Table of Contents
NURSING .................................................................................................1 DIAGNOSIS..............................................................................................1 Table of Contents....................................................................................2 Activity Intolerance Weakness; Deconditioned; Sedentary.............................................10
Ongoing Assessment..........................................................................11 Therapeutic Interventions...................................................................12 Education/Continuity of Care..............................................................14

Ineffective airway clearance..................................................................15
NIC Interventions (Nursing Interventions Classification).....................15 Ongoing Assessment..........................................................................16 Therapeutic Interventions...................................................................17 Education/Continuity of Care..............................................................20

Risk for Aspiration.................................................................................21
NOC Outcomes (Nursing Outcomes Classification).............................21 NIC Interventions (Nursing Interventions Classification).....................21 Ongoing Assessment..........................................................................22 Therapeutic Interventions...................................................................23 Education/Continuity of Care..............................................................24

NIC Interventions (Nursing Interventions Classification).....................25 Ongoing Assessment..........................................................................26 Therapeutic Interventions...................................................................26 Education/Continuity of Care..............................................................28

Decreased Cardiac Output....................................................................29
NOC Outcomes (Nursing Outcomes Classification).............................29 NIC Interventions (Nursing Interventions Classification).....................29 Ongoing Assessment..........................................................................30 Therapeutic Interventions...................................................................32

Education/Continuity of Care..............................................................33

Ineffective Breathing Pattern................................................................34
NOC Outcomes (Nursing Outcomes Classification).............................34 NIC Interventions (Nursing Interventions Classification).....................34 Ongoing Assessment..........................................................................35 Therapeutic Interventions...................................................................37 Education/Continuity of Care..............................................................38

Disturbed Body Image...........................................................................39
NOC Outcomes (Nursing Outcomes Classification).............................39 NIC Interventions (Nursing Interventions Classification).....................39 Ongoing Assessment..........................................................................41 Therapeutic Interventions...................................................................42 Education/Continuity of Care..............................................................42

Ineffective Coping.................................................................................43
NOC Outcomes (Nursing Outcomes Classification).............................43 NIC Interventions (Nursing Interventions Classification).....................43 Ongoing Assessment..........................................................................45 Therapeutic Interventions...................................................................45 Education/Continuity of Care..............................................................47

Diarrhea Loose Stools, Clostridium difficile (C. difficile).................................48
NOC Outcomes (Nursing Outcomes Classification).............................48 NIC Interventions (Nursing Interventions Classification).....................48 Ongoing Assessment..........................................................................49 Therapeutic Interventions...................................................................51 Education/Continuity of Care..............................................................52

Deficient Fluid Volume Hypovolemia; Dehydration..............................................................52
NOC Outcomes (Nursing Outcomes Classification).............................52 NIC Interventions (Nursing Interventions Classification).....................53 Ongoing Assessment..........................................................................54 Therapeutic Interventions...................................................................55 Education/Continuity of Care..............................................................57

.... OSHA68 NOC Outcomes (Nursing Outcomes Classification).......63 NIC Interventions (Nursing Interventions Classification)...61 Education/Continuity of Care................................................................................................................................ CDC Guidelines...................................58 NOC Outcomes (Nursing Outcomes Classification)........................81 ........................76 Education/Continuity of Care...............63 Ongoing Assessment....73 Ongoing Assessment............78 NOC Outcomes (Nursing Outcomes Classification)................... Standard Precautions.................................................78 Noncompliance Knowledge Deficit..................................................................74 Therapeutic Interventions.................................................................................59 Therapeutic Interventions.................58 Ongoing Assessment...................78 NIC Interventions (Nursing Interventions Classification)...........Impaired Gas Exchange Ventilation or Perfusion Imbalance........................63 NOC Outcomes (Nursing Outcomes Classification)................80 Therapeutic Interventions...................................................................79 Ongoing Assessment..................73 NOC Outcomes (Nursing Outcomes Classification)..........................................................................................................73 NIC Interventions (Nursing Interventions Classification).......................................................................................58 NIC Interventions (Nursing Interventions Classification)............62 Ineffective Health Maintenance......................................................................68 NIC Interventions (Nursing Interventions Classification)..............65 Therapeutic Interventions...67 Education/Continuity of Care..........................................................................................................................................71 Education/Continuity of Care.....................................................................................................69 Therapeutic Interventions............................... Patient Education............................................................................67 Risk for Infection Universal Precautions.........................................72 Impaired Physical Mobility Immobility.............................................68 Ongoing Assessment......................................................................................

.................................................... Anorexia.106 Ongoing Assessment............................................................................106 NOC Outcomes (Nursing Outcomes Classification)......................................................................................................................103 Education/Continuity of Care.........................................87 NIC Interventions (Nursing Interventions Classification)..........................108 .............................................................92 NOC Outcomes (Nursing Outcomes Classification)..................88 Therapeutic Interventions....................................................................................................83 NOC Outcomes (Nursing Outcomes Classification)........................................................99 Chronic Pain..........................................................................................................................................................................86 Imbalanced Nutrition: More than Body Requirements Obesity.....................................................87 Ongoing Assessment................................................................... Dressing/Grooming............................................................................................................. Feeding.............. Overweight.............................91 Acute Pain..92 Ongoing Assessment..Education/Continuity of Care....92 NIC Interventions (Nursing Interventions Classification)......................................82 Imbalanced Nutrition: Less than Body Requirements Starvation..............96 Education/Continuity of Care.................... Toileting....100 NIC Interventions (Nursing Interventions Classification).....................83 Ongoing Assessment..........................................106 NIC Interventions (Nursing Interventions Classification)......85 Education/Continuity of Care..100 NOC Outcomes (Nursing Outcomes Classification)..............................87 NOC Outcomes (Nursing Outcomes Classification)................................................93 Therapeutic Interventions.................................104 Self-Care Deficit Bathing/Hygiene..........................................................................................100 Ongoing Assessment......................................... Weight Loss................90 Education/Continuity of Care.....83 NIC Interventions (Nursing Interventions Classification)..............................84 Therapeutic Interventions.......101 Therapeutic Interventions.....................108 Therapeutic Interventions........................................................................................................

.....................117 Education/Continuity of Care....125 Therapeutic Interventions....114 NIC Interventions (Nursing Interventions Classification)............128 NIC Interventions (Nursing Interventions Classification).................................................... Decubitus Care................................. Pressure Ulcers................................ Bed Sores............................................................ Blindness.................... Deafness....................Education/Continuity of Care....................................124 Ongoing Assessment....................133 NIC Interventions (Nursing Interventions Classification)....133 Ongoing Assessment..127 Disturbed Sensory Perception: Auditory Hearing Loss.......................................114 NOC Outcomes (Nursing Outcomes Classification)...........114 Risk for Impaired Skin Integrity Pressure Sores..... Hearing Impaired................................................................128 NOC Outcomes (Nursing Outcomes Classification)....122 Education/Continuity of Care...............................................................................................................126 Education/Continuity of Care................118 Disturbed Sleep Pattern Insomnia.........................................................................................................124 NIC Interventions (Nursing Interventions Classification)...........................................................................................................................132 Disturbed Sensory Perception: Visual Vision Loss.................................................128 Ongoing Assessment..........................133 NOC Outcomes (Nursing Outcomes Classification).....115 Therapeutic Interventions.....................................................................................120 Ongoing Assessment.......119 NOC Outcomes (Nursing Outcomes Classification)....................................................................................................................................................131 Education/Continuity of Care...............................121 Therapeutic Interventions.................................. Macular Degeneration....................136 ....................................114 Ongoing Assessment.....................................................135 Therapeutic Interventions..................124 Ineffective Therapeutic Regimen Management......................................119 NIC Interventions (Nursing Interventions Classification)..................................129 Therapeutic Interventions...........

........................................................................146 Therapeutic Interventions.............................143 NIC Interventions (Nursing Interventions Classification).....................149 NOC Outcomes (Nursing Outcomes Classification)....................................................160 Education/Continuity of Care..............................156 NOC Outcomes (Nursing Outcomes Classification)......................................... decreased • Cardiac output.......................................149 NIC Interventions (Nursing Interventions Classification)......................................... Cardiopulmonary....138 Urinary Retention......... for • Disuse syndrome......................153 Education/Continuity of Care.............................................................................. risk for • Divisional activity deficit • Fatigue • Sleep pattern disturbance Circulation • Adaptive capacity: intracranial...........147 Specific Interventions......................................................................... Renal............................................................................................155 Excess Fluid Volume Hypervolemia..............Education/Continuity of Care........157 Ongoing Assessment..............141 Education/Continuity of Care.........147 Education/Continuity of Care..........................................................151 Therapeutic Interventions.... decreased • Dysreflexia ....................................................143 NOC Outcomes (Nursing Outcomes Classification)......140 Therapeutic Interventions........156 NIC Interventions (Nursing Interventions Classification)..............................150 Ongoing Assessment......................................139 NIC Interventions (Nursing Interventions Classification)......................................................... Fluid Overload...................................................158 Therapeutic Interventions..........................139 Ongoing Assessment.............................................................................................. Cerebral................................ Gastrointestinal......................149 Impaired Verbal Communication..............................................................139 NOC Outcomes (Nursing Outcomes Classification).................144 Ongoing Assessment.................................162 Activity/Rest • Activity intolerance (specify level) • Activity intolerance......142 Ineffective Tissue Perfusion: Peripheral...........................................................................................................................................

ineffective • Decisional conflict • Denial. moderate. altered • Unilateral neglect Pain/Discomfort • Pain • Pain. dysfunctional • Hopelessness • Personal identity disturbance • Post-trauma response (specify stage) • Powerlessness • Rape-trauma syndrome (specify) • Rape-trauma syndrome: compound reaction • Rape-trauma syndrome: silent reaction • Relocation stress syndrome • Self-esteem. chronic low • Self-esteem disturbance • Self-esteem. urge • Urinary elimination. anticipatory • Grieving. (acute/chronic) Food/ Fluid • Breastfeeding. risk for • Infant behavior. impaired • Spontaneous ventilation. acute • Pain. altered. ineffective • Gas exchange. interrupted • Fluid volume deficit (active loss) • Fluid volume deficit (regulatory failure) • Fluid volume deficit. less than body requirements • Nutrition: altered. altered (specify): cerebral. auditory. severe. panic) • Body image disturbance • Coping. disorganized. risk for • Sensory perception alterations (specify): visual. effective • • Breastfeeding. total • Incontinence. risk for • Breathing pattern. chronic • Infant behavior. toileting Neurosensory • Confusion. perceived • Diarrhea • Incontinence. functional • Incontinence. impaired • Health maintenance. kinesthetic. altered . ineffective • Energy field disturbance • Fear • Grieving. tactile. altered • Urinary retention. situational low • Spiritual distress (distress of the human spirit) • Spiritual well being. risk for more than body requirements • Oral mucous membrane. olfactory • Thought processes. impaired • Anxiety (mild. ineffective • Breastfeeding. ineffective • Nutrition: altered. risk for • Fluid volume excess • Infant feeding pattern. acute • Confusion. more than body requirements • Nutrition: altered. renal. bathing/hygiene. colonic • Constipation. reflex • Incontinence. potential for enhanced • Memory. impaired • Peripheral neurovascular dysfunction. disorganized • Infant behavior. potential for Elimination • Bowel incontinence Constipation • Constipation. cardiopulmonary. stress • Incontinence. defensive • Coping. gastrointestinal. dressing/ grooming. risk for • Environmental interpretation syndrome. individual. peripheral Ego Integrity • Adjustment. dysfunctional (DVWR) Safety • Body temperature. enhanced. inability to sustain • Ventilator weaning response. organized. impaired Hygiene • Self-care deficit (specify level): feeding. chronic Respiration • Airway clearance. altered • Swallowing. ineffective • Aspiration. gustatory.Tissue perfusion.

risk for • Protection.• Home maintenance management. ineffective management Therapeutic regimen: families. impaired • Trauma. risk for • Parenting. ineffective • Family coping. impaired • Social isolation Teaching/Learning • Growth and development. risk for • Violence. ineffective • Tissue integrity. altered • Self-mutilation. altered • Parenting. altered • Health-seeking behaviors (specify) Knowledge deficit (learning need) (specify) Noncompliance (compliance. risk for • Skin integrity. ineffective • Family coping. enhanced. (actual)/risk for: directed at self/others Sexuality(component of ego integrity and social interaction) • Sexual dysfunction • Sexuality patterns. altered. risk for • Thermoregulation. altered) (specify) Therapeutic regimen: community. effective management Therapeutic regimen: individual. altered Social Interaction • Caregiver role strain • Caregiver role strain. risk for • Parental role conflict • Parent/infant/child attachment. impaired verbal • Community coping. altered • Loneliness. altered: alcoholism (substance abuse) • Family processes. altered. risk for • Physical mobility. ineffective management Therapeutic regimen: individual. risk for • Suffocation. potential for growth • Family processes. altered • Social interaction. risk for • Role performance. impaired • Poisoning. ineffective management • • . potential for • Community coping. risk for • Injury. risk for • Communication. risk for • Perioperative positioning injury. impaired • Skin integrity. impaired. impaired • Hyperthermia • Hypothermia • Infection.

Nursing goals are to reduce the effects of inactivity. as well as absence of shortness of breath. Sedentary NANDA Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. malnourishment. Activity intolerance may also be related to factors such as obesity. Side effects of medications Expected Outcomes . This is especially apparent in elderly patients with a history of orthopedic. Sedentary lifestyle.. side effects of medications (e. Insufficient sleep or rest periods. and fatigue. as evidenced by normal heart rate and blood pressure during activity.related problems. -blockers). Deconditioned.Activity Intolerance Weakness. or emotional states such as depression or lack of confidence to exert one's self. which can impair the ability to maintain activity. and assist the patient to maintain a satisfactory lifestyle. diabetic. Pain. Imposed activity restriction. or pulmonary. Exertional discomfort or dyspnea Related Factors: Generalized weakness. Defining Characteristics: Verbal report of fatigue or weakness. weakness. The aging process itself causes reduction in muscle strength and function. Imbalance between oxygen supply and demand. 10 . Depression or lack of motivation.Patient maintains activity level within capabilities. Patient verbalizes and uses energy-conservation techniques. abnormal heart rate or blood pressure (BP) response to activity.g. Inability to begin or perform activity. Prolonged bed rest. promote optimal physical activity. cardiopulmonary. Deconditioned state.

This number will change depending on the intensity of exercise the patient is attempting (e. cane. • Assess patient's level of mobility. 11 . Assess potential for physical injury with activity. • Assess need for ambulation aids: bracing. This aids in defining what patient is capable of.g. climbing four flights of stairs versus shoveling snow). equipment modification for activities of daily living (ADLs).Ongoing Assessment • Determine patient's perception of causes of fatigue or activity intolerance. Adequate assessment of energy requirements is indicated. walker. These may be temporary or permanent. Some aids may require more energy expenditure for patients who have reduced upper arm strength (e. Orthostatic BP changes Elderly patients are more prone to drops in blood pressure with position changes. physical or psychological. • Assess patient's cardiopulmonary status before activity using the following measures: Heart rate Heart rate should not increase more than 20 to 30 beats/min above resting with routine activities. Assessment guides treatment. • • Assess nutritional status. can cause bradycardia and related reduced cardiac output.. Need for oxygen with increased activity Portable pulse oximetry can be used to assess for oxygen desaturation.g. Injury may be related to falls or overexertion. Supplemental oxygen may help compensate for the increased oxygen demands.. which requires breath holding and bearing down. Adequate energy reserves are required for activity. walking with crutches). How Valsalva maneuver affects heart rate when patient moves in bed Valsalva maneuver. which is necessary before setting realistic goals.

fatigue Lightheadedness. 12 .g. Difficulties sleeping need to be addressed before activity progression can be achieved. other ADLs. Therapeutic Interventions • Establish guidelines and goals of activity with the patient and caregiver. • Encourage adequate rest periods. Rest between activities provides time for energy conservation and recovery. keep telephone and tissues within reach). Report any of the following:        Rapid pulse (20 beats/min over resting rate or 120 beats/min) Palpitations Significant increase in systolic BP (20 mm Hg) Significant decrease in systolic BP (20 mm Hg) Dyspnea.• Monitor patient's sleep pattern and amount of sleep achieved over past few days. Patients with limited activity tolerance need to prioritize tasks.. labored breathing. some patients may be able to live independently and work outside the home. • Refrain from performing nonessential procedures. • Observe and document response to activity. Motivation is enhanced if the patient participates in goal setting. exercise sessions. and ambulation. diaphoresis Close monitoring serves as a guide for optimal progression of activity. Depending on the etiological factors of the activity intolerance. • Anticipate patient's needs (e. • Assess emotional response to change in physical status. Heart rate recovery following activity is greatest at the beginning of a rest period. Depression over inability to perform required activities can further aggravate the activity intolerance. pallor. dizziness. Other patients with chronic debilitating disease may remain homebound. wheezing Weakness. especially before meals.

Assisting the patient with ADLs allows for conservation of energy. then slowly progressing.• Assist with ADLs as indicated. Not all self-care and hygiene activities need to be completed in the morning. progressing to sitting and standing. Promote a positive attitude regarding abilities. Walking in room 1 to 2 minutes three times daily. Appropriate aids will enable the patient to achieve optimal independence for self-care. • Provide bedside commode as indicated. Sitting up in chair 30 minutes three times daily. Acknowledgment that living with activity intolerance is both physically and emotionally difficult aids coping. saving energy for return trip This prevents overexerting the heart and promotes attainment of short-range goals. • • Encourage patient to choose activities that gradually build endurance. • Provide emotional support while increasing activity. • • Encourage physical activity consistent with patient's energy resources. Improvise in adapting ADL equipment or environment. Likewise. Walking in hall 25 feet or walking around the house. • Encourage verbalization of feelings regarding limitations. Exercises maintain muscle strength and joint ROM. • Encourage active ROM exercises three times daily. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient's activity tolerance and self-esteem. If further reconditioning is needed. as with the following: Active range-of-motion (ROM) exercises in bed. however. Deep breathing exercises three times daily. avoid doing for patient what he or she can do for self. NOTE: A bedpan requires more energy than a commode. Dangling 10 to 15 minutes three times daily. This reduces energy expenditure. 13 . Assist patient to plan activities for times when he or she has the most energy. confer with rehabilitation personnel. • Progress activity gradually. not all housecleaning needs to be completed in 1 day.

These conserve energy and prevent injury from fall. and cleaning needs Organizing a work-restwork schedule These reduce oxygen consumption. This promotes awareness of when to reduce activity. encourage significant others to bring ambulation aid (e. elevating head of bed while patient gets out of bed. chair in bathroom.g. Pushing rather than pulling. ROM. Changing positions often This distributes work to different muscles to avoid fatigue. • • Teach ROM and strengthening exercises. bed rails.. Working at an even pace This allows enough time so not all work is completed in a short period. Using wheeled carts for laundry. attainable goals can increase self-confidence and self-esteem. Some examples include the following: Sitting to do tasks Standing requires more work. This maintains strength.Education/Continuity of Care • Teach patient/caregivers to recognize signs of physical overactivity. These reduce feelings of anxiety and fear. • Involve patient and caregivers in goal setting and care planning. walker or cane).. Encourage patient to verbalize concerns about discharge and home environment. Resting for at least 1 hour after meals before starting a new activity Energy is needed to digest food.g. Sliding rather than lifting. • • • • Teach appropriate use of environmental aids (e. shopping. and endurance gain. Teach energy conservation techniques. • Teach the importance of continued activity at home. 14 . • • • • • Assist in assigning priority to activities to accommodate energy levels. allowing more prolonged activity. • When hospitalized. • Refer to community resources as indicated. hall rails). Storing frequently used items within easy reach This avoids bending and reaching. Setting small.

respiratory muscle fatigue. wheezes). Tachycardia.g. Trauma 15 . Likewise. Hypoxemia/cyanosis. Changes in respiratory rate or depth. Chest wheezing.. Ineffective airway clearance can be an acute (e.Ineffective airway clearance NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Cough Airway Airway Suctioning    Enhancement Management NANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency Maintaining a patent airway is vital to life. Fever.. Perceptual/cognitive impairment. Coughing is the main mechanism for clearing the airway. Ineffective cough. the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma. Copious tracheobronchial secretions. bronchitis. Tracheobronchial obstruction (including foreign body aspiration). Impaired respiratory muscle function. Dyspnea. and chemical irritants) can overtax these mechanisms. macrophages. Factors such as anesthesia and dehydration can affect function of the mucociliary system..g. from cerebrovascular accident [CVA] or spinal cord injury) problem. Cough. pneumonia. Related Factors: Decreased energy and fatigue. However. rhonchi. postoperative recovery) or chronic (e. are at high risk. Defining Characteristics: Abnormal breath sounds (crackles. who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production. Elderly patients. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system. and the lymphatics.g. conditions that cause increased production of secretions (e. tracheobronchial infection. or neuromuscular weakness.

Expected Outcomes: Patient's secretions are mobilized and airway is maintained free of secretions. restlessness. pattern. assess quality. Abnormality indicates respiratory compromise. Consider possible causes for ineffective cough (e. • Assess cough for effectiveness and productivity. or thick tenacious secretions). These may indicate presence of mucus plug or other major airway obstruction. dyspnea on exertion. eupnea. • • • • • Assess changes in mental status. and position for breathing. depth. Wheezing. severe bronchospasm. Assess respirations. amount. an odor may be present. and consistency. especially in cases of trauma. Tachycardia and hypertension may be related to increased work of breathing. color. Ongoing Assessment • Assess airway for patency. A sign of infection is discolored sputum (no longer clear or white). rate. respiratory muscle fatigue. • Auscultate lungs for presence of normal or adventitious breath sounds. • Assess changes in vital signs and temperature. use of accessory muscles. Fever may develop in response to retained secretions/atelectasis.g. Increasing lethargy. or other condition. This may be a result of infection. confusion. note quality. evidence of splinting. as in the following: Decreased or absent breath sounds. bronchitis. chronic smoking.. and ability to effectively cough up secretions after treatments and deep breaths. or cardiac arrest. • Note presence of sputum. and/or irritability can be early signs of cerebral hypoxia. as evidenced by clear lung sounds. 16 . These may indicate presence of fluid along larger airways. acute neurological decompensation. odor. These may indicate increasing airway resistance. flaring of nostrils. Coarse sounds. Maintaining the airway is always the first priority.

Respiratory infections increase the work of breathing. • If patient is on mechanical ventilation. antibiotic treatment is indicated. • Assess for pain. 17 . Postoperative pain can result in shallow breathing and an ineffective cough. These improve productivity of the cough. • Monitor arterial blood gases (ABGs). Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. monitor for peak airway pressures and airway resistance. Increases in these parameters signal accumulation of secretions/ fluid and possibility for ineffective ventilation. • Assess patient’s knowledge of disease process. The sitting position and splinting the abdomen promote more effective coughing by increasing abdominal pressure and upward diaphragmatic movement. Therapeutic Interventions • Assist patient in performing coughing and breathing maneuvers.Send a sputum specimen for culture and sensitivity as appropriate. • Instruct patient in the following:       Optimal positioning (sitting position) Use of pillow or hand splints when coughing Use of abdominal muscles for more forceful cough Use of quad and huff techniques Use of incentive spirometry Importance of ambulation and frequent position changes Directed coughing techniques help mobilize secretions from smaller airways to larger airways because the coughing is done at varying times. Patient education will vary depending on the acute or chronic disease state as well as the patient’s cognitive level.

• Use positioning (if tolerated. • Use humidity (humidified oxygen or humidifier at bedside). or excessive mucus production. This loosens secretions.. ambulation).g. • If patient is bedridden. • If cough is ineffective. This prevents suction-related hypoxia. These facilitate secretion removal from a specific side (right versus left lung). routinely check the patient’s position so he or she does not slide down in bed. These promote better lung expansion and improved air exchange. precautions should be instituted before receiving the culture and sensitivity report. head of bed at 45 degrees. thick mucus plugs. 18 . and/or desaturation. Use curved-tip catheters and head positioning (if not contraindicated). which would cause respiratory embarrassment. use nasotracheal suctioning as needed:  • • Explain procedure to patient. and mask as appropriate. methicillinresistant Staphylococcus aureus [MRSA] or tuberculosis). This may cause the abdomen to compress the diaphragm. • Use universal precautions: gloves. Use soft rubber catheters. sitting in chair. • Institute appropriate isolation precautions for positive cultures (e. This prevents trauma to mucous membranes. Suctioning is indicated when patients are unable to remove secretions from the airways by coughing because of weakness. If sputum is purulent. goggles. an increase in ventricular ectopy. Instruct the patient to take several deep breaths before and after each nasotracheal suctioning procedure and use supplemental oxygen as appropriate. • • Stop suctioning and provide supplemental oxygen (assisted breaths by Ambu bag as needed) if the patient experiences bradycardia.

Fatigue is a contributing factor to ineffective coughing.• Encourage oral intake of fluids within the limits of cardiac reserve. • Administer medications (e. After intubation:   Institute suctioning of airway as determined by presence of adventitious sounds.. assist with bronchoscopy. expectorants) as ordered. • If secretions cannot be cleared. institute cardiopulmonary resuscitation (CPR) maneuvers. pace activities. • For patients with reduced energy. • For patients with chronic problems with bronchoconstriction. 19 . anticipate the need for an artificial airway (intubation). Maintain planned rest periods. bronchodilators. • For patients with complete airway obstruction. Increased fluid intake reduces the viscosity of mucus produced by the goblet cells in the airways. This obtains lavage samples for culture and sensitivity. and removes mucus plugs.g.e.. • Consult respiratory therapist for chest physiotherapy and nebulizer treatments as indicated (hospital and home care/rehabilitation environments). mucolytic agents. This helps facilitate removal of tenacious sputum. noting effectiveness and side effects. Coordinate optimal time for postural drainage and percussion (i. at least 1 hour after eating). Chest physiotherapy includes the techniques of postural drainage and chest percussion to mobilize secretions in smaller airways that cannot be removed by coughing or suctioning. • For acute problem. Use sterile saline instillations during suctioning. It is easier for the patient to mobilize thinner secretions with coughing. instruct in use of metered-dose inhaler (MDI) or nebulizer as prescribed. antibiotics. This prevents aspiration. Promote energy-conservation techniques.

as appropriate. • • • Instruct patient on indications for. or respiratory therapist as indicated. Refer to pulmonary clinical nurse specialist.g.Education/Continuity of Care • Demonstrate and teach coughing. and others). Nicoderm. as appropriate. deep breathing. • • Teach patient about environmental factors that can precipitate respiratory problems. Patient will understand the rationale and appropriate techniques to keep the airway clear of secretions. Instruct patient how to use prescribed inhalers. instruct caregivers regarding cough enhancement techniques and need for humidification.. • Refer patient and/or significant others to smoking-cessation group. Provide opportunity for return demonstration. instruct caregiver in chest physiotherapy as appropriate. • • Instruct patient on warning signs of pending or recurring pulmonary problems. Smoking contributes to bronchospasm and increased mucus production in the airways. including second-hand smoke. neuromuscular impairment. • For patients with debilitating disease being cared for at home (CVA. In home setting. Adapt technique for home setting. and side effects of medications. and splinting techniques. and discuss potential use of smoking-cessation aids (e. Explain effects of smoking. This may also be useful for the patient with bronchiectasis who is ambulatory but requires chest physiotherapy because of the volume of secretions and the inability to adequately clear them. or Habitrol) to wean off the effects of nicotine. frequency. • Instruct caregivers in suctioning techniques. Nicorette Gum. home health nurse. 20 .

such as postanesthesia effects from surgery or diagnostic tests. Elderly and cognitively impaired patients are at high risk. or mechanical ventilation may be encountered in the home. Patient’s risk of aspiration is decreased as a result of ongoing assessment and early intervention. occur predominantly in the acute care setting. or hospital settings. Risk Factors: Reduced level of consciousness. oropharyngeal secretions. Presence of tracheostomy or endotracheal tube. Acute conditions. endotracheal intubation. Anesthesia or medication administration. 21 . rehabilitative. Impaired swallowing. oral. or solids or fluids into tracheobronchial passages Both acute and chronic conditions can place patients at risk for aspiration. spinal cord injury. Decreased gastrointestinal motility. Tube feedings. Situations hindering elevation of upper body Expected Outcomes : Patient maintains patent airway. neuromuscular weakness. or neck surgery or trauma. Facial. hemiplegia and dysphagia from stroke. Depressed cough and gag reflexes. Aspiration is a common cause of death in comatose patients. including altered consciousness from head injury. Chronic conditions. use of tube feedings for nutrition. Presence of gastrointestinal tubes.Risk for Aspiration NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Risk Control Risk Detection Respiratory Status: Ventilation    NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Aspiration Precautions  NANDA Definition: At risk for entry of gastrointestinal secretions.

A depressed cough or gag reflex increases the risk of aspiration. When combined with the weaker gag reflex of elderly patients. Monitor swallowing ability: • • Assess for coughing or clearing of the throat after a swallow. which delays esophageal emptying. Assess pulmonary status for clinical evidence of aspiration. monitor the effectiveness of the cuff. Monitor for choking during eating or drinking. • In patients with endotracheal or tracheostomy tubes. to determine cuff pressure. • • Assess for presence of nausea or vomiting. as needed. Choking indicates aspiration.Ongoing Assessment Monitor level of consciousness. A decreased level of consciousness is a prime risk factor for aspiration. Decreased gastrointestinal motility increases the risk of aspiration because food or fluids accumulate in the stomach. aspiration is a higher risk. Assess for regurgitation of food or fluid through nares. •  Assess cough and gag reflexes. Elderly patients have a decrease in esophageal motility. 22 . Collaborate with the respiratory therapist. Aspiration of small amounts can occur without coughing or sudden onset of respiratory distress. Assess for residual food in mouth after eating. especially in patients with decreased levels of consciousness. • • Auscultate bowel sounds to evaluate bowel motility. Pockets of food can be easily aspirated at a later time. An ineffective cuff can increase the risk of aspiration. Auscultate breath sounds for development of crackles and/or rhonchi.

This protects the airway. This is necessary to maintain a patent airway. • Supervise or assist patient with oral intake. If the head of the bed cannot be elevated because of the patient’s condition. • Notify the physician or other health care provider immediately of noted decrease in cough and/or gag reflexes or difficulty in swallowing. • Place whole or crushed pills in soft foods (e. Proper positioning can decrease the risk of aspiration. • Position patients who have a decreased level of consciousness on their sides. remove distracting stimuli during mealtimes. Use thickening agents as appropriate. Comatose patients need frequent turning to facilitate drainage of secretions. Instruct patient not to talk while eating. This facilitates concentration on chewing and swallowing. The upright position facilitates the gravitational flow of food or fluid through the alimentary tract. Use cushions or pillows to maintain position. custard). • Encourage patient to chew thoroughly and eat slowly during meals. • Position patient at 90-degree angle. • Offer foods with consistency that patient can swallow. whether in bed or in a chair or wheelchair. Liquids and thin foods like creamed soups are most difficult for patients with dysphagia. • For patients with reduced cognitive abilities.. Early intervention protects the patient’s airway and prevents aspiration. Cut foods into small pieces. Semisolid foods like pudding and hot cereal are most easily swallowed. Never give oral fluids to a comatose patient. Substitute medication in elixir form as indicated. • Maintain upright position for 30 to 45 minutes after feeding. Proper positioning of patients with swallowing difficulties is of primary importance during feeding or eating. This will help detect abnormalities early. Verify with a pharmacist which pills should not be crushed.g. use a right side- 23 .Therapeutic Interventions • Keep suction setup available (in both hospital and home settings) and use as needed.

lying position after feedings to facilitate passage of stomach contents into the duodenum.  Position with head of bed elevated 30 to 45 degrees. Check residuals before feeding. Refer to home health nurse. • • Place dye (e. Hold feedings if residuals are high and notify the physician. • Instruct on signs and symptoms of aspiration. • • In patients with nasogastric (NG) or gastrostomy tubes: Check placement before feeding. This aids in appropriately assessing high-risk situations and determining when to call for further evaluation. Detection of the color in pulmonary secretions would indicate aspiration..g. • • Instruct on proper feeding techniques. A speech pathologist can be consulted to perform a dysphagia assessment that helps determine the need for videofluoroscopy or modified barium swallow. Education/Continuity of Care • Explain to patient/caregiver the need for proper positioning. 24 . High amounts of residual (>50% of previous hour’s intake) indicate delayed gastric emptying and can cause distention of the stomach leading to reflux emesis. Instruct on upper-airway suctioning techniques to prevent accumulation of secretions in the oral cavity. rehabilitation specialist. This removes residuals and reduces pocketing of food that can be later aspirated. This decreases the risk of aspiration. methylene blue) in NG feedings. A displaced tube may erroneously deliver tube feeding into the airway. • Use speech pathology consultation as appropriate. • Provide oral care after meals. or occupational therapist as indicated. • • Instruct caregiver on what to do in the event of an emergency.

others can become immobilized to a pathological degree. pulse. Insomnia. but the degree and the frequency with which it manifests differs broadly. Dry mouth. and respirations. severe. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat. Preoccupation 25 . Inability to problem-solve. Trembling. Restlessness. Dizziness. Defining Characteristics: Physiological: Increase in blood pressure. Frequent urination. Pacing. Anxiety is probably present at some level in every individual’s life. Some people are able to use the emotional edge that anxiety provokes to stimulate creativity or problem-solving abilities. a feeling of apprehension caused by anticipation of danger. light-headedness. Feelings of inadequacy. nightmares. Each individual’s response to anxiety is different. Crying.Anxiety NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Anxiety Reduction Presence Calming Technique Emotional Support     NANDA Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual). The feeling is generally categorized into four levels for treatment purposes: mild. Dyspnea. Flushing. The nurse can encounter the anxious patient anywhere in the hospital or community. Perspiration. Nausea and/or diarrhea. Palpitations. Difficulty concentrating. Pupil dilation. Feelings of helplessness and discomfort Behavioral: Expressions of helplessness. moderate. and panic. The presence of the nurse may lend support to the anxious patient and provide some strategies for traversing anxious moments or panic attacks. Headaches. Rumination.

With panic the patient is unable to follow directions. • Suggest that the patient keep a log of episodes of anxiety. and immobilization may be observed. Severe anxiety decreases patient’s ability to integrate information and solve problems. This assessment helps determine the effectiveness of coping strategies currently used by patient. Threat or perceived threat to self-concept. Changes in role function. Symptoms often provide the care provider with information regarding the degree of anxiety being experienced. Moderate anxiety limits awareness of environmental stimuli. Intrusive diagnostic and surgical tests and procedures. Ongoing Assessment • Assess patient’s level of anxiety. Patient may describe a reduction in the level of anxiety experienced. Instruct patient to describe what is experienced and the events leading up to and surrounding the event. Mild anxiety enhances the patient’s awareness and ability to identify and solve problems. Patient should note how the anxiety dissipates. Situational and maturational crises. This can be done by interviewing the patient. agitation.Related Factors: Threat or perceived threat to physical and emotional integrity. the log may be shared with the care provider who may be helpful in problem solving. Threat to (or change in) socioeconomic status. Hyperactivity. Because a cause for anxiety cannot always be identified. Interpersonal conflicts. and patient may need help. the patient may feel as though the feelings being experienced are 26 . • Determine how patient copes with anxiety. Therapeutic Interventions • Acknowledge awareness of patient’s anxiety. Changes in environment and routines. If the patient is comfortable with the idea. Patient may use these notes to begin to identify trends that manifest anxiety. Expected Outcomes: Patient is able to recognize signs of anxiety. Physiological symptoms and/or complaints intensify as the level of anxiety increases. Problem solving can occur but may be more difficult. Patient demonstrates positive coping mechanisms.

Avoid false reassurances. keep "threatening" equipment out of sight. • Reduce sensory stimuli by maintaining a quiet environment. The health care provider can transmit his or her own anxiety to the hypersensitive patient. clear. The patient’s feeling of stability increases in a calm and nonthreatening atmosphere. and equipment around the patient. An ongoing relationship establishes a basis for comfort in communicating anxious feelings. Acknowledgment of the patient’s feelings validates the feelings and communicates acceptance of those feelings. Assist patient in assessing the situation realistically and recognizing factors leading to the anxious feelings. Stay with patient if this appears necessary. Orientation and awareness of the surroundings promote comfort and may decrease anxiety. The presence of significant others reinforces feelings of security for the patient. When experiencing moderate to severe anxiety. • Establish a working relationship with the patient through continuity of care. patients may be unable to comprehend anything more than simple. 27 . • Use simple language and brief statements when instructing patient about self-care measures or about diagnostic and surgical procedures. and brief instructions. The presence of a trusted person may be helpful during an anxiety attack. • Reassure patient that he or she is safe. • Maintain a calm manner while interacting with patient.counterfeit. • Encourage patient to seek assistance from an understanding significant other or from the health care provider when anxious feelings become difficult. noise. Anxiety may escalate with excessive conversation. • Orient patient to the environment and new experiences or people as needed. This may be evident in both hospital and home environments. • Encourage patient to talk about anxious feelings and examine anxiety-provoking situations if able to identify them.

Emphasize the logical strategies patient can use when experiencing anxious feelings. The ability to recognize anxiety symptoms at lower-intensity levels enables the patient to intervene more quickly to manage his or her anxiety. • Assist the patient in developing anxiety-reducing skills (e. Using anxiety-reduction strategies enhances patient’s sense of personal mastery and confidence. Patient will be able to use problem-solving abilities more effectively when the level of anxiety is low. relaxation. • Instruct patient in the proper use of medications and educate him or her to recognize adverse reactions. deep breathing. • Refer the patient for psychiatric management of anxiety that becomes disabling for an extended period. encourage exploration of specific events preceding both the onset and reduction of the anxious feelings. Education/Continuity of Care • Assist patient in recognizing symptoms of increasing anxiety. explore alternatives to use to prevent the anxiety from immobilizing her or him. Medication may be used if patient’s anxiety continues to escalate and the anxiety becomes disabling. • Assist patient in developing problem-solving abilities.• As patient’s anxiety subsides. • Instruct the patient in the appropriate use of antianxiety medications. Recognition and exploration of factors leading to or reducing anxious feelings are important steps in developing alternative responses. • 28 . Learning to identify a problem and evaluate alternatives to resolve it helps the patient to cope. positive visualization. • Remind patient that anxiety at a mild level can encourage growth and development and is important in mobilizing changes.g. and reassuring self-statements). Patient may be unaware of the relationship between emotional concerns and anxiety..

congenital heart disease. tachypnea. Rales. Patients may have acute. central venous pressure [CVP]. or home care setting. Arrhythmias. Defining Characteristics: Variations in hemodynamic parameters (blood pressure [BP]. which further reduces contractility and cardiac output. pulmonary disease. cardiomyopathy. drug effects. fluid overload. heart rate. temporary problems or experience chronic. venous oxygen saturation [SVO2].Decreased Cardiac Output NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Cardiac Pump Effectiveness Circulation Status Knowledge: Disease Process Knowledge: Treatment Program     NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Cardiac Care Hemodynamic Regulation Teaching: Disease Process    NANDA Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body Common causes of reduced cardiac output include myocardial infarction. 29 . and electrolyte imbalance. hypertension. arrhythmias. ambulatory care. debilitating effects of decreased cardiac output. valvular heart disease. Patients may be managed in an acute. pulmonary artery pressures. decreased fluid volume. Geriatric patients are especially at risk because the aging process causes reduced compliance of the ventricles. electrocardiogram (ECG) changes. cardiac output). This care plan focuses on the acute management.

Restlessness is noted in the early stages. Confusion. Sinus tachycardia and increased arterial blood pressure are seen in the early stages. Pulses are weak with reduced cardiac output. Alteration in afterload. Angina. Compromised regulatory mechanisms may result in fluid and sodium retention. Syncope. Pulsus alternans. and strong bilateral. fatigue. Weakness. Related Factors: Increased or decreased ventricular filling (preload). severe anxiety and confusion are seen in later stages. Cardiac muscle disease Expected Outcomes: Patient maintains BP within normal limits. dizziness. equal peripheral pulses. Abnormal heart sounds. change in mental status. Anxiety. Assess fluid balance and weight gain. warm. Weight gain. Decreased oxygenation. abnormal arterial blood gases (ABGs). cough. dry skin. Ejection fraction less than 40%. 30 . orthopnea. cold clammy skin. and conduction. clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation. Decreased peripheral pulses. regular cardiac rhythm. frothy sputum. Pulsus alternans (alternating strong-then-weak pulse) is often seen in heart failure patients. Cold. Elderly patients have reduced response to catecholamines.dyspnea. • Assess heart rate and blood pressure. • Assess skin color and temperature. Impaired contractility. • • Assess peripheral pulses. thus their response to reduced cardiac output may be blunted. Alteration in heart rate. decreased urine output. edema. Body weight is a more sensitive indicator of fluid or sodium retention than intake and output. restlessness. rhythm. Ongoing Assessment • Assess mentation. with less rise in heart rate. BP drops as the condition deteriorates. clear lung sounds.

Monitor ECG for rate. PND is difficulty breathing that occurs at night. Orthopnea is difficulty breathing when supine. and ectopic beats can compromise cardiac output. They are more evident in the dependent areas of the lung. S4. Close monitoring of patient’s response serves as a guide for optimal progression of activity. Determine any occurrence of paroxysmal nocturnal dyspnea (PND) or orthopnea. Change in oxygen saturation of mixed venous blood is one of the earliest indicators of reduced cardiac output. ectopy. and QT intervals. QRS. Elderly patients are especially sensitive to the loss of atrial kick in atrial fibrillation. This indicates an imbalance between oxygen supply and demand. Determine how often the patient urinates. and mean). S4 occurs with reduced compliance of the left ventricle. and change in PR. S3. 31 .• Assess heart sounds. bradycardia. diastolic. This provides objective number to guide therapy. • • If hemodynamic monitoring is in place: Monitor central venous. which impairs diastolic filling. pulmonary artery pressure (PAP) (systolic. • Assess lung sounds. Oliguria can reflect decreased renal perfusion. Hemodynamic parameters provide information aiding in differentiation of decreased cardiac output secondary to fluid overload versus fluid deficit. rhythm. fatigue and exertional dyspnea are common problems with low cardiac output states. Crackles reflect accumulation of fluid secondary to impaired left ventricular emptying. right arterial pressure [RAP]. and pulmonary capillary wedge pressure (PCWP). Diuresis is expected with diuretic therapy. • Assess urine output. Physical activity increases the demands placed on the heart. Tachycardia. S3 denotes reduced left ventricular ejection and is a classic sign of left ventricular failure. • Assess for chest pain. • Monitor SVO 2 continuously. Perform cardiac output determination. • • • • Assess response to increased activity. noting gallops. Monitor continuous ECG as appropriate.

• Assess contributing factors so appropriate plan of care can be initiated. closely monitoring effects.  Maintain adequate ventilation and perfusion. Monitor progressive activity within limits of cardiac function. This reduces oxygen demands. restrict fluids and sodium as ordered. ACE inhibitors.  Administer stool softeners as needed. Organize nursing and medical care. Therapeutic Interventions Administer medication as prescribed. administer fluid challenge as prescribed. as in the following:  Place patient in semi. For patients in the acute setting. Straining for a bowel movement further impairs cardiac output. Administration of fluid increases extracellular fluid volume to raise cardiac output. The failing heart may not be able to respond to increased oxygen demands. close monitoring of these parameters guides titration of fluids and medications. Emotional stress increases cardiac demands. Administer humidified oxygen as ordered.  Maintain hemodynamic parameters at prescribed levels. Depending on etiological factors. vasodilator therapy. 32 . Place in supine position. For patients with decreased preload. relaxed environment. This reduces preload and ventricular filling. noting response and watching for side effects and toxicity. Clarify with physician parameters for withholding high-Fowler’s position. common medications include digitalis therapy. and inotropic agents. This decreases extracellular fluid volume.   Maintain optimal fluid balance. diuretics. antidysrhythmics.    Maintain physical and emotional rest. as in the following:     Restrict activity. This increases venous return. promotes diuresis. Provide quiet.  For patients with increased preload. This allows rest periods.

  Monitor sleep patterns. sodium). intraaortic balloon pump. Treat arrhythmias according to medical orders or protocol and evaluate response.g. pacemaker). document. Explain diet restrictions (fluid. maintain within prescribed protocol. administer sedative. determine patient response.. 33 . purpose. • • • Explain drug regimen.   Have antiarrhythmic drugs readily available. If arrhythmia occurs. Rest is important for conserving energy. and report if significant or symptomatic. Both tachyarrhythmias and bradyarrhythmias can reduce cardiac output and myocardial tissue perfusion. Explain progressive activity schedule and signs of overexertion. If invasive adjunct therapies are indicated (e. dose. Education/Continuity of Care •  Explain symptoms and interventions for decreased cardiac output related to etiological factors. and side effects.

Nasal flaring. neuromuscular impairment. change in depth of ventilation (Vt). and respiratory alternans. airway obstruction. Pursed-lip breathing or prolonged expiratory phase. or thyroid dysfunction). Respiratory failure can be seen with a change in respiratory rate. infection. drug overdose. change in normal abdominal and thoracic patterns for inspiration and expiration.g. Cough. Use of accessory muscles. Increased anteroposterior chest diameter 34 . peritonitis. Cyanosis. diaphragmatic paralysis. diabetic ketoacidosis [DKA]. cognitive impairment and anxiety. metabolic abnormalities (e. Respiratory depth changes. rate.Ineffective Breathing Pattern NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels   Respiratory Status: Ventilation  Vital Sign Status NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Airway Management Respiratory Monitoring   NANDA Definition: Inspiration and/or expiration that does not provide adequate ventilation Respiratory pattern monitoring addresses the patient’s ventilatory pattern. uremia.. Breathing pattern changes may occur in a multitude of cases from hypoxia. Tachypnea. heart failure. Altered chest excursion. trauma or surgery resulting in musculoskeletal impairment and/or pain. and depth. and pleural inflammation. Defining Characteristics: Dyspnea. Most acute pulmonary deterioration is preceded by a change in breathing pattern. Fremitus.

Hypoxia.  Assess for dyspnea at rest versus activity and note changes. Dyspnea that occurs with activity may indicate activity intolerance.g. or both) Kussmaul’s respirations (deep respirations with fast. Neuromuscular impairment. Decreased lung expansion Expected Outcomes: Patient’s breathing pattern is maintained as evidenced by eupnea. Musculoskeletal impairment. Ongoing Assessment • Assess respiratory rate and depth by listening to lung sounds. normal skin color. Pain. • Monitor breathing patterns:      Bradypnea (slow respirations) Tachypnea (increase in respiratory rate) Hyperventilation (increase in respiratory rate or tidal volume. normal. Decreased energy and fatigue. Anxiety. 35 . relate dyspnea to precipitating factors.Related Factors: Inflammatory process: viral or bacterial. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties. and regular respiratory rate/pattern. or slow rate) Cheyne-Stokes respiration (waxing and waning with periods of apnea between a repetitive pattern) Apneusis (sustained maximal inhalation with pause) Biot’s respiration (irregular periods of apnea alternating with periods in which four or five breaths of identical depth are taken) Ataxic patterns (irregular and unpredictable pattern with periods of apnea)    Specific breathing patterns may indicate an underlying disease process or dysfunction. Tracheobronchial obstruction. • Assess for dyspnea and quantify (e. Perception or cognitive impairment.. Cheyne-Stokes respiration represents bilateral dysfunction in the deep cerebral or diencephalon associated with brain injury or metabolic abnormalities. note how many words per breath patient can say).

and air hunger. which could result in apnea. • Note retractions or flaring of nostrils. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. These include the scalenes (attach to the first two ribs) and the sternocleidomastoid (elevates the sternum). end tidal CO2 monitoring or arterial blood gases (ABGs) would need to be obtained. • Monitor for diaphragmatic muscle fatigue (paradoxical motion). As the patient begins to fail.Apneusis and ataxic breathing are associated with failure of the respiratory centers in the pons and medulla. anxiety.g. Pulse oximetry is a useful tool to detect changes in oxygenation early on. the respiratory rate decreases and PaCO2 begins to rise. Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. capillary refill. temperature. • Avoid high concentration of oxygen in patients with chronic obstructive pulmonary disease (COPD). note central versus peripheral cyanosis. The accessory muscles of inspiration are not usually involved in quiet breathing. abdominal.. • Monitor ABGs as appropriate. • Assess skin color. • Monitor for changes in orientation. • • Assess position patient assumes for normal or easy breathing. diaphragmatic). These signify an increase in work of breathing. Restlessness is an early sign of hypoxia. Paradoxical movement of the diaphragm indicates a reversal of the normal pattern and is indicative of ventilatory muscle fatigue and/or respiratory failure. note changes. The diaphragm is the most important muscle of ventilation. Use pulse oximetry to monitor oxygen saturation and pulse rate. sternocleido-mastoid. When applying oxygen. close monitoring is imperative to prevent unsafe increases in the patient’s PaO2 . • Note muscles used for breathing (e. increased restlessness. however. normally responsible for 80% to 85% of ventilation during restful breathing. for CO2 levels. 36 .

suction as needed to clear secretions. • Ensure that oxygen delivery system is applied to the patient. The appropriate amount of oxygen is continuously delivered so that the patient does not desaturate.   • Evaluate appropriateness of inspiratory muscle training. • Encourage sustained deep breaths by:  Using demonstration (emphasizing slow inhalation.• Monitor vital capacity in patients with neuromuscular weakness and observe trends. antibiotic treatment may be indicated. This provides for adequate oxygenation. color. The inability to clear secretions may add to a change in breathing pattern. Postoperative pain can result in shallow breathing. An oxygen saturation of 90% or greater should be maintained. Respiratory infections increase the work of breathing. If secretions cannot be cleared. This improves conscious control of respiratory muscles. An infection may be present. • Maintain a clear airway by encouraging patient to clear own secretions with effective coughing. • Assess for pain. 37 . and passive exhalation) Using incentive spirometer (place close for convenient patient use) Asking patient to yawn This simple technique promotes deep inspiration. Monitoring detects changes early. as appropriate. consistency. send sputum specimen for culture and sensitivity. • Assess ability to clear secretions. Therapeutic Interventions • Position patient with proper body alignment for optimal breathing pattern. If not contraindicated. • • Assess presence of sputum for quantity. If the sputum is discolored (no longer clear or white). a sitting position allows for good lung excursion and chest expansion. holding end inspiration for a few seconds.

frequency. oxygen vendors. dosage.. This allows for pain relief and the ability to deep breathe. • Explain use of oxygen therapy. storage. and mask) as appropriate. This prevents dyspnea resulting from fatigue. ratioIssues related to home oxygen use. Explain effects of wearing restrictive clothing. • • Encourage diaphragmatic breathing for patient with chronic disease.g. 38 . Institute appropriate isolation procedures for positive cultures (e. and other resources for rental equipment as appropriate. precautions should be instituted before receiving the culture and sensitivity final report.. goggles. and potential side effects. • Review the use of at-home monitoring capabilities and refer to home health nursing. • Instruct about medications: indications. • Provide relaxation training as appropriate (e. If secretions are purulent. methicillin-resistant Staphylococcus aureus. gloves. • Anticipate the need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange with the present breathing pattern. • Provide reassurance and allay anxiety by staying with patient during acute episodes of respiratory distress. Education/Continuity of Care • • Explain all procedures before performing. tuberculosis [TB]). This decreases patient’s anxiety. and precautions need to be addressed. Include review of metered-dose inhaler and nebulizer treatments. progressive muscle relaxation). as appropriate. including the type and use of equipment and why its maintenance is important. imagery. biofeedback. Respiratory excursion is not compromised.g..g. Use pain management as appropriate. Air hunger can produce an extremely anxious state.• Use universal precautions (e. • Pace and schedule activities providing adequate rest periods.

pollen. • Assist patient or caregiver in learning signs of respiratory compromise. • Explain symptoms of a "cold" and impending problems. Disturbed Body Image NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Body Image Self-Esteem   NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels 39 . Appropriate breathing techniques during exercise are important in maintaining adequate gas exchange. • Teach patient when to inhale and exhale while doing strenuous activities.g. These facilitate adequate clearance of secretions. • Teach patient or caregivers appropriate breathing. • Teach patient how to count own respirations and relate respiratory rate to activity tolerance.• Explain environmental factors that may worsen patient’s pulmonary condition (e. • Refer to social services for further counseling related to patient’s condition and give list of support groups or a contact person from the support group for the patient to talk with. second-hand smoke) and discuss possible precipitating factors (e. allergens and emotional stress). Refer significant other/caregiver to participate in basic life support class for CPR. and splinting techniques...g. Patient will then know when to limit activities in terms of his or her own limitations. A respiratory infection would increase the work of breathing. coughing. as appropriate.

maturation. The importance that an individual places on a body part or function may be more important in determining the degree of disturbance than the actual alteration in the structure or function. growth. Refusal 40 . Defining Characteristics: Verbalization about altered structure or function of a body part. Removal of skin lesions. variations from the norm can result in body image disturbance. Therefore the loss of a limb may result in a greater body image disturbance for an athlete than for a computer programmer. changes that occur as a result of aging. The nurse’s assessment of the perceived alteration and importance placed by the patient on the altered structure or function will be very important in planning care to address body image disturbance. This attitude is dynamic and is altered through interaction with other persons and situations and influenced by age and developmental level. and changes that occur or are imposed as a result of injury or illness. Throughout the life span. altered elimination resulting from bowel or bladder surgery. changes related to childbearing and pregnancy. Naming changed body part or function. The loss of a breast to a fashion model or a hysterectomy in a nulliparous woman may cause serious body image disturbances even though the overall health of the individual has been improved. As an important part of one’s self-concept.   Body Image Enhancement Grief Work Facilitation Coping Enhancement NANDA Definition: Confusion in mental picture of one’s physical self Body image is the attitude a person has about the actual or perceived structure or function of all or part of his or her body. body image disturbance can have profound impact on how individuals view their overall selves. Verbal preoccupation with changed body part or function. In cultures where one’s appearance is important. body image changes as a matter of development. and head and neck resections are other examples that can lead to body image disturbance.

The extent of the response is more related to the value or importance the patient places on the part or function than the actual value or importance. Change in social behavior (e. Adolescents and young adults may be particularly affected by changes in the structure or function of their bodies at a time when developmental changes are normally rapid. the alteration results in a body image disturbance. Focusing behavior on changed body part and/or function. • Assess perceived impact of change on activities of daily living (ADLs). Malodorous lesions. Ongoing Assessment • Assess perception of change in structure or function of body part (also proposed change). Change in voice quality. Permanent alterations in structure and/or function (e.. and care for actual or perceived altered body part or function..g.g. Compensatory use of concealing clothing or other devices Related Factors: Situational changes ( discuss or acknowledge change. pregnancy.g.. withdrawal. social behavior. personal relationships. and occupational activities. temporary presence of a visible drain or tube. removal of body part [internal or external]). attached equipment). flamboyance). Expected Outcomes: Patient demonstrates enhanced body image and self-esteem as evidenced by ability to look at. touch. or care for altered body part. talk about. dressing. Actual change in structure or function. Even when an alteration improves the overall health of the individual (e. • Assess impact of body image disturbance in relation to patient’s developmental stage. Refusal to look at. touch. mutilating surgery. 41 .g.. an ileostomy for an individual with precancerous colon polyps). and at a time when developing social and intimate relationships is particularly important. isolation.

ranging from totally ignoring the altered structure or function to preoccupation with it. and to other activities. to work. There is a broad range of behaviors associated with body image disturbance. It is worthwhile to encourage the patient to separate feelings about changes in body structure and/or function from feelings about self-worth. Therapeutic Interventions • Acknowledge normalcy of emotional response to actual or perceived change in body structure or function. • Encourage verbalization of positive or negative feelings about actual or perceived change. the length of which varies from individual to individual. Stages of grief over loss of a body part or function is normal. and their actions and behaviors are scrutinized as the patient plans to return to home.• Note patient’s behavior regarding actual or perceived changed body part or function. • Help patient identify actual changes. • Note frequency of self-critical remarks. and typically involves a period of denial. • Assist patient in incorporating actual changes into ADLs. Professional caregivers represent a microcosm of society. Education/Continuity of Care • Teach patient about the normalcy of body image disturbance and the grief process. 42 . • Demonstrate positive caring in routine activities. Patients may perceive changes that are not present or real. and occupational activities. Opportunities for positive feedback and success in social situations may hasten adaptation. or they may be placing unrealistic value on a body structure or function. social life. interpersonal relationships.

clothing that conceals altered body part or enhances remaining part or function. getting glasses. illness. Asking patients to remember other body image issues (e. cosmetics. use of adaptive equipment. This compensates for actual changed body structure and function. Lay persons in similar situations offer a different type of support. Mended Hearts). and the 43 .g.g. work.. having a leg cast) and how they were managed may help patient adjust to the current issue. which is perceived as helpful (e. use of deodorants). wigs. • Refer patient and caregivers to support groups composed of individuals with similar alterations. everyday life includes its share of stressors and demands.. I Can Cope. Y Me?. ranging from family. United Ostomy Association.. Ineffective Coping NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Coping Decision Making Information Processing    NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Coping Enhancement  NANDA Definition: Inability to form a valid appraisal of the stressors.• Teach patient adaptive behavior (e.g. being pregnant. • Help patient identify ways of coping that have been useful in the past. inadequate choices of practiced responses. wearing orthodontics. and/or inability to use available resources For most persons. and professional role responsibilities to major life events such as divorce.

Overuse of tranquilizers. Diagnosis of serious illness.death of loved ones. Some cultures may prefer privacy and avoid sharing their fears in public. Destructive behavior toward self. Irritable bowel. Chronic fatigue. Recent change in health status. Excessive smoking and drinking. Sociocultural and religious factors may influence how people view and handle their problems. or those who find themselves suddenly physically challenged may not have the resources or skills to cope with their acute or chronic stressors. those in adverse socioeconomic situations.g. Maturational crises Expected Outcomes: Patient identifies own maladaptive coping behaviors. Situational crises. in the home or rehabilitation environment as a result of chronic illness. Inappropriate use of defense mechanisms. social support networks. Patient describes and initiates alternative coping strategies. this strategy may prove ineffective. lack of motivation). Defining Characteristics: Verbalization of inability to cope. 44 . As resources become limited and problems become more acute. Chronic depression. Inadequate coping method. during hospitalization for an acute event. Insomnia.Emotional tension. problem-solving skills. Physical symptoms such as the following: Overeating or lack of appetite. personal health and energy. Unsatisfactory support system. or in response to another threat or loss). Vulnerable populations such as elderly patients.. General irritability Related Factors: Change in or loss of body part. even to health care providers. Patient describes positive results from new behaviors. Patient identifies available resources and support systems. Inability to make decisions. Inability to ask for help. and material resources. Inadequate psychological resources (poor selfesteem. Such resources can include optimistic beliefs. Headaches. Such problems can occur in any setting (e. How one responds to such stressors depends on the person’s coping resources. High illness rate. Personal vulnerability. those with complex medical problems such as substance abuse.

Patients with history of maladaptive coping may need additional resources. Resources may include significant others. yet be discharged home without sufficient support for effective coping. Likewise. • Assess available or useful past and present coping mechanisms. • Assess specific stressors. An ongoing relationship establishes trust. Patients may feel that the threat is greater than their resources to handle it and feel a loss of control over solving the threat or problem. such as during hospitalization. Therapeutic Interventions • Establish a working relationship with patient through continuity of care. Because a patient has an altered health status does not mean the coping difficulties he or she exhibits are only (if at all) related to that.Ongoing Assessment • Assess for presence of defining characteristics. health care providers such as home health nurses. Behavioral and physiological responses to stress can be varied and provide clues to the level of coping difficulty. previously successful coping skills may be inadequate in the present situation. Patients may have support in one setting. • Assess decision-making and problem-solving abilities. and may facilitate coping. • Evaluate resources and support systems available to patient. • Assess level of understanding and readiness to learn needed lifestyle changes. 45 . and spiritual counseling. Successful adjustment is influenced by previous coping success. reduces the feeling of isolation. Often patients who are ineffectively coping are unable to hear or assimilate needed information. Appropriate problem solving requires accurate information and understanding of options. community resources. Accurate appraisal can facilitate development of appropriate coping strategies.

Patients who are coping ineffectively may not be able to assess progress. Reduce stimuli in environment that could be misinterpreted as threatening. • Encourage patient to set realistic goals. Patients who are coping ineffectively have reduced ability to assimilate information. This is especially common in the acute hospital setting where patients are exposed to new equipment and environments. • Provide information the patient wants and needs. Avoid false reassurances. Encourage patient to seek information that increases coping skills. Fostering awareness can expedite use of these strengths. and expectations. Guiding the patient to view the situation in smaller parts may make the problem more manageable. Do not provide more than patient can handle. This helps patient gain control over the situation. • Provide outlets that foster feelings of personal achievement and self-esteem. Explore attitudes and feelings about required lifestyle changes. Encourage patient to identify own strengths and abilities. fears. Opportunities to role play or rehearse appropriate actions can increase confidence for behavior in actual situation. Patients who are not coping well may need more guidance initially. Discourage decision making when under severe stress. • • • Assist patient to evaluate situation and own accomplishments accurately. • • • Assist patient to problem solve in a constructive manner. • Point out signs of positive progress or change. During crises. • • Convey feelings of acceptance and understanding.• Provide opportunities to express concerns. feelings. 46 . patients may not be able to recognize their strengths. Verbalization of actual or perceived threats can help reduce anxiety.

exercise. and diversional activities as methods to cope with stress. These facilitate coping strengths. • Teach use of relaxation. Relationships with persons with common interests and goals can be beneficial. 47 . These facilitate ability to cope. Unexpressed feelings can increase stress. • Involve social services. Encourage participation in selfhelp groups as available. • Assist in development of alternative support system. • Point out maladaptive behaviors. psychiatric liaison. This helps patient focus on more appropriate strategies. Inadequate diet and fatigue can themselves be stressors. • • Administer tranquilizer. Assist to grieve and work through the losses of chronic illness and change in body function if appropriate. and pastoral care for additional and ongoing support resources. sedative as ordered.• Encourage patient to communicate feelings with significant others. Education/Continuity of Care • Instruct in need for adequate rest and balanced diet.

Diarrhea Loose Stools.g. or those with chronic disease (e. unformed stools Diarrhea may result from a variety of factors. and hypermotility of the intestine.. increased secretion of fluid by the intestinal mucosa. Problems associated with diarrhea. including intestinal absorption disorders. acquired immunodeficiency 48 . Clostridium difficile (C. In elderly patients. which may be acute or chronic. difficile) NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Bowel Elimination Fluid Balance Medication Response    NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Diarrhea Management Enteral Tube Feeding Teaching: Prescribed Medications    NANDA Definition: Passage of loose. include fluid and electrolyte imbalance and altered skin integrity.

Bowel resection. frequency. including self. Inquire about the following: Tolerance to milk and other dairy products Patients with lactose intolerance have insufficient lactase. and hyperactive bowel sensations. diligent hand washing between patients) to avoid spreading diarrhea from person to person. Anxiety. antibiotics). Disagreeable dietary intake. Hyperactive bowel sounds or sensations Related Factors: Stress. Tube feedings. replacing fluids and electrolytes. diarrhea can be life-threatening. Crohn’s disease). and maintaining skin integrity. Medication use. Diarrhea may result from infectious (i... Short bowel syndrome. urgency. Bowel disorders: inflammation.g. Ongoing Assessment • Assess for abdominal pain. • • • Culture stool. • Medications patient is or has been taking Laxatives and antibiotics may cause diarrhea. or parasitic) processes. providing nutrition (if diarrhea is prolonged and/or severe). Urgency. Radiation. Cramping.g. difficile is a common cause of nosocomial diarrhea in health care facilities. tube feedings).. Increased secretion. loose or liquid stools.syndrome [AIDS]). radiation.. 49 . Health care workers and other caregivers must take precautions (e. Malabsorption. difficile can colonize the intestine following antibiotic use and lead to pseudomembranous enterocolitis. Defining Characteristics: Abdominal pain. primary bowel diseases (e..g. C. Enteric infections.g. formed stool no more than three times per day. bacterial. cramping. the enzyme that digests lactose. Loose or liquid stools. drug therapies (e. The presence of lactose in the intestines increases osmotic pressure and draws water into the intestinal lumen. C. Testing will identify causative organisms. Lactose intolerance Expected Outcomes: Patient passes soft. Treatment is based on addressing the cause of the diarrhea. increased osmotic loads (e. Chemotherapy.e. or increased intestinal motility such as with irritable bowel disease. viral. Frequency of stools.

Current stressors Some individuals respond to stress with hyperactivity of the GI tract. decreases usual absorption capacity. Change in eating schedule. and/or soiling accidents by providing privacy and opportunity for verbalization. Skin turgor Moisture of mucous membrane   • Assess condition of perianal skin. stimulates peristalsis.• Idiosyncratic food intolerances Spicy. Diarrheal stools may be highly corrosive. • Explore emotional impact of illness. 50 . Preparation for radiography or surgery. Level of activity. as in the following:  Input and output Diarrhea can lead to profound dehydration and electrolyte imbalance.   • Assess impact of therapeutic or diagnostic regimens on diarrhea. and causes diarrhea. or high-carbohydrate foods may cause diarrhea. as a result of increased enzyme content. and may result in diarrhea. hospitalization. Adequacy or privacy for elimination. • • • • Check for history of the following:  Previous gastrointestinal (GI) surgery Following bowel resection. a period (1 to 3 weeks) of diarrhea is normal. • Assess hydration status. Method of food preparation Fried food or food contaminated with bacteria during preparation may cause diarrhea. Osmolality of tube feedings Hyperosmolar food or fluid draws excess fluid into the gut. and radiation or chemotherapy predisposes to diarrhea by altering mucosal surface and transit time through bowel. fatty. GI diseases Abdominal radiation Radiation causes sloughing of the intestinal mucosa.

grains. caffeine. carbonated beverages) Stimulants may increase GI motility and worsen diarrhea. matzos. • Assist with or administer perianal care after each bowel movement (BM). pretzels. condition. Metamucil) "Natural" antidiarrheals (e. or those patients already depleted may require less bowel preparation or additional intravenous (IV) fluid therapy during preparation. Elderly.g. frail. thus allowing for more fluid absorption. This prevents hyperosmolar diarrhea. employ the following:  Change feeding tube equipment according to institutional policy. • Evaluate appropriateness of physician’s radiograph protocols for bowel preparation on basis of age. cheese) Avoidance of stimulants (e.. This prevents perianal skin excoriation. • Check for fecal impaction by digital examination. Most antidiarrheal drugs suppress GI motility. Contaminated equipment can cause diarrhea. and other therapies. but no less than every 24 hours. disease. Administer tube feeding at room temperature.g.Therapeutic Interventions • Give antidiarrheal drugs as ordered. consider nutritional support. Fluids compensate for malabsorption and loss of nutrients. cereal. weight. • For patients with enteral tube feeding. Extremes of temperature can stimulate peristalsis. Decrease rate or dilute feeding if diarrhea persists or worsens. • Provide the following dietary alterations as allowed:    Bulk fiber (e.g. Liquid stool (apparent diarrhea) may seep past a fecal impaction.. Initiate tube feeding slowly. • Encourage fluids..    51 .

Broil. Hygiene controls perianal skin excoriation and minimizes risk of spread of infectious diarrhea. if the one prescribed causes diarrhea. Avoid foods that are disagreeable. There are usually several antibiotics with which the patient can be treated. Dehydration NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels 52 . Encourage use of "natural" antidiarrheals (these may differ person to person). • Teach patient or caregiver the importance of fluid replacement during diarrheal episodes. or boil foods. fatty foods. bake. • Teach patient or caregiver the following measures that control diarrhea:   Take antidiarrheal medications as ordered. • Teach patient or caregiver the importance of good perianal hygiene after each BM. • Encourage reporting of diarrhea that occurs with prescription drugs.Education/Continuity of Care • Teach patient or caregiver the following dietary factors that can be controlled:    Avoid spicy. Deficient Fluid Volume Hypovolemia. Fluids prevent dehydration. avoid frying. this should be reported promptly.

Elderly patients are more likely to develop fluid imbalances. Changes in mental status Related Factors: Inadequate fluid intake. or hypovolemia. interstitial. polyuria. outpatient center. Failure of regulatory mechanisms. Decreased skin turgor. Electrolyte and acid-base imbalances. or from a reduced fluid intake. Decreased venous filling. This refers to dehydration. Active fluid loss (diuresis. and increased perspiration. Output greater than intake. Hypotension. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Early recognition and treatment are paramount to prevent potentially life-threatening hypovolemic shock. infection). abnormal drainage or bleeding. occurs from a loss of body fluid or the shift of fluids into the third space. Fluid volume deficit may be an acute or chronic condition managed in the hospital. Concentrated urine. Defining Characteristics: Decreased urine output.  Fluid Balance Hydration NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Fluid Monitoring Fluid Management Fluid Resuscitation    NANDA Definition: Decreased intravascular. Weakness. Increased pulse rate. Sudden weight loss. Hemoconcentration. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Increased serum sodium. Dry mucous membranes. Fluid shifts (edema or effusions) 53 . water loss alone without change in sodium Fluid volume deficit. Increased metabolic rate (fever. or home setting. Thirst. Possible weight gain. Common sources for fluid loss are the gastrointestinal (GI) tract. and/or intracellular fluid. diarrhea).

This can help to guide interventions. and preferably at the same time of day. Note the following orthostatic hypotension significance:   Greater than 10 mm Hg drop: circulating blood volume is decreased by 20%. Most fluid enters the body through drinking. Ongoing Assessment • Obtain patient history to ascertain the probable cause of the fluid disturbance. The skin in elderly patients loses its elasticity. • Monitor and document vital signs. therefore skin turgor should be assessed over the sternum or on the inner thighs. Hypotension is evident in hypovolemia. water in foods. large amount of drainage post-surgery. heart rate (HR) 100 beats/min. normotensive blood pressure (BP). Report urine output less than 30 ml/hr for 2 consecutive hours. consistency of weight. Usually the pulse is weak. reduced fluid intake from changes in cognition. • Assess color and amount of urine. and may be irregular if electrolyte imbalance also occurs. • Assess or instruct patient to monitor weight daily and consistently. Determine if patient has been on a fluid restriction. Causes may include acute trauma and bleeding. and water formed by oxidation of foods.Expected Outcomes : Patient experiences adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr. • Monitor blood pressure for orthostatic changes (from patient lying supine to highFowler’s). 54 . Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%. and normal skin turgor. with same scale. This facilitates accurate measurement and follows trends. • Evaluate fluid status in relation to dietary intake. • Assess skin turgor and mucous membranes for signs of dehydration. or persistent diarrhea. Sinus tachycardia may occur with hypovolemia to maintain an effective cardiac output. Longitudinal furrows may be noted along the tongue. Concentrated urine denotes fluid deficit.

flavored gelatin. Dehydration can alter mental status. shortness of breath. diarrhea. increased BP. elevated central venous pressure [CVP]. sports drink). Place at bedside within easy reach. and pulmonary capillary wedge pressure (PCWP) if available. maintain accurate input and output. • • Determine patient’s fluid preferences: type. tubes. Provide fresh water and a straw. • Document baseline mental status and record during each nursing shift. This direct measurement serves as optimal guide for therapy. 55 . temperature (hot or cold). • Monitor serum electrolytes and urine osmolality and report abnormal values. Elevated hemoglobin and elevated blood urea nitrogen (BUN) suggest fluid deficit. Urinespecific gravity is likewise increased. monitor closely for signs of circulatory overload (headache. • Evaluate whether patient has any related heart problem before initiating parenteral therapy.g. Therapeutic Interventions Encourage patient to drink prescribed fluid amounts. Cardiac and elderly patients often have precarious fluid balances and are prone to develop pulmonary edema. frozen juice bars. Febrile states decrease body fluids through perspiration and increased respiration. • If hospitalized. venous distention. This prevents complications associated with therapy. • Monitor active fluid loss from wound drainage.• Monitor temperature. pulmonary artery pressure (PAP). During treatment.   If oral fluids are tolerated. and vomiting.. tachypnea. tachycardia. flushed skin. provide oral fluids patient prefers. monitor hemodynamic status including CVP. bleeding. Be creative in selecting fluid sources (e. cough).

Parenteral fluid replacement is indicated to prevent shock.  Administer blood products as prescribed.   Administer parenteral fluids as ordered. 56 . Elderly patients are especially susceptible to fluid overload. stop infusion and sit patient up or dangle. This promotes interest in drinking. begin to advance the diet in volume and composition. • • Plan daily activities. • Assist patient if unable to feed self and encourage caregiver to assist with feedings as appropriate.. Planning prevents patient from being too tired at mealtimes. Elderly patients have a decreased sense of thirst and may need ongoing reminders to drink.  Should signs of fluid overload occur. These may be required for active GI bleeding. Institute measures to control excessive electrolyte loss (e.   Once ongoing fluid losses have stopped.Oral fluid replacement is indicated for mild fluid deficit. For more severe hypovolemia: Obtain and maintain a large-bore intravenous (IV) catheter. Anticipate the need for an IV fluid challenge with immediate infusion of fluids for patients with abnormal vital signs.  Assist the physician with insertion of a central venous line and arterial line as indicated. Provide oral hygiene. administering antipyretics as ordered). This allows more effective fluid administration and monitoring. These decrease venous return and optimize breathing.  Maintain IV flow rate.g. resting the GI tract.

in addition to IV fluids. • If patients are to receive IV fluids at home. Responsibility for maintaining venous access sites and IV supplies may be overwhelming for caregiver. and other conditions causing fluid deficits. • Refer to home health nurse as appropriate. instruct caregiver in managing IV equipment. Patients need to understand the importance of drinking extra fluid during bouts of diarrhea. elderly caregivers may not have the cognitive ability and manual dexterity required for this therapy. administer antidiarrheal or antiemetic medications as prescribed. Explain or reinforce rationale and intended effect of treatment program. For hypovolemia due to severe diarrhea or vomiting. Education/Continuity of Care • • • • Describe or teach causes of fluid losses or decreased fluid intake. Explain importance of maintaining proper nutrition and hydration. Allow sufficient time for return demonstration. • Inform patient or caregiver of importance of maintaining prescribed fluid intake and special diet considerations involved. In addition. Teach interventions to prevent future episodes of inadequate intake. 57 . fever.

Chronic conditions such as chronic obstructive pulmonary disease (COPD) put these patients at greater risk for hypoxia.g. or decreased cardiac output or shock can cause ventilation without perfusion. Elderly patients have a decrease in pulmonary blood flow and diffusion as well as reduced ventilation in the dependent regions of the lung where perfusion is greatest. The relationship between ventilation (airflow) and perfusion (blood flow) affects the efficiency of the gas exchange.. Other factors affecting gas exchange include high altitudes. atelectasis. and altered oxygen-carrying capacity of the blood from reduced hemoglobin.Impaired Gas Exchange Ventilation or Perfusion Imbalance NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Respiratory Status Gas Exchange   NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Respiratory Monitoring Oxygen Therapy Airway Management    NANDA Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane By the process of diffusion the exchange of oxygen and carbon dioxide occurs in the alveolarcapillary membrane area. resulting in impaired gas exchange. Conditions that cause changes or collapse of the alveoli (e. certain conditions can offset this balance. however. Other patients at risk for 58 . pulmonary edema. Normally there is a balance between ventilation and perfusion. and adult respiratory distress syndrome [ARDS]) impair ventilation. Altered blood flow from a pulmonary embolus. pneumonia. hypoventilation.

bronchial breathing. tracheal shift to affected side. prolonged periods of immobility. Altered oxygen-carrying capacity of blood Expected Outcomes: Patient maintains optimal gas exchange as evidenced by normal arterial blood gases (ABGs) and alert responsive mentation or no further reduction in mental status. Collapse of alveoli increases physiological shunting. • Assess for signs and symptoms of hypoxemia: tachycardia. and respiratory rate all rise. Restlessness. pleuritic pain. blood pressure (BP). Shallow. bronchial or tubular breath sounds. pain. Defining Characteristics: Confusion. depth. • Assess for signs or symptoms of pulmonary infarction: cough. shallow breathing patterns and hypoventilation affect gas exchange. limited diaphragm excursion. heart rate. Both rapid. and chest or upper abdominal incisions. restlessness. hemoptysis. headache.impaired gas exchange include those with a history of smoking or pulmonary problems. Hypoxia Related Factors: Altered oxygen supply. As the hypoxia and/or hypercapnia becomes more severe. With initial hypoxia and hypercapnia. pattern. pleural effusion. Ongoing Assessment • Assess respirations: note quality. and confusion. Alveolar-capillary membrane changes. diaphoresis. lethargy. 59 . rales. consolidation. Inability to move secretions. and immobility) reduce lung volume and decrease ventilation. and breathing effort. heart rate tends to continue to be rapid with arrhythmias. fever. noting areas of decreased ventilation and the presence of adventitious sounds. • Assess for signs and symptoms of atelectasis: diminished chest excursion. "sighless" breathing patterns postsurgery (as a result of effect of anesthesia. rate. Irritability. obesity. • Monitor vital signs. Hypercapnia. • Assess lung sounds. Somnolence. Altered blood flow. BP may drop. pleural friction rub.

and respiratory failure may ensue with the patient unable to maintain the rapid respiratory rate. and 4 L with activity). • Assess for changes in orientation and behavior. Putting the most congested lung areas in the dependent position (where perfusion is greatest) potentiates ventilation and perfusion imbalances. the respiratory rate will decrease and PaCO2 will begin to rise. 2 L at rest. As the patient begins to fail. • Assess skin color for development of cyanosis. Keep in mind that radiographic studies of lung water lag behind clinical presentation by 24 hours. Oxygen saturation should be maintained at 90% or greater. Oxygen delivery is then titrated to maintain an oxygen saturation of 90% or greater. • Monitor effects of position changes on oxygenation (SaO2. Home oxygen therapy can then be prescribed as indicated. Patients should be assessed for the need for oxygen both at rest and with activity. and end-tidal CO2). such as those with COPD. • Monitor ABGs and note changes. Pulse oximetry is a useful tool to detect changes in oxygenation.g. A higher liter flow of oxygen is generally required for activity versus rest (e. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. SVO2.. Chronic hypoxemia may result in cognitive changes such as memory changes. and any physiological stress may result in acute respiratory failure. Some patients. Medicare guidelines for reimbursement for home oxygen require a PaCO2 less than 58 and/or oxygen saturation of 88% or less on room air. Restlessness is an early sign of hypoxia. have a significant decrease in pulmonary reserves. ABGs. • Monitor chest x-ray reports. 60 . • Use pulse oximetry to monitor oxygen saturation and pulse rate. 5 g of hemoglobin must desaturate. For cyanosis to be present. Chest x-rays may guide the etiological factors of the impaired gas exchange. This tool can be especially helpful in the outpatient or rehabilitation setting where patients at risk for desaturation from chronic pulmonary diseases can monitor the effects of exercise or activity on their oxygen saturation levels.

Assess patient’s ability to cough effectively to clear secretions. Note quantity, color, and consistency of sputum. Retained secretions impair gas exchange.

Therapeutic Interventions

Maintain oxygen administration device as ordered, attempting to maintain oxygen saturation at 90% or greater. This provides for adequate oxygenation. Avoid high concentration of oxygen in patients with COPD. Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. When applying oxygen, close monitoring is imperative to prevent unsafe increases in the patient’s PaO2, which could result in apnea. NOTE: If the patient is allowed to eat, oxygen still must be given to the patient but in a different manner (e.g., changing from mask to a nasal cannula). Eating is an activity and more oxygen will be consumed than when the patient is at rest. Immediately after the meal, the original oxygen delivery system should be returned.

For patients who should be ambulatory, provide extension tubing or portable oxygen apparatus. These promote activity and facilitate more effective ventilation.

Position with proper body alignment for optimal respiratory excursion (if tolerated, head of bed at 45 degrees). This promotes lung expansion and improves air exchange.

Routinely check the patient’s position so that he or she does not slide down in bed. This would cause the abdomen to compress the diaphragm, which would cause respiratory embarrassment.

Position patient to facilitate ventilation/perfusion matching. Use upright, high-Fowler’s position whenever possible. High-Fowler’s position allows for optimal diaphragm excursion. When patient is positioned on side, the good side should be down (e.g., lung with pulmonary embolus or atelectasis should be up).


Pace activities and schedule rest periods to prevent fatigue. Even simple activities such as bathing during bed rest can cause fatigue and increase oxygen consumption.

Change patient’s position every 2 hours. This facilitates secretion movement and drainage.

Suction as needed. Suction clears secretions if the patient is unable to effectively clear the airway.

Encourage deep breathing, using incentive spirometer as indicated. This reduces alveolar collapse.

For postoperative patients, assist with splinting the chest. Splinting optimizes deep breathing and coughing efforts.

Encourage or assist with ambulation as indicated. This promotes lung expansion, facilitates secretion clearance, and stimulates deep breathing.

Provide reassurance and allay anxiety:
 

Have an agreed-on method for the patient to call for assistance (e.g., call light, bell). Stay with the patient during episodes of respiratory distress.

Anticipate need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange. Early intubation and mechanical ventilation are recommended to prevent full decompensation of the patient. Mechanical ventilation provides supportive care to maintain adequate oxygenation and ventilation to the patient. Treatment also needs to focus on the underlying causal factor leading to respiratory failure.

Administer medications as prescribed. The type depends on the etiological factors of the problem (e.g., antibiotics for pneumonia, bronchodilators for COPD, anticoagulants/thrombolytics for pulmonary embolus, analgesics for thoracic pain).

Education/Continuity of Care

Explain the need to restrict and pace activities to decrease oxygen consumption during the acute episode. 62

Explain the type of oxygen therapy being used and why its maintenance is important. Issues related to home oxygen use, storage, or precautions need to be addressed.

Teach the patient appropriate deep breathing and coughing techniques. These facilitate adequate air exchange and secretion clearance.

Assist patient in obtaining home nebulizer, as appropriate, and instruct in its use in collaboration with respiratory therapist.

Refer to home health services for nursing care or oxygen management as appropriate.

Ineffective Health Maintenance
NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Health-Promoting Behavior Self-Direction of Care Health-Seeking Behavior Social Support

   

NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Health System Guidance Support System Enhancement Discharge Planning Health Screening Risk Identification

    

NANDA Definition: Inability to identify, manage, and/or seek help to maintain health


That individual may already manifest symptoms of existing or impending physical ailment or display behaviors that are strongly or certainly linked to disease. but the increased presence of the nurse in the community and home health settings improves the ability to assess patients in their own environment. Obesity or anorexia. deafness. Poor diet selection. Frequent infections (e. Inability to follow instructions or programs for health maintenance Physical characteristics: Body or mouth odor.Altered health maintenance reflects a change in an individual’s ability to perform the functions necessary to maintain health or wellness.g. Lack of exercise. Anemia. organic brain syndrome. Dramatic change in health status.. illness. Alcohol abuse. The nurse’s role is to identify factors that contribute to an individual’s inability to maintain healthy behavior and implement measures that will result in improved health maintenance activities. Presence of adverse personal habits: Smoking. Failure to recognize or respond to important symptoms reflective of changing health state. Substance abuse Related Factors: Presence of mental retardation. Inability to communicate needs adequately (e. The nurse may encounter patients who are experiencing an alteration in their ability to maintain health either in the hospital or in the community. Morbid obesity. Poor hygiene. Poor housing conditions. Patients most likely to experience more than transient alterations in their ability to maintain their health are those whose age or infirmity (either physical or emotional) absorb much of their resources. upper respiratory infection [URI]. Apathetic attitude. speech impediment). Lack of knowledge.. Lack of support systems. Chronic fatigue. Frequent toothaches . Failure to keep appointments.g. Evidence of impaired perception. Defining Characteristics: Behavioral characteristics: Demonstrated lack of knowledge. Risk-taking behaviors. Poor hygiene . Denial of need to change current habits 64 . The task before the nurse is to identify measures that will be successful in empowering patients to maintain their own health within the limits of their ability. Unusual skin color. urinary tract infection [UTI]). Low income. pallor.Presence of physical disabilities or challenges. Expressed interest in improving behaviors. Drug abuse. Soiled clothing.

Patients may know that certain unhealthy behaviors can result in poor health outcomes but continue the behavior despite this knowledge. participating in smoking and substance abuse programs. improving home environment. • Determine patient’s motives for failing to report symptoms reflecting changes in health status. meeting these needs may be helpful in mobilizing the patient. making diet and exercise changes. • Assess health history over past 5 years. Changing ability or interest in performing the normal activities of daily living (ADLs) may be an indicator that commitment to health and well-being is waning. • Assess patient’s knowledge of health maintenance behaviors. • Determine patient’s specific questions related to health maintenance. • Assess to what degree environmental. or changes have correlated with poor health behaviors. Patient identifies available resources. Patient may be experiencing obstacles in compliance that can be resolved. • Discuss noncompliance with instructions or programs with patient to determine rationale for failure. Patient may not want to "bother" the provider. These changes may be precipitating factors or may be early fallout from a generalized condition reflecting decline. social. The health care provider needs to ensure that the patient has all of the information needed to make good lifestyle choices. Ongoing Assessment • Assess for physical defining characteristics. This may give some perspective on whether poor health habits are recent or chronic in nature. 65 .Expected Outcomes: Patient describes positive health maintenance behaviors such as keeping scheduled appointments. Patients may have health education needs. intrafamilial disruptions. and following treatment regimen. or may minimize the importance of the symptoms. Patient uses available resources.

once established. access ramps. This will help identify and solve problems that complicate health maintenance. Patients may not have understood information because of a sensory impairment or the inability to read or understand information. and orientation to time. and quality of living conditions. and alcohol or substance abuse. • Assess history of other adverse personal habits. obesity. Health teaching may need to be modified to be consistent with cultural or religious beliefs.. the patient may be able to effect enormous changes in maintaining his or her personal health. place. motor vehicle modifications. or insurance benefits could be helpful to them.• Assess the patient’s educational preparation and ability to integrate and relate to information. patients may feel that nothing positive can come from a change in behavior. • Determine whether the patient’s manual dexterity or lack of mobility is a factor in patient’s altered capacity for health maintenance. Culture or age may impair a patient’s ability to comply with the established treatment plan. 66 . accessibility. • Assess whether economic problems present a barrier to maintaining health behaviors. • Make a home visit to determine safety. Perceptual handicaps may impair an individual’s ability to maintain healthy behaviors. Patients may need assistive devices for ambulation or to complete tasks of daily living. lack of exercise. • Assess hearing. and person to determine the patient’s perceptual abilities. • Determine to what degree patient’s cultural beliefs and personality contribute to altered health habits. shower bar or chair) are available to patient. Patients may be too proud to ask for assistance or be unaware that Social Security. • Determine whether the required health maintenance facilities/equipment (e.g. Long-standing habits may be difficult to break. With adequate assistive devices. Medicare. including the following: smoking.

This will add available resources for questions or problem resolution. • Provide patient with a means of contacting health care providers. Smoking cessation Smoking has been directly linked to cancer and heart disease.. These promote independence and a sense of autonomy. patients may again be able to resume their self-care activities. This enables the patient to maintain a sense of autonomy. If stressors can be relieved. Regular exercise This promotes weight loss and increases agility and stamina. Family members need to understand that care is planned to focus on what is most important to the patient. Therapeutic Interventions • Follow up on clinic visits with telephone or home visits. wheelchair) as necessary. • • • 67 . This will develop an ongoing relationship with patient and provide ongoing support. Regular physical and dental checkups Checkups identify and treat problems early. • Provide assistive devices (e. Cessation of alcohol and drug abuse In addition to physical addictions and the social consequences. cane.• Assess patient’s experience of stress and disruptors as they relate to health habits. walker. Education/Continuity of Care • • • • Provide patient with rationale for importance of behaviors such as the following: Balanced diet low in cholesterol This prevents vascular disease. Proper hygiene This decreases risk of infection and promotes maintenance and integrity of skin and teeth.g. the physical consequences of substance abuse mitigate against it. Positive reinforcement enhances behavior change. • Compliment patient on positive accomplishments. • Involve family and friends in health planning conferences.

. an infection occurs. Open wounds. Risk for Infection Universal Precautions. can be sites for infection. Breaks in the integument. fat. muscle) and organs (kidneys.• Reporting of unusual symptoms to a health professional This initiates early treatment. Social Services. virus.g. fungus. Regular inoculations. or other parasite) invades a susceptible host. the body’s first line of defense. lungs) can also be sites for 68 . CDC Guidelines. Infections occur when an organism (e. OSHA NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Immune Status Knowledge: Infection Control   NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Infection Control Infection Protection   NANDA Definition: At increased risk for being invaded by pathogenic organisms Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and exposures that occur throughout the course of living. traumatic or surgical. Visiting Nurse Association [VNA]. Coordinated efforts are more meaningful and effective. Department of Children and Family Services [DCFS]. Standard Precautions.. Proper nutrition. soft tissues (cells.g. and/or the mucous membranes allow invasion by pathogens. Meals-on-Wheels) are following through with plans. Early and regular prenatal care • Ensure that other agencies (e. If the host’s (patient’s) immune system cannot combat the invading organism adequately. bacterium.

Inadequate secondary defenses: immunosuppression. requiring multiple antimicrobial therapy. Failure to avoid pathogens (exposure). drains. or by invasion of pathogens carried through the bloodstream or lymphatic system. Indwelling catheters. Invasive procedures. Infections can be transmitted.infection either after trauma. peritoneal). Because identification of infected individuals is not always apparent. body fluid stasis. venous or arterial access 69 . or sharing of intravenous (IV) drug paraphernalia. Organisms may become resistant to antimicrobials. standard precautions recommended by the Centers for Disease Control and Prevention (CDC) are widely practiced. such as the human immunodeficiency virus (HIV). and can result in death if untreated. wound drainage tubes (T-tubes. Intravenous (IV) devices. endotracheal or tracheostomy tubes. Malnutrition. Penrose. invasive procedures. Rupture of amniotic membranes. in-dwelling catheters (Foley. Infection is recognized early to allow for prompt treatment. Being malnourished. Antimicrobials are used to treat infections when susceptibility is present. Infections prolong healing. leucopenia. and tubes. Ease and increase in world travel has also increased opportunities for transmission of disease from abroad. injured tissue. Ongoing Assessment • Assess for presence. to protect themselves and others from disease transmission. must understand how to take precautions to prevent transmission. the Occupational Safety and Health Administration (OSHA) has set forth the Blood Borne Pathogens Standard. Chronic disease. incisions. as evidenced by normal vital signs and absence of purulent drainage from wounds. Jackson-Pratt). Risk Factors: Inadequate primary defenses: broken skin. existence of. and history of risk factors such as open wounds and abrasions. Health care workers. Inadequate acquired immunity Expected Outcomes: Patient remains free of infection. sexual contact. There are organisms for which no antimicrobial is effective. and lacking knowledge about disease transmission place individuals at risk for infection. either by contact or through airborne transmission. Intubation. having inadequate resources for sanitary living conditions. In addition. developed to protect workers and the public from infection.

and orthopedic fixator pins. or purulent drainage at incisions. antibiotic therapy is determined by pathogens identified at culture. • • Assess for exposure to individuals with active infections. infection may be present without an increased WBC. Very low WBC (neutropenia <1000 mm3) indicates severe risk for infection because patient does not have sufficient WBCs to fight infection. foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection.7° C (99. drains. history of weight loss.8° F) suggests infection. very high fever accompanied by sweating and chills may indicate septicemia. assess intactness of amniotic membranes. and serum albumin. after 48 hours. Patients with poor nutritional status may be anergic. • Color of respiratory secretions Yellow or yellow-green sputum is indicative of respiratory infection. or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection. fever above 37. injured sites. Each of these examples represent a break in the body’s normal first lines of defense. • Elevated temperature Fever of up to 38° C (100. • Monitor white blood count (WBC). • In pregnant patients. NOTE: In elderly patients. increased pain. Appearance of urine Cloudy. normal values: 4000 to 11. Prolonged rupture of amniotic membranes before delivery places the mother and infant at increased risk for infection.4° F) for 48 hours after surgery is related to surgical stress. • • Monitor the following for signs of infection: Redness. Antineoplastic agents and corticosteroids reduce immunocompetence. fever spikes that occur and subside are indicative of wound infection.000 mm3. swelling. 70 . Assess for history of drug use or treatment modalities that may cause immunosuppression. exit sites of tubes. or catheters Any suspicious drainage should be cultured. including weight.devices. • • Assess nutritional status. Rising WBC indicates body’s efforts to combat pathogens.

The most common modes of transmission are by direct contact (touching) and by droplet (airborne).g. • Encourage intake of protein. in turn.and calorie-rich foods. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another (e. • Encourage coughing and deep breathing. Ideally.• Assess immunization status. This reduces the number of organisms in patient’s environment and restricts visitation by individuals with any type of infection to reduce the transmission of pathogens to the patient at risk for infection. catheter care and handling. Friction and running water effectively remove microorganisms from hands. antifungal. perineal care or central line care). Use of disposable gloves does not reduce the need for hand washing.. and peripheral IV and central venous access management. Elderly patients and those not raised in the United States may not have completed immunizations. Therapeutic Interventions • Maintain or teach asepsis for dressing changes and wound care. antiparasitic. pathogens can cause upper respiratory infections. • Administer or teach use of antimicrobial (antibiotic) drugs as ordered. All of these agents are either toxic to the pathogen or retard the pathogen’s growth. including pneumonia. This maintains optimal nutritional status. reduces risk of bladder infection or urinary tract infection (UTI). When stasis occurs. • Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient. Fluids promote diluted urine and frequent emptying of bladder. the 71 . consider use of incentive spirometer. These measures reduce stasis of secretions in the lungs and bronchial tree. • Limit visitors. Antimicrobial drugs include antibacterial. reducing stasis of urine. • Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated). and antiviral agents. and therefore not have sufficient acquired immunocompetence.

Institutional protocols may vary. • Teach family members and caregivers about protecting susceptible patient from themselves and others with infections or colds. • Teach patient to take antibiotics as prescribed. • Teach patient and caregiver the signs and symptoms of infection. and caregivers the purpose and proper technique for maintaining isolation. • Teach patient. and in these cases. Most antibiotics work best when a constant blood level is maintained. Protective isolation is established if white blood cell counts indicate neutropenia (<500 to 1000 mm3). peripheral or central IV site 72 . • Place patient in protective isolation if patient is at very high risk. hand washing reduces these risks. a constant blood level is maintained when medications are taken as prescribed. Education/Continuity of Care • Teach patient or caregiver to wash hands often. such as dressing changes. this is often impossible or impractical. • Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes.selection of the drug is based on cultures from the infected area. before meals. empirical management usually is undertaken with a broad-spectrum drug. • Demonstrate and allow return demonstration of all high-risk procedures that patient or caregiver will do after discharge. family. patient should be instructed accordingly. as well as pick up surface pathogens. and when to report these to the physician or nurse. • Teach patient the importance of avoiding contact with those who have infections or colds. The absorption of some antibiotics is hindered by certain foods. especially after toileting. Patients and caregivers can spread infection from one part of the body to another. and before and after administering self-care.

. leg fracture. Most disease and rehabilitative states involve some degree of immobility (e. trauma. self-catheterization (may use clean technique). Bladder infection is more related to overdistended bladder resulting from infrequent catheterization than to use of clean versus sterile technique. and multiple sclerosis). purposeful physical movement of the body or of one or more extremities Alteration in mobility may be a temporary or more permanent problem. morbid obesity. as seen in strokes. Impaired Physical Mobility Immobility NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Ambulation: Walking Joint Movement: Active Mobility Level    NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Exercise Therapy: Ambulation Joint Mobility Fall Precautions Positioning Bed Rest Care      NANDA Definition: Limitation in independent. peritoneal dialysis.g. With the longer life expectancy for most 73 .care.

strength. Patient is free of complications of immobility. and ensure a safe environment. 74 . Mobility is paramount if elderly patients are to maintain any independent living. Medical restrictions. Identifying the specific cause (e. and gait changes affecting balance can significantly compromise the mobility of elderly patients. stiffer and less mobile joints. and impaired coordination. And with shorter hospital stays.. Decreased muscle endurance. and normal bowel pattern. and ambulation.g. or mass. Prolonged bed rest. transfers. Perceptual or cognitive impairment. Limited range of motion (ROM). Loss of muscle mass. including bed mobility. control. Restricted movement affects the performance of most activities of daily living (ADLs). Inability to perform action as instructed Related Factors: Activity intolerance. Neuromuscular impairment. Limited strength. patients are being transferred to rehabilitation facilities or sent home for physical therapy in the home environment. Reluctance to attempt movement. Pain or discomfort.Americans. reduction in muscle strength and function. Musculoskeletal impairment. prevent additional impairment of physical activity. medical protocol. Mobility is also related to body changes from aging. Imposed restrictions of movement including mechanical. Elderly patients are also at increased risk for the complications of immobility. the incidence of disease and disability continues to grow. absence of thrombophlebitis. Depression or severe anxiety Expected Outcomes : Patient performs physical activity independently or with assistive devices as needed. Nursing goals are to maintain functional ability. as evidenced by intact skin. Ongoing Assessment • Assess for impediments to mobility (see Related Factors in this care plan). Defining Characteristics: Inability to move purposefully within physical environment. chronic arthritis versus stroke versus chronic neurological disease) guides design of optimal treatment plan.

Pressure sores develop more quickly in patients with a nutritional deficit. Bed rest or immobility promote clot formation. ankles. present patterns.. Safety with ambulation is an important concern. calf pain. heels. muscle weakness. and rise in temperature). Proper nutrition also provides needed energy for participating in an exercise or rehabilitative program. sacrum.g.• Assess patient’s ability to perform ADLs effectively and safely on a daily basis. physical therapy. visiting nurse). • Monitor input and output record and nutritional pattern. pneumonia. usual pattern. or teaching 3 Requires help from another person and equipment or device 4 Is dependent. • Assess patient or caregiver’s knowledge of immobility and its implications. • Assess elimination status (e. supervision. does not participate in activity Restricted movement affects the ability to perform most ADLs. tissue ischemia (especially over ears. Evaluate need for home assistance (e. • Assess skin integrity. elbows. Homans’ sign. and toes). localized swelling. constipation. possible hypocalcemia... • Assess for developing thrombophlebitis (e. and depression. Assess nutritional needs as they relate to immobility (e.g.g. • • Assess emotional response to disability or limitation.g.. Check for signs of redness. negative nitrogen balance). redness. shoulders. Immobility promotes constipation. Even patients who are temporarily immobile are at risk for effects of immobility such as skin breakdown. 75 . hips. signs of constipation). Suggested Code for Functional Level Classification 0 Completely independent 1 Requires use of equipment or device 2 Requires help from another person for assistance. thrombophlebitis.

This keeps heavy bed linens off feet. or stretcher. and other assistance can promote activity and reduce danger of falls. Encourage independent activity as able and safe. sitting in chair. chair. 76 . thereby slowing the patient’s recovery and reducing his or her self-esteem. Do not rush patient. • Allow patient to perform tasks at his or her own rate. or prefabricated splints). ambulation. • Provide positive reinforcement during activity. • Facilitate transfer training by using appropriate assistance of persons or devices when transferring patients to bed. This optimizes circulation to all tissues and relieves pressure. with pillows. wedges.g. and pets can further impede one’s ability to ambulate safely. • Encourage appropriate use of assistive devices in the home setting. Proper use of wheelchairs. Obstacles such as throw rugs..• Evaluate need for assistive devices. Support feet in dorsiflexed position. Therapeutic Interventions • Encourage and facilitate early ambulation and other ADLs when possible. sandbags. Turn and position every 2 hours or as needed. • Evaluate the safety of the immediate environment. • Maintain limbs in functional alignment (e. Use bed cradle. The longer the patient remains immobile the greater the level of debilitation that will occur. • • Keep side rails up and bed in low position. Hospital workers and family caregivers are often in a hurry and do more for patients than needed. Assist with each initial change: dangling. canes. Patients may be reluctant to move or initiate new activity due to a fear of falling. children’s toys. transfer bars. Mobility aids can increase level of mobility. This prevents footdrop and/or excessive plantar flexion or tightness. This promotes a safe environment.

physical activity. 77 . • Set up a bowel program (e. Encourage coughing and deep-breathing exercises. laxatives) as needed. These prevent buildup of secretions. This increases lung expansion. • • Clean. Exercise promotes increased venous return. foods high in bulk. • Promote resistance training services. Antispasmodic medications may reduce muscle spasms or spasticity that interfere with mobility. • Initiate supplemental high-protein feedings as appropriate. adequate fluid. This drains bronchial tree. This prevents tissue breakdown. Liquids optimize hydration status and prevent hardening of stool. Research supports that strength training and other forms of exercise in older adults can preserve the ability to maintain independent living status and reduce risk of falling. Use incentive spirometer. • Turn patient to prone or semiprone position once daily unless contraindicated.g.• Perform passive or active assistive ROM exercises to all extremities. • Administer medications as appropriate. initiate nutritional counseling as indicated. and moisturize skin as needed. Record bowel activity level. Decreased chest excursions and stasis of secretions are associated with immobility. and maintains muscle strength and endurance. If impairment results from obesity.. dry. stool softeners. • Use prophylactic antipressure devices as appropriate. Proper nutrition is required to maintain adequate energy level. prevents stiffness. Use suction as needed. • Encourage liquid intake of 2000 to 3000 ml/day unless contraindicated.

weaknesses. no gain" is not always true! • Instruct patient/family regarding need to make home environment safe. emphasizing that joints are to be exercised to the point of pain. ROM. Physical therapists can provide specialized services. Emphasize abilities. A safe environment is a prerequisite to improved mobility. "No pain. Education/Continuity of Care • Explain progressive activity to patient. These optimize patient’s limited reserves. not beyond. • Instruct patient or caregivers regarding hazards of immobility. • Encourage verbalization of feelings. • Reinforce principles of progressive exercise. Help patient or caregivers to establish reasonable and obtainable goals. Assist patient in accepting limitations. Noncompliance Knowledge Deficit. strengths. and concerns. coughing. Emphasize importance of measures such as position change. Patient Education NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Adherence Behavior Compliance Behavior Knowledge: Treatment Regimen Participation: Health Care Decisions     78 . • Refer to multidisciplinary health team as appropriate. and exercises.• • Teach energy-saving techniques.

homeless individuals. and the growing number of uninsured and underinsured patients often forces patients with limited incomes to choose between food and medications. The rising costs of health care. lack of social support. and compromised emotional state.. serve to explain those factors that influence patient compliance. People living in adverse social situations (e. Much research has been conducted in this area to identify key predictive factors. those living amid street violence. person’s or caregiver’s behavior is fully or partially non-adherent and may lead to clinically ineffective or partially ineffective outcomes The fact that a patient has attained knowledge regarding the treatment plan does not guarantee compliance. such as the Health Belief Model. lack of financial resources. the unemployed. Several theoretical models.g. 79 . battered women.NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Behavior Modification Decision-Making Support Patient Contracting Health Education     NANDA Definition: Behavior of person and/or caregiver that fails to coincide with a healthpromoting or therapeutic plan agreed on by the person (and/or family and/or community) and health care professional. The problem is especially complex for elderly patients living on fixed incomes but requiring complex and costly medical therapies. that certain behaviors will reduce the likelihood of contracting the disease. stressful lifestyles. Failure to follow the prescribed plan may be related to a number of factors. Patients are more likely to comply when they believe that they are susceptible to an illness or disease that could seriously affect their health. and that the prescribed actions are less threatening than the disease itself. contrary cultural or religious beliefs and values. Factors that may predict noncompliance include past history of noncompliance. or those in poverty) may purposefully defer following medical recommendations until their acute socioeconomic situation is improved. In the presence of an agreed-on health-promoting or therapeutic plan.

Missed appointments. a patient’s perceived susceptibility to and perceived seriousness and threat of disease affect compliance with treatment plan. pilgrimage). Understanding any worries or misconceptions patient may have about the plan or side effects will guide future interventions. not medications. Cultural beliefs. as evidenced by appropriate pill count. body fluid analysis inconsistent with compliance. and any concerns about the diagnosis or symptoms will provide a basis for planning future care. how likely it is that the symptoms may return. Many people view illness as a punishment from God that must be treated through spiritual healing practices (e. Evidence of exacerbation of symptoms. prayer. not a microbe. Objective tests: improper pill counts or missed prescription refills. • Assess religious beliefs or practices that affect health. Spiritual values. For some cultures the causative agent may be a person. Ongoing Assessment • Assess patient’s individual perceptions of health problems.. • Assess beliefs about current illness. maintained appointments.g. Patient complies with therapeutic plan. • Assess beliefs about the treatment plan. evidence of therapeutic effect.Defining Characteristics: Behavior indicative of failure to adhere. Evidence of development of complications. and/or fewer hospital admissions. According to the Health Belief Model. 80 . "Revolving-door" hospital admissions. appropriate amount of drug in blood or urine. Health beliefs. Therapeutic effect not achieved or maintained Related Factors: Patient’s value system. Determining what patient thinks is causing his or her symptoms or disease. Clientprovider relationships Expected Outcomes: Patient and/or significant other report compliance with therapeutic plan. Persons of other cultures and religious heritages may hold differing views regarding health and illness.

herbs... 81 . Such reasons may include cognitive impairment. impaired manual dexterity (e. Compliance increases with a trusting relationship with a consistent caregiver. blood transfusions.g. • Assess serum or urine drug level. Ask patient to bring prescription drugs to appointment. Patients who become comanagers of their care have a greater stake in achieving a positive outcome. not taking pills because unable to open container). Therapeutic Interventions • Develop a therapeutic relationship with patient and family. unable to read written instructions). acupuncture). • Determine cultural or spiritual influences on importance of health care. For example. failure to understand instructions regarding plan (e. Others may only want to follow a "natural" or "health food" regimen.• Determine reasons for noncompliance in the past.g. Technique is commonly used in drug research protocols. • Include patient in planning the treatment regimen. count remaining pills. sensory deficit (e.. Therapeutic blood levels will not be achieved without consistent ingestion of medication. however. This provides some objective evidence of compliance. or surgery. if therapy is ineffective or based on a faulty diagnosis. even perfect compliance will not result in the expected therapeutic effect. Use of a skilled interpreter is necessary for patients not speaking the dominant language.g. fear of actually experiencing medication side effects. and disregard for nontraditional treatments (e. Not all persons view maintenance of health the same.g.. prayer. liniments. Provides information on compliance. • Compare actual therapeutic effect with expected effect. some may place trust in God for treatment and refuse pills. overdosage or overtreatment can likewise be assessed. difficulty understanding a low-sodium diet). • • Plot pattern of hospitalizations and clinic appointments.

The physical demands and financial burdens of traveling must be considered. • Develop a behavioral contract. as appropriate). Compliance increases when therapy is as short and includes as few treatments as possible.• Remove disincentives to compliance.g. • Teach significant others to eliminate disincentives and/or increase rewards to patient for compliance. diuretics may be taken with the evening meal for patients who work outside the home) and culture (incorporate herbal medicinal massage or prayer. 82 . and frequent return visits or appointments can provide increased supervision. Eliminate unnecessary clinic visits. • Increase the amount of supervision provided. Education/Continuity of Care • • Provide specific instruction as indicated. • Develop with patient a system of rewards that follow successful compliance. Tailor the information in terms of what the patient feels is the cause of his or her health problem and his or her concerns about therapy. telephone monitoring. • As compliance improves. gradually reduce the amount of professional supervision and reinforcement. recommending lower levels of activity. • Simplify therapy. Rewards provide positive reinforcement for compliant behavior.. or suggesting medications that do not cause side effects that are unacceptable to patient can improve compliance. • Tailor the therapy to patient’s lifestyle (e. Home health nurses. Actions such as decreasing waiting time in the clinic. Suggest long-acting forms of medications and eliminate unnecessary medication. This helps patient understand and accept his or her role in the plan of care and clarifies what patient can expect from the health care worker or system.

adequate nutrition plays an important role in healing and recovery. boredom). activity intolerance.• Explore community resources.g. Women exhibit a higher incidence of voluntary restriction of 83 .. burns). Anorexia NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Nutritional Status: Food and Fluid Intake Nutritional Status: Nutrient Intake   NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Nutrition Monitoring Nutrition Therapy Nutrition Management    NANDA Definition: Intake of nutrients insufficient to meet metabolic needs Adequate nutrition is necessary to meet the body’s demands. substance abuse)..g. Cultural and religious factors strongly affect the food habits of patients. depression. muscle weakness. surgery. Imbalanced Nutrition: Less than Body Requirements Starvation. physical factors (e.. Nutritional status can be affected by disease or injury states (e. trauma. Churches.. During times of illness (e. • Provide social support through patient’s family and self-help groups.g. or psychological factors (e.g. Such groups may assist patient in gaining greater understanding of the benefits of treatment. lack of financial resources to obtain nutritious foods). social clubs. Weight Loss. sepsis. and community groups can play a dominant role in some cultures. poor dentition. burns). gastrointestinal [GI] malabsorption.. pain. Outreach workers from a given community may effectively serve as a bridge to the health care provider. social factors (e.g. cancer.

Proper assessment guides intervention. 10% to 20% below ideal body weight. Patients who are elderly likewise experience problems in nutrition related to lack of financial resources. Defining Characteristics: Loss of weight with or without adequate caloric intake. Unwillingness to eat. Knowledge deficit. psychosocial. or caregiver in assessment. and self-constructed fad dieting. Patient’s perception of actual intake may differ. reduction of gastric secretion that accompanies aging and interferes with digestion. Patients may be unaware of their actual weight or weight loss due to estimating weight. Many psychological. and appropriateness of food consumed. Increased metabolic needs caused by disease process or therapy Expected Outcomes: Patient or caregiver verbalizes and demonstrates selection of foods or meals that will achieve a cessation of weight loss. Inability to digest foods. include family. do not estimate. 84 . • Monitor or explore attitudes toward eating and food. cognitive impairments causing them to forget to eat. bulimia. patients with dentition problems require referral to a dentist. Documented inadequate caloric intake Related Factors: Inability to ingest foods. Inability to absorb or metabolize foods. whereas patients with memory losses may require services such as Meals-onWheels. physical limitations that interfere with preparing food. amount. Ongoing Assessment • Document actual weight. deterioration of their sense of taste and smell. significant others. This care plan addresses general concerns related to nutritional deficits for the hospital or home intake secondary to anorexia. For example. and social isolation and boredom that cause a lack of interest in eating. Patient weighs within 10% of ideal body weight. and cultural factors determine the type. • intervObtain nutritional history. Inability to procure adequate amounts of food. • Determine etiological factors for reduced nutritional intake.

"soul foods." Hispanic dishes. • Transferrin This is important for iron transfer and typically decreases as serum protein decreases. and pattern of food or fluid intake is facilitated by accurate documentation by patient or caregiver as the intake occurs. Fewer families today have a general meal together.g. During aggressive nutritional support. • • • Weigh patient weekly.• Monitor environment in which eating occurs. RBC and WBC counts These are usually decreased in malnutrition.5 g/dl is normal). Without realistic short-term goals to provide tangible rewards.g.5 g/dl indicates severe depletion. Depending on the etiological factors of the problem. indicating anemia and decreased resistance to infection..and long-range goals. in the car) or relying heavily on fast foods with reduced nutritional components. Serum electrolyte values Potassium is typically increased and sodium is typically decreased in malnutrition. amount. 3. •  Establish appropriate short. improvement in nutritional status may take a long time. Determination of type. 85 . • Monitor laboratory values that indicate nutritional well-being/deterioration: serum albumin This indicates degree of protein depletion (2. Many adults find themselves "eating on the run" (e.8 to 4.. patients may lose interest in addressing this problem. memory is insufficient. patient can gain up to 0. Therapeutic Interventions Consult dietitian for further assessment and recommendations regarding food preferences and nutritional support.5 pound/day. Dietitians have a greater understanding of the nutritional value of foods and may be helpful in assessing specific ethnic or cultural foods (e. kosher foods). • Encourage patient participation in recording food intake using a daily log. at their desk.

• • For patients with changes in sense of taste. long-term care. and provide good oral hygiene and dentition. Either solution can be modified to provide required glucose. Feedings may be continuous or intermittent (bolus). These may decrease appetite and lead to early satiety. vitamins. encourage family to bring food from home as appropriate. or restrictions may not be able to eat hospital foods. religious preferences. • • Suggest liquid drinks for supplemental nutrition. Elevating the head of bed 30 degrees aids in swallowing and reduces risk of aspiration. • Encourage exercise. Ensure a pleasant environment. electrolytes. Fat and fat-soluble vitamins can also be administered two or three times per week. For patients with physical impairments. encourage use of seasoning.• Suggest ways to assist patient with meals as needed. • Discuss possible need for enteral or parenteral nutritional support with patient. refer to occupational therapist for adaptive devices. Education/Continuity of Care • Review and reinforce the following to patient or caregivers: 86 . protein. and caregiver as appropriate. Enteral tube feedings are preferred for patients with a functioning GI tract. as well as in the home. Attention to the social aspects of eating is important in both the hospital and home settings. and subacute care settings. facilitate proper position. Parenteral nutrition may be indicated for patients who cannot tolerate enteral feedings. and trace elements. • Provide companionship during mealtime. These feedings may be used with in-hospital. minerals. Metabolism and utilization of nutrients are enhanced by activity. Patients with specific ethnic. family. • For hospitalized patients. Discourage beverages that are caffeinated or carbonated.

small frequent meals of foods high in calories and protein)   • Provide referral to community nutritional resources such as Meals-on-Wheels or hot lunch programs for seniors as indicated. severe infections. as well as the need for specific minerals or vitamins Patients may not understand what is involved in a balanced diet. Imbalanced Nutrition: More than Body Requirements Obesity. patients with burns. Overweight NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Nutritional Status: Food and Fluid Intake Weight Control   NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Nutritional Monitoring Nutrition Counseling Weight Reduction Assistance    87 . or draining wounds may require 3000 to 4000 kcal/day Foods high in calories and protein that will promote weight gain and nitrogen balance (e. The basic four food groups.. an average adult (70 kg) needs 1800 to 2200 kcal/ day.g. Importance of maintaining adequate caloric intake.

do not estimate. disease states such as diabetes mellitus and Cushing’s syndrome. Overall nutritional requirements of elderly patients are similar to those of younger individuals. 88 . Factors that affect weight gain include genetics. Reported or observed dysfunctional eating patterns. Metabolic disorders. and cultural or ethnic influences on eating. African Americans and Hispanic individuals are more likely to be overweight than Caucasians. Patient begins an appropriate program of exercise. Ongoing Assessment • • Document weight. Determine body fat composition by skinfold measurements. Patient demonstrates appropriate selection of meals or menu planning toward the goal of weight reduction. Defining Characteristics: Weight 20% over ideal for height and frame. and shortened life expectancy.NANDA Definition: Intake of nutrients that exceeds metabolic needs Obesity is a common problem in the United States and accounts for significant other health problems including cardiovascular disease. Eating in response to external cues such as time of day or social situation Related Factors: Excessive intake in relation to metabolic need. Skin calipers can be used to estimate amount of fat. Poor dietary habits. except calories should be reduced because of their leaner body mass. and/or appropriate food preparation. sedentary lifestyle. Eating in response to internal cues other than hunger. emotional factors associated with dysfunctional eating. Use of food as coping mechanism. food intake. aggravated musculoskeletal problems. 25 mm in women. sleep disorders. Sedentary activity level Expected Outcomes: Patient verbalizes measures necessary to achieve weight reduction. Triceps skinfold greater than 15 mm in men. Lack of knowledge of nutritional needs. Patients may be unaware of their actual weight. insulin dependent diabetes. Women are more likely to be overweight than men. infertility in women.

time of day. Cultural or ethnic influences need to be identified and addressed. BMIs greater than 25 are associated with increased morbidity and mortality. • Assess ability to read food labels. • Explore the importance and meaning of food with the patient. • Assess knowledge regarding nutritional needs for height and level of activity or other factors (e. and aggravation of musculoskeletal disorders. Medical complications include cardiovascular and respiratory dysfunction. Serving sizes must be understood to limit intake according to a planned diet. intake pattern (e. When food is used as a coping mechanism or as a self-reward.g. making appropriate food selections. 89 . frequency. other activities patient does while eating). pregnancy). • Perform a nutritional assessment. Food labels contain information necessary in making appropriate selections.. In most cultures. the emotional needs being met by intake of food will need to be addressed as part of the overall plan for weight reduction. A BMI between 20 and 24 is associated with healthier outcomes. Patients may confuse routine activity with exercise necessary to enhance and maintain weight loss.. but can be misleading. This includes types and amount of food. Social complications and poor self-esteem may also result from obesity.• Calculate body mass index as a ratio of height and weight. • Assess usual level of activity. higher incidence of diabetes mellitus. Patients need to understand that "low-fat" or "fat-free" does not mean that a food item is calorie-free. eating is a social activity. how food is prepared.g. Body mass index (BMI) is the person’s weight in kilograms divided by the square of his or her height in meters. • Assess effects or complications of being overweight. • Assess ability to plan a menu. • Assess ability to accurately identify appropriate food portions.

g. odor. time. This controls environmental stimuli for eating and other impulse eating. •  Establish appropriate short. One pound of adipose tissue contains 3500 kcal..Therapeutic Interventions Consult dietitian for further assessment and recommendations regarding a weight loss program.. • Encourage water intake.g. To eat in a designated place (e. Dietitians have a greater understanding of the nutritional value of foods and may be helpful in assessing or substituting specific high-fat cultural or ethnic foods. Therefore to lose 1 pound/week. Memory is inadequate for quantification of intake.. at the table rather than in front of the television). three balanced meals a day. television viewing. Eating when not hungry is a commonly recognized symptom among overeaters.and long-range goals. and personal factors. or boredom). reading. and a visual record may also help patient to make more appropriate food choices and serving sizes. To observe for cues that lead to eating (e. Changes in eating patterns are required for weight loss. avoidance of certain high-fat foods). Water assists in the excretion of byproducts of fat breakdown and helps prevent ketosis. The type of program may vary (e. • • • • To recognize actual hunger versus desire to eat. or telephoning). To focus on eating and to avoid other diversional activities (e. depression. Diet change is a complicated process that involves changing patterns that have been firmly established by culture.. • Encourage patient to keep a daily log of food or liquid ingestion and caloric intake. the patient must have a calorie deficit of 500 kcal/day. • Encourage calorie intake appropriate for body type and lifestyle. 90 .g. Hurried eating may result in overeating because satiety is not realized until 15 to 20 minutes after ingestion of food. • Encourage patient to be more aware of nutritional habits that may contribute to or prevent overeating: To realize the time needed for eating.g. family.

caregiver. Obesity and diabetes are risk factors for coronary artery disease. 91 . Review and reinforce principles of dietary management of diabetes. Refer patient to commercial weight-loss program as appropriate. whereas others are able (and may prefer) to manage a weight-loss program independently. or food preparer in the nutrition counseling. Success rates are higher when the family incorporates a healthy eating plan. such as substituting baking and grilling for frying foods  • Include family. • Incorporate behavior modification strategies. • Remind patient that significant weight loss requires a long period. • Encourage diabetic patients to attend diabetic classes. • Inform patient about pharmacological agents such as appetite suppressants that can aid in weight loss. • • Review complications associated with obesity. Encourage successes. Multifactorial programs that include behavioral interventions and counseling are more successful than education alone. Exercise is an integral part of weight reduction programs. Some individuals require the regimented approach or ongoing support during weight loss. Education as the sole intervention is unlikely to achieve and maintain weight loss. These drugs act by chemically altering the patient’s desire to eat. Education/Continuity of Care • Review and reinforce teaching regarding the following:    Four food groups or the food pyramid Proper serving sizes Caloric content of food Many patients are unaware of the calories present in low-fat foods. The combination of diet and exercise promotes loss of adipose tissue rather than lean tissue.• Encourage exercise. assist patient to cope with setbacks. Methods of preparation. • Provide positive reinforcement as indicated.

• Refer to community support groups as indicated. Acute Pain NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Comfort Level Medication Response Pain Control    NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Analgesic Administration Conscious Sedation Pain Management Patient-Controlled Analgesia Assistance 92     .

Pain may also arise from emotional. Pain resulting from emotional.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). pain should be accepted as described by the sufferer. Pain assessment can be challenging.g. restlessness).. where cognitive impairment and sensory-perceptual deficits are more common. pulse rate.. Musculoskeletal pain. Ongoing Assessment • Assess pain characteristics:  Quality (e.g. shooting) 93 . pallor. Guarding behavior. change in respiratory rate. change in blood pressure [BP]. rigidity or tension. protecting body part. Cardiovascular pain. Alteration in muscle tone: listlessness or flaccidness. Defining Characteristics: Patient reports pain. seeking out other people or activities. psychological. cultural.. Autonomic responses (e. Facial mask of pain. crying. pupillary dilation. sharp. Relief or distraction behavior (e. especially in elderly patients. Narrowed focus (e. moaning. Pain can be very difficult to explain. Selffocused.. pacing. psychological. altered time perception. Pain resulting from diagnostic procedures or medical treatments.g. nausea) Related Factors: Postoperative pain. or spiritual distress. diaphoresis. Pain resulting from medical problems. burning.g. withdrawal from social or physical contact). Pain may be a symptom of injury or illness. or cultural distress Expected Outcomes: Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain. Obstetrical pain. Pain resulting from trauma. because it is unique to the individual. spiritual. 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 Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer.

However. environmental. temperature. emotion. Some people deny the experience of pain when it is present. intermittent or continuous) Precipitating or relieving factors     • Observe or monitor signs and symptoms associated with pain. For example. These variables may modify the patient’s expression of his or her experience. Often a combination of therapies (e. 94 . Some patients may be unaware of the effectiveness of nonpharmacological methods and may be willing to try them. • Assess to what degree cultural. mild analgesics with distraction or heat) may prove most effective. restlessness. or anxiety) the effect of pain relief measures. Attention to associated signs may help the nurse in evaluating pain. color and moisture of skin. Discrepancies between behavior or appearance and what patient says about pain relief (or lack of it) may be more a reflection of other methods patient is using to cope with than pain relief itself. health care providers should not stereotype any patient response but rather evaluate the unique response of each patient. • Assess for probable cause of pain.g. and intrapsychic factors may contribute to pain or pain relief. some cultures openly express feelings... It is important to help patients express as factually as possible (i. and ability to focus.e. with 10 being the most severe) Other methods such as a visual analog scale or descriptive scales can be used to identify extent of pain. heart rate. • Assess patient’s knowledge of or preference for the array of pain-relief strategies available. without the effect of mood. while others restrain such expression. Severity (scale of 1 to 10. either with or instead of traditional analgesic medications. Location (anatomical description) Onset (gradual or sudden) Duration (how long. Different etiological factors respond better to different therapies. • Evaluate patient’s response to pain and medications or therapeutics aimed at abolishing or relieving pain. such as BP. intrapersonal.

• • 95 . Some patients may be content to have pain decreased. • Assess appropriateness of patient as a patient-controlled analgesia (PCA) candidate: no history of substance abuse. a PCA patient becomes confused and cannot manage PCA. clear sensorium. • Assess patient’s willingness or ability to explore a range of techniques aimed at controlling pain. and no history of major psychiatric disorder. For example. This affects their perceptions of the effectiveness of the treatment modality and their willingness to participate in additional treatments. hepatic. Some patients will feel uncomfortable exploring alternative methods of pain relief. If demands are very low. patient’s dosage may need to be increased. as in relaxation breathing. patient will not receive pain medication. PCA is the intravenous (IV) infusion of a narcotic (usually morphine or Demerol) through an infusion pump that is controlled by the patient. cooperative and motivated about use. This allows the patient to manage pain relief within prescribed limits. no history of renal. may feel that the "act of suffering" meets a spiritual need.• Evaluate what the pain means to the individual. Some patients. assess the following: Pain relief The basal or lock-out dose may need to be increased to cover the patient’s pain. Intactness of IV line If the IV is not patent. others will expect complete elimination of pain. In the hospice or home setting. However. patient may require further instruction to properly use PCA. • Assess patient’s expectations for pain relief. or respiratory disease. • Monitor for changes in general condition that may herald need for change in pain relief method. manual dexterity. especially the dying. Amount of pain medication patient is requesting If demands for medication are quite frequent. • • If patient is on PCA. patients need to be informed that there are multiple ways to manage pain. or a successful modality ceases to provide adequate pain relief. a nurse or caregiver may be needed to assist the patient in managing the infusion. no allergy to narcotic analgesics. The meaning of the pain will directly influence the patient’s response.

urinary retention. • • Possible epidural analgesia complications such as excessive sedation. • Provide rest periods to facilitate comfort. or swelling Patients may also experience mild allergic response to the analgesic agent. Early intervention may decrease the total amount of analgesic required. tingling in extremities. or of improper catheter placement. respiratory distress.• Possible PCA complications such as excessive sedation. Prompt responses to complaints may result in decreased anxiety in the patient. If patient is receiving epidural analgesia. One can most effectively deal with pain by preventing it. intrapersonal. or catheter migration Respiratory depression and intravascular infusion of anesthesia (resulting from catheter migration) can be potentially lifethreatening. In a cyclic 96 ." Numbness. • Respond immediately to complaint of pain. assess the following: • Pain relief Intermittent epidurals require redosing at intervals. Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental. • Eliminate additional stressors or sources of discomfort whenever possible. respiratory distress. a metallic taste in the mouth These symptoms may be indicators of an allergic response to the anesthesia agent. Variations in anatomy may result in a "patch effect. redness. Therapeutic Interventions • Anticipate need for pain relief. In the midst of painful experiences a patient’s perception of time may become distorted. and IV site pain. sleep. marked by generalized itching or nausea and vomiting. nausea/vomiting. or intrapsychic factors are further stressing them. The patient’s experiences of pain may become exaggerated as the result of fatigue. constipation. and relaxation. Demonstrated concern for patient’s welfare and comfort fosters the development of a trusting relationship. urinary retention.

A quiet environment. Some methods are breathing modifications and nerve stimulation. Nonpharmacological methods include the following: IV. systemically by patient-controlled analgesia (PCA) systems. intramuscularly. The goal of these techniques is to reduce tension. II. Cutaneous stimulation as follows:   97 . which may result in exaggerated pain and exhaustion. III. Biofeedback. music therapy Massage of affected area when appropriate Massage decreases muscle tension and can promote comfort. especially in the hospice or home setting. Narcotics are indicated for severe pain. subcutaneously. Transcutaneous electrical nerve stimulation (TENS) units    V. a darkened room. or epidurally (either by bolus or continuous infusion). ketorolac is the only available parenteral NSAID). Distraction techniques Heighten one’s concentration upon nonpainful stimuli to decrease one’s awareness and experience of pain. intravenously. breathing exercises. and a disconnected phone are all measures geared toward facilitating pain may result in fatigue. Local anesthetic agents. Relaxation exercises Techniques are used to bring about a state of physical and mental awareness and tranquility. Nonsteroidal antiinflammatory drugs (NSAIDs) that may be administered orally or parenterally (to date. Cognitive-behavioral strategies as follows:  Imagery The use of a mental picture or an imagined event involves use of the five senses to distract oneself from painful stimuli. • Determine the appropriate pain relief method. Pharmacological methods include the following: I. subsequently reducing pain. Use of opiates that may be administered orally.

so their effectiveness must be evaluated from patient to patient. epidural catheter. Analgesics may cause side effects that range from mild to life-threatening. • Give analgesics as ordered. Pain medications are absorbed and metabolized differently by patients.g. Patients who request pain medications at more frequent intervals than prescribed may actually require higher doses or more potent analgesics.. • Notify physician if interventions are unsuccessful or if current complaint is a significant change from patient’s past experience of pain. these drugs reverse the narcotic effect. reassure patient that pain is time-limited and that there is more than one approach to easing pain. 98 . For patients with PCA or epidural analgesia: • Keep Narcan or other narcotic-reversing agent readily available. When pain is perceived as everlasting and unresolvable. moist compresses have a penetrating effect. In the event of respiratory depression. consult pharmacist before mixing drug with narcotic being infused. • Whenever possible. thereby promoting comfort. If patient is on PCA: Dedicate use of IV line for PCA only. If patient is receiving epidural analgesia:  • Label all tubing (e. evaluating effectiveness and observing for any signs and symptoms of untoward effects. IV incompatibilities are possible. patient may give up trying to cope with or experience a sense of hopelessness and loss of control. IV tubing to epidural catheter) clearly to prevent inadvertent administration of inappropriate fluids or drugs into epidural space. The warmth rushes blood to the affected area to promote healing. Hot or cold compress Hot. Cold compresses may reduce total edema and promote some numbing.

Post "No additional analgesia" sign over bed. This prevents inadvertent analgesic overdosing.

Education/Continuity of Care

Provide anticipatory instruction on pain causes, appropriate prevention, and relief measures.

• • • •

Explain cause of pain or discomfort, if known. Instruct patient to report pain. Relief measures may be instituted. Instruct patient to evaluate and report effectiveness of measures used. Teach patient effective timing of medication dose in relation to potentially uncomfortable activities and prevention of peak pain periods. For patients on PCA or those receiving epidural analgesia:

• •

Teach patient preoperatively. Anesthesia effects should not obscure teaching. Teach patient the purpose, benefits, techniques of use/action, need for IV line (PCA only), other alternatives for pain control, and of the need to notify nurse of machine alarm and occurrence of untoward effects.


Chronic Pain
NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Pain Control Quality of Life Family Coping

  

NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Pain Management Medication Management Acupressure Heat/Cold Application Progressive Muscle Relaxation Transcutaneous Electrical Nerve Stimulation (TENS) Simple Massage

      

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


Chronic pain may be classified as chronic malignant pain or chronic nonmalignant pain. In the former, the pain is associated with a specific cause such as cancer. With chronic nonmalignant pain the original tissue injury is not progressive or has been healed. Identifying an organic cause for this type of chronic pain is more difficult. Chronic pain differs from acute pain in that it is harder for the patient to provide specific information about the location and the intensity of the pain. Over time it becomes more difficult for the patient to differentiate the exact location of the pain and clearly identify the intensity of the pain. The patient with chronic pain often does not present with behaviors and physiological changes associated with acute pain. Family members, friends, coworkers, employers, and health care providers question the legitimacy of the patient’s pain complaints because the patient may not look like someone in pain. The patient may be accused of using pain to gain attention or to avoid work and family responsibilities. With chronic pain, the patient’s level of suffering usually increases over time. Chronic pain can have a profound impact on the patient’s activities of daily living, mobility, activity tolerance, ability to work, role performance, financial status, mood, emotional status, spirituality, family interactions, and social interactions. Defining Characteristics: Weight changes, Verbal or coded report or observed evidence of protective behavior, guarding behavior, facial mask, irritability, self-focusing, restlessness, depression, Atrophy of involved muscle group, Changes in sleep pattern, Fatigue, Fear of reinjury, Reduced interaction with people, Altered ability to continue previous activities, Sympathetic mediated responses (e.g., temperature, cold, changes of body position, hypersensitivity), Anorexia Related Factors: Chronic physical or psychosocial disability Expected Outcomes : Patient verbalizes acceptable level of pain relief and ability to engage in desired activities. Ongoing Assessment

Assess pain characteristics:

Quality (e.g., sharp, burning) 101

continuous. anxiety. The patient with chronic pain may not expect complete absence of pain. irritability. but may be satisfied with decreasing the severity of the pain and increasing activity level. Pulse and blood pressure are usually within normal ranges. Understanding the variables that affect the patient’s pain experience can be useful in developing a plan of care that is acceptable to the patient. • Assess the patient’s expectations about pain relief. and religious factors that may influence the patient’s pain experience and response to pain relief. societal. intermittent) Aggravating factors Relieving factors Gathering information about the pain can provide information about the extent of the chronic pain. or depression. restlessness. • Evaluate gender. weight loss. The patient often looks tired with a drawn facial expression that lacks animation. Patients with chronic pain have a long history of using many pharmacological and nonpharmacological methods to control their pain. • Assess the patient’s perception of the effectiveness of methods used for pain relief in the past. sleep pattern disturbance.. 102 . cultural. Patients with chronic pain may not exhibit the physiological changes and behaviors associated with acute pain. The guarding behavior of acute pain may become a persistent change in body posture for the patient with chronic pain. changes in body posture.      Severity (1 to 10 scale) Anatomical location Onset Duration (e.g. Coping with chronic pain can deplete the patient’s energy for other activities. • Assess for signs and symptoms associated with chronic pain such as fatigue. decreased appetite.

Therapeutic Interventions • Encourage the patient to keep a pain diary to help in identifying aggravating and relieving factors of chronic pain. assess for side effects. instrumental activities of daily living (IADLs). Knowledge about factors that influence the pain experience can guide the patient in making decisions about lifestyle modifications that promote more effective pain management. dependency. Patients may question the effectiveness of nonpharmacological interventions and see medications as the only treatment for pain. Conveying acceptance of the patient’s pain promotes a more cooperative nurse-patient relationship.• Assess the patient’s attitudes toward pharmacological and nonpharmacological methods of pain management. • Provide the patient and family with information about chronic pain and options available for pain management. and tolerance. The patient may begin to feel confident about the effectiveness of these interventions. • Assess the patient’s ability to accomplish activities of daily living (ADLs). Fatigue. • For patients taking opioid analgesics. • Assist the patient in making decisions about selecting a particular pain management strategy. and depression associated with chronic pain can limit the person’s ability to complete self-care activities and fulfill role responsibilities. 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. The patient may have had negative experiences in the past with attitudes of health care providers toward the patient’s pain experience. Guidance and support from the nurse can increase the patient’s willingness to choose new interventions to promote pain relief. Drug dependence and tolerance to opioid analgesics is a concern in the longterm management of chronic pain. anxiety. and demands of daily living (DDLs). • Acknowledge and convey acceptance of the patient’s pain experience. 103 .

Guided imagery can help the patient explore images about pain. Massage of the painful area Massage interrupts pain transmission. and music These centrally acting techniques for pain management work through reducing muscle tension and stress. and therapies to promote relaxation of tense muscles. Heat applications should last no more than 20 min/hr. This intervention requires no special equipment and can be cost effective. Progressive relaxation. imagery. These techniques require practice to be effective. Cold applications should last about 20 to 30 min/hr. and healing. The patient may feel an increased sense of control over his/her pain. It should be used for a short duration. and decreases tissue edema. inflammation. and muscle spasticity by decreasing the release of pain-inducing chemicals and slowing the conduction of pain impulses. This intervention may require another person to provide the massage.• Refer the patient to a physical therapist for evaluation. increases endorphin levels. usually less than 2 hours at a time. 104 . This is a cost-effective intervention that requires no special equipment. The physical therapist can help the patient with exercises to promote muscle strength and joint mobility. Heat applications Heat reduces pain through improved blood flow to the area and through reduction of pain reflexes. Distraction Distraction is a temporary pain management strategy that works by increasing the pain threshold. Special attention needs to be given to preventing burns with this intervention. These interventions can contribute to effective pain management. Education/Continuity of Care • Teach the patient and family about using nonpharmacological pain management strategies: Cold applications Cold reduces pain. pain relief. Many health insurance programs will not reimburse for the cost of therapeutic massage.

Acupressure Acupressure involves finger pressure applied to acupressure points on the body. Transcutaneous Electrical Nerve Stimulation (TENS) TENS requires the application of 2 to 4 skin electrodes. Nausea. Pain reduction occurs through a mild electrical current. They work in peripheral tissues by inhibiting the synthesis of prostaglandins that cause pain. Knowledge about how to implement nonpharmacological pain management strategies can help the patient and family gain maximum benefit from these interventions. constipation. In addition to their effects on the patient’s mood. tolerance. The side effects associated with this group of drugs tend to be more significant that those with the NSAIDs. the antidepressants may have analgesic properties apart from their antidepressant actions. • Teach the patient and family about the use of pharmacological interventions for pain management: Nonsteroidal antiinflammatory agents (NSAIDs) These drugs are the first step in an analgesic ladder. vomiting. The patient is able to regulate the intensity and frequency of the electrical stimulation. 105 . sedation. Using the gate control theory." This approach requires training and practice. respiratory depression. the technique works to interrupt pain transmission by "closing the gate. inflammation.Prolonged use can add to fatigue and increased pain when the distraction is no longer present. and dependency are of concern in patients using these drugs for chronic pain management. The advantages of these drugs are they can be taken orally and are not associated with dependency and addiction. Anti-depressants These drugs may be useful adjuncts in a total program of pain management. and edema. Opioid analgesics These drugs act on the central nervous system to reduce pain by binding with opiate receptors throughout the body.

Providing the patient and family with ongoing support and guidance will increase the success of these strategies. In addition to their effects on the patient’s mood. • Assist the patient and family in identifying lifestyle modifications that may contribute to effective pain management. Adding to the patient’s network of social support can reduce the burden of suffering associated with chronic pain and provide additional resources. Changes in work routines. Self-Care Deficit Bathing/Hygiene. and the home physical environment may be needed to promote more effective pain management. the antidepressants may have analgesic properties apart from their antidepressant actions. • Refer the patient and family to community support groups and self-help groups for people coping with chronic pain. Feeding. Dressing/Grooming. Toileting NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Self-Care: Eating Self-Care: Bathing Self-Care: Dressing Self-Care: Grooming Self-Care: Hygiene Self-Care: Toileting       NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels 106 .Antianxiety agents These drugs may be useful adjuncts in a total program of pain management. household responsibilities.

The nurse coordinates services to maximize the independence of the patient and to ensure that the environment that the patient lives in is safe and supportive of his or her special needs. or the result of progressive deterioration that erodes the individual’s ability or willingness to perform the activities required to care for himself or herself. Inability to perform miscellaneous common tasks such as telephoning and writing Related Factors: Neuromuscular impairment. Inability to bathe and groom self independently. Decreased motivation. impaired mobility or transfer ability. 107 . Musculoskeletal disorder such as rheumatoid arthritis.      Self-Care Assistance: Bathing/Hygiene Self-Care Assistance Dressing/Grooming Self-Care Assistance: Feeding Self-Care Assistance: Toileting Environment Management NANDA Definition: Impaired ability to perform or complete activities of daily living. bathing. such as feeding. secondary to cerebrovascular accident (CVA). Careful examination of the patient’s deficit is required in order to be certain that the patient is not failing at self-care because of a lack in material resources or a problem with arranging the environment to suit the patient’s physical limitations. Energy deficit. Inability to ambulate independently. toileting The nurse may encounter the patient with a self-care deficit in the hospital or in the community. The deficit may be the result of transient limitations. Severe anxiety. Inability to perform toileting tasks independently. Pain. such as those one might experience while recuperating from surgery. Inability to transfer from bed to wheelchair. Environmental barriers. dressing. Defining Characteristics: Inability to feed self independently. Cognitive impairment. Inability to dress self independently.

Expected Outcomes: Patient safely performs (to maximum ability) self-care activities. Resources are identified which are useful in optimizing the autonomy and independence of the patient. Ongoing Assessment

Assess ability to carry out ADLs (e.g., feed, dress, groom, bathe, toilet, transfer, and ambulate) on regular basis. Determine the aspects of self care that are problematic to the patient. The patient may only require assistance with some self-care measures.

Assess specific cause of each deficit (e.g., weakness, visual problems, cognitive impairment). Different etiological factors may require more specific interventions to enable self-care.

Assess patient’s need for assistive devices. This increases independence in ADLs performance. Assess for need of home health care after discharge. Shortened hospital stays mean that patients are more debilitated on discharge from the hospital, and that patients need more assistance after discharge.

Identify preferences for food, personal care items, and other things. These support patient’s individual and personal preferences.

Therapeutic Interventions

Assist patient in accepting necessary amount of dependence. If disease, injury, or illness resulting in self-care deficit is recent, patient may need to grieve before accepting that dependence is possible.

Set short-range goals with patient. Assisting the patient to set realistic goals will decrease frustration.

Encourage independence, but intervene when patient cannot perform. An appropriate level of assistive care can prevent injury with activities without causing frustration.


Use consistent routines and allow adequate time for patient to complete tasks. This helps patient organize and carry out self-care skills.

Provide positive reinforcement for all activities attempted; note partial achievements. This provides the patient with an external source of positive reinforcement. Feeding:

Encourage patient to feed self as soon as possible (using unaffected hand, if appropriate). Assist with setup as needed. It is probable that the dominant hand will also be the affected hand if there is upper extremity involvement.

Ensure that patient wears dentures and eyeglasses if needed. Deficits may be exaggerated if other senses or strengths are not functioning optimally.

Assure that consistency of diet is appropriate for patient’s ability to chew and swallow, as assessed by speech therapist. Mechanical problems may prohibit the patient from eating.

Provide patient with appropriate utensils (e.g., drinking straw, food guard, rocking knife, nonskid place mat) to aid in self-feeding. These items increase opportunities for success.

Place patient in optimal position for feeding, preferably sitting up in a chair; support arms, elbows, and wrists as needed.

Consider appropriate setting for feeding where patient has supportive assistance yet is not embarrassed. Embarrassment or fear of spilling food on self may hinder patient’s attempts to feed self.

If patient has visual problems, advise the patient of the placement of food on the plate. Following CVA, patients may have unilateral neglect, and may ignore half the plate. Dressing/grooming:


Provide privacy during dressing. Patients may take longer to dress and may be fearful of breaches in privacy.

Provide frequent encouragement and assistance as needed with dressing. These reduce energy expenditure and frustration.

• •

Plan daily activities so patient is rested before activity. Provide appropriate assistive devices for dressing as assessed by nurse and occupational therapist. The use of a button hook or of loop and pile closures on clothes may make it possible for a patient to continue independence in this self-care activity.

Place the patient in wheelchair or stationary chair. This assists with support when dressing. Dressing can be fatiguing.

• • • •

Encourage use of clothing one size larger. This ensures easier dressing and comfort. Suggest front-opening brassiere and half slips. These may be easier to manage. Suggest elastic shoelaces or loop and pile closures on shoes. These eliminate tying. Provide makeup and mirror; assist as needed. Fine motor activities may take more coordinated actions and may be beyond the abilities of the patient. Bathing/hygiene:

Maintain privacy during bathing as appropriate. The need for privacy is fundamental for most patients.

• •

Ensure that needed utensils are close by. This conserves energy and optimizes safety. Instruct patient to select bath time when he or she is rested and unhurried. Hurrying may result in accidents and the energy required for these activities may be substantial.

Provide patient with appropriate assistive devices (e.g., long-handled bath sponge; shower chair; safety mats for floor; grab bars for bath or shower). These aid in bed bathing.


Suggest hairstyles that are low-maintenance. 111 . institute a toileting schedule that factors these habits into the program. This eliminates incontinence. The effectiveness of the bowel or bladder program will be enhanced if the natural and personal patterns of the patient are respected.• Encourage patient to comb own hair (a one-handed task). Some patients find it impossible to toilet on a bedpan. • Encourage patient to perform minimal oral-facial hygiene as soon after rising as possible. Clothing that is difficult to get in and out of may compromise a patient’s ability to be continent. This enables the patient to maintain autonomy for as long as possible. This enables staff members to have time to assist with transfer to commode or toilet. Patients often have difficulty seeing progress. Patients may require podiatric care to prevent injury to feet during nail trimming or because special implements are required to cut nails. • Offer frequent encouragement. Lack of privacy may inhibit the patient’s ability to evacuate bowel and bladder. • Assist patient in removing or replacing necessary clothing. Toileting: • Evaluate or document previous and current patterns for toileting. • Keep call light within reach and instruct patient to call as early as possible. Time intervals can be lengthened as the patient begins to express the need to toilet on demand. Patients are more effective in evacuating bowel and bladder when sitting on a commode. • Offer bedpan or place patient on toilet every 1 to 1½ hours during day and three times during night. • Assist patient with care of fingernails and toenails as required. as needed. • Provide privacy while patient is toileting. Assist with brushing teeth and shaving. • Encourage use of commode or toilet as soon as possible.

Keep commode and toilet tissue near the bedside for nighttime use. This may cause caregiver to lose balance and fall. and each of these factors must be considered when developing/teaching a patient a new system for self-care. Fatigued patients may have more difficulty and may become unnecessarily frustrated. When patient is sitting up at side of bed. 112 . pressure sores.   This prevents disabling contractures. Patient will weight-bear on the stronger side. It will take time for the patient to learn and then gain confidence in his or her ability to perform these new self-care measures. • Assist with bed mobility by doing the following:  Encourage patient to use the stronger side (if appropriate) as best as possible. Many factors may influence a patient’s ability to move freely. Allow patient to work at own rate of speed. and muscle weakness from disuse. Tasks require energy. always place chair on patient’s stronger side at slight angle to bed and lock brakes.• Closely monitor patient for loss of balance or fall. therefore it will be necessary for them to develop muscle strength and coordination on the stronger side. Patients may rush readiness to ambulate to the toilet or commode during the night because of fear of soiling themselves and may fall in the process. • When transferring to wheelchair. Transferring/ambulation: • Plan teaching session for transferring/walking when patient is rested. instruct him or her not to pull on caregiver. Stroke patients experience weakness in their dominant side.

to prevent back strain. and crutches:   Stand on patient’s weak side. Evaluate need for splint on writing hand. • Encourage maximum independence. The patient’s ability to perform self-care measures may change often over time and will need to be assessed regularly. This forces patient to keep his or her weight forward. place caregiver’s arms under both armpits with caregiver’s hands on patient’s back. Miscellaneous skills: • Telephone: Evaluate need for adaptive equipment through therapy department (e. place cane in patient’s strong hand and ensure proper foot-cane sequence. • Assist with ambulation.g. teach the use of ambulation devices such as canes.• When minimal assistance is needed. pushbutton phone. grasp patient around waist with both arms. (CAREGIVER: Keep your feet well apart. • For maximum assistance. This enhances patient safety. encourage patient to put weight on strong side. and pull him or her forward. • Writing: Supply patient with felt-tip pens. reevaluate regularly to be certain that the patient is maintaining skill level and remains safe in environment. walkers. increased volume). • Provide supervision for each activity until patient performs skill competently and is safe in independent care. This assists in holding the writing device. place right knee against patient’s strong knee. If using cane. These mark with little pressure and are easier to use.) • For moderate assistance. This assists with balance and support. larger numbers. stand on patient’s weak side and place nurse’s hand under patient’s weak arm. lift with legs. 113 .. This stance maximizes patient support while protecting the care provider from back injury. Patients will require an effective tool for communicating needs from home. not back.

the normal loss of elasticity. Teach family and caregivers to foster independence and to intervene if the patient becomes fatigued. Pressure Ulcers. Bed Sores. This demonstrates caring and concern but does not interfere with patient’s efforts to achieve independence.Education/Continuity of Care • • • Plan teaching sessions so patient has time to practice tasks. is unable to perform task. Instruct patient in use of assistive devices as appropriate. or becomes excessively frustrated. shear. and friction. inadequate 114 . Decubitus Care NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Risk Control Risk Detection Tissue Integrity: Skin and Mucous Membranes    NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Pressure Ulcer Prevention Skin Surveillance   NANDA Definition: At risk for skin being adversely altered Immobility. is the factor most likely to put an individual at risk for altered skin integrity. which leads to pressure. Advanced age. Risk for Impaired Skin Integrity Pressure Sores.

be free of impairment (scratches. Areas where skin is stretched tautly over bony prominences are at higher risk for breakdown because the possibility of ischemia to skin is high as a result of 115 .nutrition.g. environmental moisture. excoriation. Environmental moisture. elbows. Edema. and vascular insufficiency potentiate the effects of pressure and hasten the development of skin breakdown. Pressure relief and pressure reduction devices for the prevention of skin breakdown include a wide range of surfaces. Incontinence . Risk Factors: Extremes of age. and have quick capillary refill (<6 seconds). Altered sensation. Ongoing Assessment • Determine age. especially from incontinence.. even though costs related to treatment once breakdown occurs are greater. and those who have altered sensation that triggers the normal protective weight shifting. scapulae. feel warm and dry to the touch. but should have good turgor (an indication of moisture). Poor nutrition. Pronounced bony prominences. Elderly patients’ skin is normally less elastic and has less moisture. • Assess general condition of skin. Immobility. Expected Outcomes: Patient’s skin remains intact. Healthy skin varies from individual to individual. rashes). and other devices. inner and outer knees. specialty beds and mattresses. back of head). Hyperthermia or hypothermia. heels. friction). inner and outer malleolus. • Specifically assess skin over bony prominences (e. making for higher risk of skin impairment. Acquired immunodeficiency syndrome (AIDS). sacrum.g. those who are confined to bed or wheelchair for prolonged periods of time. Groups of persons with the highest risk for altered skin integrity are the spinal cord injured. pressure. Preventive measures are usually not reimbursable. Poor circulation. as evidenced by no redness over bony prominences and capillary refill less than 6 seconds over areas of redness.. trochanters. those with edema. History of radiation. shear. Mechanical forces (e. bruises.

because of their immunocompromise. patients with AIDS often have skin breakdown. Normally.compression of skin capillaries between a hard surface (e. • Assess for environmental moisture (e. chair. and ultimately.. additionally. Research has shown that patients whose serum albumin is less than 2.. skin ischemia. Radiated skin becomes thin and friable.g. weight loss. mattress. even during sleep.g. Moisture may contribute to skin maceration. • Assess patient’s awareness of the sensation of pressure. • Assess patient’s nutritional status. and serum albumin levels. • Assess for history of radiation therapy. Patients who spend the majority of time on 116 . or table) and the bone. turn over in bed. An albumin level less than 2.g.. The urea in urine turns into ammonia within minutes and is caustic to the skin. shift weight while sitting. and is at higher risk for breakdown. • Assess for history or presence of AIDS. This results in prolonged pressure on skin capillaries. cushion for persons in wheelchairs). Kaposi’s sarcoma). • Assess for edema.g. • Assess patient’s ability to move (e.5 g/dl are at high risk for skin breakdown. all other factors being equal.5 g/dl is a grave sign. may have less blood supply. Immobility is the greatest risk factor in skin breakdown. Early manifestations of HIV-related diseases may include skin lesions (e. Skin stretched tautly over edematous tissue is at risk for impairment. indicating severe protein depletion. individuals shift their weight off pressure areas every few minutes. including weight. move from bed to chair).g. Patients with decreased sensation are unaware of unpleasant stimuli (pressure) and do not shift weight. • Assess for fecal and/or urinary incontinence. wound drainage. this occurs more or less automatically.. Stool may contain enzymes that cause skin breakdown.. mattress for bedridden patient. • Assess surface that patient spends majority of time on (e. Use of diapers and incontinence pads with plastic liners traps moisture and hastens breakdown. high humidity).

Kinair) or air-fluidized therapy (Clinitron. A false sense of security with the use of these mattresses can delay initiation of devices useful in relieving pressure. at least 5 inches thick) foam mattress overlay Egg crate mattresses less than 4 to 5 inches thick do not relieve pressure. The incidence and onset of skin breakdown is directly related to the number of risk factors present. restricting time in one position to 2 hours or less and customizing the schedule to patient’s routine and caregiver’s needs. • Reassess skin often and whenever the patient’s condition or treatment plan results in an increased number of risk factors. For high-risk patients or those with existing stage III or IV pressure sores (or with stage II pressure sores and multiple risk factors): low-air-loss beds (Mediscus. Common causes of friction include the patient rubbing heels or elbows against bed linen. Encourage implementation of pressure-relieving devices commensurate with degree of risk for skin impairment: • For low-risk patients: good-quality (dense. • Assess amount of shear (pressure exerted laterally) and friction (rubbing) on patient’s surface need a pressure reduction or pressure relief device to distribute pressure more evenly and lessen the risk for breakdown. a waterbed is a good alternative. A common cause of shear is elevating the head of the patient’s bed: the body’s weight is shifted downward onto the patient’s sacrum. A schedule that does not interfere with the patient’s and caregivers’ activities is most likely to be followed. Therapeutic Interventions • If patient is restricted to bed:  Encourage implementation and posting of a turning schedule. • For moderate risk patients: water mattress. and moving the patient up in bed without the use of a lift sheet. static or dynamic air mattress In the home. moisture can be trapped. Skytron) Low-air-loss beds are constructed to allow • 117 . Flexicare. because they are made of foam.

These measures reduce shearing forces on the skin. Leaving them intact maintains the skin’s natural function as barrier to pathogens while the impaired area below the blister heals. • • Encourage patient and/or caregiver to maintain functional body alignment. especially over bony prominences. 118  . Patients with limited cardiovascular reserve may not be able to tolerate this much fluid. or applying a hydrocolloid (Duoderm. If powder is desirable. Fluid intake of 2000 ml/day unless medically restricted. These should be used when pulmonary concerns necessitate elevating HOB or when getting patient up is feasible. use medical-grade cornstarch. The pressure necessary to close skin capillaries is around 32 mm Hg. Limit chair sitting to 2 hours at any one time. Education/Continuity of Care Consult dietitian as appropriate. Sween-Appeal) or a vapor-permeable membrane dressing (Op-Site. • Encourage adequate nutrition and hydration:   2000 to 3000 kcal/day (more if increased metabolic demands). Blisters are sterile natural dressings. Increase tissue perfusion by massaging around affected area. "Air-fluidized" therapy supports patient’s weight at well below capillary closing pressure but restricts getting patient out of bed easily. Massaging reddened area may damage skin further. Hydrated skin is less prone to breakdown. avoid talc. and moisturize skin. • Encourage use of lift sheets to move patient in bed and discourage patient or caregiver from elevating HOB repeatedly. Pressure over sacrum may exceed 100 mm Hg pressure during sitting.elevated head of bed (HOB) and patient transfer. • • Encourage ambulation if patient is able. Tegaderm). twice daily or as indicated by incontinence or sweating. dry. any pressure greater than 32 mm Hg results in skin ischemia. • Clean. • Leave blisters intact by wrapping in gauze.

turning. especially over bony prominences Incontinence Poor nutrition Shearing or friction against skin • Reinforce the importance of mobility. or ambulation in prevention of pressure ulcers.• Teach patient and caregiver the cause(s) of pressure ulcer development:     Pressure on skin. • Teach patient or caregiver the proper use and maintenance of pressure-relieving devices to be used at home. Disturbed Sleep Pattern Insomnia NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels 119 .

and wakefulness. or emotional problems such as depression or anxiety. These patients experience sleep disturbance secondary to the noisy. The amount of sleep that individuals require varies with age and personal characteristics. acute illness. This care plan focuses on general disturbances in sleep patterns and does not address organic problems such as narcolepsy or sleep apnea. Sleep patterns can be affected by environment. jet lag. Such sleep disturbance is a significant stressor in the intensive care unit (ICU) and can affect recovery. Awakening earlier or later than desired. especially in hospital critical care units. Verbal complaints of not feeling rested. Such disruptions may result in both subjective distress and apparent impairment in functional abilities. alcohol ingestion. periodic suspension of consciousness) amount and quality Sleep is required to provide energy for physical and mental activities. bright environment. In general the demands for sleep decrease with age. night-shift rotations that change one’s circadian rhythms. consisting of different stages of consciousness: rapid eye movement (REM) sleep. and frequent monitoring and treatments. Elderly patients sleep less during the night. Other factors that can affect sleep patterns include temporary changes in routines such as in traveling. The sleep-wake cycle is complex. Disruption in the individual’s usual diurnal pattern of sleep and wakefulness may be temporary or chronic. but may take more naps during the day to feel rested. 120 . Interrupted sleep. sharing a room with another. Defining Characteristics: Verbal complaints of difficulty falling asleep. As persons age the amount of time spent in REM sleep diminishes. nonrapid eye movement (NREM) sleep. Restlessness. use of medications (especially hypnotic and antianxiety drugs).  Anxiety Control Sleep NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Sleep Enhancement  NANDA Definition: Time-limited disruption of sleep (natural.

Altered mental status.. For short-term problems. Excessive or inadequate stimulation.g.g.. • Assess patient’s perception of cause of sleep difficulty and possible relief measures to facilitate treatment. urinary frequency) and/or psychological (e. verbalization of feeling rested. aids. Altered facial expression (e. Expected Outcomes: Patient achieves optimal amounts of sleep as evidenced by rested appearance... Often. Knowledge of its role in health/wellness and the wide variation among individuals may allay anxiety. and interfering agents. • Document nursing or caregiver observations of sleeping and wakeful behaviors. length. fear over results of a diagnostic test. anxiety) circumstances that interrupt sleep. Sleep patterns are unique to each individual.. positions.Irritability. Environmental changes. depth. thereby promoting rest and sleep.g. Normal changes associated with aging. In both the hospital and home care settings. blank look. patients may have insight into the etiological factors of the problem (e. Considerable confusion and myths about sleep exist. Depression. Record number of sleep hours. Knowing the specific etiological factor will guide appropriate therapy. noise. Difficulty in arousal.g. Ongoing Assessment • Assess past patterns of sleep in normal environment: amount. patients may be following medication schedules that require 121 . fatigued appearance) Related Factors: Pain/discomfort.g. Change in activity level. the patient’s perception of the problem may differ from objective evaluation. dyspnea. Medications. and improvement in sleep pattern. hypoxia. Anxiety/fear. • Evaluate timing or effects of medications that can disrupt sleep. depression over the loss of a loved one). Abnormal physiological status or symptoms (e. Dozing. Note physical (e. • Identify factors that may facilitate or interfere with normal patterns. or neurological dysfunction). Yawning. pain or discomfort. fear. concern over a daughter getting divorced. bedtime rituals.

• Instruct to avoid large fluid intake before bedtime. gastric digestion and stimulation from caffeine and nicotine can disturb sleep. Milk contains L-tryptophan. warm bath. Suggest use of earplugs or eye shades as appropriate. relaxation exercises).. darkness.g. closed door). however. • Instruct to avoid heavy meals. • Increase daytime physical activities as indicated. or smoking before retiring.. which facilitates sleep. and reduces the energy required for adaptation to changes. • Suggest engaging in a relaxing activity before retiring (e. Napping can disrupt normal sleep patterns. Overfatigue may cause insomnia.g. ventilation. Instruct to avoid strenuous activity before bedtime. • Suggest use of soporifics such as milk. Though hunger can also keep one awake. quiet.awakening in the early morning hours. This reduces stress and promotes sleep. This promotes regulation of the circadian rhythm. caffeine. This helps patients who otherwise may need to void during the night. alcohol. • Recommend an environment conducive to sleep or rest (e. elderly patients do better with frequent naps during the day to counter their shorter nighttime sleep schedules. calm music. reading an enjoyable book. Attention to changes in the schedule or changes to once-a-day medication may solve the problem. comfortable temperature. • Discourage pattern of daytime naps unless deemed necessary to meet sleep requirements or if part of one’s usual pattern. 122 . Therapeutic Interventions • Instruct patient to follow as consistent a daily schedule for retiring and arising as possible.

Medications that suppress REM sleep should be avoided. 123 . back rub. Planning a designated time during the next day to address these concerns may provide permission to "let go" of the worries at bedtime. The bed should not be associated with wakefulness. This promotes minimal interruption in sleep or rest. pain relief. Experimental studies have indicated that 60 to 90 minutes are needed to complete one sleep cycle. use of hypnotic medications should be thoughtfully considered and avoided if less aggressive means are effective. • Organize nursing care:   Eliminate nonessential nursing activities. suggest getting out of bed and engaging in a relaxing activity.. These aids promote rest. Post a "Do not disturb" sign on the door. Different drugs are prescribed depending on whether the patient has trouble falling asleep or staying asleep.• Explain the need to avoid concentrating on the next day’s activities or on one’s problems at bedtime. Obviously. • If unable to fall asleep after about 30 to 45 minutes. and the completion of an entire cycle is necessary to benefit from sleep. • • Move patient to room farther from the nursing station if noise is a contributing factor. Prepare patient for necessary anticipated interruptions/disruptions. this will interfere with inducing a restful state. bedtime care. evaluate effectiveness. • Attempt to allow for sleep cycles of at least 90 minutes. comfortable position. For patients who are hospitalized: • Provide nursing aids (e. • Suggest using hypnotics or sedatives as ordered. relaxation techniques). Because of their potential for cumulative effects and generally limited period of benefit.g.

are especially at high risk for ineffective management of the therapeutic plan. financial limitations.g. and are faced with increasing complex therapeutic regimens to be handled in the home environment. poverty.. depression over the illness being treated or other life crises or problems).Education/Continuity of Care • • Teach about possible causes of sleeping difficulties and optimal ways to treat them.g. patients are being expected to be comanagers of their care. and patients with substance abuse problems. Likewise. ethnicity. unemployment. patients with chronic illness often have limited access to health care providers and are expected to assume responsibility for managing the nuances of their disease (e. altered cognition.. Other vulnerable populations include patients living in adverse social conditions (e. Ineffective Therapeutic Regimen Management NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Self-Modification Assistance Teaching: Individual   NANDA Definition: Pattern of regulating and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals With the ongoing changes in health care. and religion may influence one’s 124 . Culture. and those lacking support systems may find themselves overwhelmed and unable to follow the treatment plan. Instruct on nonpharmacological sleep enhancement techniques. They are being discharged from hospitals earlier. who often experience most of the above problems. Patients with sensory-perception deficits.g. Elderly patients. heart failure patients taking an extra furosemide [Lasix] tablet for a 2-pound weight gain).. little education). patients with emotional problems (e.

factors such as cultural phenomena and heritage can affect how people view their health. Expected Outcomes: Patient describes intention to follow prescribed regimen. Patient identifies appropriate resources. This may range from financial constraints to physical limitations. Excessive demands made on individual or family. Social support deficits. patient’s perceived susceptibility to and perceived seriousness and threat of disease affect his or her compliance with the program. In addition. Ongoing Assessment • • Assess prior efforts to follow regimen. Inadequate number and types of cues to action. Assess for related factors that may negatively affect success with following regimen. Complexity of therapeutic regimen. Family patterns of health care.. Perceived seriousness. Knowledge deficit of prescribed regimen. Patient describes or demonstrates required competencies. and assertiveness in pursuing specific health care services. folk medicine. Defining Characteristics: Choices of daily living ineffective for meeting the goals of treatment or prescription program. • Assess patient’s confidence in his or her ability to perform desired behavior. positive conviction that one can successfully execute a behavior is correlated with performance and successful outcome. 125 . According to the Health Belief Model. Perceived powerlessness. • Assess patient’s individual perceptions of his or her health problems. Family beliefs. Related Factors: Complexity of health care. access to health services. Knowledge of causative factors provides direction for subsequent intervention. Increased illness. Verbalized desire to manage illness. Verbalized difficulty with prescribed regimen. Verbalization by patient that he or she did not follow prescribed regimen. Perceived barriers. health practices (e. Economic difficulties. Decisional conflicts. Perceived susceptibility. According to the self-efficacy theory. alternative therapies).

They know best their personal and environmental barriers to success. child care). Patients with arthritis may be unable to open child-proof pill containers.. Patients with limited financial resources may be unable to purchase special diet foods such as those low in fat or low in salt. Once identified. the greater the risk of not following through.• Assess patient’s ability to learn or remember the desired health-related activity. the financial costs incurred (loss of day’s work. can be instituted. or daily phone reminders. • Inform patient of the benefits of adherence to prescribed regimen. taking diuretics at dinner if working during the day). as well as the commonly long waits can cause patients to avoid follow-ups when they are required. the Mini-Mental Status Examination can be used to identify memory problems that could interfere with accurate pill taking. Patients who become comanagers of their care have a greater stake in achieving a positive outcome. Cognitive impairments need to be identified so an appropriate alternative plan can be devised. Attempt to reduce nonessential drug usage. • Simplify the regimen. Telephone follow-up may be substituted as appropriate. Therapeutic Interventions • Include patient in planning the treatment regimen. • Eliminate unnecessary clinic visits. alternative actions such as using egg cartons to dispense medications. • Tailor the therapy to patient’s lifestyle (e. The greater the number of times during the day that patients need to take medications. Suggest long-acting forms of medications and eliminate unnecessary medication. 126 . The physical demands of traveling to an appointment. Increased knowledge fosters compliance.g. • Assess patient’s ability to perform the desired activity. the negative feelings of being "talked down to" by health care providers not fluent in patient’s language. For example. Polypharmacy is a significant problem with elderly patients.

. special privileges (e. Groups that come together for mutual support and information can be beneficial. Education/Continuity of Care • Use a variety of teaching methods. Nonadherence because of medication side effects is a commonly reported problem. stress management classes. American Diabetes Association. Different people learn in different ways. Rewards may consist of verbal praise. monetary rewards. • If negative side effects of prescribed treatment are a problem. This allows learner to concentrate more completely on one topic at a time. For some patients this may require grocery shopping for "healthy foods" with a dietitian.g. initiate referral to a support group (e. Although many cultures in the United States are future-oriented and are 127 . Match the learning style with the educational approach. smoking cessation clinics. • If patient lacks adequate support in following prescribed treatment plan. explain that many side effects can be controlled or eliminated. and possible interplay with over-the-counter medications. Health care providers need to determine actual etiological factors for side effects. The exercise prescription may need to be revised. free parking). weight loss programs. Patients likewise report fatigue or muscle cramps with exercise. social services). Develop with patient a system of rewards that follow successful follow-through. American Association of Retired Persons [AARP]. senior groups. • Concentrate on the behaviors that will make the greatest contribution to the therapeutic effect. • Instruct patient on the importance of reordering medications 2 to 3 days before running out. • Introduce complicated therapy one step at a time.. or a home visit by the nurse to review a psychomotor skill.• • Develop a system for patient to monitor his or her own progress. Y Me.g. earlier office appointment. or telephone calls.

This may enhance overall adaptation to the program. This allows patient to use new information immediately. This difference in time orientation may need to be addressed. provide immediate feedback on performance.concerned with measures to prevent illness. Deafness NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Hearing Compensation Behavior Risk Control: Hearing Impairment   NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Communication Enhancement: Hearing Deficit  128 . • Role-play scenarios when nonadherence to plan may easily occur. • Allow learner to practice new skills. Immediate feedback allows learner to make corrections rather than practice the skill incorrectly. Disturbed Sensory Perception: Auditory Hearing Loss. Helping patient expand his or her repertoire of responses to difficult situations assists in meeting treatment goals. Relapse prevention needs to be addressed early in the treatment plan. thus enhancing retention. other cultures are more oriented to the present. Demonstrate appropriate behaviors. Encourage their support and assistance in following plans. Hearing Impaired. • Include significant others in explanations and teaching.

Inappropriate response to questions. Irritability. Otosclerosis. Head tilting. When hearing loss is profound and precedes language development. Social avoidance or withdrawal. Ongoing Assessment • Assess patient’s ability to hear by performing the following: 129 . Difficulty learning or following directions. When hearing is impaired or lost later in life. infection. Acoustic neuroma. Nursing interventions with the hearing impaired are aimed at assisting the individual in effective communication despite the loss of normal hearing. Accumulated earwax Expected Outcomes: Patient achieves optimal functioning within limits of hearing impairment as evidenced by ability to communicate effectively and to engage in meaningful activities. Ototoxic drug use. or impaired response to such stimuli Hearing loss is common among older adults but may also occur as the result of congenital exposure to virus. Inoperative or poorly fitted hearing aids. Prolonged or cumulative exposure to environmental noise greater than 85 dB. History of head trauma. Many hearing assistive devices and services are available to help the hearing-impaired individual. Ear pain Related Factors: Middle ear injuries secondary to penetration of eardrum. Some causes of hearing loss are surgically correctable. or exposure to occupational and/or environmental noise. Chronic or recurring otitis media. Presbycusis (loss of hearing associated with aging). Dizziness. the ability to learn speech and interact with hearing peers can be severely impaired. including depression and isolation. Meniere’s disease. exaggerated. Ear Care NANDA Definition: Change in the amount or patterning of incoming stimuli accompanied by a diminished. during childhood after frequent ear infections or trauma. Congenital rubella exposure. serious emotional and social consequences can occur. especially direct blow to ear(s). Defining Characteristics: Asking others to repeat spoken messages. distorted. and during adulthood as the result of trauma. Cupping hands around ears.

and caregivers often first notice requests for verbal repetition. As screening. either as the result of occupation. friends. progressive. • Assess whether hearing loss is recent. History of head or ear trauma and frequent bouts with ear infections are often associated with hearing loss. Ask family or caregivers about their perception of patient’s hearing impairment. • Review recent use of drugs that are ototoxic. Young persons who frequent rock concerts or listen to very loud music place themselves at risk for hearing loss. Wax prevents sound transmission and may clog hearing aid(s). whereas those who have had hearing loss since birth or childhood probably have the skills. some chemotherapeutic agents. Withdrawal of these drugs when hearing impairment occurs often allows for full return of hearing. • Review medical history. or present since childhood. Review audiogram. are the earliest effects. do this within patient’s sight. Aspirin. Patients may rely on lip-reading to a greater extent than they are aware. highpitched sounds. and resources available to cope with hearing impairment. or accident. if available. Hearing loss that results from noise is not reversible. note patient’s ability to hear and appropriately respond to normal conversational voice. quinidine. tools. and the ability to comprehend some consonants.   • Assess age. lack of response to verbalizations. This diagnostic study indicates both type and amount of hearing loss. Occupational Safety and Health Act (OSHA) requires hearing protection in workplaces with noise levels exceeding 90 dB. • Review exposure to environmental noise. and misanswered questions. Adults with new or progressive hearing loss require attention to the emotional and social implications of impaired communication. • Check ears for earwax. family. Patients may be unaware of progressive hearing loss. 130 . recreation. and the aminoglycosides are known ototoxic agents. Neurosensory hearing loss affects many older individuals. then again from out of patient’s sight.

Check hearing aid(s) for fresh.• Note/investigate social and emotional impact of hearing loss. • Ask patient whether the ear(s) is painful. and withdrawal from usual activities. The decision to wear a hearing aid is often resisted because of the social stigma perceived in conjunction with aging and loss of abilities. serous. 131  . functional batteries. dysequilibrium. Pain is a symptom of increased pressure behind the eardrum. depression. Face patient in good light and keep hands away from mouth. • Assess patient’s ability to effectively administer ear drops. facial expressions. Check hearing aid(s) for wax impaction. • For patients with hearing aids:     Note condition/age of hearing aid(s). usually a result of infection. Disorders of the ear (e.. Meniere’s disease) may be accompanied by dizziness because of the inner ear’s role in maintenance of equilibrium. Reduce noise so that speaker does not have to compete to be heard. mucoid. These gain patient’s attention. This determines presence of infectious pathogens. Purulent. Therapeutic Interventions • • Use touch and eye contact. and gesturing. When speaking. This enhances patient’s use of lip-reading. • Assess for drainage from ear canal. Loss of hearing may lead to reclusiveness.g. or bloody drainage may indicate effusion of the middle ear after an upper respiratory or sinus infection. • Assess for dizziness. Note frequency with which patient wears hearing aid(s). isolation. foul-smelling drainage indicates an infection. • Culture any drainage from the ear canal(s). do the following:  Reduce or minimize environmental noise.

Patients with new hearing aid(s) need time to adjust to the sound produced. computers. and services for the hearing impaired (e. modifiers for telephones. Speak slowly. Avoid shouting or yelling. These 132 . Thin washcloths and fingers are best for cleaning ears. or other writing tools. These help communicate with profoundly hearing-impaired individuals. • Teach patient or caregiver use and care of hearing aid(s) and/or other assistive hearing devices. • For patients with hearing aid(s).. especially among elderly patients who may decide that the hearing aid(s) is not worth the effort. as appropriate. • Instruct patient or caregiver in safe techniques for cleaning ears. Use simple language and short sentences. this position should be maintained for 1 to 2 minutes.    • Speak close to patient’s "better" ear. Head should be positioned to allow medication to flow into ear canal. Cotton-tipped applicators should be avoided to prevent inadvertent injury to eardrum. closed-caption TV.g. clean and working. telephone hearing-impaired assistance). • Explore technology such as amplifiers. restoration of bones with prostheses) and mastoidectomy (removal of all or portions of the middle ear structures) are common surgical treatments for hearing loss. Encouragement is often needed. tip of applicator or dropper should not be allowed to come into contact with anything. Drops should be administered at room temperature to avoid pain and dizziness. This prevents humiliation. Use grease boards. Prepare patient for ear surgery. Education/Continuity of Care • Teach patient or caregiver to administer ear medications. • • Provide encouragement to use hearing aid(s). Tympanoplasty (removal of dead tissue. ensure that hearing aid(s) is in place.

• Instruct patient in the importance of routine examination by an audiologist.may assist the hearing-impaired person function and participate in meaningful activities. Macular Degeneration. Disturbed Sensory Perception: Visual Vision Loss. Exams detect changes in hearing or need for change in hearing aid(s). Blindness NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Visual Compensation Behavior Risk Control: Visual Impairment   NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Communication Enhancement: Visual Deficit Environmental Management Self-Esteem Enhancement    133 .

astigmatism (caused by abnormal corneal curvature). Nursing interventions in persons with visual impairment are aimed at assisting the individual to cope with the loss and remain functional and safe. and presbyopia (loss of accommodation as the result of normal. Defining Characteristics:   • • • • • • • • Reported or measured changes in visual acuity Change in usual response to visual stimuli Lack of eye-to-eye contact Abnormal eye movement Failure to locate distant objects Squinting. also accounts for visual impairment or loss to a lesser degree. or surgery (lens implants. may require ongoing supervision and/or institutionalization. As the American population ages. These include myopia (nearsightedness). or long-term care facilities). Some forms of visual impairment can be corrected. Ability to be independent with self-care. distorted. accompanied by a diminished. either by refraction (glasses. Trauma. contact lenses). especially in the management of medications. in outpatient settings.. exaggerated. including noncorrectable loss from progressive macular degeneration. medications (used mainly in the treatment of glaucoma). keratorefractive procedures). hyperopia (farsightedness).g. is a growing concern. frequent blinking Bumping into things Clumsy behavior Closing of one eye to see Frequent rubbing of eye • • • • • • • • Deviation of eye Gray opacities in eyes Head tilting Disorientation Anxiety Anger Visual distortions Incoordination 134 . This care plan addresses needs of persons who are out of their usual environments (e. usually associated with alcohol use. Genetics. visual impairment. Other types of visual impairment or loss cannot be corrected.NANDA Definition: Change in the amount or patterning of incoming stimuli. hospitals. aging. or impaired response to such stimuli Visual impairment and/or loss of vision affects more than 100 million Americans. and chronic diseases such as diabetes and glaucoma account for the majority of visual impairment. age-related changes in the lens).

• • Review medical history. Recent loss. intracranial aneurysms. history of falls. IV. presbyopia). accidents Related Factors: Diabetes. thyroid disease. astigmatism. quantification of loss may be difficult for the patient to articulate. onset. Inquire about patient or family history of systemic or central nervous system (CNS) disease. retinal detachments. Family or patient history of atherosclerosis. The incidence of macular degeneration. III. and VI. • Ask patient about specifics such as ability to read. Ongoing Assessment • Assess age. or ability to self-medicate. Glaucoma.• History of falls. Refractive disorders (myopia. or hypertension should be investigated as possible cause for visual loss. hyperopia. or long-standing loss have different implications for nursing intervention and the patient’s level of adaptation or resource use. Macular degeneration. and degree of visual loss. myasthenia gravis. Ocular infection. and to engage in meaningful activities. Cataracts. Retinal detachment. diabetes. brain tumor. trauma. Conjunctival Kaposi’s sarcoma of acquired immunodeficiency syndrome (AIDS)  Disease or trauma to visual pathways or cranial nerves II. loss over a long period. diabetic retinopathy. to navigate environment safely. secondary to Advanced age stroke. 135 . • Determine nature of visual symptoms. or multiple sclerosis  Expected Outcomes: Patient achieves optimal functioning within limits of visual impairment as evidenced by ability to care for self. Since visual loss may occur gradually. cataracts. see television. and glaucoma increase with aging. Ocular trauma.

Therapeutic Interventions • Introduce self to patient. Glaucoma affects peripheral vision. edema. • Assess factors or aids that improve vision. • Evaluate patient’s ability to function within limits of visual impairment. such as glasses. depression. Do not make unnecessary changes in environment. contact lenses. and deviation. Personal appearance and condition of clothing and surroundings are good indicators of the patient’s adaptation to visual loss. or bright and/or natural light. • Assess eye and lid for inflammation. The use of natural or halogen lighting is preferred to improve vision for patients with diminished vision. Anger. or ocular pain. and may not affect both eyes to the same extent. and acknowledge visual impairment. and has no associated symptoms. Macular degeneration affects central vision.• • Inquire about history of visual complaints. Orientation reduces fear related to unfamiliar environment. central. and is irreversible. individually and together. • Orient patient to environment. Assess central vision with each eye. 136 . its onset is insidious. Vision loss may be unilateral. and withdrawal are common responses. • Assess peripheral field of vision and visual acuity. These are correctable problems that can negatively affect vision. and/or peripheral. eye trauma. is more common among cigarette smokers. Self-esteem is often negatively affected. • Evaluate psychological response to visual loss. bilateral. • Provide adequate lighting. This ensures safety and maintains what the patient has arranged. This reduces patient’s anxiety. positional defects.

large-type printed books. • Recommend use of visual aids when appropriate. and talking books. Supervise patient when smoking. • Place food on tray and plate in same place each meal and explain arrangement of food on tray and plate. These reduce the risk of falls. 137 . If furniture or wastebaskets are moved. • Maintain bed in low position with side rails up. • Discourage doors from being left partially open. • Instruct patient to hold both arms of chair before sitting and to feel for the seat on chairs or sofas without arms. • Remove environmental barriers to ensure safety. Keep bed in locked position. Describe where you are walking. • Guide patient when ambulating. tapes. Encourage use of radios. and magazines encourage reading. Radio and television increase awareness of day and time. if appropriate. • • Consult occupational therapy staff for assistive devices and training in their use. if appropriate. This enhances continuity of care. Side rails help remind patient not to get up without help when needed. and call light within patient’s range of vision or reach. Supervision prevents accidental fires. • Communicate type and degree of impairment to all involved in patient’s care. tissues. This prevent falls. • Encourage use of sense of touch. notify patient of changes. using clockwise sequence. • • Explain sounds or other unusual stimuli in environment. Touch encourages patient to become familiar with unfamiliar objects. Fully open or closed doors reduce the risk for injury among the vision-impaired.• Place meal tray. These ensure safety and sense of independence. identify obstacles. Visual aids such as magnifying glass. Diversional activities should be encouraged. Explanations reduce fear. water.

New York. tubes of medications. 138 .Education/Continuity of Care • Involve caregiver in patient’s care and instructions. if indicated (e. Do not rub eyes. and other items. • Teach general eye care:  Maintain sterility of all eye droppers.g. • Reinforce need to use community agencies. This reduces the risk of eye infection.    • Demonstrate the proper administration of eye drops or ointments. NY 10011). • Help family or caregiver identify and make arrangements at home.. Do not share eye makeup. if any. 15 West 16th Street. • Make appropriate referrals to home health agency for nursing and social service follow-up. Care for contact lenses as recommended by manufacturer. Help patient understand nature and limitations of disease. allow for return demonstration by patient and/or caregiver. Patient and family need information to plan strategies for assisting the visually impaired patient to cope. as indicated. Lighthouse for the Blind [check local listings] or American Foundation for the Blind. • Reinforce physician’s explanation of medical management and surgical procedures. These provide for patient’s safety and sense of independence.

Urinary retention is the inability to empty the bladder even though urine is present.Urinary Retention NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Urinary Continence Urinary Elimination Infection Status    NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Urinary Retention Care  NANDA Definition: Incomplete emptying of the bladder Urinary retention may occur in conjunction with or independent of urinary incontinence. These drugs interfere with the nerve impulses necessary to 139 . antihistamines. antispasmodics. this may occur as a side effect of certain medications. including anesthetic agents. and anticholinergics. antihypertensives.

Defining Characteristics: • • • • Decreased (<30 ml/hr) or absent urinary output for 2 consecutive hours Frequency Hesitancy Urgency • • • Lower abdominal distention Abdominal discomfort Dribbling Related Factors: • • • • High urethral pressures caused by disease. or edema General anesthesia Regional anesthesia Pain. which allow urination. Retention of urine in the bladder predisposes that patient to urinary tract infection and may indicate the need for an intermittent catheterization program. Most commonly. 140 . this type of obstruction in men is the result of benign prostatic hypertrophy. Keeping an hourly log for 48 hours gives a clear picture of the patient’s voiding pattern and amounts. Obstruction of outflow is another cause of urinary retention. injury. Ongoing Assessment • Evaluate time intervals between voidings and record the amount voided each time. and can help to establish a toileting schedule.cause relaxation of the sphincters. fear of pain • • • Infection Inadequate intake Urethral blockage Expected Outcomes: Patient empties bladder completely. • Catheterize and measure residual urine if incomplete emptying is suspected.

Encourage patient to void at least every 4 hours. acidic urine is less likely to become infected. assess for patency and kinking. and specific gravity) of urine. and this in turn may stimulate relaxation of sphincter to allow voiding. This stimulates urination.. Credé’s method (pressing down over the and/or pour warm water over perineum. This helps least 1500 ml/24 hours. Perform Credé’s method over bladder. • • If indwelling catheter is in place.   bladder with the hands) increases bladder pressure. or place hands in warm water Offer fluids before voiding. or bedside commode within reach. urine culture. frequency. Unless medically contraindicated. urinal.• Assess amount. • Monitor urinalysis. These facilitate voiding. Provide privacy. Have patient listen to sound of running water. odor. This will differentiate between urinary retention and renal failure. and sensitivity. fluid intake should be at Encourage intake of cranberry juice daily. which maintains an acidic urine. Urinary tract infection can cause retention but is more likely to cause frequency. Intake greater than output may indicate retention. This keeps urine acidic. 141 . Therapeutic Interventions •  Initiate the following methods: Encourage fluids. • Determine balance between intake and output. color. and character (e.     Place bedpan. Monitor blood urea nitrogen (BUN) and creatinine.g.  prevent infection because cranberry juice metabolizes to hippuric acid.

bradycardia. This stimulates parasympathetic nervous system to release acetylcholine at nerve endings and to increase tone and amplitude of contractions of smooth muscles of urinary bladder. vomiting.• Encourage patient to take bethanechol (Urecholine) as ordered. asthmatic attacks. diarrhea. hesitancy. •   Insert indwelling (Foley) catheter as ordered: Tape catheter to abdomen (male). headache. Because many causes of urinary retention are self-limited. urgency.. 8 to 10 glasses of fluids daily). Side effects are rare after oral administration of therapeutic dose. frequency. side effects may include abdominal cramps.g. and flushing.. chills and fever. • Institute intermittent catheterization. This reduces the risk of infection. lowered blood pressure (BP). This prevents inadvertent displacement. sweating. decreased or absent urine. the decision to leave an indwelling catheter in should be avoided. Tape catheter to thigh (female). and cardiac arrest. Instruct patient or caregiver on signs and symptoms of over-distended bladder (e. or discomfort). In small subcutaneous doses. 142 . atrioventricular block. In larger doses they may include malaise. nausea. (e. and utilizes the force of gravity. This prevents urethral fistula. frequent urination or concentrated urine.g. and abdominal or back pain). lower abdominal distention. Education/Continuity of Care • Educate patient or caregiver about the importance of adequate intake. • Teach patient to achieve an upright position on toilet if possible. • • Instruct patient or caregiver on measures to help voiding (as described above).g. • Teach patient or caregiver to perform meatal care twice daily with soap and water and dry thoroughly.. • Instruct patient or caregiver on signs and symptoms of urinary tract infection (e. This is the natural position for voiding.

Cerebral NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels • Tissue Perfusion: Cardiopulmonary • Tissue Perfusion: Cerebral • Tissue Perfusion: Abdominal Organs • Tissue Perfusion: Peripheral • Fluid Balance • Electrolyte and Acid/Base Balance 143 . Cardiopulmonary. Renal.Ineffective Tissue Perfusion: Peripheral. Gastrointestinal.

pain. Management is directed at removing vasoconstricting factor(s). Diminished tissue perfusion.NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels    Circulatory Care Cardiac Care: Acute Cerebral Perfusion Promotion NANDA Definition: Decrease resulting in the failure to nourish the tissues at the capillary level Reduced arterial blood flow causes decreased nutrition and oxygenation at the cellular level. invariably results in tissue or organ damage or death. Defining Characteristics:  Peripheral:  Differences in blood pressure (BP) in opposite extremities Weak or absent peripheral Edema Numbness. If the decreased perfusion is acute and protracted. which is chronic in nature. ache in       Cool extremities Dependent rubor Clammy skin Mottling Prolonged capillary refill pulses   extremities   Cardiopulmonary:  • • Abnormal arterial blood gases (ABGs) Tachycardia Dysrhythmias • • Hypotension Tachypnea 144 . improving peripheral blood flow. and reducing metabolic demands on the body. This care plan focuses on problems in hospitalized patients. it can have devastating effects on the patient. Decreased tissue perfusion can be transient with few or minimal consequences to the health of the patient.

•   Angina Cerebral:        Restlessness Confusion Lethargy Seizure activity Decreased Glasgow Coma Scale scores Pupillary changes Decreased reaction to light Altered blood pressure Hematuria Decreased urine output (<30 ml/hr) Elevated BUN/creatinine ratio Decreased or absent bowel sounds Nausea Abdominal distention/pain  Renal:      Gastrointestinal:    Related Factors:  Peripheral:        Indwelling arterial catheters Constricting cast Compartment syndrome Embolism or thrombus Arterial spasm Vasoconstriction Positioning  Cardiopulmonary: 145 .

• Assess for possible causative factors related to temporarily impaired arterial blood flow. and absence of chest pain.      Pulmonary embolism Low hemoglobin Myocardial ischemia Vasospasm Hypovolemia Increased intracranial pressure (ICP) Vasoconstriction Intracranial bleeding Cerebral edema Chemical irritants Hypovolemia Reduced arterial flow Hemolysis Hypovolemia Obstruction Reduced arterial flow Cerebral:      Renal:      Gastrointestinal:    Expected Outcome: Patient maintains optimal tissue perfusion to vital organs. Ongoing Assessment • Assess for signs of decreased tissue perfusion (see Defining Characteristics for each category in this care plan). effective treatment. alert LOC. 146 . as evidenced by strong peripheral pulses. Early detection of cause facilitates prompt. normal ABGs.

elevation of affected limb. Doppler flow studies or angiograms may be required for accurate diagnosis. Use soft restraints or arm boards as needed. heparinization. Exercise prevents venous stasis. 147 . thrombolytic therapy.. Therapeutic Interventions • Maintain optimal cardiac output. • Monitor quality of all pulses. Support may be required to facilitate peripheral circulation (e. Movement may cause trauma to artery. antiembolism devices). • Anticipate or continue anticoagulation as ordered. Specific Interventions Peripheral • Keep cannulated extremity still.• Monitor international normalized ratio (INR) and prothrombin time/partial thromboplastin time (PT/PTT) if anticoagulants are used for treatment. and fluid rescue.g. Assessment is needed for ongoing comparisons. • Assist with diagnostic testing as indicated. Blood clotting studies are used to determine or ensure that clotting factors remain within therapeutic levels. This ensures adequate perfusion of vital organs. • Do passive range-of-motion (ROM) exercises to unaffected extremity every 2 to 4 hours. and oral anticoagulants to antiplatelet drugs. subcutaneous heparin. vasodilator therapy. These facilitate perfusion when obstruction to blood flow exists or when perfusion has dropped to such a dangerous level that ischemic damage would be inevitable without treatment. Therapy may range from intravenous (IV) heparin. loss of peripheral pulses must be reported or treated immediately. • Anticipate need for possible embolectomy.

hypercapnia). Circulation is potentially compromised with a cannula. This promotes optimal lung ventilation and perfusion. anticipate that physician will bivalve the cast or remove it. This reduces the risk of thrombus. This maintains maximal oxygenation and ion balance and reduces systemic effects of poor perfusion. • If cast causes altered tissue perfusion.g.• Prepare for removal of arterial catheter as needed. administer oxygen as needed. Cerebral Ensure proper functioning of intracranial pressure (ICP) catheter (if present).   Administer oxygen as ordered. This saturates circulating hemoglobin and increases the effectiveness of blood that is reaching the ischemic tissues. This restores perfusion in affected extremity. metabolic acidosis.g. • Institute continuous pulse oximetry and titrate oxygen administered. • If compartment syndrome is suspected. 148  . This improves myocardial perfusion. It should be removed as soon as therapeutically safe.. • Anticipate and institute anticoagulation as prescribed.. hypoxemia. The facial covering over muscles is relatively unyielding. Titrate medications to treat acidosis. • Position properly. prepare for surgical intervention (e. This maintains adequate oxygen saturation of arterial blood. • Report changes in ABGs (e. The patient will experience optimal lung expansion in upright position. Cardiovascular Administer nitroglycerin (NTG) sublingually for complaints of angina. Blood flow to tissues can become dangerously reduced as tissues swell in response to trauma from the fracture. • Administer oxygen as needed. fasciotomy).

Education/Continuity of Care • • Explain all procedures and equipment to the patient. • Avoid measures that may trigger increased ICP (e. positioning with neck in flexion. • Reorient to environment as needed.. Instruct the patient to inform the nurse immediately if symptoms of decreased perfusion persist. • Provide information on normal tissue perfusion and possible causes for impairment. This promotes venous outflow from brain and helps reduce pressure. Increased intracranial pressures will further reduce cerebral blood flow.g. which may result from cerebral edema or ischemia. Impaired Verbal Communication NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Communication: Expressive Ability Communication: Receptive Ability   149 . head flat). These reduce risk of seizure. • Administer anticonvulsants as needed. Decreased cerebral blood flow or cerebral edema may result in changes in the LOC. straining. increase or return (see Defining Characteristics of this care plan).• If ICP is increased. strenuous coughing. elevate head of bed 30 to 45 degrees.

The task for the nurse. process. Communication is a multifaceted. communication is conducted entirely through hand gestures that may or may not be accompanied by body movements and pantomime. or absent ability to receive. and sometimes a combination of all of the mechanisms listed above. whether encountering the patient in the hospital or in the community. and use a system of symbols Human communication takes many forms. effective communication involves a dialogue that not only involves the transmission of information but also clarification of points made. becomes recognizing when communication has become ineffective and then using strategies to improve transmission of information. art. reciprocal process. expansion of ideas and concepts. When communication is received it ceases to be the sole product of the sender as the entire experiential history of the receiver takes over and interprets the information sent. They communicate using body movements to supplement. and exploration of factors that fall out of the original thoughts transmitted. Communication implies the sending of information as well as the receiving of information. 150 . such as American Sign Language (the formal language of the deaf community) or Signed English. but rarely are all avenues for communication compromised at one time. Persons communicate verbally through the vocalization of a system of sounds that has been formalized into a language. At its best. transmit. Communication may be impaired for any number of reasons. Information Processing NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Active Listening Communication Enhancement: Hearing Deficit Communication Enhancement: Speech Deficit    NANDA Definition: Decreased. emphasize. or even alter what is being verbally communicated. kinetic. written means. Humans communicate through touch. delayed. In some cases. Language can be read by watching an individual’s lips to observe words as they are shaped. intuition.

reception or interpretation of language or other forms of communication Structural problem (e.. or names of known persons. recognize. verbal..g. intubation. speaks different language) Dyspnea Fatigue Sensory challenge involving hearing or vision Expected Outcomes:       Patient is able to use a form of communication to get needs met and to relate effectively with persons and his or her environment. or understand words Difficulty vocalizing words Inability to recall familiar words. objects. Ability to understand spoken word. phrases. gestures). written.g. Ongoing Assessment • • Assess the following: The patient’s primary and preferred means of communication (e.Defining Characteristics:    Inability to find. It is important for health care workers to understand that the construct of gestured language has an entirely different 151 .. cleft palate. or wired jaws) Cultural difference (e. and places Unable to speak dominant language Problems in receiving the type of sensory input being sent or sending the type of input necessary for understanding Related Factors:    Brain injury that adversely affects the transmission.g. laryngectomy. tracheostomy.

Patients may speak a language quite well without being able to read it effectively. In some cases the only way to be certain that communication has been effective is to arrange for a certified interpreter to validate information from both sides of the dialogue.structure from verbal and written English.e. Orofacial/maxillary problems (e. • The patient’s preferred language for verbal and written communication. Discharge selfcare and follow-up information must be communicated and reinforced with written information that the patient can use.g. oral or nasal intubation). Some members of the deaf community learn to do so effectively. The nurse can no longer assume that it is the patient’s responsibility to grasp the information that is being provided. When air does not pass over vocal cords. word meaning may be scrambled during the processing of information by the patient’s brain). wired jaws). sounds are not produced. such as the following:  Alternate airway (e. when movement is impinged. • Ability to understand written words. • Assess conditions or situations that may hinder the patient’s ability to use or understand language. communication may be ineffective..S.g. Patients who are experiencing breathing problems may reduce or cease verbal communication that may complicate their respiratory efforts.. Signed English is not the true language of the deaf community but an instructional mechanism developed to teach it the structure of English so that individuals with hearing impairments may read and write it. federal law requires the use of an official interpreter to communicate with persons who choose to receive informed consent and other important medical information in their own language. American Sign Language is the true language of the deaf community. In recognition of the vast array of cultures and physical challenges that patients face. it is the nurse’s responsibility to communicate effectively.. Words are articulated by coordinated movement of mouth and tongue. pictures. 152 . • Assess for presence and history of dyspnea. tracheostomy. U. gestures.  • Assess for presence of expressive aphasia (inability to convey information verbally) and receptive aphasia (i.

Therapeutic Interventions • Assist the patient in seeking an evaluation of his or her home and work settings. This will keep patient focused. Individuals who have no formal training in sign language usually develop mechanisms for communication. Clarify your understanding of the patient’s communication with the patient or an interpreter. and enhance the nurse’s ability to listen.• Assess energy level. telephone typing device. • Provide alternate means of communication for times when interpreters are not available (e. The nurse should set aside enough time to attend to all of the details of patient care. praise attempts and achievements. Listen attentively when patient attempts to communicate. This will evaluate the need for things such as assistive devices. • Place important objects within reach. family’s. • Anticipate patient needs and pay attention to nonverbal cues.. Fatigue and/or shortness of breath can make communication difficult or impossible. This maximizes patient’s sense of independence. a phone contact who can interpret the patient’s needs). Care measures may take longer to complete in the presence of a communication deficit. or caregiver’s understanding of sign language. • Never talk in front of patient as though he or she comprehends nothing. and interpreters. consider formal training for patient and caregivers to enhance communication. decrease stimuli going to the brain for interpretation. This will prevent increasing the patient’s sense of frustration and feelings of helplessness. 153 . • • Encourage patient’s attempts to communicate. • Assess knowledge of patient’s.g. but since communication is such a critical aspect of everyone’s life. as appropriate. • Keep distractions such as television and radio at a minimum when talking to patient. talking computers.

aphasia. Allow the patient to complete his or her sentence and thought.. within patient’s line of vision (generally midline). "point to the pain. Be calm and accepting during attempts. or make necessary language translations.• Do not speak loudly unless patient is hearing-impaired. Patients may have defect in field of vision or may need to see the nurse’s face or lips to enhance understanding of what is being communicated. • Speak slowly and distinctly. repeating key words to prevent confusion. It may be difficult for patients to respond under pressure. This provides the patient with more channels through which information can be communicated. do not say you understand if you do not. 154 . The inability to communicate enhances a patient’s sense of isolation and may promote a sense of helplessness. • Maintain eye contact with patient when speaking. • Use short sentences and ask only one question at a time. • Give the patient ample time to respond. Say the word or phrase slowly and distinctly if help is requested. Acknowledge his or her frustrations. Stand close. find the correct word. This may increase frustration and decrease the patient’s trust in you. ask the patient for permission to help them. or a sensory deficit. • Praise patient’s accomplishments. Supplement verbal communication with meaningful gestures. Loud talking does not improve the patient’s ability to understand if the barriers are primary language. • Avoid finishing sentences for the patient." and "turn your head"). try to phrase questions so that the patient can use these responses. • Give concrete directions that the patient is physically capable of doing (e. • If the patient’s ability to speak is limited to yes and no answers. but if the patient appears to be having difficulty. This allows the patient to stay focused on one thought. they may need extra time to organize responses." "open your mouth.g.

significant other. significant others. this may or may not be true. some of the effects may be amenable to remediation. This is especially helpful for intubated and tracheal patients or those whose jaws are wired. • Provide patient with word-and-phrase cards." "this is a cup"). • Provide a list of words patient can say.. add new words to it. "yes. writing pad and pencil. • Consult a speech therapist for additional help." "no. • Carry on a one-way conversation with a totally aphasic patient. See that patient is well-rested before each session with the speech therapist. Many family members assume that a patient’s mentation has been affected by a brain injury.g. Fatigue may have an adverse effect on learning ability. • When patient cannot identify objects by name. Share this list with family. • Correct errors. This broadens the group of people with whom the patient can communicate. but it should not be assumed that the patient understands nothing about his or her environment. or picture board. and will make correction more difficult later. or caregiver of the type of aphasia the patient has and how it affects speech. It may not be possible to determine what information is understood by the patient.• When patient has difficulty with verbal expressions. and understanding. and if true. point to an object and clearly enunciate its name: "cup" or "pen"). then progress. Not correcting errors reinforces undesirable performance.g. It is important for the family to know that there are many 155 .. and other care providers. Education/Continuity of Care • Inform patient. • Consider use of electronic speech generator in postlaryngectomy patients. language skills. give practice in receiving word images (e. • Offer significant others the opportunity to ask questions about patient’s communication problem. support the work the patient is doing in speech therapy by providing practice sessions often throughout the day. Begin with simple words (e.

• Provide answers and helpful suggestions for what is known while not providing false assurances. Suggest that the family engage the patient often throughout the day for short periods. Excess Fluid Volume Hypervolemia. • • Explain that brain injury decreases attention span. education. • Deaf patients and their families should be referred to their local hearing society for community support. Encourage the family to look for cues that the patient is overstimulated or fatigued. • Encourage patient to socialize with family and friends.ways to send information to someone and that time may be needed to understand the special needs of the patient. and sign language training. • Encourage family member/caregiver to talk to patient even though patient may not respond. Communication should be encouraged despite impairment. • • Provide patient with an appointment with a speech therapist. MD 20852. if not already done. 10810 Rockwell Pike. Rockville. This decreases patient’s sense of isolation and may assist in recovery from aphasia. Fluid Overload NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Fluid Balance  156 . Inform patient and significant others to seek information about aphasia from the American Speech-Language-Hearing Association.

It may also be caused by excessive intake of sodium from foods. kidney failure. or home setting. Defining Characteristics:             Weight gain Edema Bounding pulses Shortness of breath. or hypervolemia. occurs from an increase in total body sodium content and an increase in total body water. orthopnea Pulmonary congestion on x-ray Abnormal breath sounds: crackles (rales) Change in respiratory pattern Third heart sound (S3) Intake greater than output Decreased hemoglobin or hematocrit Increased blood pressure Increased central venous pressure (CVP) 157 . intravenous (IV) solutions. For acute cases dialysis may be required. and liver failure. Treatment consists of fluid and sodium restriction. and the use of diuretics. outpatient center. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF).NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels Fluid Monitoring Fluid Management   NANDA Definition: Increased isotonic fluid retention Fluid volume excess. or diagnostic contrast dyes. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Hypervolemia may be an acute or chronic condition managed in the hospital. medications.

Ongoing Assessment • Obtain patient history to ascertain the probable cause of the fluid disturbance. or compromised regulatory mechanisms. pulmonary congestion absent on x-ray. May include increased fluids or sodium intake. and resolution of edema. chronic or acute heart disease Head injury Liver disease Severe stress Hormonal disturbances Expected Outcomes: Patient maintains adequate fluid volume and electrolyte balance as evidenced by vital signs within normal limits.        Increased pulmonary artery pressure (PAP) Jugular vein distension Change in mental status (lethargy or confusion) Oliguria Specific gravity changes Azotemia Change in electrolytes Restlessness and anxiety Related Factors:           Excessive fluid intake Excessive sodium intake Renal insufficiency or failure Steroid therapy Low protein intake or malnutrition Decreased cardiac output. This can help to guide interventions. clear lung sounds. 158 .

sherbet. and sacrum. • Monitor for distended neck veins and ascites. thus their response to fluid overload may be blunted. and orthopnea. shortness of breath. • • Monitor for a significant weight change (2 pounds) in 1 day. • Assess for presence of edema by palpating over tibia. weight may be a poor indicator of fluid volume status. feet. Sinus tachycardia and increased blood pressure are seen in early stages. with same scale and preferably at the same time of day. and assess for bounding peripheral pulses. changes in respiratory pattern. In some heart failure patients. Elderly patients have reduced response to catecholamines. and Popsicles. • If patient is on fluid restriction. Instruction facilitates accurate measurement and helps to follow trends. Measurement of an extremity with a measuring tape is another method of following edema. review daily log or chart for recorded intake. with less rise in heart rate. ankles. These are early signs of pulmonary congestion. Monitor abdominal girth to follow any ascites accurately. • Monitor and document vital signs. Pitting edema is manifested by a depression that remains after one’s finger is pressed over an edematous area and then removed. which may be accompanied by fluid retention even though the net weight remains unchanged. Evaluate weight in relation to nutritional status. These are signs of fluid overload. • Monitor chest x-ray reports. As interstitial edema accumulates. the x-rays show cloudy white lung fields.• Assess or instruct patient to monitor weight daily and consistently. Patients should be reminded to include items that are liquid at room temperature such as Jell-O. • Assess for crackles in lungs. 159 . Poor nutrition and decreased appetite over time result in a decrease in weight. Grade edema from trace (indicating barely perceptible) to 4 (severe edema). • Auscultate for a third sound.

weakness. and urine-specific gravity. This direct measurement serves as optimal guide for therapy. if available. • Evaluate urine output in response to diuretic therapy. it is unrealistic to expect patients to measure each void. • During therapy. For some patients. The risk of this occurring increases when diuretics are given. Medications may need to be given intravenously by a nurse in the home or outpatient setting. Although overall fluid intake may be adequate. • • Monitor serum electrolytes. NOTE: Fluid volume excess in the abdomen may interfere with absorption of oral diuretic medications. rather than the actual amount voided. At home. • Monitor for excessive response to diuretics: 2-pound loss in 1 day.• Monitor input and output closely. Assess the need for an indwelling urinary catheter. monitor for signs of hypovolemia. Therefore recording two voids versus six voids after a diuretic medication may provide more useful information. This helps reduce extracellular volume. fluids may need to be restricted to 1000 ml/day. Monitoring prevents complications associated with therapy. Focus is on monitoring the response to the diuretics.  160 . and PCWP. PAP. • If hospitalized. urine osmolality. Patients may use diaries for home assessment. Treatment focuses on diuresis of excess fluid. Therapeutic Interventions Institute/instruct patient regarding fluid restrictions as appropriate. hypotension. blood urea nitrogen (BUN) elevated out of proportion to serum creatinine level. shifting of fluid out of the intravascular to the extravascular spaces may result in dehydration. monitor hemodynamic status including CVP.

Provide innovative techniques for monitoring fluid allotment at home. For example, suggest that patients measure out and pour into a large pitcher the prescribed daily fluid allowance (e.g., 1000 ml); then every time patient drinks some fluid, he or she is to remove that amount from the pitcher. This provides a visual guide for how much fluid is still allowed throughout the day.

Restrict sodium intake as prescribed. Sodium diets of 2 to 3 g are usually prescribed.

Administer or instruct patient to take diuretics as prescribed. Diuretic therapy may include several different types of agents for optimal therapy, depending on the acuteness or chronicity of the problem. For chronic patients, compliance is often difficult for patients trying to maintain a normal lifestyle.

Instruct patient to avoid medications that may cause fluid retention, such as over-thecounter nonsteroidal antiinflammatory agents, certain vasodilators, and steroids.

Elevate edematous extremities. This increases venous return and, in turn, decreases edema.

Reduce constriction of vessels (e.g., use appropriate garments, avoid crossing of legs or ankles). This prevents venous pooling.

Instruct in need for antiembolic stockings or bandages as ordered. These help promote venous return and minimize fluid accumulation in the extremities.

Provide interventions related to specific etiological factors (e.g., inotropic medications for heart failure, paracentesis for liver disease). For acute patients: Consider admission to acute care setting for hemofiltration or ultrafiltration. This is a very effective method to draw off excess fluid.

Collaborate with the pharmacist to maximally concentrate IVs and medications. This decreases unnecessary fluids.


Apply saline lock on IV line. This maintains patency but decreases fluid delivered to patient in a 24-hour period.

Administer IV fluids through infusion pump, if possible. This ensures accurate delivery of IV fluids.

Assist with repositioning every 2 hours if patient is not mobile. This prevents fluid accumulation in dependent areas.

Education/Continuity of Care
• •

Teach causes of fluid volume excess and/or excess intake to patient or caregiver. Provide information as needed regarding the individual’s medical diagnosis (e.g., congestive heart failure [CHF], renal failure).

• • •

Explain or reinforce rationale and intended effect of treatment program. Identify signs and symptoms of fluid volume excess. Explain importance of maintaining proper nutrition and hydration, and diet modifications.

Identify symptoms to be reported.

Activity Intolerance Altered family processes Altered growth and development Altered health maintenance

Impaired skin integrity Impaired social interaction Impaired swallowing Impaired tissue integrity


Altered nutrition: less than body requirements Altered nutrition: more than body requirements Altered nutrition: potential for more than body requirements Altered oral mucous membrane Altered parenting Altered patterns of urinary elimination Altered protection Altered role performance Altered sexuality patterns Altered thought processes Altered (specify type) tissue perfusion (cerebral, cardiopulmonary, renal, gastrointestinal, peripheral) Anticipatory grieving Anxiety Bathing/hygiene self-care deficit Body-image disturbance Bowel incontinence Chronic low self-esteem Chronic pain Colonic constipation

Impaired verbal communication

Ineffective airway clearance

Ineffective breastfeeding Ineffective breathing pattern Ineffective denial Ineffective family coping; compromised Ineffective family coping; disabled Ineffective individual coping Ineffective thermoregulation Knowledge deficit (specify)

Noncompliance (specify)

Pain Parental role conflict Perceived constipation Personal identity disturbance Post-trauma response Potential activity intolerance Potential altered body temperature Potential fluid volume deficit


tactile. gustatory. visual) Sexual dysfunction Situational low self-esteem Sleep pattern disturbance 164 . olfactory. kinesthetic.Constipation Decisional conflict (specify) Decreased cardiac output Defensive coping Diarrhea Dressing/grooming self-care deficit Dysfunctional grieving Dysreflexia Effective breastfeeding Family coping: potential for growth Fatigue Fear Feeding self-care deficit Fluid volume deficit Fluid volume excess Functional incontinence Health seeking behaviors (specify) or desire for high-level wellness (specify) Hopelessness Hyperthermia Hypothermia Potential for aspiration Potential for disuse syndrome Potential for infection Potential for injury Potential for poisoning Potential for suffocating Potential for trauma Potential for violence: self-directed or directed at others Potential impaired skin integrity Powerlessness Rape-trauma syndrome Rape-trauma syndrome: compound reaction Rape-trauma syndrome: compound reaction Rape-trauma syndrome: silent reaction Reflex incontinence Self-esteem disturbance Sensory/perceptual alterations (specify) (auditory.

Impaired adjustment Impaired gas exchange Impaired home maintenance management Impaired physical mobility Total incontinence Urge incontinence Social isolation Spiritual distress (distress of the human spirit) Stress incontinence Toileting self-care deficit Unilateral neglect Urinary retention 165 .

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