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Global: ^GMRD(124.2

Package: General Medical Record - Generator

Global: ^GMRD(124.2


Information

FileMan FileNo FileMan Filename Package
124.2 AGGREGATE TERM General Medical Record - Generator

Description

Directly Accessed By Routines, Total: 30

Package Total Routines
Nursing Service 30 EVALUATION DATE    NURCAS1    NURCCP1    NURCCP3    NURCCP4    NURCCPE    NURCCPU1    NURCCPU2
NURCCPU4    NURCCPU5    NURCES1    NURCEVE0    NURCEVE1    NURCEVE4    NURCEVP0    NURCPP0
NURCPP1    NURCPP2    NURCPP6    NURCPP9    NURCPPS1    NURCPPS2    NURCPPS3    NURCRL1
NURCRL4    NURCROP0    NURCROP1    ORDER INFO    TARGET DATE    ^NURSF(219.7    

Accessed By FileMan Db Calls, Total: 8

Package Total Routines
General Medical Record - Generator 8 GMRGED0    GMRGEDA    GMRGPRNT    GMRGTGI0    GMRGTGI2    GMRGTGIF    GMRGXAGC    GMRGXPST

Pointed To By FileMan Files, Total: 3

Package Total FileMan Files
General Medical Record - Generator 2 GMR TEXT(#124.3)[.01, #124.31(.01)]    AGGREGATE TERM(#124.2)[#124.21(.01)]    
Nursing Service 1 NURS CARE PLAN(#216.8)[#216.81(.01), #216.82(.02), #216.83(.03), #216.84(.02)]    

Pointer To FileMan Files, Total: 2

Package Total FileMan Files
General Medical Record - Generator 2 AGGREGATE TERM(#124.2)[#124.21(.01)]    TERM CLASSIFICATION(#124.25)[.04]    

Fields, Total: 18

Field # Name Loc Type Details
.01 NAME 0;1 FREE TEXT
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  K:X[""""!($A(X)=45) X I $D(X) K:$L(X)>60!($L(X)<3)!'(X'?1P.E!(X?1"[".E)!(X?1"<".E)) X
  • LAST EDITED:  DEC 06, 1990
  • HELP-PROMPT:  Answer must be 3-60 characters in length.
  • DESCRIPTION:  
    Text that composes the Aggregate Term
  • CROSS-REFERENCE:  124.2^B
    1)= S ^GMRD(124.2,"B",$E(X,1,30),DA)=""
    2)= K ^GMRD(124.2,"B",$E(X,1,30),DA)
    This is a regular cross-reference on the Name field.
  • CROSS-REFERENCE:  124.2^AA^MUMPS
    1)= D EN3^GMRGUT1
    2)= S GMRG=$S($D(^GMRD(124.2,DA,0)):^(0),1:""),GMRG(2)=$P(GMRG,"^",2),GMRG(3)=$P(GMRG,"^",3),GMRG(5)=$P(GMRG,"^",5) K:GMRG(2)'=""&(GMRG(3)'="")&(GMRG(5)'="") ^GMRD(124.2,"AA",GMRG(3),GMRG(2),X,GMRG(5),DA) K GMRG
    This cross-reference triggers data into the Node Identification field if its null, and sets a multiple cross-reference ("AA") over four fields. The fields used are the Name (.01), Type of Term (.02), Package (.03) and
    Node Identification (.05). The structure of the cross-reference is: ^GMRD(124.2,"AA",Package,Type_of_Term,Name,Node_Identification,DA)="".
  • CROSS-REFERENCE:  124.2^ATXTUP^MUMPS
    1)= S GMRGX("D")=1,GMRGX("F")=1 D EN6^GMRGUT2
    2)= S GMRGX("D")=0,GMRGX("F")=1 D EN6^GMRGUT2
    This field triggers in the new value of the Name field into the Child Text sub-field of the Children multiple for all entries that point to this entry.
  • CROSS-REFERENCE:  124.2^C^MUMPS
    1)= D EN4^GMRGUT3
    2)= D EN5^GMRGUT3
    This cross-reference has the format of a regular cross-reference, but the value used for the lookup is the uppercase version of the Name field. ^GMRD(124.2,"C",Uppercase_Name,DA)="" is the structure.
.02 TYPE OF TERM 0;2 SET
************************REQUIRED FIELD************************
  • '2' FOR FRAME;
  • '3' FOR TERM;

  • LAST EDITED:  MAY 17, 1989
  • DESCRIPTION:  
    Set of codes that identifies the basic types of text.
  • SCREEN:  S DIC("S")="D EN4^GMRGUT1"
  • EXPLANATION:  You cannot make a term out of an Aggregate term with children.
  • CROSS-REFERENCE:  124.2^ATY
    1)= S ^GMRD(124.2,"ATY",$E(X,1,30),DA)=""
    2)= K ^GMRD(124.2,"ATY",$E(X,1,30),DA)
    This is a regular cross-reference on the Type of Term field.
  • CROSS-REFERENCE:  124.2^AA02^MUMPS
    1)= D EN3^GMRGUT1
    2)= S GMRG=$S($D(^GMRD(124.2,DA,0)):^(0),1:""),GMRG(1)=$P(GMRG,"^"),GMRG(3)=$P(GMRG,"^",3),GMRG(5)=$P(GMRG,"^",5) K:GMRG(1)'=""&(GMRG(3)'="")&(GMRG(5)'="") ^GMRD(124.2,"AA",GMRG(3),X,GMRG(1),GMRG(5),DA) K GMRG
    This cross-reference triggers data into the Node Identification field if its null, and sets a multiple cross-reference ("AA") over four fields. The fields used are the Name (.01), Type of Term (.02), Package (.03) and
    Node Identification (.05). The structure of the cross-reference is: ^GMRD(124.2,"AA",Package,Type_of_Term,Name,Node_Identification,DA)="".
  • CROSS-REFERENCE:  124.2^ATYUP^MUMPS
    1)= S GMRGX("D")=1,GMRGX("F")=2 D EN6^GMRGUT2
    2)= S GMRGX("D")=0,GMRGX("F")=2 D EN6^GMRGUT2
    This cross-reference triggers the value of the Type of Term field into the Child Type sub-field of the Children multiple for all entries that point to this entry.
.03 PACKAGE 0;3 FREE TEXT
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  K:X[""""!($A(X)=45) X I $D(X) K:$L(X)>5!($L(X)<2) X
  • LAST EDITED:  JUL 19, 1990
  • HELP-PROMPT:  Please enter Package Name (2-5 chars.)
  • DESCRIPTION:  The DHCP package associated with this aggregate term.
    If an application wants to allow site configuration of its care plans, the changes made by the site should be given 'ZZ' as a package. In other words calls made to the Generic Input Utility routine (GMRGTGIF) for site
    configuration options should set the variable GMRGPK="ZZ".
  • CROSS-REFERENCE:  124.2^PK
    1)= S ^GMRD(124.2,"PK",$E(X,1,30),DA)=""
    2)= K ^GMRD(124.2,"PK",$E(X,1,30),DA)
    This is a regular cross-refence on the Package field.
  • CROSS-REFERENCE:  124.2^AA03^MUMPS
    1)= D EN3^GMRGUT1
    2)= S GMRG=$S($D(^GMRD(124.2,DA,0)):^(0),1:""),GMRG(1)=$P(GMRG,"^"),GMRG(2)=$P(GMRG,"^",2),GMRG(5)=$P(GMRG,"^",5) K:GMRG(1)'=""&(GMRG(2)'="")&(GMRG(5)'="") ^GMRD(124.2,"AA",X,GMRG(2),GMRG(1),GMRG(5),DA) K GMRG
    This cross-reference triggers data into the Node Identification field if its null, and sets a multiple cross-reference ("AA") over four fields. The fields used are the Name (.01), Type of Term (.02), Package (.03) and
    Node Identification (.05). The structure of the cross-reference is: ^GMRD(124.2,"AA",Package,Type_of_Term,Name,Node_Identification,DA)="".
  • CROSS-REFERENCE:  124.2^APKUP^MUMPS
    1)= S GMRGX("D")=1,GMRGX("F")=3 D EN6^GMRGUT2
    2)= S GMRGX("D")=0,GMRGX("F")=3 D EN6^GMRGUT2
    This cross-reference triggers the value of the Package field into the Child Package sub-field of the Children multiple for all entries that point to this entry.
  • CROSS-REFERENCE:  124.2^ATD1^MUMPS
    1)= S GMRG=.03 D EN1^GMRGUT2
    2)= S GMRG=.03 D EN2^GMRGUT2
    This cross-reference sets a multiple index ("ATD") on the Package (.03) and Classification (.04) fields and Begin Text (1) field of the Term Classification file for the entry pointed to by the Classification (.04) field.
    The value of the Begin Text field will determine if this index will be set. If the Begin Text field is null, the index is not set, if it is 'YES' it is set. The format of the "ATD" cross-reference is:
    ^GMRD(124.2,"ATD",Package,Classification,DA)="".
    This cross-reference also triggers the values into the Action on Entering Selection (7), Action on Filing Selection (8), Action on Leaving Selection (9) and Action on Printing Selection (10) from the corresponding fields
    in the Term Classification file for the entry which is pointed to by the Classification field.
.04 CLASSIFICATION 0;4 POINTER TO TERM CLASSIFICATION FILE (#124.25) TERM CLASSIFICATION(#124.25)

  • LAST EDITED:  JUL 19, 1994
  • HELP-PROMPT:  Please enter Classification of aggregate term.
  • DESCRIPTION:  
    Special classification that further identifies an aggregate term.
  • CROSS-REFERENCE:  124.2^CL
    1)= S ^GMRD(124.2,"CL",$E(X,1,30),DA)=""
    2)= K ^GMRD(124.2,"CL",$E(X,1,30),DA)
    This is a regular cross-reference on the Classification field.
  • CROSS-REFERENCE:  124.2^ATD^MUMPS
    1)= S GMRG=.04 D EN1^GMRGUT2
    2)= S GMRG=.04 D EN2^GMRGUT2
    This cross-reference sets a multiple index ("ATD") on the Package (.03) and Classification (.04) fields and Begin Text (1) field of the Term Classification file for the entry pointed to by the Classification (.04) field.
    The value of the Begin Text field will determine if this index will be set. If the Begin Text field is null, the index is not set, if it is 'YES' it is set. The format of the "ATD" cross-reference is:
    ^GMRD(124.2,"ATD",Package,Classification,DA)="".
    This cross-reference also triggers the values into the Action on Entering Selection (7), Action on Filing Selection (8), Action on Leaving Selection (9) and Action on Printing Selection (10) from the corresponding fields
    in the Term Classification file for the entry which is pointed to by the Classification field.
.05 NODE IDENTIFICATION 0;5 NUMBER
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  K:+X'=X!(X>99999)!(X<1)!(X?.E1"."1N.N) X
  • LAST EDITED:  MAY 17, 1989
  • HELP-PROMPT:  Please enter this Aggregate Term's "NODE" (a whole number between 1 and 99999).
  • DESCRIPTION:  
    Identification which separates this Aggregate Term NODE from another Aggregate Term NODE that has the same NAME(.01), but different logical parent NODE.
    DELETE AUTHORITY: ^
    WRITE AUTHORITY: ^
    UNEDITABLE
  • CROSS-REFERENCE:  124.2^ANDUP^MUMPS
    1)= S GMRGX("D")=1,GMRGX("F")=4 D EN6^GMRGUT2
    2)= S GMRGX("D")=0,GMRGX("F")=4 D EN6^GMRGUT2
    This cross-reference triggers the value of the Node Identification field into the Child Node ID sub-field of the Children multiple for all entries that point to this entry.
  • CROSS-REFERENCE:  124.2^AA05^MUMPS
    1)= S GMRGX=$S($D(^GMRD(124.2,DA,0)):^(0),1:""),GMRGX(1)=$P(GMRGX,"^"),GMRGX(2)=$P(GMRGX,"^",2),GMRGX(3)=$P(GMRGX,"^",3) S:GMRGX(1)'=""&(GMRGX(2)'="")&(GMRGX(3)'="") ^GMRD(124.2,"AA",GMRGX(3),GMRGX(2),GMRGX(1),X,DA)="" K G
    MRGX
    2)= S GMRGX=$S($D(^GMRD(124.2,DA,0)):^(0),1:""),GMRGX(1)=$P(GMRGX,"^"),GMRGX(2)=$P(GMRGX,"^",2),GMRGX(3)=$P(GMRGX,"^",3) K:GMRGX(1)'=""&(GMRGX(2)'="")&(GMRGX(3)'="") ^GMRD(124.2,"AA",GMRGX(3),GMRGX(2),GMRGX(1),X,DA) K GMRG
    X
    This cross-reference sets a multiple cross-reference ("AA") over four fields. The fields used are the Name (.01), Type of Term (.02), Package (.03) and Node Identification (.05). The structure of the cross-reference is:
    ^GMRD(124.2,"AA",Package,Type_of_Term,Name,Node_Identification,DA)="".
.1 TERM DEFINITION TD;0 WORD-PROCESSING #124.22

  • DESCRIPTION:  If further clarification of this term is needed, it may be added here. The definition of the term displays when a user types '???' while selecting terms through the Patient Data Enter/Edit module. added here, and when
    selecting terms in the patient edit, if the user types in '???' then this definition will appear in conjunction with this term.
  • LAST EDITED:  MAR 01, 1989
  • DESCRIPTION:  
    A further clarification of this term.
1 CHILDREN 1;0 POINTER Multiple #124.21 124.21

  • DESCRIPTION:  
    Children are aggregate terms that are under this frame/document.
  • IDENTIFIED BY:  CHILD TEXT(#1)[R], CHILD TYPE(#2)[R], CHILD PACKAGE(#3)[R], CHILD NODE ID(#4)[R], DISPLAY ORDER(#6)
2 MIN 0;6 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>99)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  OCT 08, 1988
  • HELP-PROMPT:  Enter The minimum number of selections allowed under this frame/document. (0-99)
  • DESCRIPTION:  
    The minimum number of selections allowed under this frame/document. Null entry means zero.
3 MAX 0;7 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>99)!(X<0)!(X?.E1"."1N.N) X
  • LAST EDITED:  OCT 08, 1988
  • HELP-PROMPT:  Enter the maximum number of selections allowed under this frame/document. (0-99)
  • DESCRIPTION:  
    The maximum number of selections allowed under this frame/document. A null entry means there is no maximum.
3.5 SUPRESS MIN/MAX MESSAGE 0;12 SET
  • '0' FOR NO SUPRESSION;
  • '1' FOR SUPRESS MIN MESSAGE;
  • '2' FOR SUPRESS MAX MESSAGE;
  • '3' FOR SUPRESS BOTH MESSAGES;

  • LAST EDITED:  MAR 25, 1991
  • DESCRIPTION:  
    This field determines whether the MIN and MAX messages should be supressed for this frame.
4 LEAD TEXT 4;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>200!($L(X)<1) X
  • LAST EDITED:  OCT 08, 1988
  • HELP-PROMPT:  Enter a Header Text that would precede this frame/document.(1-200 chars.)
  • DESCRIPTION:  
    Text that precedes the text of this frame/document in displays.
5 TRAIL TEXT 5;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>200!($L(X)<1) X
  • LAST EDITED:  OCT 08, 1988
  • HELP-PROMPT:  Enter a Trailing Text that would follow this frame/document. (1-200 chars.)
  • DESCRIPTION:  
    Text that follows the text of this frame/document in displays.
6 FORMAT OF OUTPUT 0;8 SET
  • 'S' FOR SENTENCE;
  • 'T' FOR TABULAR;
  • 'B' FOR BRIEF TABULAR;

  • LAST EDITED:  OCT 08, 1988
  • DESCRIPTION:  This is the format of the frame/document display. Tabular, and brief tabular displays in an outline format; tabular uses lead and trail texts, and brief tabular does not. Sentence creates paragraphs using lead and trail
    texts, and ends sentences with periods.
6.5 ASK ADDITIONAL TEXT 0;9 SET
  • '0' FOR NO;
  • '1' FOR YES;

  • LAST EDITED:  MAR 03, 1989
  • DESCRIPTION:  
    A flag determining whether Additional Text can be entered for an aggregate term or not.
  • SCREEN:  S DIC("S")="I $P(^GMRD(124.2,DA,0),U,4)'=$O(^GMRD(124.25,""B"",""PRIME DOCUMENT"",0))"
  • EXPLANATION:  Cannot have an entry for a term with classification of Prime Document.
7 ACTION ON ENTERING SELECTION 7;E1,245 FREE TEXT

  • INPUT TRANSFORM:  D ^DIM
  • LAST EDITED:  OCT 06, 1988
  • HELP-PROMPT:  ANSWER MUST BE VALID MUMPS CODE, 1-245 CHARACTERS IN LENGTH
  • DESCRIPTION:  This is valid MUMPS code that is executed upon entering the screen of an Aggregate Term in the General Medical Record Generator patient edit.
    The variables that the programmer can rely on being set and the
    programmer should not kill are:
    DFN and arrays from DEM^VADPT and INP^VADPT
    GMRGRT=Prime document data for this term in the following format:
    AGGY IEN^Term text
    GMRGPDA=ENTRY IN GMR TEXT (124.3) FILE
    GMRGTERM=Data on term being processed in the following format:
    124.2 FILE IEN^Term text^IEN in 124.31 multiple if exists.
    GMRGTERM(0)=^GMRD(124.2,+GMRGTERM,0)
    WRITE AUTHORITY: @
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
8 ACTION ON FILING 8;E1,245 FREE TEXT

  • INPUT TRANSFORM:  D ^DIM
  • LAST EDITED:  OCT 08, 1988
  • HELP-PROMPT:  ANSWER MUST BE 1-245 CHARACTERS IN LENGTH
  • DESCRIPTION:  This is valid MUMPS code that will be executed upon the filing of an Aggregate Term in the General Medical Record Treatment Planner.
    The variables that the programmer can rely on being set and the
    programmer should not kill are:
    DFN and arrays from DEM^VADPT and INP^VADPT
    GMRGRT=Prime document data for this term in the following format:
    AGGY IEN^Term text
    GMRGPDA = ENTRY IN GMR TEXT (124.3) FILE
    GMRGTERM=Data on term being filed in the following format:
    124.2 FILE IEN^Term text^IEN in 124.31 multiple if exists.
    GMRGTERM(0)=^GMRD(124.2,+GMRGTERM,0)
    GMRGART=$S(0:if term is being deleted,1:if term is being added)
    WRITE AUTHORITY: @
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
9 ACTION ON LEAVING SELECTION 9;E1,245 FREE TEXT

  • INPUT TRANSFORM:  D ^DIM
  • LAST EDITED:  MAR 01, 1989
  • HELP-PROMPT:  ANSWER MUST BE VALID MUMPS CODE, 1-245 CHARACTERS IN LENGTH
  • DESCRIPTION:  This is valid MUMPS code that will be executed upon the leaving of this aggregate term screen from the General Medical Record Generator patient edit.
    The variables that the programmer can rely on being set, and that the
    programmer should not kill are:
    DFN and arrays from DEM^VADPT and INP^VADPT
    GMRGRT=Prime document data for this term in the following format:
    AGGY IEN^Term text
    GMRGPDA= ENTRY IN GMR TEXT (124.3) FILE
    GMRGTERM=Data on term being processed in the following format:
    124.2 FILE IEN^Term text^IEN in 124.31 multiple if exist.
    GMRGTERM(0)=^GMRD(124.2,+GMRGTERM,0)
    WRITE AUTHORITY: @
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
10 ACTION ON PRINTING SELECTION 10;E1,245 FREE TEXT

  • INPUT TRANSFORM:  D ^DIM
  • LAST EDITED:  MAR 14, 1989
  • HELP-PROMPT:  Answer must be 1-245 characters in length.
  • DESCRIPTION:  An action that occurs when an aggregate term is printed as a selection on the screen.
    The variables that the programmer can rely on being set, and that the
    programmer should not kill are:
    DFN and arrays from DEM^VADPT and INP^VADPT
    GMRGRT=Prime document data for this term in the following format:
    AGGY IEN^Term text
    GMRGPDA= ENTRY IN GMR TEXT (124.3) FILE
    GMRGTERM=Term data whose selections are being printed as follows:
    124.2 FILE IEN^Term text^IEN in 124.31 multiple if exists
    GMRGTERM(0)=^GMRD(124.2,GMRGTERM,0)
    GMRGSEL=Selection being printed for term in GMRGTERM
    124.2 FILE IEN^Term text^$S(1:data is active for term
    ,0:data is not active for term)
    If there is other information that needs to be printed with a selection for a particular package, this is a way to get this information to print.
    WRITE AUTHORITY: @
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER

Found Entries, Total: 6552

NAME: Nursing Care Plan    NAME: Health Management    NAME: Activities of Daily Living    NAME: Respiratory System    NAME: Circulatory System    NAME: Nutrition-Metabolic Area    NAME: Elimination    NAME: Integumentary (Skin)    
NAME: Musculoskeletal/Neurological    NAME: Cognitive-Sensory Area    NAME: Sleep/Rest    NAME: Sexual Functioning/Reproductive System    NAME: Psycho-Social Area    NAME: Spiritual Needs    NAME: Health Maintenance, Alteration in    NAME: Knowledge Deficit [specify]    
NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: altered communication    NAME: cognition impaired    NAME: development tasks impaired    NAME: ineffective family/individual coping    NAME: lack of ability to make judgement    
NAME: lack of growth of fine motor skills    NAME: maintains a state of wellness    NAME: relationships with others    NAME: coping behavior    NAME: attention to physical appearance/grooming    NAME: tissue intact    NAME: maintains or regains optimal level of mobility    NAME: remains/regains orientation to time, place and space    
NAME: communicates within capacity    NAME: assess causative factors on admission    NAME: assist to maintain and manage health care    NAME: promote wellness through patient/family knowledge [specify]    NAME: level of dependence/independence (mobility, self-care, etc.)    NAME: long term/new problem for patient    NAME: recent changes in lifestyle    NAME: ability to meet health maintenance needs    
NAME: communication skills    NAME: knowledge level regarding health maintenance    NAME: motivation regarding health care    NAME: use of professional resources    NAME: involve family/friends in care management    NAME: develop care plan with patient/family    NAME: provide time to listen to patient/family concerns    NAME: make necessary referrals within Medical Center    
NAME: Coping, Ineffective Family    NAME: Home Maintenance Management, Impaired    NAME: Self-Care Deficit [Specify]    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    
NAME: Nursing Intervention/Orders    NAME: demonstrates realistic responses to stress    NAME: effective client coping skills    NAME: effective problem solving    NAME: assess family's coping response    NAME: assist family to appraise stressors    NAME: assist family to develop plan to cope with stressors    NAME: teach effective coping skills    
NAME: problem solving/decision making    NAME: assertiveness    NAME: help-seeking    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: client providing little support for SO    NAME: inadequate/incorrect information/understanding by a SO    
NAME: prolonged disease/disability exhausting SO    NAME: situational/developmental crises the SO may be facing    NAME: SO is unable to perceive/act effectively to client's needs    NAME: temporary family disorganization and role changes    NAME: Related Problems    NAME: communication, impaired    NAME: coping, family: potential for growth    NAME: family process, alteration in    
NAME: grieving    NAME: health maintenance, alteration in    NAME: home management, maintenance    NAME: parenting, alteration in    NAME: sexual dysfunction    NAME: sexual pattern, altered    NAME: social interaction, impaired    NAME: social isolation    
NAME: spiritual distress    NAME: Related Problems    NAME: disease or injury of individual/family member    NAME: impaired cognition    NAME: inadequate support system    NAME: insufficient family planning    NAME: insufficient finances    NAME: lack of role modeling    
NAME: unfamiliarity with neighborhood resources    NAME: substance abuse    NAME: role fatigue of care giver    NAME: substance abuse, alcohol    NAME: substance abuse, drugs    NAME: identifies factors restricting self-care and home management    NAME: demonstrates skills for home maintenance    NAME: expresses satisfaction with the home situation    
NAME: assess causative/contributing factors    NAME: reduce or eliminate causative/contributing factors    NAME: lack of knowledge    NAME: lack of necessary equipment    NAME: inability to perform household tasks    NAME: impaired cognitive functioning    NAME: impaired emotional functioning    NAME: assist patient/family to plan for a clean, healthful home    
NAME: refer to Social Work for assistance with finances    NAME: assist patient/family to acquire needed equipment/supplies    NAME: refer to O.T. for instructions on work simplification skills    NAME: refer to community agency for homemaker services/meals    NAME: report building violations to landlord/city department    NAME: encourage patient/family to report building violations    NAME: assess ability to safely maintain household    NAME: discuss long-term plan for managing situation    
NAME: Activity Intolerance    NAME: Airway Clearance, Ineffective    NAME: Breathing Pattern, Ineffective    NAME: Gas Exchange, Impaired    NAME: Hypoventilation (see Breathing Pattern, Ineffective)    NAME: Hypoxia (see Gas Exchange, Impaired)    NAME: Infection Potential (Specific to Respiratory System)    NAME: Etiology/Related and/or Risk Factors    
NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: Related Problems    NAME: bed rest or immobility    NAME: generalized weakness    NAME: imbalance between oxygen supply and demand    NAME: sedentary life-style    NAME: Comfort, Altered: Chest Pain    
NAME: Related Problems    NAME: bathing/hygiene    NAME: coping, ineffective, individual    NAME: alteration in comfort related to pain    NAME: external locus of control    NAME: health beliefs (lack of perceived health threat)    NAME: inaccessibility to adequate health care services    NAME: religious beliefs    
NAME: Related Problems    NAME: specific diseases    NAME: susceptibility, e.g., presence of risk factors    NAME: value of early detection    NAME: promote wellness through past patterns of health care    NAME: discuss role of nutrition    NAME: discuss role of exercise    NAME: discuss role of safety measures    
NAME: discuss role of stress management    NAME: discuss role of social support systems    NAME: expectations    NAME: interaction with health care system    NAME: influences of family, cultural/peer groups, mass media    NAME: Etiology/Related and/or Risk Factors    NAME: cognitive limitation    NAME: information misinterpretation    
NAME: lack of exposure    NAME: lack of recall    NAME: lack of interest in learning    NAME: patient's request for no information    NAME: unfamiliarity with information resources    NAME: Goals/Expected Outcomes    NAME: verbalizes ability to make decisions on health care    NAME: Nursing Intervention/Orders    
NAME: assess knowledge base    NAME: decide what patient needs to know    NAME: determine ability to learn and implement plan    NAME: implement teaching plan based on readiness/ability to learn    NAME: involve S/O in teaching plan    NAME: evaluate effectiveness of teaching plan    NAME: Noncompliance/Nonadherence [specify]    NAME: Etiology/Related and/or Risk Factors    
NAME: client and provider relationships    NAME: cultural influences    NAME: health benefits    NAME: patient value system    NAME: spiritual values    NAME: Related Problems    NAME: Goals/Expected Outcomes    NAME: participates in development/implementation of treatment plan    
NAME: verbalizes experiences causing alteration in prescribed plan    NAME: verbalizes accurate knowledge of disease    NAME: verbalizes accurate understanding of treatment regime    NAME: demonstrates realistic alternatives to treatment regime    NAME: identifies sources of dissatisfaction    NAME: participates in selection of more desirable treatment plan    NAME: verbalizes intent to adhere to realistic alternative plan    NAME: Nursing Intervention/Orders    
NAME: assist exploring factors influencing non-compliance    NAME: develop therapeutic nurse/patient relationship    NAME: determine value systems and cultural factors    NAME: determine developmental level    NAME: determine prohibitive factors    NAME: assess level of anxiety    NAME: assess support system    NAME: provide for patient care conferences for mutual goal setting    
NAME: discuss patient's/SO's understanding of treatment regime    NAME: review instructions related to therapy    NAME: provide information and encourage patient to seek it on own    NAME: emphasize positive effects of plan    NAME: avoid a judgemental attitude/approach    NAME: be receptive to patient/SO's expressions of doubt/concern    NAME: depression, severe anxiety    NAME: intolerance to activity; decreased strength and endurance    
NAME: musculoskeletal impairment    NAME: neuromuscular impairment    NAME: pain, discomfort    NAME: general self-care deficit outcomes    NAME: feeding deficit outcomes    NAME: bathing/hygiene deficit outcomes    NAME: dressing/grooming deficit outcomes    NAME: identifies factors limiting self-care    
NAME: accepts home health care    NAME: accepts interventions to modify self-care deficits    NAME: physical therapy    NAME: occupational therapy    NAME: increased interest and desire to eat    NAME: causative factors for feeding deficit    NAME: use of adaptive devices    NAME: increased ability to feed self    
NAME: participation in adaptive process    NAME: describes causative factors of bathing deficit [specify]    NAME: performs bathing activity at optimal level    NAME: verbalizes comfort and satisfaction with body cleanliness    NAME: increased ability to dress self    NAME: ability to request/accept assistance in dressing    NAME: increased interest in appearance and dress    NAME: general self-care deficit interventions    
NAME: feeding deficit interventions    NAME: bathing/hygiene deficit interventions    NAME: dressing/grooming deficit interventions    NAME: assess degree of disability    NAME: assess memory/intellectual functioning    NAME: determine individual strengths and skills    NAME: identify if deficit is temporary or permanent    NAME: assess causative factors (of deficit)    
NAME: assess post discharge needs    NAME: encourage patient to control timing of self-care activity    NAME: visual deficits    NAME: impaired functional mobility    NAME: contributory medical problems    NAME: identify food likes/dislikes    NAME: encourage person to wear dentures/eyeglasses if applicable    NAME: determine person's usual eating pattern    
NAME: position person in upright, comfortable eating position    NAME: provide assistance or adaptive devices    NAME: explain/demonstrate adaptive devices    NAME: identify deterring factors when using devices    NAME: provide bathing time and routine to encourage independence    NAME: provide adaptive equipment    NAME: teach safe use of adaptive equipment [specify]    NAME: encourage patient to wear street clothing    
NAME: ensure easy access to all clothing    NAME: lay clothing out in order for dressing    NAME: allow sufficient time for dressing and undressing    NAME: select appropriate clothing    NAME: allow person to demonstrate activity in steps    NAME: keep instructions simple and repeat often    NAME: provide dressing aids as necessary    NAME: loose fitting    
NAME: wide sleeves    NAME: front fasteners    NAME: long handled shoe horn    NAME: velcro    NAME: toileting deficit outcomes    NAME: demonstrates increased ability to toilet self    NAME: demonstrates increased ability to cope with assistance    NAME: verbalizes positive feelings related to continency    
NAME: identifies causative factors related to toileting deficit    NAME: demonstrates use of adaptive devices to facilitate toileting    NAME: verbalizes/demonstrates decreased fatigue with activity    NAME: demonstrates increased control of dyspnea with activity    NAME: demonstrates increased independence for self-care    NAME: hemodynamically stable during activity    NAME: appropriate pulse rate for pt [specify range]    NAME: B/P    
NAME: skin color and temperature WNL for pt    NAME: assess for signs of fatigue and weakness    NAME: administer oxygen/cannula at [specify]L/min or mask at [ ]%    NAME: administer bronchodilators as ordered    NAME: plan activities to maximize medication/treatment benefits    NAME: provide [number of] minutes of rest between activities    NAME: passive/active ROM q[frequency]hrs.    NAME: initiate muscle strengthening/conditioning as indiciated    
NAME: refer for appropriate consults    NAME: teach patient    NAME: exertional dyspnea    NAME: inability to be independent for self-care    NAME: weight loss or gain    NAME: deteriorating personal appearance    NAME: sleep pattern    NAME: Dietetic Service    
NAME: Chaplain Service    NAME: use of adaptive equipment to assist with ADLs    NAME: using analgesics appropriately    NAME: relaxation therapy    NAME: tub bench    NAME: shower hose    NAME: Related Problems    NAME: Etiology/Related and/or Risk Factors    
NAME: infection, tracheobronchial    NAME: obstruction, tracheobronchial    NAME: secretions, tracheobronchial    NAME: perceptual/cognitive impairment    NAME: trauma    NAME: Nursing Intervention/Orders    NAME: Goals/Expected Outcomes    NAME: has decreased abnormal breath sounds    
NAME: has normal respiratory rate/breathing pattern    NAME: has decreased use of accessory muscles    NAME: is afebrile    NAME: attains/maintains ABGs/pulse oximetry within normal range    NAME: verbalizes patient education information    NAME: S/O assists with quad cough    NAME: etiological factor    NAME: assess respiratory rate and pattern/breath sounds    
NAME: TPR q[frequency]    NAME: B/P q[frequency]    NAME: respiratory pattern q [frequency]    NAME: monitor use of accessory muscles    NAME: ABGs/pulse oximetry q[frequency]    NAME: cardiac rhythm q[frequency]    NAME: monitor peak flows q [frequency]    NAME: observe sputum for color, consistency, amount    
NAME: administer bronchodilators as ordered    NAME: elevate head of bed    NAME: position to mobilize secretions q [frequency]    NAME: out of bed q[frequency]    NAME: chest percussion q[frequency]    NAME: pulmonary toilet q [frequency]    NAME: mouth care q[frequency]    NAME: provide adequate hydration and nutrition    
NAME: I&O q[frequency]    NAME: Activity Intolerance (Circulatory System)    NAME: Cardiac Output, Decreased (Electrical Factors)    NAME: Pain, Chest    NAME: Fluid Volume Excess (Actual/Potential)    NAME: Hyperthermia    NAME: Hypothermia    NAME: Knowledge Deficit    
NAME: Tissue Integrity, Impaired    NAME: Tissue Perfusion, Alteration In    NAME: Appetite, Altered    NAME: Nutrition, Alteration in:(Less Than Required)    NAME: Nutrition, Alteration in:(More Than Required)    NAME: Swallowing, Impaired    NAME: Constipation    NAME: Diarrhea    
NAME: Incontinence, Bowel    NAME: Incontinence, Urine    NAME: Infection Potential (Specific to Elimination)    NAME: Stress Incontinence    NAME: Urinary Elimination, Alteration In Pattern    NAME: Urinary Retention    NAME: Infection Potential (Specific to Integumentary System)    NAME: Oral Mucous Membrane, Alteration In    
NAME: Skin Integrity, Impairment Of (Actual)    NAME: Skin Integrity, Impairment Of (Potential)    NAME: Skin Ulcer (See Skin Integrity, Impairment (Actual))    NAME: Injury Potential    NAME: Mobility, Impaired Physical    NAME: Pain, Chronic    NAME: Cognitive Impairment    NAME: Communication Impaired    
NAME: Knowledge Deficit for Cognitive-Sensory Problems    NAME: Neglect, Unilateral    NAME: Sensory-Perceptual, Alteration In    NAME: Sleep Pattern Disturbance    NAME: toileting deficit interventions    NAME: assess bowel history    NAME: determine a method for communicating the need for toileting    NAME: maintain records to determine bowel patterns    
NAME: promote elimination by encouraging appropriate activity    NAME: allow sufficient time to toilet    NAME: avoid using indwelling and condom catheters    NAME: provide for safe, clear pathway to toilet area    NAME: provide for privacy as well as safety    NAME: provide for continual practice at specified intervals    NAME: provide for adaptive equipment as indicated    NAME: weight q[frequency]    
NAME: observe for anxiety; use calm, confident manner    NAME: incentive spirometer q[frequency]    NAME: suction q[frequency] and/or PRN    NAME: sputum culture as indicated    NAME: oxygen [numeric value]% per [flow rate]    NAME: humidity as indicated    NAME: explain procedures; be reassuring    NAME: administer pain medication as needed    
NAME: splint incision while providing pulmonary toilet    NAME: teach methods to reduce pain, such as splinting    NAME: provide patient teaching (Airway Clearance, Ineffective)    NAME: teach patient and SO procedures for quad cough    NAME: anatomy, physiology, and corrective factors    NAME: educate in S/S of respiratory infection, bronchospasm, etc    NAME: teach patient actions to take when S/S reoccur    NAME: consider/discuss preventive measures    
NAME: postural drainage    NAME: humidification therapy    NAME: use of expectorants    NAME: aerosol therapy q [frequency]    NAME: fluid intake    NAME: antibiotic therapy    NAME: avoidance of respiratory irritants    NAME: contact health professional for assistance    
NAME: annual flu shot    NAME: pneumococcus vaccine    NAME: avoid others who have infections    NAME: eliminate inhaled irritants    NAME: compliance with prescribed treatment program    NAME: avoidance of allergens specific to [ ]    NAME: Etiology/Related and/or Risk Factors    NAME: Related Problems    
NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: anxiety    NAME: decreased energy and fatigue    NAME: decreased lung expansion    NAME: tracheobronchial obstruction    NAME: establishes breathing pattern within normal rate    NAME: remains free from S/S of hypoxia and hypercapnia    
NAME: identifies causative factors and preventive measures    NAME: level of consciousness q[frequency]    NAME: respiratory pattern q [frequency]    NAME: peak flows [frequency]    NAME: reposition/turn q[frequency]    NAME: percussion q[frequency]    NAME: ambulate with assistance q[frequency]    NAME: provide for relief of pain    
NAME: use relaxation techniques    NAME: provide calm, supportive environment    NAME: provide patient teaching on the mechanical ventilator    NAME: assess for complications of mechanical ventilation    NAME: provide communication (see Communication, Impaired Verbal)    NAME: Hypotension    NAME: tube displacement    NAME: GI bleed    
NAME: pneumothorax    NAME: subcutaneous emphysema    NAME: Etiology/Related and/or Risk Factors    NAME: Related Problems    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: alveoli-capillary membrane changes    NAME: blood flow, altered    
NAME: oxygen carrying capacity of blood altered    NAME: remains free of S/S of hypoxia    NAME: identifies etiology    NAME: complies with treatment    NAME: CBC with differential q [frequency]    NAME: encourage rest    NAME: tracheostomy care q[frequency]    NAME: provide patient teaching (Gas Exchange, Impaired)    
NAME: discuss risk factors [specify]    NAME: disease process    NAME: medications    NAME: pulmonary hygiene    NAME: signs of infection (for reporting to health care provider)    NAME: inhalation equipment and oxygen therapy    NAME: fire and safety    NAME: ventilator use, cleaning, assembly, and back-up equipment    
NAME: suctioning    NAME: emergency care    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: has normal sputum production    NAME: has reduced risk of pulmonary infection    NAME: maintains intact mucous membranes    
NAME: maintains optimal weight [specify lbs/kgs]    NAME: maintains optimal fluid balance    NAME: states actions taken to prevent cross infection    NAME: states S/S of infection    NAME: chronic disease    NAME: immunosuppression    NAME: inadequate acquired immunity    NAME: inadequate primary defenses    
NAME: inadequate secondary defenses    NAME: malnutrition    NAME: medical procedures    NAME: pharmaceutical agents    NAME: tissue destruction and increased environmental exposure    NAME: oxygen flow, altered    NAME: mucous membrane trauma (suctioning/bronchoscopy)    NAME: impaired cough mechanism    
NAME: use of antibiotics    NAME: inability to breathe deeply due to weakness, chest pain etc    NAME: monitor sputum    NAME: increase in production    NAME: change in color    NAME: change in consistency    NAME: culture sputum [frequency]    NAME: ambulate q[frequency]    
NAME: provide humidity q[frequency]    NAME: pacing activities, exercise, rest    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: Related Problems    NAME: alteration in conduction    NAME: alteration in rate    
NAME: alteration in rhythm    NAME: electrophysiological disturbances in impulse formation    NAME: electrophysiological disturbances in cardiac conduction    NAME: returns to and maintains NSR or pacing rhythm    NAME: maintains cardiac output    NAME: maintains therapeutic levels of antiarrhythmic agents    NAME: avoids toxicity/allergic reactions to drugs    NAME: limits myocardial infarction area    
NAME: avoids metabolic death    NAME: vital signs WNL or returns to baseline    NAME: skin is warm to touch and is normal color    NAME: capillary filling WNL    NAME: lab data (e.g. BUN, creatinine) is normal or baseline    NAME: Medical Diagnoses    NAME: Nursing Problems    NAME: Cardiovascular    
NAME: Endocrine    NAME: Gastrointestinal    NAME: GU/Renal    NAME: HEENT    NAME: Immune (Cancer,AIDS,Transplant,Arthritis)    NAME: Integument    NAME: Musculo-Skeletal/Orthopedic    NAME: Neurologic    
NAME: Nutrition/Metabolic    NAME: Other    NAME: Pulmonary    NAME: Plastic Surgery    NAME: Psychosocial    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    
NAME: inadequate primary defenses:    NAME: broken skin    NAME: traumatized tissue    NAME: decrease of ciliary action    NAME: stasis of body fluids    NAME: change in pH secretions    NAME: altered peristalsis    NAME: inadequate secondary defenses:    
NAME: decreased hemoglobin    NAME: leukopenia    NAME: suppressed inflammatory response    NAME: normal sputum production    NAME: reduced risk of pulmonary infection    NAME: intact mucous membrane    NAME: optimal weight    NAME: optimal fluid balance    
NAME: patient demonstrates knowledge    NAME: actions to take to prevent cross-infection    NAME: s/s of infection    NAME: temperature per[route] q[ frequency ]    NAME: turn/reposition q[frequency]hrs.    NAME: Spiritual Distress    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    
NAME: Nursing Intervention/Orders    NAME: Related Problems    NAME: challenged belief value system    NAME: beliefs opposed by family, peers, health care providers    NAME: conflicts to belief system    NAME: no emergency resuscitation    NAME: divorce    NAME: blood transfusions    
NAME: death or illness of significant other    NAME: hospital barriers to practicing spiritual rituals    NAME: isolation    NAME: ICU restrictions    NAME: surgery    NAME: as a response    NAME: terminal illness    NAME: debilitating disease    
NAME: loss of body part or function    NAME: achieves personal/spiritual goals of [specify]    NAME: expresses satisfaction about his relationship-God/Diety    NAME: continues spiritual practices not detrimental to health    NAME: expresses decreased feelings of guilt and fear    NAME: verbalizes feeling supported in health care decisions    NAME: assess causative, contributing factors    NAME: assess pt's beliefs, involvement, and spiritual practices    
NAME: note expression of inability to find reason for living    NAME: assist patient/family to deal with feelings:    NAME: help patient find reason for living    NAME: help patient find meaning in illness/suffering    NAME: assist to develope coping skills    NAME: assist patient to identify his strengths and support systems    NAME: religious practices in use    NAME: if yes, to what religion do you belong?    
NAME: how will your illness affect your practices/beliefs?    NAME: how can I help you maintain your spiritual strength?    NAME: contact minister/priest/rabbi    NAME: provide privacy at special times    NAME: request reading material    NAME: make time for discussions of philosophic issues    NAME: make time for questions about treatment regimen    NAME: listen attentively and non-judgementally to patient    
NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: Related Problems    NAME: altered body structure or function    NAME: ineffectual or absent role models    NAME: lack of privacy    NAME: lack of significant other    
NAME: misinformation or lack of knowledge    NAME: values conflict    NAME: vulnerability    NAME: physical or psychosocial abuse, e.g. harmful relationships    NAME: verbalizes awareness of the cause/contributing factors    NAME: verbalizes effects of medical tx. on sexual functioning    NAME: relates confidence to resume satisfying sexual activity    NAME: relates ability to resume satisfying sexual activity    
NAME: identifies stressors in life related to sexual dysfunction    NAME: elicit personal information about sexual history    NAME: provide privacy and assure confidentiality    NAME: establish a trusting relationship    NAME: discuss sexual activity limitations    NAME: discuss the varied etiologies of impotence    NAME: discuss ways to enhance sexual expression    NAME: teach sexual physiology as indicated    
NAME: teach the likelihood of adverse effects    NAME: provide information regarding altered body structure    NAME: teach possible reconstructive surgical intervention    NAME: teach relaxation techniques    NAME: refer for consultation or support resource    NAME: fatigue    NAME: alcohol consumption    NAME: prostatitis/urethritis    
NAME: anger    NAME: ignorance    NAME: therapy    NAME: psychology    NAME: psychiatry    NAME: American Cancer Society    NAME: American Heart Association    NAME: other [ ADDITIONAL TEXT ]    
NAME: Infection Potential    NAME: Sexual Dysfunction    NAME: Sexual Pattern, Altered    NAME: home maintenance management, impaired    NAME: knowledge deficit [specify]    NAME: Etiology/Related and/or Risk Factors    NAME: Abdominal Aortic Aneurysm Repair    NAME: Angina/Chest Pain    
NAME: Aortobifemoral Bypass Graft    NAME: Arterial Insufficiency    NAME: Atherosclerosis    NAME: Cardiac Surgery Post-Operative (CABG, Valve Replacement)    NAME: Cardiac Tamponade    NAME: Cardiogenic Shock    NAME: Cardiomyopathy    NAME: Carotid Artery Endarterectomy    
NAME: Digoxin Toxicity    NAME: Dysrhythmias    NAME: Endocarditis    NAME: Heart Failure    NAME: Hypertension    NAME: Pericarditis    NAME: Peripheral Vascular Surgery Procedures    NAME: Pulmonary Embolus    
NAME: Thrombophlebitis (DVT)    NAME: Valvular Heart Disease    NAME: Vein Ligation and Stripping    NAME: Cancer of the Larynx    NAME: COPD, Bronchitis, Asthma    NAME: Lung Cancer    NAME: Cholecystectomy    NAME: Diverticulitis    
NAME: Esophageal Varices    NAME: Fecal Diversion (Ileostomy, Colostomy)    NAME: Gastric Resection/Gastrectomy    NAME: Gastrointestinal Hemorrhage    NAME: Hemorrhoidectomy    NAME: Hemmorrhoids/Anal Fissure/Pilonidal Cyst    NAME: Herniorrhaphy    NAME: Intestinal Surgery    
NAME: Liver Failure/Cirrhosis    NAME: Mallory-Weiss Syndrome    NAME: Pancreatitis    NAME: Peritonitis    NAME: Surgical Procedures of the GI Tract    NAME: Ulcers/Peptic    NAME: Anxiety    NAME: Acute/Chronic Renal Failure    
NAME: Adrenalectomy    NAME: Benign Prostatic Hypertrophy    NAME: Hemodialysis    NAME: Urinary Diversion/Ileal Conduit    NAME: Nephritis    NAME: Peritoneal Dialysis    NAME: Prostatectomy    NAME: Transurethral Procedures    
NAME: Urinary Tract Infection/Kidney Infection    NAME: Urolithiasis    NAME: Fear    NAME: Amputation    NAME: Carpal Tunnel Syndrome    NAME: Casts    NAME: Fractures    NAME: Total Joint Replacement (knee, hip, elbow, fingers, wrist)    
NAME: Traction    NAME: Pressure Sores    NAME: Skin Grafts    NAME: Addison's Disease (Adrenal Insufficiency)    NAME: Cushing's Disease    NAME: Hyperthyroidism (Graves' Disease)    NAME: Hypothyroidism    NAME: Parathyroidectomy    
NAME: Thyroidectomy    NAME: OBS (Alzheimer's/Wernicke-Korsakoff Syndrome)    NAME: Spinal Procedures (Laminectomy/Spinal Fusion)    NAME: CVA/TIA    NAME: Hypophysectomy (Craniotomy)    NAME: Spinal Cord Injury    NAME: Syncope    NAME: Substance Abuse, Alcohol/Drug    
NAME: Bipolar Disorder    NAME: Depressive Disorder    NAME: Paranoid Disorder    NAME: Post Traumatic Stress Disorder    NAME: Schizophrenia    NAME: Somatoform Disorders    NAME: Cancer of the Larynx: Radical Neck/Permanent Laryngostomy    NAME: Reconstructive Facial Surgery    
NAME: Rhinoplasty    NAME: Septorhinoplasty    NAME: Anorexia Nervosa/Anorexia Bulemia    NAME: Hypovolemia    NAME: Hypokalemia    NAME: Malnutrition    NAME: Obesity    NAME: Immune Deficient Conditions    
NAME: Sepsis    NAME: Lung Cancer: Surgical Intervention    NAME: Pneumonia and Pleurisy    NAME: Pneumothorax/Hemothorax/Pleural Effusion    NAME: Self Concept, Disturbance In    NAME: Coping, Ineffective Individual    NAME: Grieving, Anticipatory    NAME: Grieving, Dysfunctional    
NAME: Powerlessness    NAME: Depressive Behavior    NAME: Violence, Potential For, Self Directed    NAME: Violence Potential, Directed At Others    NAME: Social Isolation    NAME: Social Interaction, Impaired    NAME: Family Processes, Alteration in    NAME: Diversional Activity Deficit    
NAME: Thought Processes, Alteration In    NAME: Ocular Disorders/Surgery    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: individual/environment conditions which impose a risk    NAME: biological    NAME: developmental    
NAME: physiologic    NAME: psychologic perception    NAME: people provider    NAME: psychologic    NAME: loss of motor ability from disease/injury/aging/restraints    NAME: sensory loss from disease/injury/aging/restraints    NAME: cognitive deficit    NAME: perceptual deficit    
NAME: adverse effects of chemicals/drugs    NAME: self-mutilation    NAME: nonadherence/noncompliance    NAME: infestation    NAME: clothing    NAME: unfamiliar setting    NAME: physical restraints/barriers    NAME: remains free from injuries    
NAME: verbalizes how to prevent injury    NAME: inspect for external factors which produce injury q [freq.]    NAME: observe for adverse effects of chemical agents/treatments    NAME: identify and eliminate potential sources of injury    NAME: provide physically safe environment    NAME: protect with restraints [specify]    NAME: provide restraint care q[frequency]    NAME: teach patient regarding health maintenance    
NAME: teach S/O regarding potential for injury    NAME: assure understanding of informed consent    NAME: bedrails    NAME: call light    NAME: prosthetic devices    NAME: night light    NAME: safety restraints    NAME: isolation    
NAME: remove constrictive clothing    NAME: eliminate source of infestation    NAME: pain and discomfort    NAME: perceptual or cognitive    NAME: Related Problems    NAME: medical protocols    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    
NAME: Nursing Intervention/Orders    NAME: Related Problems    NAME: intolerance to activity; decreased strength and endurance    NAME: musculoskeletal impairment    NAME: neuromuscular impairment    NAME: free from injury    NAME: maintains ROM in all joints    NAME: maintains independent ambulation    
NAME: assess mobility, limitations q[frequency]    NAME: assess risks if mobile    NAME: protect from injury as indicated    NAME: prior to restraints, teach purpose    NAME: perimeter protection    NAME: adjust environment as appropriate    NAME: range of motion exercise as appropriate q[frequency]    NAME: reposition/turn q[frequency]    
NAME: utilize devices [specify] to facilitate mobility    NAME: limit activities as set by medical protocols & as indicated    NAME: skin integrity, impairment of    NAME: tissue perfusion, alteration in    NAME: gas exchange, impaired    NAME: constipation    NAME: injury, potential for    NAME: alteration in skin turgor (change in elasticity)    
NAME: mechanical factors    NAME: physical immobilization    NAME: radiation    NAME: Etiology/Related and/or Risk Factors    NAME: Post Trauma Response    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: Related Problems    
NAME: maintains intact skin    NAME: maintains normal skin color and temperature    NAME: identifies relevant risk factors    NAME: verbalizes preventive measures    NAME: Tissue integrity, impaired    NAME: Skin integrity, impairment, actual    NAME: perform skin assessment q[frequency]    NAME: provide comfort/preventive measures    
NAME: sheepskin    NAME: alternating pressure pads    NAME: overhead bars    NAME: reposition q[frequency]hrs    NAME: massage bony prominence [frequency]    NAME: other    NAME: avoid irritants/noxious stimuli/oral irritants    NAME: encourage adequate food and fluid intake    
NAME: up in chair q[frequency]    NAME: provide stoma care q [frequency]    NAME: teach how to maintain skin integrity    NAME: teach radiation therapy precautions    NAME: Substance Abuse, Alcohol    NAME: Substance Abuse, Drugs    NAME: Etiology/Related and/or Risk Factors    NAME: Related Problems    
NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: environmental changes, social cues    NAME: Acute Myocardial Infarction    NAME: illness, psychologic stress    NAME: identifies techniques to fall asleep    NAME: falls asleep within one hour of going to bed    NAME: sleeps for 90 minute period without awakening    
NAME: sleeps for 4-5 hours without awakening    NAME: sleeps 7-9 hours without awakening    NAME: falls asleep within minutes if awakened    NAME: states feels rested after sleep    NAME: states feels less tense, less anxious after sleep    NAME: assess length of time and time of day naps are taken    NAME: assess length of time patient is awake at night    NAME: increase daytime activity    
NAME: discuss pros/cons of napping    NAME: decrease stimulants from [time] until [time]    NAME: avoid stimulants and foods difficult to digest at bedtime    NAME: schedule tests to allow for uninterrupted periods of sleep    NAME: limit amount of fluids after [time]    NAME: listen to pt if pt appears anxious or needs to talk    NAME: offer comfort measures    NAME: back rub    
NAME: warm milk    NAME: soft music    NAME: analgesic for pain    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    NAME: Nursing Intervention/Orders    NAME: Etiology/Related and/or Risk Factors    NAME: Goals/Expected Outcomes    
NAME: Related Problems    NAME: Nursing Intervention/Orders    NAME: Related Problems    NAME: diagnostic procedures    NAME: emotional status    NAME: insuring agents    NAME: gastrointestinal obstructive lesions    NAME: less than adequate physical activity or immobility    
NAME: less than adequate dietary intake and bulk    NAME: pain on defecation    NAME: personal habits    NAME: pregnancy    NAME: use of medication and enemas    NAME: weak abdominal musculature    NAME: chemical    NAME: physical    
NAME: evacuates soft, formed stool q[ ]days without pain/strain    NAME: describes contributing factors    NAME: maintains fluid intake of <2,000cc q day    NAME: consumes bulk/high fiber daily    NAME: expresses sense of comfort with ICU/CCU routine    NAME: states anxiety and fears are alleviated    NAME: conserves energy    NAME: demonstrates increased activity/exercise within own limits    
NAME: indicates decreased related stress/anxiety    NAME: presents with normal bowel sounds    NAME: describes methods to reduce or prevent constipation    NAME: overt activity is moderated within [hrs or days]    NAME: expressed need for oxygen is decreased within [hrs or days]    NAME: assess bowel elimination pattern/routine    NAME: assess for signs/symptoms such as:    NAME: verbalizes onset & description of chest pain on 1-10 scale    
NAME: headache    NAME: nausea    NAME: remains hemodynamically stable    NAME: abdominal distention/cramping    NAME: feeling of fullness    NAME: pressure in abdomen/rectum    NAME: identify factors contributing to constipation    NAME: EKG indicates no MI, ongoing ischemia, or extension of MI    
NAME: absence of dyspnea/crackles/wheezes    NAME: monitor effects of laxatives, stool softeners, enemas etc...    NAME: absence of extra heart sounds    NAME: place in sitting position unless contraindicated    NAME: B/P WNL (baseline)    NAME: allow for time in the bathroom or on commode/bedpan    NAME: stable heart rate/rhythm    NAME: level of consciousness WNL, oriented x3    
NAME: provide privacy    NAME: provide comfort    NAME: encourage fluids [ ]cc/day, roughage; discuss rationale    NAME: administer prescribed laxative, stool softener or enema    NAME: states free of pain    NAME: lab values return to normal e.g. enzymes, ABGs, CBC    NAME: use digital stimulation to relax sphincter    NAME: maintains personal integrity and self worth    
NAME: teach patient to respond immediately to elimination urge    NAME: teach adverse effects of habitual use of enemas, laxatives    NAME: free from complications related to immobility/hemostasis    NAME: teach about normal bowel pattern    NAME: absence of DVT    NAME: absence of pulmonary emboli    NAME: extremities freely moveable    NAME: teach when to seek medical attention    
NAME: relates risk factors of CAD    NAME: describes preventive measures related to CAD    NAME: teach side effects of many medications maybe constipation    NAME: attach to cardiac monitor; obtain rhythm strip    NAME: teach to attempt defecation [ ]hr/s after meal and @ [ ]    NAME: document history of pain    NAME: location    NAME: quality    
NAME: intensity    NAME: Etiology/Related and/or Risk Factors    NAME: precipitating and alleviating factors    NAME: Goals/Expected Outcomes    NAME: assess status of chest pain    NAME: Nursing Intervention/Orders    NAME: Related Problems    NAME: contaminants    
NAME: dietary intake    NAME: quality of pain on a scale of 1-10    NAME: inflammation, irritation or malabsorption of bowel    NAME: stress and anxiety    NAME: 12 lead EKG findings    NAME: ST segment elevation [specify location]    NAME: T wave depression [specify location]    NAME: Q waves [specify location]    
NAME: evacuates soft, formed stool q[ ]days without pain/strain    NAME: describes S/S requiring medical attention    NAME: describes methods to manage chronic diarrhea    NAME: verbalizes medication regimen    NAME: verbalizes dietary management regime    NAME: maintains perineal area free from irritation/pain    NAME: reports decrease in diarrhea to [# of episodes]    NAME: identifies factors contributing to diarrhea    
NAME: assess for S/S of decreased cardiac out; monitor, document    NAME: assess for contributing factors such as:    NAME: B/P changes    NAME: oliguria    NAME: tube feedings    NAME: food allergies    NAME: S3 or S4    NAME: untoward side effects    
NAME: situational changes    NAME: assess for impaction    NAME: assess for signs of dehydration    NAME: shortness of breath    NAME: diaphoresis, pallor    NAME: record color, odor, amt., consistency, frequency of stool    NAME: monitor serum electrolytes    NAME: assess general appearance    
NAME: test stool for Guiac    NAME: diaphoretic    NAME: pale    NAME: cyanotic    NAME: anxious/fearful    NAME: about critical care environment and routines    NAME: monitor side effects and tolerance of all medications    NAME: advise patient to notify the nurse of pain/discomfort    
For the entire list of entries see: Here
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