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 healthiness Sciences, Colorado Springs. Pocket-sized reference bargains the newest revised nursing diagnoses in the course of the NANDA convention. each one analysis gains similar elements, defining features, wanted results, interventions, and documentation. Interventions contain rationales. prior variation: c2002. Softcover.
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Additional info for Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales
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. Progress notes are an integral component of the overall medical record and should include all significant events that occur in the daily life of the client. A. Favis implementation of the treatment plan and document that appropriate actions have been carried out, precautions taken, and so forth.
A. ” Tingling/numbness: feet, once or twice a week (as noted) Eyes: Vision loss, farsighted, “Seems a little blurry now” Examination: 2 yr ago Ears: Hearing loss R: “Some” L: no (has not been tested) Nose: Epistaxis: 0 Sense of smell: “No problem” Sample Assessment Tool Scalp and eyebrows: scaly white patches No body odor OBJECTIVE (EXHIBITS) Mental status: alert, oriented to time, place, person, situation Affect: concerned Memory: Remote/Recent: clear and intact Speech: clear/coherent, appropriate Pupil reaction: PERLA/small Glasses: reading Hearing aid: no Handgrip/release: strong/equal Pain/Discomfort SUBJECTIVE (REPORTS) Primary problem focus: Location: medial aspect, heel of L foot Intensity (0–10): 4 to 5 Quality: dull ache with occ.