Assess Notes: Nursing Assessment & Diagnostic Reasoning by Marjory Gordon PhD RN FAAN

By Marjory Gordon PhD RN FAAN

A DAVIS NOTES e-book! this convenient, pocket-sized consultant through Marjory Gordon makes use of sensible healthiness styles to aid your scholars collect the main appropriate evaluation info to figure out nursing diagnoses, and to choose the main applicable nursing interventions emphasizing the basic connection among diagnostic judgment and healing judgment.

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Ankle edema or rings unusually tight? ■ Oral mucous membranes: Color? Moistness? Lesions? ■ Teeth and gums: General appearance? Alignment of teeth? Dentures? Cavities? Missing teeth? ■ Actual weight and height? ■ Body mass index? See below. ■ Waist-to-hip ratio? See below. ■ Intravenous or other type of feeding (specify type)? NUTRI/ METABOLIC 04Gordan(F)-04 11/29/07 5:17 PM Page 30 NUTRI/ METABOLIC Food Pyramid Diagnostic Categories The following nursing diagnoses from the NANDA International Taxonomy II (2007) describe diagnostic judgments.

Complex functions of four supporting systems: cardiac, pulmonary, musculoskeletal, and neurological. 46 06Gordan(F)-06 11/29/07 5:16 PM Page 47 47 Individuals at Risk Some individuals are at increased risk for problems in this pattern. Be sensitive to cues when assessing individuals with any of the following characteristics: ■ Imbalance between cellular oxygen supply and demand, such as from cardiovascular or pulmonary conditions. ■ Long-term bedrest or wheelchair usage or deconditioning due to sedentary lifestyle.

Assessment Items History ■ ■ ■ ■ Problems in waste and garbage disposal? Adequate disposal of pet waste, both indoor and outdoor? Problems with flies, roaches, rodents, or indoor air pollution? Able to get adequately hot water for washing dishes and clothes? Examination ■ ■ ■ ■ Toilet facilities? Garbage disposal? Pet waste disposal? Indicators of risk for flies, roaches, rodents? Diagnostic Categories No family diagnoses have been identified in this pattern. Community Assessment In most countries of the world, there is heightened sensitivity to pollution of the air, soil, and water.

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