By Marilynn E. Doenges APRN BC-retired, Mary Frances Moorhouse RN MSN CRRN LNC, Alice C. Murr BSN RN-retired
Beth-El collage of Nursing and future health Sciences, Colorado Springs. Pocket-sized reference deals the most recent revised nursing diagnoses during the NANDA convention. each one analysis gains comparable elements, defining features, wanted results, interventions, and documentation. Interventions comprise rationales. earlier version: c2002. Softcover.
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Extra info for Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales
The plan of care provides documentation of the planning process and serves as a framework/outline for charting of administered care. The primary nurse needs to periodically review the client’s progress and the effectiveness of the treatment plan. Persons then are able to read the notes and have a clear picture of what occurred with the client in order to make appropriate judgments regarding client management. The best way to ensure the clarity of progress notes is through the use of descriptive (or observational) statements.
The primary nurse needs to periodically review the client’s progress and the effectiveness of the treatment plan. Persons then are able to read the notes and have a clear picture of what occurred with the client in order to make appropriate judgments regarding client management. The best way to ensure the clarity of progress notes is through the use of descriptive (or observational) statements. Observations of client behavior and response to therapy provide invaluable information. Through this communication, it can be determined if the client’s current desired outcomes or interventions need to be eliminated or altered and if the development of new outcomes or interventions is warranted.
5-cm diameter, approx. A. Favis SUBJECTIVE (REPORTS) Marital status: married 45 yr Living with: wife Report of problems: none Extended family: 1 daughter lives in town (30 miles away); 1 daughter married/grandson, living out of state Other: several couples, he and wife play cards/socialize with 2 to 3 times/mo Role: works farm alone; husband/father/grandfather Report of problems related to illness/condition: none until now Coping behaviors: “My wife and I have always talked things out. ” Presence of Advance Directives: yes—wife to bring in Durable Medical Power of Attorney: wife Familial risk factors/relationship: Diabetes: maternal uncle Tuberculosis: brother died, age 27 Heart disease: father died, age 78, heart attack Strokes: mother died, age 81 High BP: mother Prescribed medications: Drug: Diabeta Dose: 10 mg bid Schedule: 8 AM/6 PM, last dose 6 PM today Purpose: control diabetes Takes medications regularly?