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SPARKS AND TAYLOR’S

Nursing Diagnosis
Pocket Guide

Sheila Sparks Ralph, RN, PhD, FAAN

Professor, Division of Nursing
Shenandoah University
Winchester, VA
Member of NANDA-I Foundation
Philadelphia

Cynthia M. Taylor, RN, MS

Nurse Consultant
Coordinator, Parish Nurse Program
St. Michael’s Church
Kailua Kona, HI
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Acquisitions Editor: Jean Rodenberger

Development Editor: Helene T. Caprari
Marketing Manager: Laura Meiskey
Director of Nursing Production: Helen Ewan
Art Director, Design: Joan Wendt
Manufacturing Coordinator: Karin Duffield
Production Services: Aptara, Inc.

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

All rights reserved. This book is protected by copyright. No part of this book may be
reproduced or transmitted in any form or by any means, including as photocopies or
scanned-in or other electronic copies, or utilized by any information storage and
retrieval system without written permission from the copyright owner, except for brief
quotations embodied in critical articles and reviews. Materials appearing in this book
prepared by individuals as part of their official duties as U.S. government employees
are not covered by the above-mentioned copyright. To request permission, please con-
tact Lippincott Williams & Wilkins at 530 Walnut Street, Philadelphia, PA 19106, via
e-mail at [email protected], or via Web site at lww.com (products and services).
9 8 7 6 5 4 3 2 1

Printed in China

Library of Congress Cataloging-in-Publication Data

Ralph, Sheila Sparks.
Sparks and Taylor’s nursing diagnosis pocket guide / Sheila Sparks
Ralph, Cynthia M. Taylor.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-58255-733-5
1. Nursing diagnosis—Handbooks, manuals, etc. I. Taylor, Cynthia M.
II. Title. III. Title: Nursing diagnosis pocket guide.
[DNLM: 1. Nursing Diagnosis—methods—Handbooks. WY 49 R163sa 2011]

RT48.6.R35 2011
616.07'5—dc22
2009028540

Care has been taken to confirm the accuracy of the information presented and
to describe generally accepted practices. However, the authors, editors, and publisher
are not responsible for errors or omissions or for any consequences from application
of the information in this book and make no warranty, expressed or implied, with
respect to the currency, completeness, or accuracy of the contents of the publication.
Application of this information in a particular situation remains the professional
responsibility of the practitioner; the clinical treatments described and recommended
may not be considered absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that
drug selection and dosage set forth in this text are in accordance with the current rec-
ommendations and practice at the time of publication. However, in view of ongoing
research, changes in government regulations, and the constant flow of information
relating to drug therapy and drug reactions, the reader is urged to check the package
insert for each drug for any change in indications and dosage and for added warnings
and precautions. This is particularly important when the recommended agent is a new
or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and
Drug Administration (FDA) clearance for limited use in restricted research settings.
It is the responsibility of the healthcare provider to ascertain the FDA status of each
drug or device planned for use in his or her clinical practice.
LWW.COM
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CONTRIBUTORS

Marcia Perkins, MSN, RN

Adjunct Clinical Instructor, Division of Nursing
Shenandoah University
Winchester, VA

Helen H. Mautner, MSN, RN

Assistant Professor, Division of Nursing
Shenandoah University
Winchester, VA

Anne Z. Cockerham, PhD, CNM

Course Coordinator
Frontier School of Midwifery and Family Nursing
Hyden, KY

Jennifer Matthews, PhD, RN

Associate Professor, Division of Nursing
Shenandoah University
Winchester, VA

Billinda Tebbenhoff, MSN, RN

Adjunct Clinical Instructor, Division of Nursing
Shenandoah University
Winchester, VA

Sherry Rawls-Bryce, MSN, RN

Adjunct Assistant Professor, Division of Nursing
Shenandoah University
Winchester, VA

Maryann Valcourt, MSN, CPNP

Assistant Professor
Trinity University
Washington, DC

iii
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PREFACE

For student nurses as well as expert clinicians, Sparks and Taylor’s

Nursing Diagnosis Pocket Guide offers a clearly written, authoritative
care plan for each of the NANDA International (NANDA-I) approved
nursing diagnoses to help meet patients’ healthcare needs. The guide
is organized using a unique assessment framework based on the NNN
Taxonomy of Nursing Practice: A Common Unifying Structure for
Nursing Language (Dochterman & Jones, 2003) and the intervention
terms from the International Classification for Nursing Practice
(ICNP® Version 1; International Council of Nurses, 2005). This
framework provides a comprehensive yet easy-to-use format for writ-
ing plans of care for clients. The book also includes the linkages
between NANDA-I and the Nursing Interventions Classification (NIC)
and Nursing Outcomes Classification (NOC) labels. You’ll find the
care plans in this book, which are designed for easy use with a left-
and right-page sequence, are invaluable in every healthcare setting you
encounter throughout your career.

GUIDELINES FOR USING SPARKS AND TAYLOR’S NURSING

DIAGNOSIS POCKET GUIDE
All care plans contain the following sections:
■ Diagnostic statement. Each diagnostic statement includes a
NANDA-I-approved diagnosis. The Sparks and Taylor’s Nursing
Diagnosis Pocket Guide contains all the diagnoses approved by
NANDA-I through 2009.
■ Definition. Each diagnosis is explained with a NANDA-I
approved definition.
■ Defining characteristics. This section lists clinical findings that confirm
the diagnosis. For diagnoses expressing the possibility of a problem,
such as “Risk for Injury,” this section is labeled Risk Factors.
■ Assessment. This section suggests parameters to use when collect-
ing data to ensure an accurate diagnosis. Complete assessment
parameters are presented in Appendix A. The parameters are
based on the NNN Taxonomy of Nursing Practice and include
four domains: functional, physiological, psychosocial, and
environmental (see Appendix A). The domains are subdivided

v
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vi Preface

into classes; each class includes key subjective and objective data
to be assessed. For each plan, the authors have indicated the
parameters that are most necessary for that diagnosis.
■ Expected outcomes. Here you’ll find realistic goals for resolving
or ameliorating the patient’s health problem, written in measura-
ble behavioral terms. You should select outcomes that are appro-
priate to the condition of your patient. Outcomes are arranged
to flow logically from admission to discharge of the patient.
Outcomes identified by NOC research are included for your con-
sideration.
■ Interventions and rationales. This section provides specific
activities you carry out to help attain expected outcomes. Inter-
ventions are organized using the following terms: determine,
perform, inform, attend, and manage. These intervention types
use the International Classification of Nursing Practice
taxonomy that is explained in more detail later in these guide-
lines. Each intervention contains a rationale, highlighted in
italic. Rationales receive typographic emphasis because they
form the premise for every nursing action. You’ll find it helpful
to consider rationales before intervening. Understanding the why
of your actions can help you see that carrying out repetitive or
difficult interventions is an essential element of your nursing
practice. More importantly, it can improve critical thinking and
help you avoid mistakes. Interventions from NIC research are
included for your consideration.
■ Reference. Each plan concludes with a reference that you may
find useful if you need further information about the nursing
diagnosis.

NURSING PROCESS OVERVIEW

The cornerstone of clinical nursing, the nursing process, is a system-
atic method for taking independent nursing action. Steps in the
nursing process include the following:
■ assessing the patient’s problems
■ forming a diagnostic statement
■ identifying expected outcomes
■ creating a plan to achieve expected outcomes
■ implementing the plan or assigning steps for implementation to
others
■ evaluating the plan’s effectiveness
These phases of the nursing process—assessment, nursing diagnosis
formation, outcome identification, care planning, implementation,
and evaluation—are dynamic and flexible; they commonly overlap.
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Preface vii
Becoming familiar with this process has many benefits. It will
allow you to apply your knowledge and skills in an organized, goal-
oriented manner. It will also enable you to communicate about pro-
fessional topics with colleagues from all clinical specialties and prac-
tice settings. Using the nursing process is essential to documenting
nursing’s role in the provision of comprehensive, quality patient
care.
By clearly defining those problems a nurse may treat independently,
the nursing process has helped dispel the notion that nursing practice
is based solely on carrying out physician’s orders. Nurse researchers
and expert practitioners continue to develop a body of knowledge
specific to the field. Nursing literature is providing direction to stu-
dents and seasoned practitioners for evidence-based practice. A
strong foundation in the nursing process will enable you to better
assimilate emerging concepts and to incorporate these concepts into
your practice.
Assessment
The vital first phase in the nursing process—assessment—consists of
the patient history, the physical examination, and pertinent diagnos-
tic studies. The other nursing process phases depend on the quality
of the assessment data for their effectiveness.
Your initial patient assessment begins with the collection of
data (patient history, physical examination findings, and diagnostic
study data) and ends with a statement of the patient’s nursing
diagnosis(es).
Building a database
The information you collect in taking the patient’s history, perform-
ing a physical examination, and analyzing test results serves as your
assessment database. Your goal is to gather and record information
that will be most helpful in assessing your patient. You can’t realisti-
cally collect—or use—all the information that exists about the
patient. To limit your database appropriately, ask yourself the
following questions:
■ What data do I want to collect?
■ How should I collect the data?
■ How should I organize the data to make care planning decisions?
Your answers will help you be selective in collecting meaningful data
during patient assessment.
The well-defined database for a patient may begin with admission
signs and symptoms, chief complaint, or medical diagnosis. It may
also center on the type of patient care given in a specific setting,
such as the intensive care unit, the emergency department, or an
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viii Preface

outpatient care center. For example, you wouldn’t ask a trauma vic-
tim in the emergency department whether she has a family history
of breast cancer, nor would you perform a routine breast examina-
tion on her. You would, however, do these types of assessment dur-
ing a comprehensive health checkup in an outpatient care setting.
If you work in a setting where patients with similar diagnoses are
treated, choose your database from information pertinent to this
specific patient population. Even when addressing patients with simi-
lar diagnoses, however, complete a thorough assessment to make
sure that unanticipated problems don’t go unnoticed.

Collecting Subjective and Objective Data

The assessment data you collect and analyze fall into two important
categories: subjective and objective. The patient’s history, embodying
a personal perspective of problems and strengths, provides subjective
data. It’s your most important assessment data source. Because it’s
also the most subjective source of patient information, it must be
interpreted carefully.
In the physical examination of a patient—involving inspection,
palpation, percussion, and auscultation—you collect one form of
objective data about the patient’s health status or about the patho-
logic processes that may be related to his illness or injury. In addi-
tion to adding to the patient’s database, this information helps you
interpret his history more accurately by providing a basis for com-
parison. Use it to validate and amplify the historical data. However,
don’t allow the physical examination to assume undue importance—
formulate your nursing diagnosis by considering all the elements of
your assessment, not just the examination.
Laboratory test results are another objective form of assessment
data and the third essential element in developing your assessment.
Laboratory values will help you interpret—and usually clarify—your
history and physical examination findings. The advanced technology
used in laboratory tests enables you to assess anatomic, physiologic,
and chemical processes that can’t be assessed subjectively or by phys-
ical examination alone. For example, if the patient complains of
fatigue (history) and you observe conjunctival pallor (physical exami-
nation), check his hemoglobin level and hematocrit (laboratory data).
Both subjective (history) and objective (physical examination and
laboratory test results) data are essential for comprehensive patient
assessment. They validate each other and together provide more
data than either can provide alone. By considering history, physical
examination, and laboratory data in their appropriate relationships
to one another, you’ll be able to develop a nursing diagnosis on
which to formulate an effective care plan.
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Preface ix
A patient may request a complete physical checkup as part of
a periodic (perhaps annual) health maintenance routine. Such a
patient may not have a chief complaint; therefore, this patient’s
health history should be comprehensive, with detailed information
about lifestyle, self-image, family and other interpersonal relation-
ships, and degree of satisfaction with current health status.
Be sure to record health history data in an organized fashion
so that the information will be meaningful to everyone involved in
the patient’s care. Some healthcare facilities provide patient ques-
tionnaires or computerized checklists. (See assessment parameters
based on NNN Taxonomy of Nursing Practice in Appendix A.)
When documenting the health history, be sure to record negative
findings as well as positive ones; that is, note the absence of symp-
toms that other history data indicate might be present. For example,
if a patient reports pain and burning in his abdomen, ask him
whether he has experienced nausea and vomiting or noticed blood
in his stools. Record the presence or absence of these symptoms.
Remember that the information you record will be used by others
who will be caring for the patient. It could even be used as a legal
document in a liability case, a malpractice suit, or an insurance dis-
ability claim. With these considerations in mind, record history data
thoroughly and precisely. Continue your questioning until you’re sat-
isfied that you’ve recorded sufficient detail.
Don’t be satisfied with inadequate answers, such as “a lot” or
“a little”; such subjective terms must be explained within the
patient’s context to be meaningful. If taking notes seems to make
the patient anxious, explain the importance of keeping a written
record. To facilitate accurate recording of the patient’s answers,
familiarize yourself with standard history data abbreviations.
When you complete the patient’s health history, it becomes part of
the permanent written record. It will serve as a database with which
you and other healthcare professionals can monitor the patient’s
progress. Remember that history data must be specific and precise.
Avoid generalities. Instead, provide pertinent, concise, detailed infor-
mation that will help determine the direction and sequence of the
physical examination—the next phase in your patient assessment.
After taking the patient’s health history, the next step in the
assessment process is the physical examination. During this assess-
ment phase, you obtain objective data that usually confirm or rule
out suspicions raised during the health history interview.
Use four basic techniques to perform a physical examination:
inspection, palpation, percussion, and auscultation (IPPA). These
skills require you to use your senses of sight, hearing, touch, and
smell to formulate an accurate appraisal of the structures and
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x Preface

functions of body systems. Using IPPA skills effectively lessens the

chances that you’ll overlook something important during the physi-
cal examination. In addition, each examination technique collects
data that validate and amplify data collected through other IPPA
techniques.
Accurate and complete physical assessments depend on two inter-
related elements.
One is the critical act of sensory perception, by which you receive
and perceive external stimuli. The other element is the conceptual,
or cognitive, process by which you relate these stimuli to your
knowledge base. This two-step process gives meaning to your assess-
ment data.
Develop a system for assessing patients that identifies their prob-
lem areas in priority order. By performing physical assessments sys-
tematically and efficiently instead of in a random or indiscriminate
manner, you’ll save time and identify priority problems quickly.
First, choose an examination method. The most commonly used
methods for completing a total systematic physical assessment are
head-to-toe and major body systems.
The head-to-toe method is performed by systematically assessing
the patient by—as the name suggests—beginning at the head and
working toward the toes.
Examine all parts of one body region before progressing to the
next region to save time and to avoid tiring the patient or yourself.
Proceed from left to right within each region so you can make sym-
metrical comparisons; that is, when examining the head, proceed
from the left side of the head to the right side.
After completing both sides of one body region, proceed to the next.
The major body systems method of examination involves system-
atically assessing the patient by examining each body system in pri-
ority order or in an established sequence.
Both the head-to-toe and major body systems methods are system-
atic and provide a logical, organized framework for collecting physi-
cal assessment data.
They also provide the same information; therefore, neither is more
correct than the other. Choose the method (or a variation of it) that
works well for you and is appropriate for your patient population.
Follow this routine whenever you assess a patient, and try not to
deviate from it.
You may want to plan your physical examination around the
patient’s chief complaint or concern. To do this, begin by examining
the body system or region that corresponds to the chief complaint.
This allows you to identify priority problems promptly and reassures
the patient that you’re paying attention to his chief complaint.
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Preface xi
Physical examination findings are crucial to arriving at a nursing
diagnosis and, ultimately, to developing a sound nursing care plan.
Record your examination results thoroughly, accurately, and clearly.
Although some examiners don’t like to use a printed form to record
physical assessment findings, preferring to work with a blank paper,
others believe that standardized data collection forms can make
recording physical examination results easier. These forms simplify
comprehensive data collection and documentation by providing a
concise format for outlining and recording pertinent information.
They also remind you to include all essential assessment data.
When documenting, describe exactly what you’ve inspected, pal-
pated, percussed, or auscultated. Don’t use general terms such as
normal, abnormal, good, or poor. Instead, be specific. Include posi-
tive and negative findings. Try to document as soon as possible after
completing your assessment. Remember that abbreviations aid con-
ciseness.

Nursing diagnosis
According to NANDA-I, the nursing diagnosis is a “clinical
judgment about individual, family, or community responses to actual
or potential health problems/life processes. A nursing diagnosis
provides the basis for selection of nursing interventions to achieve
outcomes for which the nurse is accountable” (Herdman, 2009,
p. 419). The nursing diagnosis must be supported by clinical infor-
mation obtained during patient assessment.
Each nursing diagnosis describes a patient problem that a nurse
can professionally and legally manage. Becoming familiar with nurs-
ing diagnoses will enable you to better understand how nursing prac-
tice is distinct from medical practice. Although the identification of
problems commonly overlaps in nursing and medicine, the approach
to treatment clearly differs. Medicine focuses on curing disease; nurs-
ing focuses on holistic care that includes care and comfort.
Nurses can independently diagnose and treat the patient’s response
to illness, certain health problems and risk for health problems,
readiness to improve health behaviors, and the need to learn new
health information. Nurses comfort, counsel, and care for patients
and their families until they’re physically, emotionally, and spiritually
ready to provide self-care.
The nursing diagnosis expresses your professional judgment of the
patient’s clinical status, responses to treatment, and nursing care
needs. You perform this step so that you can develop your care
plan. In effect, the nursing diagnosis defines the practice of nursing.
Translating the history, physical examination, and laboratory data
about a patient into a nursing diagnosis involves organizing the data
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xii Preface

into clusters and interpreting what the clusters reveal about the
patient’s ability to meet basic needs. In addition to identifying the
patient’s needs in coping with the effects of illness, consider what
assistance the patient requires to grow and develop to the fullest
extent possible. Your nursing diagnosis describes the cluster of signs
and symptoms indicating an actual or potential health problem that
you can identify—and that your care can resolve. Nursing diagnoses
that indicate potential health problems can be identified by the
words “risk for’’ that appear in the diagnostic label. There are also
nursing diagnoses that focus on prevention of health problems and
enhanced wellness.
Creating your nursing diagnosis is a logical extension of collecting
assessment data. In your patient assessment, you asked each history
question, performed each physical examination technique, and con-
sidered each laboratory test result because it provided evidence of
how the patient could be helped by your care or because the data
could affect nursing care.
To develop the nursing diagnosis, use the assessment data you’ve
collected to develop a problem list. Less formal in structure than a
fully developed nursing diagnosis, this list describes the patient’s
problems or needs. It’s easy to generate such a list if you use a con-
ceptual model or an accepted set of criterion norms. Examples of
such norms include normal physical and psychological development
and the assessment parameters based on the NNN Taxonomy of
Nursing Practice (see Appendix A).
You can identify the patient’s problems and needs with simple
phrases, such as poor circulation, high fever, or poor hydration.
Next, prioritize the problems on the list and then develop the work-
ing nursing diagnosis.
Some nurses are confused about how to document a nursing diag-
nosis because they think the language is too complex. By remember-
ing the following basic guidelines, however, you can ensure that
your diagnostic statement is correct:
■ Use proper terminology that reflects the patient’s nursing needs.
■ Make your statement concise so it’s easily understood by other
healthcare team members.
■ Use the most precise words possible.
■ Use a problem-and-cause format, stating the problem and its
related cause.
Whenever possible, use the terminology recommended by NANDA-I.
NANDA-I diagnostic headings, when combined with suspected eti-
ology, provide a clear picture of the patient’s needs. Thus, for clarity
in charting, start with one of the NANDA-I categories as a heading
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Preface xiii
for the diagnostic statement. The category can reflect an actual or
potential problem. Consider this sample diagnosis:
■ Heading: Disturbed Sleep Pattern
■ Etiology: select the appropriate “Related To” phrase from the
choices in the care plan
■ Signs and symptoms: “I don’t get enough sleep.” “My husband
wakes me several times during the night to assist him.” You note
dark circle under her eyes and some jitteriness. Do not state a
direct cause-and-effect relationship (which may be hard to prove).
Remember to state only the patient’s problems and the probable
origin. Omit references to possible solutions. (Your solutions will
derive from your nursing diagnosis, but they aren’t part of it.)

Errors can also occur when nurses take shortcuts in the nursing
process, either by omitting or hurrying through assessment or by
basing the diagnosis on inaccurate assessment data.
Keep in mind that a nursing diagnosis is a statement of a health
problem that a nurse is licensed to treat—a problem for which
you’ll assume responsibility for therapeutic decisions and accounta-
bility for the outcomes. A nursing diagnosis is not a:

■ diagnostic test (“schedule for cardiac angiography”)

■ piece of equipment (“set up intermittent suction apparatus”)
■ problem with equipment (“the patient has trouble using a commode”)
■ nurse’s problem with a patient (“Mr. Jones is a difficult patient;
he’s rude and won’t take his medication.”)
■ nursing goal (“encourage fluids up to 2,000 ml per day”)
■ nursing need (“I have to get through to the family that they must
accept the fact that their father is dying.”)
■ medical diagnosis (“cervical cancer”)
■ treatment (“catheterize after each voiding for residual urine”).

At first, these distinctions may not be clear. The following examples

should help clarify what a nursing diagnosis is:

■ Don’t state a need instead of a problem.

– Incorrect: Fluid replacement related to fever
– Correct: Deficient fluid volume related to fever
■ Don’t reverse the two parts of the statement.
– Incorrect: Lack of understanding related to noncompliance with
diabetic diet
– Correct: Noncompliance with diabetic diet related to lack of
understanding
■ Don’t identify an untreatable condition instead of the problem it
indicates (which can be treated).
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xiv Preface

– Incorrect: Inability to speak related to laryngectomy

– Correct: Social isolation related to inability to speak because of
laryngectomy
■ Don’t write a legally inadvisable statement.
– Incorrect: Skin integrity impairment related to improper posi-
tioning
– Correct: Impaired skin integrity related to immobility
■ Don’t identify as unhealthful a response that would be appropri-
ate, allowed for, or culturally acceptable.
– Incorrect: Anger related to terminal illness
– Correct: Ineffective therapeutic regimen management related to
anger over terminal illness
■ Don’t make a tautological statement (one in which both parts of
the statement say the same thing).
– Incorrect: Pain related to alteration in comfort
– Correct: Acute pain related to postoperative abdominal disten-
tion and anxiety
■ Don’t identify a nursing problem instead of a patient problem.
– Incorrect: Difficulty suctioning related to thick secretions
– Correct: Ineffective airway clearance related to thick tracheal
secretions

Outcome identification
During this phase of the nursing process, you identify expected out-
comes for the patient. Expected outcomes are measurable, patient-
focused goals that are derived from the patient’s nursing diagnoses.
These goals may be short- or long-term. Short-term goals include
those of immediate concern that can be achieved quickly. Long-term
goals take more time to achieve and usually involve prevention,
patient teaching, and rehabilitation.
In many cases, you can identify expected outcomes by converting
the nursing diagnosis into a positive statement. For instance, for the
nursing diagnosis “impaired physical mobility related to a fracture
of the right hip,” the expected outcome might be “The patient will
ambulate independently before discharge.”
When writing the care plan, state expected outcomes in terms
of the patient’s behavior—for example, “the patient correctly
demonstrates turning, coughing, and deep breathing.” Also iden-
tify a target time or date by which the expected outcomes should
be accomplished. The expected outcomes will serve as the basis
for evaluating your nursing interventions. Keep in mind that each
expected outcome must be stated in measurable terms. If possible,
consult with the patient and his family when establishing expected
outcomes. As the patient progresses, expected outcomes should be
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Preface xv
increasingly directed toward planning for discharge and follow-up
care.
Outcome statements should be tailored to your practice setting.
For example, in the intensive care unit you may focus on maintain-
ing hemodynamic stability, whereas on a rehabilitation unit you
would focus on maximizing the patient’s independence and prevent-
ing complications.
When writing expected outcomes in your care plan, always start
with a specific action verb that focuses on the patient’s behavior. By
telling your reader how the patient should look, walk, eat, drink,
turn, cough, speak, or stand, for example, you give a clear picture
of how to evaluate progress.
The expected outcomes in the Sparks and Taylor’s Nursing Diagnosis
Pocket Guide all start with the phrase: “The patient will...” and list
all the appropriate outcomes. You need to choose which ones are
needed for this patient. You will have to specify which person the
goals refer to when family, friends, or others are directly concerned.
The Expected Outcome section is followed by selected outcomes
from the Nursing Outcomes Classification (NOC) list.
Understanding NOC
The NOC is a standardized language of patient–client outcomes
that was developed by a nursing research team at the University of
Iowa. It contains 330 outcomes organized into 29 classes and seven
domains. Each outcome has a definition, a list of measurable indica-
tors, and references. The outcomes are research-based, and studies
are ongoing to evaluate their reliability, validity, and sensitivity. More
information about NOC can be found at the Center for Nursing
Classification and Clinical Effectiveness (www.nursing.uiowa.edu/cnc).
Planning
The nursing care plan refers to a written plan of action designed to
help you deliver quality patient care. It includes relevant nursing
diagnoses, expected outcomes, and nursing interventions. Keep in
mind that the care plan usually forms a permanent part of the
patient’s health record and will be used by other members of the
nursing team. The care plan may be integrated into an interdiscipli-
nary plan for the patient. In this instance, clear guidelines should
outline the role of each member of the healthcare team in providing
care.
A written care plan gives direction by showing colleagues the
goals you have set for the patient and giving clear instructions
for helping achieve them. If the patient is discharged from your
healthcare facility to another, your care plan can help ease this
transition.
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xvi Preface

Selecting appropriate nursing actions (interventions): Next, you’ll

select one or more nursing interventions to achieve each of the
expected outcomes identified for the patient. For example, if one
expected outcome statement reads “The patient will transfer to chair
with assistance,” the appropriate nursing interventions include plac-
ing the wheelchair facing the foot of the bed and assisting the
patient to stand and pivot to the chair. If another expected outcome
statement reads “The patient will express feelings related to recent
injury,” appropriate interventions might include spending time with
the patient each shift, conveying an open and nonjudgmental
attitude, and asking open-ended questions. Interventions used in the
Sparks and Taylor’s Nursing Diagnosis Pocket Guide are organized
according to the ICNP types (Description of NNN Taxonomy of
Nursing Practice and ICNP, 2005). Because all of your activities are
based on assessment data, “Determine” is listed first. The interven-
tion types will appear in the following order: Determine, Perform,
Inform, Attend, and Manage. To provide comprehensive care, con-
sider each of the intervention types carefully in your selection.
Reviewing the second part of the nursing diagnosis statement (the
part describing etiologic factors) may help guide your choice of
nursing interventions. For example, for the nursing diagnosis
“Impaired individual resistance related to poor impulse control,”
you would determine the best nursing interventions for learning
techniques to manage behavior. Try to think creatively during this
step in the nursing process. It’s an opportunity to describe exactly
what you and your patient would like to have happen and to estab-
lish the criteria against which you’ll judge further nursing actions.
The planning phase culminates when you write the care plan and
document the nursing diagnoses, expected outcomes, and nursing
interventions. Write your care plan in concise, specific terms so that
other healthcare team members can follow it. Keep in mind that
because the patient’s problems and needs will change, you’ll have to
review your care plan frequently and modify it when necessary.
Implementation
During this phase, you put your care plan into action. Implementa-
tion encompasses all nursing interventions directed toward solving
the patient’s nursing problems and meeting healthcare needs. While
you coordinate implementation, you also seek help from other care-
givers, the patient, and the patient’s family.
Implementation requires some (or all) of the following types of
interventions:
■ Determine: assessing and monitoring (e.g., recording vital signs)
■ Perform: providing care
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Preface xvii
■ Inform: teaching and counseling
■ Attend: making the patient more comfortable, giving emotional
support
■ Manage: referring the patient to appropriate agencies or
services
Although it may be brief or narrowly focused, reassessment should
confirm that the planned interventions remain appropriate.
Implementation isn’t complete until you’ve documented each
intervention, the time it occurred, the patient’s response, and any
other pertinent information. Make sure each entry relates to a
nursing diagnosis. Remember that any action not documented
may be overlooked during quality assurance monitoring or evalua-
tion of care. Another good reason for thorough documentation: It
offers a way for you to take rightful credit for your contribution
in helping a patient achieve the highest possible level of wellness.
After all, nurses use a unique and worthwhile combination of
interpersonal, intellectual, and technical skills when providing
care.

Understanding Nursing Interventions Classification

The Nursing Interventions Classification (NIC) is a standardized lan-
guage of treatments that was developed by a nursing research team
at the University of Iowa. It contains 514 interventions organized
into 30 classes and seven domains.
Each intervention has a definition, a list of detailed activities, and
references. The interventions are research-based and studies are ongo-
ing to evaluate the effectiveness and cost of nursing treatments. More
information about NIC can be found at the Center for Nursing Clas-
sification and Clinical Effectiveness (www.nursing.uiowa.edu/cnc).

Evaluation
In this phase of the nursing process, you assess the effectiveness of
the care plan by answering such questions as:
■ How has the patient progressed in terms of the plan’s projected
outcomes?
■ Does the patient have new needs?
■ Does the care plan need to be revised?
Evaluation also helps you determine whether the patient received
high-quality care from the nursing staff and the healthcare facility.
Your facility bases its own nursing quality assurance system on nurs-
ing evaluations.
Include the patient, family members, and other healthcare profes-
sionals in the evaluation. Then, follow the following steps:
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xviii Preface

■ Select evaluation criteria. The care plan’s projected outcomes—the

desired effects of nursing interventions—form the basis for evalu-
ation.
■ Compare the patient’s response with the evaluation criteria. Did the
patient respond as expected? If not, the care plan may need revision.
■ Analyze your findings. If your plan wasn’t effective, determine
why. You may conclude, for example, that several nursing diag-
noses were inaccurate.
■ Modify the care plan. Make revisions (e.g., change inaccurate
nursing diagnoses) and implement the new plan.
■ Reevaluate. Like all steps in the nursing process, evaluation is
ongoing. Continue to assess, plan, implement, and evaluate for as
long as you care for the patient.

DESCRIPTION OF NNN TAXONOMY OF NURSING

PRACTICE AND ICNP
Two organizing frameworks are used in the Sparks and Taylor’s Nurs-
ing Diagnosis Pocket Guide: The NNN Taxonomy of Nursing Prac-
tice and intervention terms from the International Classification of
Nursing Practice. Each of the frameworks is described in this section.
We recommend that you get more information about these from the
references cited.
NNN Taxonomy of Nursing Practice
The NNN Taxonomy of Nursing Practice (NNNTNP) consists of
nursing diagnoses, nursing interventions, and nursing outcomes
developed as the result of an invitational conference funded by
the National Library of Medicine in 2001 (Dochterman & Jones,
2003). Leaders in nursing language development from NANDA-I
for nursing diagnoses, the Center for Nursing Classification
and Clinical Effectiveness at the University of Iowa for nursing
outcomes and nursing interventions, and selected other experts
convened to develop a common unifying taxonomy to further the
development, testing, and refinement of nursing language. Results
of their efforts were published in Unifying Nursing Languages: The
Harmonization of NANDA, NIC, and NOC (Dochterman & Jones,
2003) and NANDA International Nursing Diagnoses: Definitions
and Classification 2003–2004 (Ralph, Craft-Rosenberg, Herdman,
& Lavin, 2003). Since that time the NANDA Taxonomy Committee
has placed new diagnoses in the taxonomy (Herdman, 2009).
The NNNTNP has four domains and 28 classes. The domains,
classes, and their definitions are depicted in Appendix B. Assess-
ment parameters based on the taxonomy were developed for the
Sparks and Taylor’s Nursing Diagnosis Pocket Guide.
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Preface xix
International Classification for Nursing Practice
There has been universal agreement among nurses about the impor-
tance of recognizing our practice parameters since the time of Flo-
rence Nightingale. A resolution to establish an International Classifi-
cation for Nursing Practice (ICNP®) was passed by the International
Council of Nurses (ICN) in 1989. The components of the ICNP®
describe the elements of nursing practice: “what nurses do relative
to certain human needs to produce certain results (nursing interven-
tions, diagnoses, and outcomes)” (ICN, 2005, p. 11).
The ICNP® is a unified nursing language system. It consists of a
multiaxial model intended to be a resource in developing
information systems for nursing globally. The 7 axes include Focus,
Judgment, Means, Action, Time, Location, and Client. The Sparks
and Taylor’s Nursing Diagnosis Pocket Guide uses the Action Axis
for the basis of selecting nursing interventions. The terms used are
Determine, Perform, Inform, Attend, and Manage. Each of these
terms is further defined in Appendix C. Each care plan in the Sparks
and Taylor’s Nursing Diagnosis Pocket Guide uses at least one of
each type of intervention and they are always listed in the order
above.
References
Dochterman, J. M., & Jones, D. A. (Eds.). (2003). Unifying nursing
languages: The Harmonization of NANDA, NIC, and NOC. Washington,
DC: NursesBooks.org.
Herdman, T. H. (2009). NANDA International nursing diagnoses: Definitions
and classification 2009–2011. West Sussex, UK: Wiley-Blackwell.
International Council of Nurses. (2005). International classification for nursing
practice. Geneva, Switzerland: Author.
Ralph, S. S., Craft-Rosenberg, M., Herdman, T. H., & Lavin, M. A., (2003).
NANDA Nursing Diagnoses & Classification. Philadelphia: NANDA Inter-
national.
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ACKNOWLEDGMENTS

We would like to express our sincere appreciation to the nurses who

contributed to the Nursing Diagnosis Pocket Guide. Their expertise
and commitment to quality patient care made this work possible.
We are also grateful to Helene Caprari and Jean Rodenberger from
Lippincott Williams & Wilkins for their assistance and enthusiastic
support of our work.
Finally, we dedicate this book to nursing students and clinicians
who are striving to provide quality care in today’s challenging
healthcare arena.

Sheila Sparks Ralph, RN, PhD, FAAN

Cynthia M. Taylor, RN, MS

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CONTENTS

PREFACE

Guidelines for Using Sparks and Taylor’s Nursing Diagnosis

Pocket Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Nursing Process Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Description of NNN Taxonomy of Nursing Practice

and ICNP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii

PA R T 1
Nursing Diagnoses Care Plans . . . . . . . . . . . . . . . . . . . . . . . . . 1

PA R T 2
Selected Nursing Diagnoses by Medical Diagnosis . . . . . . . . . 417

APPENDICES
APPENDIX A ■ Assessment Parameters© Based on
Taxonomy of Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . 458

APPENDIX B ■ Taxonomy of Nursing Practice: A Common

Unified Structure for Nursing Language . . . . . . . . . . . . . . . . 468

APPENDIX C ■ Action Intervention Types . . . . . . . . . . . . . . . 470

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471

xxiii
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PA R T O N E

Nursing Diagnoses
Care Plans

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• INEFFECTIVE ACTIVITY PLANNING

DEFINITION
Inability to prepare for a set of actions fixed in time and under
certain conditions
DEFINING CHARACTERISTICS
• Verbalization of fear toward a task to be undertaken
• Verbalization of worries toward a task to be undertaken
• Excessive anxieties toward a task to be undertaken
• Failure pattern of behavior
• Procrastination
• Unmet goals for chosen activity
• Lack of sequential organization
• Lack of plan
RELATED FACTORS
• Lack of family support • Hedonism
• Lack of friend support • Compromised ability to
• Unrealistic perception of events process information
• Defensive flight behavior when
faced with proposed solution
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Behavior • Roles/relationships
• Communication • Self-perception
EXPECTED OUTCOMES
The patient will
• Demonstrate improved self-confidence to accomplish tasks.
• Demonstrate improved concentration in task planning and execution.
• Minimize procrastination.
• Articulate personal goals for activity planning and completion.
• Verbalize diminished fear and anxiety concerning task planning
and execution.
SUGGESTED NOC OUTCOMES
Cognition; Cognition Orientation; Concentration; Decision-Making;
Information Processing; Memory
INTERVENTIONS AND RATIONALES
Determine: Assess patient’s concerns related to activity planning and
execution to be able to suggest strategies to overcome challenges.
Perform: Model effective techniques for planning and executing
activities. Patients who are challenged by planning and executing
activities often find it helpful to observe practical approaches instead
of solely hearing theoretical information.
Inform: Teach behavior management strategies to help the person
minimize fears of failure.
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Attend: Praise successes in any steps of planning or executing activi-
ties; positive reinforcement enhances self-confidence.
Manage: Refer or comanage with behavioral specialists. Colleagues
in related disciplines bring valuable additional perspectives to these
complex clinical situations.
SUGGESTED NIC INTERVENTIONS
Anxiety Reduction; Behavior Management; Behavior Modification;
Calming Technique; Memory Training; Planning Assistance;
Sequence Guidance
Reference
Adler, D. A., McLaughlin, T. J., Rogers, W. H., Chang, H., Lapitsky, L., &
Lerner, D. (2006). Job performance deficits due to depression. American
Journal of Psychiatry, 163, 1569–1576.
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• ACTIVITY INTOLERANCE
DEFINITION
Insufficient physiological or psychological energy to endure or com-
plete required or desired daily activities
DEFINING CHARACTERISTICS
• Abnormal blood pressure and heart rate response to activity
• Electrocardiographic changes reflecting arrhythmias and/or ischemia
• Exertional discomfort and/or dyspnea
• Verbal report of fatigue and/or weakness
RELATED FACTORS
• Bed rest • Immobility
• Generalized weakness • Sedentary lifestyle
• Imbalance between oxygen
supply and demand
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Respiratory function
EXPECTED OUTCOMES
The patient will
• Regain and maintain muscle mass and strength.
• Maintain maximum joint range of motion (ROM).
• Perform isometric exercises.
• Help perform self-care activities.
• Maintain heart rate, rhythm, and blood pressure within expected
range during periods of activity.
• State understanding of and willingness to cooperate in maximizing
the activity level.
• Perform self-care activities to tolerance level.
SUGGESTED NOC OUTCOMES
Activity Tolerance; Endurance; Energy Conservation; Self-Care:
Activities of Daily Living (ADLs); Self-Care: Instrumental Activities
of Daily Living (IADLs)
INTERVENTIONS AND RATIONALES
Determine: Monitor physiologic responses to increased activity level,
including respirations, heart rate and rhythm, and blood pressure, to
ensure that these return to normal within 2–5 min after stopping
exercise.
Perform: Perform active or passive ROM exercises to all extremities
every 2–4 hr. These exercises foster muscle strength and tone, main-
tain joint mobility, and prevent contractures.
Turn and reposition patient at least every 2 hr. Establish a turning
schedule for the dependent patient. Post schedule at bedside and
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monitor frequency. Turning and repositioning prevent skin
breakdown and improve lung expansion and prevent atelectasis.
Maintain proper body alignment at all times to avoid
contractures and maintain optimal musculoskeletal balance and
physiologic function.
Encourage active exercise: Provide a trapeze or other assistive
device whenever possible. Such devices simplify moving and turning
for many patients and allow them to strengthen some upper-body
muscles.
Inform: Teach about isometric exercises to allow patients to maintain
or increase muscle tone and joint mobility.
Teach caregivers to assist patients with ADLs in a way that maxi-
mizes patients’ potential. This enables caregivers to participate in
patients’ care and encourages them to support patients’
independence.
Attend: Provide emotional support and encouragement to help
improve patient’s self-concept and motivate patient to perform
ADLs.
Involve patient in planning and decision making. Having the abil-
ity to participate will encourage greater compliance with the plan
for activity.
Have patient perform ADLs. Begin slowly and increase daily, as
tolerated. Performing ADLs will assist patient to regain independence
and enhance self-esteem.
Manage: Refer to case manager/social worker to ensure that a home
assessment has been done and that whatever modifications were
needed to accommodate the patient’s level of mobility have been
made. Making adjustments in the home will allow the patient a
greater degree of independence in performing ADLs, allowing better
conservation of energy.
SUGGESTED NIC INTERVENTIONS
Activity Therapy; Ambulation; Body Mechanics Promotion; Energy
Management; Exercise Promotion: Strength Training; Exercise
Therapy: Balance, Joint Mobility, Muscle Control
Reference
Shin, Y., Yun, S., Jang, H., & Lim, J. (2006). A tailored program for the pro-
motion of physical exercise among Korean adults. Applied Nursing
Research, 19(2), 88–94.
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• RISK FOR ACTIVITY INTOLERANCE

DEFINITION
At risk for experiencing insufficient physiological or psychological
energy to endure or complete required or desired activity
RISK FACTORS
• Circulatory or respiratory • Inexperience with a particular
problems activity
• History of previous intolerance • Deconditioned status
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Respiratory function
EXPECTED OUTCOMES
The patient will
• Maintain muscle strength and joint ROM.
• Carry out isometric exercise regimen.
• Communicate understanding of rationale for maintaining activity
level.
• Avoid risk factors that may lead to activity intolerance.
• Perform self-care activities to tolerance level.
• Maintain blood pressure, pulse, and respiratory rate within
prescribed range during periods of activity (specify).
SUGGESTED NOC OUTCOMES
Activity Tolerance; Endurance; Energy Conservation; Self-Care:
ADLs; Self-Care: IADLs
INTERVENTIONS AND RATIONALES
Determine: Assess patient’s level of functioning using the functional
mobility scale to determine patient’s capabilities.
Assess patient’s physiologic response to increased activity (blood
pressure, respirations, heart rate, and rhythm). Monitoring vital
signs helps assess tolerance for increased exertion and activity.
Perform: Position patient to maintain proper body alignment. Use
assistive devices as needed to maintain joint function and prevent
musculoskeletal deformities.
Turn and position patient at least every 2 hr. Establish turning
schedule for the dependent patient. Post at bedside and monitor fre-
quency. Turning helps prevent skin breakdown by relieving pressure.
Unless contraindicated, perform ROM exercises every 2–4 hr.
Progress from passive to active, according to patient tolerance.
ROM exercises prevent joint contractures and muscular atrophy.
Encourage active movement by helping patient use trapeze or
other assistive devices to improve muscle tone and enhance self-
esteem.
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Inform: Teach patient how to perform isometric exercises to
maintain and improve muscle tone and joint mobility.
Teach patient, family member, or other caregiver skills such as
placing joints in proper body alignment or correct positioning to
maximize patient’s participation in self-care. Informed caregivers can
encourage patient to become more independent.
Teach patient symptoms of overexertion, such as dizziness, chest
pain, and dyspnea, to help him or her take responsibility for moni-
toring his or her own activity level.
Assist patient in carrying out self-care activities. Increase patient’s
participation in self-care, as tolerated, to foster independence and
improve mobility.
Attend: Encourage patient to become involved in planning care and
making decisions related to treatment. Participation in planning
enhances patient compliance.
Explain rationale for maintaining or improving activity level. Dis-
cuss factors that increase the risk of activity intolerance. Education
helps patient avoid activity intolerance.
Encourage patient to carry out ADLs. Provide emotional support,
and offer positive feedback when the patient displays initiative.
Offering emotional support enhances patient’s self-esteem and moti-
vation.
Manage: Communicate patient’s level of functioning to all staff.
Communication among staff members ensures continuity of care and
enables patient to preserve the identified level of independence.
SUGGESTED NIC INTERVENTIONS
Activity Therapy; Ambulation; Body Mechanics Promotion; Energy
Management; Exercise Promotion: Strength Training; Exercise
Therapy: Balance, Joint Mobility, Muscle Control
Reference
Killey, B., & Watt, E. (2006, July). The effect of extra walking on the mobil-
ity, independence, and exercise self-efficacy of elderly patients: A pilot study.
Contemporary Nurse, 22(1), 120–133.
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• DEFICIENT DIVERSIONAL ACTIVITY

DEFINITION
Decreased stimulation from (or interest or engagement in)
recreational or leisure activities
DEFINING CHARACTERISTICS
• Usual hobbies are not performed in hospital setting.
• Patient states feelings of boredom or wishing for something to do.
RELATED FACTORS
• Environmental lack of diversional activity
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function • Physical status
• Emotional status • Respiratory function
• Neurocognition
EXPECTED OUTCOMES
The patient will
• Express interest in using leisure time meaningfully.
• Express interest and participate in activities that can be provided
(e.g., watch selected television program, listen to radio or music
daily).
• Report satisfaction with use of leisure time.
• Modify environment to provide maximum stimulation (e.g.,
hanging posters or cards and moving bed next to a window).
SUGGESTED NOC OUTCOMES
Leisure Participation; Motivation; Social Involvement
INTERVENTIONS AND RATIONALES
Determine: Assess leisure activity preferences. Identify the type of music
patient prefers; seek help from family and hospital resources to provide
selected music daily that relieves boredom and stimulates interest.
Perform: Provide supplies and set time to indulge in hobby. Obtain
radio, television, or crochet hook and yarn (if desired). Allow
patient to (if TV or radio) select programs. Communicate patient’s
desires to coworkers (e.g., Turn on television set at _____ [time]
to _____ [channel]. Give crochet hook and yarn to patient daily
at _____ [time]). Specifying time for activity indicates its value.
Avoid scheduling activities during leisure time, which is integral
to quality of life.
Ask volunteers (friends, family, or hospital volunteer) to read
newspapers, books, or magazines to patient at specific times.
Personal contact helps alleviate boredom.
Engage patient in conversation while carrying out routine care.
Discuss patient’s favorite topics as much as possible. Conversation
conveys caring and recognition of patient’s worth.
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Provide talking books or I-Pod if available. These provide low-
effort sources of enjoyment for bedridden patient.
Obtain an adapter for television to provide captions for hearing-
impaired patient.
Provide plants for the patient to tend to. Caring for live plants
may stimulate interest.
Change scenery when possible; for example, take the patient out-
side in a wheelchair to help reduce boredom.
Attend: Encourage discussion of previously enjoyed hobbies,
interests, or skills to direct planning of new activities. Suggest per-
forming an activity helpful to others or otherwise productive to pro-
mote interest.
Encourage patient’s family or caregiver to bring personal articles
(posters, cards, and pictures) to help make environment more stimu-
lating (the patient may respond better to objects with personal
meaning).
Manage: Make referral to recreational, occupational, or physical
therapist for consultation on adaptive equipment to carry out
desired activity; arrange for therapy sessions. Adaptive equipment
allows patient to continue enjoying activities or may stimulate inter-
est in new activities.
SUGGESTED NIC INTERVENTIONS
Activity Therapy; Animal-Assisted Therapy; Art Therapy; Recreation
Therapy
Reference
Wheeler, S. L., & Houston, K. (2005, March–April). The role of diversional
activities in the general medical hospital setting. Holistic Nursing Practice,
19(2), 87–89.
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• INEFFECTIVE AIRWAY CLEARANCE

DEFINITION
Inability to clear secretions or obstructions from the respiratory tract
to maintain a clear airway
DEFINING CHARACTERISTICS
• Adventitious breath sounds, • Difficulty vocalizing
such as crackles, rhonchi, and • Dyspnea
wheezes • Ineffective or absent cough
• Changes in respiratory rate • Orthopnea
and rhythm • Restlessness
• Cyanosis • Sputum production
• Diminished breath sounds • Wide-eyed
RELATED FACTORS
• Environmental: second-hand smoke, smoke inhalation, smoking
• Physiological: allergic airways, asthma, chronic obstructive
pulmonary disease, infection, neuromuscular dysfunction, and
hyperplasia of the bronchial walls
• Obstructed airway: airway spasm, excessive mucus, exudate in the
alveoli, foreign body in airway, presence of artificial airway,
retained secretions, secretions in the bronchi
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Respiratory function
EXPECTED OUTCOMES
The patient will
• Maintain patent airway.
• Have no adventitious breath sounds.
• Have a normal chest x-ray.
• Have an oxygen level in normal range.
• Breathe deeply and cough to remove secretions.
• Expectorate sputum.
• Demonstrate controlled coughing techniques.
• Have adequate ventilation.
• Demonstrate skill in conserving energy while attempting to clear
airway.
• State understanding of changes needed to diminish oxygen demands.
SUGGESTED NOC OUTCOMES
Aspiration Prevention; Respiratory Status: Airway Patency; Respira-
tory Status: Ventilation
INTERVENTIONS AND RATIONALES
Determine: Assess respiratory status at least every 4 hr or according
to established standards. Obstruction in the airway leads to atelectasis,
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pneumonia, or respiratory failure. Monitor arterial blood gases val-
ues and hemoglobin levels to assess oxygenation and ventilatory
status. Report deviations from baseline levels; oxygen saturation
should be higher than 90%.
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.
Perform: 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.
Inform: Teach patient an easily performed cough technique to clear
airway without fatigue.
Attend: 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 Fowler’s position or sitting on side of bed. Such posi-
tions promote chest expansion and ventilation of basilar lung fields.
Encourage adequate water intake (3–4 qt [3–4 L/day]) to ensure
optimal hydration and loosening of secretions, unless contraindicated.
Encourage sputum expectoration to remove pathogens and prevent
spread of infection. Provide tissues and paper bags for hygienic
disposal.
Manage: 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.
SUGGESTED NIC INTERVENTIONS
Airway Management; Aspiration Precautions; Cough Enhancement;
Oxygen Therapy; Respiratory Monitoring; Ventilation Assistance
Reference
Cigna, J. A., & Turner-Cigna, L. M. (2005, September). Rehabilitation for the
home care patient with COPD. Home Healthcare Nurse, 23(9), 578–584.
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• LATEX ALLERGY RESPONSE

DEFINITION
A hypersensitive reaction to natural latex rubber products
DEFINING CHARACTERISTICS
Immediate reactions (1 hr of exposure) can be life-threatening
• Contact urticaria progressing to generalized symptoms
• Edema of the lips, eyelids, sclera, tongue, uvula, and/or throat
• Shortness of breath or tightness in the chest, wheezing or
bronchospasm leading to respiratory arrest
• Hypotension, syncope, and cardiac arrest
• Abdominal pain or nausea
• Complaints of increasing body warmth and/or restlessness
• Erythema, itching, and/or tearing of the eyes and/or face
• Nasal congestion, erythema, itching, and/or rhinorrhea
Type 1V Reactions (1 hr after exposure)
• Generalized discomfort
• Eczema, irritation, and/or redness
RELATED FACTORS
• Absent immune system response
• Hypersensitivity to natural latex rubber
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Respiratory function
• Tissue integrity
EXPECTED OUTCOMES
The patient will
• Regain vital signs, respiratory status, and laboratory values.
• 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.
SUGGESTED NOC OUTCOMES
Comfort Level; Immune Hypersensitivity Response; Knowledge:
Infection Control; Tissue Integrity: Skin and Mucous Membrane
INTERVENTIONS AND RATIONALES
Determine: 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.
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13
Remove all latex products from immediate proximity of patient and
staff treating the patient to prevent inadvertent use of products by
staff or patient, increasing the risk for contact and allergic reaction.
Perform: 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.
Inform: 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.
Attend: Provide emotional support and encouragement to help
improve patient’s 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.
Manage: 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 patient’s
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 patient’s permission, communicate with employee
health department and discuss patient’s need to avoid contact with
latex products to prevent further contamination.
SUGGESTED NIC INTERVENTIONS
Allergy Management; Anaphylaxis Management; Environmental Risk
Protection; Latex Precautions; Risk Identification; Teaching: Individual
Reference
Crippa, M., et al. (2006, August). 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), 550–557.
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• RISK FOR LATEX ALLERGY RESPONSE

DEFINITION
Risk of hypersensitivity to natural latex rubber products
RISK FACTORS
• Spina bifida • Professions that involve daily
• Frequent medical or occupa- exposure to latex
tional exposure to latex • Conditions associated with
• History of atopy continuous intermittent
• History of food allergies, such catheterizations
as allergies to bananas, kiwi, • Allergy to poinsettia plants
avocados, chestnuts, or • History of reaction to latex
pineapple • History of allergies and asthma
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Nutrition
• Tissue integrity
EXPECTED OUTCOMES
The patient will
• Regain normal vital signs, respiratory status, and laboratory values.
• Exhibit moist, clear skin that is free of erythema, edema, itching,
urticaria, and breakdown.
• Express awareness of allergic response to latex-containing products.
SUGGESTED NOC OUTCOMES
Allergy Response: Localized; Immune Hypersensitivity Response;
Risk Control
INTERVENTIONS AND RATIONALES
Determine: 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 patient’s 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.
Perform: 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 administration of treatment.
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15
Inform: 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. Prevention
is the foundation of treatment of latex allergies.
Educate patient and his or her family about importance of seeking
immediate medical treatment of allergic reactions to foster timely
intervention.
Attend: 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.
Manage: 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 patient’s permission, communicate with
employee health department and discuss patient’s need to avoid con-
tact with latex products to prevent further contamination.
SUGGESTED NIC INTERVENTIONS
Allergy Management; Anaphylaxis Management; Environmental Risk
Protection; Latex Precautions; Risk Identification; Teaching: Individual
Reference
Crippa, M., et al. (2006, August). 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), 550–557.
LWBK392-c01_p01-47.qxd 11/17/09 7:37 PM Page 16 Aptara Inc

• ANXIETY
DEFINITION
Vague uneasy feeling of discomfort or dread accompanied by an
autonomic response (the source often non-specific or unknown to
the individual); a feeling of apprehension caused by anticipation of
danger. It is an alerting signal that warns of impeding danger and
enables the individual to take measures to deal with threat
DEFINING CHARACTERISTICS
• Behavioral: 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: Anorexia, cardiovascular excitation, diarrhea, facial
flushing, increased blood pressure and/or pulse, dilated pupils
• Parasympathetic: Abdominal pain, decreased blood pressure and/or
pulse, fatigue, nausea, urinary frequency, hesitancy, or urgency
• Cognitive: Blocking of thoughts, confusion, impaired attention,
forgetfulness, tendency to blame others
RELATED FACTORS
• Threat to self-concept • Role change
• Situational crises • Familial association
• Maturational crises • Substance abuse
• Stress • Unconscious conflict about
• Unmet needs goals or values
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Communication • Emotional status
• Coping • Psychological status
EXPECTED OUTCOMES
The patient will
• Identify factors that elicit anxious behaviors.
• 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.
SUGGESTED NOC OUTCOMES
Anxiety Level; Coping; Grief Resolution; Hyperactivity Level;
Impulse Self-Control; Psychosocial Adjustment: Life Change; Social
Interaction Skills; Stress Level; Symptom Control
INTERVENTIONS AND RATIONALES
Determine: Listen attentively to patient to determine exactly what he or
she is feeling. Listening on the part of the nurse helps the patient
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17
identify anxious behaviors more easily and discover the source of
anxiety.
Assess types of activities that help reduce patient’s stress levels.
Monitor physiologic responses including respirations, heart rate
and rhythm, and blood pressure.
Perform: Reduce environmental stressors (including people), and
remain with patient during severe anxiety. Anxiety often results from
lack of trust in the environment and/or fear of being alone.
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.
Inform: 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.
Attend: 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
patient’s 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 patient’s cognitive abilities.
Manage: Refer to case manager/social worker or professional mental
health caretaker to provide mental health assistance. Encouraging
the use of community mental health resources reinforces the fact
that anxiety reduction is a long-term process.
SUGGESTED NIC INTERVENTIONS
Anger Control Assistance; Anticipatory Guidance; Anxiety
Reduction; Behavior Modification: Social Skills; Calming Technique;
Coping Enhancement; Simple Guided Imagery; Support Group
Reference
Buffin, M. D., et al. (2006, September). A music intervention to reduce anxi-
ety before vascular angiography procedures. Journal of Vascular Nursing,
24(3), 68–73.
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• DEATH ANXIETY
DEFINITION
Vague uneasy feeling of discomfort or dread generated by
perceptions of a real or imagined threat to one’s existence
DEFINING CHARACTERISTICS
• Worry about the impact of one’s death on significant others
• Powerlessness over issues related to dying
• Fear of loss of physical and mental abilities when dying
• Total loss of control over aspects of one’s own death
• Worry about being the cause of others’ suffering or grief
• Fear of leaving family alone after death
• Fear of developing a terminal illness
RELATED FACTORS
• Anticipating the impact of • Uncertainty about life after
death on others death
• Anticipating suffering • Uncertainty about the
• Experiencing the dying process existence of a higher power
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Behavior
• Communication
• Emotional status
EXPECTED OUTCOMES
The patient will
• Identify time alone and time needed with others.
• Communicate important thoughts and feelings to family members.
• Obtain the level of spiritual support desired.
• Use available support systems.
• Perform self-care activities to tolerance level.
• Express feelings of comfort and peacefulness.
SUGGESTED NOC OUTCOMES
Acceptance: Health Status; Anxiety Level; Depression Level; Digni-
fied Life Closure; Fear Self-Control; Hope
INTERVENTIONS AND RATIONALES
Determine: 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 patient’s 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.
Perform: Administer medication to relieve pain and provide comfort
as required. Medicating at an appropriate level does much to relieve
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19
pain and often helps the dying person maintain greater feeling of
self-control.
Turn and reposition patient at least every 2 hr. Turning and repo-
sitioning prevent skin breakdown, improve lung expansion, and pre-
vent atelectasis. Establish a turning schedule for the dependent
patient. 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 patient’s
preferences. These measures promote relaxation and feelings of well
being.
Inform: Teach family members ways of discerning unobtrusively what
the patient’s 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 patient’s rights to choose. This enables caregivers to
participate in patient’s care while supporting patient’s independence.
Attend: Help family identify, discuss, and resolve issues related to
patient’s 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 patient’s 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.
Manage: 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 patient’s preference, to show respect for the patient’s
beliefs and provide spiritual care.
SUGGESTED NIC INTERVENTIONS
Active Listening; Anticipatory Guidance; Family Involvement Promo-
tion; Pain Management; Spiritual Support; Touch
Reference
Duggleby, W., & Berry, P. (2005, August). Transitions and shifting goals of
care for palliative patients and their families. Clinical Journal of Oncology
Nursing, 9(4), 425–448.
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• RISK FOR ASPIRATION

DEFINITION
At risk for entry of gastrointestinal (GI) secretions, oropharyngeal
secretions, solids, or fluids into the tracheobronchial passages
RISK FACTORS
• Decreased GI motility • Medication administration
• Delayed gastric emptying • Reduced level of consciousness
• Depressed cough and gag (LOC)
reflexes • Situations hindering elevation
• Feeding or GI tubes of upper body
• Impaired swallowing • Surgery or trauma to face,
• Incompetent lower esophageal mouth, or neck
sphincter • Tracheotomy or endotracheal
• Increased gastric residual or tube
intragastric pressure • Wired jaws
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Elimination
• Neurocognition
• Respiratory function
EXPECTED OUTCOMES
The patients will
• Have clear breath sounds on auscultation.
• 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.
SUGGESTED NOC OUTCOMES
Aspiration Prevention; Knowledge: Treatment Procedure(s); Respira-
tory Status: Ventilation; Risk Control; Swallowing Status
INTERVENTIONS AND RATIONALES
Determine: 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 Fowler’s posi-
tion to aid breathing.
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21
Recognize the progression of airway compromise and report your
findings to detect complications early.
Perform: Help patient turn, cough, and deep breathe every 2–4 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.
Inform: 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.
Attend: Encourage fluids within prescribed restrictions. Provide
humidification, as ordered (such as a nebulizer). Fluids and humidifi-
cation liquefy secretions.
SUGGESTED NIC INTERVENTIONS
Airway Management; Aspiration Precautions; Feeding; Positioning;
Respiratory Monitoring; Vital Signs Monitoring; Vomiting Manage-
ment
Reference
Thoyre, S. M., et al. (2005, May–June). The early feeding skills assessment for
preterm infants. Neonatal Network, 24(3), 7–16.
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• RISK FOR IMPAIRED PARENT–CHILD

ATTACHMENT
DEFINITION
Disruption of the interactive process between parent/significant other
and child/infant that fosters the development of a protective and
nurturing reciprocal relationship
RISK FACTORS
• Anxiety over parental roles • Inability of parents to meet
• Illness in infant that doesn’t their personal needs
allow initiation of interaction • Lack of privacy, physical barri-
with parents ers, separation, substance abuse
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Communication • Role/relationships
• Coping • Sleep and rest
• Emotional status • Values and beliefs
EXPECTED OUTCOMES
The parents will
• Initiate positive interaction with child.
• Hold child and talk to him or her.
• Express confidence in their ability to respond to child’s 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.
SUGGESTED NOC OUTCOMES
Parenting Performance; Role Performance
INTERVENTIONS AND RATIONALES
Determine: 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; child’s neurological and sensory
status, including vision and hearing; sleep patterns of parents and
child. This information will assist in establishing appropriate inter-
ventions.
Perform: 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.
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23
Provide physical care to child when appropriate. This may be to
demonstrate to the family the appropriate way to perform ADLs.
Inform: 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.
Attend: 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.
Manage: Provide the name of professionals and/or agencies where
parents can receive assistance to continue developing attachment
skills and/or ongoing support. Refer to case manager/social worker
to assess the home environment to enable the parents to make mod-
ifications that will be needed.
SUGGESTED NIC INTERVENTIONS
Abuse Protection Support: Child; Child Coping Enhancement; Devel-
opmental Enhancement; Parenting
Reference
Delaney, K. R. (2006, November). Learning to observe relationships and cop-
ing. Journal of Child and Adolescent Psychiatric Nursing, 19(4), 194–202.
LWBK392-c01_p01-47.qxd 11/17/09 7:37 PM Page 24 Aptara Inc

• AUTONOMIC DYSREFLEXIA
DEFINITION
Life-threatening, uninhibited sympathetic response of nervous system
to noxious stimulus after spinal cord injury at T7 or above
DEFINING CHARACTERISTICS
• Paroxysmal hypertension (sud- • Lack of caregiver and patient
den periodic elevated blood pres- knowledge
sure, systolic over 140 mm Hg • Chilling
and diastolic over 90 mm Hg) • Conjunctival congestion
• Bradycardia or tachycardia • Horner’s syndrome (contracted
(pulse less than 60 or more pupils, partial ptosis, enoph-
than 100 beats/min) Diaphore- thalmos, loss of sweating on
sis above injury affected side of face
• Red splotches (vasodilation) [sometimes])
on skin above injury • Paresthesia
• Pallor below injury • Pilomotor reflex
• Diffuse headache not confined • Blurred vision
to any nerve distribution area • Chest pain
• Bladder distention • Metallic taste
• Bowel distention • Nasal congestion
RELATED FACTORS
• Bladder distension • Deficient patient knowledge
• Bowel distension • Skin irritation
• Deficient caregiver knowledge
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function • Neurocognition
• Elimination • Risk management
EXPECTED OUTCOMES
The patient will
• Have cause of dysreflexia identified and corrected.
• Experience cardiovascular stability as evidenced by ____ systolic
range, ____ diastolic range, and _____ heart rate range.
• 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.
Other documents randomly have
different content
carried him from me down the field. On another
occasion I found myself between two knights who were
vying with each other to see who could strike me down
the first. I warded off their fury with what skill I had
until one of them was stricken from behind by a hand
that was as sudden as it was sure. The other I struck a
fortunate blow for I stunned him so hard that he rode
off the field to nurse his wound.

Late in the afternoon I was knocked from my horse, but

had wit enough left to scramble again into the saddle. I
was tossed here and there with driving force as the
battle swayed this way or that. My helmet was dented in
from the swing of a mace. My right arm near the
shoulder was numbed from over action and from a
sword beat that had landed on it.

But I came out of it with a whole skin and no bones

broken which was enough to make me thankful. As for
Charles of Gramont, I never laid eyes on him from the
outbreak of the fight. It was long after dark when I
found him inquiring among the troops who had been
near me if they knew if I had fallen. When he saw me
he threw out his hands. I must confess that a kind of
weakness came over me at the sight of my companion.
As though we were children we flew to each other’s
arms and cried like babies.

Then came the parting. It is true that the Black Prince 297
asked us to go along with him to Bordeaux to stay there
for the winter with the promise that he would take us
with him in the early spring on a campaign into Spain.
For a while we were divided two ways, but the longing
for home won in the end. Charles was anxious to get
home to put his house in order and (now that he was
left alone) to give care to the estate. As for me, I knew
that my brother, André, was lying awake far into the
nights, wondering what had become of me and whether
he would ever lay eyes on me again. Besides the fall
was coming on (it was already September) and I knew
the streams were full of fish and that the woods about
my home were thick with game.

You should have been present in our village when we

rode in. The country folk (they had been warned of our
coming beforehand) gathered from the fields. They
wore their best of everything and I can tell you that
their simple dress of velvet jerkins, their breeches of
leather, their hats with feathers in them, never looked
more welcome or more pleasing to my eye. You would
have thought it was some great holiday for the country
players were assembled. Jugglers and sleight-of-hand
artists and to my surprise the man with the birds whom
I had met on my journey out, came to greet us and to
display the best of their wares. And in the midst of all
the merrymaking it was my brother, André, who was the
proudest man alive. He never left my side and when my
name was mentioned, he boasted of my courage and
my strength of will that led me on a quest through the
heart of our enemies, till I had to turn my face away in
shame.

We settled down to the quiet life of the countryside. The 298

first snows of winter came and the fields about the
house were covered white, when a courier rode into the
yard. He was from Bordeaux on his way to the great city
of Paris to negotiate for peace and a return of the King.
He had been commanded, he said, to deliver a letter
from his master, the Black Prince.

With my brother André looking over my shoulder, I

broke the seal and read,
 At Bordeaux.
December

To Henri la Mar, the Norman,

My lad,

It has long been in my minde to write you a lettre

of thanks for the helpfull deed you performed. Your
name shall always be enscrolled in my memorie
and I shall think of you as a brave and worthie
servant of your countrie. If there come a time when
you wish to try your hande as a soldier of England,
you will but come to me.

Your timely warning saved an army from

destruction. Not only that, it saved your land and
fireside from the greed of your enemies.

Edward.

Postscriptum.

It may be to your interest to learn that De Marsac

recovered from the blow I gave him when we
fought together on the highway. But he was slain
later at Poitiers.

That was all.

“Well, Henri,” said André, “that letter is worth while.” 299

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