By Marilynn E. Doenges APRN BC-retired, Mary Frances Moorhouse RN MSN CRRN LNC, Alice C. Murr BSN RN-retired
Beth-El university of Nursing and future health Sciences, Colorado Springs, CO. Pocket-sized define aids scholars and nurses opting for interventions quite often linked to nursing diagnoses. comprises an alphabetical directory of latest and revised nursing diagnoses throughout the most recent NANDA convention. earlier variation: c2000. Softcover. DNLM: Nursing Diagnosis--Handbooks.
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Extra info for Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales
Example text
A. Davis Company MALE: SUBJECTIVE (REPORTS) Penile discharge: __________ Prostate disorder: __________ Circumcised: ______________ Vasectomy: ______________ Practice self-examination: Breast: _______ Testicles: _______ Last proctoscopic/prostate examination: __________________ OBJECTIVE (EXHIBITS) Breast: __________ Penis: __________ Testicles: __________ Genital warts/lesions: ___________ Discharge: ___________ Social Interactions SUJECTIVE (REPORTS) Marital status: __________ Years in relationship: __________ Perception of relationship: ____________________________ Living with: ______________________________________ Concerns/stresses: _________________________________ Extended family: ____________________________________ Other support person(s): ___________________________ Role within family structure: ___________________________ Perception of relationships with family members: __________ Feelings of: Mistrust: ___________ Rejection: ___________ Unhappiness: _____________________________________ Loneliness/isolation: _______________________________ Problems related to illness/condition: ____________________ Problems with communication: ________________________ Genogram: _________________________________________ OBJECTIVE (EXHIBITS) Speech: Clear: _______________ Slurred: _______________ Unintelligible: ______________ Aphasic: ______________ Unusual speech pattern/impairment: __________________ Use of speech/communication aids: ___________________ Laryngectomy present: _____________________________ Verbal/nonverbal communication with family/SO(s): _______ Family interaction (behavioral) pattern: ________________ Teaching/Learning SUBJECTIVE (REPORTS) Dominant language (specify): _____ Second language: _____ Literate: _____________ Education level: _____________ Learning disabilities (specify): ________________________ Cognitive limitations: ______________________________ Where born: ______________ If immigrant, how long in this country?
46 ACTIONS/INTERVENTIONS RATIONALE Pain Management (NIC) Determine pain characteristics through patient’s description. Establishes baseline for assessing improvement/changes. A. Davis Company Avoids direct pressure to area of injury, which could result in vasoconstriction/ increased pain. Provides relief of discomfort when unrelieved by other measures. ” Outcome: Knowledge: Diabetes Management (NOC) Indicators: Patient Will: Verbalize understanding of relationship between chronic disease (diabetes mellitus) and circulatory changes within 48 hr (6/30 1900).
Davis Company ACTIONS/INTERVENTIONS Administer antidiabetic medications: 10 U Humulin N insulin SC q AM/hs after fingerstick BG; Diabeta 10 mg PO bid; Glucophage 500 mg PO qd. Note onset of side effects. RATIONALE Although no prior history of penicillin reaction, it may occur at any time. Treats underlying metabolic dysfunction, reducing hyperglycemia and promoting healing. Glucophage lowers serum glucose levels by improving insulin sensitivity, increasing glucose utilization in the muscles. , 2000 mg/day).
