hess, CT: Wound care. Nursing 28(3):18, 1998. Hoffman, J: Tuning in to the power of music. RN 60(6):52, 1997. Holcomb, SS: Understanding the ins and outs of diuretic therapy. Nursing 27(2):34, 1997. Holm, K, and Foreman, M: Analysis of measures of functional and cognitive ability for aging adults with cardiac and vascular disease. J of Cardiovascular Nursing 21(5–Suppl):40–5, 2006. Houghton, D: HAI prevention: The power is in your hands. Nursing Management 37(5): Suppl: 1–7, 2006. Hughes, L. Physical and psychological variables that influence pain in patients with fibromyalgia. Orthopaedic Nursing 25(2):112–19, 2006. Hunt, R: Community-based nursing. Am J Nurs 98(10):44, 1998. Hunter, A, Denman-Vitale, S, and Garzon, L: Global infections: Recognition, management, and prevention. The Nurse Practitioner 32(2):34–41, 2007. Huston, CJ: Emergency! Dental luxation and avulsion. Am J Nurs 97(9):48, 1997. Hutchison, CP: Healing touch: An energetic approach. Am J Nurs 99(4):43, 1999. Isaacs, A: Depression and your patient. Am J Nurs 98(7):26, 1998. Iscoe, KE, Campbell, JE, Jamnik, V, et al: Efficacy of continuous realtime blood glucose monitoring during and after prolonged highintensity cycling exercise: Spinning with a continuous glucose monitoring system. Diabetes Technology and Therapeutic 8(6):627–35, 2006. It’s probably not Alzheimer’s: New insights on memory loss. Focus on Healthy Aging 2(7):1, 1999. Iyasu, S, Randall, L, Welty, K, et al: Risk factors for sudden infant death syndrome among Northern Plains Indians. JAMA 288(21):2717, 2002. Jaempf, G, and Goralski, VJ: Monitoring postop patients. RN 59(7):30, 1996. Jennings, LM: Latex allergy: Another real Y2K issue. Rehab Nurs 24(4):140, 1999. BIBLIOGRAPHY 925
Jirovec, MM, Wyman, JF, and Wells, TJ: Addressing urinary incontinence with educational continence-care competencies. Image J Nurs Sch 30(4):375, 1998. Johnson, CV, and Hayes, JA: Troubled spirits: Prevalence and predictors of religious and spiritual concerns among university students and counseling center clients. J of Counseling Psychology 50:409–419, 2003. Johnson, J, Pearson, V, and McDivitt, L: Stroke rehabilitation: Assessing stroke survivors’ long-term learning needs. Rehab Nurs 22(5):243, 1997. Kachourbos, MJ: Relief at last: An implanted bladder control system helps people control their bodily functions. Team Rehab Rep, p. 31, August, 1997. Kanachki, L: How to guide ventilator-dependent patients from hospital to home. Am J Nurs 97(2):37, 1997. Kania, DS, and Scott, CM: Postexposure prophylaxis considerations for occupational and nonoccupational exposures. Advanced Emergency Nursing Journal 29(1):20–32, 2007. Kaplow, R: AACN synergy model for patient care: A framework to optimize outcomes. Crit Care Nurse Suppl (Feb): 27–30, 2003. Kearney, PM, and Griffin, T: Between joy and sorrow: Being a parent of a child with a developmental disability. Journal of Advanced Nursing 34:582–592, 2001. Keegan, L: Getting comfortable with alternative and complementary therapies. Nursing 28(4):50, 1998. Kersting, K: A new approach to complicated grief. Monitor on Psychology 35(10): 51, 2004. King, B: Preserving renal function. RN 60(8):34, 1997. Kinloch, D: Instillation of normal saline during endotracheal suctioning: Effects on mixed venous oxygen saturation. Am J Crit Care 8(4):231, 1999. Kirshblum, S, and O’Connor, K: The problem of pain: A common condition of people with SCI. Team Rehab Rep, p. 15, August, 1997. Kirton, C: The HIV/AIDS epidemic: A case of good news/bad news. Nursing Made Incredibly Easy! 3(2):28–40, 2005. Klonowski, EI, and Masodi, JE: The patient with Crohn’s disease. RN 62(3):32, 1999. Klotter, J: Latex allergy prevention. Townsend Letter for Doctors and Patients, May 1, 2006. Kolcaba, K, and DiMarco, MA: Comfort theory and its application to pediatric nursing. Pediatr Nurse 31(3):187–194, 2005. Kolcaba, KY, and Fisher, EM: A holistic perspective on comfort care as an advance directive. Crit Care Nurs Quarterly 18(4):66–7, 1996. Kopala, B, and Burkhart, L: Ethical dilemma and moral distress: Proposed new NANDA diagnoses. International Journal of Nursing Terminologies and Classifications 16(1):3–13, 2005. Korinko, A, and Yurick, A: Maintaining skin integrity during radiation therapy. Am J Nurs 97(2):40, 1997. Kouch, M: Managing symptoms for a “good death.” Nursing 36(11): 58–63, 2006. Kumasaka, L, and Miles, A: “My pain is God’s will.” Am J Nurs 96(6):45, 1996. Kurtz, MJ, Van Zandt, DK, and Sapp, LR: A new technique in independent intermittent catheterization: The Mitrofanoff catheterizable channel. Rehab Nurs 21(6):311, 1996. 926 NURSE’S POCKET GUIDE
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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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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
Page 820 and 821:
y limited range of motion, impaired
Page 822 and 823:
Autistic disorder PED/PSY impaired
Page 824 and 825:
are refuted or wishes denied, manic
Page 826 and 827:
isk for deficient Fluid Volume: ris
Page 828 and 829:
evidenced by expressions of boredom
Page 830 and 831:
deficient Fluid Volume [isotonic] m
Page 832 and 833:
impaired verbal [and/or written] Co
Page 834 and 835:
(wasting), aversion to eating, repo
Page 836 and 837:
fluid intake, possibly evidenced by
Page 838 and 839:
aggressive feelings, lacking a sens
Page 840 and 841:
feeling of abdominal/rectal fullnes
Page 842 and 843:
abnormal breath sounds, ineffective
Page 844 and 845:
taste sensation, lack of interest i
Page 846 and 847:
personal resources, decreased energ
Page 848 and 849:
y verbal expression of distress/unr
Page 850 and 851:
Anxiety [specify level] may be rela
Page 852 and 853:
and ineffective sucking/swallowing
Page 854 and 855:
impaired Gas Exchange may be relate
Page 856 and 857:
situational low Self-Esteem may be
Page 858 and 859:
impaired physical Mobility may be r
Page 860 and 861:
moving in direction of health-promo
Page 862 and 863:
Guillain-Barré syndrome (acute pol
Page 864 and 865:
Hemorrhoidectomy MS/CH acute Pain m
Page 866 and 867:
ehaviors, narrowed focus, and auton
Page 868 and 869:
Hyperactivity disorder PED/PSY defe
Page 870 and 871:
isk for unstable blood Glucose: ris
Page 872 and 873:
secondary defenses (e.g., decreased
Page 874 and 875:
isk for Poisoning: risk factors may
Page 876 and 877:
equired voice rest, possibly eviden
Page 878 and 879:
alance, presence of multiple diseas
Page 880 and 881:
Mastitis OB/GYN acute Pain may be r
Page 882 and 883:
imbalanced Nutrition: risk for more
Page 884 and 885:
Powerlessness/Hopelessness may be r
Page 886 and 887:
acute Pain may be related to ischem
Page 888 and 889:
isk for disorganized Infant Behavio
Page 890 and 891:
Hyperthermia may be related to incr
Page 892 and 893:
disturbed kinesthetic/tactile Senso
Page 894 and 895:
negative self-appraisal in response
Page 896 and 897: ehaviors, self-focus, and autonomic
Page 898 and 899: evidenced by frequency, dysuria, ur
Page 900 and 901: ineffective Breathing Pattern may b
Page 902 and 903: decreased Cardiac Output may be rel
Page 904 and 905: changes (atelectasis, airway/alveol
Page 906 and 907: coping methods, multiple stressors
Page 908 and 909: increased metabolic rate, restlessn
Page 910 and 911: isk for deficient Fluid Volume: ris
Page 912 and 913: minimizes health status change, fai
Page 914 and 915: eadings, jugular vein distention, c
Page 916 and 917: Sprain of ankle or foot CH acute Pa
Page 918 and 919: distraction behaviors, self-focus,
Page 920 and 921: isk for Injury [tetany]: risk facto
Page 922 and 923: impaired Skin/Tissue Integrity may
Page 924 and 925: possibly evidenced by reports of he
Page 926 and 927: Anxiety [specify level] may be rela
Page 928: isk for Infection: risk factors may
Page 931 and 932: Domain 4 Activity/Rest: The product
Page 933 and 934: Domain 13 Growth/Development: Age-a
Page 935 and 936: Enhanced: Improved in quality, valu
Page 937 and 938: 916 Books Bibliography Aacovou, I:
Page 939 and 940: Lampe, S: Focus Charting, 7th ed. C
Page 941 and 942: AORN latex guideline: 2004 standard
Page 943 and 944: Carroll, P: Preventing nosocomial p
Page 945: Frost, KL, and Topp, R: A physical
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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