Home > Books > Sparks and Taylor's Nursing Diagnosis Reference Manual. Sparks and Taylor's Nursing Diagnosis Reference Manual View PDF. Sparks and Taylor's Nursing Diagnosis Pocket Guide (1) - Ebook download as PDF File .pdf), Text File .txt) or read book online. to another. or others are directly concerned. and nursing interventions. and references. your care plan can help. Sparks and Taylor's Nursing Diagnosis Reference Manual 9th edition provides clearly written, authoritative care plan guidelines for all NANDA.
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This clearly written, easy-to-use reference manual contains the evidence-based information that nursing students and practicing nurses need to diagnose and. Read Sparks & Taylor's Nursing Diagnosis Reference Manual PDF Ebook by Linda Phelps DNP perpemethico.gqhed by LWW, ePUB/PDF. Ralph, Sheila Sparks and Cynthia M. Taylor. Sparks and Taylor's Nursing Diagnosis Reference Manual. Philadelphia: Wolters Kluwer/Lippincott Williams.
Airway Patency; Respira- tory Status: Assess respiratory status at least every 4 hr or according to established standards. Monitor arterial blood gases val- ues and hemoglobin levels to assess oxygenation and ventilatory status. Monitor sputum, noting amount, odor, and consistency. Sputum amount and consistency may indicate hydration status and effectiveness of therapy.
Foul-smelling sputum may indicate respiratory infection. Turn patient every 2 hr; place the patient in lateral, sitting, prone, and upright positions as much as possible for maximal aera- tion of lung fields and mobilization of secretions.
Mobilize patient to full capabilities to facilitate chest expansion and ventilation. Suction, as ordered, to stimulate cough and clear airways. Be alert for progression of airway compromise. Perform postural drainage, percussion, and vibration to facilitate secretion movement. Provide adequate humidification to loosen secretions. Administer expectorants, bronchodilators, and other drugs, as ordered, and moni- tor effectiveness.
Provide bronchodilator treatments before chest phys- iotherapy to optimize results of the treatment. Administer oxygen, as ordered, to promote oxygenation of cells throughout the body. Teach patient an easily performed cough technique to clear airway without fatigue.
Avoid placing patient in a supine position for extended peri- ods to prevent atelectasis. When helping the patient cough and deep-breathe, use whatever position best ensures cooperation and minimizes energy expenditure, such as high Fowlers position or sitting on side of bed.
Such posi- tions promote chest expansion and ventilation of basilar lung fields. Encourage sputum expectoration to remove pathogens and prevent spread of infection. Provide tissues and paper bags for hygienic disposal. If conservative measures fail to maintain partial pressure of arterial oxygen PaO2 within an acceptable range, prepare for endo- tracheal intubation, as ordered, to maintain artificial airway and optimize PaO2 Level.
Rehabilitation for the home care patient with COPD. Home Healthcare Nurse, 23 9 , Exhibit skin that is moist, clear, and free of erythema, edema, itch- ing, urticaria, and breakdown. Express awareness of allergic response to latex-containing products. Infection Control; Tissue Integrity: Determine whether patient has had past episodes of latex allergy; food, pollen, or drug allergy. Report contacts with latex products including when, where, and what. History will lead to more precise assessment.
Monitor respiratory status; include rate, rhythm, skin color, and breath sounds. Be particularly alert for signs of bronchospasms and complaints of dyspnea. Assess heart rate, rhythm, and blood pressure. Check skin carefully for urticaria. Document findings.
These measures detect changes in status to more accurately determine interventions. Administer prescribed drugs and treatments as ordered. Wheezing and shortness of breath can quickly deteriorate to respiratory distress and failure. Skin with urticaria and itching is uncomfortable and unsightly so patients appreciate timely adminis- tration of treatment.
Teach patient and his or her family to avoid latex products to prevent future contact and allergic reactions. Provide instruction about household items that contain latex provide a written list and tell them about nonlatex substitutes.
Prevention is the foundation of treatment of latex allergies. Instruct patient and his or her family about importance of seeking immediate medical treatment of allergic reactions to foster timely intervention. Provide emotional support and encouragement to help improve patients self-concept.
Involve patient in planning and decision making, and have him or her perform self-care activities. Having the ability to participate will encourage greater compliance with the plan for activity. When latex allergy is confirmed, document and label record clearly to prevent future contact with the allergen.
Emphasize need to inform all healthcare providers about patients sensitivity to latex. Stress the importance of wearing a medical iden- tification bracelet that specifies latex allergy to prevent future contact and allergic reactions. Provide documentation of latex allergy for the patient to take to employer; with the patients permission, communicate with employee health department and discuss patients need to avoid contact with latex products to prevent further contamination.
Individual Reference Crippa, M.
Prevention of latex allergy among health care workers and in the general population: Latex protein content in devices commonly used in hospitals and general practice. International Archives of Occupational and Environmental Health, 79 7 , Exhibit moist, clear skin that is free of erythema, edema, itching, urticaria, and breakdown. These measures detect changes in patients response to latex or other substances that cause allergic reactions status.
Remove all latex products from the immediate proximity of the patient and staff treating the patient to prevent inadvertent use of latex products by the staff or patient, increasing the risk for contact and allergic reaction. Skin with urticaria and itching is uncomfortable and unsightly so patients appreciate timely administration of treatment. Educate patient and family about allergic reaction to latex products to prevent future contact and allergic reactions.
Provide a list of household items containing latex, emphasize importance of avoiding these, and tell them about nonlatex substitutes. Educate patient and his or her family about importance of seeking immediate medical treatment of allergic reactions to foster timely intervention. Involve patient in planning and decision making, and have the patient perform self-care activities.
Having the ability to partici- pate will encourage greater compliance with the plan for activity. Emphasize need to inform all healthcare providers about sensitivity to latex.
Stress importance of wearing a medical identifi- cation bracelet that specifies possible latex allergy to prevent contact and allergic reactions.
Provide documentation of the risk of latex allergy for the patient to take to employer. With patients permission, communicate with employee health department and discuss patients need to avoid con- tact with latex products to prevent further contamination.
Diminished productivity, fidgeting, restlessness, scanning and vigilance, poor eye contact, insomnia Affective: Apprehensive, distressed, fearful, jittery, uncertain, wary Physiological: Facial tension, hand tremors, increased perspiration, quivering voice Sympathetic: Participate in activities that decrease feelings of anxious behaviors.
Practice relaxation techniques at specific intervals each day. Cope with current medical situation without demonstrating severe signs of anxiety. Demonstrate observable signs of reduced anxiety. State that the level of anxiety has decreased. Listen attentively to patient to determine exactly what he or she is feeling.
Assess types of activities that help reduce patients stress levels. Monitor physiologic responses including respirations, heart rate and rhythm, and blood pressure. Reduce environmental stressors including people , and remain with patient during severe anxiety. Offer relaxing types of music for quiet listening periods. Listening to relaxing music may have a calming effect. Promote proper body alignment to avoid contractures and main- tain optimal musculoskeletal balance and physiologic function.
Encourage active exercise to promote a sense of well-being. Teach patient relaxation techniques guided imagery, progres- sive muscle relaxation, and meditation to be performed at least every 4 hr to restore psychological and physical equilibrium by decreasing autonomic response to anxiety.
Provide emotional support and encouragement to improve self-concept and encourage frequent use of relaxation techniques. Allow extra visiting times with family if this seems to allay patients anxiety about activities of daily living.
Involve patient in planning and decision making to encourage interest and compliance. Encourage patient to talk about the kinds of activities that promote feelings of comfort. Assist patient to create a plan to try engaging in at least one of these activities each day. This gives the patient a sense of control. Make sure that patient has clear explanations for everything that will happen to him or her.
Ask for feedback to ensure that the patient understands. Anxiety may impair patients cognitive abilities. Encouraging the use of community mental health resources reinforces the fact that anxiety reduction is a long-term process. A music intervention to reduce anxi- ety before vascular angiography procedures. Journal of Vascular Nursing, 24 3 , Communicate important thoughts and feelings to family members.
Obtain the level of spiritual support desired. Use available support systems. Express feelings of comfort and peacefulness. Assess how much support the patient desires. Patients may want a higher degree of independence in dealing with death than the caregiver wants to allow.
Assess patients spiritual needs. Often as death approaches, indi- viduals begin thinking more about the needs of the spirit. Determine which comfort measures the family believes will enhance feelings of well-being.
Dying patients have the right to decide how much physical, emotional, and spiritual care they wish to have. Administer medication to relieve pain and provide comfort as required. Turning and repo- sitioning prevent skin breakdown, improve lung expansion, and pre- vent atelectasis.
Post schedule at bedside and monitor frequency. Provide simple physical gestures of support such as holding hands with the patient and encouraging family members to do the same. Patient may want to experience less touching when he or she begins to let go. Provide comfort measures including bath, massage, regulation of environmental temperature, and mouth care according to patients preferences.
These measures promote relaxation and feelings of well being. Teach family members ways of discerning unobtrusively what the patients desires for comfort and peace are at this time because some patients prefer not to be bothered unless they specifically request comfort measures.
Being sensitive to patient needs promotes individualized care. Teach caregivers to assist patient with self-care activities in a way that maximizes patients rights to choose. This enables caregivers to participate in patients care while supporting patients independence. Help family identify, discuss, and resolve issues related to patients dying. Provide emotional support and encouragement to help. Clear communication promotes family integrity. Demonstrate to patient willingness to discuss the spiritual aspects of death and dying to foster an open discussion.
Keep conversation focused on patients spiritual values and the role they play coping with dying. Meeting the patient's spiritual needs conveys respect for the importance of all aspects of care.
If patient is confused, provide reassurance by telling him or her who is in the room. This information may help to reduce anxiety.
Refer to hospice for end-of-life care if this has not already been done. Communicate to the hospice nurse where the patient is at present in coping with the terminal illness. Continuity of care is crucial during times of stress. Refer to a member of the clergy or a spiritual counselor, accord- ing to the patients preference, to show respect for the patients beliefs and provide spiritual care. Transitions and shifting goals of care for palliative patients and their families. Clinical Journal of Oncology Nursing, 9 4 , Have normal bowel sounds.
Maintain patent airway. Breathe easily, cough effectively, and show no signs of respiratory distress or infection. Demonstrate measures to prevent aspiration.
Maintain respiratory rate within normal limits for age. Describe plan for home care. Treatment Procedure s ; Respira- tory Status: Assess for gag and swallowing reflexes. Impaired reflexes may cause aspiration.
Assess respiratory status at least every 4 hr or according to estab- lished standards; begin cardiopulmonary monitoring to detect signs of possible aspiration increased respiratory rate, cough, sputum pro- duction, and diminished breath sounds. Auscultate bowel sounds every 4 hr and report changes. Delayed gastric emptying may cause regurgitation of stomach contents. Elevate the head of the bed or place the patient in Fowlers posi- tion to aid breathing.
Help patient turn, cough, and deep breathe every 24 hr. Perform postural drainage, percussion, and vibration every 4 hr, or as ordered. Suction, as needed, to stimulate cough and clear upper and lower airways. These measures promote drainage of secretions and full expansion of lungs. Perform chest physiotherapy before feeding to decrease the risk of emesis leading to aspiration.
Elevate patient during feeding, and use an upright position after feeding. Such positioning uses gravity to prevent regurgitation of stomach contents and promotes lung expansion. Place patient in the lateral or prone position and change position at least every 2 hr to reduce the potential for aspiration by allowing secretions to drain.
Instruct patient and family members in home care plan. They must demonstrate the ability to carry out measures to prevent or respond to aspiration events to ensure adequate home care before discharge. Encourage fluids within prescribed restrictions. Provide humidification, as ordered such as a nebulizer.
Fluids and humidifi- cation liquefy secretions. The early feeding skills assessment for preterm infants. Neonatal Network, 24 3 , Hold child and talk to him or her. Express confidence in their ability to respond to childs needs. Respond appropriately to child. Express positive feelings about child. Express confidence in their ability to care for child. Recognize when they need assistance. The child will Respond positively to parents.
Show interest in parents faces. Become calm when soothed by parents. Assess composition of family and ages of members; ability of family to meet physical and emotional needs of its mem- bers; knowledge of growth and development patterns; energy levels of parents; recent life changes; childs neurological and sensory status, including vision and hearing; sleep patterns of parents and child.
This information will assist in establishing appropriate inter- ventions. Reduce environmental stressors including people where it is possible to observe whether the parents responses to the child are appropriate. Provide parents and child with periods of privacy to promote attachment. This may be to demonstrate to the family the appropriate way to perform ADLs. Teach parents to observe and understand behavioral cues from the child. For example, the child may become fussy when he or she is ready for a nap or may pull his or her ear if he or she has an earache.
Explain the range of options for responding to these cues positively. It is important that the parents have a variety of options made available to them. Teach parents to give physical care when the needs exist to increase their self-confidence and self-competence. Teach relaxation techniques guided imagery, progressive muscle relaxation, and meditation that can be done by the parents to restore psychological and physical equilibrium by decreasing autonomic response to anxiety.
Provide emotional support and encouragement to help improve parents self-concept and self-confidence in parental roles. Initiate discussions with parents on life changes precipitated by the birth of the child.
Parents are often confused and blame them- selves because the stress of birth causes frustration and anger. Encourage parents to talk about the kinds of activities that promote feelings of comfort. Assist parents to create a plan to engage in at least one of these activities each day. This provides par- ents with a sense of control over their own lives.
Make sure parents have clear explanations for everything that is expected of them. Ask for feedback to ensure parents understand. Anxiety may impair their cognitive abilities. Learning to observe relationships and cop- ing. Journal of Child and Adolescent Psychiatric Nursing, 19 4 , Avoid bladder distention and urinary tract infection UTI. Have no fecal impaction.
Have no noxious stimuli in environment. State relief from symptoms of dysreflexia. Have few, if any, complications. Maintain normal bladder elimination pattern. Maintain normal bowel elimination pattern.
Demonstrate knowledge and understanding of dysreflexia and will describe care measures. Experience few or no dysreflexic episodes. Assess for signs of dysreflexia especially severe hyperten- sion to detect condition so that prompt treatment may be initiated.
Take vital signs frequently to monitor effectiveness of prescribed medications. Place patient in a sitting position or elevate the head of bed to aid venous drainage from brain, lower intracranial pressure, and temporarily reduce blood pressure. Ascertain and correct probable cause of dysreflexia. Check for bladder distention and patency of catheter. If necessary, irrigate catheter with small amount of solution, or insert a new catheter immediately. A blocked urinary catheter can trigger dysreflexia.
Check for fecal mass in rectum. Failure to use ointment may aggravate autonomic response. Check environment for cold drafts and objects putting pressure on patients skin, which could act as dysreflexia stimuli. Send urine for culture if no other cause becomes apparent to detect possible UTI. Implement and maintain bowel and bladder elimination programs to avoid stimuli that could trigger dysreflexia Inform: Instruct patient, family members, or caregiver about dysreflexia, including its causes, signs and symptoms, and care measures to prepare them to handle possible emergencies related to condition.
Reassure patient that everyone involved in his or her care will be instructed in management of this problem to relieve anxiety. If hypertension persists despite other measures, administer ganglionic blocking agent, vasodilator, or other medication as ordered. Drugs may be required if hypertension persists or if noxious stimuli cant be removed. Autonomic dysfunction in spinal cord injury: Clinical presentation of symptoms and signs.
Progress in Brain Research, , Avoid bladder distention. Will not experience a UTI. Maintain normal urinary and bowel elimination patterns. Be free from fecal impaction. Have an environment free from noxious stimuli that may cause dysreflexia. Express understanding of causes of dysreflexia. Demonstrate understanding of measures to prevent dysreflexia.
Assess for risk factors of dysreflexia, such as constipation, fecal impaction, distended bladder, and presence of noxious stimuli. Identifying risk factors can prevent or minimize dysreflexic episodes. Monitor and record intake and output accurately to ensure ade- quate fluid replacement, thereby helping to prevent constipation. Monitor vital signs frequently to ensure effectiveness of preventive measures. Severe hypertension may indicate dysreflexia. A blocked catheter can trigger dysreflexia.
Check for abdominal distention and assess bowel sounds. Monitor and record characteristics and frequency of stools. Fecal impaction may lead to dysreflexia. Administer laxative, enema, or suppositories, as prescribed, to promote elimination of solids and gases from GI tract.
Monitor effectiveness. Implement and maintain bowel and bladder programs to avoid stimuli that could trigger dysreflexia. Instruct patient, family member, or caregiver about risk fac- tors, signs and symptoms, and care measures for dysreflexia to help prevent a possible dysreflexic episode and help him or her respond appropriately should dysreflexia occur.
Encourage fluid intake of qt 2. Adequate fluid intake helps maintain patency of catheter and aids bowel elimination. Consult with dietitian about increasing fiber and bulk in diet to maximum prescribed by physician to improve intestinal mus- cle tone and promote comfortable elimination.
The incidence of urinary tract infection and autonomic dysreflexia in a challenging popula- tion. Urologic Nursing, 24 5 , Express understanding of the illness or disease. Participate in healthcare regimen including planning activities. Demonstrate ability to manage health problems. Show ability to accept and adapt to a new health status and inte- grate learning.
Demonstrate new coping abilities. Assess patients present understanding of health status and treatment to form the basis for any further planning. Assess feelings about present health status.
Do this in a safe, nonthreaten- ing environment to allow the patient to gain insight into and ration- ally define fears, goals, and potential problems. Monitor patient involvement in care-related activities. Make changes in the environment that will encourage healthy behavior. Teach patient and caregiver the skills necessary to manage care adequately. Teaching will encourage compliance and adjustment to optimum wellness.
Teach patient how to find areas in which it is possible to maintain control to avoid feelings of powerlessness and allow the patient to feel like a member of the teams effort to assist him or her.
Teach caregivers to assist patient with self-care activities in a way that maximizes patients potential. This enables caregivers to partici- pate in patients care and encourages them to support patients inde- pendence.
Provide emotional support and encouragement by listening to the patients feelings. This will reassure the patient that you care. Allow patient to grieve. Grieving is a normal and essential aspect of any kind of negative change in health status. After working through denial and isolation, anger, bargaining, and depression, the patient will progress toward acceptance.
Provide reassurance that the patients feelings, under the circum- stances, are normal. By realizing that it is acceptable to grieve, the patient will be willing to look for positive ways of coping. Discuss health problems with family members to encourage partic- ipation in the patients care.
Refer to a mental health specialist if patient develops severe depression or other psychiatric problem. Although trauma or illness commonly causes some depression or other psychiatric disorders, consultation with a mental health professional may help minimize it. Arrange for an individual who has the same problem to meet with the patient. This exposes the patient to suitable role models and may encourage a supportive relationship to evolve.
Acceptance and denial: Implications for people adapting to chronic illness: Literature review. Journal of Advanced Nursing, 55 4 , Receive follow-through intervention. Receive appropriate clinician staffing and surveillance for a rapid response to rescue the patient before serious bleeding occurs. Maintain heart rate, rhythm, blood pressure, and tissue perfusion within expected ranges during episodes of risk.
Identify and avoid risk situations with potential for trauma injury. Assessment findings may indicate need for protective measures.
Anticipate conditions and episodes of care that may precipitate bleeding especially in high-risk patient care areas to provide early intervention. Monitor physiologic responses for values that exceed expected or normal ranges; early bleeding compensatory mechanisms alter respirations, pulse, and blood pressure and may be present as subtle changes. Monitor for occult and for frank bleedingurine, feces, wounds, and dressingsby visual inspection or point-of-care testing to identify need for intervention.
Correlate findings, risk factors, and current episode of care and patient condition to determine the imminent level of risk for bleeding. Perform vital signs and basic physical assessments for the patient who is at risk for bleeding until assured the risk is past to provide data needed for early intervention. Obtain laboratory tests hemoglobin, hematocrit, complete blood cell count, thrombin time, prothrombin time, activated partial thromboplastin time, etc.
Examine dressings, drainage tubes, and collection canisters for pres- ence of blood; report findings to support need for changes in therapy. Teach patient about intended and unintended effects of med- ications heparin, enoxaparin [Lovenox], warfarin Coumadin , clopi- dogrel [Plavix], aspirin that increase the risk of bleeding or prolong clotting. This enables the patient to avoid bleeding-risk situations. Discuss alternatives in ADLs to avoid trauma-causing injury and bleeding.
Provide care protecting an individual from injury to prevent bleeding. Implement interventions that reverse or remove the risk of bleeding or bleeding condition to prevent bleeding or stabilize the patients physiologic condition and assist in recovery. Provide emotional support to the patient who is bleeding and is experiencing physiologic compensatory responses of anxiety, fear, and a sense of dread as this support provides assurance and is calming.
Support participation in decisions about the treatment placing the patient at risk for bleeding. Active participation encourages fuller understanding of the rationale and compliance with the treatment. Refer to case manager or APN those at risk for bleeding secondary to treatment i. Monitor the recovery of the individual who expe- rienced a bleeding episode because weakness causes a safety risk for falls or injury.
McCance, K. The biologic basis for disease in adults and children 5th ed. Louis, MO: Identify at least one positive aspect of aging. Use vision or hearing aids appropriately.
Demonstrate increased flexibility and willingness to consider lifestyles changes. Participate in at least one social activity regularly.
Exercise and engage in other physical activity at level consistent with desire, ability, and safety. Monitor physiologic responses to increased activity level, including respirations, heart rate and rhythm, and blood pressure. Assessment information is helpful in deter- mining appropriate interventions.
Perform ADL measures that the patient is unable to perform for self while promoting as much independence as possible. Provide patient with information on appropriate self-care activities e. Teach patient about isometric exercises to maintain or increase muscle tone and joint mobility. This enables caregivers to partici- pate in patients care while supporting patients independence.
Provide emotional support and encouragement to improve patients self-concept and promote motivation to perform ADLs. Assist patient to learn how to perform self-care activities. Performing self-care activities will assist patient to regain independence and enhance self-esteem.
Focus on patients strengths and what the patient is able to do for self. Encourage patient to engage in social activities with people of all age groups. Participation once a week will help relieve patients sense of isolation. Refer patient to a support group. In the context of a group, the patient may develop a more positive view of present situation. Refer for corrective eyewear and hearing aids to address sensory deficits.
What are old people for? Journal of Gerontological Nursing, 32 8 , Maintain balanced intake and output within normal limits for age. Have a urine-specific gravity between 1. Assess temperature every 4 hr. Use a temperature-taking method appropriate for age and size rectal or axillary for an infant or toddler, axillary or oral for a preschooler, and oral for a school- aged child or adult.
Weigh patient every morning and record results. A decrease in weight may indicate dehydration. Assess the patients knowledge and lifestyle before teaching about hypothermia and hyperthermia to gear the teaching plan to the patients needs.
Maintain adequate fluid intake by offering small amounts of flavored fluids at frequent intervals; record intake and output every shift. Fever increases fluid requirements by increasing the metabolic rate. Provide high-calorie liquids, such as colas, fruit juices, and flavored water sweetened with corn syrup, to help prevent dehydration. Administer antipyretics, as ordered, and monitor effectiveness.
Antipyretics act on the hypothalamus to regulate body temperature. An annual anal Embed Size px. Start on. Show related SlideShares at end. WordPress Shortcode.
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