NANDA LIST & NEEDS
1. OXYGEN
NEEDS WITH DIAGNOSES
1. Gas exchange impaired
2. Impaired spontaneous ventilation
3. Suffocation, risk for
4. Ventilatory weaning response
5. Airway clearance, ineffective
6. Breathing pattern, ineffective
7. Aspiration, risk for
8. Cardiac output, decrease
9. Tissue integrity, impaired
10. Tissue perfusion, ineffective (specify
INTERVENTIONS & RATIONALE
1. Assess airway
2. Ensure & maintain a patient airway (To ensure
that patients airway is clear)
3. Place pt in semi/high fowlers position to facilitate
(diaphragmatic expansion adding adequate
ventilation) adequate lung expansion
4. Administer & maintain humidified oxygen (3-5L)
as ordered (to improve tissue oxygenation)
5. Keep room well ventilated (Ensure room is
adequately ventilated) --- (to ensure adequate
oxygen supply)
6. Monitor SPO2 using pulse oximetre (to detect
amount of oxygen available)
7. Suction prn/Q2H, unless contraindicated --- (to
clear the airway and stimulate cough)
8. Monitor peripheral pulse --- (to assess peripheral
perfusion)
9. Assess nail-bed/capillary refill
10. Observe for signs of cyanosis (to indicate
hypoxia)
11. Encourage pt to cough & deep breathe (to clear
airway & facilitate oxygen delivery to lungs)
12. Encourage use of incentive spirometre
13. Monitor v/s especially respiration for rate & depth
(for baseline data then to determine any
improvement or deterioration)
14. Auscultate breath sounds q2-4 hrs noting
adventitious sounds (to indicate congestion)
1
15. Advise pts not to smoke especially during O2
therapy (as this reduces the oxygen capacity of the
lungs & causes more hypoxia)
16. Cluster or space nursing activities (allowing time
for rest to avoid fatiguing pt)
17. Place on bed rest & observe closely
18. Administer anti-histamine/anticholingergic as
prescribed eg. Atropine
19. Ensure chest physiotherapy (to loosen secretions)
20. Monitor ABGs (to detect severe hypoxia or
acidosis)
21. Keep resuscitation equipment closely.
22. Collect sputum specimen & send for culture &
sensitivity
23. Record & report abnormalities as necessary
24. Monitor chest expansion & observe for splinting
25. Note oscillations in under water seal system

2
2. REST COMFORT AND ACTIVITY

NEEDS WITH DIAGNOSES INTERVENTIONS & RATIONALE

1. Activity intolerance
1. Allow/facilitate total bed rest
2. Activity intolerance risk for
2. Provide a quiet environment
3. Adjusted, impaired
3. Encourage arm exercises (eg. Breast Ca post-op
4. Body temperature: imbalance risk for
pts.)
5. Diversional activity, deficient
Elevate arms --- to promote lymphatic drainage &
6. Dysreflexia, autonomic
prevent infection
7. Dysreflexia, autonomic risk for
Alternate periods of rest with activity --- to decrease
8. Energy field, disturbed
O2 demand
9. Fatigue
Liase with & provide care by physiotherapy
10. Health maintenance, ineffective
4. Position pt appropriately
11. Hyperthermia
To teach activities for strength & endurance --- to
12. Hypothermia
improve breathing & gradually increase activity
13. Mobility, bed, impaired
level
14. Mobility, wheelchair, impaired
5. Perform ROM exercises
15. Pain acute
Support & encourage activity, pts level of tolerance
16. Pain, chronic
& helps develop pts. independent
17. Peri operative positioning injury, risk
6. Perform total/assisted bed bath
for
7. Provide backrubs
18. Self-care deficit, bathing/hygiene
8. Allow pt to participate in ADL & teach how to
19. Self-care deficit: dressing/grooming
conserve energy --- to reduce cellular metabolism
20. Sleep deprivation
& O2 demand.
21. Sleep pattern disturbed
9. Formulate exercise plan before discharge with pt -
22. Sleep, readiness for enhance
-- encourage satisfaction & compliance
23. Social isolation
10. Keep bed linen clean, wrinkle free dry & tact
24. Social interaction, impaired
11. Provide diversional activities
25. Surgery, recovery, delayed
12. Provide clean environment
26. Urinary elimination, impaired
13. Assist with ambulation
27. Urinary incontinence, urge
14. Allow feet to dangle by sitting out (bed ridden Pt)
28. Urinary incontinence, total

3
29. Urinary retention
30. Home maintenance, impaired
15. Allow pt to sit out of bed
16. Cluster care/group activities --- to prevent over
exercise
17. Administer medication before procedures that may
be considered painful (eg. Analgesics)
18. Avoid pressure to painful areas
19. Ensure strict bed rest
20. Assess for pain & medicate (Analgesics) as ordered
21. Room temperature
22. Mild sedatives
23. Restrict visitors
24. Dietary restrictions to relieve symptoms of radium
enteritis
25. Treat hematuria
26. Fluid restrictions to prevent nocturia
27. Position pt on unaffected side
28. Position affected arm elevated on pillow
29. Assist with turning
30. Ensure quiet environment
31. Encourage deep breathing exercises
32. Assess post op day pain level using pain scale
33. First instruct pt to get out of bed on unaffected side
34. Cluster nursing care activities, allowing time for
rest to avoid fatiguing pt
35. Monitor response to each activity & observe for the
development of dyspnea to determine tolerance
levels
36. Assess v/s prior to activity, immediately after & 3
mins later to determine the length of time v/s take
to return to baseline which determines the degree
of cardiac de conditioning & slows the nurse to
plan activities
4
37. Limit activities to avoid fatigue that demands more
cardiac output than the heart can manage
38. Ensure pt is in high fowlers position to promote
comfort
39. Elevate limbs at intervals to help reduce edema
40. Nurse the pt on pressure reduction mattress
41. Assist to change position q2 hly
42. Assist with AODL
43. Place items within easy reach (personal items)
44. Monitor stressful situations that cause exertion eg.
Too much visitors & address this
45. Administer meds as ordered
46. Educate mother to bathe child with emulsifier to
soothe skin
47. Change bed linen/clothing prn & wash with warm
water -- to improve comfort
48. Change night gown nightly to facilitate rest &
comfort
49. Avoid hot water baths as it exacerbate symptoms &
increase itching
50. Pat dry skin thoroughly after baths & apply
ointment as prescribed eg. Betnovate cream
51. Encourage use of cotton clothes to absorb moisture
& keep body cool
52. Allow pt to participate in care to promote
independence
53. Assist pt with personal hygiene & grooming eg.
Combing hair so pt can feel good about self
54. Assist with appropriate choice of clothes to
increase social acceptance
55. Administer antidepressant as ordered to stabilize
mood

5
56. Position pt on lateral side. To promote drainage
from T-tube
57. Support incision site when coughing or
turning. Ask pt to splint abdomen when coughing
58. Nurse pt in a cool room
59. Observe for kinks/blocks in tube
60. Early ambulation
61. Allow enough tube leeway to promote comfort &
prevent tube being dislodged when moving
62. Provide diversional activities
63. Apply skin protectant eg. Zinc oxide
64. Observe site for swelling, redness
65. Bed rest with head elevated
66. Provide warmth
67. Explain to child the importance of staying in bed
to get childs cooperation & to let child
understand why
68. Maintain strict bed rest to decrease workload on
the heart
69. Allow child to assume comfortable position (any
desired position) to promote comfort
70. Administer analgesics as ordered to reduce
symptoms of pain in the joint
71. Give total pt care eg. Assisted bed baths, assist with
meals to avoid over exertion
72. Ensure environment is well ventilated to increase
comfort & promote rest
73. Gradually increase activity according to tolerance
level to prevent exertion & exhaustion
74. Include child in grooming self to promote
independence provide diversional therapies eg.
Reading, watching TV to decrease anxiety
which would cause workload of heart to increase

6

3. SAFETY & SECURITY
NEEDS WITH DIAGNOSES
1. Aspiration, risk for
2. Body temperature: imbalance, risk for
3. Disuse syndrome, risk for
4. Environmental interpretation syn.
Impaired
5. Falls, risk for
6. Health maintenance, ineffective
7. Hyperthermia
8. Hypothermia
9. Development: delayed, risk for
10. Infection risk for
11. Injury, risk for
12. Latex allergy response, risk for
13. Latex allergy response
14. Mobility: physical, impaired
15. Mobility: wheelchair, impaired
16. Neurovascular dysfunctional:
peripheral, risk noncompliance (specify
17. Oral mucous membrane, impaired
18. Pain (acute
75. Use of bed cradle to prevent sheet from shering
on joints
INTERVENTIONS & RATIONALE
1. Monitor vital signs- ---- for signs of
shock/infection
2. Remove hazards from the environment
3. Observe op site for bleeding
4. Record & report drainage
5. Ensure tube patency
6. Provide wound care using aseptic technique
7. Provide catheter care
8. Avoid performing procedures (eg. BP, IV access,
blood sampling & injection) on affected areas
(contraindicated)
9. Ensure adequate lighting of room
10. Educate pt to wear medic alert bracelet
11. Test bathe water & heating pad before applying
it to the patient
12. Interpret lab results & report abnormalities
13. Teach appropriate skin & (pressure area care)
PAC
14. Place pt near the nurses station
7
Preoperative positioning injury, risk for)
19. positioning, risk for
20. Protection, ineffective
21. Self mutilation
22. Skin integrity, impaired
23. Spontaneous ventilation, impaired
24. Sudden infant death syndrome, risk for
25. Suffocation, risk for
26. Suicide, risk for
27. Surgical recovery, delayed
28. Swallowing, impaired
29. Tissue integrity, impaired
30. Tissue perfusion, ineffective (specify
31. Trauma, risk for
32. Ventilatory weaning response,
dysfunction
33. Violence: other-directed, risk for
34. Violence: self directed, risk for
35. Walking, impaired
36. Wandering
37. Sensory perception, disturbed
38. Thermoregulation, ineffective
15. Medicate as ordered, ensuring the 6 rights of
medication
16. Encourage use of adaptive devices
17. Provide skin care & hygienic needs prn
18. Orient pt to (time, place & person) TPP
19. Ensure things are within the pts reach
20. Ask the family members to sit with the pt
21. Assure wound care to ulcers, also turn &
provide PAC Q2H
22. Ensure pt. is adequately immunized
23. Isolate infected person with contagious
disorders
24. Maintain hydration status
25. Safe houses & well lit areas/homes & house
safety for elderly & children
26. Bed rest while implant is in place
27. Nurse with head to door & feet to wall
28. Organize care & perform with speed
29. Place radioactive sign on door
30. Protection worn by staff
31. Restrict visitors/Limit visitors
32. Never pick up dislodged radioactive source with
hands
33. Restrict access to pregnant nurses
34. Notify radiation therapist immediately if source
becomes dislodged
35. Store/save all dressings/bed linens
36. Keep covered long handle forceps in room
(never use hands)
37. Keep lead cover container in room
38. Monitor chest tube drainage
39. Nurse with bed rails up
40. Monitor for signs of hypovolemic shock
8
41. Assist with oral & personal hygiene
42. Dress wound prn & observe for signs of
hemorrhage, infection
43. Monitor v/s
44. Administer antibiotics as ordered
45. Monitor u/cath drainage
46. Perform catheter care
47. Administer narcotic analgesics as ordered
48. Encourage rest (to facilitate healing)
49. Assist with pertinent lab studies
50. Monitor for reaction to blood transfusion
51. Ensure hemorrhage drainage system is patent,
assess drainage site, noting color & consistency
52. Monitor v/s q15 mins for the first hr, then1/2
hrly until stable
53. Position pt on lateral side till fully wake
54. Elevate affected arm on pillow
55. Nurse pt with bed rails up -- (to prevent risk for
injury from fall)
56. Place pt in lateral position on side with t-tube
until awakened
57. Clean suture site with n/s & dress with dry gauze
58. Observe wound site for colour, consistency &
amount of drainage
59. Ambulate first post-op day
60. First post-op day encourage use of affected arm
such as opening & closing fist, flexing &
extending elbow each hr
61. Teach pt to avoid touching the dressing &
drainage device
62. Perform drain site care using aseptic technique
63. Ensure no B/P on affected arm & post sign
alerting other members of the health team.

9
64. Ensure no IM injection on affected arm of
venipuncture
65. Administer prophylactic antibiotics as ordered
66. Monitor IV site for signs of infiltration
67. Pt should demonstrate the ability to empty &
change the bag independently before discharge
68. Teach signs & symptoms of infection,
obstruction to the intestine & perforation
69. Teach pt that if infection occurs, to return to dr
immediately
70. Teach the importance of taking meds as
prescribed for pains & infection or to reduce
motility
71. When changing bag, prevent contamination of
surgical would by fecal matter (change bag
when full)
72. Teach how to change bag, where to buy new
ones assess pts efficiency
73. Report diarrhea, constipation, examine
electrolytes imbalances
74. Encourage client to join support groups
75. Rest adequately to prevent embolism, thrombus
formation
76. Teach how to assess stoma. Site should be red
& moist. Report if stoma becomes dark & dusky
77. Clean skin around stoma with mild soap &
water, treat skin with barrier cram before
applying pouch
78. Change pouch q4-5 dys or more often if leakage
occurs
79. Inform client to clean skin regularly around
stoma to prevent irritation

10
80. Teach how to irrigate bowel to develop bowel
pattern
81. Administer meds as ordered eg. Slow k to
replace potassium to maintain electrolyte
balance
82. Assess pulse rate before administering digoxin
& give only if above 60 bpm
83. Assess/monitor prn for signs of digitalis toxicity
(tachycardia, confusion, headache)
84. Monitor lab results for serum digitalis &
potassium levels
85. Administer antihypertensive if ordered
86. Assess for hypokalemia (tready weak pulse,
postural hypotension, anxiety, lethargy,
confusion, nausea, vomiting)
87. Assess mental status
88. Ensure that child nails are kept short to prevent
irritation to skin when she scratches skin
89. Avoid food that triggers flare ups
90. Apply topical ointments as ordered
91. Monitor for effectiveness & side effects on meds
92. Place clean cotton glove or sock over childs
hand to reduce irritation to skin from
scratching, reducing the chance of secondary
infection
93. Monitor for signs of secondary infection
94. Avoid use of harsh soaps, perfumed soaps that
can trigger flare ups
95. Use moisturizers immediately after baths to
retain skin moisture
96. Use of wet wraps to give moisture back to skin

11
97. Explain the importance of following treatment
plan to promote healing & reduce risk
secondary infection
98. Use of bed accessories eg. Bed cradles to keep
sheets from off joints
99. Use of accessory gadgets eg. Padded rails for
protection, from child accidentally hitting rails
which would increase pain
100. Monitor pt & mediate as ordered with
anti inflammatory & antibiotics as ordered to
reduce pain & inflammatory process & halt
progression of disease
101. Nurse pt away from other pt with
infection to reduce the risk of pt contracting a
secondary infection
102. Monitor pt for side effects & effectiveness
of meds administered to determine
effectiveness of meds for further interventions
103. Monitor vital signs for abnormalities eg.
Increase temp-that would indicate infection
104. Maintain food nutritional state (serve
meals high in nutrients & vitamins) to boost
immune system & for adequate nutrition
105. Observe for swelling to detect fluid
retention, for further complications of disease
106. Maintain intake & output charts
107. Monitor hydration status to detect
excess fluid loss
108. Test urine for specific gravity an
increase indicates dehydration
109. Encourage high fiber & adequate fluid
intake to reduce risk of complications
110. Hand washing between handling pts

12
111. Skin & pressure are a care
112. Compliment her on her appearance to
boost self esteem

13
 4. NUTRITIONAL

NEEDS WITH DIAGNOSES INTERVENTIONS & RATIONALE

1. Aspiration, risk for 1. Provide mouth care Q2H

2. Breastfeeding, effective 2. Assess for gag reflex
3. Breeding, ineffective 3. Encourage oral feeds
4. Breastfeeding, interrupted 4. Provide vitamin supplementation
5. Constipation 5. Provide small frequent meals
6. Constipation, perceived 6. Place in high fowlers/a comfortable position
7. Constipation, risk for while feeding---- to prevent aspiration
8. Dentition, impaired 7. Monitor intake & output
9. Diarrhoea 8. Administer clear fluids & graduate accordingly
10. Development: delayed, risk for post operatively
11. Energy field, disturbed 9. Keep NPO (pre-op, post-op, as ordered)
12. Failure to thrived, adult depending on time
13. Growth and development, delayed 10. Assess bowel sounds
14. Health maintenance, ineffective 11. Keep environment free from odour also clean &
15. Infant feeding pattern, ineffective calm
16. Nausea 12. Assist with feeding as necessary
17. Nutrition, imbalance: less than body 13. Administer parenrtal feed as ordered
requirements 14. Administer IVF & adequate fluids
18. Nutrition, imbalance: more than body 15. Monitor hydration status
requirement 16. Ascertain pts likes & dislikes
19. Nutrition, imbalance: More than body 17. Assess allergies to food
requirements, risk nutrition, readiness 18. Refer to dietician as necessary
for enhance 19. Ensure adequate fluid 200mls/day
20. Self-care deficit: feeding 20. Replace fluid loss (eg. Diarrhoea & vomiting )
21. Skin integrity, impaired with IVF/oral fluids
22. Skin integrity, risk for impaired 21. Monitor U&Es especially Na & K
23. Tissue integrity impaired 22. Monitor pulse rate as K affects heart rate
23. Weigh pt daily before breakfast to determine
weight gain indicating fluid retention
14
24. Ensure low sodium diet as ordered to prevent
tubular re-absorption of water leading to
increased edema
25. Avoid alcohol consumption & proper handling,
preparation of food
26. Utilize local foods/backyard garden & food
economic purchasing
27. Availability & accessibility of food & expiry date
on foods
28. Appropriate diet for children & adults eg.
Menstruating women need increased iron in
diet
29. NPO status
30. Maintain fluid balance chart
31. Administer anti emetic to reduce vomiting
32. Clear fluids after 24hrs post op
33. NG feeds for severe dietary resistance
34. Soft, low residue diet as tolerated
35. Avoid sights, smells which may predispose to
vomiting
36. Vitamin supplements
37. Assess mothers knowledge about nutrition
38. Educate on meal preparation for age
39. Teach mother about substitution list
40. Assess for bowel sounds before feeds
41. Educate on importance of one-pot meals eg.
Soups, seasoned rice
42. Educate her about economic shopping
43. Encourage to offer a variety of meals to
enhance appetite
44. Offer nutritious snacks eg. Finger foods
45. Provide attractive & colorful meals

15
46. Encourage mother to sit with child & assist with
feeds
47. Encourage mother to keep appointments at well
baby clinic
48. Educate on social services available eg. Food
stamp programme
49. Develop a 1-1 pt relationship (to build trust)
50. Listen to pt & allow her to talk (to find out the
problem)
51. Asses nutritional status (base line data)
52. Ask pt food preferences (to plan meals
accordingly)
53. Serve foods at right temperature (to make food
palatable)
54. Allow pt to eat with other pts (to encourage
eating to meet nutritional needs)
55. Weekly weights (to detect weight gain/loss
56. Serve small frequent meals that are nutritionally
balanced at least thee times /day (to ensure pt
pt gets adequate nutrients
57. Remove environmental stimuli eg. Bed pans (to
provide a pleasant surrounding conducive to
eating)
58. Involve family/significant other to assist in
preparation
59. Provide mouth care prn
60. Involve dietician
61. Check dentition (to know type of food to prepare
eg. Soft diet
62. Assist with feeding if necessary
63. Maintain IV therapy as ordered
64. Give diet low in at & high carbohydrates &
proteins when tolerated & as ordered

16
65. After 5-6 days clamp T-tube 1hr before & after
meals as ordered
66. Avoid food that cause adverse GI symptoms
67. Observe for incidence of NVD, flatulence &
abdominal discomfort

17
5. ELIMINATION

NEEDS WITH DIAGNOSES INTERVENTIONS & RATIONALE

1. Constipation
1. Monitor intake & output
2. Constipation, perceived
2. Note characteristics (amount, odour, colour, and
3. Constipation, risk for
bout/day) of output (eg. Urine, vomitus, stools---
4. Diarrhoea
insensible fluid loss eg. Sweat)
5. Fluid balance: readiness for enhance
3. Monitor & administer fluids as
6. Fluid volume, deficient
ordered/prescribed
7. Fluid volume excess
4. Ensure fluid restriction where necessary
8. Self-care deficit: toileting
5. Monitor for signs of fluid overload
9. Urinary elimination, readiness for
6. Monitor for signs of increase fluid loss
enhanced
(dehydaration)
10. Urinary elimination impaired
7. Pass or assist with passing a urinary catheter
11. Urinary incontinence, reflex
8. Ensure no kinks
12. Urinary incontinence, stress
9. Ensure proper anchoring of tubing
13. Urinary incontinence, urge
10. Perform catheter care
14. Urinary incontinence, risk for urge
11. Monitor wound drainage, NG aspirate, vomiting
15. Urinary retention
12. Report & record colour, consistency, amount &
16. Body temperature: imbalanced, risk for
odour of wound drainage (if present)
17. Skin integrity, impaired
13. Ensure tube patency
18. Tissue integrity, impaired
14. Ensure proper flow of solution by gravity
19. Tissue perfusion, ineffective
15. Observe voiding pattern & bowel habits
20. Urinary incontinence, total
16. Administer laxatives & diuretics as prescribed
17. Offer/remove bed pan, urinals or commode
18. Hand washing before & after
19. Perineal care teach female pts and family to
clean from front to back
20. Assist the child to the toilet and change pampers
prn
21. Provide skin care after stool
22. Nothing by mouth (NPO)

18
23. Request results of appropriate lab test eg. Serum
electrolyte
24. Pass NG tube
25. Monitor for hydration status
26. Monitor electrolyte imbalance
27. Monitor infusion rate & signs of infiltration
28. Assist with lab studies for electrolyte imbalances
29. Record & report condition
30. Monitor drains & chart output
31. Graduated fluids/feeds as ordered when fully
awake
32. Assist with fluid & electrolyte studies
33. Teach how to irrigate stoma & regulate bowel
when stool is hard
34. Importance of taking meds as ordered such as
stool softener
35. Increase fluid & vegetable fiber if constipation
occurs
36. Avoid eating gas forming foods such as legumes
37. Teach how to ruffle passage of gas from
colostomy
38. Use over proof pouches
39. Teach how to dilate stoma with glove/lubricated
finger
40. Monitor & Record urinary frequency & output
carefully. Initial drainage 500-1000ml
41. Provided privacy
42. Administer cardiac glycoside to improve blood
flow to kidneys/urinary system to aid exertion of
excess fluid
43. Palpate bladder for distention & provide
measures t aid in urinary output
44. Assess effectiveness of diuretic therapy

19
 45. Monitor for signs of peritonitis & report

7. PSYCHOSOCIAL

NEEDS WITH DIAGNOSES INTERVENTIONS & RATIONALE

1. Adjustment, impaired
1. Assess pt & family concerns/fears
2. Anxiety
2. Identify previous coping mechanism for use in
3. Anxiety, risk for
stressful times
4. Attachment, parent/child/infant, risk for
3. Correct disability or potentially disabling coping
impaired
mechanism
5. Body image, disturbed
4. Provide emotional support
6. Caregiver role strain, risk for
5. Allow pt time to ask questions --- to encourage
7. Caregiver role strain
verbalization & ventilation of feelings
8. Communication, readiness for enhanced
Answer questions clearly & honestly
9. Communication :verbal, impaired
Refer where necessary
10. Confusion, acute
6. Build a therapeutic relationship --- to establish
11. Confusion, chronic
rapport
12. Coping: community, readiness for
Have someone with similar condition to talk to the
enhance
pt
13. Coping, defensive
Involve pt in his/her care
14. Coping : family, disable
7. Refer to appropriate support group
15. Coping, Ineffective (individual/family)
Facilitate communication between pt & significant
other
Encourage pt (eg. With breast Ca) to look at
incision
Teach pt how to clean wound
Educate about signs & symptoms of infection
8. Encourage pt to express self to allay fear &
anxiety
9. Listen alternatively
10. Ensure & facilitate family visits

20
11. Encourage spiritual advisors/clergy visits
12. Educate the pt & family
13. Empathize with pt to display caring attitude
14. Ensure soft voice tone
15. Explain reasons why care givers cannot stay long
with pt
16. Explain cause of skin changes
17. Allow for expression of fear & anxiety
18. Include family members in management of care &
encourage their support
19. Develop a nurse pt relationship
20. Provide psychological rest by maintaining a calm &
quiet environment
21. Answer questions truthfully & listen to pt fears &
concerns
22. Encourage pt to participate in & make decisions
about care
23. Assess for signs of anxiety & ally fears
24. Counsel client about any life style changes
25. Refer to support groups
26. Refer to substance abuse centre
27. Reassure patients
28. Empathize with patient

Self Esteem

1. B build on strength
2. E encourage healthy relationships
3. D develop confidence
4. R respect individuality
5. E encourage independent thinking
6. S- show recognition & appreciation
7. P Provide positive re-enforcement eg. Praise

21
8. I incorporate them in decision making with
regards to their own health
9. Encourage self care skills
10. Assist with resetting goals
11. Help to accept body image
12. Strengthen peer s & family relationship
13. Build problem solving skills

LOVE & BELONGING

1. Sense of worth realization

2. Read with patient
3. Social worker encourage to visit
4. Provide privacy for married couple
5. Build self esteem
6. Educate about prosthesis
7. Praise/encourage patient method of doing this
8. Teach family how to care for patients
9. Build confidence
10. Establish and develop rapport
11. Develop trust
12. Maintain confidentiality
13. Refer patient when in doubt/ not knowledgeable
14. Do not give false hope
15. Increase family participation in plan
16. Involve family members in decision making
17. Plan family activities
18. Foster roles & responsibilities assignments
19. Conflict resolution & develop sense of trust
20. Involvement in community group
21. Ability to give & accept love
22. Maintain privacy
23. Develop nurse pt relationship

22
24. Encourage pt to participate in basic care
25. Listen to pt attentively
26. Assist in meeting spiritual needs
27. Maintain acceptance & non-judgmental attitude
28. Involve patient in decision making about care
29. Involve family in decision making about care
30. Restrict visitors to family
31. Keep family abreast of pts condition
32. Arrange family conference with dr
33. Record & report care given
34. Develop a nurse pt relationship
35. Encourage pt to verbalize feelings re-change in
body structure
36. Encourage pt to look at op-site
37. Encourage husband to support & to look at site
38. Refer to support groups on discharge
39. Assess pt for fear & uncertainty, apprehension
40. Establish 1-1 rapport to build trust, good
interpersonal relationships & co-operation
41. Allow pt to ventilate feelings to identify problems
42. Frequent visits from family to feel loved & cared
for
43. Participate in group therapy to increase
socialization & express feelings
44. Counseling sessions for pts & family to enable
family to understand condition & assist in care
45. Counsel ling sessions with pt at least 15 mins per
session to help client find alternatives to
problems

23
24