Activity Intolerance

NANDA Definition
Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Discussion of the Problem

Activity tolerance is the type and amount of exercise or daily living activities an individual is able to
perform without experiencing adverse effects. Functional strength is the ability of the body to perform work. When
activity tolerance and functional strength had been affected by a certain condition, it leads to activity intolerance.
Activity intolerance is usually associated to generalized weakness (body malaise) and debilitation secondary to acute
or chronic illness and disease. Medical conditions that could lead to activity intolerance are as follows: hypertension,
heart failure, myocardial infarction, anemia and end of life conditions. This problem is especially apparent in
geriatric patients who have the mentioned medical problems. In addition, the aging process causes reduction in
muscle strength and function, which can impair the ability to maintain activity. Other factors that contribute to
activity intolerance are as follows: obesity, malnourishment, side effects of medications, depression or lack of
confidence to exert one's self. Nursing goals are as follows: to reduce the effects of inactivity, promote optimal
physical activity, and assist the patient to maintain a satisfactory lifestyle.

Nursing Interventions Classification (NIC)

 Energy Management
 Teaching: Prescribed Activity/Exercise

Nursing Outcomes Classification (NOC)

 Activity Tolerance
 Energy Conservation
 Knowledge: Treatment Regimen

Goals and Objectives

 Patient will adjust lifestyle to energy level
 Patient will demonstrate a reduction in physiological signs of tolerance
 Patient will express understanding of potential loss of ability in relation to existing condition
 Patient will Identify negative factors affecting performance and will remove or will minimize their effects
when possible
 Patient will maintain activity level within capabilities, as evidenced by the following: normal heart rate and
blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue.
 Patient will report a measurable augmentation in activity tolerance, manifested by reduced fatigue and
weakness and by vital signs within acceptable limits during activity
 Patient will report absence of chest pain with activity
 Patient will take part in necessary or desired activities, and will meet own self-care needs
 Patient will verbalize and utilize energy-conservation techniques.

Subjective and Objective Data

 Abnormal heart rate or blood pressure (BP) response to activity
 Changes in skin color/moisture
 Changes in vital signs
 Disinterested in surroundings/introspection
 Electrocardiogram (ECG) changes reflecting ischemia; dysrhythmias
 Exertional angina
 Exertional discomfort or dyspnea
 Generalized weakness
 Inability to begin or perform activity
 Lethargic; drowsy; decreased performance
 Pallor, diaphoresis
  Report of lack of energy, inability to maintain usual routines
 Verbal report of fatigue or weakness
 Verbalizes no desire and/or lack of interest in activity

Related Factors
 Cognitive deficits/emotional status, secondary to underlying disease process/depression
 Deconditioned state
 Depression or lack of motivation
 Generalized weakness
 Imbalance between oxygen supply and demand
 Imposed activity restriction
 Insufficient sleep or rest periods
 Pain, extreme stress
 Presence of ischemia/necrotic myocardial tissues
 Prolonged bed rest or immobility; progressive disease state/debilitating condition
 Sedentary lifestyle
 Side effects of medications; Cardiac depressant effects of certain drugs (beta-blockers, antidysrhythmics)

Assessment (Dx)
 Determine patient's opinion of causes of fatigue or activity intolerance. The cause may be temporary or
permanent, physical or psychological. Determination guides treatment.

 Assess level of mobility of the patient. Defining what the patient is capable of is necessary before setting
realistic goals.

GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT TOOL

ACTIVITY-EXERCISE PATTERN ASSESSMENT
SUBJECTIVE
1. Have patient rate each area of self-care on a scale of 0 to 4.

0 – Completely independent
1 – requires use of equipment or device
2 – requires help from another person for assistance, supervision or
teaching
3 – requires help from another person and equipment device
4 – dependent; does not participate in activity

Feeding__; Bathing/hygiene__; Dressing/grooming__; Toileting__; Ambulation__;

Care of home__; Shopping__; Meal preparation__; Laundry__; Transportation__

2. Oxygen use at home? No__ Yes__ Describe: ______________________

3. How many pillows do you use to sleep on?_____
4. Do you frequently experience fatigue? No__ Yes__ Describe: _________
5. How many stairs can you climb without experiencing any difficulty (can be individual
number or number of flights)? ___________________________
6. How far can you walk without experiencing any difficulty? _____________
7. Has assistance at home for self-care and maintenance of home:
No__ Yes__ Who? __________ If no, would you like to have or believes needs
assistance: No__ Yes__ With what activities? _________________
8.Occupation (if retired, former occupation): _________________________
9.Describe you usual leisure time activities/hobbies: ___________________
10. Any complaints of weakness or lack of energy? No__ Yes__ Describe:
11. Any difficulties in maintaining activities of daily living? No__ Yes__ Describe:
12. Any problems with concentration? No__ Yes__ Describe: ______

OBJECTIVE
1.Cardiovascular
a. Cyanosis: No__ Yes__ Where? _______________________________
b. Pulses: Easily palpable?
Carotid: Yes__ No__; Jugular: Yes__ No__; Temporal: Yes__ No__
Radial: Yes__ No__; Femoral: Yes__ No__; Popliteal: Yes__ No__;
Postibial: Yes__ No__; Dorsalis Pedis: Yes__ No__
c. Extremities:
i. Temperature: Cold__ Cool__ Warm__ Hot__
ii. Capillary refill: Normal__ Delayed__
iii. Color: Pink__ Pale__ Cyanotic__ Other__ Describe: __________
iv. Homan’s sign: No__ Yes__
v. Nails: Normal__ Abnormal__ Describe: _____________________
vi. Hair distribution: Normal__ Abnormal__ Describe: ____________
vii. Claudication: No__ Yes__ Describe: _______________________
d. Heart: PMI location: ________
i. Abnormal rhythm: No__ Yes__ Describe: ___________________
ii. Abnormal sounds: No__ Yes__ Describe: ___________________

2.Respiratory
a. Rate:__ Depth: Shallow__ Deep__ Abdominal__ Diaphragmatic__
b. Have patient cough. Any sputum? No__ Yes__ Describe: ___________
c. Fremitus: No__ Yes__
d. Any chest excursion? No__ Yes__ Equal__ Unequal__
e. Auscultate chest:
i. Any abnormal sounds (rales, rhonchi)? No__ Yes__ Describe: __
f. Have patient walk in place for 3 minutes (if permissible):
i. Any shortness of breath after activity? No__ Yes__
ii. Any dypnea? No__ Yes__
iii. BP after activity: ___/___ in (right/left) arm
iv. Respiratory rate after activity: _______
v. Pulse rate after activity: _______

3.Musculoskeletal
a. Range of motion: Normal__ Limited__ Describe: __________________
b. Gait: Normal__ Abnormal__ Describe: __________________________
c. Balance: Normal__ Abnormal__ Describe: ______________________
d. Muscle mass/strength: Normal__ Increased__ Decreased__
Describe: ________________________________________________
e. Hand grasp: Right:: Normal__ Decreased__
Left: Normal__ Decreased__
f. Toe wiggle: Right: Normal__ Decreased__
Left: Normal__ Decreased__
g. Postural: Normal__ Kyphosis__ Lordosis__
h. Deformities: No__ Yes__ Describe: ____________________________
i. Missing limbs: No__ Yes__ Where? ____________________________
j. Uses mobility aids (walker, crutches, etc)? No__ Yes__ Describe: ____
k. Tremors: No__ Yes__ Describe: ______________________________
4.Spinal cord injury: No__ Yes__ Level: ____________________________
5. Paralysis present: No__ Yes__ Where? ___________________________
6.Developmental Assessment: Normal__ Abnormal__ Describe: _________

FUNCTIONAL LEVEL CLASSIFICATION (GORDON, 1987)

Level 1 Walk, regular pace, on level indefinitely; one flight or more but more short of breath
than normally
Level 2 Walk one city block or 500 ft on level; climb one flight slowly without stopping
Level 3 Walk no more than 50 ft on level without stopping; unable to climb one flight of
stairs without stopping
Level 4 Dyspnea and fatigue at rest

 Assess for possible physical injury with activity. Injury may be results of falls or overexertion.

 Review nutritional status or the use of food supplements. Adequate reserves of energy are necessary for
activity.

 Assess need for ambulation aids, such as bracing, cane, walker, equipment modification, for activities of
daily living (ADLs). Some aids may necessitate more energy expenditure for patients who have diminished
upper arm strength. Sufficient estimation of energy requirements is indicated.

AMBULATORY (GAIT) AIDS

Purposes
1. To increase area of support
2. To decrease loading & demand on the lower extremities. & skeletal structures
3. To reduce lower limb pain
4. To assist with acceleration & deceleration during ambulation
5. To provide additional sensory information

Indications
1. For need of increase in balance
2. For pain reduction of the lower extremities
3. For decreased weight bearing on the injure/inflamed lower extremity
4. For compensation of weak muscles.

ENERGY USING IN GAIT TRAINING AMBULATION

GAIT TRAINING % ENERGY INCREASE
(FROM NORMAL AMBULATION)
Three point (NWB) 61
Three point (PWB) 36
Two point 18
Swing through 41
Wheelchair 9

 Assess patient's cardiopulmonary status before activity using the following measures:
1) Chest pain or dyspnea; too much weakness and fatigue
2) Dizziness or fainting; excessive perspiration
3) Effect of Valsalva maneuver on heart rate. When patient moves in bed, the patient holds breath
and bears down. This then causes bradycardia and decreased cardiac output.
4) Heart rate should not rise to more than 20 to 30 beats per min over resting with routine activities.
Depending on the intensity of exercise the patient is attempting, this range will change.
5) Oxygen demand with increased activity. Evaluation for oxygen desaturation can be done with the
aid of portable pulse oximetry. Compensation for the increased oxygen demands can be aided by
supplemental oxygen.
6) Postural hypotension. Geriatric patients are more prone to drops in blood pressure with changes is
position.
  Monitor sleep pattern of the patient and amount of sleep for the recent days. Sleeping difficulties should be
prioritized before activity progression can be achieved.

 Monitor and document response to activity. Report any of the following:

1) Body malaise, fatigue
2) Dizziness, excessive perspiration, lightheadedness, pallor
3) Increase or decrease of about 20 mm Hg in systolic BP
4) Labored breathing
5) Palpitations
6) Rapid pulse (120 beats per min during resting rate )
A guide for optimal progression of activity is provided during close monitoring of these responses to
activity.

 Assess response of the patient’s emotions with regards to change in physical status. Inability to perform
required activities can result to depression that could further worsen the activity intolerance.

Therapeutic Interventions (Tx)

 Anticipate patient's needs.

 Assist with ADLs as indicated. Supporting the patient with ADLs allows for conservation of energy.

 Avoid performing unnecessary procedures. Patients with limited tolerance to activity need to prioritize
tasks.

 Combine activity periods with ample rest periods, especially for the following: during ambulation, before
meals, other ADLs, and exercise sessions. Time for energy conservation and recovery is provided during
rest between activities.

 Help out patient to plan activities during the times when the patient has the most energy. Not all self-care
and hygiene activities need to be completed at once. Likewise, not all house chores need to be done in a
day.

 Offer bedside commode as indicated. This reduces expenditure of energy. It must be noted that a bedpan
would require more energy than a commode.

 Set up guidelines and goals of activity with the patient and caregiver. Goal setting involving participation
of the patient enhances motivation. Depending on the cause of the activity intolerance, some patients may
be able to live independently and work outside the home, while others remain homebound.

 Progress activity slowly, as with the following:

1) Active range-of-motion (ROM) exercises in bed, progressing lying to sitting and standing
2) Dangling of feet 10 to 15 minutes three times a day.
3) Deep breathing exercises three times a day
4) Sitting up in chair 30 minutes three times a day
5) Walking in room 1 to 2 minutes three times a day
This promotes achievement of short-range goals and avoids overexerting the heart.

 Offer emotional support while the patient increases his/her activity. Upholds a positive attitude regarding
abilities.

Educative (EDx)
 Encourage expression of feelings with regard to limitations. Coping is enhanced, when it is acknowledged
that living with activity intolerance is both physically and emotionally difficult.
  Persuade performing of active ROM exercises three times a day. Exercises sustain muscle strength and
joint ROM.

CLIENT TEACHING: ACTIVE ROM

Exercises
1. Execute each ROM exercise as trained to the point of slight resistance, but not beyond, and by
no means to the point of discomfort.
2. Execute the actions systematically, using the similar sequence during each session.
3. Execute each exercise thrice.
4. Execute each series of exercises twice a day.
5.
Geriatric considerations
 For geriatric patients, it is not necessary to attain full ROM in all joints. Emphasize instead on
achieving a adequate ROM to carry out activities of daily living, such as the following: walking,
dressing, combing hair, showering, and preparing a meal.

 Educate patient and caregivers to be familiar with signs and symptoms reflecting intolerance of present
activity level or requiring notification of nurse or physician. This promotes awareness of when to decrease
present activity. Also, development of signs and symptoms such as syncope, angina, and dyspnea, point
outs the need for changes in exercise procedure or medication.

 Educate the importance of continued activity at home. This sustains strength, ROM, and endurance gain.

 Involve patient together with the caregivers in the setting of goal and planning of care. Setting little,
achievable goals can augment self-confidence and self-esteem.

 Persuade progressive activity and self-care as tolerated. Offer support as needed. Continuing activity
progression avoids a sudden increase in workload of the heart. Offering support as needed encourages
independence in performing activities.

 Help out in assigning priority to activities in able to accommodate energy levels.

 Teach energy conservation techniques. Some examples include the following:

1) Changing positions frequently. This distributes work to different muscles to prevent fatigue.
2) Making a work-rest-work schedule
3) Pushing instead of pulling
4) Resting for at least an hour after meals before initiating a new activity. Energy is required to digest
food.
5) Sitting to do everyday activities. Standing requires more work.
6) Sliding instead of lifting
7) Storing often used items within easy reach. This avoids bending and reaching.
8) Utilizing wheeled carts for laundry, shopping, and cleaning requirements
9) Working at an even pace. This allows sufficient time so not all work is done in a short period.
These allow more prolonged activity due to reduced oxygen consumption.

 Teach appropriate use of environmental aids such as bed rails. These preserve energy and avoid injury from
fall.
Acute Pain
NANDA Definition
Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end and a duration of less than 6 months.
Discussion of the Problem
Pain, the fifth vital sign, is a very covert condition in which a range of unpleasant sensations and a wide
variety of upsetting factors may be experienced by the patient. It is the most common reason for seeking health care.
Pain occurs as the result of many disorders, diagnostic tests, and treatments. Medical conditions that causes pain are
as follows: hypertension, angina, myocardial infarction, thromboplebitis, DVT, pneumonia, lung cancer, ruptured
intervertebral disc, upper GI bleeding, esophageal bleeding, pancreatitis, sickle cell crisis, peritonitis, renal calculi,
fractures, burns, AIDS, cancer and end of life condition. Surgical interventions such as gastrectomy, cardiac surgery,
thyroidectory, mastectomy and the likes also cause pain. In addition, it may also arise from emotional,
psychological, cultural, or spiritual distress. Its highly subjective nature means that its assessment and management
presents challenges to nurse. The description of pain is a social transaction; thus, assessment and management of it
require a good rapport of the nurse and the patient.

Nursing Interventions Classification (NIC)

 Analgesic Administration
 Conscious Sedation
 Pain Management
 Patient-Controlled Analgesia Assistance

Nursing Outcomes Classification (NOC)

 Comfort Level
 Medication Response
 Pain Control

Goal and Objectives

 Patient will demonstrate relaxed body posture, facial expression, ability to rest or sleep appropriately and
engage in desired activity and other methods to promote comfort
 Patient will demonstrate use of non-pharmacological pain management
 Patient will follow prescribed pharmacological regimen
 Patient will verbalize methods that provide pain relief
 Patient will verbalize sufficient relief of pain or ability to cope with incompletely relieved pain.

Subjective and Objective Data

 Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
 Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation;
change in respiratory rate; pallor; nausea)
 Changes in sleep patterns; physical/social withdrawal
 Facial grimacing
 Facial mask of pain; distraction
 Guarding behavior, protecting body part
 Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
 Patient reports pain with varying in frequency, duration, and intensity (especially as condition worsens)
 Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities,
restlessness)
 Self-focused

Related Factors
 Accumulation of fluid in abdominal/peritoneal cavity (abdominal distension)
 Cancer invasion of pleura, chest wall
 Cellular reactions to circulating toxins
 Chemical contamination of peritoneal surfaces by pancreatic exudate/autodigestion of pancreas
 Chemical irritation of the parietal peritoneum (toxins)
 Chronic physical disability
  Decreased myocardial blood flow
 Diminished arterial circulation and oxygenation of tissues with production/accumulation of lactic acid in
tissues
 Extension of inflammation to the retroperitoneal nerve plexus
 Increased cardiac workload/oxygen consumption
 Infusion of cold or acidic dialysate, abdominal distension, rapid infusion of dialysate
 Insertion of catheter through abdominal wall/catheter irritation, improper catheter placement
 Intraoperative nerve trauma
 Irritation/infection within the peritoneal cavity
 Manipulation of injured tissues, e.g., wound debridement
 Mediastinal incision and/or donor site (leg/arm incision)
 Movement of bone fragments, edema, and injury to the soft tissue
 Muscle spasms
 Myocardial ischemia (acute MI, angina)
 Obstruction of pancreatic, biliary ducts
 Peripheral neuropathies, myalgias, and arthralgias
 Persistent coughing
 Physical agent: surgical manipulation, edema, inflammation, harvesting of bone graft
 Presence of chest tube(s)
 Side effects of various cancer therapy agents
 Surgical interruption/manipulation of tissues/muscles
 Tissue inflammation/edema formation
 Tissue ischemia (coronary artery occlusion)
 Traction/immobility device
 Pain resulting from:
 medical problems
 diagnostic procedures or medical treatments
 trauma
 Physical factors: e.g., disruption of skin/tissues (incisions/drains)
 emotional factors
 psychological factors: e.g., fear, anxiety
 spiritual, or cultural distress
 biological: activity of disease process (cancer, trauma)

Assessment (Dx)
 Assess pain characteristics:
1. Quality: is it sharp, burning, or shooting
2. Severity: scale of 1 to 10, with 1 being least severe and 10 being the most severe. Other methods
were provided below.
3. Location: ask the patient to point is with his/her index finger
4. Onset: is it sudden or gradual
5. Duration: is it intermittent or continuous
6. Precipitating factors: e.g. moving in bed
7. Relieving factors: e.g. lying in bed

Pain Assessment Tools Neonatal/Infant Pain Scale (NIPS)

(Recommended for children less than 1 year old) - A score greater than 3 indicates pain
Pain Assessment Score
Facial Expression    
0 – Relaxed Restful face, neutral expression  
muscles
1 – Grimace Tight facial muscles; furrowed brow, chin, jaw, (negative facial  
expression – nose, mouth and brow)
Cry    
0 – No Cry Quiet, not crying  
1 – Whimper Mild moaning, intermittent  
2 – Vigorous Cry Loud scream; rising, shrill, continuous (Note: Silent cry may be scored if  
baby is intubated as evidenced by obvious mouth and facial movement.
Breathing Patterns    
0 – Relaxed Usual pattern for this infant  
1 – Change in Indrawing, irregular, faster than usual; gagging; breath holding  
Breathing
Arms    
0– No muscular rigidity; occasional random movements of arms  
Relaxed/Restrained
1– Tense, straight legs; rigid and/or rapid extension, flexion  
Flexed/Extended
Legs    
0– No muscular rigidity; occasional random leg movement  
Relaxed/Restrained
1– Tense, straight legs; rigid and/or rapid extension, flexion  
Flexed/Extended
State of Arousal    
0 – Sleeping/Awake Quiet, peaceful sleeping or alert random leg movement  
1 – Fussy Alert, restless, and thrashing  
 
Children's Hospital Eastern Ontario Pain Scale (CHEOPS)
(Recommended for children 1-7 years old) - A score greater than 4 indicates pain 
I Behavioral   Definition Score
t
e
m
C No cry 1 Child is not crying.  
r
y
  Moaning 2 Child is moaning or quietly vocalizing silent cry.  

  Crying 2 Child is crying, but the cry is gentle or whimpering.  

  Scream 3 Child is in a full-lunged cry; sobbing; may be scored with  

complaint or without complaint.
F Composed 1 Neutral facial expression.  
a
c
i
a
l

  Grimace 2 Score only if definite negative facial expression.  

  Smiling 0 Score only if definite positive facial expression.  

C None 1 Child not talking.  
h
i
l
d

V
e
r
b
a
l
  Other 1 Child complains, but not about pain, e.g., “I want to see  
complaints mommy” of “I am thirsty”.
  Pain 2 Child complains about pain.  
complaints
  Both 2 Child complains about pain and about other things, e.g., “It  
complaints hurts; I want my mommy”.
  Positive 0 Child makes any positive statement or talks about others  
things without complaint.
T Neutral 1 Body (not limbs) is at rest; torso is inactive.  
o
r
s
o
  Shifting 2 Body is in motion in a shifting or serpentine fashion.  

  Tense 2 Body is arched or rigid.  

  Shivering 2 Body is shuddering or shaking involuntarily.  

  Upright 2 Child is in a vertical or upright position.  

  Restrained 2 Body is restrained.  

T Not touching 1 Child is not touching or grabbing at wound.  

o
u
c
h
  Reach 2 Child is reaching for but not touching wound.  

  Touch 2 Child is gently touching wound or wound area.  

  Grab 2 Child is grabbing vigorously at wound.  

  Restrained 2 Child's arms are restrained.  

L Neutral 1 Legs may be in any position but are relaxed; includes  

e gentle swimming or separate-like movements.
g
 s
  Squirm/kicking 2 Definitive uneasy or restless movements in the legs and/or  
striking out with foot or feet.
  Drawn 2 Legs tensed and/or pulled up tightly to body and kept there.  
up/tensed
  Standing 2 Standing, crouching or kneeling.  

  Restrained 2 Child's legs are being held down.  

 
FLACC SCALE 
CATEGORIES SCORING
  0 1 2
FACE No particular Occasional grimace Frequent to constant
expression or smile or frown, withdrawn, quivering chin,
disinterested. clenched jaw.
LEGS Normal position or Uneasy, restless, Kicking, or legs
relaxed. tense. drawn up.
ACTIVITY Lying quietly, Squirming, shifting Arched, rigid or
normal position back and forth, jerking.
moves easily. tense.
CRY No cry, (awake or Moans or whimpers; Crying steadily,
asleep) occasional complaint screams or sobs,
frequent complaints.
CONSOLABILITY Content, relaxed. Reassured by Difficulty to console
occasional touching or comfort
hugging or being
talked to,
distractable.

 Assess degree of personal adaptation to diagnosis, such as the following: anger, irritability, withdrawal, and
acceptance. The motioned factors are variable and usually affect the perception of pain or capability to cope
and need for pain management.

 Assess patient’s eagerness or capability to explore a variety of techniques intended at controlling pain.
Some patients will sense uncomfortable exploring other methods of pain relief. Nevertheless, patients need
to be educated that there are numerous ways to manage pain.

 Assess patient’s outlook for pain relief. Some patients may be satisfied to have pain diminished, while
others will anticipate total elimination of pain. Their expectation affects their perceptions of the
effectiveness of the management modality and their willingness to partake in additional managements.

 Determine patient’s reaction to pain and medications meant to abolish or relieve pain. It is important to
help patients convey as accurately as possible the effect of pain relief procedures. Discrepancies between
behavior or appearance and what patient coveys about pain relief may be more a manifestation of other
methods patient is utilizing to cope with than pain relief itself.
  Determine patient’s understanding of or preference for the array of pain-relief management available. Some
patients may be uninformed of the usefulness of nonpharmacological methods and may be willing to try
them alone or in combination with traditional analgesic medications.

 Determine to what extent cultural, environmental, intrapersonal, and intrapsychic factors may add to pain
or pain relief. The mentioned variables may alter the patient’s expression of his or her experience. It is
important that nurses should not stereotype any patient reaction but rather appraise the unique response of
each patient.

 Monitor signs and symptoms related with pain, such as the following: ability to focus BP, color and
moisture of skin, heart rate, temperature, and restlessness. Some patients deny the presence of pain.
Notification of associated signs may help the nurse to evaluate pain.

 Note for possible cause of pain. Depending on etiological factors pain responds better to different
managements.

 Note: If patient is getting epidural analgesia, evaluate the following:

1) Numbness, tingling sensation in extremities, a metallic taste in the mouth. These symptoms may
indicate an allergic response to the anesthesia agent, or an improper catheter placement.
2) Pain relief. Intermittent epidurals need to be released at intervals.
3) Potential epidural analgesia complications such as the following: excessive sedation, respiratory
distress, urinary retention, or catheter migration. Intravascular infusion of anesthesia and
respiratory depression can be potentially life-threatening.

Therapeutic Interventions (Tx)

 Anticipate necessitate for pain relief. By preventing pain, one can most effectively deal with it. Early
intervention may reduce the total quantity of analgesic required.

 Eradicate sources of discomfort or additional stressors whenever possible. Patients may experience an
increased intensity of pain or a reduced ability to tolerate painful stimuli if the milieu or intrapersonal are
further stressing them.

 Give details about the procedures before initiating them. Permits patient to set up mentally for activity and
to partake in controlling level of discomfort.

 Give rest periods to make comfort, relaxation, and sleep possible. The patient’s perception of pain may
become more intense as the result of fatigue. Pain may result in fatigue in a cyclic fashion, which may
result in increased pain intensity and tiredness. A quiet atmosphere, a darkened room, and a disconnected
phone are all methods aimed toward promoting rest.

 Place important items within easy reach. This prevents the risk or straining to reach.

 Take action promptly to complaint of pain. Amidst painful experiences a patient’s awareness of time may
become vague. Immediate responses to complaints may result in reduced anxiety in the patient. In addition,
a trusting relationship is developed, when the nurse demonstrates concern for patient’s welfare and
comfort.

 Pharmacological methods:
I. Nonsteroidal anti-inflammatory drugs (NSAIDs) that may be given orally or parenterally
II. Utilization of opiates (orally, intramuscularly, subcutaneously, intravenously, patient-controlled
analgesia (PCA) systems, or epidurally) Narcotics are given for severe pain, especially in the
hospice or home setting.
III. Local anesthetic agents.

 Nonpharmacological methods:
 IV. Cognitive-behavioral strategies:
1. Biofeedback, breathing exercises, music therapy
2. Distraction techniques. Focuses the patient’s concentration upon non-painful stimuli to
diminish one’s perception and experience of pain.
3. Imagery. This uses mental picture or imagination of an event. It involves the use of the
five senses to divert oneself from painful stimuli.
4. Offer quiet, dimly lit room
5. Relaxation exercises. These are techniques used to bring about a condition of physical
and mental consciousness and calmness. The objective of these techniques is to decrease
tension, then reducing pain.
V. Cutaneous stimulation:
1. Hot or cold compress. Hot, humid compresses have a penetrating effect. The heat rushes
blood to the affected region to promote healing. Cold compresses may lessen total edema
and promote some numbing, thus promoting comfort.
2. Massage and back rubs of affected area if possible. Massage and back rubs reduce muscle
tension and can promote comfort.
3. Transcutaneous electrical nerve stimulation (TENS) units

 Administer analgesics as ordered, assessing effectiveness and noting for any signs and symptoms of
undesired effects. Pain medications are absorbed and metabolized differently in every patient, so their
efficacy must be assessed on a patient to patient basis. Analgesics may root untoward effects that range
from mild to life-threatening.

 Engage patient in determining his/her schedule for activities, treatments, drug administration. This
strengthens the patient’s coping mechanisms and enhances his/her sense of control.

 Notify physician if management are ineffective or if present complaint a significant change from patient’s
previous experience of pain. Patients who ask for pain medications at often intervals than prescribed may
actually need higher doses or more potent analgesics.

 Propose to the patient to assume position of comfort while lying in bed or sitting in chair. May alleviate
pain and improve circulation, in addition, positioning relieves muscle tension.

 Reassure patient whenever possible, that pain is time-limited and that there are multiple approaches to
reduce pain. When pain is supposed as never-ending and unresolvable, patient may give up and experience
a sense of despair and loss of control.

Educative (Edx)
 Educate patient efficient timing of medication dose in relation to probable uncomfortable activities and
avoidance of peak pain periods.

 Encourage patient to express concerns. Active-Listen these concerns and offer support by acceptance,
staying with patient and providing appropriate information. Lowering anxiety level can uphold relaxation
or comfort. This also permits outlet of emotions and may augment coping mechanisms.

 Explicate origin of pain or discomfort, if known. This helps in enhancing patient’s coping ability and may
lessen anxiety.

 Instruct in/encourage proper body mechanics or body posture. Prevents stress on muscles and avoids
further worsening of injury.

 Instruct patient to assess and report efficacy of measures used. Persuade enough medication to control pain;
change medication or time span as appropriate. Pain perception and pain relief are covert; therefore
management of pain is best left to patient’s judgment. However, if patient is not capable to provide input,
 the nurse should monitor physiological and nonverbal cues of pain and administer medications on a
standard basis.

 Instruct patient to report pain promptly. This is so that relief procedures may be instituted immediately.
Postponement in reporting pain hinders pain relief or may necessitate augmented dosage of medication to
attain relief. Further, severe pain may induce shock by provoking sympathetic nervous system, thus
creating more damage and interfering with diagnostics and relief of pain.

 Offer anticipatory instruction on pain causes, appropriate prevention, and relief procedures.

Anxiety
NANDA Definition
Anxiety is a vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the
source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger.
It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the
threat.

Discussion of the Problem

Anxiety is a common reaction to stress. It is experienced at conscious, subconscious, or unconscious level.
Anxiety is probably present at some point in every person, but its degree and frequency of its manifestation differs.
Some people are capable of using the emotional rim that anxiety provokes to inspire creativity or problem-solving
abilities, while others can become immobilized to a pathological degree. It is categorized in four levels namely:
mild, moderate, severe, and panic. Medical and surgical conditions that could trigger anxiety as follows: angina,
myocardial infarction, lung cancer, ventilatory assistance, ruptured intervertebral disc, gastrectomy, peritonitis,
tyrotoxicosis, renal dialysis, BPH, mastectomy, burns, transplantation, phychosocial conditions, surgical
interventions, cancer, and disaster situations. The presence of the nurse may provide support to an anxious patient
and offer some strategies for traversing anxious moments or panic attacks.

Nursing Interventions Classification (NIC)

 Anxiety Reduction
 Presence
 Calming Technique
 Emotional Support

Nursing Outcomes Classification (NOC)

 Anxiety or Fear Control
 Coping

Goal and Objectives

 Patient may describe a decrease in the level of anxiety experienced.
 Patient will acknowledge and discuss fears or concerns
 Patient will appear calmed and relaxed
 Patient will be able to identify or recognize feelings and signs of anxiety.
 Patient will demonstrate problem-solving skills and behaviors to cope with current situations.
 Patient will identify or use available resources appropriately
 Patient will identify possible causes or contributing factors to the current situation
 Patient will report beginning the use of individually appropriate coping strategies.
 Patient will use available resources or support systems effectively.
 Patient will verbalize or communicate awareness of feelings and healthy ways to deal with them

Subjective and Objective Data

 Physiological:
  Anger and irritability
 Apprehension, increased tension, restlessness
 Dizziness, light-headedness
 Dry mouth
 Dyspnea
 Feelings of helplessness and discomfort
 Flushing
 Frequent urination
 Headaches
 Hypervigilance; overexcited
 Impaired functioning; verbal expressions of having no control or influence over situation,
outcome, or self-care
 Increase in blood pressure, pulse, and respirations
 Increased muscle/facial tension
 Insomnia, nightmares
 Nausea and/or diarrhea
 Pacing
 Palpitations
 Perspiration
 Pupil dilation
 Restlessness
 Somatic complaints/sympathetic stimulation; extraneous movements (restlessness, foot shuffling,
hand/arm fidgeting, rocking movements)
 Trembling

 Behavioral:
 Apprehension, uncertainty, restlessness, worry, sense of impending doom
 Association of diagnosis with loss of healthy body image, loss of place/influence
 Crying
 Difficulty concentrating
 Expressed concern regarding changes in life events
 Expressions of denial, shock, guilt, insomnia
 Expressions of helplessness
 Fear of death as an imminent reality
 Feelings of inadequacy
 Fight (e.g., belligerent attitude) or flight behavior
 Focus on self, expressions of concern about current and future events
 Focus on self/negative self-talk
 Inability to problem-solve
 Preoccupation
 Rumination
 Scanning and vigilance; or lack of awareness of surroundings
 Uncertainty, feelings of inadequacy
 View of self as noncontributing member of family/society
 Withdrawal

Related Factors
 Changes in environment and routines
 Changes in role function
 Embarrassment/loss of dignity associated with genital exposure before, during, and after treatment;
concern about sexual ability
 Interpersonal conflicts
 Interpersonal transmission/contagion
 Intrusive diagnostic and surgical tests and procedures
 Negative self-talk
  Perceived threat of death/dependency on mechanical support
 Physiological factors, hypermetabolic state
 Sensory impairment; environmental stimuli; substance abuse; stress
 Separation from support system(hospitalization, treatments); knowledge deficit
 Side effects of steroids and/or cyclosporine
 Situational (hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the
trauma experience, threat of death and/or disfigurement) and maturational crises
 Threat or perceived threat to physical and emotional integrity
 Threat or perceived threat to self-concept (altered image/abilities; [perceived or actual] organ rejection,
threat of death)
 Threat to (or change in) socioeconomic status
 Threat to or change in health status (disease course that can lead to further compromise, debility, even
death)
 Unconscious conflict about essential values, beliefs, and goals of life
 Underlying pathophysiological response
 Unmet needs

Assessment (Dx)
 Monitor and document patient’s level of anxiety. Patient’s awareness and ability to identify and solve
problems are enhanced by mild anxiety. While moderate anxiety limits awareness of environmental stimuli
and problem solving can occur but may be more difficult, and patient may need help. In severe anxiety,
patient’s ability to integrate information and solve problems decreases. With panic, the final state of
anxiety, the patient is unable to follow directions and may experienced hyperactivity, agitation, and
immobilization.

ANXIETY ASSESSMENT GUIDELINE

Background
Anxiety disorders are not negligible – they cause as much distress and social
interference as depressive disorders. It affects all ages. Thus, there is a real need for the
following: early and precise identifications in all ages, differentiation from other clinical
problems, and effective management.

Screening
Possible questions which can help with an initial evaluation of whether anxiety is
present include the following:
 Have you been feeling tense or anxious lately?
 If so, please can you tell me more?
 Have you been worrying a lot about things lately?
 Have you been experiencing any unusual physical symptoms?
 What situations make the symptoms worse?
 What do you do when stressed or anxious?
 What makes the symptoms better?

Levels of anxiety

Level 1 Mild Anxiety increased alertness to inner feelings/environment;

increased ability to learn
Level 2 Moderate Anxiety concentration is focused to a specific thing;
characterized by tremors and rapid speaking
Level 3 Severe Anxiety ability to perceive is narrowed: characterized by inability
to communicate, decreased intellectual functioning and
feeling of worthlessness
Level 4 Panic State ability to perceive is completely disrupted: characterized
by disintegration of personality and loss of control
 Common signs and symptoms of anxiety disorders

AFFECTIVE/
PHYSICAL EMOTIONAL COGNITIVE BEHAVIOURAL
 appetite  anger  catastrophising  agitation
changes  anxiety  excessive,  avoidance
 chest pains  depersonalisation worrying  checking
 cold hands  depression thoughts  drinking
 dizziness/light-  derealisation  fear of losing alcohol/substa
headedness  fear control nce abuse
 dry mouth  guilt  impaired  escape
 fatigue  irritability concentration  fidgeting
 hyperventilation  numbness  jumping to  hypervigilance
 muscular  panic negative  inhibition
aches/pains conclusions  restlessness
 palpitations  memory  safety
 shortness of impairment behaviour
breath  negative  tearfulness
 sleep problems anticipation
 sweating  negative
 tension predictions
headache  self-blaming
 tremor  thoughts of
impending
doom/catastro
phe

 Acknowledge positive behaviors indicative of beginning acceptance and/or use of effective strategies to
deal with situation. Fear/anxiety will decrease as patient begins to accept/deal positively with reality.

 Establish how patient deal with anxiety. Interviewing the patient may be done to determine the
effectiveness of his coping strategies.

 Explore changes in mentation and occurrence of hypervigilance, hallucinations, sleep disturbances (e.g.,
nightmares), agitation/apathy, disorientation, and labile affect, all of which may vary from time to time.
These are signs of extreme anxiety/delirium state in which patient is literally struggling for life. Although
psychologically based can be a cause, pathological life-threatening causes (e.g., shock, sepsis, hypoxia)
must be ruled out.

 Monitor and document mental status, including mood/affect, understanding of events, content of thoughts
and judgement, e.g., false impressions or manifestations of terror/panic. Initially, patient may use defense
mechanism or coping mechanism- denial and repression- to minimize and sort out information that might
be overwhelming. While some patient exhibit calm behavior and alert mental status, representing
dissociation from truth or reality, which is also a defense mechanism.

 Observe behavioral cues and clues, e.g., restlessness, irritability, withdrawal, narrowed attention, lack of
eye contact, demanding behavior. Indicators of level of anxiety/stress, e.g., patient may feel uncontrollable
at home or work in managing personal problems. Stress may build up as a result of physical symptoms of
condition and the reaction of others.

 Observe presence of aggression, withdrawal, and or denial (inappropriate refusal or rejection to comply
with medical regimen). Reinforce patients coping strategies/abilities.
  Recommend that the patient notes episodes of anxiety. Instruct patient to describe what is experienced and
the events leading up to and surrounding the event. Patient should note how the anxiety starts or what
triggers it. Symptoms often provide the care provider with information regarding the degree of anxiety
being experienced. Physiological symptoms and/or complaints intensify as the level of anxiety increases.

 Watch for physical responses, e.g., restlessness, changes in vital signs, repetitive movements and agitation.
Note for conformity of verbal/nonverbal communication. This is helpful in evaluating extent/degree of
concerns, especially when compared with “verbal” comments.

Therapeutic Interventions (Tx)

 Acknowledge but do not reinforce use of denial. Avoid confrontations as much as possible. Denial can be
beneficial in reducing anxiety but can delay dealing with the truth or reality of the current situation.
Confrontation can promote anger and boost use of denial which eventually reduces cooperation and
recovery may be delayed.

 Acknowledge patient’s awareness of anxiety. Acknowledgment of the patient’s feelings confirms the
feelings and corresponds acceptance of those feelings.

 Answer all questions truthfully. Provide information that is consistent; repeat as necessary. Factual
information about the situation decreases fear, builds up nurse-patient relationship, and assists
patient/significant others to deal realistically with the current situation. Attention span may be short, and
repetition of information aids with retention.

 As patient’s level of anxiety subsides, encourage exploration of specific events prior to both the beginning
and reduction of the anxious feelings. Recognition and exploration of causative factors leading to or
reducing anxious feelings are essential steps in developing alternative reactions.

 Assist the patient in developing anxiety-reducing skills (e.g., relaxation, deep breathing, positive
visualization, and reassuring self-statements). Using anxiety-reduction strategies enhances patient’s sense
of personal mastery and confidence.

 Assist the patient to identify or recall positive coping behaviors used in the past. Successful behaviors in
the past can be reinforced in dealing with current problems/stress, enhancing patient’s sense of self-control.

 Be empathic and nonjudgmental while working with patient and family. Showing empathy and
nonjudgmental attitude enhances cooperation of the patient and family.

 Familiarize patient to the environment, routine procedures, anticipated activities and new experiences or
people as necessary. Encourage participation when possible. Expectedness of information can promote
comfort and may lessen anxiety.

 Identify and discuss with patient and significant others the safety and standard precautions being taken,
e.g., power supply backup and emergency equipment. Discuss the meanings and significant of alarm
system. Provides reassurance to help allay anxiety, decrease concerns of the unknown, and preplan for
response in emergency condition.

 Maintain a calm and confident behavior while interacting with patient (without false reassurance). A calm
and nonthreatening atmosphere can enhance patient’s feeling of stability. Honest explanations can lessen
fear and anxiety.

 Maintain matter-0f-fact approach in dealing with patient. Protect patient’s privacy. Communicates
acceptance and reduces patient’s embarrassment.
  Minimize sensory stimuli by promoting a quiet environment; keep "threatening" equipment out of sight.
Anxiety may be triggered by excessive conversation, noise, and equipment around the patient.

 Observe for congruency of verbal/nonverbal signs of anxiety, and stay with patient. Intervene if patient
displays destructive behavior. Patients may not express concerns directly through words, but actions may
suggest sense of agitation, aggression, and hostility.

 Provide adequate rest periods or uninterrupted time for sleep, quiet surroundings, with patient controlling
type, and the amount of external stimuli. Conservation of energy and enhances patients coping abilities.

 Provide Therapeutic Touch, massage, and other adjunctive therapies as indicated e.g., tapping of shoulders.
Helps patient in meeting basic human need, reducing sense of isolation, and assisting patient to feel less
anxious. Note: Therapeutic Touch entails the nurse to have specific knowledge and experience with the use
of hands correctly in order alley patient’s feeling of anxiety.

 Reassure patient that he or she is safe. If necessary, stay with the patient. The existence of a trusted person
may be helpful to reduce fear/ anxiety during an attack.

 Set up a working relationship with the patient through continuity of care. A continuing relationship
establishes a foundation for comfort in communicating anxious feelings.

 Utilize simple language and brief statements when teaching patient about self-care measures or about
diagnostic and surgical procedures. Keep it short and simple. Attention span may be reduced, concentration
lessen, limiting capacity to understand information.

 Help patient in acknowledging problem-solving capabilities.

1. Provide positive feedback when patient exhibits better ways to manage anxiety and is able to calmly and /or
realistically evaluate own situation. Promotes acknowledgement and reinforcement, and enhances ability to
deal with anxious feelings.
2. Provide support of normal grieving process, including time necessary for resolution. Can provide
encouragement that feelings are normal response to situation or perceived alterations.
3. Refer to spiritual counselor as needed. Facing one’s mortality may aggravate feelings of anxiety and
questions about one’s spiritual beliefs and practices.
4. Stress the importance of logical strategies that patient can use when experiencing anxiety. Learning to
recognize a problem and evaluate alternatives to resolve it assists the patient to cope.

Education/Continuity of Care
 Assist patient in guided imagery/relaxation techniques; e.g., imaging a pleasant place, use of music/tapes,
deep-breathing, meditation, and mindfulness. Reduces anxiety by promoting the release of endorphins
which assists in developing internal locus of control, enhancing coping skills, and allowing body to go
about its work of healing. Note: Mindfulness is a technique of being in the here and now concentrating on
what is occurring at the moment.

 Demonstrate how to utilize relaxation techniques, e.g., focused breathing, progressive relaxation, and
guided imagery. Provide music therapy, biofeedback as needed. This promotes active management of
situation to decrease feelings of helplessness.

 Discuss to patient the proper use of medications and educate him or her to identify adverse reactions.
Medication may be used if patient’s anxiety continues to rise and the feeling of anxiety becomes disabling
or hindrance to activities of daily living.

 Encourage autonomy, self-care, and decision making within accepted treatment plan. Increased
independence and autonomy from staff promotes self-confidence and reduces feelings of abandonment.
  Encourage patient to verbalize feelings of anxiety and assess anxiety-provoking situations if able to identify
them. Helps patient in evaluating the situation realistically and recognizing causative factors to the anxious
feelings. Avoid false reassurances. Establish a therapeutic and working relationship to assists patient and
significant others in identifying problems causing stressful situations.

 Help patient in identifying symptoms of increasing feeling of anxiety; identify other alternatives use to
prevent the anxiety from immobilizing her or him. The ability to distinguish anxiety symptoms at lower-
intensity levels facilitates the patient to intervene faster to manage his or her anxiety.

 Refer the patient for psychiatric assistance if anxiety becomes disabling to activities of daily living. May
need additional support in regaining control and coping with acute and chronic episodes/exacerbations and
consequences of the disease and therapeutic regimen.

 Reiterate to patient that mild anxiety level can encourage growth and development.

 Support patient to look for assistance from an understanding significant other or health care provider when
difficulty arises from feelings of anxiety. The presence of significant others strengthens feelings of safety
and security for the patient.

Chronic Pain
NANDA Definition
Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in
terms of such damage (International Association for the Study of Pain); sudden or slow onset of intensity from mild
to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months.

Discussion of the Problem

Chronic pain is a constant or intermittent pain that continue beyond the anticipated curing time and that can
rarely attributed to a specific cause or injury. It may be poorly defined onset. In addition, it is difficult to treat
because the cause its unclear origin. Though acute pain may be a useful signal that something is wrong, chronic pain
often becomes a problem in its own right. Chronic pain may be classified into two categories: the chronic malignant
pain and the chronic nonmalignant pain. Chronic malignant pain is associated with a specific cause, cancer, for
example. On the other hand, the original tissue injury is not progressive or has been healed in the chronic
nonmalignant pain. It differs from acute pain in a way that it is more difficult for the patient to provide precise
information about the pain’s location or intensity. Patient’s level of suffering usually increases over time. Chronic
pain could have a intense impact on the following; activities of daily living, mobility, activity tolerance, ability to
work, role performance, financial status, mood, emotional status, spirituality, family interactions, and social
interactions. Chronic pain is usually experienced by patients who have rheumatoid arthritis, cancer, and those who
are in the end of life stage.

Nursing Outcomes Classification (NOC)

 Family Coping
 Pain Control
 Quality of Life

Nursing Interventions Classification (NIC)

 Acupressure
 Heat/Cold Application
 Medication Management
 Pain Management
 Progressive Muscle Relaxation
 Simple Massage
 Transcutaneous Electrical Nerve Stimulation (TENS)
Goal and Objectives
 Patient will demonstrate use of different relaxation skills and diversional activities as indicated for
individual situation
 Patient will follow Prescribed pharmacological regimen of the physician
 Patient will verbalizes acceptable level of pain relief and ability to engage in desired activities.

Subjective and Objective Data

 Alteration in muscle tone(varies from flaccid to rigid); facial mask of pain
 Altered ability to continue previous activities
 Anorexia
 Atrophy of involved muscle group
 Autonomic responses (diaphoresis, changes in BP, respiration, pulse)
 Changes in appetite/eating, weight; sleep patterns; altered ability to continue desired activities; fatigue
 Changes in sleep pattern
 Distraction/guarding behaviors
 Facial mask; expressive behavior (restlessness, moaning, crying, irritability); self-focusing; narrowed
focus (altered time perception, impaired thought process)
 Fatigue
 Fear of reinjury
 Guarded/protective behavior; distraction behavior (pacing/repetitive activities, reduced interaction with
others)
 Reduced interaction with people
 Self-focusing/narrowed focus
 Sympathetic mediated responses (e.g., temperature, cold, changes of body position, hypersensitivity)
 Verbal or coded report or observed evidence of protective behavior, guarding behavior, facial mask,
irritability, self-focusing, restlessness, depression
 Verbal/coded report; preoccupation with pain

Related Factors
 Chronic physical or psychosocial disability
 Disease process (compression/destruction of nerve tissue/body organs, infiltration of nerves or their
vascular supply, obstruction or a nerve pathway, inflammation)
 Injuring agents (biological , chemical, physical, psychological)
 Side effects of various cancer therapy agent

Assessment (Dx)
 Monitor and document the following pain characteristics:
 Aggravating factors
 Anatomical location
 Duration (e.g., continuous, intermittent)
 Onset
 Quality (e.g., sharp, burning)
 Relieving factors
 Severity (1 to 10 scale)
Gathering information about the pain can provide accurate and individualized nursing interventions for the
patient.

Pain Assessment Tools Neonatal/Infant Pain Scale (NIPS)

 (Recommended for children less than 1 year old) - A score greater than 3 indicates pain
Pain Assessment Score
Facial Expression    
0 – Relaxed Restful face, neutral expression  
muscles
1 – Grimace Tight facial muscles; furrowed brow, chin, jaw, (negative facial  
expression – nose, mouth and brow)
Cry    
0 – No Cry Quiet, not crying  
1 – Whimper Mild moaning, intermittent  
2 – Vigorous Cry Loud scream; rising, shrill, continuous (Note: Silent cry may be scored if  
baby is intubated as evidenced by obvious mouth and facial movement.
Breathing Patterns    
0 – Relaxed Usual pattern for this infant  
1 – Change in Indrawing, irregular, faster than usual; gagging; breath holding  
Breathing
Arms    
0– No muscular rigidity; occasional random movements of arms  
Relaxed/Restrained
1– Tense, straight legs; rigid and/or rapid extension, flexion  
Flexed/Extended
Legs    
0– No muscular rigidity; occasional random leg movement  
Relaxed/Restrained
1– Tense, straight legs; rigid and/or rapid extension, flexion  
Flexed/Extended
State of Arousal    
0 – Sleeping/Awake Quiet, peaceful sleeping or alert random leg movement  
1 – Fussy Alert, restless, and thrashing  
 
Children's Hospital Eastern Ontario Pain Scale (CHEOPS)
(Recommended for children 1-7 years old) - A score greater than 4 indicates pain 
I Behavioral   Definition Score
t
e
m
C No cry 1 Child is not crying.  
r
y
  Moaning 2 Child is moaning or quietly vocalizing silent cry.  

  Crying 2 Child is crying, but the cry is gentle or whimpering.  

  Scream 3 Child is in a full-lunged cry; sobbing; may be scored with  

complaint or without complaint.
F Composed 1 Neutral facial expression.  
a
c
i
a
l

  Grimace 2 Score only if definite negative facial expression.  

  Smiling 0 Score only if definite positive facial expression.  

C None 1 Child not talking.  

h
i
l
d

V
e
r
b
a
l
  Other 1 Child complains, but not about pain, e.g., “I want to see  
complaints mommy” of “I am thirsty”.
  Pain 2 Child complains about pain.  
complaints
  Both 2 Child complains about pain and about other things, e.g., “It  
complaints hurts; I want my mommy”.
  Positive 0 Child makes any positive statement or talks about others  
things without complaint.
T Neutral 1 Body (not limbs) is at rest; torso is inactive.  
o
r
s
o
  Shifting 2 Body is in motion in a shifting or serpentine fashion.  

  Tense 2 Body is arched or rigid.  

  Shivering 2 Body is shuddering or shaking involuntarily.  

  Upright 2 Child is in a vertical or upright position.  

  Restrained 2 Body is restrained.  

T Not touching 1 Child is not touching or grabbing at wound.  

o
u
c
h
  Reach 2 Child is reaching for but not touching wound.  

  Touch 2 Child is gently touching wound or wound area.  

  Grab 2 Child is grabbing vigorously at wound.  

  Restrained 2 Child's arms are restrained.  

L Neutral 1 Legs may be in any position but are relaxed; includes  

e gentle swimming or separate-like movements.
 g
s
  Squirm/kicking 2 Definitive uneasy or restless movements in the legs and/or  
striking out with foot or feet.
  Drawn 2 Legs tensed and/or pulled up tightly to body and kept there.  
up/tensed
  Standing 2 Standing, crouching or kneeling.  

  Restrained 2 Child's legs are being held down.  

 
FLACC SCALE 
CATEGORIES SCORING
  0 1 2
FACE No particular Occasional grimace Frequent to constant
expression or smile or frown, withdrawn, quivering chin,
disinterested. clenched jaw.
LEGS Normal position or Uneasy, restless, Kicking, or legs
relaxed. tense. drawn up.
ACTIVITY Lying quietly, Squirming, shifting Arched, rigid or
normal position back and forth, jerking.
moves easily. tense.
CRY No cry, (awake or Moans or whimpers; Crying steadily,
asleep) occasional complaint screams or sobs,
frequent complaints.
CONSOLABILITY Content, relaxed. Reassured by Difficulty to console
occasional touching or comfort
hugging or being
talked to,
distractable.

 Assess for factors such as gender, cultural, societal, and religious features that may influence the patient’s
pain experience and reaction to pain relief. Recognizing the variables that influence the patient’s pain
experience can be helpful in developing a plan of care that is acceptable to the patient.

 Assess for side effects, dependency, and tolerance (including alcohol) of patients taking opioid analgesics.
Long-term management of chronic pain is concern about drug dependence and tolerance to opioid
analgesics.

 Evaluate the patient’s approach towards pharmacological and nonpharmacological means of pain
management. Patients may see medications as the only treatment to alleviate pain and may question the
effectiveness of nonpharmacological interventions.

 Evaluate the patient’s beliefs and expectations about pain relief. Patients who suffer from chronic pain may
not anticipate complete relief of pain, but may be satisfied with diminishing severity of the pain and
increasing activity level.
  Evaluate the patient’s capability to achieve activities of daily living (ADLs), instrumental activities of daily
living (IADLs), and demands of daily living (DDLs). The person’s ability to complete self-care activities
and fulfill role responsibilities can be limited by exhaustion anxiety, and depression associated with chronic
pain.

 Evaluate the patient’s perception of the effectiveness of techniques used for pain relief in the past. Patients
with chronic pain have a long history of using many pharmacological and nonpharmacological means to
control and alleviate their pain.

 Monitor and document for signs and symptoms related with chronic pain such as weakness, decreased
appetite, weight loss, changes in body posture, sleep pattern disturbance, anxiety, irritability, agitation, or
depression. Physiological changes may not be exhibit by patients with chronic pain and behaviors
associated with acute pain. Coping with Chronic pain can reduce the patient’s energy for other activities.

Therapeutic Interventions (Tx)

 Help the patient in making decisions about choosing a particular pain management strategy. The nurse can
increase the patient’s willingness to choose new interventions to promote pain relief through guidance and
support. The patient may start to feel confident regarding the effectiveness of these interventions.

 Provide support for patient and family in identifying lifestyle modifications that may contribute to effective
pain management. Providing the patient and family with ongoing support and guidance will increase the
success of this approach.

 Recognize and communicate acceptance of the patient’s pain experience. Conveying acceptance of the
patient’s pain encourages a more cooperative nurse-patient relationship.

 Refer the patient and family to community support groups and self-help groups for people coping with
chronic pain. To reduce the burden of suffering associated with chronic pain and provides additional
resources like patient’s support network.

 Refer the patient to a physical therapist for assessment and evaluation. To promote muscle strength and
joint mobility, and therapies to promote relaxation of tense muscles, the physical therapist can help the
patient with exercises suitable for his/her condition. These interventions can influence the effectiveness of
pain management.

Educative (Edx)
 Discuss to patient and family the advantages of using nonpharmacological pain management strategies:
1. Acupressure. Acupressure is a pain management strategy which utilizes finger pressure applied to
acupressure points on the body. Using the gate control theory, the technique works to interrupt
pain transmission by "closing the gate." This approach requires training and practice.
2. Cold applications. Cold application reduces pain, inflammation, and muscle spasticity through
vasoconstriction and by decreasing the release of pain-inducing chemicals and slowing the
conduction of pain impulses. This intervention is cost effective and requires no special equipment.
Cold applications should last about 20 to 30 min/hr or depending on the patient’s tolerance.
3. Distraction. Distraction is a pain management strategy that works temporarily by increasing the
pain threshold. It should be utilize for a short duration, usually less than 2 hours at a time.
Prolonged utilization can add to fatigue that may lead to exhaustion and may further increase pain
when the distraction is no longer present.
4. Heat applications. Heat application reduces pain through vasodilatation that causes improved
blood flow to the area and through reduction of pain reflexes. This requires no special equipment
and also cost effective. Heat applications also depends on patient’s tolerance but should last no
more than 20 min/hr. Special attention needs to be given to preventing burns with this
intervention.
 5. Massaging of the painful area. Massage interrupts pain transmission by increasing the release of
endorphins and decreases tissue edema. This intervention may require another person to provide
the massage.
6. Progressive relaxation technique, guided imagery, and music therapy. These pain management
techniques are centrally acting that works through reducing muscle tension and stress. The patient
may feel an increased sense of control over his/her pain. Guided imagery can aid the patient to
explore images about pain, pain relief, and healing. These techniques require practice to be
effective.
7. Transcutaneous Electrical Nerve Stimulation (TENS) TENS utilizes the application of 2 to 4 skin
electrodes. Pain reduction occurs when a mild electrical current passes through the electrode then
unto the skin. The patient is able to regulate the intensity and frequency of the electrical
stimulation that depends to his/her tolerance.

 Teach the patient and family about the use of pharmacological interventions for pain management:
1. Antianxiety agents. These drugs are also useful adjuncts in a total program of pain management
plan. Its effects are the same with anti-depressants.
2. Anti-depressants. These drugs may be useful adjuncts in a total program of pain management. In
addition to their effects on the patient’s mood, the antidepressants may have analgesic properties
apart from their antidepressant actions.
3. Nonsteroidal anti-inflammatory agents (NSAIDs). These drugs are the first step in the analgesic
ladder. They work by inhibiting the synthesis of prostaglandins that cause pain in peripheral
tissues, inflammation, and edema. The advantages of these drugs are not associated with
dependency and addiction and they can be taken orally.
4. Opioid analgesics. These drugs reduce pain by binding with opiate receptors throughout the body.
They act on the central nervous system so the side effects associated with this group of drugs tend
to be more significant that those with the NSAIDs. The primary concern in patients using these
drugs for chronic pain management are Nausea, vomiting, constipation, sedation, respiratory
depression, tolerance, and dependency.

 Instruct the patient to take notes to help identify aggravating and relieving factors of chronic pain.
Knowledge about factors that influence the pain experience provides guidance for the patient in making
decisions about lifestyle modifications that promote more effective pain management strategy.

 Provide the patient and family with adequate and truthful information about chronic pain and options
available for pain management. Lack of knowledge about the characteristics of chronic pain and pain
management strategies can add to the burden of pain in the patient’s life.

Constipation
NANDA Definition
Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or
passage of excessively hard, dry stool.

Discussion of the Problem

Constipation is the most common bowel-management problem in the elder population. It is one of the four
most common problems related to fecal elimination namely; constipation, diarrhea, bowel incontinence, and
flatulence. It is usually episodic; however, it can become a lifelong, chronic problem. Constipation can be caused by
the following factors: too little fluid, too little fiber, inactivity or immobility, disruption in daily routines, lack of
privacy, irritable bowel syndrome (IBS), neurological conditions, stroke, paralysis, pelvic floor dysfunction or
muscle damage, pregnancy, use of medications (analgesics, overuse of laxatives, iron supplements, antihistamines,
antacids, and antidepressants), overuse of enemas, ignoring the need to defecate, stress and depression. If the
constipation becomes chronic, it could lead to development of hemorrhoids, diverticulosis and rarely, perforation of
the colon. Sudden death could also occur during straining of a stool. The Valsalva maneuver can present serious
problems to people with heart disease, brain injuries, or respiratory disease. Obstipation, the complete lack of
passage of stool, could occur when tumors are present in the colon and rectum. Other medical conditions that could
cause constipation as follows: disc surgery, fecal diversions, anemias and renal dialysis. Although dietary
management, increasing fluid and fiber, still remains the most effective treatment for constipation, exercise and
daily routine are important as well.

Nursing Interventions Classification (NIC)

 Bowel Training
 Constipation/Impaction Management
 Teaching: Prescribed Medication

Nursing Outcomes Classification (NOC)

 Bowel Elimination
 Medication Response
 Self-Care Toileting

Goal and Objectives

 Patient or caregiver will articulate procedures that will avoid recurrence of constipation.
 Patient will demonstrate changes in behaviors or lifestyle, as necessitated by causative, contributing factors.
 Patient will exhibit active bowel sounds or peristaltic activity.
 Patient will pass soft, formed stool at a regularity perceived as "normal" by the patient.
 Patient will pass stool of soft or semiformed consistency without straining.

Subjective and Objective Data

 Abdominal distention
 Abdominal pain/rectal fullness, nausea
 Anorexia
 Change in frequency, consistency, and amount of stool
 Decreased bowel sounds
 Dull headache, restlessness, and depression
 Frequent but nonproductive desire to defecate
 Increased abdominal girth
 Nausea and vomiting
 Passage of hard, dry stool
 Passage of liquid fecal seepage
 Straining at stools
 Verbalized pain or fear of pain

Related Factors:
 Altered nerve stimulation, ileus
 Changes/restriction of dietary intake
 Drug therapy side effects
 Emotional stress, lack of privacy
 Fear of pain
 Hormone-secreting tumor, carcinoma of colon
 Immobilization, decreased physical activity, lack of exercise, use of opiates/narcotics
 Inactivity, immobility
 Inadequate fluid intake
 Irritation of the GI mucosa from either chemotherapy or radiation therapy; malabsorption of fat
 Lack of privacy
 Laxative abuse
 Low-fiber diet/fluid intake; changes in digestive processes
 Medication use
  Neurologic disorders
 Pain/discomfort in abdomen or perineal area and swelling in surgical area
 Physical factors: abdominal surgery, with manipulation of bowel, weakening of abdominal musculature
 Placement of ostomy in descending or sigmoid colon
 Pregnancy
 Reduced intestinal motility, compression of bowel (peritoneal dialysate); electrolyte imbalances;
decreased mobility
 Tumor or other obstructing mass

Assessment (Dx)
 Assess and document usual pattern of elimination then compare it with present pattern. Take in to
consideration the following characteristics: size, frequency, color, odor and quality. The "Normal"
frequency of passing stool varies from twice daily to once every third or fourth day. Establishing what is
"normal" for each individual is important.

GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT TOOL

ELIMINATION PATTERN ASSESSMENT
SUBJECTIVE
1. What is your usual frequency of bowel movements? _________________
a. Have to strain to have a bowel movement? No__ Yes__
b. Same time each day? No__ Yes__
2. Has the number of bowel movements changed in the past week?
No__ Yes__ Increased?__ Decreased?__
3. Character of stool
a. Consistency: Hard__ Soft__ Liquid__
b. Color: Brown__ Black__ Yellow__ Clay-colored__
c. Bleeding with bowel movements: No__ Yes__
4. History of constipation: No__ Yes__ How often? ____________________
5. History of diarrhea: No__ Yes__ When?___________________________
6. History of incontinence: No__ Yes__ Related to increased abdominal pressure
(coughing, aughing, sneezing)? No__ Yes__
7. History of travel? No__ Yes__ Where?____________________________
8. Usual voiding pattern:
a. Frequency (times per day) ____ Decreased?__ Increased?__
b. Change in awareness of need to void: No__ Yes__ Increased?__
Decreased?__
c. Change in urge to void: No__ Yes__ Increased?__ Decreased?__
d. Any change in amount? No__ Yes__ Increased?__ Decreased?__
e. Color: Yellow__ Smokey__ Dark__
f. Incontinence: No__ Yes__ When? _____________________________

Difficulty holding voiding when urge to void develops? No__ Yes__

Have time to get to bathroom: Yes__ No__ How often does problem reaching bathroom
occur?
g. Retention: No__ Yes__ Describe: _____________________________
h. Pain/burning: No__ Yes__ Describe: ___________________________
i. Sensation of bladder spasms: No__ Yes__ When? ________________

OBJECTIVE
1. Auscultate abdomen:
a. Bowel sounds: Normal__ Increased__ Decreased__ Absent__
2. Palpate abdomen:
a. Tender: No__ Yes__ Where?_________________________________
b. Soft: No__ Yes__; Firm: No__ Yes__
c. Masses: No__ Yes__ Describe: _______________________________
 d. Distention (include distended bladder): No__ Yes__ Describe: _______
e. Overflow urine when bladder palpated? Yes__ No__
3. Rectal Exam:
a. Sphincter tone: Describe: ____________________________________
b. Hemorrhoids: No__ Yes__ Describe: ___________________________
c. Stool in rectum: No__ Yes__ Describe: _________________________
d. Impaction: No_- Yes__ Describe:______________________________
e. Occult blood: No__ Yes__ Location: ___________________________
4. Ostomy present: No__ Yes__ Location: ___________________________

 Assess and document for history of neurologic diseases, for example multiple sclerosis and Parkinson’s
disease. Alteration of the colon’s ability to perform peristalsis may be affected by neurologic disorders.

 Assess current use of medication that may contribute or cause constipation. Narcotics, antacids with
calcium or aluminum base, antidepressants, anticholinergics, antihypertensives, and iron and calcium
supplements are some examples of drugs that can cause constipation.

 Assess dependency on enemas for elimination. Because the colon becomes distended and does not respond
normally to the presence of stool, abuse or overuse of cathartics and enemas can result in dependence on
them for evacuation,

 Assess for anxiety/fear with regards to pain. Anorectal disorders like hemorrhoids and anal fissures are
painful and can cause ignoring urge to defecate, which over time results in a dilated rectum that no longer
responds to the presence of stool.

 Assess for laxative use, type, and frequency. The function of the nerves and muscles of the colon function
inadequately in producing urge to defecate due to chronic laxative use. Over some time, the colon becomes
atonic and distended.

 Assess usual dietary habits, eating habits, eating schedule, and liquid intake prior to hospitalization. An
alteration in mealtime, type of food, interruption of usual schedule, and anxiety can lead to constipation.

 Evaluate activity level. Prolonged bed rest, lack/decrease in exercise, and inactivity contribute to
constipation.

 Evaluate the degree of patient’s tendency to delay the defecation that may contribute to constipation.
Ignoring the urge to defecate eventually leads to chronic constipation. It is because the rectum no longer
senses, or responds to, the presence of stool. The longer the stool remains in the rectum, the drier and
harder (and more difficult to pass) it becomes.

 Explore the possible causes of delayed onset/absence of effluent. Auscultate for bowel sounds. In
constipation bowel sounds are commonly decreased.

 Inspect perianal skin condition frequently, noting changes or beginning of skin breakdown. Assist patient
with perineal care after each bowel movement (BM). Proper perineal care prevents skin excoriation and
breakdown.

 Monitor and document intake and output (I&O) with specific attention to food/fluid intake. Excessive loss
of fluids or liquids aids in identifying dietary deficiencies.

 Monitor and document laboratory studies as indicated, e.g., electrolytes. Altered GI function may be caused
by electrolyte imbalances that need to be corrected.
  Provide privacy for elimination (e.g., access to bathroom facilities with privacy during work hours or use of
bedpan). Being away from home limits their ability to have a bowel movement as reported by many
individuals.

Therapeutic Interventions
 Assist in removal of fecal impaction digitally. Elderly patients (especially debilitated patients) whose stool
remains in the rectum for long periods becomes dry and hard, may not be able to pass these stools without
manual assistance.

 Encourage daily fluid intake of 2000 to 3000 ml/day (2 to 3 liters/day), if medically not contraindicated.
Patients with cardiovascular limitations, like most elderly patients, may require lesser fluid to be taken.

 Encourage to establish a regular time for elimination. Depending on the person’s usual schedule, any time,
as long as it is regular, is fine.

 Instruct patient to increased fiber in diet (e.g., raw fruits, fresh vegetables, prunes, prune juice, cold cereal,
and bean products); a minimum of 20 g of dietary fiber per day is essential to promote good bowel.
Through the intestine, fiber essentially passes unchanged. When it reaches the colon, it absorbs water and
forms a gel, which adds bulk to the stool and makes defecation easier.

 Support physical activity and regular exercise (e.g., isometric abdominal and gluteal exercises). Defecation
is facilitated through ambulation and/or abdominal exercises that strengthen abdominal muscles. Unless it
is medically contraindicated.

 To minimize discomfort, suggest the following measures:

1. Warm sitz bath
2. Hemorrhoidal preparations. These aids in shrinking swollen hemorrhoidal tissue.

STEP IN MAKING SITZ BATH

Step 1. You need to get a bathtub, shallow bucket or a sitz bath.
Step 2. Fill up your bathtub, bucket or sitz bath with warm water. The water
should be warm enough to the point that it is almost uncomfortable, but not
to the point that it is warm enough to burn. The water should be just deep
enough to envelop your entire buttocks and hips.
Step 3. (Optional) You can fill up another bathtub, bucket or sitz bath with
cold water. You could move back and forth between the cold and warm
water every few minutes.
Step 4. The majority practitioners advise sitting in the water for about 20-30
minutes a number of times a week to promote healing.
Step 5. When you’re done. Get out of your sitz bath; make sure that you
dry the region with a clean, cotton towel. Note that you should pat, not rub
dry. Some practitioners recommend letting the area air dry however.
Note: You can also add salts to sitz baths if your doctor advises it. The
quantity of salt depends on the size of your sitz bath.

 The following should be employed for hospitalized patients,:

1. Allow patient adequate time to relax.
2. Familiarize and reorient patient to location of bathroom and encourage use, unless medically
contraindicated. To facilitate defecation, a sitting position with knees flexed that straightens the
rectum may be used. This is to enhance the use of abdominal muscles which eventually facilitates
easier defecation.
3. Provide a warmed bedpan to bedridden patients and assist patient to assume a high-Fowler’s
position with knees flexed. This position best utilizes gravity and allows for effective Valsalva
maneuver.
 4. Provide curtain off the area. This promotes privacy.
 Consult dietitian if necessary. A gradual increase in fiber intake is recommended by a professional.

Educative (Edx)
 clarify or reinforce to patient and significant others the importance of the following:
1. A balanced diet that contains adequate fiber, fresh fruits, vegetables, and grains is essential.
Twenty grams per day is recommended.
2. Adequate fluid intake. Drink 8 glasses/day or 2000 to 3000 ml/day. This facilitates defecation.
3. Avoid gas-forming foods. Decreases gastric distress and abdominal distention.
4. Privacy for defecation
5. Regular exercise/activity. Regular activities promote better peristalsis.
6. Regular meals. Successful bowel training relies on routine.
7. Regular time for evacuation and adequate time for defecation. Regular time should be established
to monitor patient’s elimination progress.

 Discuss the use of pharmacological agents as ordered, as in the following:

1. Bulk fiber (Metamucil and similar fiber products). These increase fluid, gaseous, and solid bulk of
intestinal contents.
2. Chemical irritants (e.g., castor oil, cascara, Milk of Magnesia). These drugs cause irritation of the
bowel mucosa that result to rapid propulsion of contents of small intestines.
3. Oil retention enema. This causes the stool to soften.
4. Stool softeners (e.g., Colace). This lubricates intestinal mucosa and soften stool for easier
evacuation.
5. Suppositories. These help in softening stools and stimulate rectal mucosa; best results occur when
given 30 minutes before usual defecation time or after breakfast.

Decreased Cardiac Output

NANDA Definition
Inadequate blood pumped by the heart to meet the metabolic demands of the body.

Discussion of the Problem

Though advances in diagnostic procedures that allow prompt and more precise diagnoses so that early
management could be initiated before significant debilitation occur, heart disease still remains a chronic condition.
Common etiologies of decreased cardiac output include the following: angina, myocardial infarction, severe
hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, pulmonary disease, arrhythmias,
chronic heart failure, cardiac surgery, acute and chronic renal failure, Grave’s disease, drug effects, fluid overload,
decreased fluid volume, and electrolyte imbalance. Geriatric patients are at high risk of developing this problem
since their ventricles have reduced compliance due to aging process. The overall goals of management are to relieve
patient symptoms, to improve functional status and quality of life, and to extend survival.

Nursing Interventions Classification (NIC)

 Cardiac Care
 Hemodynamic Regulation
 Teaching: Disease Process

Nursing Outcomes Classification (NOC)

 Cardiac Pump Effectiveness
 Circulation Status
 Knowledge: Disease Process
 Knowledge: Treatment Program
Goal and Objectives
 Patient will demonstrate an enhancement in activity tolerance
 Patient will demonstrate unwavering cardiac rhythm and rate within own normal range.
 Patient will maintain BP within standard limits; have regular cardiac rhythms; maintain warm, dry skin;
clear lung sounds, and strong bilateral, equal peripheral pulses.
 Patient will participate in activities that decrease BP or cardiac workload

Subjective and Objective Data

 Abnormal heart sounds
 Angina
 Anxiety, restlessness
 Arrhythmias, electrocardiogram (ECG) changes
 Chest pain
 Confusion, change in mental status
 Cool, ashen skin; diaphoresis
 Decreased peripheral pulses, ejection fraction less than 40%
 Decreased urine output
 Extra heart sounds (S3, S4)
 JVD, liver engorgement, edema
 Pulsus alternans
 Rales, tachypnea, dyspnea, orthopnea, cough, abnormal arterial blood gases (ABGs), frothy sputum
 Syncope, dizziness
 Variations in hemodynamic parameters (blood pressure [BP], heart rate, central venous pressure [CVP],
pulmonary artery pressures, venous oxygen saturation [SVO2], cardiac output)
 Weakness, fatigue
 Weight gain, edema, decreased urine output

Related Factors
 Alteration in afterload
 Alterations in heart rate, rhythm, electrical conduction
 Cardiac muscle disease
 Decreased oxygenation
 Impaired contractility/inotropic changes
 Increased or decreased ventricular filling (preload)
 Structural changes (e.g., valvular defects, ventricular aneurysm)

Assessment (Dx)
 Assess color and temperature of skin and time of capillary refill. Cold, clammy skin is due to compensatory
increase in sympathetic nervous system stimulation, reduced cardiac output, and desaturation.

 Assess mentation status. In the early stages, restlessness is seen; in later stages, severe anxiety and
confusion are being manifested.

 Auscultate apical pulse; monitor heart rate, rhythm (if telemetry is available record dysrhythmia). To
compensate for reduced ventricular contractility, tachycardia is usually present even at rest. Common
dysrythmias associated with heart failure are as follows: Premature atrial contractions (PACs), paroxysmal
atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and atrial fibrillation (AF).

 Monitor heart rate and blood pressure. In the early stages, sinus tachycardia and augmented arterial blood
pressure are being manifested; blood pressure drops as the state deteriorates. Geriatric patients have
diminished response to catecholamines, hence their response to decreased cardiac output may be blunted,
 with lower rise in heart rate. In heart failure patients, pulsus alternans (alternating strong-then-weak pulse)
is often seen.

 Observe changes in sensorium(anxiety, confusion, depression, disorientation, and lethargy). This may
indicate insufficient cerebral perfusion secondary to reduced cardiac output.

 Observe presence and quality of central and peripheral pulses. With reduced cardiac output, pulses are
weak. In addition, bounding carotid, femoral, jugular, and radial pulses may be noted or palpated. Due to
the effects of vasoconstriction and venous congestion, pulses in the legs or feet may be reduced.

PERIPHERAL VASCULAR ASSESSMENT

Check for Symmetry  Compare Right to Left
 Compare Upper Extremity to Lower Extremity
Palpable Pulses  Temporal
 Carotid
 Brachial BP, CPR in infant
 Radial pulse
 Ulnar
 Femoral arterial studies
 Popliteal
 Dorsalis Pedis
 Posterior Tibial
History  blood clots
 edema of feet or legs
 intermittent claudication
 leg cramps
 leg ulcers
pain on walking
disappears with rest
 pallor of fingertips
 varicose veins
INSPECTION Compare Side to Side
(Upper Extremities )  Size
 Symmetry
 Skin/color
 Nail Beds / Capillary Refill
Nails
 Hair Growth
 Venous Pattern
INSPECTION Compare Side to Side
(Lower Extremities)  Size
 Symmetry
 Skin -color, lesions
 Nail Beds / Capillary Refill
 Nails
 Venous Pattern
Hair Growth
PALPATION Compare Side to Side
(Upper Extremities)  Temperature
 Capillary refill
 Pulses
o Radial
o Brachial
o Ulnar
 CHARACTERISTICS OF PULSES
palpate along LENGTH of artery with finger pads
 Rate
 Rhythm
 Contour/elasticity
 Strength (Amplitude)
o +4 = bounding
o +3 = full, increased
o +2 = normal
o +1 = diminished, weak
o 0 = absent
Rhythm/Pattern
regular
 irregular (dysrhythmia)
 if irregular - take apical
apical/radial
PALPATION Compare Side to Side
( Lower Extremities)  Pulses
 Femoral
 Popliteal Pulses
o Dorsalis Pedis
o Posterior Tibial
o Femoral
o Popliteal
 Temperature
 Edema
+1- +4 pitting
 Sensation

Arterial Insufficiency of Lower Extremities

Pulses Decreased/Absent
Pale on elevation
Color       Dusky Rubor on
dependency
Temperature Cool/Cold
Edema None
Shiny, thick nails, no
Skin hair
     Ulcers on Toes
Pain, more with
Sensation exercise
   Paresthesias

Venous Insufficiency of Lower Extremities

Pulses Present
Pink to cyanotic
Color Brown pigment at
ankles
TemperatureWarm
Edema Present
Discolored, scaly
Skin       ulcers on
ankles
 Pain, More with
standing or sitting.
Sensation Relieved with
elevation/support
hose

 Auscultate lung sounds. Note any episode of paroxysmal nocturnal dyspnea (PND) or orthopnea.
Orthopnea is difficulty breathing when the patient is in supine Position. PND is difficulty breathing that
occurs during the night. Crackles echoes accumulation of fluid secondary to damaged left ventricular
emptying. They are more apparent in the dependent areas of the lungs.

 Monitor heart sounds, noting gallops, S3, S4. S3 indicates lowered left ventricular ejection and is a classic
sign of left ventricular failure. S4 take place with lowered compliance of the left ventricle, which impairs
diastolic filling.

 Review weight gain and fluid balance. Body weight is a more accurate indicator of fluid or sodium
retention than intake and output. Fluid and sodium retention may be caused by compromised regulatory
mechanisms.

 If hemodynamic monitoring is in place:

1) Check central venous, pulmonary artery pressure, pulmonary capillary wedge pressure, and right
arterial pressure. Hemodynamic parameters give information aiding in differentiation of reduced
cardiac output due to fluid overload versus deficit in fluid.
2) Watch SVO 2 continuously. One of the initial indicators of decreased cardiac output is change in
oxygen saturation of mixed venous blood.
3) Do cardiac output determination. Gives objective number to guide therapy.

 Check ECG for rate; rhythm; ectopy; and change in PR, QRS, and QT intervals. Tachycardia, bradycardia,
and ectopic beats can compromise cardiac output. Geriatric patients are particularly sensitive to the loss of
atrial kick in atrial fibrillation.

THE STANDARD 12 LEAD ECG

The standard 12-lead electrocardiogram (ECG/EKG) represents the heart's electrical activity
recorded from electrodes on the body surface.

ECG Waves and Intervals

P wave the sequential activation (depolarization) of the right and left atria
QRS complex right and left ventricular depolarization (normally the ventricles are activated
simultaneously)
ST-T wave ventricular repolarization
U wave origin for this wave is not clear - but probably represents "afterdepolarizations" in
the ventricles
PR interval time interval from onset of atrial depolarization (P wave) to onset of ventricular
depolarization (QRS complex)
QRS duration duration of ventricular muscle depolarization
QT interval duration of ventricular depolarization and repolarization
RR interval duration of ventricular cardiac cycle (an indicator of ventricular rate)
PP interval duration of atrial cycle (an indicator of atrial rate)

Orientation of the 12 Lead ECG

It is significant to consider that the 12-lead ECG provides spatial information about the heart's
electrical activity of the heart in 3 approximately orthogonal directions namely: Right Left, Superior
Inferior, and Anterior Posterior. Further, each of the 12 leads represents a particular orientation in space.
(RA = right arm; LA = left arm, LF = left foot)

Bipolar limb leads (frontal plane):

Lead I: RA (-) to LA (+) (Right Left, or lateral)
Lead II: RA (-) to LF (+) (Superior Inferior)
Lead III: LA (-) to LF (+) (Superior Inferior)
Augmented unipolar limb leads (frontal plane):
Lead aVR: RA (+) to [LA & LF] (-) (Rightward)
Lead aVL: LA (+) to [RA & LF] (-) (Leftward)
Lead aVF: LF (+) to [RA & LA] (-) (Inferior)
Unipolar (+) chest leads (horizontal plane):
Leads V1, V2, V3: (Posterior Anterior)
Leads V4, V5, V6:(Right Left, or lateral)

Location of chest electrodes

V1: right 4th intercostal space

V2: left 4th intercostal space
V3: halfway between V2 and V4
V4: left 5th intercostal space, mid-clavicular line
V5: horizontal to V4, anterior axillary line
V6: horizontal to V5, mid-axillary line

 Check laboratory data (cardiac enzymes, ABGs, electrolytes, etc). Enzymes evaluate resolution/extension
of infarction. Existence of hypoxia show necessitate for supplemental oxygen. Electrolyte imbalance,
hypo/hyperkalemia for example, unfavorably affects cardiac rhythm/contractility.

 Look out for dependent or general edema. May signify heart failure, renal or vascular injury.

 Monitor response to increased activity. Physical activity augments the demands placed on the heart; fatigue
and exertional dyspnea are frequent problems with reduced cardiac output conditions. Close monitoring of
patient’s response to increased activity serves as a guide for most favorable succession of activity.

 Note for chest pain. This signifies an imbalance between oxygen supply and demand.

 Review urine output. Find out how often the patient urinates. Oliguria can echo decreased renal perfusion.
Diuresis is anticipated with diuretic therapy.
Therapeutic Interventions (Tx)
 Give medication as prescribed, noting reaction and inspecting for side effects and toxicity. Make clear with
physician parameters for halting medication particularly the following: digitalis therapy, diuretics,
vasodilator therapy, antidysrhythmics, ACE inhibitors, and inotropic agents.

 Limit fluids and sodium as prescribed for patients with increased preload. This reduces extracellular fluid
volume.

 Retain hemodynamic parameters at prescribed levels. Close monitoring of these parameters directs titration
of fluids and medications for patients in the acute setting.

 Sustain optimal fluid balance. Giving of fluid increases extracellular fluid volume to elevate cardiac output.

 Keep up adequate ventilation and perfusion, as in the following:

1) Put patient in semi- to high-Fowler’s position. This lessens preload and ventricular filling.
2) Put patient in supine position. This promotes venous return, increases diuresis.
3) Give humidified oxygen as ordered. The deteriorating heart may not be able to compensate with
increased oxygen demands.

 Maintain physical and emotional rest, as in the following:

1) Limit activity. This decreases oxygen demands.
2) Offer quiet, relaxed milieu. Emotional stress adds to cardiac demands.
3) Systematize nursing and medical care. This permits rest periods.
4) Check progressive activity within restriction of cardiac function.

 Check sleep patterns; administer sedative as prescribed. Rest is essential for conserving energy.

 Offer bedside commode. Have patient keep away from activities provoking a vasovagal response, Give
stool softeners as considered necessary. Use of commode lowers works getting to bathroom or having a
great effort to use bedpan. Vasovagal maneuver grounds vagal stimulation. Rebound tachycardia
subsequently occurs, which more compromises cardiac function or output.

 Offer little, easily digested meals. Restrict caffeine intake. Huge meals may augment myocardial workload
and root vagal stimulation, leading to bradycardia or ectopic beats. Caffeine is a direct cardiac stimulant
that can rise up the heart rate. Note: New guidelines propose no need to limit caffeine in regular coffee
drinkers.

 If arrhythmia takes place, verify patient response, document, and report if significant or symptomatic.
1. Have antiarrhythmic drugs readily accessible.
2. Care for arrhythmias according to medical orders or procedure and evaluate reaction.
Either tachyarrhythmias or bradyarrhythmias can lower cardiac output and myocardial tissue
perfusion.

 Have emergency apparatus or medications accessible. Abrupt coronary occlusion, lethal dysrhythmias,
infarct, and unremitting pain are conditions that may lead to cardiac arrest, requiring urgent life-saving
managements.

Educative (Edx)
 Clarify progressive activity program and signs of overexertion.
 Explain diet restrictions especially regarding fluid and sodium.
 Give details on symptoms and management for reduced cardiac output related to respective etiological
factors.
 Give explanation about the drug regimen, purpose, dose, and possible side effects.
 Deficient Fluid Volume
NANDA Definition
Fluid volume deficit is the decreased intravascular, interstitial, and/or intracellular fluid. This refers to
dehydration, water loss alone without change in sodium.

Discussion of the Problem

Fluid volume deficit (FVD), or hypovolemia, occurs when loss of ECF volume exceeds the intake of fluid.
In addition, it occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids,
so the ratio or serum electrolytes to water remain the same. It may occur alone or in combination with other
imbalances. Early detection and management are vital to prevent potentially life-threatening hypovolemic shock.
Risk factors for FVD are as follows: vomiting, diarrhea, GI suctioning, sweating, decreased intake, nausea, inability
to gain access to fluids, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, third-space fluid shifts, burns,
ascites, and liver dysfunction. Medical conditions that could contribute to fluid volume deficit are as follows:
gastrectomy, fecal diversions, eating disorders (anorexia nervosa and bulimia nervosa), diabetes insipidus, DKA,
hepatitis, pancreatitis, leukemia, peritoneal renal diaysis, hemodyalysis, BPH, septicemia, and AIDS. Geriatric
patients are more apt to develop fluid imbalances. The goals of management are to treat the underlying disorder and
return the extracellular fluid compartment to normal, to restore fluid volume, and to correct any electrolyte
imbalances.

Nursing Interventions Classification (NIC)

 Electrolyte Management
 Fluid Management
 Fluid Monitoring
 Fluid Resuscitation

Nursing Outcomes Classification (NOC)

 Coagulation Status
 Fluid Balance
 Hydration
 Risk Control

Goal and Objectives

 Patient will be free of hemorrhage wit clotting times WNL.
 Patient will experience sufficient fluid volume and electrolyte balance as manifested by palpable peripheral
pulses, moist mucous membranes, urine output greater than 30 ml/hr, normotensive blood pressure (BP),
heart rate (HR) 100 beats/min, consistency of weight, normal skin turgor, electrolyte levels within normal
range, and capillary refill.
 Patient will start behaviors/lifestyle changes to avoid progression of dehydration.
 Patient will verbalize awareness of causative factors and behaviors essential to correct fluid deficit.

Subjective and Objective Data

 Changes in mental status
 Dark/concentrated urine
 Decreased urine output
 Decreased venous filling
 Dry skin/mucous membranes
 Hemoconcentration, altered electrolyte balance
 Hypotension, tachycardia, delayed capillary refill
 Increased pulse rate, body temperature, decreased BP
 Increased serum sodium
 Increased urinary output, dilute urine
 Output greater than input (diuretic use); concentrated urine/decreased urine output (dehydration)
  Poor skin turgor
 Possible weight gain
 Sudden weight loss
 Thirst
 Weak peripheral pulses
 Weakness; thirst; sudden weight loss

Related Factors
 Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea)
 Chronic/excessive laxative/diuretic use
 Consistent self-induced vomiting
 Electrolyte and acid-base imbalances
 Excessive gastric losses: diarrhea, vomiting
 Failure of regulatory mechanisms
 Fluid shifts from extracellular, intravascular, and interstitial compartments into intestines and/or
peritoneal space (edema or effusions)
 Inadequate intake of food and liquids
 Increased metabolic rate (fever, infection)
 NG/intestinal aspiration
 Osmotic diuresis (from hyperglycemia)
 Restricted intake: nausea, confusion

Assessment (Dx)
 Assess alteration in mentation/sensorium, e.g., confusion, agitation, slowed responses, etc. Changes or
alteration in mentation/sensorium is may be caused by abnormally high or low glucose, electrolyte
abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Impaired consciousness can
predispose patient to aspiration regardless of the cause.

 Assess fluid status in relation to dietary intake. Most fluid comes into the body through drinking, water in
foods, and water formed by oxidation of foods. Establishing if the patient is on a fluid restriction is
necessary.

 Auscultate and document heart sounds; note rate, rhythm or other abnormal findings. Cardiac alterations
like dysrhythmias may reflect hypovolemia and/or electrolyte imbalance, commonly
hypocalemia/hyopocalcemia. Note: MI, pericarditis, and pericardial effusion with/ without tamponade are
common cardiovascular complications.

 Discuss the importance of monitoring weight daily with same scale, and preferably at the same time of day.
Weight is the best assessment data for possible fluid volume imbalance. An increased in 2 lbs a week is
consider normal.

 Explore patient history to determine the possible cause of the fluid disturbance or imbalance. Establishing a
database of history will aid to give accurate and individualized care for each patient. This can help to guide
interventions.

 Monitor and document vital signs. This will serve as a baseline data for future comparison.

 Note presence of nausea, vomiting and fever. These factors affect intake, fluid needs, and route of
replacement.

 Assess blood pressure for orthostatic changes (from patient lying supine to high-Fowler’s position or to
standing). Note the following orthostatic hypotension significance:
1. Greater than 10 mm Hg drop: circulating blood volume is decreased by 20%.
2. Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%.
 ORTHOSTATIC HYPOTENSION
Orthostatic hypotension, also called postural hypotension, is defined as a “temporary lowering of
blood pressure (hypotension) due usually to suddenly standing up (orthostatic).” This sudden change in
position causes a temporary decrease in blood flow, thus, a deficiency of oxygen to the brain. This leads
to symptoms such as lightheadedness, dizziness, feeling about to black out, and tunnel vision,
sometimes, a "black out" episode (a loss of consciousness). The symptoms are usually worse when
standing and get better with lying down.
A test used to confirm orthostatic hypotension is called the Tilt-table testing. It involves positioning
the patient on a table with a foot-support. The table is then tilted upward. Blood pressure and pulse is
measured while symptoms are recorded subsequently in various positions.
There is no treatment is required for orthostatic hypotension. If someone with orthostatic
hypotension faints, they will regain consciousness by simply sitting or lying down. The person is afterward
counseled to exercise care and to make it gradual in changing positions from lying to sitting to standing.
This simple method can permit the body to adjust to the new position and allow the nerves to circulation
of the legs to adjust gradually in older person.

 Assess and document temperature. Febrile states reduce body fluids by perspiration and increased
respiration. This is known as insensible water loss.

 Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours.
Concentrated urine denotes fluid deficit. A normal urine output is considered normal not less than
30ml/hour.

 Inspect and take note of skin turgor and mucous membranes for signs of dehydration. Signs of dehydration
are also seen through the skin. Skin of elderly patients losses elasticity therefore skin turgor should be
assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue.

 Measure and document I&O including vomitus/ gastric aspirate, elimination and urination. Calculate for
24-hour fluid balance. These are good indicators of fluid replacement needs/ effectiveness of therapy.

 Monitor and document hemodynamic status including CVP, pulmonary artery pressure (PAP), and
pulmonary capillary wedge pressure (PCWP) if available in hospital setting. This direct measurement
serves as optimal guide for therapy.

 Monitor closely for signs of circulatory overload (headache, flushed skin, tachycardia, venous distention,
elevated central venous pressure [CVP], shortness of breath, increased BP, tachypnea, cough) during
treatment. This prevents complications associated with fluid replacement therapy.

 Monitor, document and report abnormal values of serum electrolytes (especially potassium, magnesium),
urine osmolality, ABGs (acid-base balance). Fluid deficit is suggested if there is elevated hemoglobin and
elevated blood urea nitrogen (BUN). Urine-specific gravity is also increased.

Therapeutic Interventions (Tx)

 Encourage patient to drink liberal amounts of fluids. Oral fluid replacement is indicated for mild fluid
deficit.

 Help patient if he/ she is unable to feed self. Encourage caregiver to assist with feedings as necessary.
  If patient can tolerate oral fluids, provide what oral fluids patient prefers. Provide fluid and straw at bedside
within easy reach. Provide fresh water and a straw. Most elderly patients may have reduced sense of thirst
and may require continuing reminders to drink.

 Plan daily activities. Planning conserves patients’ energy.

 Promote comfortable environment by covering patient with light sheets. Avoid situations where patient can
experience overheating to prevent further fluid loss.

 Provide proper and oral hygiene as necessary. This promotes the patients’ interest in drinking fluids.

 For more severe hypovolemia:

1. Administer blood products as prescribed by the physician. These may be necessary for active GI
bleeding.
2. Assist in administering parenteral fluids as ordered by the physician. To correct fluid and
electrolyte imbalance.
3. Assist the physician with insertion of a central venous line and arterial line as indicated. This
promotes more effective fluid administration and monitoring.

 Maintain IV flow on prescribed rate.

1. Stop or slow the infusion if signs of fluid overload occur, refer to physician accordingly. Most
susceptible to fluid overload are elderly patient and requires
immediate attention.

 Administer antidiarrheal or antiemetic medications as prescribed. In addition to IV fluids to prevent

hypovolemia due to severe diarrhea or vomiting.

 Administer blood transfusion and parenteral fluids accordingly. To maintain the bowel at rest, the body
requires alternative fluid replacement to prevent and correct losses/ anemia. Note: If there is the presence of
regional enteritis, fluids and foods containing sodium is restricted.

 Assist patient in monitoring weight daily. Weight is a good indicator of overall fluid and nutritional status.

 Provide adequate rest periods; instruct patient to avoid exertion and maintain oral restrictions if indicated.
To reduce intestinal fluid losses, the colon is placed at rest for healing.

 Provide measures to prevent excessive electrolyte loss (e.g., resting the GI tract, administering antipyretics
as ordered by the physician). Preventing electrolyte imbalance is essential especially to elderly patient.

Educative (Edx)
 Discuss the possible cause and effect of fluid losses or decreased fluid intake. This is to encourage the
patient to take part in his/her plan of care.

 Encourage to drink liberal amounts of liquid as tolerated or based on individual needs. Patient may have
restricted oral intake in an attempt to control urinary symptoms, reducing homeostatic reserves and
increasing risk of dehydration/hypovolemia.

 Enumerate interventions to prevent or minimize future episodes of dehydration. Patient needs to appreciate
the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid
deficits.

 If needed, refer patient to home health nurse or private nurse in able to assist patient. This is a cost effective
strategy if patients’ condition is not severe.
 Stress the importance of maintaining proper nutrition and hydration. To promote and establish cooperation
of the patient.

 Stress to patient and significant others the importance of maintaining prescribed fluid intake including
special diet considerations involved. If future episodes occur, patient can rely on home treatment if
necessary.