Nurse's Pocket Guide

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Scleroderma, 890 Scoliosis, 890–891 Seasonal affective disorder, 788 Seasonal allergies, 790 Seborrheic dermatitis, 825 Sedentary lifestyle, 440–445 Seizure disorder, 891 Self, connections to, 647, 655 Self-care deficit in, 575–580 readiness for enhanced, 580–583 Self-concept, enhanced, readiness for, 583–587 Self-directed violence, risk for, 768–774 Self-esteem chronic low, 587–591 risk for situational low, 595–597 situational low, 591–594 Self-mutilation, 597–601 risk for, 601–605 Senile dementia, 823–824 Sensory perception, disturbed, 605–610 Sepsis, puerperal, 891 Septic arthritis, 799 Septic shock, 893 Septicemia, 891–892 Serum sickness, 892 Sexual dysfunction, 610–615 Sexuality, 29, 38, 45, 52 Sexuality pattern, ineffective, 615–618 Sexually transmitted disease, 892, 895 Shingles. See Herpes zoster Shock, 892 cardiogenic, 892–893 hypovolemic/hemorrhagic, 893 septic, 893 Sick sinus syndrome, 893 Sickle cell anemia, 793–794 Situational low self-esteem, 591–594 risk for, 595–597 Skin abscess, 783 Skin integrity, 55 impaired, 619–624 SLE. See Lupus erythematosus, systemic Sleep, readiness for enhanced, 627–630 Sleep deprivation, 630–634 Smallpox, 893–894 SNOMED. See Systematized Nomenclature of Medicine Snow blindness, 894 SOAP/focus charting, 65–69 SOAP/SOAPIER charting for prototype plan of care, sample, 65–67 Social interaction, 45 impaired, 635–639 Social interactions, 31, 52 INDEX 965
Social isolation, 639–643 Social Policy Statement, American Nurses Association, 1, 5–6 Somatoform disorders, 894 Sore nipple, 134 Sorrow, chronic, 643–646 Spastic hemiplegia, 869 Spinal cord injury, 894 Spiritual distress, 646–651 risk for, 651–654 Spiritual well-being, readiness for enhanced, 655–658 Spontaneous termination, abortion, 782–783 Spontaneous ventilation, impaired, 756–762 Sporadic wandering, 777–780 Sprain of ankle or foot, 895 Stage I (active phase) labor, 853 Stage II (expulsion) labor, 853–854 Standards of Clinical Nursing Practice, American Nurses Association, 1 Stapedectomy, 895 STD. See Sexually transmitted disease Steps of nursing process, 1–4 Stress, relocation, 565–569 Stress overload, 658–662 Stress urinary incontinence, 741–744 Subluxation of joint, 829 Substance abuse, 296–300 rehabilitation, 895–896 Sudden infant death syndrome, risk for, 243–247 Suffocation, risk for, 662–666 Suicide, risk for, 666–670 Surgical recovery, delayed, 670–675 Swallowing, impaired, 675–680 Sympathetic system, 89 Synovitis, knee, 896–897 Syphilis, congenital, 897 Syringomyelia, 897 Systematized Nomenclature of Medicine, 14 Systemic lupus erythematosus, 857, 893 T Tay-Sachs disease, 897–898 Therapeutic regimen management effective, 680–683 ineffective, 683–686 ineffective community, 686–688 ineffective family, 689–691 readiness for enhanced, 691–694 Thermoregulation, ineffective, 694–696 Thought processes, disturbed, 696–700 Thrombophlebitis, 898 Thrombosis, venous, 898 Thrush, 898 Thyroidectomy, 898–899 966 INDEX
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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
Page 490 and 491:
Page 492 and 493:
• Assess ability to distinguish b
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maximize independence, allow client
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• Establish graduated goals or mo
Page 500 and 501:
[Abnormal laboratory studies (e.g.,
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Appetite stimulants (e.g., wine), i
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• 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:
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• Discuss use of non-food rewards
Page 516 and 517:
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Assist with/provide denture care wh
Page 520 and 521:
Related Factors Injuring agents (bi
Page 522 and 523:
• Note cultural and developmental
Page 524 and 525:
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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
Page 532 and 533:
Parents with significant impairment
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voice, are indicative of attachment
Page 538 and 539:
DISCHARGE PLANNING • Long-range n
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• Participate in activities, clas
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• Assess capillary return, skin c
Page 544 and 545:
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• Review results of laboratory te
Page 548 and 549:
Page 550 and 551:
• 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
Page 558 and 559:
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• Assist client to set realistic
Page 562 and 563:
Moderate Dependence on others that
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• Develop contract with client sp
Page 566 and 567:
Inadequate coping patterns Absence
Page 568 and 569:
• Cultural values/religious belie
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DRUG THERAPIES, TREATMENTS, AND DIS
Page 572 and 573:
[C] SILENT REACTION—(00141) Defin
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• 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
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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:
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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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Page 638 and 639:
• Determine client’s interpreta
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impaired Skin Integrity Taxonomy II
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• 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
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NURSING PRIORITY NO.2.To assist cli
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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
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• Cultural/religious beliefs and
Page 662 and 663:
• Identify blocks to social conta
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• Acknowledge reality of feelings
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• Encourage client/family to ask
Page 672 and 673:
• Physical/emotional responses to
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• 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
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Risk Factors INTERNAL Reduced olfac
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• Develop plan with client/caregi
Page 688 and 689:
Guilt Gay or lesbian youth DEMOGRAP
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it will help individual to resolve
Page 692 and 693:
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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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
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Page 738 and 739:
Risk Factors INTERNAL Weakness; bal
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• 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
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• Review with client/SO(s) the si
Page 752 and 753:
• Determine if client is voluntar
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Related Factors Bladder outlet obst
Page 756 and 757:
• Instruct client/SO(s) in clean
Page 758 and 759:
• Measure amount of each voiding
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Risk Factors Effects of medications
Page 762 and 763:
Page 764 and 765:
Practice timed voidings (e.g., ever
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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:
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• Promote maximal ventilation of
Page 782 and 783:
• Discuss impact of specific acti
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Defining Characteristics MILD Subje
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determine if client can assume the
Page 788 and 789:
Risk Factors/[Indicators]* HISTORY
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• Identify precipitating factors.
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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
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CHAPTER 5 Health Conditions and Cli
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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 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: Risk for delayed development, 256-2
Page 989: Urolithiasis, 904 Uterine bleeding,
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